Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

ALPS INLINE FUSION PLATE 3.5MM

Facility

$1,410.00

Hospital Charge Code	3258134
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,339.50
Rate for Payer: Aetna Commercial	$1,269.00
Rate for Payer: UnitedHealthcare Commercial	$1,339.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

alteplase 100 mg IV Inj [HMC]

Facility

$18,480.75

Service Code	HCPCS J2997
Hospital Charge Code	3805469
Hospital Revenue Code	250
Min. Negotiated Rate	$93.83
Max. Negotiated Rate	$17,556.71
Rate for Payer: Aetna Commercial	$16,632.67
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$112.88
Rate for Payer: Humana Medicare Advantage	$7,761.91
Rate for Payer: UnitedHealthcare Commercial	$17,556.71
Rate for Payer: UnitedHealthcare Medicaid	$93.83
Rate for Payer: WPPA Medicare Advantage	$11,088.45

alteplase 100 mg IV Inj [HMC]

Facility

$18,480.75

Service Code	HCPCS J2997
Hospital Charge Code	3805469
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$17,556.71
Rate for Payer: Aetna Commercial	$16,632.67
Rate for Payer: UnitedHealthcare Commercial	$17,556.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

alteplase 2 mg IV Inj [HMC]

Facility

$337.43

Service Code	HCPCS J2997
Hospital Charge Code	3850484
Hospital Revenue Code	250
Min. Negotiated Rate	$93.83
Max. Negotiated Rate	$320.56
Rate for Payer: Aetna Commercial	$303.69
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$112.88
Rate for Payer: Humana Medicare Advantage	$141.72
Rate for Payer: UnitedHealthcare Commercial	$320.56
Rate for Payer: UnitedHealthcare Medicaid	$93.83
Rate for Payer: WPPA Medicare Advantage	$202.46

alteplase 2 mg IV Inj [HMC]

Facility

$337.43

Service Code	HCPCS J2997
Hospital Charge Code	3850484
Hospital Revenue Code	250
Min. Negotiated Rate	$303.69
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$303.69
Rate for Payer: UnitedHealthcare Commercial	$320.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Alternaria alternata (M6) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1001
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

Alternaria alternata (M6) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1001
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

amantadine 100 mg Cap [HMC]

Facility

$10.05

Service Code	NDC 00904704206
Hospital Charge Code	3804230
Hospital Revenue Code	250
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.04
Rate for Payer: UnitedHealthcare Commercial	$9.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amantadine 100 mg Cap [HMC]

Facility

$15.45

Service Code	NDC 50268006915
Hospital Charge Code	3804230
Hospital Revenue Code	250
Min. Negotiated Rate	$13.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.90
Rate for Payer: UnitedHealthcare Commercial	$14.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amantadine 100 mg Cap [HMC]

Facility

$9.66

Service Code	NDC 00904704261
Hospital Charge Code	3804230
Hospital Revenue Code	250
Min. Negotiated Rate	$8.69
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.69
Rate for Payer: UnitedHealthcare Commercial	$9.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amantadine 100 mg Cap [HMC]

Facility

$10.05

Service Code	NDC 00904704206
Hospital Charge Code	3804230
Hospital Revenue Code	250
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$9.55
Rate for Payer: Aetna Commercial	$9.04
Rate for Payer: Humana Medicare Advantage	$4.22
Rate for Payer: UnitedHealthcare Commercial	$9.55
Rate for Payer: UnitedHealthcare Medicaid	$4.02
Rate for Payer: WPPA Medicare Advantage	$6.03

amantadine 100 mg Cap [HMC]

Facility

$15.45

Service Code	NDC 50268006915
Hospital Charge Code	3804230
Hospital Revenue Code	250
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$14.68
Rate for Payer: Aetna Commercial	$13.90
Rate for Payer: Humana Medicare Advantage	$6.49
Rate for Payer: UnitedHealthcare Commercial	$14.68
Rate for Payer: UnitedHealthcare Medicaid	$6.18
Rate for Payer: WPPA Medicare Advantage	$9.27

amantadine 100 mg Cap [HMC]

Facility

$9.66

Service Code	NDC 00904704261
Hospital Charge Code	3804230
Hospital Revenue Code	250
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$9.18
Rate for Payer: Aetna Commercial	$8.69
Rate for Payer: Humana Medicare Advantage	$4.06
Rate for Payer: UnitedHealthcare Commercial	$9.18
Rate for Payer: UnitedHealthcare Medicaid	$3.86
Rate for Payer: WPPA Medicare Advantage	$5.80

AMB methylprednisolone sodium Charge

Facility

$57.00

Service Code	HCPCS J2930
Hospital Charge Code	3803298
Hospital Revenue Code	636
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$54.15
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Humana Medicare Advantage	$23.94
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: UnitedHealthcare Medicaid	$22.80
Rate for Payer: WPPA Medicare Advantage	$34.20

AMB methylprednisolone sodium Charge

Facility

$57.00

Service Code	HCPCS J2930
Hospital Charge Code	3803298
Hospital Revenue Code	636
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amikacin 250 mg/mL [HMC]

Facility

$46.47

Service Code	HCPCS J0278
Hospital Charge Code	3808678
Hospital Revenue Code	250
Min. Negotiated Rate	$41.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.82
Rate for Payer: Aetna Commercial	$57.71
Rate for Payer: UnitedHealthcare Commercial	$60.91
Rate for Payer: UnitedHealthcare Commercial	$44.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amikacin 250 mg/mL [HMC]

Facility

$64.12

Service Code	HCPCS J0278
Hospital Charge Code	3808678
Hospital Revenue Code	250
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$60.91
Rate for Payer: Aetna Commercial	$57.71
Rate for Payer: Aetna Commercial	$41.82
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.09
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.09
Rate for Payer: Humana Medicare Advantage	$19.52
Rate for Payer: Humana Medicare Advantage	$26.93
Rate for Payer: UnitedHealthcare Commercial	$44.15
Rate for Payer: UnitedHealthcare Commercial	$60.91
Rate for Payer: UnitedHealthcare Medicaid	$0.62
Rate for Payer: UnitedHealthcare Medicaid	$0.62
Rate for Payer: WPPA Medicare Advantage	$27.88
Rate for Payer: WPPA Medicare Advantage	$38.47

Amino Acids 4.25% with 10% Dextrose (Clinimix Sulfite-Free) IV Sol 2000 mL [HMC]

Facility

$342.94

Service Code	NDC 00338109104
Hospital Charge Code	3800117
Hospital Revenue Code	250
Min. Negotiated Rate	$308.65
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$308.65
Rate for Payer: UnitedHealthcare Commercial	$325.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Amino Acids 4.25% with 10% Dextrose (Clinimix Sulfite-Free) IV Sol 2000 mL [HMC]

Facility

$342.94

Service Code	NDC 00338109104
Hospital Charge Code	3800117
Hospital Revenue Code	250
Min. Negotiated Rate	$137.18
Max. Negotiated Rate	$325.79
Rate for Payer: Aetna Commercial	$308.65
Rate for Payer: Humana Medicare Advantage	$144.03
Rate for Payer: UnitedHealthcare Commercial	$325.79
Rate for Payer: UnitedHealthcare Medicaid	$137.18
Rate for Payer: WPPA Medicare Advantage	$205.76

aminophylline 25 mg/mL IV Sol [HMC]

Facility

$69.49

Service Code	HCPCS J0280
Hospital Charge Code	3800019
Hospital Revenue Code	250
Min. Negotiated Rate	$10.41
Max. Negotiated Rate	$66.02
Rate for Payer: Aetna Commercial	$62.54
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.36
Rate for Payer: Humana Medicare Advantage	$29.19
Rate for Payer: UnitedHealthcare Commercial	$66.02
Rate for Payer: UnitedHealthcare Medicaid	$10.41
Rate for Payer: WPPA Medicare Advantage	$41.69

aminophylline 25 mg/mL IV Sol [HMC]

Facility

$69.49

Service Code	HCPCS J0280
Hospital Charge Code	3800019
Hospital Revenue Code	250
Min. Negotiated Rate	$62.54
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$62.54
Rate for Payer: UnitedHealthcare Commercial	$66.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amiodarone 200 mg Tab [HMC]

Facility

$15.15

Service Code	NDC 29300035916
Hospital Charge Code	3804255
Hospital Revenue Code	250
Min. Negotiated Rate	$13.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.63
Rate for Payer: UnitedHealthcare Commercial	$14.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amiodarone 200 mg Tab [HMC]

Facility

$6.06

Service Code	NDC 00904699361
Hospital Charge Code	3804255
Hospital Revenue Code	250
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.45
Rate for Payer: UnitedHealthcare Commercial	$5.76
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amiodarone 200 mg Tab [HMC]

Facility

$6.06

Service Code	NDC 00904699361
Hospital Charge Code	3804255
Hospital Revenue Code	250
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$5.76
Rate for Payer: Aetna Commercial	$5.45
Rate for Payer: Humana Medicare Advantage	$2.55
Rate for Payer: UnitedHealthcare Commercial	$5.76
Rate for Payer: UnitedHealthcare Medicaid	$2.42
Rate for Payer: WPPA Medicare Advantage	$3.64

amiodarone 200 mg Tab [HMC]

Facility

$15.15

Service Code	NDC 29300035916
Hospital Charge Code	3804255
Hospital Revenue Code	250
Min. Negotiated Rate	$6.06
Max. Negotiated Rate	$14.39
Rate for Payer: Aetna Commercial	$13.63
Rate for Payer: Humana Medicare Advantage	$6.36
Rate for Payer: UnitedHealthcare Commercial	$14.39
Rate for Payer: UnitedHealthcare Medicaid	$6.06
Rate for Payer: WPPA Medicare Advantage	$9.09

Know your out-of-pocket cost for care.

All Charges