Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

DOPamine 1.6 mg/mL-D5W intravenous solution [HMC]

Facility

$61.14

Service Code	HCPCS J1265
Hospital Charge Code	3808646
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$58.08
Rate for Payer: Aetna Commercial	$55.03
Rate for Payer: Aetna Commercial	$53.72
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.37
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.37
Rate for Payer: Humana Medicare Advantage	$25.07
Rate for Payer: Humana Medicare Advantage	$25.68
Rate for Payer: UnitedHealthcare Commercial	$56.71
Rate for Payer: UnitedHealthcare Commercial	$58.08
Rate for Payer: UnitedHealthcare Medicaid	$24.46
Rate for Payer: UnitedHealthcare Medicaid	$23.88
Rate for Payer: WPPA Medicare Advantage	$36.68
Rate for Payer: WPPA Medicare Advantage	$35.81

DOPamine 40 mg/mL IV Sol [HMC]

Facility

$34.36

Service Code	HCPCS J1265
Hospital Charge Code	3800234
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$32.64
Rate for Payer: Aetna Commercial	$30.92
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.37
Rate for Payer: Humana Medicare Advantage	$14.43
Rate for Payer: UnitedHealthcare Commercial	$32.64
Rate for Payer: UnitedHealthcare Medicaid	$13.74
Rate for Payer: WPPA Medicare Advantage	$20.62

DOPamine 40 mg/mL IV Sol [HMC]

Facility

$34.36

Service Code	HCPCS J1265
Hospital Charge Code	3800234
Hospital Revenue Code	250
Min. Negotiated Rate	$30.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.92
Rate for Payer: UnitedHealthcare Commercial	$32.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dornase alfa 2.5 mg/2.5 mL Inh Sol [HMC]

Facility

$253.78

Service Code	HCPCS J7639
Hospital Charge Code	3800498
Hospital Revenue Code	250
Min. Negotiated Rate	$228.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$228.40
Rate for Payer: UnitedHealthcare Commercial	$241.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dornase alfa 2.5 mg/2.5 mL Inh Sol [HMC]

Facility

$253.78

Service Code	HCPCS J7639
Hospital Charge Code	3800498
Hospital Revenue Code	250
Min. Negotiated Rate	$67.00
Max. Negotiated Rate	$241.09
Rate for Payer: Aetna Commercial	$228.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.00
Rate for Payer: Humana Medicare Advantage	$106.59
Rate for Payer: UnitedHealthcare Commercial	$241.09
Rate for Payer: UnitedHealthcare Medicaid	$101.51
Rate for Payer: WPPA Medicare Advantage	$152.27

doxapram 20 mg/mL IV Sol [HMC]

Facility

$115.79

Service Code	NDC 00641601801
Hospital Charge Code	3801435
Hospital Revenue Code	250
Min. Negotiated Rate	$104.21
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$104.21
Rate for Payer: UnitedHealthcare Commercial	$110.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxapram 20 mg/mL IV Sol [HMC]

Facility

$115.79

Service Code	NDC 00641601801
Hospital Charge Code	3801435
Hospital Revenue Code	250
Min. Negotiated Rate	$46.32
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.21
Rate for Payer: Humana Medicare Advantage	$48.63
Rate for Payer: UnitedHealthcare Commercial	$110.00
Rate for Payer: UnitedHealthcare Medicaid	$46.32
Rate for Payer: WPPA Medicare Advantage	$69.47

doxazosin 2 mg Tab [HMC]

Facility

$16.27

Service Code	NDC 51079095820
Hospital Charge Code	3809602
Hospital Revenue Code	250
Min. Negotiated Rate	$14.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$14.64
Rate for Payer: UnitedHealthcare Commercial	$15.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxazosin 2 mg Tab [HMC]

Facility

$16.27

Service Code	NDC 51079095820
Hospital Charge Code	3809602
Hospital Revenue Code	250
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$15.46
Rate for Payer: Aetna Commercial	$14.64
Rate for Payer: Humana Medicare Advantage	$6.83
Rate for Payer: UnitedHealthcare Commercial	$15.46
Rate for Payer: UnitedHealthcare Medicaid	$6.51
Rate for Payer: WPPA Medicare Advantage	$9.76

doxazosin 2 mg Tab [HMC]

Facility

$9.05

Service Code	NDC 60505009400
Hospital Charge Code	3809602
Hospital Revenue Code	250
Min. Negotiated Rate	$8.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.14
Rate for Payer: UnitedHealthcare Commercial	$8.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxazosin 2 mg Tab [HMC]

Facility

$7.91

Service Code	NDC 00904552361
Hospital Charge Code	3809602
Hospital Revenue Code	250
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$7.51
Rate for Payer: Aetna Commercial	$7.12
Rate for Payer: Humana Medicare Advantage	$3.32
Rate for Payer: UnitedHealthcare Commercial	$7.51
Rate for Payer: UnitedHealthcare Medicaid	$3.16
Rate for Payer: WPPA Medicare Advantage	$4.75

doxazosin 2 mg Tab [HMC]

Facility

$9.05

Service Code	NDC 60505009400
Hospital Charge Code	3809602
Hospital Revenue Code	250
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$8.60
Rate for Payer: Aetna Commercial	$8.14
Rate for Payer: Humana Medicare Advantage	$3.80
Rate for Payer: UnitedHealthcare Commercial	$8.60
Rate for Payer: UnitedHealthcare Medicaid	$3.62
Rate for Payer: WPPA Medicare Advantage	$5.43

doxazosin 2 mg Tab [HMC]

Facility

$7.91

Service Code	NDC 00904552361
Hospital Charge Code	3809602
Hospital Revenue Code	250
Min. Negotiated Rate	$7.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.12
Rate for Payer: UnitedHealthcare Commercial	$7.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxepin 10 mg Cap [HMC]

Facility

$7.19

Service Code	NDC 00904705261
Hospital Charge Code	3801699
Hospital Revenue Code	250
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$6.83
Rate for Payer: Aetna Commercial	$6.47
Rate for Payer: Humana Medicare Advantage	$3.02
Rate for Payer: UnitedHealthcare Commercial	$6.83
Rate for Payer: UnitedHealthcare Medicaid	$2.88
Rate for Payer: WPPA Medicare Advantage	$4.31

doxepin 10 mg Cap [HMC]

Facility

$6.87

Service Code	NDC 00378104901
Hospital Charge Code	3801699
Hospital Revenue Code	250
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.18
Rate for Payer: UnitedHealthcare Commercial	$6.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxepin 10 mg Cap [HMC]

Facility

$7.19

Service Code	NDC 00904705261
Hospital Charge Code	3801699
Hospital Revenue Code	250
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.47
Rate for Payer: UnitedHealthcare Commercial	$6.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxepin 10 mg Cap [HMC]

Facility

$6.87

Service Code	NDC 00378104901
Hospital Charge Code	3801699
Hospital Revenue Code	250
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$6.53
Rate for Payer: Aetna Commercial	$6.18
Rate for Payer: Humana Medicare Advantage	$2.89
Rate for Payer: UnitedHealthcare Commercial	$6.53
Rate for Payer: UnitedHealthcare Medicaid	$2.75
Rate for Payer: WPPA Medicare Advantage	$4.12

doxepin 25 mg Cap [HMC]

Facility

$7.89

Service Code	NDC 00904705361
Hospital Charge Code	3809867
Hospital Revenue Code	250
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$7.10
Rate for Payer: Humana Medicare Advantage	$3.31
Rate for Payer: UnitedHealthcare Commercial	$7.50
Rate for Payer: UnitedHealthcare Medicaid	$3.16
Rate for Payer: WPPA Medicare Advantage	$4.73

doxepin 25 mg Cap [HMC]

Facility

$7.89

Service Code	NDC 00904705361
Hospital Charge Code	3809867
Hospital Revenue Code	250
Min. Negotiated Rate	$7.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.10
Rate for Payer: UnitedHealthcare Commercial	$7.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxepin 25 mg Cap [HMC]

Facility

$7.53

Service Code	NDC 51079043720
Hospital Charge Code	3809867
Hospital Revenue Code	250
Min. Negotiated Rate	$6.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.78
Rate for Payer: UnitedHealthcare Commercial	$7.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxepin 25 mg Cap [HMC]

Facility

$7.53

Service Code	NDC 51079043720
Hospital Charge Code	3809867
Hospital Revenue Code	250
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$7.15
Rate for Payer: Aetna Commercial	$6.78
Rate for Payer: Humana Medicare Advantage	$3.16
Rate for Payer: UnitedHealthcare Commercial	$7.15
Rate for Payer: UnitedHealthcare Medicaid	$3.01
Rate for Payer: WPPA Medicare Advantage	$4.52

doxycycline 100 mg IV Inj [HMC]

Facility

$59.10

Service Code	NDC 67457043710
Hospital Charge Code	3800341
Hospital Revenue Code	250
Min. Negotiated Rate	$53.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$53.19
Rate for Payer: UnitedHealthcare Commercial	$56.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxycycline 100 mg IV Inj [HMC]

Facility

$65.30

Service Code	NDC 68382091010
Hospital Charge Code	3800341
Hospital Revenue Code	250
Min. Negotiated Rate	$26.12
Max. Negotiated Rate	$62.03
Rate for Payer: Aetna Commercial	$58.77
Rate for Payer: Humana Medicare Advantage	$27.43
Rate for Payer: UnitedHealthcare Commercial	$62.03
Rate for Payer: UnitedHealthcare Medicaid	$26.12
Rate for Payer: WPPA Medicare Advantage	$39.18

doxycycline 100 mg IV Inj [HMC]

Facility

$63.49

Service Code	NDC 63323013011
Hospital Charge Code	3800341
Hospital Revenue Code	250
Min. Negotiated Rate	$25.40
Max. Negotiated Rate	$60.32
Rate for Payer: Aetna Commercial	$57.14
Rate for Payer: Humana Medicare Advantage	$26.67
Rate for Payer: UnitedHealthcare Commercial	$60.32
Rate for Payer: UnitedHealthcare Medicaid	$25.40
Rate for Payer: WPPA Medicare Advantage	$38.09

doxycycline 100 mg IV Inj [HMC]

Facility

$65.30

Service Code	NDC 68382091010
Hospital Charge Code	3800341
Hospital Revenue Code	250
Min. Negotiated Rate	$58.77
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$58.77
Rate for Payer: UnitedHealthcare Commercial	$62.03
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges