Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Chicken Meat (F83) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552803
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

Chicken Meat (F83) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552803
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

CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES

Facility

$138,104.19

Service Code	MSDRG 018
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$138,104.19
Rate for Payer: UnitedHealthcare Medicaid	$138,104.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chlamydia trachomatis DNA -GeneXpert

Facility

$249.00

Service Code	HCPCS 87491
Hospital Charge Code	3551724
Hospital Revenue Code	300
Min. Negotiated Rate	$224.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$224.10
Rate for Payer: UnitedHealthcare Commercial	$236.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chlamydia trachomatis DNA -GeneXpert

Facility

$249.00

Service Code	HCPCS 87491
Hospital Charge Code	3551724
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$236.55
Rate for Payer: Aetna Commercial	$224.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$75.32
Rate for Payer: Humana Medicare Advantage	$104.58
Rate for Payer: UnitedHealthcare Commercial	$236.55
Rate for Payer: UnitedHealthcare Medicaid	$35.09
Rate for Payer: WPPA Medicare Advantage	$149.40

chloraseptic lozenge 6mg-10mg [HMC]

Facility

$5.77

Service Code	NDC 78112001106
Hospital Charge Code	3800858
Hospital Revenue Code	257
Min. Negotiated Rate	$5.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.19
Rate for Payer: UnitedHealthcare Commercial	$5.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

chloraseptic lozenge 6mg-10mg [HMC]

Facility

$5.77

Service Code	NDC 78112001106
Hospital Charge Code	3800858
Hospital Revenue Code	257
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$5.48
Rate for Payer: Aetna Commercial	$5.19
Rate for Payer: Humana Medicare Advantage	$2.42
Rate for Payer: UnitedHealthcare Commercial	$5.48
Rate for Payer: UnitedHealthcare Medicaid	$2.31
Rate for Payer: WPPA Medicare Advantage	$3.46

chlordiazePOXIDE 25 mg Cap [HMC]

Facility

$7.38

Service Code	NDC 60687080701
Hospital Charge Code	3804826
Hospital Revenue Code	250
Min. Negotiated Rate	$6.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.64
Rate for Payer: UnitedHealthcare Commercial	$7.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

chlordiazePOXIDE 25 mg Cap [HMC]

Facility

$7.01

Service Code	NDC 51079014120
Hospital Charge Code	3804826
Hospital Revenue Code	250
Min. Negotiated Rate	$6.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.31
Rate for Payer: UnitedHealthcare Commercial	$6.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

chlordiazePOXIDE 25 mg Cap [HMC]

Facility

$7.01

Service Code	NDC 51079014120
Hospital Charge Code	3804826
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$6.66
Rate for Payer: Aetna Commercial	$6.31
Rate for Payer: Humana Medicare Advantage	$2.94
Rate for Payer: UnitedHealthcare Commercial	$6.66
Rate for Payer: UnitedHealthcare Medicaid	$2.80
Rate for Payer: WPPA Medicare Advantage	$4.21

chlordiazePOXIDE 25 mg Cap [HMC]

Facility

$7.38

Service Code	NDC 60687080701
Hospital Charge Code	3804826
Hospital Revenue Code	250
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$7.01
Rate for Payer: Aetna Commercial	$6.64
Rate for Payer: Humana Medicare Advantage	$3.10
Rate for Payer: UnitedHealthcare Commercial	$7.01
Rate for Payer: UnitedHealthcare Medicaid	$2.95
Rate for Payer: WPPA Medicare Advantage	$4.43

chlorhexidine Top 4% Soap [HMC]

Facility

$33.98

Service Code	NDC 67618020004
Hospital Charge Code	3807969
Hospital Revenue Code	250
Min. Negotiated Rate	$13.59
Max. Negotiated Rate	$32.28
Rate for Payer: Aetna Commercial	$30.58
Rate for Payer: Humana Medicare Advantage	$14.27
Rate for Payer: UnitedHealthcare Commercial	$32.28
Rate for Payer: UnitedHealthcare Medicaid	$13.59
Rate for Payer: WPPA Medicare Advantage	$20.39

chlorhexidine Top 4% Soap [HMC]

Facility

$33.98

Service Code	NDC 67618020004
Hospital Charge Code	3807969
Hospital Revenue Code	250
Min. Negotiated Rate	$30.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.58
Rate for Payer: UnitedHealthcare Commercial	$32.28
Rate for Payer: WPPA Medicare Advantage	$1,200.00

chlorhexidine Top 4% Soap [HMC]

Facility

$29.01

Service Code	NDC 00234057504
Hospital Charge Code	3807969
Hospital Revenue Code	250
Min. Negotiated Rate	$26.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.11
Rate for Payer: UnitedHealthcare Commercial	$27.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

chlorhexidine Top 4% Soap [HMC]

Facility

$29.01

Service Code	NDC 00234057504
Hospital Charge Code	3807969
Hospital Revenue Code	250
Min. Negotiated Rate	$11.60
Max. Negotiated Rate	$27.56
Rate for Payer: Aetna Commercial	$26.11
Rate for Payer: Humana Medicare Advantage	$12.18
Rate for Payer: UnitedHealthcare Commercial	$27.56
Rate for Payer: UnitedHealthcare Medicaid	$11.60
Rate for Payer: WPPA Medicare Advantage	$17.41

chlorhexidine topical 0.12% Liq

Facility

$20.05

Service Code	NDC 00116200116
Hospital Charge Code	3804141
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$19.05
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Humana Medicare Advantage	$8.42
Rate for Payer: UnitedHealthcare Commercial	$19.05
Rate for Payer: UnitedHealthcare Medicaid	$8.02
Rate for Payer: WPPA Medicare Advantage	$12.03

chlorhexidine topical 0.12% Liq

Facility

$20.05

Service Code	NDC 00116200116
Hospital Charge Code	3804141
Hospital Revenue Code	250
Min. Negotiated Rate	$18.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: UnitedHealthcare Commercial	$19.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chloride Level

Facility

$7.00

Service Code	HCPCS 82435
Hospital Charge Code	3550239
Hospital Revenue Code	300
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$9.87
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$9.87
Rate for Payer: Humana Medicare Advantage	$2.94
Rate for Payer: UnitedHealthcare Commercial	$6.65
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: WPPA Medicare Advantage	$4.20

Chloride Level

Facility

$7.00

Service Code	HCPCS 82435
Hospital Charge Code	3550239
Hospital Revenue Code	300
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: UnitedHealthcare Commercial	$6.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chloride U w/o Creatinine QST

Facility

$62.00

Service Code	HCPCS 82436
Hospital Charge Code	3552436
Hospital Revenue Code	300
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$55.80
Rate for Payer: UnitedHealthcare Commercial	$58.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chloride U w/o Creatinine QST

Facility

$62.00

Service Code	HCPCS 82436
Hospital Charge Code	3552436
Hospital Revenue Code	300
Min. Negotiated Rate	$4.89
Max. Negotiated Rate	$58.90
Rate for Payer: Aetna Commercial	$55.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$20.82
Rate for Payer: Humana Medicare Advantage	$26.04
Rate for Payer: UnitedHealthcare Commercial	$58.90
Rate for Payer: UnitedHealthcare Medicaid	$4.89
Rate for Payer: WPPA Medicare Advantage	$37.20

chlorpheniramine-HYDROcodone 8 mg-10 mg/5 mL Oral Susp, ER 115 mL [HMC]

Facility

$244.02

Service Code	NDC 53014054801
Hospital Charge Code	3807655
Hospital Revenue Code	250
Min. Negotiated Rate	$219.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$219.62
Rate for Payer: UnitedHealthcare Commercial	$231.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

chlorpheniramine-HYDROcodone 8 mg-10 mg/5 mL Oral Susp, ER 115 mL [HMC]

Facility

$113.90

Service Code	NDC 62175049064
Hospital Charge Code	3807655
Hospital Revenue Code	250
Min. Negotiated Rate	$45.56
Max. Negotiated Rate	$108.20
Rate for Payer: Aetna Commercial	$102.51
Rate for Payer: Humana Medicare Advantage	$47.84
Rate for Payer: UnitedHealthcare Commercial	$108.20
Rate for Payer: UnitedHealthcare Medicaid	$45.56
Rate for Payer: WPPA Medicare Advantage	$68.34

chlorpheniramine-HYDROcodone 8 mg-10 mg/5 mL Oral Susp, ER 115 mL [HMC]

Facility

$244.02

Service Code	NDC 53014054801
Hospital Charge Code	3807655
Hospital Revenue Code	250
Min. Negotiated Rate	$97.61
Max. Negotiated Rate	$231.82
Rate for Payer: Aetna Commercial	$219.62
Rate for Payer: Humana Medicare Advantage	$102.49
Rate for Payer: UnitedHealthcare Commercial	$231.82
Rate for Payer: UnitedHealthcare Medicaid	$97.61
Rate for Payer: WPPA Medicare Advantage	$146.41

chlorpheniramine-HYDROcodone 8 mg-10 mg/5 mL Oral Susp, ER 115 mL [HMC]

Facility

$113.90

Service Code	NDC 62175049064
Hospital Charge Code	3807655
Hospital Revenue Code	250
Min. Negotiated Rate	$102.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$102.51
Rate for Payer: UnitedHealthcare Commercial	$108.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges