Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

benzocaine topical 20% Gel [HMC]

Facility

$27.58

Service Code	NDC 10310028313
Hospital Charge Code	3800636
Hospital Revenue Code	250
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$26.20
Rate for Payer: Aetna Commercial	$24.82
Rate for Payer: Humana Medicare Advantage	$11.58
Rate for Payer: UnitedHealthcare Commercial	$26.20
Rate for Payer: UnitedHealthcare Medicaid	$11.03
Rate for Payer: WPPA Medicare Advantage	$16.55

benzocaine topical 20% Gel [HMC]

Facility

$27.58

Service Code	NDC 10310028313
Hospital Charge Code	3800636
Hospital Revenue Code	250
Min. Negotiated Rate	$24.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.82
Rate for Payer: UnitedHealthcare Commercial	$26.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Benzodiazepine, Confirmation, Urine QST

Facility

$174.00

Service Code	HCPCS 80346
Hospital Charge Code	3558034
Hospital Revenue Code	300
Min. Negotiated Rate	$156.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$156.60
Rate for Payer: UnitedHealthcare Commercial	$165.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Benzodiazepine, Confirmation, Urine QST

Facility

$174.00

Service Code	HCPCS 80346
Hospital Charge Code	3558034
Hospital Revenue Code	300
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$165.30
Rate for Payer: Aetna Commercial	$156.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.75
Rate for Payer: Humana Medicare Advantage	$73.08
Rate for Payer: UnitedHealthcare Commercial	$165.30
Rate for Payer: UnitedHealthcare Medicaid	$23.71
Rate for Payer: WPPA Medicare Advantage	$104.40

Benzodiazepines, Qnt, U QST

Facility

$183.00

Service Code	HCPCS 80346
Hospital Charge Code	3558034
Hospital Revenue Code	300
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$173.85
Rate for Payer: Aetna Commercial	$164.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.75
Rate for Payer: Humana Medicare Advantage	$76.86
Rate for Payer: UnitedHealthcare Commercial	$173.85
Rate for Payer: UnitedHealthcare Medicaid	$23.71
Rate for Payer: WPPA Medicare Advantage	$109.80

Benzodiazepines, Qnt, U QST

Facility

$183.00

Service Code	HCPCS 80346
Hospital Charge Code	3558034
Hospital Revenue Code	300
Min. Negotiated Rate	$164.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$164.70
Rate for Payer: UnitedHealthcare Commercial	$173.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Benzoin Swab Stick

Facility

$3.00

Hospital Charge Code	3257735
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Humana Medicare Advantage	$1.26
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: WPPA Medicare Advantage	$1.80

Benzoin Swab Stick

Facility

$3.00

Hospital Charge Code	3257735
Hospital Revenue Code	270
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Benzoin Tincture 0.6ML Ampule

Facility

$2.50

Hospital Charge Code	3254053
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Benzoin Tincture 0.6ML Ampule

Facility

$2.50

Hospital Charge Code	3254053
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

benzonatate 100 mg Cap [HMC]

Facility

$6.78

Service Code	NDC 00904715361
Hospital Charge Code	3804529
Hospital Revenue Code	250
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$6.44
Rate for Payer: Aetna Commercial	$6.10
Rate for Payer: Humana Medicare Advantage	$2.85
Rate for Payer: UnitedHealthcare Commercial	$6.44
Rate for Payer: UnitedHealthcare Medicaid	$2.71
Rate for Payer: WPPA Medicare Advantage	$4.07

benzonatate 100 mg Cap [HMC]

Facility

$7.19

Service Code	NDC 68084021401
Hospital Charge Code	3804529
Hospital Revenue Code	250
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$6.83
Rate for Payer: Aetna Commercial	$6.47
Rate for Payer: Humana Medicare Advantage	$3.02
Rate for Payer: UnitedHealthcare Commercial	$6.83
Rate for Payer: UnitedHealthcare Medicaid	$2.88
Rate for Payer: WPPA Medicare Advantage	$4.31

benzonatate 100 mg Cap [HMC]

Facility

$12.51

Service Code	NDC 42806071401
Hospital Charge Code	3804529
Hospital Revenue Code	250
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$11.88
Rate for Payer: Aetna Commercial	$11.26
Rate for Payer: Humana Medicare Advantage	$5.25
Rate for Payer: UnitedHealthcare Commercial	$11.88
Rate for Payer: UnitedHealthcare Medicaid	$5.00
Rate for Payer: WPPA Medicare Advantage	$7.51

benzonatate 100 mg Cap [HMC]

Facility

$6.78

Service Code	NDC 00904656461
Hospital Charge Code	3804529
Hospital Revenue Code	250
Min. Negotiated Rate	$6.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.10
Rate for Payer: UnitedHealthcare Commercial	$6.44
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benzonatate 100 mg Cap [HMC]

Facility

$12.51

Service Code	NDC 42806071401
Hospital Charge Code	3804529
Hospital Revenue Code	250
Min. Negotiated Rate	$11.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.26
Rate for Payer: UnitedHealthcare Commercial	$11.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benzonatate 100 mg Cap [HMC]

Facility

$6.78

Service Code	NDC 00904715361
Hospital Charge Code	3804529
Hospital Revenue Code	250
Min. Negotiated Rate	$6.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.10
Rate for Payer: UnitedHealthcare Commercial	$6.44
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benzonatate 100 mg Cap [HMC]

Facility

$6.78

Service Code	NDC 00904656461
Hospital Charge Code	3804529
Hospital Revenue Code	250
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$6.44
Rate for Payer: Aetna Commercial	$6.10
Rate for Payer: Humana Medicare Advantage	$2.85
Rate for Payer: UnitedHealthcare Commercial	$6.44
Rate for Payer: UnitedHealthcare Medicaid	$2.71
Rate for Payer: WPPA Medicare Advantage	$4.07

benzonatate 100 mg Cap [HMC]

Facility

$7.19

Service Code	NDC 68084021401
Hospital Charge Code	3804529
Hospital Revenue Code	250
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.47
Rate for Payer: UnitedHealthcare Commercial	$6.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benztropine 1 mg/mL Inj Sol [HMC]

Facility

$132.50

Service Code	HCPCS J0515
Hospital Charge Code	3800375
Hospital Revenue Code	250
Min. Negotiated Rate	$13.82
Max. Negotiated Rate	$125.88
Rate for Payer: Aetna Commercial	$119.25
Rate for Payer: Aetna Commercial	$97.31
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$21.15
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$21.15
Rate for Payer: Humana Medicare Advantage	$45.41
Rate for Payer: Humana Medicare Advantage	$55.65
Rate for Payer: UnitedHealthcare Commercial	$125.88
Rate for Payer: UnitedHealthcare Commercial	$102.71
Rate for Payer: UnitedHealthcare Medicaid	$13.82
Rate for Payer: UnitedHealthcare Medicaid	$13.82
Rate for Payer: WPPA Medicare Advantage	$64.87
Rate for Payer: WPPA Medicare Advantage	$79.50

benztropine 1 mg/mL Inj Sol [HMC]

Facility

$108.12

Service Code	HCPCS J0515
Hospital Charge Code	3800375
Hospital Revenue Code	250
Min. Negotiated Rate	$97.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$97.31
Rate for Payer: Aetna Commercial	$119.25
Rate for Payer: UnitedHealthcare Commercial	$102.71
Rate for Payer: UnitedHealthcare Commercial	$125.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benztropine 2 mg Tab [HMC]

Facility

$7.05

Service Code	NDC 00904729061
Hospital Charge Code	3807051
Hospital Revenue Code	250
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: UnitedHealthcare Commercial	$6.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benztropine 2 mg Tab [HMC]

Facility

$7.10

Service Code	NDC 00904678961
Hospital Charge Code	3807051
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

benztropine 2 mg Tab [HMC]

Facility

$7.01

Service Code	NDC 60687037901
Hospital Charge Code	3807051
Hospital Revenue Code	250
Min. Negotiated Rate	$6.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.31
Rate for Payer: UnitedHealthcare Commercial	$6.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

benztropine 2 mg Tab [HMC]

Facility

$7.10

Service Code	NDC 00904678961
Hospital Charge Code	3807051
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

Know your out-of-pocket cost for care.

All Charges