Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Diffusion (DLCO) - RT CHARGE PFT

Facility

$436.00

Service Code	HCPCS 94729
Hospital Charge Code	3912068
Hospital Revenue Code	460
Min. Negotiated Rate	$42.11
Max. Negotiated Rate	$414.20
Rate for Payer: Aetna Commercial	$392.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$118.54
Rate for Payer: Humana Medicare Advantage	$183.12
Rate for Payer: UnitedHealthcare Commercial	$414.20
Rate for Payer: UnitedHealthcare Medicaid	$42.11
Rate for Payer: WPPA Medicare Advantage	$261.60

Diffusion (DLCO) - RT CHARGE PFT

Facility

$436.00

Service Code	HCPCS 94729
Hospital Charge Code	3912068
Hospital Revenue Code	460
Min. Negotiated Rate	$392.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$392.40
Rate for Payer: UnitedHealthcare Commercial	$414.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diflunisal 500 mg Tab [HMC]

Facility

$11.20

Service Code	NDC 64980018106
Hospital Charge Code	3806178
Hospital Revenue Code	250
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.08
Rate for Payer: UnitedHealthcare Commercial	$10.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diflunisal 500 mg Tab [HMC]

Facility

$11.20

Service Code	NDC 64980018106
Hospital Charge Code	3806178
Hospital Revenue Code	250
Min. Negotiated Rate	$4.48
Max. Negotiated Rate	$10.64
Rate for Payer: Aetna Commercial	$10.08
Rate for Payer: Humana Medicare Advantage	$4.70
Rate for Payer: UnitedHealthcare Commercial	$10.64
Rate for Payer: UnitedHealthcare Medicaid	$4.48
Rate for Payer: WPPA Medicare Advantage	$6.72

difluprednate Ophth 0.05% Emul [HMC]

Facility

$373.16

Service Code	NDC 00065924007
Hospital Charge Code	3800228
Hospital Revenue Code	250
Min. Negotiated Rate	$149.26
Max. Negotiated Rate	$354.50
Rate for Payer: Aetna Commercial	$335.84
Rate for Payer: Humana Medicare Advantage	$156.73
Rate for Payer: UnitedHealthcare Commercial	$354.50
Rate for Payer: UnitedHealthcare Medicaid	$149.26
Rate for Payer: WPPA Medicare Advantage	$223.90

difluprednate Ophth 0.05% Emul [HMC]

Facility

$373.16

Service Code	NDC 00065924007
Hospital Charge Code	3800228
Hospital Revenue Code	250
Min. Negotiated Rate	$335.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$335.84
Rate for Payer: UnitedHealthcare Commercial	$354.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DIGESTIVE MALIGNANCY WITH CC

Facility

$5,591.52

Service Code	MSDRG 375
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,591.52
Rate for Payer: UnitedHealthcare Medicaid	$5,591.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DIGESTIVE MALIGNANCY WITH MCC

Facility

$9,880.47

Service Code	MSDRG 374
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,880.47
Rate for Payer: UnitedHealthcare Medicaid	$9,880.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DIGESTIVE MALIGNANCY WITHOUT CC/MCC

Facility

$4,257.18

Service Code	MSDRG 376
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,257.18
Rate for Payer: UnitedHealthcare Medicaid	$4,257.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

digoxin 125 mcg (0.125 mg) Tab [HMC]

Facility

$10.05

Service Code	NDC 00904592161
Hospital Charge Code	3805013
Hospital Revenue Code	250
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$9.55
Rate for Payer: Aetna Commercial	$9.04
Rate for Payer: Humana Medicare Advantage	$4.22
Rate for Payer: UnitedHealthcare Commercial	$9.55
Rate for Payer: UnitedHealthcare Medicaid	$4.02
Rate for Payer: WPPA Medicare Advantage	$6.03

digoxin 125 mcg (0.125 mg) Tab [HMC]

Facility

$13.64

Service Code	NDC 24987024256
Hospital Charge Code	3805013
Hospital Revenue Code	250
Min. Negotiated Rate	$12.28
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.28
Rate for Payer: UnitedHealthcare Commercial	$12.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

digoxin 125 mcg (0.125 mg) Tab [HMC]

Facility

$13.64

Service Code	NDC 24987024256
Hospital Charge Code	3805013
Hospital Revenue Code	250
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$12.96
Rate for Payer: Aetna Commercial	$12.28
Rate for Payer: Humana Medicare Advantage	$5.73
Rate for Payer: UnitedHealthcare Commercial	$12.96
Rate for Payer: UnitedHealthcare Medicaid	$5.46
Rate for Payer: WPPA Medicare Advantage	$8.18

digoxin 125 mcg (0.125 mg) Tab [HMC]

Facility

$10.05

Service Code	NDC 00904592161
Hospital Charge Code	3805013
Hospital Revenue Code	250
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.04
Rate for Payer: UnitedHealthcare Commercial	$9.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

digoxin 250 mcg/mL (0.25 mg/mL) Inj Sol [HMC]

Facility

$39.80

Service Code	NDC 00641141035
Hospital Charge Code	3805039
Hospital Revenue Code	250
Min. Negotiated Rate	$15.92
Max. Negotiated Rate	$37.81
Rate for Payer: Aetna Commercial	$35.82
Rate for Payer: Humana Medicare Advantage	$16.72
Rate for Payer: UnitedHealthcare Commercial	$37.81
Rate for Payer: UnitedHealthcare Medicaid	$15.92
Rate for Payer: WPPA Medicare Advantage	$23.88

digoxin 250 mcg/mL (0.25 mg/mL) Inj Sol [HMC]

Facility

$39.80

Service Code	HCPCS J1160
Hospital Charge Code	3805039
Hospital Revenue Code	250
Min. Negotiated Rate	$35.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.82
Rate for Payer: Aetna Commercial	$38.18
Rate for Payer: UnitedHealthcare Commercial	$37.81
Rate for Payer: UnitedHealthcare Commercial	$40.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

digoxin 250 mcg/mL (0.25 mg/mL) Inj Sol [HMC]

Facility

$39.80

Service Code	NDC 00641141035
Hospital Charge Code	3805039
Hospital Revenue Code	250
Min. Negotiated Rate	$35.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.82
Rate for Payer: UnitedHealthcare Commercial	$37.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

digoxin 250 mcg/mL (0.25 mg/mL) Inj Sol [HMC]

Facility

$42.42

Service Code	HCPCS J1160
Hospital Charge Code	3805039
Hospital Revenue Code	250
Min. Negotiated Rate	$9.57
Max. Negotiated Rate	$40.30
Rate for Payer: Aetna Commercial	$38.18
Rate for Payer: Aetna Commercial	$35.82
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.66
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.66
Rate for Payer: Humana Medicare Advantage	$16.72
Rate for Payer: Humana Medicare Advantage	$17.82
Rate for Payer: UnitedHealthcare Commercial	$40.30
Rate for Payer: UnitedHealthcare Commercial	$37.81
Rate for Payer: UnitedHealthcare Medicaid	$9.57
Rate for Payer: UnitedHealthcare Medicaid	$9.57
Rate for Payer: WPPA Medicare Advantage	$23.88
Rate for Payer: WPPA Medicare Advantage	$25.45

Digoxin Level

Facility

$179.00

Service Code	HCPCS 80162
Hospital Charge Code	3550361
Hospital Revenue Code	300
Min. Negotiated Rate	$13.28
Max. Negotiated Rate	$170.05
Rate for Payer: Aetna Commercial	$161.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.39
Rate for Payer: Humana Medicare Advantage	$75.18
Rate for Payer: UnitedHealthcare Commercial	$170.05
Rate for Payer: UnitedHealthcare Medicaid	$13.28
Rate for Payer: WPPA Medicare Advantage	$107.40

Digoxin Level

Facility

$179.00

Service Code	HCPCS 80162
Hospital Charge Code	3550361
Hospital Revenue Code	300
Min. Negotiated Rate	$161.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$161.10
Rate for Payer: UnitedHealthcare Commercial	$170.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dihydroergotamine 1 mg/mL Inj Sol [HMC]

Facility

$319.00

Service Code	HCPCS J1110
Hospital Charge Code	3805073
Hospital Revenue Code	250
Min. Negotiated Rate	$47.74
Max. Negotiated Rate	$303.05
Rate for Payer: Aetna Commercial	$287.10
Rate for Payer: Aetna Commercial	$230.79
Rate for Payer: Aetna Commercial	$129.88
Rate for Payer: Aetna Commercial	$144.36
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.74
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.74
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.74
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.74
Rate for Payer: Humana Medicare Advantage	$60.61
Rate for Payer: Humana Medicare Advantage	$133.98
Rate for Payer: Humana Medicare Advantage	$67.37
Rate for Payer: Humana Medicare Advantage	$107.70
Rate for Payer: UnitedHealthcare Commercial	$152.38
Rate for Payer: UnitedHealthcare Commercial	$137.09
Rate for Payer: UnitedHealthcare Commercial	$243.61
Rate for Payer: UnitedHealthcare Commercial	$303.05
Rate for Payer: UnitedHealthcare Medicaid	$57.08
Rate for Payer: UnitedHealthcare Medicaid	$57.08
Rate for Payer: UnitedHealthcare Medicaid	$57.08
Rate for Payer: UnitedHealthcare Medicaid	$57.08
Rate for Payer: WPPA Medicare Advantage	$191.40
Rate for Payer: WPPA Medicare Advantage	$153.86
Rate for Payer: WPPA Medicare Advantage	$86.59
Rate for Payer: WPPA Medicare Advantage	$96.24

dihydroergotamine 1 mg/mL Inj Sol [HMC]

Facility

$144.31

Service Code	HCPCS J1110
Hospital Charge Code	3805073
Hospital Revenue Code	250
Min. Negotiated Rate	$129.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$129.88
Rate for Payer: Aetna Commercial	$287.10
Rate for Payer: Aetna Commercial	$144.36
Rate for Payer: Aetna Commercial	$230.79
Rate for Payer: UnitedHealthcare Commercial	$152.38
Rate for Payer: UnitedHealthcare Commercial	$303.05
Rate for Payer: UnitedHealthcare Commercial	$137.09
Rate for Payer: UnitedHealthcare Commercial	$243.61
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

Dilator Esophageal Ballon CRE 16 -18

Facility

$750.00

Hospital Charge Code	3259951
Hospital Revenue Code	270
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$712.50
Rate for Payer: Aetna Commercial	$675.00
Rate for Payer: Humana Medicare Advantage	$315.00
Rate for Payer: UnitedHealthcare Commercial	$712.50
Rate for Payer: UnitedHealthcare Medicaid	$300.00
Rate for Payer: WPPA Medicare Advantage	$450.00

Dilator Esophageal Ballon CRE 16 -18

Facility

$750.00

Hospital Charge Code	3259951
Hospital Revenue Code	270
Min. Negotiated Rate	$675.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$675.00
Rate for Payer: UnitedHealthcare Commercial	$712.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DILATOR ESOPH CRE 12-15

Facility

$655.00

Service Code	HCPCS C1726
Hospital Charge Code	3259952
Hospital Revenue Code	278
Min. Negotiated Rate	$589.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$589.50
Rate for Payer: UnitedHealthcare Commercial	$622.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DILATOR ESOPH CRE 12-15

Facility

$655.00

Service Code	HCPCS C1726
Hospital Charge Code	3259952
Hospital Revenue Code	278
Min. Negotiated Rate	$262.00
Max. Negotiated Rate	$622.25
Rate for Payer: Aetna Commercial	$589.50
Rate for Payer: Humana Medicare Advantage	$275.10
Rate for Payer: UnitedHealthcare Commercial	$622.25
Rate for Payer: UnitedHealthcare Medicaid	$262.00
Rate for Payer: WPPA Medicare Advantage	$393.00

Know your out-of-pocket cost for care.

All Charges