Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

cycloSPORINE Ophth 0.05% Emul [HMC]

Facility

$516.79

Service Code	NDC 00378876058
Hospital Charge Code	3807368
Hospital Revenue Code	250
Min. Negotiated Rate	$206.72
Max. Negotiated Rate	$490.95
Rate for Payer: Aetna Commercial	$465.11
Rate for Payer: Humana Medicare Advantage	$217.05
Rate for Payer: UnitedHealthcare Commercial	$490.95
Rate for Payer: UnitedHealthcare Medicaid	$206.72
Rate for Payer: WPPA Medicare Advantage	$310.07

cycloSPORINE Ophth 0.05% Emul [HMC]

Facility

$542.94

Service Code	NDC 00023916330
Hospital Charge Code	3807368
Hospital Revenue Code	250
Min. Negotiated Rate	$488.65
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$488.65
Rate for Payer: UnitedHealthcare Commercial	$515.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

cycloSPORINE Ophth 0.05% Emul [HMC]

Facility

$542.94

Service Code	NDC 00023916330
Hospital Charge Code	3807368
Hospital Revenue Code	250
Min. Negotiated Rate	$217.18
Max. Negotiated Rate	$515.79
Rate for Payer: Aetna Commercial	$488.65
Rate for Payer: Humana Medicare Advantage	$228.03
Rate for Payer: UnitedHealthcare Commercial	$515.79
Rate for Payer: UnitedHealthcare Medicaid	$217.18
Rate for Payer: WPPA Medicare Advantage	$325.76

Cystatin C w/ GFR, Estimated (eGFR) QST

Facility

$177.00

Service Code	HCPCS 82610
Hospital Charge Code	3559458
Hospital Revenue Code	300
Min. Negotiated Rate	$159.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$159.30
Rate for Payer: UnitedHealthcare Commercial	$168.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cystatin C w/ GFR, Estimated (eGFR) QST

Facility

$177.00

Service Code	HCPCS 82610
Hospital Charge Code	3559458
Hospital Revenue Code	300
Min. Negotiated Rate	$14.93
Max. Negotiated Rate	$168.15
Rate for Payer: Aetna Commercial	$159.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$14.93
Rate for Payer: Humana Medicare Advantage	$74.34
Rate for Payer: UnitedHealthcare Commercial	$168.15
Rate for Payer: UnitedHealthcare Medicaid	$70.80
Rate for Payer: WPPA Medicare Advantage	$106.20

Cystic Fibrosis Screen REF

Facility

$776.00

Service Code	HCPCS 81220
Hospital Charge Code	3551220
Hospital Revenue Code	300
Min. Negotiated Rate	$310.40
Max. Negotiated Rate	$2,371.24
Rate for Payer: Aetna Commercial	$698.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,371.24
Rate for Payer: Humana Medicare Advantage	$325.92
Rate for Payer: UnitedHealthcare Commercial	$737.20
Rate for Payer: UnitedHealthcare Medicaid	$310.40
Rate for Payer: WPPA Medicare Advantage	$465.60

Cystic Fibrosis Screen REF

Facility

$776.00

Service Code	HCPCS 81220
Hospital Charge Code	3551220
Hospital Revenue Code	300
Min. Negotiated Rate	$698.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$698.40
Rate for Payer: UnitedHealthcare Commercial	$737.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cytology, Non-Gyn QST

Facility

$182.00

Service Code	HCPCS 88112
Hospital Charge Code	3558112
Hospital Revenue Code	310
Min. Negotiated Rate	$60.92
Max. Negotiated Rate	$172.90
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$81.92
Rate for Payer: Humana Medicare Advantage	$76.44
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: UnitedHealthcare Medicaid	$60.92
Rate for Payer: WPPA Medicare Advantage	$109.20

Cytology, Non-Gyn QST

Facility

$182.00

Service Code	HCPCS 88112
Hospital Charge Code	3558112
Hospital Revenue Code	310
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cytology Thin Prep Non Gyn MOL

Facility

$182.00

Service Code	HCPCS 88112
Hospital Charge Code	3558811
Hospital Revenue Code	310
Min. Negotiated Rate	$60.92
Max. Negotiated Rate	$172.90
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$81.92
Rate for Payer: Humana Medicare Advantage	$76.44
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: UnitedHealthcare Medicaid	$60.92
Rate for Payer: WPPA Medicare Advantage	$109.20

Cytology Thin Prep Non Gyn MOL

Facility

$182.00

Service Code	HCPCS 88112
Hospital Charge Code	3558811
Hospital Revenue Code	310
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cytomegalovirus Abs (IgG, IgM) QST

Facility

$145.00

Service Code	HCPCS 86645
Hospital Charge Code	3558665
Hospital Revenue Code	300
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$130.50
Rate for Payer: UnitedHealthcare Commercial	$137.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cytomegalovirus Abs (IgG, IgM) QST

Facility

$145.00

Service Code	HCPCS 86645
Hospital Charge Code	3558665
Hospital Revenue Code	300
Min. Negotiated Rate	$14.32
Max. Negotiated Rate	$137.75
Rate for Payer: Aetna Commercial	$130.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$72.11
Rate for Payer: Humana Medicare Advantage	$60.90
Rate for Payer: UnitedHealthcare Commercial	$137.75
Rate for Payer: UnitedHealthcare Medicaid	$14.32
Rate for Payer: WPPA Medicare Advantage	$87.00

Cytomegalovirus DNA, Qn, RT PCR QST

Facility

$503.13

Service Code	HCPCS 87497
Hospital Charge Code	3558664
Hospital Revenue Code	300
Min. Negotiated Rate	$452.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$452.82
Rate for Payer: UnitedHealthcare Commercial	$477.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cytomegalovirus DNA, Qn, RT PCR QST

Facility

$503.13

Service Code	HCPCS 87497
Hospital Charge Code	3558664
Hospital Revenue Code	300
Min. Negotiated Rate	$36.41
Max. Negotiated Rate	$477.97
Rate for Payer: Aetna Commercial	$452.82
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$91.92
Rate for Payer: Humana Medicare Advantage	$211.31
Rate for Payer: UnitedHealthcare Commercial	$477.97
Rate for Payer: UnitedHealthcare Medicaid	$36.41
Rate for Payer: WPPA Medicare Advantage	$301.88

dabigatran 75 mg Cap UD [HMC]

Facility

$29.80

Service Code	NDC 00597035556
Hospital Charge Code	3800711
Hospital Revenue Code	250
Min. Negotiated Rate	$26.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.82
Rate for Payer: UnitedHealthcare Commercial	$28.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dabigatran 75 mg Cap UD [HMC]

Facility

$18.12

Service Code	NDC 00597010760
Hospital Charge Code	3800711
Hospital Revenue Code	250
Min. Negotiated Rate	$16.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.31
Rate for Payer: UnitedHealthcare Commercial	$17.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dabigatran 75 mg Cap UD [HMC]

Facility

$33.74

Service Code	NDC 60687074421
Hospital Charge Code	3800711
Hospital Revenue Code	250
Min. Negotiated Rate	$30.37
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.37
Rate for Payer: UnitedHealthcare Commercial	$32.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dabigatran 75 mg Cap UD [HMC]

Facility

$18.12

Service Code	NDC 00597010760
Hospital Charge Code	3800711
Hospital Revenue Code	250
Min. Negotiated Rate	$7.25
Max. Negotiated Rate	$17.21
Rate for Payer: Aetna Commercial	$16.31
Rate for Payer: Humana Medicare Advantage	$7.61
Rate for Payer: UnitedHealthcare Commercial	$17.21
Rate for Payer: UnitedHealthcare Medicaid	$7.25
Rate for Payer: WPPA Medicare Advantage	$10.87

dabigatran 75 mg Cap UD [HMC]

Facility

$29.80

Service Code	NDC 00597035556
Hospital Charge Code	3800711
Hospital Revenue Code	250
Min. Negotiated Rate	$11.92
Max. Negotiated Rate	$28.31
Rate for Payer: Aetna Commercial	$26.82
Rate for Payer: Humana Medicare Advantage	$12.52
Rate for Payer: UnitedHealthcare Commercial	$28.31
Rate for Payer: UnitedHealthcare Medicaid	$11.92
Rate for Payer: WPPA Medicare Advantage	$17.88

dabigatran 75 mg Cap UD [HMC]

Facility

$33.74

Service Code	NDC 60687074421
Hospital Charge Code	3800711
Hospital Revenue Code	250
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$32.05
Rate for Payer: Aetna Commercial	$30.37
Rate for Payer: Humana Medicare Advantage	$14.17
Rate for Payer: UnitedHealthcare Commercial	$32.05
Rate for Payer: UnitedHealthcare Medicaid	$13.50
Rate for Payer: WPPA Medicare Advantage	$20.24

dapagliflozin 10 mg Tab

Facility

$28.99

Service Code	NDC 00310621039
Hospital Charge Code	3800539
Hospital Revenue Code	250
Min. Negotiated Rate	$11.60
Max. Negotiated Rate	$27.54
Rate for Payer: Aetna Commercial	$26.09
Rate for Payer: Humana Medicare Advantage	$12.18
Rate for Payer: UnitedHealthcare Commercial	$27.54
Rate for Payer: UnitedHealthcare Medicaid	$11.60
Rate for Payer: WPPA Medicare Advantage	$17.39

dapagliflozin 10 mg Tab

Facility

$28.99

Service Code	NDC 00310621039
Hospital Charge Code	3800539
Hospital Revenue Code	250
Min. Negotiated Rate	$26.09
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.09
Rate for Payer: UnitedHealthcare Commercial	$27.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dapsone 25 mg Tab [HMC]

Facility

$12.40

Service Code	NDC 13925050430
Hospital Charge Code	3800043
Hospital Revenue Code	250
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$11.78
Rate for Payer: Aetna Commercial	$11.16
Rate for Payer: Humana Medicare Advantage	$5.21
Rate for Payer: UnitedHealthcare Commercial	$11.78
Rate for Payer: UnitedHealthcare Medicaid	$4.96
Rate for Payer: WPPA Medicare Advantage	$7.44

dapsone 25 mg Tab [HMC]

Facility

$12.40

Service Code	NDC 70954013510
Hospital Charge Code	3800043
Hospital Revenue Code	250
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$11.78
Rate for Payer: Aetna Commercial	$11.16
Rate for Payer: Humana Medicare Advantage	$5.21
Rate for Payer: UnitedHealthcare Commercial	$11.78
Rate for Payer: UnitedHealthcare Medicaid	$4.96
Rate for Payer: WPPA Medicare Advantage	$7.44

Know your out-of-pocket cost for care.

All Charges