Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

citalopram 20 mg Tab [HMC]

Facility

$13.08

Service Code	NDC 00904608561
Hospital Charge Code	3802747
Hospital Revenue Code	250
Min. Negotiated Rate	$11.77
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.77
Rate for Payer: UnitedHealthcare Commercial	$12.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

citalopram 20 mg Tab [HMC]

Facility

$12.66

Service Code	NDC 00378623201
Hospital Charge Code	3802747
Hospital Revenue Code	250
Min. Negotiated Rate	$11.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.39
Rate for Payer: UnitedHealthcare Commercial	$12.03
Rate for Payer: WPPA Medicare Advantage	$1,200.00

citalopram 20 mg Tab [HMC]

Facility

$12.65

Service Code	NDC 68084074401
Hospital Charge Code	3802747
Hospital Revenue Code	250
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$12.02
Rate for Payer: Aetna Commercial	$11.38
Rate for Payer: Humana Medicare Advantage	$5.31
Rate for Payer: UnitedHealthcare Commercial	$12.02
Rate for Payer: UnitedHealthcare Medicaid	$5.06
Rate for Payer: WPPA Medicare Advantage	$7.59

citalopram 20 mg Tab [HMC]

Facility

$13.08

Service Code	NDC 00904608561
Hospital Charge Code	3802747
Hospital Revenue Code	250
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$12.43
Rate for Payer: Aetna Commercial	$11.77
Rate for Payer: Humana Medicare Advantage	$5.49
Rate for Payer: UnitedHealthcare Commercial	$12.43
Rate for Payer: UnitedHealthcare Medicaid	$5.23
Rate for Payer: WPPA Medicare Advantage	$7.85

citric acid-potassium citrate 30 mEq Oral Pwdr [HMC]

Facility

$13.32

Service Code	NDC 60258000501
Hospital Charge Code	3800630
Hospital Revenue Code	250
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$12.65
Rate for Payer: Aetna Commercial	$11.99
Rate for Payer: Humana Medicare Advantage	$5.59
Rate for Payer: UnitedHealthcare Commercial	$12.65
Rate for Payer: UnitedHealthcare Medicaid	$5.33
Rate for Payer: WPPA Medicare Advantage	$7.99

citric acid-potassium citrate 30 mEq Oral Pwdr [HMC]

Facility

$13.32

Service Code	NDC 60258000501
Hospital Charge Code	3800630
Hospital Revenue Code	250
Min. Negotiated Rate	$11.99
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.99
Rate for Payer: UnitedHealthcare Commercial	$12.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

citric acid-sodium citrate 334 mg-500 mg/5 mL Oral Sol 30 mL [HMC]

Facility

$15.46

Service Code	NDC 58657031016
Hospital Charge Code	3807167
Hospital Revenue Code	250
Min. Negotiated Rate	$13.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.91
Rate for Payer: UnitedHealthcare Commercial	$14.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

citric acid-sodium citrate 334 mg-500 mg/5 mL Oral Sol 30 mL [HMC]

Facility

$21.10

Service Code	NDC 00121119000
Hospital Charge Code	3807167
Hospital Revenue Code	250
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.99
Rate for Payer: UnitedHealthcare Commercial	$20.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

citric acid-sodium citrate 334 mg-500 mg/5 mL Oral Sol 30 mL [HMC]

Facility

$21.10

Service Code	NDC 00121119000
Hospital Charge Code	3807167
Hospital Revenue Code	250
Min. Negotiated Rate	$8.44
Max. Negotiated Rate	$20.05
Rate for Payer: Aetna Commercial	$18.99
Rate for Payer: Humana Medicare Advantage	$8.86
Rate for Payer: UnitedHealthcare Commercial	$20.05
Rate for Payer: UnitedHealthcare Medicaid	$8.44
Rate for Payer: WPPA Medicare Advantage	$12.66

citric acid-sodium citrate 334 mg-500 mg/5 mL Oral Sol 30 mL [HMC]

Facility

$15.46

Service Code	NDC 58657031016
Hospital Charge Code	3807167
Hospital Revenue Code	250
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$14.69
Rate for Payer: Aetna Commercial	$13.91
Rate for Payer: Humana Medicare Advantage	$6.49
Rate for Payer: UnitedHealthcare Commercial	$14.69
Rate for Payer: UnitedHealthcare Medicaid	$6.18
Rate for Payer: WPPA Medicare Advantage	$9.28

Citric Acid, U24 (w/o Creatinine) QST

Facility

$389.00

Service Code	HCPCS 82507
Hospital Charge Code	3552507
Hospital Revenue Code	300
Min. Negotiated Rate	$350.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$350.10
Rate for Payer: UnitedHealthcare Commercial	$369.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Citric Acid, U24 (w/o Creatinine) QST

Facility

$389.00

Service Code	HCPCS 82507
Hospital Charge Code	3552507
Hospital Revenue Code	300
Min. Negotiated Rate	$23.63
Max. Negotiated Rate	$369.55
Rate for Payer: Aetna Commercial	$350.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$99.90
Rate for Payer: Humana Medicare Advantage	$163.38
Rate for Payer: UnitedHealthcare Commercial	$369.55
Rate for Payer: UnitedHealthcare Medicaid	$23.63
Rate for Payer: WPPA Medicare Advantage	$233.40

CK-MB

Facility

$180.00

Service Code	HCPCS 82553
Hospital Charge Code	3550288
Hospital Revenue Code	300
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna Commercial	$162.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.02
Rate for Payer: Humana Medicare Advantage	$75.60
Rate for Payer: UnitedHealthcare Commercial	$171.00
Rate for Payer: UnitedHealthcare Medicaid	$11.55
Rate for Payer: WPPA Medicare Advantage	$108.00

CK-MB

Facility

$180.00

Service Code	HCPCS 82553
Hospital Charge Code	3550288
Hospital Revenue Code	300
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$162.00
Rate for Payer: UnitedHealthcare Commercial	$171.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CK with CKMB if Indicated

Facility

$74.00

Service Code	HCPCS 82550
Hospital Charge Code	3553550
Hospital Revenue Code	300
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$70.30
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.11
Rate for Payer: Humana Medicare Advantage	$31.08
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: UnitedHealthcare Medicaid	$6.51
Rate for Payer: WPPA Medicare Advantage	$44.40

CK with CKMB if Indicated

Facility

$74.00

Service Code	HCPCS 82550
Hospital Charge Code	3553550
Hospital Revenue Code	300
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cladosporium herbarum (M2) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1005
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$16.20

Cladosporium herbarum (M2) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1005
Hospital Revenue Code	300
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

clarithromycin 500 mg Tab [HMC]

Facility

$16.69

Service Code	NDC 00904687204
Hospital Charge Code	3809321
Hospital Revenue Code	250
Min. Negotiated Rate	$15.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.02
Rate for Payer: UnitedHealthcare Commercial	$15.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

clarithromycin 500 mg Tab [HMC]

Facility

$20.04

Service Code	NDC 00781196260
Hospital Charge Code	3809321
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$19.04
Rate for Payer: Aetna Commercial	$18.04
Rate for Payer: Humana Medicare Advantage	$8.42
Rate for Payer: UnitedHealthcare Commercial	$19.04
Rate for Payer: UnitedHealthcare Medicaid	$8.02
Rate for Payer: WPPA Medicare Advantage	$12.02

clarithromycin 500 mg Tab [HMC]

Facility

$20.04

Service Code	NDC 00781196260
Hospital Charge Code	3809321
Hospital Revenue Code	250
Min. Negotiated Rate	$18.04
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.04
Rate for Payer: UnitedHealthcare Commercial	$19.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

clarithromycin 500 mg Tab [HMC]

Facility

$16.69

Service Code	NDC 00904687204
Hospital Charge Code	3809321
Hospital Revenue Code	250
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$15.86
Rate for Payer: Aetna Commercial	$15.02
Rate for Payer: Humana Medicare Advantage	$7.01
Rate for Payer: UnitedHealthcare Commercial	$15.86
Rate for Payer: UnitedHealthcare Medicaid	$6.68
Rate for Payer: WPPA Medicare Advantage	$10.01

Clavicle Strap Adult Large

Facility

$15.17

Hospital Charge Code	3250283
Hospital Revenue Code	270
Min. Negotiated Rate	$6.07
Max. Negotiated Rate	$14.41
Rate for Payer: Aetna Commercial	$13.65
Rate for Payer: Humana Medicare Advantage	$6.37
Rate for Payer: UnitedHealthcare Commercial	$14.41
Rate for Payer: UnitedHealthcare Medicaid	$6.07
Rate for Payer: WPPA Medicare Advantage	$9.10

Clavicle Strap Adult Large

Facility

$15.17

Hospital Charge Code	3250283
Hospital Revenue Code	270
Min. Negotiated Rate	$13.65
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.65
Rate for Payer: UnitedHealthcare Commercial	$14.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Clavicle Strap Adult X-Large

Facility

$22.00

Hospital Charge Code	3250275
Hospital Revenue Code	270
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$20.90
Rate for Payer: Aetna Commercial	$19.80
Rate for Payer: Humana Medicare Advantage	$9.24
Rate for Payer: UnitedHealthcare Commercial	$20.90
Rate for Payer: UnitedHealthcare Medicaid	$8.80
Rate for Payer: WPPA Medicare Advantage	$13.20

Know your out-of-pocket cost for care.

All Charges