Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC

Facility

$8,704.98

Service Code	MSDRG 283
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,704.98
Rate for Payer: UnitedHealthcare Medicaid	$8,704.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Facility

$2,636.91

Service Code	MSDRG 285
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,636.91
Rate for Payer: UnitedHealthcare Medicaid	$2,636.91
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acyclovir 400 mg Tab [HMC]

Facility

$11.51

Service Code	NDC 63304050401
Hospital Charge Code	3804156
Hospital Revenue Code	250
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.36
Rate for Payer: UnitedHealthcare Commercial	$10.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acyclovir 400 mg Tab [HMC]

Facility

$6.46

Service Code	NDC 00904750761
Hospital Charge Code	3804156
Hospital Revenue Code	250
Min. Negotiated Rate	$5.81
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.81
Rate for Payer: UnitedHealthcare Commercial	$6.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acyclovir 400 mg Tab [HMC]

Facility

$11.50

Service Code	NDC 00904579061
Hospital Charge Code	3804156
Hospital Revenue Code	250
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$10.93
Rate for Payer: Aetna Commercial	$10.35
Rate for Payer: Humana Medicare Advantage	$4.83
Rate for Payer: UnitedHealthcare Commercial	$10.93
Rate for Payer: UnitedHealthcare Medicaid	$4.60
Rate for Payer: WPPA Medicare Advantage	$6.90

acyclovir 400 mg Tab [HMC]

Facility

$11.51

Service Code	NDC 63304050401
Hospital Charge Code	3804156
Hospital Revenue Code	250
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$10.93
Rate for Payer: Aetna Commercial	$10.36
Rate for Payer: Humana Medicare Advantage	$4.83
Rate for Payer: UnitedHealthcare Commercial	$10.93
Rate for Payer: UnitedHealthcare Medicaid	$4.60
Rate for Payer: WPPA Medicare Advantage	$6.91

acyclovir 400 mg Tab [HMC]

Facility

$6.46

Service Code	NDC 00904750761
Hospital Charge Code	3804156
Hospital Revenue Code	250
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$6.14
Rate for Payer: Aetna Commercial	$5.81
Rate for Payer: Humana Medicare Advantage	$2.71
Rate for Payer: UnitedHealthcare Commercial	$6.14
Rate for Payer: UnitedHealthcare Medicaid	$2.58
Rate for Payer: WPPA Medicare Advantage	$3.88

acyclovir 400 mg Tab [HMC]

Facility

$11.50

Service Code	NDC 31722077701
Hospital Charge Code	3804156
Hospital Revenue Code	250
Min. Negotiated Rate	$10.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.35
Rate for Payer: UnitedHealthcare Commercial	$10.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acyclovir 400 mg Tab [HMC]

Facility

$11.50

Service Code	NDC 31722077701
Hospital Charge Code	3804156
Hospital Revenue Code	250
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$10.93
Rate for Payer: Aetna Commercial	$10.35
Rate for Payer: Humana Medicare Advantage	$4.83
Rate for Payer: UnitedHealthcare Commercial	$10.93
Rate for Payer: UnitedHealthcare Medicaid	$4.60
Rate for Payer: WPPA Medicare Advantage	$6.90

acyclovir 400 mg Tab [HMC]

Facility

$11.50

Service Code	NDC 00904579061
Hospital Charge Code	3804156
Hospital Revenue Code	250
Min. Negotiated Rate	$10.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.35
Rate for Payer: UnitedHealthcare Commercial	$10.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acyclovir 50 mg/mL IV Sol [HMC]

Facility

$58.00

Service Code	HCPCS J0133
Hospital Charge Code	3808017
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$55.10
Rate for Payer: Aetna Commercial	$52.20
Rate for Payer: Aetna Commercial	$58.73
Rate for Payer: Aetna Commercial	$49.61
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.06
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.06
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.06
Rate for Payer: Humana Medicare Advantage	$27.41
Rate for Payer: Humana Medicare Advantage	$23.15
Rate for Payer: Humana Medicare Advantage	$24.36
Rate for Payer: UnitedHealthcare Commercial	$52.36
Rate for Payer: UnitedHealthcare Commercial	$55.10
Rate for Payer: UnitedHealthcare Commercial	$62.00
Rate for Payer: UnitedHealthcare Medicaid	$0.12
Rate for Payer: UnitedHealthcare Medicaid	$0.12
Rate for Payer: UnitedHealthcare Medicaid	$0.12
Rate for Payer: WPPA Medicare Advantage	$34.80
Rate for Payer: WPPA Medicare Advantage	$33.07
Rate for Payer: WPPA Medicare Advantage	$39.16

acyclovir 50 mg/mL IV Sol [HMC]

Facility

$55.12

Service Code	HCPCS J0133
Hospital Charge Code	3808017
Hospital Revenue Code	250
Min. Negotiated Rate	$49.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$49.61
Rate for Payer: Aetna Commercial	$52.20
Rate for Payer: Aetna Commercial	$58.73
Rate for Payer: UnitedHealthcare Commercial	$62.00
Rate for Payer: UnitedHealthcare Commercial	$52.36
Rate for Payer: UnitedHealthcare Commercial	$55.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Adalimumab Ada, Ibd QST

Facility

$347.00

Service Code	HCPCS 83520
Hospital Charge Code	3556296
Hospital Revenue Code	300
Min. Negotiated Rate	$36.48
Max. Negotiated Rate	$329.65
Rate for Payer: Aetna Commercial	$312.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.48
Rate for Payer: Humana Medicare Advantage	$145.74
Rate for Payer: UnitedHealthcare Commercial	$329.65
Rate for Payer: UnitedHealthcare Medicaid	$138.80
Rate for Payer: WPPA Medicare Advantage	$208.20

Adalimumab Ada, Ibd QST

Facility

$347.00

Service Code	HCPCS 83520
Hospital Charge Code	3556296
Hospital Revenue Code	300
Min. Negotiated Rate	$312.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$312.30
Rate for Payer: UnitedHealthcare Commercial	$329.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Adenoidectomy < 12 yrs age Procedure

Facility

$3,518.00

Service Code	HCPCS 42830
Hospital Charge Code	3152830
Hospital Revenue Code	360
Min. Negotiated Rate	$1,042.99
Max. Negotiated Rate	$3,439.30
Rate for Payer: Aetna Commercial	$3,166.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,439.30
Rate for Payer: Humana Medicare Advantage	$1,477.56
Rate for Payer: UnitedHealthcare Commercial	$3,342.10
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$2,110.80

Adenoidectomy < 12 yrs age Procedure

Facility

$3,518.00

Service Code	HCPCS 42830
Hospital Charge Code	3152830
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,342.10
Rate for Payer: Aetna Commercial	$3,166.20
Rate for Payer: UnitedHealthcare Commercial	$3,342.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

adenosine 3 mg/mL IV Sol 2 mL[HMC]

Facility

$63.18

Service Code	HCPCS J0153
Hospital Charge Code	3807226
Hospital Revenue Code	250
Min. Negotiated Rate	$56.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.86
Rate for Payer: Aetna Commercial	$34.92
Rate for Payer: Aetna Commercial	$35.77
Rate for Payer: UnitedHealthcare Commercial	$36.86
Rate for Payer: UnitedHealthcare Commercial	$37.76
Rate for Payer: UnitedHealthcare Commercial	$60.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

adenosine 3 mg/mL IV Sol 2 mL[HMC]

Facility

$39.75

Service Code	HCPCS J0153
Hospital Charge Code	3807226
Hospital Revenue Code	250
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$37.76
Rate for Payer: Aetna Commercial	$35.77
Rate for Payer: Aetna Commercial	$34.92
Rate for Payer: Aetna Commercial	$56.86
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.71
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.71
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.71
Rate for Payer: Humana Medicare Advantage	$16.70
Rate for Payer: Humana Medicare Advantage	$16.30
Rate for Payer: Humana Medicare Advantage	$26.54
Rate for Payer: UnitedHealthcare Commercial	$36.86
Rate for Payer: UnitedHealthcare Commercial	$37.76
Rate for Payer: UnitedHealthcare Commercial	$60.02
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: WPPA Medicare Advantage	$23.85
Rate for Payer: WPPA Medicare Advantage	$37.91
Rate for Payer: WPPA Medicare Advantage	$23.28

ADL Training Charges

Facility

$128.00

Service Code	HCPCS 97535 GO
Hospital Charge Code	3970135
Hospital Revenue Code	430
Min. Negotiated Rate	$19.46
Max. Negotiated Rate	$121.60
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$34.17
Rate for Payer: Humana Medicare Advantage	$53.76
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: UnitedHealthcare Medicaid	$19.46
Rate for Payer: WPPA Medicare Advantage	$76.80

ADL Training Charges

Facility

$128.00

Service Code	HCPCS 97535 GO
Hospital Charge Code	3970135
Hospital Revenue Code	430
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Admin Set w/Integrated ChemoLock_x0099_ Port Drip Chamber, ChemoLock_x0099_ w/Red Cap, Bag Hanger, 30 (76 cm) A

Facility

$30.92

Hospital Charge Code	3253569
Hospital Revenue Code	270
Min. Negotiated Rate	$12.37
Max. Negotiated Rate	$29.37
Rate for Payer: Aetna Commercial	$27.83
Rate for Payer: Humana Medicare Advantage	$12.99
Rate for Payer: UnitedHealthcare Commercial	$29.37
Rate for Payer: UnitedHealthcare Medicaid	$12.37
Rate for Payer: WPPA Medicare Advantage	$18.55

Admin Set w/Integrated ChemoLock_x0099_ Port Drip Chamber, ChemoLock_x0099_ w/Red Cap, Bag Hanger, 30 (76 cm) A

Facility

$30.92

Hospital Charge Code	3253569
Hospital Revenue Code	270
Min. Negotiated Rate	$27.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.83
Rate for Payer: UnitedHealthcare Commercial	$29.37
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC

Facility

$7,815.42

Service Code	MSDRG 614
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,815.42
Rate for Payer: UnitedHealthcare Medicaid	$7,815.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC

Facility

$4,987.89

Service Code	MSDRG 615
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,987.89
Rate for Payer: UnitedHealthcare Medicaid	$4,987.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Aerosol Drainage Bag 750cc w/Y Adapter 22mm OD

Facility

$5.00

Hospital Charge Code	3251630
Hospital Revenue Code	270
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

Know your out-of-pocket cost for care.

All Charges