Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

betaxolol 10 mg Tab [HMC]

Facility

$8.73

Service Code	NDC 10702001301
Hospital Charge Code	3804537
Hospital Revenue Code	250
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$8.29
Rate for Payer: Aetna Commercial	$7.86
Rate for Payer: Humana Medicare Advantage	$3.67
Rate for Payer: UnitedHealthcare Commercial	$8.29
Rate for Payer: UnitedHealthcare Medicaid	$3.49
Rate for Payer: WPPA Medicare Advantage	$5.24

bethanechol 10 mg Tab [HMC]

Facility

$9.82

Service Code	NDC 65162057210
Hospital Charge Code	3800612
Hospital Revenue Code	250
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$9.33
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: Humana Medicare Advantage	$4.12
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: UnitedHealthcare Medicaid	$3.93
Rate for Payer: WPPA Medicare Advantage	$5.89

bethanechol 10 mg Tab [HMC]

Facility

$11.01

Service Code	NDC 00832051101
Hospital Charge Code	3800612
Hospital Revenue Code	250
Min. Negotiated Rate	$9.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.91
Rate for Payer: UnitedHealthcare Commercial	$10.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bethanechol 10 mg Tab [HMC]

Facility

$11.01

Service Code	NDC 51293064601
Hospital Charge Code	3800612
Hospital Revenue Code	250
Min. Negotiated Rate	$9.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.91
Rate for Payer: UnitedHealthcare Commercial	$10.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bethanechol 10 mg Tab [HMC]

Facility

$11.01

Service Code	NDC 51293064601
Hospital Charge Code	3800612
Hospital Revenue Code	250
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$10.46
Rate for Payer: Aetna Commercial	$9.91
Rate for Payer: Humana Medicare Advantage	$4.62
Rate for Payer: UnitedHealthcare Commercial	$10.46
Rate for Payer: UnitedHealthcare Medicaid	$4.40
Rate for Payer: WPPA Medicare Advantage	$6.61

bethanechol 10 mg Tab [HMC]

Facility

$9.82

Service Code	NDC 65162057210
Hospital Charge Code	3800612
Hospital Revenue Code	250
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bethanechol 10 mg Tab [HMC]

Facility

$11.01

Service Code	NDC 00832051101
Hospital Charge Code	3800612
Hospital Revenue Code	250
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$10.46
Rate for Payer: Aetna Commercial	$9.91
Rate for Payer: Humana Medicare Advantage	$4.62
Rate for Payer: UnitedHealthcare Commercial	$10.46
Rate for Payer: UnitedHealthcare Medicaid	$4.40
Rate for Payer: WPPA Medicare Advantage	$6.61

bethanechol 25 mg Tab [HMC]

Facility

$13.01

Service Code	NDC 00832051200
Hospital Charge Code	3800044
Hospital Revenue Code	250
Min. Negotiated Rate	$11.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.71
Rate for Payer: UnitedHealthcare Commercial	$12.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bethanechol 25 mg Tab [HMC]

Facility

$13.01

Service Code	NDC 00832051200
Hospital Charge Code	3800044
Hospital Revenue Code	250
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$12.36
Rate for Payer: Aetna Commercial	$11.71
Rate for Payer: Humana Medicare Advantage	$5.46
Rate for Payer: UnitedHealthcare Commercial	$12.36
Rate for Payer: UnitedHealthcare Medicaid	$5.20
Rate for Payer: WPPA Medicare Advantage	$7.81

BF Cell Count w/Diff

Facility

$128.00

Service Code	HCPCS 89051
Hospital Charge Code	3550767
Hospital Revenue Code	300
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$121.60
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$41.45
Rate for Payer: Humana Medicare Advantage	$53.76
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: UnitedHealthcare Medicaid	$4.76
Rate for Payer: WPPA Medicare Advantage	$76.80

BF Cell Count w/Diff

Facility

$128.00

Service Code	HCPCS 89051
Hospital Charge Code	3550767
Hospital Revenue Code	300
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC

Facility

$20,904.66

Service Code	MSDRG 461
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$20,904.66
Rate for Payer: UnitedHealthcare Medicaid	$20,904.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC

Facility

$10,071.09

Service Code	MSDRG 462
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,071.09
Rate for Payer: UnitedHealthcare Medicaid	$10,071.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bile Acids, Fract & Ttl, Pregnancy QST

Facility

$292.00

Service Code	HCPCS 82542
Hospital Charge Code	3552239
Hospital Revenue Code	300
Min. Negotiated Rate	$262.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$262.80
Rate for Payer: UnitedHealthcare Commercial	$277.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bile Acids, Fract & Ttl, Pregnancy QST

Facility

$292.00

Service Code	HCPCS 82542
Hospital Charge Code	3552239
Hospital Revenue Code	300
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$277.40
Rate for Payer: Aetna Commercial	$262.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$194.29
Rate for Payer: Humana Medicare Advantage	$122.64
Rate for Payer: UnitedHealthcare Commercial	$277.40
Rate for Payer: UnitedHealthcare Medicaid	$20.48
Rate for Payer: WPPA Medicare Advantage	$175.20

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC

Facility

$7,021.17

Service Code	MSDRG 409
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,021.17
Rate for Payer: UnitedHealthcare Medicaid	$7,021.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC

Facility

$11,468.97

Service Code	MSDRG 408
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,468.97
Rate for Payer: UnitedHealthcare Medicaid	$11,468.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$5,114.97

Service Code	MSDRG 410
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,114.97
Rate for Payer: UnitedHealthcare Medicaid	$5,114.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bilirubin Direct

Facility

$56.00

Service Code	HCPCS 82248
Hospital Charge Code	3550098
Hospital Revenue Code	300
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$53.20
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$20.18
Rate for Payer: Humana Medicare Advantage	$23.52
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: UnitedHealthcare Medicaid	$4.27
Rate for Payer: WPPA Medicare Advantage	$33.60

Bilirubin Direct

Facility

$56.00

Service Code	HCPCS 82248
Hospital Charge Code	3550098
Hospital Revenue Code	300
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bilirubin Total

Facility

$189.00

Service Code	HCPCS 82247
Hospital Charge Code	3550080
Hospital Revenue Code	300
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$170.10
Rate for Payer: UnitedHealthcare Commercial	$179.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bilirubin Total

Facility

$189.00

Service Code	HCPCS 82247
Hospital Charge Code	3550080
Hospital Revenue Code	300
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$179.55
Rate for Payer: Aetna Commercial	$170.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$21.30
Rate for Payer: Humana Medicare Advantage	$79.38
Rate for Payer: UnitedHealthcare Commercial	$179.55
Rate for Payer: UnitedHealthcare Medicaid	$5.02
Rate for Payer: WPPA Medicare Advantage	$113.40

Bill Only 87147 ID AGGLUTININ

Facility

$58.00

Service Code	HCPCS 87147
Hospital Charge Code	3553010
Hospital Revenue Code	300
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$55.10
Rate for Payer: Aetna Commercial	$52.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$18.45
Rate for Payer: Humana Medicare Advantage	$24.36
Rate for Payer: UnitedHealthcare Commercial	$55.10
Rate for Payer: UnitedHealthcare Medicaid	$5.18
Rate for Payer: WPPA Medicare Advantage	$34.80

Bill Only 87147 ID AGGLUTININ

Facility

$58.00

Service Code	HCPCS 87147
Hospital Charge Code	3553010
Hospital Revenue Code	300
Min. Negotiated Rate	$52.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$52.20
Rate for Payer: UnitedHealthcare Commercial	$55.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only ABO

Facility

$46.00

Service Code	HCPCS 86900
Hospital Charge Code	3560081
Hospital Revenue Code	300
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.40
Rate for Payer: UnitedHealthcare Commercial	$43.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges