Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Allergy Injection POC Multi

Facility

$49.00

Service Code	HCPCS 95117
Hospital Charge Code	3295117
Hospital Revenue Code	761
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$46.55
Rate for Payer: Aetna Commercial	$44.10
Rate for Payer: Humana Medicare Advantage	$20.58
Rate for Payer: UnitedHealthcare Commercial	$46.55
Rate for Payer: UnitedHealthcare Medicaid	$19.60
Rate for Payer: WPPA Medicare Advantage	$29.40

Allergy Injection POC Multi

Facility

$49.00

Service Code	HCPCS 95117
Hospital Charge Code	3295117
Hospital Revenue Code	761
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$44.10
Rate for Payer: UnitedHealthcare Commercial	$46.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Allergy Injection POC Single

Facility

$44.00

Service Code	HCPCS 95115
Hospital Charge Code	3295115
Hospital Revenue Code	761
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$41.80
Rate for Payer: Aetna Commercial	$39.60
Rate for Payer: Humana Medicare Advantage	$18.48
Rate for Payer: UnitedHealthcare Commercial	$41.80
Rate for Payer: UnitedHealthcare Medicaid	$17.60
Rate for Payer: WPPA Medicare Advantage	$26.40

Allergy Injection POC Single

Facility

$44.00

Service Code	HCPCS 95115
Hospital Charge Code	3295115
Hospital Revenue Code	761
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.60
Rate for Payer: UnitedHealthcare Commercial	$41.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Allergy-Shellfish Panel QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552810
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Allergy-Shellfish Panel QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552810
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$12.60

ALLOGENEIC BONE MARROW TRANSPLANT

Facility

$38,441.70

Service Code	MSDRG 014
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$38,441.70
Rate for Payer: UnitedHealthcare Medicaid	$38,441.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

allopurinol 100 mg Tab [HMC]

Facility

$6.50

Service Code	NDC 60687067701
Hospital Charge Code	3804196
Hospital Revenue Code	250
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$6.17
Rate for Payer: Aetna Commercial	$5.85
Rate for Payer: Humana Medicare Advantage	$2.73
Rate for Payer: UnitedHealthcare Commercial	$6.17
Rate for Payer: UnitedHealthcare Medicaid	$2.60
Rate for Payer: WPPA Medicare Advantage	$3.90

allopurinol 100 mg Tab [HMC]

Facility

$6.13

Service Code	NDC 51079020520
Hospital Charge Code	3804196
Hospital Revenue Code	250
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$5.82
Rate for Payer: Aetna Commercial	$5.52
Rate for Payer: Humana Medicare Advantage	$2.57
Rate for Payer: UnitedHealthcare Commercial	$5.82
Rate for Payer: UnitedHealthcare Medicaid	$2.45
Rate for Payer: WPPA Medicare Advantage	$3.68

allopurinol 100 mg Tab [HMC]

Facility

$6.19

Service Code	NDC 00904704161
Hospital Charge Code	3804196
Hospital Revenue Code	250
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$5.88
Rate for Payer: Aetna Commercial	$5.57
Rate for Payer: Humana Medicare Advantage	$2.60
Rate for Payer: UnitedHealthcare Commercial	$5.88
Rate for Payer: UnitedHealthcare Medicaid	$2.48
Rate for Payer: WPPA Medicare Advantage	$3.71

allopurinol 100 mg Tab [HMC]

Facility

$6.19

Service Code	NDC 00904704161
Hospital Charge Code	3804196
Hospital Revenue Code	250
Min. Negotiated Rate	$5.57
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.57
Rate for Payer: UnitedHealthcare Commercial	$5.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

allopurinol 100 mg Tab [HMC]

Facility

$6.13

Service Code	NDC 51079020520
Hospital Charge Code	3804196
Hospital Revenue Code	250
Min. Negotiated Rate	$5.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.52
Rate for Payer: UnitedHealthcare Commercial	$5.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

allopurinol 100 mg Tab [HMC]

Facility

$6.50

Service Code	NDC 60687067701
Hospital Charge Code	3804196
Hospital Revenue Code	250
Min. Negotiated Rate	$5.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.85
Rate for Payer: UnitedHealthcare Commercial	$6.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Almond (F20) IgE QST

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3552820
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$24.70
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$10.92
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$15.60

Almond (F20) IgE QST

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3552820
Hospital Revenue Code	300
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AlOH/diphenhyd/lidocaine/MgOH/simeth Top 3.15 g-0.2 g-1.6 g-3.15 g-0.315 g/237 mL Susp 119mL [HMC]

Facility

$155.80

Service Code	NDC 65628005004
Hospital Charge Code	3804490
Hospital Revenue Code	250
Min. Negotiated Rate	$62.32
Max. Negotiated Rate	$148.01
Rate for Payer: Aetna Commercial	$140.22
Rate for Payer: Humana Medicare Advantage	$65.44
Rate for Payer: UnitedHealthcare Commercial	$148.01
Rate for Payer: UnitedHealthcare Medicaid	$62.32
Rate for Payer: WPPA Medicare Advantage	$93.48

AlOH/diphenhyd/lidocaine/MgOH/simeth Top 3.15 g-0.2 g-1.6 g-3.15 g-0.315 g/237 mL Susp 119mL [HMC]

Facility

$155.80

Service Code	NDC 65628005004
Hospital Charge Code	3804490
Hospital Revenue Code	250
Min. Negotiated Rate	$140.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$140.22
Rate for Payer: UnitedHealthcare Commercial	$148.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AlOH/diphenhyd/lidocaine/MgOH/simeth Top 3.15 g-0.2 g-1.6 g-3.15 g-0.315 g/237 mL Susp [HMC]

Facility

$222.50

Service Code	NDC 65628005001
Hospital Charge Code	3802929
Hospital Revenue Code	250
Min. Negotiated Rate	$89.00
Max. Negotiated Rate	$211.38
Rate for Payer: Aetna Commercial	$200.25
Rate for Payer: Humana Medicare Advantage	$93.45
Rate for Payer: UnitedHealthcare Commercial	$211.38
Rate for Payer: UnitedHealthcare Medicaid	$89.00
Rate for Payer: WPPA Medicare Advantage	$133.50

AlOH/diphenhyd/lidocaine/MgOH/simeth Top 3.15 g-0.2 g-1.6 g-3.15 g-0.315 g/237 mL Susp [HMC]

Facility

$222.50

Service Code	NDC 65628005001
Hospital Charge Code	3802929
Hospital Revenue Code	250
Min. Negotiated Rate	$200.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$200.25
Rate for Payer: UnitedHealthcare Commercial	$211.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Alpha-1-Antitrypsin (AAT) Phenotype QST

Facility

$164.00

Service Code	HCPCS 82104
Hospital Charge Code	3552104
Hospital Revenue Code	300
Min. Negotiated Rate	$13.65
Max. Negotiated Rate	$155.80
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$82.51
Rate for Payer: Humana Medicare Advantage	$68.88
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: UnitedHealthcare Medicaid	$13.65
Rate for Payer: WPPA Medicare Advantage	$98.40

Alpha-1-Antitrypsin (AAT) Phenotype QST

Facility

$164.00

Service Code	HCPCS 82104
Hospital Charge Code	3552104
Hospital Revenue Code	300
Min. Negotiated Rate	$147.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Alpha-1-Antitrypsin Qn QST

Facility

$164.00

Service Code	HCPCS 82104
Hospital Charge Code	3552104
Hospital Revenue Code	300
Min. Negotiated Rate	$147.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Alpha-1-Antitrypsin Qn QST

Facility

$164.00

Service Code	HCPCS 82104
Hospital Charge Code	3552104
Hospital Revenue Code	300
Min. Negotiated Rate	$13.65
Max. Negotiated Rate	$155.80
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$82.51
Rate for Payer: Humana Medicare Advantage	$68.88
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: UnitedHealthcare Medicaid	$13.65
Rate for Payer: WPPA Medicare Advantage	$98.40

Alpha Fetoprotein, Tumor Marker QST

Facility

$91.00

Service Code	HCPCS 82105
Hospital Charge Code	3551278
Hospital Revenue Code	300
Min. Negotiated Rate	$14.25
Max. Negotiated Rate	$86.45
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$55.63
Rate for Payer: Humana Medicare Advantage	$38.22
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: UnitedHealthcare Medicaid	$14.25
Rate for Payer: WPPA Medicare Advantage	$54.60

Alpha Fetoprotein, Tumor Marker QST

Facility

$91.00

Service Code	HCPCS 82105
Hospital Charge Code	3551278
Hospital Revenue Code	300
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges