Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

dapsone 25 mg Tab [HMC]

Facility

$12.40

Service Code	NDC 13925050430
Hospital Charge Code	3800043
Hospital Revenue Code	250
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.16
Rate for Payer: UnitedHealthcare Commercial	$11.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dapsone 25 mg Tab [HMC]

Facility

$12.40

Service Code	NDC 70954013510
Hospital Charge Code	3800043
Hospital Revenue Code	250
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.16
Rate for Payer: UnitedHealthcare Commercial	$11.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dapsone 25 mg Tab [HMC]

Facility

$13.21

Service Code	NDC 49938010230
Hospital Charge Code	3800043
Hospital Revenue Code	250
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$12.55
Rate for Payer: Aetna Commercial	$11.89
Rate for Payer: Humana Medicare Advantage	$5.55
Rate for Payer: UnitedHealthcare Commercial	$12.55
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: WPPA Medicare Advantage	$7.93

dapsone 25 mg Tab [HMC]

Facility

$13.21

Service Code	NDC 49938010230
Hospital Charge Code	3800043
Hospital Revenue Code	250
Min. Negotiated Rate	$11.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.89
Rate for Payer: UnitedHealthcare Commercial	$12.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DAPTOmycin 500 mg IV Inj [HMC]

Facility

$82.00

Service Code	HCPCS J0878
Hospital Charge Code	3852190
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$77.90
Rate for Payer: Aetna Commercial	$73.80
Rate for Payer: Aetna Commercial	$57.28
Rate for Payer: Aetna Commercial	$138.60
Rate for Payer: Aetna Commercial	$730.68
Rate for Payer: Aetna Commercial	$730.63
Rate for Payer: Aetna Commercial	$60.84
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.25
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.25
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.25
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.25
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.25
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.25
Rate for Payer: Humana Medicare Advantage	$34.44
Rate for Payer: Humana Medicare Advantage	$64.68
Rate for Payer: Humana Medicare Advantage	$340.99
Rate for Payer: Humana Medicare Advantage	$340.96
Rate for Payer: Humana Medicare Advantage	$28.39
Rate for Payer: Humana Medicare Advantage	$26.73
Rate for Payer: UnitedHealthcare Commercial	$771.28
Rate for Payer: UnitedHealthcare Commercial	$64.22
Rate for Payer: UnitedHealthcare Commercial	$60.46
Rate for Payer: UnitedHealthcare Commercial	$146.30
Rate for Payer: UnitedHealthcare Commercial	$771.22
Rate for Payer: UnitedHealthcare Commercial	$77.90
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: WPPA Medicare Advantage	$49.20
Rate for Payer: WPPA Medicare Advantage	$92.40
Rate for Payer: WPPA Medicare Advantage	$38.18
Rate for Payer: WPPA Medicare Advantage	$40.56
Rate for Payer: WPPA Medicare Advantage	$487.09
Rate for Payer: WPPA Medicare Advantage	$487.12

DAPTOmycin 500 mg IV Inj [HMC]

Facility

$811.81

Service Code	NDC 16729043505
Hospital Charge Code	3852190
Hospital Revenue Code	250
Min. Negotiated Rate	$324.72
Max. Negotiated Rate	$771.22
Rate for Payer: Aetna Commercial	$730.63
Rate for Payer: Humana Medicare Advantage	$340.96
Rate for Payer: UnitedHealthcare Commercial	$771.22
Rate for Payer: UnitedHealthcare Medicaid	$324.72
Rate for Payer: WPPA Medicare Advantage	$487.09

DAPTOmycin 500 mg IV Inj [HMC]

Facility

$811.81

Service Code	NDC 16729043505
Hospital Charge Code	3852190
Hospital Revenue Code	250
Min. Negotiated Rate	$730.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$730.63
Rate for Payer: UnitedHealthcare Commercial	$771.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DAPTOmycin 500 mg IV Inj [HMC]

Facility

$154.00

Service Code	HCPCS J0878
Hospital Charge Code	3852190
Hospital Revenue Code	250
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$138.60
Rate for Payer: Aetna Commercial	$57.28
Rate for Payer: Aetna Commercial	$60.84
Rate for Payer: Aetna Commercial	$730.63
Rate for Payer: Aetna Commercial	$730.68
Rate for Payer: Aetna Commercial	$73.80
Rate for Payer: UnitedHealthcare Commercial	$77.90
Rate for Payer: UnitedHealthcare Commercial	$146.30
Rate for Payer: UnitedHealthcare Commercial	$771.22
Rate for Payer: UnitedHealthcare Commercial	$771.28
Rate for Payer: UnitedHealthcare Commercial	$60.46
Rate for Payer: UnitedHealthcare Commercial	$64.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

darbepoetin alfa 200 mcg/0.4 mL Sol [HMC]

Facility

$2,806.40

Service Code	HCPCS J0881
Hospital Charge Code	3850024
Hospital Revenue Code	250
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$2,666.08
Rate for Payer: Aetna Commercial	$2,525.76
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.77
Rate for Payer: Humana Medicare Advantage	$1,178.69
Rate for Payer: UnitedHealthcare Commercial	$2,666.08
Rate for Payer: UnitedHealthcare Medicaid	$3.02
Rate for Payer: WPPA Medicare Advantage	$1,683.84

darbepoetin alfa 200 mcg/0.4 mL Sol [HMC]

Facility

$2,806.40

Service Code	HCPCS J0881
Hospital Charge Code	3850024
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,666.08
Rate for Payer: Aetna Commercial	$2,525.76
Rate for Payer: UnitedHealthcare Commercial	$2,666.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

darbepoetin alfa 40 mcg/0.4 mL Inj Sol [HMC]

Facility

$577.28

Service Code	HCPCS J0881
Hospital Charge Code	3850089
Hospital Revenue Code	250
Min. Negotiated Rate	$519.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$519.55
Rate for Payer: UnitedHealthcare Commercial	$548.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

darbepoetin alfa 40 mcg/0.4 mL Inj Sol [HMC]

Facility

$577.28

Service Code	HCPCS J0881
Hospital Charge Code	3850089
Hospital Revenue Code	250
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$548.42
Rate for Payer: Aetna Commercial	$519.55
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.77
Rate for Payer: Humana Medicare Advantage	$242.46
Rate for Payer: UnitedHealthcare Commercial	$548.42
Rate for Payer: UnitedHealthcare Medicaid	$3.02
Rate for Payer: WPPA Medicare Advantage	$346.37

darbepoetin alfa 500 mcg/mL Inj Sol [HMC]

Facility

$6,986.00

Service Code	HCPCS J0881
Hospital Charge Code	3850022
Hospital Revenue Code	250
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$6,636.70
Rate for Payer: Aetna Commercial	$6,287.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.77
Rate for Payer: Humana Medicare Advantage	$2,934.12
Rate for Payer: UnitedHealthcare Commercial	$6,636.70
Rate for Payer: UnitedHealthcare Medicaid	$3.02
Rate for Payer: WPPA Medicare Advantage	$4,191.60

darbepoetin alfa 500 mcg/mL Inj Sol [HMC]

Facility

$6,986.00

Service Code	HCPCS J0881
Hospital Charge Code	3850022
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,636.70
Rate for Payer: Aetna Commercial	$6,287.40
Rate for Payer: UnitedHealthcare Commercial	$6,636.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC

Facility

$6,862.32

Service Code	MSDRG 744
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,862.32
Rate for Payer: UnitedHealthcare Medicaid	$6,862.32
Rate for Payer: WPPA Medicare Advantage	$1,200.00

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC

Facility

$3,812.40

Service Code	MSDRG 745
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,812.40
Rate for Payer: UnitedHealthcare Medicaid	$3,812.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

D-Dimer

Facility

$163.00

Service Code	HCPCS 85379
Hospital Charge Code	3550059
Hospital Revenue Code	300
Min. Negotiated Rate	$10.18
Max. Negotiated Rate	$154.85
Rate for Payer: Aetna Commercial	$146.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$73.62
Rate for Payer: Humana Medicare Advantage	$68.46
Rate for Payer: UnitedHealthcare Commercial	$154.85
Rate for Payer: UnitedHealthcare Medicaid	$10.18
Rate for Payer: WPPA Medicare Advantage	$97.80

D-Dimer

Facility

$163.00

Service Code	HCPCS 85379
Hospital Charge Code	3550059
Hospital Revenue Code	300
Min. Negotiated Rate	$146.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$146.70
Rate for Payer: UnitedHealthcare Commercial	$154.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Decalcification of Specimen

Facility

$58.00

Service Code	HCPCS 88311
Hospital Charge Code	3558311
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

Decalcification of Specimen

Facility

$58.00

Service Code	HCPCS 88311
Hospital Charge Code	3558311
Hospital Revenue Code	300
Min. Negotiated Rate	$16.19
Max. Negotiated Rate	$55.10
Rate for Payer: Aetna Commercial	$52.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$48.24
Rate for Payer: Humana Medicare Advantage	$24.36
Rate for Payer: UnitedHealthcare Commercial	$55.10
Rate for Payer: UnitedHealthcare Medicaid	$16.19
Rate for Payer: WPPA Medicare Advantage	$34.80

deferoxamine 2 g Powder [HMC]

Facility

$94.16

Service Code	HCPCS J0895
Hospital Charge Code	3801295
Hospital Revenue Code	250
Min. Negotiated Rate	$84.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$84.74
Rate for Payer: UnitedHealthcare Commercial	$89.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

deferoxamine 2 g Powder [HMC]

Facility

$94.16

Service Code	HCPCS J0895
Hospital Charge Code	3801295
Hospital Revenue Code	250
Min. Negotiated Rate	$8.47
Max. Negotiated Rate	$89.45
Rate for Payer: Aetna Commercial	$84.74
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.60
Rate for Payer: Humana Medicare Advantage	$39.55
Rate for Payer: UnitedHealthcare Commercial	$89.45
Rate for Payer: UnitedHealthcare Medicaid	$8.47
Rate for Payer: WPPA Medicare Advantage	$56.50

deferoxamine 500 mg Inj [HMC]

Facility

$43.64

Service Code	HCPCS J0895
Hospital Charge Code	3801294
Hospital Revenue Code	250
Min. Negotiated Rate	$39.28
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.28
Rate for Payer: Aetna Commercial	$45.97
Rate for Payer: UnitedHealthcare Commercial	$41.46
Rate for Payer: UnitedHealthcare Commercial	$48.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

deferoxamine 500 mg Inj [HMC]

Facility

$43.64

Service Code	HCPCS J0895
Hospital Charge Code	3801294
Hospital Revenue Code	250
Min. Negotiated Rate	$8.47
Max. Negotiated Rate	$41.46
Rate for Payer: Aetna Commercial	$39.28
Rate for Payer: Aetna Commercial	$45.97
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.60
Rate for Payer: Humana Medicare Advantage	$18.33
Rate for Payer: Humana Medicare Advantage	$21.45
Rate for Payer: UnitedHealthcare Commercial	$41.46
Rate for Payer: UnitedHealthcare Commercial	$48.53
Rate for Payer: UnitedHealthcare Medicaid	$8.47
Rate for Payer: UnitedHealthcare Medicaid	$8.47
Rate for Payer: WPPA Medicare Advantage	$26.18
Rate for Payer: WPPA Medicare Advantage	$30.65

degarelix 120 mg Pow [HMC]

Facility

$1,391.76

Service Code	HCPCS J9155
Hospital Charge Code	3800382
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,322.17
Rate for Payer: Aetna Commercial	$1,252.58
Rate for Payer: UnitedHealthcare Commercial	$1,322.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges