Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

CA 15-3 QST

Facility

$45.00

Service Code	HCPCS 86300
Hospital Charge Code	3555819
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$54.84
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.84
Rate for Payer: Humana Medicare Advantage	$18.90
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: UnitedHealthcare Medicaid	$20.81
Rate for Payer: WPPA Medicare Advantage	$27.00

CA 15-3 QST

Facility

$45.00

Service Code	HCPCS 86300
Hospital Charge Code	3555819
Hospital Revenue Code	300
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CA 19-9 QST

Facility

$60.00

Service Code	HCPCS 86301
Hospital Charge Code	3556395
Hospital Revenue Code	300
Min. Negotiated Rate	$20.81
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.51
Rate for Payer: Humana Medicare Advantage	$25.20
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: UnitedHealthcare Medicaid	$20.81
Rate for Payer: WPPA Medicare Advantage	$36.00

CA 19-9 QST

Facility

$60.00

Service Code	HCPCS 86301
Hospital Charge Code	3556395
Hospital Revenue Code	300
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CA 27.29 QST

Facility

$122.00

Service Code	HCPCS 86300
Hospital Charge Code	3552425
Hospital Revenue Code	300
Min. Negotiated Rate	$109.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CA 27.29 QST

Facility

$122.00

Service Code	HCPCS 86300
Hospital Charge Code	3552425
Hospital Revenue Code	300
Min. Negotiated Rate	$20.81
Max. Negotiated Rate	$115.90
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.84
Rate for Payer: Humana Medicare Advantage	$51.24
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: UnitedHealthcare Medicaid	$20.81
Rate for Payer: WPPA Medicare Advantage	$73.20

Caffeine 200 mg Tab [HMC]

Facility

$5.00

Service Code	NDC 62011034010
Hospital Charge Code	3800297
Hospital Revenue Code	250
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Caffeine 200 mg Tab [HMC]

Facility

$5.00

Service Code	NDC 62011034010
Hospital Charge Code	3800297
Hospital Revenue Code	250
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: Humana Medicare Advantage	$2.10
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: UnitedHealthcare Medicaid	$2.00
Rate for Payer: WPPA Medicare Advantage	$3.00

calcitonin 200 intl units/inh Nasal Spry 3.7 mL [HMC]

Facility

$180.03

Service Code	NDC 60505082306
Hospital Charge Code	3801996
Hospital Revenue Code	250
Min. Negotiated Rate	$72.01
Max. Negotiated Rate	$171.03
Rate for Payer: Aetna Commercial	$162.03
Rate for Payer: Humana Medicare Advantage	$75.61
Rate for Payer: UnitedHealthcare Commercial	$171.03
Rate for Payer: UnitedHealthcare Medicaid	$72.01
Rate for Payer: WPPA Medicare Advantage	$108.02

calcitonin 200 intl units/inh Nasal Spry 3.7 mL [HMC]

Facility

$180.03

Service Code	NDC 60505082306
Hospital Charge Code	3801996
Hospital Revenue Code	250
Min. Negotiated Rate	$162.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$162.03
Rate for Payer: UnitedHealthcare Commercial	$171.03
Rate for Payer: WPPA Medicare Advantage	$1,200.00

calcitonin 200 intl units/inh Nasal Spry 3.7 mL [HMC]

Facility

$180.03

Service Code	NDC 49884016111
Hospital Charge Code	3801996
Hospital Revenue Code	250
Min. Negotiated Rate	$72.01
Max. Negotiated Rate	$171.03
Rate for Payer: Aetna Commercial	$162.03
Rate for Payer: Humana Medicare Advantage	$75.61
Rate for Payer: UnitedHealthcare Commercial	$171.03
Rate for Payer: UnitedHealthcare Medicaid	$72.01
Rate for Payer: WPPA Medicare Advantage	$108.02

calcitonin 200 intl units/inh Nasal Spry 3.7 mL [HMC]

Facility

$180.03

Service Code	NDC 49884016111
Hospital Charge Code	3801996
Hospital Revenue Code	250
Min. Negotiated Rate	$162.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$162.03
Rate for Payer: UnitedHealthcare Commercial	$171.03
Rate for Payer: WPPA Medicare Advantage	$1,200.00

calcitonin 200 intl units/inh Nasal Spry [HMC]

Facility

$462.51

Service Code	NDC 00078031154
Hospital Charge Code	3801996
Hospital Revenue Code	250
Min. Negotiated Rate	$416.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$416.26
Rate for Payer: UnitedHealthcare Commercial	$439.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

calcitonin 200 intl units/inh Nasal Spry [HMC]

Facility

$462.51

Service Code	NDC 00078031154
Hospital Charge Code	3801996
Hospital Revenue Code	250
Min. Negotiated Rate	$185.00
Max. Negotiated Rate	$439.38
Rate for Payer: Aetna Commercial	$416.26
Rate for Payer: Humana Medicare Advantage	$194.25
Rate for Payer: UnitedHealthcare Commercial	$439.38
Rate for Payer: UnitedHealthcare Medicaid	$185.00
Rate for Payer: WPPA Medicare Advantage	$277.51

Calcitonin QST

Facility

$162.00

Service Code	HCPCS 82308
Hospital Charge Code	3550742
Hospital Revenue Code	300
Min. Negotiated Rate	$145.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$145.80
Rate for Payer: UnitedHealthcare Commercial	$153.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Calcitonin QST

Facility

$162.00

Service Code	HCPCS 82308
Hospital Charge Code	3550742
Hospital Revenue Code	300
Min. Negotiated Rate	$22.77
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna Commercial	$145.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$102.28
Rate for Payer: Humana Medicare Advantage	$68.04
Rate for Payer: UnitedHealthcare Commercial	$153.90
Rate for Payer: UnitedHealthcare Medicaid	$22.77
Rate for Payer: WPPA Medicare Advantage	$97.20

calcitriol 0.25 mcg Oral Cap [HMC]

Facility

$7.66

Service Code	NDC 60687034501
Hospital Charge Code	3806369
Hospital Revenue Code	250
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$7.28
Rate for Payer: Aetna Commercial	$6.89
Rate for Payer: Humana Medicare Advantage	$3.22
Rate for Payer: UnitedHealthcare Commercial	$7.28
Rate for Payer: UnitedHealthcare Medicaid	$3.06
Rate for Payer: WPPA Medicare Advantage	$4.60

calcitriol 0.25 mcg Oral Cap [HMC]

Facility

$8.84

Service Code	NDC 00054000713
Hospital Charge Code	3806369
Hospital Revenue Code	250
Min. Negotiated Rate	$7.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.96
Rate for Payer: UnitedHealthcare Commercial	$8.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

calcitriol 0.25 mcg Oral Cap [HMC]

Facility

$7.66

Service Code	NDC 60687034501
Hospital Charge Code	3806369
Hospital Revenue Code	250
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.89
Rate for Payer: UnitedHealthcare Commercial	$7.28
Rate for Payer: WPPA Medicare Advantage	$1,200.00

calcitriol 0.25 mcg Oral Cap [HMC]

Facility

$8.84

Service Code	NDC 00054000713
Hospital Charge Code	3806369
Hospital Revenue Code	250
Min. Negotiated Rate	$3.54
Max. Negotiated Rate	$8.40
Rate for Payer: Aetna Commercial	$7.96
Rate for Payer: Humana Medicare Advantage	$3.71
Rate for Payer: UnitedHealthcare Commercial	$8.40
Rate for Payer: UnitedHealthcare Medicaid	$3.54
Rate for Payer: WPPA Medicare Advantage	$5.30

Calcitriol(1,25 di-OH Vit D) LC

Facility

$166.00

Service Code	HCPCS 82652
Hospital Charge Code	3552652
Hospital Revenue Code	300
Min. Negotiated Rate	$66.40
Max. Negotiated Rate	$157.70
Rate for Payer: Aetna Commercial	$149.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$88.45
Rate for Payer: Humana Medicare Advantage	$69.72
Rate for Payer: UnitedHealthcare Commercial	$157.70
Rate for Payer: UnitedHealthcare Medicaid	$66.40
Rate for Payer: WPPA Medicare Advantage	$99.60

Calcitriol(1,25 di-OH Vit D) LC

Facility

$166.00

Service Code	HCPCS 82652
Hospital Charge Code	3552652
Hospital Revenue Code	300
Min. Negotiated Rate	$149.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$149.40
Rate for Payer: UnitedHealthcare Commercial	$157.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

calcium carbonate 750 mg Chew Tab [HMC]

Facility

$5.48

Service Code	NDC 00135045603
Hospital Charge Code	3809271
Hospital Revenue Code	250
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$5.21
Rate for Payer: Aetna Commercial	$4.93
Rate for Payer: Humana Medicare Advantage	$2.30
Rate for Payer: UnitedHealthcare Commercial	$5.21
Rate for Payer: UnitedHealthcare Medicaid	$2.19
Rate for Payer: WPPA Medicare Advantage	$3.29

calcium carbonate 750 mg Chew Tab [HMC]

Facility

$5.24

Service Code	NDC 00135024302
Hospital Charge Code	3809271
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.98
Rate for Payer: Aetna Commercial	$4.72
Rate for Payer: Humana Medicare Advantage	$2.20
Rate for Payer: UnitedHealthcare Commercial	$4.98
Rate for Payer: UnitedHealthcare Medicaid	$2.10
Rate for Payer: WPPA Medicare Advantage	$3.14

calcium carbonate 750 mg Chew Tab [HMC]

Facility

$5.24

Service Code	NDC 00135024302
Hospital Charge Code	3809271
Hospital Revenue Code	250
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.72
Rate for Payer: UnitedHealthcare Commercial	$4.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges