Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

atropine-diphenoxylate 0.025 mg-2.5 mg Tab [HMC]

Facility

$6.43

Service Code	NDC 51079006720
Hospital Charge Code	3806078
Hospital Revenue Code	250
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$6.11
Rate for Payer: Aetna Commercial	$5.79
Rate for Payer: Humana Medicare Advantage	$2.70
Rate for Payer: UnitedHealthcare Commercial	$6.11
Rate for Payer: UnitedHealthcare Medicaid	$2.57
Rate for Payer: WPPA Medicare Advantage	$3.86

atropine-diphenoxylate 0.025 mg-2.5 mg Tab [HMC]

Facility

$6.43

Service Code	NDC 51079006720
Hospital Charge Code	3806078
Hospital Revenue Code	250
Min. Negotiated Rate	$5.79
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.79
Rate for Payer: UnitedHealthcare Commercial	$6.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

atropine-diphenoxylate 0.025 mg-2.5 mg Tab [HMC]

Facility

$7.10

Service Code	NDC 62559049001
Hospital Charge Code	3806078
Hospital Revenue Code	250
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$6.75
Rate for Payer: Aetna Commercial	$6.39
Rate for Payer: Humana Medicare Advantage	$2.98
Rate for Payer: UnitedHealthcare Commercial	$6.75
Rate for Payer: UnitedHealthcare Medicaid	$2.84
Rate for Payer: WPPA Medicare Advantage	$4.26

atropine-diphenoxylate 0.025 mg-2.5 mg Tab [HMC]

Facility

$7.10

Service Code	NDC 62559049001
Hospital Charge Code	3806078
Hospital Revenue Code	250
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.39
Rate for Payer: UnitedHealthcare Commercial	$6.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

atropine Ophth 1% Sol 2 mL [HMC]

Facility

$84.61

Service Code	NDC 17478021502
Hospital Charge Code	3800236
Hospital Revenue Code	250
Min. Negotiated Rate	$33.84
Max. Negotiated Rate	$80.38
Rate for Payer: Aetna Commercial	$76.15
Rate for Payer: Humana Medicare Advantage	$35.54
Rate for Payer: UnitedHealthcare Commercial	$80.38
Rate for Payer: UnitedHealthcare Medicaid	$33.84
Rate for Payer: WPPA Medicare Advantage	$50.77

atropine Ophth 1% Sol 2 mL [HMC]

Facility

$84.61

Service Code	NDC 17478021502
Hospital Charge Code	3800236
Hospital Revenue Code	250
Min. Negotiated Rate	$76.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$76.15
Rate for Payer: UnitedHealthcare Commercial	$80.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

atropine Ophth 1% Sol [HMC]

Facility

$94.87

Service Code	NDC 60505622601
Hospital Charge Code	3800236
Hospital Revenue Code	250
Min. Negotiated Rate	$85.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$85.38
Rate for Payer: UnitedHealthcare Commercial	$90.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

atropine Ophth 1% Sol [HMC]

Facility

$113.26

Service Code	NDC 00065081701
Hospital Charge Code	3800236
Hospital Revenue Code	250
Min. Negotiated Rate	$101.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.93
Rate for Payer: UnitedHealthcare Commercial	$107.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

atropine Ophth 1% Sol [HMC]

Facility

$113.26

Service Code	NDC 00065081701
Hospital Charge Code	3800236
Hospital Revenue Code	250
Min. Negotiated Rate	$45.30
Max. Negotiated Rate	$107.60
Rate for Payer: Aetna Commercial	$101.93
Rate for Payer: Humana Medicare Advantage	$47.57
Rate for Payer: UnitedHealthcare Commercial	$107.60
Rate for Payer: UnitedHealthcare Medicaid	$45.30
Rate for Payer: WPPA Medicare Advantage	$67.96

atropine Ophth 1% Sol [HMC]

Facility

$98.81

Service Code	NDC 60219174903
Hospital Charge Code	3800236
Hospital Revenue Code	250
Min. Negotiated Rate	$88.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$88.93
Rate for Payer: UnitedHealthcare Commercial	$93.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

atropine Ophth 1% Sol [HMC]

Facility

$98.81

Service Code	NDC 60219174903
Hospital Charge Code	3800236
Hospital Revenue Code	250
Min. Negotiated Rate	$39.52
Max. Negotiated Rate	$93.87
Rate for Payer: Aetna Commercial	$88.93
Rate for Payer: Humana Medicare Advantage	$41.50
Rate for Payer: UnitedHealthcare Commercial	$93.87
Rate for Payer: UnitedHealthcare Medicaid	$39.52
Rate for Payer: WPPA Medicare Advantage	$59.29

atropine Ophth 1% Sol [HMC]

