Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

cholecalciferol 1,000 IntlUnit Tab [HMC]

Facility

$5.00

Service Code	NDC 96295012848
Hospital Charge Code	3809505
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

cholecalciferol 125 mcg Cap UD [HMC]

Facility

$6.12

Service Code	NDC 50268086815
Hospital Charge Code	3800524
Hospital Revenue Code	250
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$5.81
Rate for Payer: Aetna Commercial	$5.51
Rate for Payer: Humana Medicare Advantage	$2.57
Rate for Payer: UnitedHealthcare Commercial	$5.81
Rate for Payer: UnitedHealthcare Medicaid	$2.45
Rate for Payer: WPPA Medicare Advantage	$3.67

cholecalciferol 125 mcg Cap UD [HMC]

Facility

$6.12

Service Code	NDC 50268086815
Hospital Charge Code	3800524
Hospital Revenue Code	250
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.51
Rate for Payer: UnitedHealthcare Commercial	$5.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

cholecalciferol 25 mcg 1000 IU Tab [HMC]

Facility

$5.14

Service Code	NDC 20555003300
Hospital Charge Code	3809505
Hospital Revenue Code	250
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.63
Rate for Payer: UnitedHealthcare Commercial	$4.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

cholecalciferol 25 mcg 1000 IU Tab [HMC]

Facility

$5.14

Service Code	NDC 20555003300
Hospital Charge Code	3809505
Hospital Revenue Code	250
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$4.88
Rate for Payer: Aetna Commercial	$4.63
Rate for Payer: Humana Medicare Advantage	$2.16
Rate for Payer: UnitedHealthcare Commercial	$4.88
Rate for Payer: UnitedHealthcare Medicaid	$2.06
Rate for Payer: WPPA Medicare Advantage	$3.08

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC

Facility

$6,639.93

Service Code	MSDRG 415
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,639.93
Rate for Payer: UnitedHealthcare Medicaid	$6,639.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC

Facility

$11,468.97

Service Code	MSDRG 414
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,468.97
Rate for Payer: UnitedHealthcare Medicaid	$11,468.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$4,384.26

Service Code	MSDRG 416
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,384.26
Rate for Payer: UnitedHealthcare Medicaid	$4,384.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cholecystectomy Laparoscopy

Facility

$9,729.00

Service Code	HCPCS 47562
Hospital Charge Code	3150341
Hospital Revenue Code	360
Min. Negotiated Rate	$1,869.18
Max. Negotiated Rate	$9,242.55
Rate for Payer: Aetna Commercial	$8,756.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$6,871.99
Rate for Payer: Humana Medicare Advantage	$4,086.18
Rate for Payer: UnitedHealthcare Commercial	$9,242.55
Rate for Payer: UnitedHealthcare Medicaid	$1,869.18
Rate for Payer: WPPA Medicare Advantage	$5,837.40

Cholecystectomy Laparoscopy

Facility

$9,729.00

Service Code	HCPCS 47562
Hospital Charge Code	3150341
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,242.55
Rate for Payer: Aetna Commercial	$8,756.10
Rate for Payer: UnitedHealthcare Commercial	$9,242.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHOLECYSTECTOMY WITH C.D.E. WITH CC

Facility

$6,767.01

Service Code	MSDRG 412
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,767.01
Rate for Payer: UnitedHealthcare Medicaid	$6,767.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHOLECYSTECTOMY WITH C.D.E. WITH MCC

Facility

$10,642.95

Service Code	MSDRG 411
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,642.95
Rate for Payer: UnitedHealthcare Medicaid	$10,642.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC

Facility

$5,337.36

Service Code	MSDRG 413
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,337.36
Rate for Payer: UnitedHealthcare Medicaid	$5,337.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cholesterol Total

Facility

$54.00

Service Code	HCPCS 82465
Hospital Charge Code	3550247
Hospital Revenue Code	300
Min. Negotiated Rate	$4.35
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$10.87
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$4.35
Rate for Payer: WPPA Medicare Advantage	$32.40

Cholesterol Total

Facility

$54.00

Service Code	HCPCS 82465
Hospital Charge Code	3550247
Hospital Revenue Code	300
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

cholestyramine 4 g/5.5 g Pow UD [HMC]

Facility

$210.00

Service Code	NDC 68382052960
Hospital Charge Code	3803530
Hospital Revenue Code	250
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$189.00
Rate for Payer: UnitedHealthcare Commercial	$199.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

cholestyramine 4 g/5.5 g Pow UD [HMC]

Facility

$309.59

Service Code	NDC 00245003642
Hospital Charge Code	3803530
Hospital Revenue Code	250
Min. Negotiated Rate	$278.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$278.63
Rate for Payer: UnitedHealthcare Commercial	$294.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

cholestyramine 4 g/5.5 g Pow UD [HMC]

Facility

$309.59

Service Code	NDC 00245003642
Hospital Charge Code	3803530
Hospital Revenue Code	250
Min. Negotiated Rate	$123.84
Max. Negotiated Rate	$294.11
Rate for Payer: Aetna Commercial	$278.63
Rate for Payer: Humana Medicare Advantage	$130.03
Rate for Payer: UnitedHealthcare Commercial	$294.11
Rate for Payer: UnitedHealthcare Medicaid	$123.84
Rate for Payer: WPPA Medicare Advantage	$185.75

cholestyramine 4 g/5.5 g Pow UD [HMC]

Facility

$210.00

Service Code	NDC 68382052960
Hospital Charge Code	3803530
Hospital Revenue Code	250
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$199.50
Rate for Payer: Aetna Commercial	$189.00
Rate for Payer: Humana Medicare Advantage	$88.20
Rate for Payer: UnitedHealthcare Commercial	$199.50
Rate for Payer: UnitedHealthcare Medicaid	$84.00
Rate for Payer: WPPA Medicare Advantage	$126.00

Chromogranin A QST

Facility

$116.00

Service Code	HCPCS 86316
Hospital Charge Code	3558631
Hospital Revenue Code	300
Min. Negotiated Rate	$20.81
Max. Negotiated Rate	$110.20
Rate for Payer: Aetna Commercial	$104.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.49
Rate for Payer: Humana Medicare Advantage	$48.72
Rate for Payer: UnitedHealthcare Commercial	$110.20
Rate for Payer: UnitedHealthcare Medicaid	$20.81
Rate for Payer: WPPA Medicare Advantage	$69.60

Chromogranin A QST

Facility

$116.00

Service Code	HCPCS 86316
Hospital Charge Code	3558631
Hospital Revenue Code	300
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$104.40
Rate for Payer: UnitedHealthcare Commercial	$110.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Chromosomal Microarray, Postnatal, Clarisure Oligo-SNP QST

Facility

$3,150.00

Service Code	HCPCS 81229
Hospital Charge Code	3551229
Hospital Revenue Code	300
Min. Negotiated Rate	$986.00
Max. Negotiated Rate	$2,992.50
Rate for Payer: Aetna Commercial	$2,835.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,528.00
Rate for Payer: Humana Medicare Advantage	$1,323.00
Rate for Payer: UnitedHealthcare Commercial	$2,992.50
Rate for Payer: UnitedHealthcare Medicaid	$986.00
Rate for Payer: WPPA Medicare Advantage	$1,890.00

Chromosomal Microarray, Postnatal, Clarisure Oligo-SNP QST

Facility

$3,150.00

Service Code	HCPCS 81229
Hospital Charge Code	3551229
Hospital Revenue Code	300
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,992.50
Rate for Payer: Aetna Commercial	$2,835.00
Rate for Payer: UnitedHealthcare Commercial	$2,992.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC

Facility

$3,240.54

Service Code	MSDRG 191
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,240.54
Rate for Payer: UnitedHealthcare Medicaid	$3,240.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC

Facility

$5,083.20

Service Code	MSDRG 190
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,083.20
Rate for Payer: UnitedHealthcare Medicaid	$5,083.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges