Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

divalproex sodium 500 mg DR Tab [HMC]

Facility

$5.70

Service Code	NDC 00904686161
Hospital Charge Code	3800267
Hospital Revenue Code	250
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.13
Rate for Payer: UnitedHealthcare Commercial	$5.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

divalproex sodium 500 mg DR Tab [HMC]

Facility

$5.70

Service Code	NDC 00904686161
Hospital Charge Code	3800267
Hospital Revenue Code	250
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$5.42
Rate for Payer: Aetna Commercial	$5.13
Rate for Payer: Humana Medicare Advantage	$2.39
Rate for Payer: UnitedHealthcare Commercial	$5.42
Rate for Payer: UnitedHealthcare Medicaid	$2.28
Rate for Payer: WPPA Medicare Advantage	$3.42

divalproex sodium 500 mg DR Tab [HMC]

Facility

$9.27

Service Code	NDC 00832712401
Hospital Charge Code	3800267
Hospital Revenue Code	250
Min. Negotiated Rate	$8.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.34
Rate for Payer: UnitedHealthcare Commercial	$8.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

divalproex sodium 500 mg Tab ER UD [HMC]

Facility

$12.41

Service Code	NDC 00904636461
Hospital Charge Code	3800267
Hospital Revenue Code	250
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$11.79
Rate for Payer: Aetna Commercial	$11.17
Rate for Payer: Humana Medicare Advantage	$5.21
Rate for Payer: UnitedHealthcare Commercial	$11.79
Rate for Payer: UnitedHealthcare Medicaid	$4.96
Rate for Payer: WPPA Medicare Advantage	$7.45

divalproex sodium 500 mg Tab ER UD [HMC]

Facility

$12.41

Service Code	NDC 00904636461
Hospital Charge Code	3800267
Hospital Revenue Code	250
Min. Negotiated Rate	$11.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.17
Rate for Payer: UnitedHealthcare Commercial	$11.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DNA (ds) Antibody QST

Facility

$102.00

Service Code	HCPCS 86225
Hospital Charge Code	3551815
Hospital Revenue Code	300
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DNA (ds) Antibody QST

Facility

$102.00

Service Code	HCPCS 86225
Hospital Charge Code	3551815
Hospital Revenue Code	300
Min. Negotiated Rate	$13.74
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$60.75
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$13.74
Rate for Payer: WPPA Medicare Advantage	$61.20

DNase B Antibody QSTS

Facility

$170.00

Service Code	HCPCS 86215
Hospital Charge Code	3556215
Hospital Revenue Code	300
Min. Negotiated Rate	$11.26
Max. Negotiated Rate	$161.50
Rate for Payer: Aetna Commercial	$153.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$63.07
Rate for Payer: Humana Medicare Advantage	$71.40
Rate for Payer: UnitedHealthcare Commercial	$161.50
Rate for Payer: UnitedHealthcare Medicaid	$11.26
Rate for Payer: WPPA Medicare Advantage	$102.00

DNase B Antibody QSTS

Facility

$170.00

Service Code	HCPCS 86215
Hospital Charge Code	3556215
Hospital Revenue Code	300
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$153.00
Rate for Payer: UnitedHealthcare Commercial	$161.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DOBUTamine 12.5 mg/mL IV Sol [HMC]

Facility

$42.93

Service Code	HCPCS J1250
Hospital Charge Code	3805956
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$40.78
Rate for Payer: Aetna Commercial	$38.64
Rate for Payer: Aetna Commercial	$38.94
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.91
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.91
Rate for Payer: Humana Medicare Advantage	$18.03
Rate for Payer: Humana Medicare Advantage	$18.17
Rate for Payer: UnitedHealthcare Commercial	$40.78
Rate for Payer: UnitedHealthcare Commercial	$41.11
Rate for Payer: UnitedHealthcare Medicaid	$8.02
Rate for Payer: UnitedHealthcare Medicaid	$8.02
Rate for Payer: WPPA Medicare Advantage	$25.96
Rate for Payer: WPPA Medicare Advantage	$25.76

DOBUTamine 12.5 mg/mL IV Sol [HMC]

Facility

$43.27

Service Code	HCPCS J1250
Hospital Charge Code	3805956
Hospital Revenue Code	250
Min. Negotiated Rate	$38.94
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.94
Rate for Payer: Aetna Commercial	$38.64
Rate for Payer: UnitedHealthcare Commercial	$40.78
Rate for Payer: UnitedHealthcare Commercial	$41.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DOBUTamine 1 mg/mL-D5W intravenous solution [HMC]

Facility

$46.26

Service Code	HCPCS J1250
Hospital Charge Code	3800834
Hospital Revenue Code	250
Min. Negotiated Rate	$41.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.63
Rate for Payer: Aetna Commercial	$57.49
Rate for Payer: UnitedHealthcare Commercial	$60.69
Rate for Payer: UnitedHealthcare Commercial	$43.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DOBUTamine 1 mg/mL-D5W intravenous solution [HMC]

Facility

$46.26

Service Code	HCPCS J1250
Hospital Charge Code	3800834
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$43.95
Rate for Payer: Aetna Commercial	$41.63
Rate for Payer: Aetna Commercial	$57.49
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.91
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.91
Rate for Payer: Humana Medicare Advantage	$26.83
Rate for Payer: Humana Medicare Advantage	$19.43
Rate for Payer: UnitedHealthcare Commercial	$60.69
Rate for Payer: UnitedHealthcare Commercial	$43.95
Rate for Payer: UnitedHealthcare Medicaid	$8.02
Rate for Payer: UnitedHealthcare Medicaid	$8.02
Rate for Payer: WPPA Medicare Advantage	$38.33
Rate for Payer: WPPA Medicare Advantage	$27.76

docosanol Top 10% Crm [HMC]

Facility

$49.15

Service Code	NDC 00536137904
Hospital Charge Code	3800388
Hospital Revenue Code	250
Min. Negotiated Rate	$19.66
Max. Negotiated Rate	$46.69
Rate for Payer: Aetna Commercial	$44.23
Rate for Payer: Humana Medicare Advantage	$20.64
Rate for Payer: UnitedHealthcare Commercial	$46.69
Rate for Payer: UnitedHealthcare Medicaid	$19.66
Rate for Payer: WPPA Medicare Advantage	$29.49

docosanol Top 10% Crm [HMC]

Facility

$61.82

Service Code	NDC 00135020001
Hospital Charge Code	3800388
Hospital Revenue Code	250
Min. Negotiated Rate	$55.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$55.64
Rate for Payer: UnitedHealthcare Commercial	$58.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

docosanol Top 10% Crm [HMC]

Facility

$61.82

Service Code	NDC 00135020001
Hospital Charge Code	3800388
Hospital Revenue Code	250
Min. Negotiated Rate	$24.73
Max. Negotiated Rate	$58.73
Rate for Payer: Aetna Commercial	$55.64
Rate for Payer: Humana Medicare Advantage	$25.96
Rate for Payer: UnitedHealthcare Commercial	$58.73
Rate for Payer: UnitedHealthcare Medicaid	$24.73
Rate for Payer: WPPA Medicare Advantage	$37.09

docosanol Top 10% Crm [HMC]

Facility

$49.15

Service Code	NDC 00536137904
Hospital Charge Code	3800388
Hospital Revenue Code	250
Min. Negotiated Rate	$44.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$44.23
Rate for Payer: UnitedHealthcare Commercial	$46.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

docusate 10 mg/mL Liq

Facility

$98.57

Service Code	NDC 00904727972
Hospital Charge Code	3800040
Hospital Revenue Code	250
Min. Negotiated Rate	$88.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$88.71
Rate for Payer: UnitedHealthcare Commercial	$93.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

docusate 10 mg/mL Liq

Facility

$98.57

Service Code	NDC 00904727972
Hospital Charge Code	3800040
Hospital Revenue Code	250
Min. Negotiated Rate	$39.43
Max. Negotiated Rate	$93.64
Rate for Payer: Aetna Commercial	$88.71
Rate for Payer: Humana Medicare Advantage	$41.40
Rate for Payer: UnitedHealthcare Commercial	$93.64
Rate for Payer: UnitedHealthcare Medicaid	$39.43
Rate for Payer: WPPA Medicare Advantage	$59.14

docusate-senna 50 mg-8.6 mg Tab

Facility

$5.58

Service Code	NDC 60687062201
Hospital Charge Code	3803712
Hospital Revenue Code	250
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$5.30
Rate for Payer: Aetna Commercial	$5.02
Rate for Payer: Humana Medicare Advantage	$2.34
Rate for Payer: UnitedHealthcare Commercial	$5.30
Rate for Payer: UnitedHealthcare Medicaid	$2.23
Rate for Payer: WPPA Medicare Advantage	$3.35

docusate-senna 50 mg-8.6 mg Tab

Facility

$5.58

Service Code	NDC 60687062201
Hospital Charge Code	3803712
Hospital Revenue Code	250
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.02
Rate for Payer: UnitedHealthcare Commercial	$5.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

docusate-senna 50 mg-8.6 mg Tab [HMC]

Facility

$5.33

Service Code	NDC 68084005001
Hospital Charge Code	3803712
Hospital Revenue Code	250
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$5.06
Rate for Payer: Aetna Commercial	$4.80
Rate for Payer: Humana Medicare Advantage	$2.24
Rate for Payer: UnitedHealthcare Commercial	$5.06
Rate for Payer: UnitedHealthcare Medicaid	$2.13
Rate for Payer: WPPA Medicare Advantage	$3.20

docusate-senna 50 mg-8.6 mg Tab [HMC]

Facility

$5.07

Service Code	NDC 69618006501
Hospital Charge Code	3803712
Hospital Revenue Code	250
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$4.82
Rate for Payer: Aetna Commercial	$4.56
Rate for Payer: Humana Medicare Advantage	$2.13
Rate for Payer: UnitedHealthcare Commercial	$4.82
Rate for Payer: UnitedHealthcare Medicaid	$2.03
Rate for Payer: WPPA Medicare Advantage	$3.04

docusate-senna 50 mg-8.6 mg Tab [HMC]

Facility

$5.33

Service Code	NDC 68084005001
Hospital Charge Code	3803712
Hospital Revenue Code	250
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.80
Rate for Payer: UnitedHealthcare Commercial	$5.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

docusate-senna 50 mg-8.6 mg Tab [HMC]

Facility

$5.07

Service Code	NDC 69618006501
Hospital Charge Code	3803712
Hospital Revenue Code	250
Min. Negotiated Rate	$4.56
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.56
Rate for Payer: UnitedHealthcare Commercial	$4.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges