Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

ciprofloxacin Ophth 0.3% Sol [HMC]

Facility

$45.20

Service Code	NDC 61314065605
Hospital Charge Code	3800187
Hospital Revenue Code	250
Min. Negotiated Rate	$18.08
Max. Negotiated Rate	$42.94
Rate for Payer: Aetna Commercial	$40.68
Rate for Payer: Humana Medicare Advantage	$18.98
Rate for Payer: UnitedHealthcare Commercial	$42.94
Rate for Payer: UnitedHealthcare Medicaid	$18.08
Rate for Payer: WPPA Medicare Advantage	$27.12

ciprofloxacin Ophth 0.3% Sol [HMC]

Facility

$45.20

Service Code	NDC 69315030805
Hospital Charge Code	3800187
Hospital Revenue Code	250
Min. Negotiated Rate	$40.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.68
Rate for Payer: UnitedHealthcare Commercial	$42.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Circuit High Flow Patient Disposable Vapotherm

Facility

$394.20

Hospital Charge Code	3250560
Hospital Revenue Code	270
Min. Negotiated Rate	$157.68
Max. Negotiated Rate	$374.49
Rate for Payer: Aetna Commercial	$354.78
Rate for Payer: Humana Medicare Advantage	$165.56
Rate for Payer: UnitedHealthcare Commercial	$374.49
Rate for Payer: UnitedHealthcare Medicaid	$157.68
Rate for Payer: WPPA Medicare Advantage	$236.52

Circuit High Flow Patient Disposable Vapotherm

Facility

$394.20

Hospital Charge Code	3250560
Hospital Revenue Code	270
Min. Negotiated Rate	$354.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$354.78
Rate for Payer: UnitedHealthcare Commercial	$374.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Circuit Infant

Facility

$155.00

Hospital Charge Code	3255015
Hospital Revenue Code	270
Min. Negotiated Rate	$62.00
Max. Negotiated Rate	$147.25
Rate for Payer: Aetna Commercial	$139.50
Rate for Payer: Humana Medicare Advantage	$65.10
Rate for Payer: UnitedHealthcare Commercial	$147.25
Rate for Payer: UnitedHealthcare Medicaid	$62.00
Rate for Payer: WPPA Medicare Advantage	$93.00

Circuit Infant

Facility

$155.00

Hospital Charge Code	3255015
Hospital Revenue Code	270
Min. Negotiated Rate	$139.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$139.50
Rate for Payer: UnitedHealthcare Commercial	$147.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Circuit Low Flow Patient Disposable Vapotherm

Facility

$394.20

Hospital Charge Code	3250564
Hospital Revenue Code	270
Min. Negotiated Rate	$157.68
Max. Negotiated Rate	$374.49
Rate for Payer: Aetna Commercial	$354.78
Rate for Payer: Humana Medicare Advantage	$165.56
Rate for Payer: UnitedHealthcare Commercial	$374.49
Rate for Payer: UnitedHealthcare Medicaid	$157.68
Rate for Payer: WPPA Medicare Advantage	$236.52

Circuit Low Flow Patient Disposable Vapotherm

Facility

$394.20

Hospital Charge Code	3250564
Hospital Revenue Code	270
Min. Negotiated Rate	$354.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$354.78
Rate for Payer: UnitedHealthcare Commercial	$374.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Circuit resuscitation with mask size 0 iRes Panda Infant Warmer

Facility

$52.83

Hospital Charge Code	3255019
Hospital Revenue Code	270
Min. Negotiated Rate	$47.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$47.55
Rate for Payer: UnitedHealthcare Commercial	$50.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Circuit resuscitation with mask size 0 iRes Panda Infant Warmer

Facility

$52.83

Hospital Charge Code	3255019
Hospital Revenue Code	270
Min. Negotiated Rate	$21.13
Max. Negotiated Rate	$50.19
Rate for Payer: Aetna Commercial	$47.55
Rate for Payer: Humana Medicare Advantage	$22.19
Rate for Payer: UnitedHealthcare Commercial	$50.19
Rate for Payer: UnitedHealthcare Medicaid	$21.13
Rate for Payer: WPPA Medicare Advantage	$31.70

Circuit resuscitation with mask size 1 iRes Panda Infant Warmer

Facility

$53.78

Hospital Charge Code	3255020
Hospital Revenue Code	270
Min. Negotiated Rate	$21.51
Max. Negotiated Rate	$51.09
Rate for Payer: Aetna Commercial	$48.40
Rate for Payer: Humana Medicare Advantage	$22.59
Rate for Payer: UnitedHealthcare Commercial	$51.09
Rate for Payer: UnitedHealthcare Medicaid	$21.51
Rate for Payer: WPPA Medicare Advantage	$32.27

Circuit resuscitation with mask size 1 iRes Panda Infant Warmer

Facility

$53.78

Hospital Charge Code	3255020
Hospital Revenue Code	270
Min. Negotiated Rate	$48.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.40
Rate for Payer: UnitedHealthcare Commercial	$51.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Circuit Ventilator HFT - V60 Bipap Heated Circuit

Facility

$110.29

Hospital Charge Code	3250567
Hospital Revenue Code	270
Min. Negotiated Rate	$99.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$99.26
Rate for Payer: UnitedHealthcare Commercial	$104.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Circuit Ventilator HFT - V60 Bipap Heated Circuit

Facility

$110.29

Hospital Charge Code	3250567
Hospital Revenue Code	270
Min. Negotiated Rate	$44.12
Max. Negotiated Rate	$104.78
Rate for Payer: Aetna Commercial	$99.26
Rate for Payer: Humana Medicare Advantage	$46.32
Rate for Payer: UnitedHealthcare Commercial	$104.78
Rate for Payer: UnitedHealthcare Medicaid	$44.12
Rate for Payer: WPPA Medicare Advantage	$66.17

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC

Facility

$8,419.05

Service Code	MSDRG 286
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,419.05
Rate for Payer: UnitedHealthcare Medicaid	$8,419.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC

Facility

$5,019.66

Service Code	MSDRG 287
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,019.66
Rate for Payer: UnitedHealthcare Medicaid	$5,019.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Circumcision

Facility

$426.00

Service Code	HCPCS 54150
Hospital Charge Code	3110075
Hospital Revenue Code	723
Min. Negotiated Rate	$178.92
Max. Negotiated Rate	$659.82
Rate for Payer: Aetna Commercial	$383.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$600.00
Rate for Payer: Humana Medicare Advantage	$178.92
Rate for Payer: UnitedHealthcare Commercial	$404.70
Rate for Payer: UnitedHealthcare Medicaid	$659.82
Rate for Payer: WPPA Medicare Advantage	$255.60

Circumcision

Facility

$426.00

Service Code	HCPCS 54150
Hospital Charge Code	3110075
Hospital Revenue Code	723
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$383.40
Rate for Payer: UnitedHealthcare Commercial	$404.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC

Facility

$4,606.65

Service Code	MSDRG 433
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

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC

Facility

$6,894.09

Service Code	MSDRG 432
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,894.09
Rate for Payer: UnitedHealthcare Medicaid	$6,894.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$3,018.15

Service Code	MSDRG 434
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,018.15
Rate for Payer: UnitedHealthcare Medicaid	$3,018.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

citalopram 10 mg Tab [HMC]

Facility

$12.28

Service Code	NDC 00904608461
Hospital Charge Code	3804863
Hospital Revenue Code	250
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$11.67
Rate for Payer: Aetna Commercial	$11.05
Rate for Payer: Humana Medicare Advantage	$5.16
Rate for Payer: UnitedHealthcare Commercial	$11.67
Rate for Payer: UnitedHealthcare Medicaid	$4.91
Rate for Payer: WPPA Medicare Advantage	$7.37

citalopram 10 mg Tab [HMC]

Facility

$12.28

Service Code	NDC 00904608461
Hospital Charge Code	3804863
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.05
Rate for Payer: UnitedHealthcare Commercial	$11.67
Rate for Payer: WPPA Medicare Advantage	$1,200.00

citalopram 20 mg Tab [HMC]

Facility

$12.65

Service Code	NDC 68084074401
Hospital Charge Code	3802747
Hospital Revenue Code	250
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$12.02
Rate for Payer: Aetna Commercial	$11.38
Rate for Payer: Humana Medicare Advantage	$5.31
Rate for Payer: UnitedHealthcare Commercial	$12.02
Rate for Payer: UnitedHealthcare Medicaid	$5.06
Rate for Payer: WPPA Medicare Advantage	$7.59

citalopram 20 mg Tab [HMC]

Facility

$12.66

Service Code	NDC 00378623201
Hospital Charge Code	3802747
Hospital Revenue Code	250
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$12.03
Rate for Payer: Aetna Commercial	$11.39
Rate for Payer: Humana Medicare Advantage	$5.32
Rate for Payer: UnitedHealthcare Commercial	$12.03
Rate for Payer: UnitedHealthcare Medicaid	$5.06
Rate for Payer: WPPA Medicare Advantage	$7.60

Know your out-of-pocket cost for care.

All Charges