Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

BD Bone Density DEXA App Skeleton

Facility

$149.00

Service Code	HCPCS 77081 TC
Hospital Charge Code	3690010
Hospital Revenue Code	320
Min. Negotiated Rate	$47.47
Max. Negotiated Rate	$141.55
Rate for Payer: Aetna Commercial	$134.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.47
Rate for Payer: Humana Medicare Advantage	$62.58
Rate for Payer: UnitedHealthcare Commercial	$141.55
Rate for Payer: UnitedHealthcare Medicaid	$59.60
Rate for Payer: WPPA Medicare Advantage	$89.40

BD Bone Density DEXA Axial Skeleton

Facility

$438.00

Service Code	HCPCS 77080 TC
Hospital Charge Code	3690015
Hospital Revenue Code	320
Min. Negotiated Rate	$394.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$394.20
Rate for Payer: UnitedHealthcare Commercial	$416.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BD Bone Density DEXA Axial Skeleton

Facility

$438.00

Service Code	HCPCS 77080 TC
Hospital Charge Code	3690015
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$416.10
Rate for Payer: Aetna Commercial	$394.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$197.96
Rate for Payer: Humana Medicare Advantage	$183.96
Rate for Payer: UnitedHealthcare Commercial	$416.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$262.80

beclomethasone Nasal 0.042 mg/inh Spry [HMC]

Facility

$495.24

Service Code	NDC 00173038879
Hospital Charge Code	3807036
Hospital Revenue Code	250
Min. Negotiated Rate	$198.10
Max. Negotiated Rate	$470.48
Rate for Payer: Aetna Commercial	$445.72
Rate for Payer: Humana Medicare Advantage	$208.00
Rate for Payer: UnitedHealthcare Commercial	$470.48
Rate for Payer: UnitedHealthcare Medicaid	$198.10
Rate for Payer: WPPA Medicare Advantage	$297.14

beclomethasone Nasal 0.042 mg/inh Spry [HMC]

Facility

$495.24

Service Code	NDC 00173038879
Hospital Charge Code	3807036
Hospital Revenue Code	250
Min. Negotiated Rate	$445.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$445.72
Rate for Payer: UnitedHealthcare Commercial	$470.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Beef (F27) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552801
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

Beef (F27) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552801
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

BEHAVIORAL AND DEVELOPMENTAL DISORDERS

Facility

$2,350.98

Service Code	MSDRG 886
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,350.98
Rate for Payer: UnitedHealthcare Medicaid	$2,350.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Behav/Qual Analysis of Voice and Resonance Charge

Facility

$226.00

Service Code	HCPCS 92524 GN
Hospital Charge Code	4052524
Hospital Revenue Code	444
Min. Negotiated Rate	$66.74
Max. Negotiated Rate	$214.70
Rate for Payer: Aetna Commercial	$203.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$116.15
Rate for Payer: Humana Medicare Advantage	$94.92
Rate for Payer: UnitedHealthcare Commercial	$214.70
Rate for Payer: UnitedHealthcare Medicaid	$66.74
Rate for Payer: WPPA Medicare Advantage	$135.60

Behav/Qual Analysis of Voice and Resonance Charge

Facility

$226.00

Service Code	HCPCS 92524 GN
Hospital Charge Code	4052524
Hospital Revenue Code	444
Min. Negotiated Rate	$203.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$203.40
Rate for Payer: UnitedHealthcare Commercial	$214.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

belatacept 250 mg Powder [HMC]

Facility

$1,755.78

Service Code	HCPCS J0485
Hospital Charge Code	3852067
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,667.99
Rate for Payer: Aetna Commercial	$1,580.20
Rate for Payer: UnitedHealthcare Commercial	$1,667.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

belatacept 250 mg Powder [HMC]

Facility

$1,755.78

Service Code	HCPCS J0485
Hospital Charge Code	3852067
Hospital Revenue Code	250
Min. Negotiated Rate	$3.89
Max. Negotiated Rate	$1,667.99
Rate for Payer: Aetna Commercial	$1,580.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4.88
Rate for Payer: Humana Medicare Advantage	$737.43
Rate for Payer: UnitedHealthcare Commercial	$1,667.99
Rate for Payer: UnitedHealthcare Medicaid	$3.89
Rate for Payer: WPPA Medicare Advantage	$1,053.47

belladonna-opium 16.2 mg-30 mg Supp [HMC]

Facility

$51.28

Service Code	NDC 00574704512
Hospital Charge Code	3807788
Hospital Revenue Code	250
Min. Negotiated Rate	$20.51
Max. Negotiated Rate	$48.72
Rate for Payer: Aetna Commercial	$46.15
Rate for Payer: Humana Medicare Advantage	$21.54
Rate for Payer: UnitedHealthcare Commercial	$48.72
Rate for Payer: UnitedHealthcare Medicaid	$20.51
Rate for Payer: WPPA Medicare Advantage	$30.77

belladonna-opium 16.2 mg-30 mg Supp [HMC]

Facility

$51.28

Service Code	NDC 00574704512
Hospital Charge Code	3807788
Hospital Revenue Code	250
Min. Negotiated Rate	$46.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$46.15
Rate for Payer: UnitedHealthcare Commercial	$48.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benazepril 10 mg Tab [HMC]

Facility

$8.15

Service Code	NDC 43547033610
Hospital Charge Code	3800295
Hospital Revenue Code	250
Min. Negotiated Rate	$7.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.33
Rate for Payer: UnitedHealthcare Commercial	$7.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benazepril 10 mg Tab [HMC]

Facility

$8.15

Service Code	NDC 65862011601
Hospital Charge Code	3800295
Hospital Revenue Code	250
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$7.74
Rate for Payer: Aetna Commercial	$7.33
Rate for Payer: Humana Medicare Advantage	$3.42
Rate for Payer: UnitedHealthcare Commercial	$7.74
Rate for Payer: UnitedHealthcare Medicaid	$3.26
Rate for Payer: WPPA Medicare Advantage	$4.89

benazepril 10 mg Tab [HMC]

Facility

$8.15

Service Code	NDC 65862011601
Hospital Charge Code	3800295
Hospital Revenue Code	250
Min. Negotiated Rate	$7.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.33
Rate for Payer: UnitedHealthcare Commercial	$7.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benazepril 10 mg Tab [HMC]

Facility

$7.83

Service Code	NDC 50268011015
Hospital Charge Code	3800295
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$7.44
Rate for Payer: Aetna Commercial	$7.05
Rate for Payer: Humana Medicare Advantage	$3.29
Rate for Payer: UnitedHealthcare Commercial	$7.44
Rate for Payer: UnitedHealthcare Medicaid	$3.13
Rate for Payer: WPPA Medicare Advantage	$4.70

benazepril 10 mg Tab [HMC]

Facility

$8.15

Service Code	NDC 43547033610
Hospital Charge Code	3800295
Hospital Revenue Code	250
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$7.74
Rate for Payer: Aetna Commercial	$7.33
Rate for Payer: Humana Medicare Advantage	$3.42
Rate for Payer: UnitedHealthcare Commercial	$7.74
Rate for Payer: UnitedHealthcare Medicaid	$3.26
Rate for Payer: WPPA Medicare Advantage	$4.89

benazepril 10 mg Tab [HMC]

Facility

$7.83

Service Code	NDC 50268011015
Hospital Charge Code	3800295
Hospital Revenue Code	250
Min. Negotiated Rate	$7.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.05
Rate for Payer: UnitedHealthcare Commercial	$7.44
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BENIGN PROSTATIC HYPERTROPHY WITH MCC

Facility

$3,748.86

Service Code	MSDRG 725
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,748.86
Rate for Payer: UnitedHealthcare Medicaid	$3,748.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC

Facility

$2,319.21

Service Code	MSDRG 726
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,319.21
Rate for Payer: UnitedHealthcare Medicaid	$2,319.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benzocaine/dextromethorphan/menthol topical 6 mg-5 mg-10 mg Loz [HMC]

Facility

$5.92

Service Code	NDC 78112080122
Hospital Charge Code	3800858
Hospital Revenue Code	250
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.33
Rate for Payer: UnitedHealthcare Commercial	$5.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benzocaine/dextromethorphan/menthol topical 6 mg-5 mg-10 mg Loz [HMC]

Facility

$5.92

Service Code	NDC 78112080122
Hospital Charge Code	3800858
Hospital Revenue Code	250
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$5.62
Rate for Payer: Aetna Commercial	$5.33
Rate for Payer: Humana Medicare Advantage	$2.49
Rate for Payer: UnitedHealthcare Commercial	$5.62
Rate for Payer: UnitedHealthcare Medicaid	$2.37
Rate for Payer: WPPA Medicare Advantage	$3.55

benzocaine Top 20% mucous membrane spray [HMC]

Facility

$63.61

Service Code	NDC 00283067902
Hospital Charge Code	3800841
Hospital Revenue Code	250
Min. Negotiated Rate	$25.44
Max. Negotiated Rate	$60.43
Rate for Payer: Aetna Commercial	$57.25
Rate for Payer: Humana Medicare Advantage	$26.72
Rate for Payer: UnitedHealthcare Commercial	$60.43
Rate for Payer: UnitedHealthcare Medicaid	$25.44
Rate for Payer: WPPA Medicare Advantage	$38.17

Know your out-of-pocket cost for care.

All Charges