Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Coblator II Turbinator Wand

Facility

$696.00

Hospital Charge Code	3252140
Hospital Revenue Code	270
Min. Negotiated Rate	$278.40
Max. Negotiated Rate	$661.20
Rate for Payer: Aetna Commercial	$626.40
Rate for Payer: Humana Medicare Advantage	$292.32
Rate for Payer: UnitedHealthcare Commercial	$661.20
Rate for Payer: UnitedHealthcare Medicaid	$278.40
Rate for Payer: WPPA Medicare Advantage	$417.60

Coblator II Turbinator Wand

Facility

$696.00

Hospital Charge Code	3252140
Hospital Revenue Code	270
Min. Negotiated Rate	$626.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$626.40
Rate for Payer: UnitedHealthcare Commercial	$661.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Coblator Tonsil Wand

Facility

$893.05

Hospital Charge Code	3252142
Hospital Revenue Code	270
Min. Negotiated Rate	$357.22
Max. Negotiated Rate	$848.40
Rate for Payer: Aetna Commercial	$803.75
Rate for Payer: Humana Medicare Advantage	$375.08
Rate for Payer: UnitedHealthcare Commercial	$848.40
Rate for Payer: UnitedHealthcare Medicaid	$357.22
Rate for Payer: WPPA Medicare Advantage	$535.83

Coblator Tonsil Wand

Facility

$893.05

Hospital Charge Code	3252142
Hospital Revenue Code	270
Min. Negotiated Rate	$803.75
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$803.75
Rate for Payer: UnitedHealthcare Commercial	$848.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Coblator Werewolf Irrigation ENT Saline Tubing Set

Facility

$94.00

Hospital Charge Code	3252141
Hospital Revenue Code	270
Min. Negotiated Rate	$84.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$84.60
Rate for Payer: UnitedHealthcare Commercial	$89.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Coblator Werewolf Irrigation ENT Saline Tubing Set

Facility

$94.00

Hospital Charge Code	3252141
Hospital Revenue Code	270
Min. Negotiated Rate	$37.60
Max. Negotiated Rate	$89.30
Rate for Payer: Aetna Commercial	$84.60
Rate for Payer: Humana Medicare Advantage	$39.48
Rate for Payer: UnitedHealthcare Commercial	$89.30
Rate for Payer: UnitedHealthcare Medicaid	$37.60
Rate for Payer: WPPA Medicare Advantage	$56.40

Cocaine Metabolites By GC/MS (U) QST

Facility

$147.00

Service Code	HCPCS 80353
Hospital Charge Code	3553053
Hospital Revenue Code	300
Min. Negotiated Rate	$9.98
Max. Negotiated Rate	$139.65
Rate for Payer: Aetna Commercial	$132.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$35.00
Rate for Payer: Humana Medicare Advantage	$61.74
Rate for Payer: UnitedHealthcare Commercial	$139.65
Rate for Payer: UnitedHealthcare Medicaid	$9.98
Rate for Payer: WPPA Medicare Advantage	$88.20

Cocaine Metabolites By GC/MS (U) QST

Facility

$147.00

Service Code	HCPCS 80353
Hospital Charge Code	3553053
Hospital Revenue Code	300
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$132.30
Rate for Payer: UnitedHealthcare Commercial	$139.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cockroach (I6) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1006
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

Cockroach (I6) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1006
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

Coconut (f36) IgE REF

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552836
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

Coconut (f36) IgE REF

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552836
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

codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup 118 mL [HMC]

Facility

$25.84

Service Code	NDC 00603158554
Hospital Charge Code	3800232
Hospital Revenue Code	250
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$24.55
Rate for Payer: Aetna Commercial	$23.26
Rate for Payer: Humana Medicare Advantage	$10.85
Rate for Payer: UnitedHealthcare Commercial	$24.55
Rate for Payer: UnitedHealthcare Medicaid	$10.34
Rate for Payer: WPPA Medicare Advantage	$15.50

codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup 118 mL [HMC]

Facility

$25.84

Service Code	NDC 00603158554
Hospital Charge Code	3800232
Hospital Revenue Code	250
Min. Negotiated Rate	$23.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.26
Rate for Payer: UnitedHealthcare Commercial	$24.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup 473 mL [HMC]

Facility

$54.21

Service Code	NDC 57664018534
Hospital Charge Code	3806847
Hospital Revenue Code	250
Min. Negotiated Rate	$48.79
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.79
Rate for Payer: UnitedHealthcare Commercial	$51.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup 473 mL [HMC]

Facility

$54.21

Service Code	NDC 57664018534
Hospital Charge Code	3806847
Hospital Revenue Code	250
Min. Negotiated Rate	$21.68
Max. Negotiated Rate	$51.50
Rate for Payer: Aetna Commercial	$48.79
Rate for Payer: Humana Medicare Advantage	$22.77
Rate for Payer: UnitedHealthcare Commercial	$51.50
Rate for Payer: UnitedHealthcare Medicaid	$21.68
Rate for Payer: WPPA Medicare Advantage	$32.53

codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup 473 mL [HMC]

Facility

$54.14

Service Code	NDC 27808006502
Hospital Charge Code	3806847
Hospital Revenue Code	250
Min. Negotiated Rate	$48.73
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.73
Rate for Payer: UnitedHealthcare Commercial	$51.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup 473 mL [HMC]

Facility

$54.14

Service Code	NDC 27808006502
Hospital Charge Code	3806847
Hospital Revenue Code	250
Min. Negotiated Rate	$21.66
Max. Negotiated Rate	$51.43
Rate for Payer: Aetna Commercial	$48.73
Rate for Payer: Humana Medicare Advantage	$22.74
Rate for Payer: UnitedHealthcare Commercial	$51.43
Rate for Payer: UnitedHealthcare Medicaid	$21.66
Rate for Payer: WPPA Medicare Advantage	$32.48

Codfish (F3) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552804
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

Codfish (F3) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552804
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

colchicine 0.6 mg Tab [HMC]

Facility

$19.39

Service Code	NDC 00904712004
Hospital Charge Code	3808752
Hospital Revenue Code	250
Min. Negotiated Rate	$7.76
Max. Negotiated Rate	$18.42
Rate for Payer: Aetna Commercial	$17.45
Rate for Payer: Humana Medicare Advantage	$8.14
Rate for Payer: UnitedHealthcare Commercial	$18.42
Rate for Payer: UnitedHealthcare Medicaid	$7.76
Rate for Payer: WPPA Medicare Advantage	$11.63

colchicine 0.6 mg Tab [HMC]

Facility

$24.75

Service Code	NDC 70010000201
Hospital Charge Code	3808752
Hospital Revenue Code	250
Min. Negotiated Rate	$22.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.27
Rate for Payer: UnitedHealthcare Commercial	$23.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

colchicine 0.6 mg Tab [HMC]

Facility

$26.57

Service Code	NDC 64764011901
Hospital Charge Code	3808752
Hospital Revenue Code	250
Min. Negotiated Rate	$23.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.91
Rate for Payer: UnitedHealthcare Commercial	$25.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

colchicine 0.6 mg Tab [HMC]

Facility

$26.57

Service Code	NDC 64764011901
Hospital Charge Code	3808752
Hospital Revenue Code	250
Min. Negotiated Rate	$10.63
Max. Negotiated Rate	$25.24
Rate for Payer: Aetna Commercial	$23.91
Rate for Payer: Humana Medicare Advantage	$11.16
Rate for Payer: UnitedHealthcare Commercial	$25.24
Rate for Payer: UnitedHealthcare Medicaid	$10.63
Rate for Payer: WPPA Medicare Advantage	$15.94

colchicine 0.6 mg Tab [HMC]

Facility

$19.39

Service Code	NDC 00904712004
Hospital Charge Code	3808752
Hospital Revenue Code	250
Min. Negotiated Rate	$17.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.45
Rate for Payer: UnitedHealthcare Commercial	$18.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges