Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

EPINEPHrine-lidocaine 1:100,000-1% Inj Sol 10 mL [HMC]

Facility

$40.82

Service Code	NDC 63323048217
Hospital Charge Code	3803943
Hospital Revenue Code	250
Min. Negotiated Rate	$16.33
Max. Negotiated Rate	$38.78
Rate for Payer: Aetna Commercial	$36.74
Rate for Payer: Humana Medicare Advantage	$17.14
Rate for Payer: UnitedHealthcare Commercial	$38.78
Rate for Payer: UnitedHealthcare Medicaid	$16.33
Rate for Payer: WPPA Medicare Advantage	$24.49

EPINEPHrine-lidocaine 1:100,000-1% Inj Sol 10 mL [HMC]

Facility

$40.82

Service Code	NDC 63323048217
Hospital Charge Code	3803943
Hospital Revenue Code	250
Min. Negotiated Rate	$36.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.74
Rate for Payer: UnitedHealthcare Commercial	$38.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

epinephrine-lidocaine 1:100000-1% