Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Alpha Subunit QST

Facility

$166.00

Service Code	HCPCS 83520
Hospital Charge Code	3558658
Hospital Revenue Code	300
Min. Negotiated Rate	$36.48
Max. Negotiated Rate	$157.70
Rate for Payer: Aetna Commercial	$149.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.48
Rate for Payer: Humana Medicare Advantage	$69.72
Rate for Payer: UnitedHealthcare Commercial	$157.70
Rate for Payer: UnitedHealthcare Medicaid	$66.40
Rate for Payer: WPPA Medicare Advantage	$99.60

Alpha Subunit QST

Facility

$166.00

Service Code	HCPCS 83520
Hospital Charge Code	3558658
Hospital Revenue Code	300
Min. Negotiated Rate	$149.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$149.40
Rate for Payer: UnitedHealthcare Commercial	$157.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPRAZolam 0.25 mg oral Dis Tab [HMC]

Facility

$9.55

Service Code	NDC 49884011052
Hospital Charge Code	3800461
Hospital Revenue Code	250
Min. Negotiated Rate	$8.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.60
Rate for Payer: UnitedHealthcare Commercial	$9.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPRAZolam 0.25 mg oral Dis Tab [HMC]

Facility

$9.55

Service Code	NDC 49884011052
Hospital Charge Code	3800461
Hospital Revenue Code	250
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$9.07
Rate for Payer: Aetna Commercial	$8.60
Rate for Payer: Humana Medicare Advantage	$4.01
Rate for Payer: UnitedHealthcare Commercial	$9.07
Rate for Payer: UnitedHealthcare Medicaid	$3.82
Rate for Payer: WPPA Medicare Advantage	$5.73

ALPRAZolam 0.25 mg oral Dis Tab [HMC]

Facility

$9.55

Service Code	NDC 49884011074
Hospital Charge Code	3800461
Hospital Revenue Code	250
Min. Negotiated Rate	$8.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.60
Rate for Payer: UnitedHealthcare Commercial	$9.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPRAZolam 0.25 mg oral Dis Tab [HMC]

Facility

$9.55

Service Code	NDC 49884011074
Hospital Charge Code	3800461
Hospital Revenue Code	250
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$9.07
Rate for Payer: Aetna Commercial	$8.60
Rate for Payer: Humana Medicare Advantage	$4.01
Rate for Payer: UnitedHealthcare Commercial	$9.07
Rate for Payer: UnitedHealthcare Medicaid	$3.82
Rate for Payer: WPPA Medicare Advantage	$5.73

ALPRAZolam 0.25 mg Tab [HMC]

Facility

$6.09

Service Code	NDC 60687037701
Hospital Charge Code	3808280
Hospital Revenue Code	250
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$5.79
Rate for Payer: Aetna Commercial	$5.48
Rate for Payer: Humana Medicare Advantage	$2.56
Rate for Payer: UnitedHealthcare Commercial	$5.79
Rate for Payer: UnitedHealthcare Medicaid	$2.44
Rate for Payer: WPPA Medicare Advantage	$3.65

ALPRAZolam 0.25 mg Tab [HMC]

Facility

$6.09

Service Code	NDC 60687037701
Hospital Charge Code	3808280
Hospital Revenue Code	250
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.48
Rate for Payer: UnitedHealthcare Commercial	$5.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPRAZolam 0.25 mg Tab [HMC]

Facility

$6.85

Service Code	NDC 59762371901
Hospital Charge Code	3808280
Hospital Revenue Code	250
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$6.51
Rate for Payer: Aetna Commercial	$6.17
Rate for Payer: Humana Medicare Advantage	$2.88
Rate for Payer: UnitedHealthcare Commercial	$6.51
Rate for Payer: UnitedHealthcare Medicaid	$2.74
Rate for Payer: WPPA Medicare Advantage	$4.11

ALPRAZolam 0.25 mg Tab [HMC]

Facility

$6.98

Service Code	NDC 51991070401
Hospital Charge Code	3808280
Hospital Revenue Code	250
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$6.63
Rate for Payer: Aetna Commercial	$6.28
Rate for Payer: Humana Medicare Advantage	$2.93
Rate for Payer: UnitedHealthcare Commercial	$6.63
Rate for Payer: UnitedHealthcare Medicaid	$2.79
Rate for Payer: WPPA Medicare Advantage	$4.19

ALPRAZolam 0.25 mg Tab [HMC]

Facility

$6.85

Service Code	NDC 59762371901
Hospital Charge Code	3808280
Hospital Revenue Code	250
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.17
Rate for Payer: UnitedHealthcare Commercial	$6.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPRAZolam 0.25 mg Tab [HMC]

Facility

$7.08

Service Code	NDC 65862067601
Hospital Charge Code	3808280
Hospital Revenue Code	250
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$6.73
Rate for Payer: Aetna Commercial	$6.37
Rate for Payer: Humana Medicare Advantage	$2.97
Rate for Payer: UnitedHealthcare Commercial	$6.73
Rate for Payer: UnitedHealthcare Medicaid	$2.83
Rate for Payer: WPPA Medicare Advantage	$4.25

ALPRAZolam 0.25 mg Tab [HMC]

Facility

$7.08

Service Code	NDC 65862067601
Hospital Charge Code	3808280
Hospital Revenue Code	250
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.37
Rate for Payer: UnitedHealthcare Commercial	$6.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPRAZolam 0.25 mg Tab [HMC]

Facility

$6.98

Service Code	NDC 51991070401
Hospital Charge Code	3808280
Hospital Revenue Code	250
Min. Negotiated Rate	$6.28
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.28
Rate for Payer: UnitedHealthcare Commercial	$6.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPRAZolam 1 mg ER Tab [HMC]

Facility

$13.02

Service Code	NDC 65862045560
Hospital Charge Code	3800118
Hospital Revenue Code	250
Min. Negotiated Rate	$5.21
Max. Negotiated Rate	$12.37
Rate for Payer: Aetna Commercial	$11.72
Rate for Payer: Humana Medicare Advantage	$5.47
Rate for Payer: UnitedHealthcare Commercial	$12.37
Rate for Payer: UnitedHealthcare Medicaid	$5.21
Rate for Payer: WPPA Medicare Advantage	$7.81

ALPRAZolam 1 mg ER Tab [HMC]

Facility

$13.42

Service Code	NDC 00228308406
Hospital Charge Code	3800118
Hospital Revenue Code	250
Min. Negotiated Rate	$12.08
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.08
Rate for Payer: UnitedHealthcare Commercial	$12.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPRAZolam 1 mg ER Tab [HMC]

Facility

$13.02

Service Code	NDC 65862045560
Hospital Charge Code	3800118
Hospital Revenue Code	250
Min. Negotiated Rate	$11.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.72
Rate for Payer: UnitedHealthcare Commercial	$12.37
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPRAZolam 1 mg ER Tab [HMC]

Facility

$13.42

Service Code	NDC 00228308406
Hospital Charge Code	3800118
Hospital Revenue Code	250
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$12.75
Rate for Payer: Aetna Commercial	$12.08
Rate for Payer: Humana Medicare Advantage	$5.64
Rate for Payer: UnitedHealthcare Commercial	$12.75
Rate for Payer: UnitedHealthcare Medicaid	$5.37
Rate for Payer: WPPA Medicare Advantage	$8.05

ALPRAZolam 1 mg Tab [HMC]

Facility

$18.46

Service Code	NDC 65862067801
Hospital Charge Code	3800354
Hospital Revenue Code	250
Min. Negotiated Rate	$16.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.61
Rate for Payer: UnitedHealthcare Commercial	$17.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPRAZolam 1 mg Tab [HMC]

Facility

$17.95

Service Code	NDC 59762372101
Hospital Charge Code	3800354
Hospital Revenue Code	250
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.16
Rate for Payer: UnitedHealthcare Commercial	$17.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPRAZolam 1 mg Tab [HMC]

Facility

$17.95

Service Code	NDC 59762372101
Hospital Charge Code	3800354
Hospital Revenue Code	250
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$17.05
Rate for Payer: Aetna Commercial	$16.16
Rate for Payer: Humana Medicare Advantage	$7.54
Rate for Payer: UnitedHealthcare Commercial	$17.05
Rate for Payer: UnitedHealthcare Medicaid	$7.18
Rate for Payer: WPPA Medicare Advantage	$10.77

ALPRAZolam 1 mg Tab [HMC]

Facility

$18.46

Service Code	NDC 65862067801
Hospital Charge Code	3800354
Hospital Revenue Code	250
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$17.54
Rate for Payer: Aetna Commercial	$16.61
Rate for Payer: Humana Medicare Advantage	$7.75
Rate for Payer: UnitedHealthcare Commercial	$17.54
Rate for Payer: UnitedHealthcare Medicaid	$7.38
Rate for Payer: WPPA Medicare Advantage	$11.08

ALPS COMPRESSION WIRESHORT

Facility

$141.75

Hospital Charge Code	3258138
Hospital Revenue Code	270
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$134.66
Rate for Payer: Aetna Commercial	$127.58
Rate for Payer: Humana Medicare Advantage	$59.53
Rate for Payer: UnitedHealthcare Commercial	$134.66
Rate for Payer: UnitedHealthcare Medicaid	$56.70
Rate for Payer: WPPA Medicare Advantage	$85.05

ALPS COMPRESSION WIRESHORT

Facility

$141.75

Hospital Charge Code	3258138
Hospital Revenue Code	270
Min. Negotiated Rate	$127.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$127.58
Rate for Payer: UnitedHealthcare Commercial	$134.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ALPS INLINE FUSION PLATE 3.5MM

Facility

$1,410.00

Hospital Charge Code	3258134
Hospital Revenue Code	270
Min. Negotiated Rate	$564.00
Max. Negotiated Rate	$1,339.50
Rate for Payer: Aetna Commercial	$1,269.00
Rate for Payer: Humana Medicare Advantage	$592.20
Rate for Payer: UnitedHealthcare Commercial	$1,339.50
Rate for Payer: UnitedHealthcare Medicaid	$564.00
Rate for Payer: WPPA Medicare Advantage	$846.00

Know your out-of-pocket cost for care.

All Charges