Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

bacitracin/neomycin/polymyxin B Top Oint [HMC]

Facility

$26.59

Service Code	NDC 45802014303
Hospital Charge Code	3807498
Hospital Revenue Code	250
Min. Negotiated Rate	$10.64
Max. Negotiated Rate	$25.26
Rate for Payer: Aetna Commercial	$23.93
Rate for Payer: Humana Medicare Advantage	$11.17
Rate for Payer: UnitedHealthcare Commercial	$25.26
Rate for Payer: UnitedHealthcare Medicaid	$10.64
Rate for Payer: WPPA Medicare Advantage	$15.95

bacitracin/neomycin/polymyxin B Top Oint [HMC]

Facility

$29.22

Service Code	NDC 00168001235
Hospital Charge Code	3807498
Hospital Revenue Code	250
Min. Negotiated Rate	$26.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.30
Rate for Payer: UnitedHealthcare Commercial	$27.76
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bacitracin Top 500 units/g Oint [HMC]

Facility

$46.39

Service Code	NDC 00713028031
Hospital Charge Code	3808967
Hospital Revenue Code	250
Min. Negotiated Rate	$18.56
Max. Negotiated Rate	$44.07
Rate for Payer: Aetna Commercial	$41.75
Rate for Payer: Humana Medicare Advantage	$19.48
Rate for Payer: UnitedHealthcare Commercial	$44.07
Rate for Payer: UnitedHealthcare Medicaid	$18.56
Rate for Payer: WPPA Medicare Advantage	$27.83

bacitracin Top 500 units/g Oint [HMC]

Facility

$64.96

Service Code	NDC 45802006070
Hospital Charge Code	3808967
Hospital Revenue Code	250
Min. Negotiated Rate	$58.46
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$58.46
Rate for Payer: UnitedHealthcare Commercial	$61.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bacitracin Top 500 units/g Oint [HMC]

Facility

$46.39

Service Code	NDC 00713028031
Hospital Charge Code	3808967
Hospital Revenue Code	250
Min. Negotiated Rate	$41.75
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.75
Rate for Payer: UnitedHealthcare Commercial	$44.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bacitracin Top 500 units/g Oint [HMC]

Facility

$64.96

Service Code	NDC 45802006070
Hospital Charge Code	3808967
Hospital Revenue Code	250
Min. Negotiated Rate	$25.98
Max. Negotiated Rate	$61.71
Rate for Payer: Aetna Commercial	$58.46
Rate for Payer: Humana Medicare Advantage	$27.28
Rate for Payer: UnitedHealthcare Commercial	$61.71
Rate for Payer: UnitedHealthcare Medicaid	$25.98
Rate for Payer: WPPA Medicare Advantage	$38.98

bacitracin topical 500 units/g Oint [HMC]

Facility

$56.45

Service Code	NDC 45802006003
Hospital Charge Code	3808967
Hospital Revenue Code	250
Min. Negotiated Rate	$50.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.80
Rate for Payer: UnitedHealthcare Commercial	$53.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bacitracin topical 500 units/g Oint [HMC]

Facility

$56.45

Service Code	NDC 45802006003
Hospital Charge Code	3808967
Hospital Revenue Code	250
Min. Negotiated Rate	$22.58
Max. Negotiated Rate	$53.63
Rate for Payer: Aetna Commercial	$50.80
Rate for Payer: Humana Medicare Advantage	$23.71
Rate for Payer: UnitedHealthcare Commercial	$53.63
Rate for Payer: UnitedHealthcare Medicaid	$22.58
Rate for Payer: WPPA Medicare Advantage	$33.87

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC

Facility

$7,561.26

Service Code	MSDRG 519
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,561.26
Rate for Payer: UnitedHealthcare Medicaid	$7,561.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR

Facility

$14,137.65

Service Code	MSDRG 518
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,137.65
Rate for Payer: UnitedHealthcare Medicaid	$14,137.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC

Facility

$5,655.06

Service Code	MSDRG 520
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,655.06
Rate for Payer: UnitedHealthcare Medicaid	$5,655.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

baclofen 0.5 mg/mL intrathecal Sol 20 mL [HMC]

Facility

$445.33

Service Code	NDC 66794015502
Hospital Charge Code	3800404
Hospital Revenue Code	250
Min. Negotiated Rate	$400.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$400.80
Rate for Payer: UnitedHealthcare Commercial	$423.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

baclofen 0.5 mg/mL intrathecal Sol 20 mL [HMC]

Facility

$407.00

Service Code	HCPCS J0475
Hospital Charge Code	3800404
Hospital Revenue Code	250
Min. Negotiated Rate	$170.94
Max. Negotiated Rate	$386.65
Rate for Payer: Aetna Commercial	$366.30
Rate for Payer: Aetna Commercial	$400.80
Rate for Payer: Aetna Commercial	$331.12
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$234.41
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$234.41
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$234.41
Rate for Payer: Humana Medicare Advantage	$187.04
Rate for Payer: Humana Medicare Advantage	$154.52
Rate for Payer: Humana Medicare Advantage	$170.94
Rate for Payer: UnitedHealthcare Commercial	$423.06
Rate for Payer: UnitedHealthcare Commercial	$386.65
Rate for Payer: UnitedHealthcare Commercial	$349.51
Rate for Payer: UnitedHealthcare Medicaid	$181.47
Rate for Payer: UnitedHealthcare Medicaid	$181.47
Rate for Payer: UnitedHealthcare Medicaid	$181.47
Rate for Payer: WPPA Medicare Advantage	$267.20
Rate for Payer: WPPA Medicare Advantage	$220.75
Rate for Payer: WPPA Medicare Advantage	$244.20

baclofen 0.5 mg/mL intrathecal Sol 20 mL [HMC]

Facility

$367.91

Service Code	HCPCS J0475
Hospital Charge Code	3800404
Hospital Revenue Code	250
Min. Negotiated Rate	$331.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$331.12
Rate for Payer: Aetna Commercial	$366.30
Rate for Payer: Aetna Commercial	$400.80
Rate for Payer: UnitedHealthcare Commercial	$423.06
Rate for Payer: UnitedHealthcare Commercial	$386.65
Rate for Payer: UnitedHealthcare Commercial	$349.51
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

baclofen 0.5 mg/mL intrathecal Sol 20 mL [HMC]

Facility

$445.33

Service Code	NDC 66794015502
Hospital Charge Code	3800404
Hospital Revenue Code	250
Min. Negotiated Rate	$178.13
Max. Negotiated Rate	$423.06
Rate for Payer: Aetna Commercial	$400.80
Rate for Payer: Humana Medicare Advantage	$187.04
Rate for Payer: UnitedHealthcare Commercial	$423.06
Rate for Payer: UnitedHealthcare Medicaid	$178.13
Rate for Payer: WPPA Medicare Advantage	$267.20

baclofen 0.5 mg/mL Sol

Facility

$445.33

Service Code	HCPCS J0475
Hospital Charge Code	3800404
Hospital Revenue Code	250
Min. Negotiated Rate	$400.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$400.80
Rate for Payer: UnitedHealthcare Commercial	$423.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

baclofen 0.5 mg/mL Sol

Facility

$445.33

Service Code	HCPCS J0475
Hospital Charge Code	3800404
Hospital Revenue Code	250
Min. Negotiated Rate	$181.47
Max. Negotiated Rate	$423.06
Rate for Payer: Aetna Commercial	$400.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$234.41
Rate for Payer: Humana Medicare Advantage	$187.04
Rate for Payer: UnitedHealthcare Commercial	$423.06
Rate for Payer: UnitedHealthcare Medicaid	$181.47
Rate for Payer: WPPA Medicare Advantage	$267.20

baclofen 10 mg Tab [HMC]

Facility

$6.51

Service Code	NDC 00904647561
Hospital Charge Code	3808067
Hospital Revenue Code	250
Min. Negotiated Rate	$5.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.86
Rate for Payer: UnitedHealthcare Commercial	$6.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

baclofen 10 mg Tab [HMC]

Facility

$6.51

Service Code	NDC 00904647561
Hospital Charge Code	3808067
Hospital Revenue Code	250
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$6.18
Rate for Payer: Aetna Commercial	$5.86
Rate for Payer: Humana Medicare Advantage	$2.73
Rate for Payer: UnitedHealthcare Commercial	$6.18
Rate for Payer: UnitedHealthcare Medicaid	$2.60
Rate for Payer: WPPA Medicare Advantage	$3.91

baclofen 10 mg Tab [HMC]

Facility

$7.21

Service Code	NDC 68084085501
Hospital Charge Code	3808067
Hospital Revenue Code	250
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$6.85
Rate for Payer: Aetna Commercial	$6.49
Rate for Payer: Humana Medicare Advantage	$3.03
Rate for Payer: UnitedHealthcare Commercial	$6.85
Rate for Payer: UnitedHealthcare Medicaid	$2.88
Rate for Payer: WPPA Medicare Advantage	$4.33

baclofen 10 mg Tab [HMC]

Facility

$7.21

Service Code	NDC 68084085501
Hospital Charge Code	3808067
Hospital Revenue Code	250
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.49
Rate for Payer: UnitedHealthcare Commercial	$6.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

baclofen 2 mg/mL intrathecal Sol [HMC]

Facility

$871.40

Service Code	HCPCS J0475
Hospital Charge Code	3800149
Hospital Revenue Code	250
Min. Negotiated Rate	$181.47
Max. Negotiated Rate	$827.83
Rate for Payer: Aetna Commercial	$784.26
Rate for Payer: Aetna Commercial	$1,549.13
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$234.41
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$234.41
Rate for Payer: Humana Medicare Advantage	$722.93
Rate for Payer: Humana Medicare Advantage	$365.99
Rate for Payer: UnitedHealthcare Commercial	$827.83
Rate for Payer: UnitedHealthcare Commercial	$1,635.20
Rate for Payer: UnitedHealthcare Medicaid	$181.47
Rate for Payer: UnitedHealthcare Medicaid	$181.47
Rate for Payer: WPPA Medicare Advantage	$1,032.76
Rate for Payer: WPPA Medicare Advantage	$522.84

baclofen 2 mg/mL intrathecal Sol [HMC]

Facility

$1,721.26

Service Code	HCPCS J0475
Hospital Charge Code	3800149
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,635.20
Rate for Payer: Aetna Commercial	$1,549.13
Rate for Payer: Aetna Commercial	$784.26
Rate for Payer: UnitedHealthcare Commercial	$1,635.20
Rate for Payer: UnitedHealthcare Commercial	$827.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC

Facility

$13,470.48

Service Code	MSDRG 095
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$13,470.48
Rate for Payer: UnitedHealthcare Medicaid	$13,470.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC

Facility

$14,137.65

Service Code	MSDRG 094
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,137.65
Rate for Payer: UnitedHealthcare Medicaid	$14,137.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges