Ray County Hospital

All Charges

Charge

Type

Setting

Price

ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA

Facility

$6,053.00

Service Code	MSDRG 894
Min. Negotiated Rate	$875.00
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: 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	$2,899.43

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC

Facility

$8,201.97

Service Code	MSDRG 896
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$8,201.97
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	$8,201.97

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC

Facility

$6,053.00

Service Code	MSDRG 897
Min. Negotiated Rate	$875.00
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: 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	$4,149.16

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY

Facility

$6,653.32

Service Code	MSDRG 895
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,653.32
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	$6,653.32

ALCOHOLIC LIVER DISEASE

Facility

$13,749.45

Service Code	APR-DRG 2803
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$13,749.45
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	$13,749.45
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$13,749.45
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$13,749.45
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$13,749.45

ALCOHOLIC LIVER DISEASE

Facility

$27,477.63

Service Code	APR-DRG 2804
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$27,477.63
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	$27,477.63
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$27,477.63
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$27,477.63
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$27,477.63

ALCOHOLIC LIVER DISEASE

Facility

$6,362.54

Service Code	APR-DRG 2801
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,362.54
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	$6,362.54
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$6,362.54
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$6,362.54
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$6,362.54

ALCOHOLIC LIVER DISEASE

Facility

$8,705.27

Service Code	APR-DRG 2802
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$8,705.27
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: Family Health Partners Medicaid	$8,705.27
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$8,705.27
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$8,705.27
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$8,705.27

Allergen Spec Ige Crude Allergen Extract Each - Food Panel

Facility

$224.36

Service Code	CPT 86003
Hospital Charge Code	Px30286003001
Hospital Revenue Code	302
Min. Negotiated Rate	$168.27
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	$224.36
Rate for Payer: Cash Price	$224.36
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	$168.27
Rate for Payer: Provider Network of America Commercial	$179.49

Allergen Spec Ige Crude Allergen Extract Each - Food Panel

Facility

$224.36

Service Code	CPT 86003
Hospital Charge Code	Px30286003001
Hospital Revenue Code	302
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$179.49
Rate for Payer: Aetna Commercial/Medicare Advantage	$158.17
Rate for Payer: Aetna Workers' Compensation	$158.17
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$155.48
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$155.48
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$176.80
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$176.80
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$176.80
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$172.76
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$176.80
Rate for Payer: Cash Price	$224.36
Rate for Payer: Cash Price	$224.36
Rate for Payer: Cigna Commercial	$117.56
Rate for Payer: Cigna Medicare Advantage	$127.89
Rate for Payer: Family Health Partners Medicaid	$6.58
Rate for Payer: Harmony Health CHIP/Medicaid	$141.35
Rate for Payer: Healthy Blue Medicaid	$7.11
Rate for Payer: Home State Health Plan Exchange	$127.89
Rate for Payer: Home State Health Plan Medicaid	$6.58
Rate for Payer: Humana Medicare	$168.27
Rate for Payer: Mercy CarePlus Medicaid	$6.58
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$168.27
Rate for Payer: Provider Network of America Commercial	$179.49
Rate for Payer: UnitedHealthcare Commercial	$148.08
Rate for Payer: UnitedHealthcare Individual Exchange	$5.22
Rate for Payer: UnitedHealthcare Medicaid	$4.95

ALLERGIC REACTIONS

Facility

$22,528.68

Service Code	APR-DRG 8114
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$22,528.68
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	$22,528.68
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$22,528.68
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$22,528.68
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$22,528.68

ALLERGIC REACTIONS

Facility

$6,053.00

Service Code	APR-DRG 8111
Min. Negotiated Rate	$875.00
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: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$3,848.77
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$3,848.77
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$3,848.77
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$3,848.77

ALLERGIC REACTIONS

Facility

$6,053.00

Service Code	APR-DRG 8112
Min. Negotiated Rate	$875.00
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: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$5,623.85
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$5,623.85
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$5,623.85
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$5,623.85

ALLERGIC REACTIONS

Facility

$10,917.64

Service Code	APR-DRG 8113
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$10,917.64
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	$10,917.64
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$10,917.64
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$10,917.64
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$10,917.64

ALLERGIC REACTIONS WITH MCC

Facility

$7,903.52

Service Code	MSDRG 915
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$7,903.52
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	$7,903.52

ALLERGIC REACTIONS WITHOUT MCC

Facility

$6,053.00

Service Code	MSDRG 916
Min. Negotiated Rate	$875.00
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: 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	$3,131.61

ALLOGENEIC BONE MARROW TRANSPLANT

Facility

$56,484.13

Service Code	MSDRG 014
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$56,484.13
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	$56,484.13

ALLOGENEIC BONE MARROW TRANSPLANT

Facility

$122,842.69

Service Code	APR-DRG 0073
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$122,842.69
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	$122,842.69
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$122,842.69
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$122,842.69
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$122,842.69

ALLOGENEIC BONE MARROW TRANSPLANT

Facility

$83,981.46

Service Code	APR-DRG 0072
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$83,981.46
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: Family Health Partners Medicaid	$83,981.46
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$83,981.46
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$83,981.46
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$83,981.46

ALLOGENEIC BONE MARROW TRANSPLANT

Facility

$70,746.97

Service Code	APR-DRG 0071
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$70,746.97
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	$70,746.97
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$70,746.97
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$70,746.97
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$70,746.97

ALLOGENEIC BONE MARROW TRANSPLANT

Facility

$215,347.29

Service Code	APR-DRG 0074
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$215,347.29
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	$215,347.29
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$215,347.29
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$215,347.29
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$215,347.29

allopurinol 100 mg tablet 100 Each BLIST PACK

Facility

$4.00

Service Code	NDC 00904704161
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

allopurinol 100 mg tablet 100 Each BLIST PACK

Facility

$4.00

Service Code	NDC 00904704161
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

allopurinol 100 mg tablet 100 Each BLIST PACK

Facility

$4.00

Service Code	NDC 60687067701
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

allopurinol 100 mg tablet 100 Each BLIST PACK

Facility

$4.00

Service Code	NDC 60687067701
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

Know your out-of-pocket cost for care.

All Charges