Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

dilTIAZem 5 mg/mL Sol

Facility

$39.50

Service Code	NDC 25021031905
Hospital Charge Code	3800647
Hospital Revenue Code	250
Min. Negotiated Rate	$35.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.55
Rate for Payer: UnitedHealthcare Commercial	$37.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 60 mg ERCap [HMC]

Facility

$16.92

Service Code	NDC 51079092420
Hospital Charge Code	3806566
Hospital Revenue Code	250
Min. Negotiated Rate	$6.77
Max. Negotiated Rate	$16.07
Rate for Payer: Aetna Commercial	$15.23
Rate for Payer: Humana Medicare Advantage	$7.11
Rate for Payer: UnitedHealthcare Commercial	$16.07
Rate for Payer: UnitedHealthcare Medicaid	$6.77
Rate for Payer: WPPA Medicare Advantage	$10.15

diltiazem 60 mg ERCap [HMC]

Facility

$16.92

Service Code	NDC 51079092420
Hospital Charge Code	3806566
Hospital Revenue Code	250
Min. Negotiated Rate	$15.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.23
Rate for Payer: UnitedHealthcare Commercial	$16.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diltiazem 60 mg ERCap [HMC]

Facility

$14.52

Service Code	NDC 00378606001
Hospital Charge Code	3806566
Hospital Revenue Code	250
Min. Negotiated Rate	$5.81
Max. Negotiated Rate	$13.79
Rate for Payer: Aetna Commercial	$13.07
Rate for Payer: Humana Medicare Advantage	$6.10
Rate for Payer: UnitedHealthcare Commercial	$13.79
Rate for Payer: UnitedHealthcare Medicaid	$5.81
Rate for Payer: WPPA Medicare Advantage	$8.71

diltiazem 60 mg ERCap [HMC]

Facility

$14.52

Service Code	NDC 00378606001
Hospital Charge Code	3806566
Hospital Revenue Code	250
Min. Negotiated Rate	$13.07
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.07
Rate for Payer: UnitedHealthcare Commercial	$13.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dimethyl sulfoxide 50% Irr Sol 50 mL [HMC]

Facility

$1,145.87

Service Code	HCPCS J1212
Hospital Charge Code	3852035
Hospital Revenue Code	250
Min. Negotiated Rate	$481.27
Max. Negotiated Rate	$1,088.58
Rate for Payer: Aetna Commercial	$1,031.28
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$875.80
Rate for Payer: Humana Medicare Advantage	$481.27
Rate for Payer: UnitedHealthcare Commercial	$1,088.58
Rate for Payer: UnitedHealthcare Medicaid	$749.23
Rate for Payer: WPPA Medicare Advantage	$687.52

dimethyl sulfoxide 50% Irr Sol 50 mL [HMC]

Facility

$1,145.87

Service Code	HCPCS J1212
Hospital Charge Code	3852035
Hospital Revenue Code	250
Min. Negotiated Rate	$1,031.28
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,031.28
Rate for Payer: UnitedHealthcare Commercial	$1,088.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dinoprostone 0.3 mg/hr Vag Insert [HMC]

Facility

$633.78

Service Code	NDC 55566280001
Hospital Charge Code	3809446
Hospital Revenue Code	250
Min. Negotiated Rate	$570.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$570.40
Rate for Payer: UnitedHealthcare Commercial	$602.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dinoprostone 0.3 mg/hr Vag Insert [HMC]

Facility

$633.78

Service Code	NDC 55566280001
Hospital Charge Code	3809446
Hospital Revenue Code	250
Min. Negotiated Rate	$253.51
Max. Negotiated Rate	$602.09
Rate for Payer: Aetna Commercial	$570.40
Rate for Payer: Humana Medicare Advantage	$266.19
Rate for Payer: UnitedHealthcare Commercial	$602.09
Rate for Payer: UnitedHealthcare Medicaid	$253.51
Rate for Payer: WPPA Medicare Advantage	$380.27

diphenhydrAMINE 12.5 mg/5 mL Liq 10 mL [HMC]

Facility

$19.02

Service Code	HCPCS Q0163
Hospital Charge Code	3805088
Hospital Revenue Code	250
Min. Negotiated Rate	$17.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: UnitedHealthcare Commercial	$18.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diphenhydrAMINE 12.5 mg/5 mL Liq 10 mL [HMC]

Facility

$19.02

Service Code	HCPCS Q0163
Hospital Charge Code	3805088
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$18.07
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.36
Rate for Payer: Humana Medicare Advantage	$7.99
Rate for Payer: UnitedHealthcare Commercial	$18.07
Rate for Payer: UnitedHealthcare Medicaid	$7.61
Rate for Payer: WPPA Medicare Advantage	$11.41

diphenhydrAMINE 12.5 mg/5 mL Oral Liq [HMC]

Facility

$10.49

Service Code	HCPCS Q0163
Hospital Charge Code	3805088
Hospital Revenue Code	250
Min. Negotiated Rate	$9.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.44
Rate for Payer: Aetna Commercial	$9.41
Rate for Payer: Aetna Commercial	$9.75
Rate for Payer: UnitedHealthcare Commercial	$10.29
Rate for Payer: UnitedHealthcare Commercial	$9.97
Rate for Payer: UnitedHealthcare Commercial	$9.94
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

diphenhydrAMINE 12.5 mg/5 mL Oral Liq [HMC]

Facility

$10.46

Service Code	HCPCS Q0163
Hospital Charge Code	3805088
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$9.94
Rate for Payer: Aetna Commercial	$9.41
Rate for Payer: Aetna Commercial	$9.44
Rate for Payer: Aetna Commercial	$9.75
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.36
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.36
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.36
Rate for Payer: Humana Medicare Advantage	$4.41
Rate for Payer: Humana Medicare Advantage	$4.39
Rate for Payer: Humana Medicare Advantage	$4.55
Rate for Payer: UnitedHealthcare Commercial	$10.29
Rate for Payer: UnitedHealthcare Commercial	$9.94
Rate for Payer: UnitedHealthcare Commercial	$9.97
Rate for Payer: UnitedHealthcare Medicaid	$4.33
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicaid	$4.18
Rate for Payer: WPPA Medicare Advantage	$6.28
Rate for Payer: WPPA Medicare Advantage	$6.29
Rate for Payer: WPPA Medicare Advantage	$6.50

diphenhydrAMINE 25 mg Cap [HMC]

Facility

$5.13

Service Code	HCPCS Q0163
Hospital Charge Code	3805070
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$4.87
Rate for Payer: Aetna Commercial	$4.62
Rate for Payer: Aetna Commercial	$4.63
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.36
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.36
Rate for Payer: Humana Medicare Advantage	$2.16
Rate for Payer: Humana Medicare Advantage	$2.15
Rate for Payer: UnitedHealthcare Commercial	$4.87
Rate for Payer: UnitedHealthcare Commercial	$4.89
Rate for Payer: UnitedHealthcare Medicaid	$2.05
Rate for Payer: UnitedHealthcare Medicaid	$2.06
Rate for Payer: WPPA Medicare Advantage	$3.09
Rate for Payer: WPPA Medicare Advantage	$3.08

diphenhydrAMINE 25 mg Cap [HMC]

Facility

$5.13

Service Code	HCPCS Q0163
Hospital Charge Code	3805070
Hospital Revenue Code	250
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.62
Rate for Payer: Aetna Commercial	$4.63
Rate for Payer: UnitedHealthcare Commercial	$4.87
Rate for Payer: UnitedHealthcare Commercial	$4.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diphenhydrAMINE 25 mg Tab [HMC]

Facility

$5.66

Service Code	HCPCS Q0163
Hospital Charge Code	3805070
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$5.38
Rate for Payer: Aetna Commercial	$5.09
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.36
Rate for Payer: Humana Medicare Advantage	$2.38
Rate for Payer: UnitedHealthcare Commercial	$5.38
Rate for Payer: UnitedHealthcare Medicaid	$2.26
Rate for Payer: WPPA Medicare Advantage	$3.40

diphenhydrAMINE 25 mg Tab [HMC]

Facility

$5.66

Service Code	HCPCS Q0163
Hospital Charge Code	3805070
Hospital Revenue Code	250
Min. Negotiated Rate	$5.09
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.09
Rate for Payer: UnitedHealthcare Commercial	$5.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diphenhydrAMINE 50 mg/mL Inj Sol [HMC]

Facility

$38.00

Service Code	HCPCS J1200
Hospital Charge Code	3805062
Hospital Revenue Code	250
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$36.10
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Commercial	$24.33
Rate for Payer: Aetna Commercial	$34.25
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.04
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.04
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.04
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: Humana Medicare Advantage	$11.35
Rate for Payer: Humana Medicare Advantage	$15.99
Rate for Payer: UnitedHealthcare Commercial	$25.68
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: UnitedHealthcare Commercial	$36.16
Rate for Payer: UnitedHealthcare Medicaid	$0.71
Rate for Payer: UnitedHealthcare Medicaid	$0.71
Rate for Payer: UnitedHealthcare Medicaid	$0.71
Rate for Payer: WPPA Medicare Advantage	$22.84
Rate for Payer: WPPA Medicare Advantage	$22.80
Rate for Payer: WPPA Medicare Advantage	$16.22

diphenhydrAMINE 50 mg/mL Inj Sol [HMC]

Facility

$27.03

Service Code	HCPCS J1200
Hospital Charge Code	3805062
Hospital Revenue Code	250
Min. Negotiated Rate	$24.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.33
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Commercial	$34.25
Rate for Payer: UnitedHealthcare Commercial	$36.16
Rate for Payer: UnitedHealthcare Commercial	$25.68
Rate for Payer: UnitedHealthcare Commercial	$36.10
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

diphenhydramine-zinc acetate topical 1%-0.1% Cre [HMC]

Facility

$26.84

Service Code	NDC 12547017162
Hospital Charge Code	3800370
Hospital Revenue Code	250
Min. Negotiated Rate	$24.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.16
Rate for Payer: UnitedHealthcare Commercial	$25.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diphenhydramine-zinc acetate topical 1%-0.1% Cre [HMC]

Facility

$26.84

Service Code	NDC 12547017162
Hospital Charge Code	3800370
Hospital Revenue Code	250
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$25.50
Rate for Payer: Aetna Commercial	$24.16
Rate for Payer: Humana Medicare Advantage	$11.27
Rate for Payer: UnitedHealthcare Commercial	$25.50
Rate for Payer: UnitedHealthcare Medicaid	$10.74
Rate for Payer: WPPA Medicare Advantage	$16.10

dipyridamole 25 mg Tab [HMC]

Facility

$9.26

Service Code	NDC 64980013301
Hospital Charge Code	3805064
Hospital Revenue Code	250
Min. Negotiated Rate	$3.70
Max. Negotiated Rate	$8.80
Rate for Payer: Aetna Commercial	$8.33
Rate for Payer: Humana Medicare Advantage	$3.89
Rate for Payer: UnitedHealthcare Commercial	$8.80
Rate for Payer: UnitedHealthcare Medicaid	$3.70
Rate for Payer: WPPA Medicare Advantage	$5.56

dipyridamole 25 mg Tab [HMC]

Facility

$9.26

Service Code	NDC 64980013301
Hospital Charge Code	3805064
Hospital Revenue Code	250
Min. Negotiated Rate	$8.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.33
Rate for Payer: UnitedHealthcare Commercial	$8.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Direct LDL QST

Facility

$77.00

Service Code	HCPCS 83721
Hospital Charge Code	3557095
Hospital Revenue Code	300
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$73.15
Rate for Payer: Aetna Commercial	$69.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.33
Rate for Payer: Humana Medicare Advantage	$32.34
Rate for Payer: UnitedHealthcare Commercial	$73.15
Rate for Payer: UnitedHealthcare Medicaid	$10.50
Rate for Payer: WPPA Medicare Advantage	$46.20

Direct LDL QST

Facility

$77.00

Service Code	HCPCS 83721
Hospital Charge Code	3557095
Hospital Revenue Code	300
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$69.30
Rate for Payer: UnitedHealthcare Commercial	$73.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges