Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

degarelix 120 mg Pow [HMC]

Facility

$1,391.76

Service Code	HCPCS J9155
Hospital Charge Code	3800382
Hospital Revenue Code	250
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$1,322.17
Rate for Payer: Aetna Commercial	$1,252.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5.60
Rate for Payer: Humana Medicare Advantage	$584.54
Rate for Payer: UnitedHealthcare Commercial	$1,322.17
Rate for Payer: UnitedHealthcare Medicaid	$4.45
Rate for Payer: WPPA Medicare Advantage	$835.06

degarelix 80 mg Pow [HMC]

Facility

$899.21

Service Code	HCPCS J9155
Hospital Charge Code	3800383
Hospital Revenue Code	250
Min. Negotiated Rate	$809.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$809.29
Rate for Payer: UnitedHealthcare Commercial	$854.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

degarelix 80 mg Pow [HMC]

Facility

$899.21

Service Code	HCPCS J9155
Hospital Charge Code	3800383
Hospital Revenue Code	250
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$854.25
Rate for Payer: Aetna Commercial	$809.29
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5.60
Rate for Payer: Humana Medicare Advantage	$377.67
Rate for Payer: UnitedHealthcare Commercial	$854.25
Rate for Payer: UnitedHealthcare Medicaid	$4.45
Rate for Payer: WPPA Medicare Advantage	$539.53

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC

Facility

$12,708.00

Service Code	MSDRG 056
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,708.00
Rate for Payer: UnitedHealthcare Medicaid	$12,708.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC

Facility

$7,783.65

Service Code	MSDRG 057
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,783.65
Rate for Payer: UnitedHealthcare Medicaid	$7,783.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

denosumab 120 mg/1.7 mL [HMC]

Facility

$7,045.71

Service Code	HCPCS J0897
Hospital Charge Code	3802263
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,693.42
Rate for Payer: Aetna Commercial	$6,341.14
Rate for Payer: UnitedHealthcare Commercial	$6,693.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

denosumab 120 mg/1.7 mL [HMC]

Facility

$7,045.71

Service Code	HCPCS J0897
Hospital Charge Code	3802263
Hospital Revenue Code	250
Min. Negotiated Rate	$29.46
Max. Negotiated Rate	$6,693.42
Rate for Payer: Aetna Commercial	$6,341.14
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$32.42
Rate for Payer: Humana Medicare Advantage	$2,959.20
Rate for Payer: UnitedHealthcare Commercial	$6,693.42
Rate for Payer: UnitedHealthcare Medicaid	$29.46
Rate for Payer: WPPA Medicare Advantage	$4,227.43

denosumab 60 mg/mL Inj [HMC]

Facility

$3,235.01

Service Code	NDC 55513071021
Hospital Charge Code	3852210
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,073.26
Rate for Payer: Aetna Commercial	$2,911.51
Rate for Payer: UnitedHealthcare Commercial	$3,073.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

denosumab 60 mg/mL Inj [HMC]

Facility

$3,235.01

Service Code	NDC 55513071021
Hospital Charge Code	3852210
Hospital Revenue Code	250
Min. Negotiated Rate	$1,294.00
Max. Negotiated Rate	$3,073.26
Rate for Payer: Aetna Commercial	$2,911.51
Rate for Payer: Humana Medicare Advantage	$1,358.70
Rate for Payer: UnitedHealthcare Commercial	$3,073.26
Rate for Payer: UnitedHealthcare Medicaid	$1,294.00
Rate for Payer: WPPA Medicare Advantage	$1,941.01

denosumab 60 mg/mL Inj [HMC]

Facility

$3,235.01

Service Code	HCPCS J0897
Hospital Charge Code	3852210
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,073.26
Rate for Payer: Aetna Commercial	$2,911.51
Rate for Payer: UnitedHealthcare Commercial	$3,073.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

denosumab 60 mg/mL Inj [HMC]

Facility

$3,235.01

Service Code	HCPCS J0897
Hospital Charge Code	3852210
Hospital Revenue Code	250
Min. Negotiated Rate	$29.46
Max. Negotiated Rate	$3,073.26
Rate for Payer: Aetna Commercial	$2,911.51
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$32.42
Rate for Payer: Humana Medicare Advantage	$1,358.70
Rate for Payer: UnitedHealthcare Commercial	$3,073.26
Rate for Payer: UnitedHealthcare Medicaid	$29.46
Rate for Payer: WPPA Medicare Advantage	$1,941.01

DENTAL AND ORAL DISEASES WITH CC

Facility

$2,636.91

Service Code	MSDRG 158
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,636.91
Rate for Payer: UnitedHealthcare Medicaid	$2,636.91
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DENTAL AND ORAL DISEASES WITH MCC

Facility

$5,019.66

Service Code	MSDRG 157
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

DENTAL AND ORAL DISEASES WITHOUT CC/MCC

Facility

$2,065.05

Service Code	MSDRG 159
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,065.05
Rate for Payer: UnitedHealthcare Medicaid	$2,065.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DEPRESSIVE NEUROSES

Facility

$1,842.66

Service Code	MSDRG 881
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,842.66
Rate for Payer: UnitedHealthcare Medicaid	$1,842.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Dermabond Pen - 0.7 mL

Facility

$96.44

Hospital Charge Code	3250246
Hospital Revenue Code	270
Min. Negotiated Rate	$38.58
Max. Negotiated Rate	$91.62
Rate for Payer: Aetna Commercial	$86.80
Rate for Payer: Humana Medicare Advantage	$40.50
Rate for Payer: UnitedHealthcare Commercial	$91.62
Rate for Payer: UnitedHealthcare Medicaid	$38.58
Rate for Payer: WPPA Medicare Advantage	$57.86

Dermabond Pen - 0.7 mL

Facility

$96.44

Hospital Charge Code	3250246
Hospital Revenue Code	270
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$86.80
Rate for Payer: UnitedHealthcare Commercial	$91.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Dermabond Pen MINI - 0.36 mL

Facility

$51.57

Hospital Charge Code	3250245
Hospital Revenue Code	270
Min. Negotiated Rate	$20.63
Max. Negotiated Rate	$48.99
Rate for Payer: Aetna Commercial	$46.41
Rate for Payer: Humana Medicare Advantage	$21.66
Rate for Payer: UnitedHealthcare Commercial	$48.99
Rate for Payer: UnitedHealthcare Medicaid	$20.63
Rate for Payer: WPPA Medicare Advantage	$30.94

Dermabond Pen MINI - 0.36 mL

Facility

$51.57

Hospital Charge Code	3250245
Hospital Revenue Code	270
Min. Negotiated Rate	$46.41
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$46.41
Rate for Payer: UnitedHealthcare Commercial	$48.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Dermatophagoides Farinae (D2) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1010
Hospital Revenue Code	300
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Dermatophagoides Farinae (D2) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1010
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$16.20

Dermoplast 2.75 oz [HMC]

Facility

$20.00

Service Code	NDC 51409000722
Hospital Charge Code	3800644
Hospital Revenue Code	259
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Dermoplast 2.75 oz [HMC]

Facility

$20.00

Service Code	NDC 51409000722
Hospital Charge Code	3800644
Hospital Revenue Code	259
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: Humana Medicare Advantage	$8.40
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: UnitedHealthcare Medicaid	$8.00
Rate for Payer: WPPA Medicare Advantage	$12.00

desflurane 100% Liq [HMC]

Facility

$360.49

Service Code	NDC 00781617286
Hospital Charge Code	3170325
Hospital Revenue Code	370
Min. Negotiated Rate	$144.20
Max. Negotiated Rate	$342.47
Rate for Payer: Aetna Commercial	$324.44
Rate for Payer: Humana Medicare Advantage	$151.41
Rate for Payer: UnitedHealthcare Commercial	$342.47
Rate for Payer: UnitedHealthcare Medicaid	$144.20
Rate for Payer: WPPA Medicare Advantage	$216.29

desflurane 100% Liq [HMC]

Facility

$384.53

Service Code	NDC 10019064434
Hospital Charge Code	3170325
Hospital Revenue Code	370
Min. Negotiated Rate	$346.08
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$346.08
Rate for Payer: UnitedHealthcare Commercial	$365.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges