Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

ChemoLock_x0099_ Port

Facility

$10.94

Hospital Charge Code	3253576
Hospital Revenue Code	270
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.85
Rate for Payer: UnitedHealthcare Commercial	$10.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ChemoLock_x0099_ Port

Facility

$10.94

Hospital Charge Code	3253576
Hospital Revenue Code	270
Min. Negotiated Rate	$4.38
Max. Negotiated Rate	$10.39
Rate for Payer: Aetna Commercial	$9.85
Rate for Payer: Humana Medicare Advantage	$4.59
Rate for Payer: UnitedHealthcare Commercial	$10.39
Rate for Payer: UnitedHealthcare Medicaid	$4.38
Rate for Payer: WPPA Medicare Advantage	$6.56

ChemoLock_x0099_ Universal Vented Vial Spike

Facility

$16.70

Hospital Charge Code	3253565
Hospital Revenue Code	270
Min. Negotiated Rate	$15.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.03
Rate for Payer: UnitedHealthcare Commercial	$15.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ChemoLock_x0099_ Universal Vented Vial Spike

Facility

$16.70

Hospital Charge Code	3253565
Hospital Revenue Code	270
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$15.87
Rate for Payer: Aetna Commercial	$15.03
Rate for Payer: Humana Medicare Advantage	$7.01
Rate for Payer: UnitedHealthcare Commercial	$15.87
Rate for Payer: UnitedHealthcare Medicaid	$6.68
Rate for Payer: WPPA Medicare Advantage	$10.02

ChemoLock_x0099_ Vented Vial Spike, 13mm

Facility

$17.19

Hospital Charge Code	3253567
Hospital Revenue Code	270
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$16.33
Rate for Payer: Aetna Commercial	$15.47
Rate for Payer: Humana Medicare Advantage	$7.22
Rate for Payer: UnitedHealthcare Commercial	$16.33
Rate for Payer: UnitedHealthcare Medicaid	$6.88
Rate for Payer: WPPA Medicare Advantage	$10.31

ChemoLock_x0099_ Vented Vial Spike, 13mm

Facility

$17.19

Hospital Charge Code	3253567
Hospital Revenue Code	270
Min. Negotiated Rate	$15.47
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.47
Rate for Payer: UnitedHealthcare Commercial	$16.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ChemoLock_x0099_ w/Red Cap

Facility

$17.69

Hospital Charge Code	3253564
Hospital Revenue Code	270
Min. Negotiated Rate	$15.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.92
Rate for Payer: UnitedHealthcare Commercial	$16.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ChemoLock_x0099_ w/Red Cap

Facility

$17.69

Hospital Charge Code	3253564
Hospital Revenue Code	270
Min. Negotiated Rate	$7.08
Max. Negotiated Rate	$16.81
Rate for Payer: Aetna Commercial	$15.92
Rate for Payer: Humana Medicare Advantage	$7.43
Rate for Payer: UnitedHealthcare Commercial	$16.81
Rate for Payer: UnitedHealthcare Medicaid	$7.08
Rate for Payer: WPPA Medicare Advantage	$10.61

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC

Facility

$8,133.12

Service Code	MSDRG 837
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,133.12
Rate for Payer: UnitedHealthcare Medicaid	$8,133.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT

Facility

$7,751.88

Service Code	MSDRG 838
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,751.88
Rate for Payer: UnitedHealthcare Medicaid	$7,751.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$7,370.64

Service Code	MSDRG 839
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,370.64
Rate for Payer: UnitedHealthcare Medicaid	$7,370.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC

Facility

$4,670.19

Service Code	MSDRG 847
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,670.19
Rate for Payer: UnitedHealthcare Medicaid	$4,670.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC

Facility

$7,783.65

Service Code	MSDRG 846
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,783.65
Rate for Payer: UnitedHealthcare Medicaid	$7,783.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$2,541.60

Service Code	MSDRG 848
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,541.60
Rate for Payer: UnitedHealthcare Medicaid	$2,541.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chest Drain Oasis Dry Suction Control

Facility

$136.54

Hospital Charge Code	3256505
Hospital Revenue Code	270
Min. Negotiated Rate	$122.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$122.89
Rate for Payer: UnitedHealthcare Commercial	$129.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chest Drain Oasis Dry Suction Control

Facility

$136.54

Hospital Charge Code	3256505
Hospital Revenue Code	270
Min. Negotiated Rate	$54.62
Max. Negotiated Rate	$129.71
Rate for Payer: Aetna Commercial	$122.89
Rate for Payer: Humana Medicare Advantage	$57.35
Rate for Payer: UnitedHealthcare Commercial	$129.71
Rate for Payer: UnitedHealthcare Medicaid	$54.62
Rate for Payer: WPPA Medicare Advantage	$81.92

CHEST PAIN

Facility

$3,145.23

Service Code	MSDRG 313
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,145.23
Rate for Payer: UnitedHealthcare Medicaid	$3,145.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chest Tube 12 fr Thoracic Soft PVC

Facility

$25.52

Hospital Charge Code	3250194
Hospital Revenue Code	270
Min. Negotiated Rate	$22.97
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.97
Rate for Payer: UnitedHealthcare Commercial	$24.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chest Tube 12 fr Thoracic Soft PVC

Facility

$25.52

Hospital Charge Code	3250194
Hospital Revenue Code	270
Min. Negotiated Rate	$10.21
Max. Negotiated Rate	$24.24
Rate for Payer: Aetna Commercial	$22.97
Rate for Payer: Humana Medicare Advantage	$10.72
Rate for Payer: UnitedHealthcare Commercial	$24.24
Rate for Payer: UnitedHealthcare Medicaid	$10.21
Rate for Payer: WPPA Medicare Advantage	$15.31

Chest Tube 28 fr Thoracic Soft PVC

Facility

$27.45

Hospital Charge Code	3250195
Hospital Revenue Code	270
Min. Negotiated Rate	$24.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: UnitedHealthcare Commercial	$26.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chest Tube 28 fr Thoracic Soft PVC

Facility

$27.45

Hospital Charge Code	3250195
Hospital Revenue Code	270
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$26.08
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Humana Medicare Advantage	$11.53
Rate for Payer: UnitedHealthcare Commercial	$26.08
Rate for Payer: UnitedHealthcare Medicaid	$10.98
Rate for Payer: WPPA Medicare Advantage	$16.47

Chest Tube 32fr Thoracic Soft PVC

Facility

$23.00

Hospital Charge Code	3250196
Hospital Revenue Code	270
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.70
Rate for Payer: UnitedHealthcare Commercial	$21.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chest Tube 32fr Thoracic Soft PVC

Facility

$23.00

Hospital Charge Code	3250196
Hospital Revenue Code	270
Min. Negotiated Rate	$9.20
Max. Negotiated Rate	$21.85
Rate for Payer: Aetna Commercial	$20.70
Rate for Payer: Humana Medicare Advantage	$9.66
Rate for Payer: UnitedHealthcare Commercial	$21.85
Rate for Payer: UnitedHealthcare Medicaid	$9.20
Rate for Payer: WPPA Medicare Advantage	$13.80

Chest Tube 36fr Thoracic

Facility

$23.85

Hospital Charge Code	3250190
Hospital Revenue Code	270
Min. Negotiated Rate	$9.54
Max. Negotiated Rate	$22.66
Rate for Payer: Aetna Commercial	$21.46
Rate for Payer: Humana Medicare Advantage	$10.02
Rate for Payer: UnitedHealthcare Commercial	$22.66
Rate for Payer: UnitedHealthcare Medicaid	$9.54
Rate for Payer: WPPA Medicare Advantage	$14.31

Chest Tube 36fr Thoracic

Facility

$23.85

Hospital Charge Code	3250190
Hospital Revenue Code	270
Min. Negotiated Rate	$21.46
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.46
Rate for Payer: UnitedHealthcare Commercial	$22.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges