Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Cardio IQ(R) HS CRP QST

Facility

$102.00

Service Code	HCPCS 86141
Hospital Charge Code	3552470
Hospital Revenue Code	300
Min. Negotiated Rate	$11.01
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$61.27
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$11.01
Rate for Payer: WPPA Medicare Advantage	$61.20

Cardio IQ(R) Lipoprotein (A) QST

Facility

$89.00

Service Code	HCPCS 83698
Hospital Charge Code	3553698
Hospital Revenue Code	300
Min. Negotiated Rate	$37.38
Max. Negotiated Rate	$204.15
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$204.15
Rate for Payer: Humana Medicare Advantage	$37.38
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: UnitedHealthcare Medicaid	$40.82
Rate for Payer: WPPA Medicare Advantage	$53.40

Cardio IQ(R) Lipoprotein (A) QST

Facility

$89.00

Service Code	HCPCS 83698
Hospital Charge Code	3553698
Hospital Revenue Code	300
Min. Negotiated Rate	$80.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cardio IQ(R) LP PLA2 Activity QST

Facility

$105.00

Service Code	HCPCS 83698
Hospital Charge Code	3551792
Hospital Revenue Code	300
Min. Negotiated Rate	$40.82
Max. Negotiated Rate	$204.15
Rate for Payer: Aetna Commercial	$94.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$204.15
Rate for Payer: Humana Medicare Advantage	$44.10
Rate for Payer: UnitedHealthcare Commercial	$99.75
Rate for Payer: UnitedHealthcare Medicaid	$40.82
Rate for Payer: WPPA Medicare Advantage	$63.00

Cardio IQ(R) LP PLA2 Activity QST

Facility

$105.00

Service Code	HCPCS 83698
Hospital Charge Code	3551792
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$94.50
Rate for Payer: UnitedHealthcare Commercial	$99.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cardio IQ(R) Triglycerides QST

Facility

$61.00

Service Code	HCPCS 84478
Hospital Charge Code	3550825
Hospital Revenue Code	300
Min. Negotiated Rate	$54.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.90
Rate for Payer: UnitedHealthcare Commercial	$57.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cardio IQ(R) Triglycerides QST

Facility

$61.00

Service Code	HCPCS 84478
Hospital Charge Code	3550825
Hospital Revenue Code	300
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$57.95
Rate for Payer: Aetna Commercial	$54.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$12.35
Rate for Payer: Humana Medicare Advantage	$25.62
Rate for Payer: UnitedHealthcare Commercial	$57.95
Rate for Payer: UnitedHealthcare Medicaid	$5.74
Rate for Payer: WPPA Medicare Advantage	$36.60

Cardiolipin Ab (IgA,IgG,IgM) QST

Facility

$218.00

Service Code	HCPCS 86147
Hospital Charge Code	3552382
Hospital Revenue Code	300
Min. Negotiated Rate	$25.45
Max. Negotiated Rate	$207.10
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$78.41
Rate for Payer: Humana Medicare Advantage	$91.56
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: UnitedHealthcare Medicaid	$25.45
Rate for Payer: WPPA Medicare Advantage	$130.80

Cardiolipin Ab (IgA,IgG,IgM) QST

Facility

$218.00

Service Code	HCPCS 86147
Hospital Charge Code	3552382
Hospital Revenue Code	300
Min. Negotiated Rate	$196.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

carisoprodol 350 mg Tab [HMC]

Facility

$6.79

Service Code	NDC 50228010901
Hospital Charge Code	3807274
Hospital Revenue Code	250
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.11
Rate for Payer: UnitedHealthcare Commercial	$6.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

carisoprodol 350 mg Tab [HMC]

Facility

$6.79

Service Code	NDC 50228010901
Hospital Charge Code	3807274
Hospital Revenue Code	250
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$6.45
Rate for Payer: Aetna Commercial	$6.11
Rate for Payer: Humana Medicare Advantage	$2.85
Rate for Payer: UnitedHealthcare Commercial	$6.45
Rate for Payer: UnitedHealthcare Medicaid	$2.72
Rate for Payer: WPPA Medicare Advantage	$4.07

carisoprodol 350 mg Tab [HMC]

Facility

$6.79

Service Code	NDC 69584011110
Hospital Charge Code	3807274
Hospital Revenue Code	250
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$6.45
Rate for Payer: Aetna Commercial	$6.11
Rate for Payer: Humana Medicare Advantage	$2.85
Rate for Payer: UnitedHealthcare Commercial	$6.45
Rate for Payer: UnitedHealthcare Medicaid	$2.72
Rate for Payer: WPPA Medicare Advantage	$4.07

carisoprodol 350 mg Tab [HMC]

Facility

$6.79

Service Code	NDC 69584011110
Hospital Charge Code	3807274
Hospital Revenue Code	250
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.11
Rate for Payer: UnitedHealthcare Commercial	$6.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Carnitine, LC/MS/MS QST

Facility

$258.00

Service Code	HCPCS 82379
Hospital Charge Code	3555379
Hospital Revenue Code	300
Min. Negotiated Rate	$16.87
Max. Negotiated Rate	$245.10
Rate for Payer: Aetna Commercial	$232.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$193.77
Rate for Payer: Humana Medicare Advantage	$108.36
Rate for Payer: UnitedHealthcare Commercial	$245.10
Rate for Payer: UnitedHealthcare Medicaid	$16.87
Rate for Payer: WPPA Medicare Advantage	$154.80

Carnitine, LC/MS/MS QST

Facility

$258.00

Service Code	HCPCS 82379
Hospital Charge Code	3555379
Hospital Revenue Code	300
Min. Negotiated Rate	$232.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$232.20
Rate for Payer: UnitedHealthcare Commercial	$245.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CAROTID ARTERY STENT PROCEDURES WITH CC

Facility

$8,704.98

Service Code	MSDRG 035
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,704.98
Rate for Payer: UnitedHealthcare Medicaid	$8,704.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CAROTID ARTERY STENT PROCEDURES WITH MCC

Facility

$14,074.11

Service Code	MSDRG 034
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,074.11
Rate for Payer: UnitedHealthcare Medicaid	$14,074.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC

Facility

$7,084.71

Service Code	MSDRG 036
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,084.71
Rate for Payer: UnitedHealthcare Medicaid	$7,084.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Carter Thomason SG w/o Trocars Suture Grasper

Facility

$312.38

Hospital Charge Code	3257431
Hospital Revenue Code	270
Min. Negotiated Rate	$281.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$281.14
Rate for Payer: UnitedHealthcare Commercial	$296.76
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Carter Thomason SG w/o Trocars Suture Grasper

Facility

$312.38

Hospital Charge Code	3257431
Hospital Revenue Code	270
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$296.76
Rate for Payer: Aetna Commercial	$281.14
Rate for Payer: Humana Medicare Advantage	$131.20
Rate for Payer: UnitedHealthcare Commercial	$296.76
Rate for Payer: UnitedHealthcare Medicaid	$124.95
Rate for Payer: WPPA Medicare Advantage	$187.43

Carter Thomason SG w/Trocars Suture Grasper

Facility

$280.00

Hospital Charge Code	3257430
Hospital Revenue Code	270
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$252.00
Rate for Payer: UnitedHealthcare Commercial	$266.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Carter Thomason SG w/Trocars Suture Grasper

Facility

$280.00

Hospital Charge Code	3257430
Hospital Revenue Code	270
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$266.00
Rate for Payer: Aetna Commercial	$252.00
Rate for Payer: Humana Medicare Advantage	$117.60
Rate for Payer: UnitedHealthcare Commercial	$266.00
Rate for Payer: UnitedHealthcare Medicaid	$112.00
Rate for Payer: WPPA Medicare Advantage	$168.00

carvedilol 25 mg Tab [HMC]

Facility

$11.30

Service Code	NDC 00904630361
Hospital Charge Code	3802101
Hospital Revenue Code	250
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$10.73
Rate for Payer: Aetna Commercial	$10.17
Rate for Payer: Humana Medicare Advantage	$4.75
Rate for Payer: UnitedHealthcare Commercial	$10.73
Rate for Payer: UnitedHealthcare Medicaid	$4.52
Rate for Payer: WPPA Medicare Advantage	$6.78

carvedilol 25 mg Tab [HMC]

Facility

$5.33

Service Code	NDC 00904730861
Hospital Charge Code	3802101
Hospital Revenue Code	250
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.80
Rate for Payer: UnitedHealthcare Commercial	$5.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

carvedilol 25 mg Tab [HMC]

Facility

$5.33

Service Code	NDC 00904730861
Hospital Charge Code	3802101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$5.06
Rate for Payer: Aetna Commercial	$4.80
Rate for Payer: Humana Medicare Advantage	$2.24
Rate for Payer: UnitedHealthcare Commercial	$5.06
Rate for Payer: UnitedHealthcare Medicaid	$2.13
Rate for Payer: WPPA Medicare Advantage	$3.20

Know your out-of-pocket cost for care.

All Charges