Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

CESAREAN SECTION WITHOUT STERILIZATION WITH MCC

Facility

$3,939.48

Service Code	MSDRG 786
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,939.48
Rate for Payer: UnitedHealthcare Medicaid	$3,939.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC

Facility

$3,590.01

Service Code	MSDRG 788
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,590.01
Rate for Payer: UnitedHealthcare Medicaid	$3,590.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CESAREAN SECTION WITH STERILIZATION WITH CC

Facility

$4,384.26

Service Code	MSDRG 784
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,384.26
Rate for Payer: UnitedHealthcare Medicaid	$4,384.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CESAREAN SECTION WITH STERILIZATION WITH MCC

Facility

$4,606.65

Service Code	MSDRG 783
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,606.65
Rate for Payer: UnitedHealthcare Medicaid	$4,606.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC

Facility

$4,161.87

Service Code	MSDRG 785
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,161.87
Rate for Payer: UnitedHealthcare Medicaid	$4,161.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

cetirizine 10 mg Tab [HMC]

Facility

$12.48

Service Code	NDC 51079059720
Hospital Charge Code	3801178
Hospital Revenue Code	250
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.23
Rate for Payer: UnitedHealthcare Commercial	$11.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

cetirizine 10 mg Tab [HMC]

Facility

$5.46

Service Code	NDC 00904671761
Hospital Charge Code	3801178
Hospital Revenue Code	250
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.91
Rate for Payer: UnitedHealthcare Commercial	$5.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

cetirizine 10 mg Tab [HMC]

Facility

$5.46

Service Code	NDC 00904751061
Hospital Charge Code	3801178
Hospital Revenue Code	250
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$5.19
Rate for Payer: Aetna Commercial	$4.91
Rate for Payer: Humana Medicare Advantage	$2.29
Rate for Payer: UnitedHealthcare Commercial	$5.19
Rate for Payer: UnitedHealthcare Medicaid	$2.18
Rate for Payer: WPPA Medicare Advantage	$3.28

cetirizine 10 mg Tab [HMC]

Facility

$5.46

Service Code	NDC 00904751061
Hospital Charge Code	3801178
Hospital Revenue Code	250
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.91
Rate for Payer: UnitedHealthcare Commercial	$5.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

cetirizine 10 mg Tab [HMC]

Facility

$12.48

Service Code	NDC 51079059720
Hospital Charge Code	3801178
Hospital Revenue Code	250
Min. Negotiated Rate	$4.99
Max. Negotiated Rate	$11.86
Rate for Payer: Aetna Commercial	$11.23
Rate for Payer: Humana Medicare Advantage	$5.24
Rate for Payer: UnitedHealthcare Commercial	$11.86
Rate for Payer: UnitedHealthcare Medicaid	$4.99
Rate for Payer: WPPA Medicare Advantage	$7.49

cetirizine 10 mg Tab [HMC]

Facility

$5.46

Service Code	NDC 00904671761
Hospital Charge Code	3801178
Hospital Revenue Code	250
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$5.19
Rate for Payer: Aetna Commercial	$4.91
Rate for Payer: Humana Medicare Advantage	$2.29
Rate for Payer: UnitedHealthcare Commercial	$5.19
Rate for Payer: UnitedHealthcare Medicaid	$2.18
Rate for Payer: WPPA Medicare Advantage	$3.28

CFvantage(R) CF Expanded Scr QST

Facility

$739.00

Service Code	HCPCS 86753
Hospital Charge Code	3556753
Hospital Revenue Code	300
Min. Negotiated Rate	$665.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$665.10
Rate for Payer: UnitedHealthcare Commercial	$702.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CFvantage(R) CF Expanded Scr QST

Facility

$739.00

Service Code	HCPCS 86753
Hospital Charge Code	3556753
Hospital Revenue Code	300
Min. Negotiated Rate	$10.53
Max. Negotiated Rate	$702.05
Rate for Payer: Aetna Commercial	$665.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.65
Rate for Payer: Humana Medicare Advantage	$310.38
Rate for Payer: UnitedHealthcare Commercial	$702.05
Rate for Payer: UnitedHealthcare Medicaid	$10.53
Rate for Payer: WPPA Medicare Advantage	$443.40

charcoal 25 g Oral Susp 120 mL [HMC]

Facility

$45.05

Service Code	NDC 00574052104
Hospital Charge Code	3804347
Hospital Revenue Code	250
Min. Negotiated Rate	$40.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.55
Rate for Payer: UnitedHealthcare Commercial	$42.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

charcoal 25 g Oral Susp 120 mL [HMC]

Facility

$45.05

Service Code	NDC 00574052174
Hospital Charge Code	3804347
Hospital Revenue Code	250
Min. Negotiated Rate	$40.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.55
Rate for Payer: UnitedHealthcare Commercial	$42.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

charcoal 25 g Oral Susp 120 mL [HMC]

Facility

$45.05

Service Code	NDC 00574052104
Hospital Charge Code	3804347
Hospital Revenue Code	250
Min. Negotiated Rate	$18.02
Max. Negotiated Rate	$42.80
Rate for Payer: Aetna Commercial	$40.55
Rate for Payer: Humana Medicare Advantage	$18.92
Rate for Payer: UnitedHealthcare Commercial	$42.80
Rate for Payer: UnitedHealthcare Medicaid	$18.02
Rate for Payer: WPPA Medicare Advantage	$27.03

charcoal 25 g Oral Susp 120 mL [HMC]

Facility

$45.05

Service Code	NDC 00574052174
Hospital Charge Code	3804347
Hospital Revenue Code	250
Min. Negotiated Rate	$18.02
Max. Negotiated Rate	$42.80
Rate for Payer: Aetna Commercial	$40.55
Rate for Payer: Humana Medicare Advantage	$18.92
Rate for Payer: UnitedHealthcare Commercial	$42.80
Rate for Payer: UnitedHealthcare Medicaid	$18.02
Rate for Payer: WPPA Medicare Advantage	$27.03

charcoal-sorbitol 25 g Oral Susp 120 mL [HMC]

Facility

$45.05

Service Code	NDC 00574052074
Hospital Charge Code	3804339
Hospital Revenue Code	250
Min. Negotiated Rate	$40.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.55
Rate for Payer: UnitedHealthcare Commercial	$42.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

charcoal-sorbitol 25 g Oral Susp 120 mL [HMC]

Facility

$45.05

Service Code	NDC 00574012074
Hospital Charge Code	3804339
Hospital Revenue Code	250
Min. Negotiated Rate	$40.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.55
Rate for Payer: UnitedHealthcare Commercial	$42.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

charcoal-sorbitol 25 g Oral Susp 120 mL [HMC]

Facility

$45.05

Service Code	NDC 00574012074
Hospital Charge Code	3804339
Hospital Revenue Code	250
Min. Negotiated Rate	$18.02
Max. Negotiated Rate	$42.80
Rate for Payer: Aetna Commercial	$40.55
Rate for Payer: Humana Medicare Advantage	$18.92
Rate for Payer: UnitedHealthcare Commercial	$42.80
Rate for Payer: UnitedHealthcare Medicaid	$18.02
Rate for Payer: WPPA Medicare Advantage	$27.03

charcoal-sorbitol 25 g Oral Susp 120 mL [HMC]

Facility

$45.05

Service Code	NDC 00574052074
Hospital Charge Code	3804339
Hospital Revenue Code	250
Min. Negotiated Rate	$18.02
Max. Negotiated Rate	$42.80
Rate for Payer: Aetna Commercial	$40.55
Rate for Payer: Humana Medicare Advantage	$18.92
Rate for Payer: UnitedHealthcare Commercial	$42.80
Rate for Payer: UnitedHealthcare Medicaid	$18.02
Rate for Payer: WPPA Medicare Advantage	$27.03

ChemoLock_x0099_ Bag Spike with Additive Port

Facility

$18.23

Hospital Charge Code	3253568
Hospital Revenue Code	270
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.41
Rate for Payer: UnitedHealthcare Commercial	$17.32
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ChemoLock_x0099_ Bag Spike with Additive Port

Facility

$18.23

Hospital Charge Code	3253568
Hospital Revenue Code	270
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$17.32
Rate for Payer: Aetna Commercial	$16.41
Rate for Payer: Humana Medicare Advantage	$7.66
Rate for Payer: UnitedHealthcare Commercial	$17.32
Rate for Payer: UnitedHealthcare Medicaid	$7.29
Rate for Payer: WPPA Medicare Advantage	$10.94

ChemoLock_x0099_ Closed Vial Spike

Facility

$25.07

Hospital Charge Code	3253566
Hospital Revenue Code	270
Min. Negotiated Rate	$10.03
Max. Negotiated Rate	$23.82
Rate for Payer: Aetna Commercial	$22.56
Rate for Payer: Humana Medicare Advantage	$10.53
Rate for Payer: UnitedHealthcare Commercial	$23.82
Rate for Payer: UnitedHealthcare Medicaid	$10.03
Rate for Payer: WPPA Medicare Advantage	$15.04

ChemoLock_x0099_ Closed Vial Spike

Facility

$25.07

Hospital Charge Code	3253566
Hospital Revenue Code	270
Min. Negotiated Rate	$22.56
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.56
Rate for Payer: UnitedHealthcare Commercial	$23.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges