Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Drug Monitoring, Barbiturates, Quantitative, Urine QST

Facility

$115.00

Service Code	HCPCS 80307
Hospital Charge Code	3559369
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$150.08
Rate for Payer: Aetna Commercial	$103.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$150.08
Rate for Payer: Humana Medicare Advantage	$48.30
Rate for Payer: UnitedHealthcare Commercial	$109.25
Rate for Payer: UnitedHealthcare Medicaid	$63.74
Rate for Payer: WPPA Medicare Advantage	$69.00

Drug Monitoring, Barbiturates, Quantitative, Urine QST

Facility

$115.00

Service Code	HCPCS 80307
Hospital Charge Code	3559369
Hospital Revenue Code	300
Min. Negotiated Rate	$103.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$103.50
Rate for Payer: UnitedHealthcare Commercial	$109.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drug Monitoring, Cocaine Metabolite, Quantitative, Urine QST

Facility

$145.00

Service Code	HCPCS 80353
Hospital Charge Code	3553053
Hospital Revenue Code	300
Min. Negotiated Rate	$9.98
Max. Negotiated Rate	$137.75
Rate for Payer: Aetna Commercial	$130.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$35.00
Rate for Payer: Humana Medicare Advantage	$60.90
Rate for Payer: UnitedHealthcare Commercial	$137.75
Rate for Payer: UnitedHealthcare Medicaid	$9.98
Rate for Payer: WPPA Medicare Advantage	$87.00

Drug Monitoring, Cocaine Metabolite, Quantitative, Urine QST

Facility

$145.00

Service Code	HCPCS 80353
Hospital Charge Code	3553053
Hospital Revenue Code	300
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$130.50
Rate for Payer: UnitedHealthcare Commercial	$137.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drug Monitoring, Opiates, with Confirmation, Urine QST

Facility

$181.00

Service Code	HCPCS 80307
Hospital Charge Code	3550365
Hospital Revenue Code	300
Min. Negotiated Rate	$63.74
Max. Negotiated Rate	$171.95
Rate for Payer: Aetna Commercial	$162.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$150.08
Rate for Payer: Humana Medicare Advantage	$76.02
Rate for Payer: UnitedHealthcare Commercial	$171.95
Rate for Payer: UnitedHealthcare Medicaid	$63.74
Rate for Payer: WPPA Medicare Advantage	$108.60

Drug Monitoring, Opiates, with Confirmation, Urine QST

Facility

$181.00

Service Code	HCPCS 80307
Hospital Charge Code	3550365
Hospital Revenue Code	300
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$162.90
Rate for Payer: UnitedHealthcare Commercial	$171.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drug Monitoring, Phosphatidylethanol (PEth), Blood QST

Facility

$233.00

Service Code	HCPCS 80321
Hospital Charge Code	3552198
Hospital Revenue Code	300
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$221.35
Rate for Payer: Aetna Commercial	$209.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$46.39
Rate for Payer: Humana Medicare Advantage	$97.86
Rate for Payer: UnitedHealthcare Commercial	$221.35
Rate for Payer: UnitedHealthcare Medicaid	$15.50
Rate for Payer: WPPA Medicare Advantage	$139.80

Drug Monitoring, Phosphatidylethanol (PEth), Blood QST

Facility

$233.00

Service Code	HCPCS 80321
Hospital Charge Code	3552198
Hospital Revenue Code	300
Min. Negotiated Rate	$209.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$209.70
Rate for Payer: UnitedHealthcare Commercial	$221.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drug Monitoring, Tricyclic Antidepressants, Quantitative, Urine QST

Facility

$182.00

Service Code	HCPCS 80335
Hospital Charge Code	3558033
Hospital Revenue Code	300
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$172.90
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$62.47
Rate for Payer: Humana Medicare Advantage	$76.44
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: UnitedHealthcare Medicaid	$23.71
Rate for Payer: WPPA Medicare Advantage	$109.20

Drug Monitoring, Tricyclic Antidepressants, Quantitative, Urine QST

Facility

$182.00

Service Code	HCPCS 80335
Hospital Charge Code	3558033
Hospital Revenue Code	300
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drug Monit Tricyclic Antidep Qn,W/Medm U QST

Facility

$191.00

Service Code	HCPCS 80335
Hospital Charge Code	3558033
Hospital Revenue Code	300
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$181.45
Rate for Payer: Aetna Commercial	$171.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$62.47
Rate for Payer: Humana Medicare Advantage	$80.22
Rate for Payer: UnitedHealthcare Commercial	$181.45
Rate for Payer: UnitedHealthcare Medicaid	$23.71
Rate for Payer: WPPA Medicare Advantage	$114.60

Drug Monit Tricyclic Antidep Qn,W/Medm U QST

Facility

$191.00

Service Code	HCPCS 80335
Hospital Charge Code	3558033
Hospital Revenue Code	300
Min. Negotiated Rate	$171.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$171.90
Rate for Payer: UnitedHealthcare Commercial	$181.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drug Screen Urine

Facility

$137.00

Service Code	HCPCS 80307
Hospital Charge Code	3550255
Hospital Revenue Code	300
Min. Negotiated Rate	$57.54
Max. Negotiated Rate	$150.08
Rate for Payer: Aetna Commercial	$123.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$150.08
Rate for Payer: Humana Medicare Advantage	$57.54
Rate for Payer: UnitedHealthcare Commercial	$130.15
Rate for Payer: UnitedHealthcare Medicaid	$63.74
Rate for Payer: WPPA Medicare Advantage	$82.20

Drug Screen Urine

Facility

$137.00

Service Code	HCPCS 80307
Hospital Charge Code	3550255
Hospital Revenue Code	300
Min. Negotiated Rate	$123.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$123.30
Rate for Payer: UnitedHealthcare Commercial	$130.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drug Scr Pnl 9, M QST

Facility

$306.00

Service Code	HCPCS 80307
Hospital Charge Code	3550307
Hospital Revenue Code	300
Min. Negotiated Rate	$275.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$275.40
Rate for Payer: UnitedHealthcare Commercial	$290.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drug Scr Pnl 9, M QST

Facility

$306.00

Service Code	HCPCS 80307
Hospital Charge Code	3550307
Hospital Revenue Code	300
Min. Negotiated Rate	$63.74
Max. Negotiated Rate	$290.70
Rate for Payer: Aetna Commercial	$275.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$150.08
Rate for Payer: Humana Medicare Advantage	$128.52
Rate for Payer: UnitedHealthcare Commercial	$290.70
Rate for Payer: UnitedHealthcare Medicaid	$63.74
Rate for Payer: WPPA Medicare Advantage	$183.60

dulaglutide 0.75 mg/0.5 mL UD [HMC]

Facility

$459.84

Service Code	NDC 00002143380
Hospital Charge Code	3800562
Hospital Revenue Code	250
Min. Negotiated Rate	$413.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$413.86
Rate for Payer: UnitedHealthcare Commercial	$436.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dulaglutide 0.75 mg/0.5 mL UD [HMC]

Facility

$459.84

Service Code	NDC 00002143380
Hospital Charge Code	3800562
Hospital Revenue Code	250
Min. Negotiated Rate	$183.94
Max. Negotiated Rate	$436.85
Rate for Payer: Aetna Commercial	$413.86
Rate for Payer: Humana Medicare Advantage	$193.13
Rate for Payer: UnitedHealthcare Commercial	$436.85
Rate for Payer: UnitedHealthcare Medicaid	$183.94
Rate for Payer: WPPA Medicare Advantage	$275.90

dulaglutide 1.5 mg/0.5 mL UD [HMC]

Facility

$459.84

Service Code	NDC 00002143480
Hospital Charge Code	3800548
Hospital Revenue Code	250
Min. Negotiated Rate	$413.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$413.86
Rate for Payer: UnitedHealthcare Commercial	$436.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dulaglutide 1.5 mg/0.5 mL UD [HMC]

Facility

$459.84

Service Code	NDC 00002143480
Hospital Charge Code	3800548
Hospital Revenue Code	250
Min. Negotiated Rate	$183.94
Max. Negotiated Rate	$436.85
Rate for Payer: Aetna Commercial	$413.86
Rate for Payer: Humana Medicare Advantage	$193.13
Rate for Payer: UnitedHealthcare Commercial	$436.85
Rate for Payer: UnitedHealthcare Medicaid	$183.94
Rate for Payer: WPPA Medicare Advantage	$275.90

DULoxetine 20 mg Cap [HMC]

Facility

$10.24

Service Code	NDC 00904704304
Hospital Charge Code	3800198
Hospital Revenue Code	250
Min. Negotiated Rate	$9.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.22
Rate for Payer: UnitedHealthcare Commercial	$9.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DULoxetine 20 mg Cap [HMC]

Facility

$22.50

Service Code	NDC 60505299506
Hospital Charge Code	3800198
Hospital Revenue Code	250
Min. Negotiated Rate	$20.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.25
Rate for Payer: UnitedHealthcare Commercial	$21.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DULoxetine 20 mg Cap [HMC]

Facility

$10.24

Service Code	NDC 00904704304
Hospital Charge Code	3800198
Hospital Revenue Code	250
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$9.73
Rate for Payer: Aetna Commercial	$9.22
Rate for Payer: Humana Medicare Advantage	$4.30
Rate for Payer: UnitedHealthcare Commercial	$9.73
Rate for Payer: UnitedHealthcare Medicaid	$4.10
Rate for Payer: WPPA Medicare Advantage	$6.14

DULoxetine 20 mg Cap [HMC]

Facility

$22.50

Service Code	NDC 60505299506
Hospital Charge Code	3800198
Hospital Revenue Code	250
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$21.38
Rate for Payer: Aetna Commercial	$20.25
Rate for Payer: Humana Medicare Advantage	$9.45
Rate for Payer: UnitedHealthcare Commercial	$21.38
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: WPPA Medicare Advantage	$13.50

DULoxetine 20 mg Cap [HMC]

Facility

$22.50

Service Code	NDC 68180029407
Hospital Charge Code	3800198
Hospital Revenue Code	250
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$21.38
Rate for Payer: Aetna Commercial	$20.25
Rate for Payer: Humana Medicare Advantage	$9.45
Rate for Payer: UnitedHealthcare Commercial	$21.38
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: WPPA Medicare Advantage	$13.50

Know your out-of-pocket cost for care.

All Charges