Facility

$113.26

Service Code	NDC 00065030355
Hospital Charge Code	3800236
Hospital Revenue Code	250
Min. Negotiated Rate	$45.30
Max. Negotiated Rate	$107.60
Rate for Payer: Aetna Commercial	$101.93
Rate for Payer: Humana Medicare Advantage	$47.57
Rate for Payer: UnitedHealthcare Commercial	$107.60
Rate for Payer: UnitedHealthcare Medicaid	$45.30
Rate for Payer: WPPA Medicare Advantage	$67.96

atropine Ophth 1% Sol [HMC]

Facility

$113.26

Service Code	NDC 00065030355
Hospital Charge Code	3800236
Hospital Revenue Code	250
Min. Negotiated Rate	$101.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.93
Rate for Payer: UnitedHealthcare Commercial	$107.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

atropine Ophth 1% Sol [HMC]

Facility

$94.87

Service Code	NDC 60505622601
Hospital Charge Code	3800236
Hospital Revenue Code	250
Min. Negotiated Rate	$37.95
Max. Negotiated Rate	$90.13
Rate for Payer: Aetna Commercial	$85.38
Rate for Payer: Humana Medicare Advantage	$39.85
Rate for Payer: UnitedHealthcare Commercial	$90.13
Rate for Payer: UnitedHealthcare Medicaid	$37.95
Rate for Payer: WPPA Medicare Advantage	$56.92

Attended E-Stim Charges

Facility

$97.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	3950200
Hospital Revenue Code	420
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$92.15
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$34.34
Rate for Payer: Humana Medicare Advantage	$40.74
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: UnitedHealthcare Medicaid	$8.58
Rate for Payer: WPPA Medicare Advantage	$58.20

Attended E-Stim Charges

Facility

$97.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	3950200
Hospital Revenue Code	420
Min. Negotiated Rate	$87.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Attended E-Stim Charges

Facility

$97.00

Service Code	HCPCS 97032 GO
Hospital Charge Code	3970260
Hospital Revenue Code	430
Min. Negotiated Rate	$87.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Attended E-Stim Charges

Facility

$97.00

Service Code	HCPCS 97032 GO
Hospital Charge Code	3970260
Hospital Revenue Code	430
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$92.15
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$34.34
Rate for Payer: Humana Medicare Advantage	$40.74
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: UnitedHealthcare Medicaid	$8.58
Rate for Payer: WPPA Medicare Advantage	$58.20

AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC

Facility

$18,966.69

Service Code	MSDRG 016
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$18,966.69
Rate for Payer: UnitedHealthcare Medicaid	$18,966.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC

Facility

$17,378.19

Service Code	MSDRG 017
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$17,378.19
Rate for Payer: UnitedHealthcare Medicaid	$17,378.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Avocado (f96) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552827
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

Avocado (f96) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552827
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

Avulsion - Nail Repair Type

Facility

$301.00

Service Code	HCPCS 11730
Hospital Charge Code	3300186
Hospital Revenue Code	450
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$270.90
Rate for Payer: UnitedHealthcare Commercial	$285.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Avulsion - Nail Repair Type

Facility

$301.00

Service Code	HCPCS 11730
Hospital Charge Code	3300186
Hospital Revenue Code	450
Min. Negotiated Rate	$126.42
Max. Negotiated Rate	$285.95
Rate for Payer: Aetna Commercial	$270.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$217.71
Rate for Payer: Humana Medicare Advantage	$126.42
Rate for Payer: UnitedHealthcare Commercial	$285.95
Rate for Payer: UnitedHealthcare Medicaid	$260.00
Rate for Payer: WPPA Medicare Advantage	$180.60

azaTHIOprine 50 mg Tab [HMC]

Facility

$11.33

Service Code	HCPCS J7500
Hospital Charge Code	3804503
Hospital Revenue Code	250
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$10.76
Rate for Payer: Aetna Commercial	$10.20
Rate for Payer: Aetna Commercial	$6.79
Rate for Payer: Aetna Commercial	$8.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.30
Rate for Payer: Humana Medicare Advantage	$3.17
Rate for Payer: Humana Medicare Advantage	$4.76
Rate for Payer: Humana Medicare Advantage	$3.92
Rate for Payer: UnitedHealthcare Commercial	$8.86
Rate for Payer: UnitedHealthcare Commercial	$10.76
Rate for Payer: UnitedHealthcare Commercial	$7.16
Rate for Payer: UnitedHealthcare Medicaid	$3.73
Rate for Payer: UnitedHealthcare Medicaid	$3.02
Rate for Payer: UnitedHealthcare Medicaid	$4.53
Rate for Payer: WPPA Medicare Advantage	$6.80
Rate for Payer: WPPA Medicare Advantage	$4.52
Rate for Payer: WPPA Medicare Advantage	$5.60

Know your out-of-pocket cost for care.

All Charges