Ray County Hospital

All Charges

Charge

Type

Setting

Price

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$13,194.74

Service Code	APR-DRG 8163
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$13,194.74
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$13,194.74
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$13,194.74
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$13,194.74
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$13,194.74

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$7,225.12

Service Code	APR-DRG 8162
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$7,225.12
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$7,225.12
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$7,225.12
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$7,225.12
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$7,225.12

trace elements (Tralement) Zn-Cu-Mn-Se 3 mg-0.3 mg-55 mcg-60 mcg/mL solution 1 mL Vial

Facility

$117.80

Service Code	NDC 00517930525
Hospital Revenue Code	250
Min. Negotiated Rate	$67.15
Max. Negotiated Rate	$117.80
Rate for Payer: Aetna Commercial/Medicare Advantage	$83.05
Rate for Payer: Aetna Workers' Compensation	$83.05
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$81.64
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$81.64
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$92.83
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$92.83
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$92.83
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$90.71
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$92.83
Rate for Payer: Cash Price	$117.80
Rate for Payer: Cigna Commercial	$72.09
Rate for Payer: Cigna Medicare Advantage	$67.15
Rate for Payer: Harmony Health CHIP/Medicaid	$74.21
Rate for Payer: Home State Health Plan Exchange	$67.15
Rate for Payer: Humana Medicare	$88.35
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$88.35
Rate for Payer: Provider Network of America Commercial	$94.24
Rate for Payer: UnitedHealthcare Commercial	$77.75
Rate for Payer: UnitedHealthcare Individual Exchange	$117.80

trace elements (Tralement) Zn-Cu-Mn-Se 3 mg-0.3 mg-55 mcg-60 mcg/mL solution 1 mL Vial

Facility

$117.80

Service Code	NDC 00517930501
Hospital Revenue Code	250
Min. Negotiated Rate	$67.15
Max. Negotiated Rate	$117.80
Rate for Payer: Aetna Commercial/Medicare Advantage	$83.05
Rate for Payer: Aetna Workers' Compensation	$83.05
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$81.64
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$81.64
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$92.83
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$92.83
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$92.83
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$90.71
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$92.83
Rate for Payer: Cash Price	$117.80
Rate for Payer: Cigna Commercial	$72.09
Rate for Payer: Cigna Medicare Advantage	$67.15
Rate for Payer: Harmony Health CHIP/Medicaid	$74.21
Rate for Payer: Home State Health Plan Exchange	$67.15
Rate for Payer: Humana Medicare	$88.35
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$88.35
Rate for Payer: Provider Network of America Commercial	$94.24
Rate for Payer: UnitedHealthcare Commercial	$77.75
Rate for Payer: UnitedHealthcare Individual Exchange	$117.80

trace elements (Tralement) Zn-Cu-Mn-Se 3 mg-0.3 mg-55 mcg-60 mcg/mL solution 1 mL Vial

Facility

$117.80

Service Code	NDC 00517930525
Hospital Revenue Code	250
Min. Negotiated Rate	$88.35
Max. Negotiated Rate	$6,053.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cash Price	$117.80
Rate for Payer: Cash Price	$117.80
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$88.35
Rate for Payer: Provider Network of America Commercial	$94.24

trace elements (Tralement) Zn-Cu-Mn-Se 3 mg-0.3 mg-55 mcg-60 mcg/mL solution 1 mL Vial

Facility

$117.80

Service Code	NDC 00517930501
Hospital Revenue Code	250
Min. Negotiated Rate	$88.35
Max. Negotiated Rate	$6,053.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cash Price	$117.80
Rate for Payer: Cash Price	$117.80
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$88.35
Rate for Payer: Provider Network of America Commercial	$94.24

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC

Facility

$19,815.20

Service Code	MSDRG 012
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$19,815.20
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$19,815.20

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC

Facility

$25,634.27

Service Code	MSDRG 011
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$25,634.27
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$25,634.27

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC

Facility

$13,544.46

Service Code	MSDRG 013
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$13,544.46
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$13,544.46

TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES

Facility

$65,101.58

Service Code	MSDRG 004
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$65,101.58
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$65,101.58

TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE

Facility

$50,185.66

Service Code	APR-DRG 0041
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$50,185.66
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$50,185.66
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$50,185.66
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$50,185.66
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$50,185.66

TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE

Facility

$75,380.66

Service Code	APR-DRG 0042
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$75,380.66
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$75,380.66
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$75,380.66
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$75,380.66
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$75,380.66

TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE

Facility

$190,884.51

Service Code	APR-DRG 0044
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$190,884.51
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$190,884.51
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$190,884.51
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$190,884.51
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$190,884.51

TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE

Facility

$119,727.98

Service Code	APR-DRG 0043
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$119,727.98
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$119,727.98
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$119,727.98
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$119,727.98
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$119,727.98

TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE

Facility

$57,665.95

Service Code	APR-DRG 0052
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$57,665.95
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$57,665.95
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$57,665.95
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$57,665.95
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$57,665.95

TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE

Facility

$130,483.84

Service Code	APR-DRG 0054
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$130,483.84
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$130,483.84
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$130,483.84
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$130,483.84
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$130,483.84

TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE

Facility

$86,711.56

Service Code	APR-DRG 0053
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$86,711.56
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$86,711.56
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$86,711.56
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$86,711.56
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$86,711.56

TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE

Facility

$30,033.00

Service Code	APR-DRG 0051
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$30,033.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$30,033.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$30,033.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$30,033.00
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$30,033.00

traMADol 50 mg tablet 100 Each BLIST PACK

Facility

$4.00

Service Code	NDC 00904717961
Hospital Revenue Code	637
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$2.82
Rate for Payer: Aetna Workers' Compensation	$2.82
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$2.77
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$2.77
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$3.15
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$3.15
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$3.15
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$3.08
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$3.15
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$2.45
Rate for Payer: Cigna Medicare Advantage	$2.28
Rate for Payer: Harmony Health CHIP/Medicaid	$2.52
Rate for Payer: Home State Health Plan Exchange	$2.28
Rate for Payer: Humana Medicare	$3.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$3.00
Rate for Payer: Provider Network of America Commercial	$3.20
Rate for Payer: UnitedHealthcare Commercial	$2.64
Rate for Payer: UnitedHealthcare Individual Exchange	$4.00

traMADol 50 mg tablet 100 Each BLIST PACK

Facility

$4.00

Service Code	NDC 00904717961
Hospital Revenue Code	637
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$6,053.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$3.00
Rate for Payer: Provider Network of America Commercial	$3.20

tranexamic acid 1,000 mg/10 mL (100 mg/mL) solution 10 mL Vial

Facility

$35.00

Service Code	NDC 72485010701
Hospital Revenue Code	250
Min. Negotiated Rate	$26.25
Max. Negotiated Rate	$6,053.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$26.25
Rate for Payer: Provider Network of America Commercial	$28.00

tranexamic acid 1,000 mg/10 mL (100 mg/mL) solution 10 mL Vial

Facility

$35.00

Service Code	HCPCS J3290
Hospital Revenue Code	250
Min. Negotiated Rate	$26.25
Max. Negotiated Rate	$6,053.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$26.25
Rate for Payer: Provider Network of America Commercial	$28.00

tranexamic acid 1,000 mg/10 mL (100 mg/mL) solution 10 mL Vial

Facility

$35.00

Service Code	HCPCS J3290
Hospital Revenue Code	250
Min. Negotiated Rate	$19.95
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$24.68
Rate for Payer: Aetna Workers' Compensation	$24.68
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$24.25
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$24.25
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$27.58
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$27.58
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$27.58
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$26.95
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$27.58
Rate for Payer: Cash Price	$35.00
Rate for Payer: Cigna Commercial	$21.42
Rate for Payer: Cigna Medicare Advantage	$19.95
Rate for Payer: Harmony Health CHIP/Medicaid	$22.05
Rate for Payer: Home State Health Plan Exchange	$19.95
Rate for Payer: Humana Medicare	$26.25
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$26.25
Rate for Payer: Provider Network of America Commercial	$28.00
Rate for Payer: UnitedHealthcare Commercial	$23.10
Rate for Payer: UnitedHealthcare Individual Exchange	$35.00

tranexamic acid 1,000 mg/10 mL (100 mg/mL) solution 10 mL Vial

Facility

$35.00

Service Code	NDC 72485051001
Hospital Revenue Code	250
Min. Negotiated Rate	$19.95
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$24.68
Rate for Payer: Aetna Workers' Compensation	$24.68
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$24.25
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$24.25
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$27.58
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$27.58
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$27.58
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$26.95
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$27.58
Rate for Payer: Cash Price	$35.00
Rate for Payer: Cigna Commercial	$21.42
Rate for Payer: Cigna Medicare Advantage	$19.95
Rate for Payer: Harmony Health CHIP/Medicaid	$22.05
Rate for Payer: Home State Health Plan Exchange	$19.95
Rate for Payer: Humana Medicare	$26.25
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$26.25
Rate for Payer: Provider Network of America Commercial	$28.00
Rate for Payer: UnitedHealthcare Commercial	$23.10
Rate for Payer: UnitedHealthcare Individual Exchange	$35.00

tranexamic acid 1,000 mg/10 mL (100 mg/mL) solution 10 mL Vial

Facility

$35.00

Service Code	NDC 72485051001
Hospital Revenue Code	250
Min. Negotiated Rate	$26.25
Max. Negotiated Rate	$6,053.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$26.25
Rate for Payer: Provider Network of America Commercial	$28.00

Know your out-of-pocket cost for care.

All Charges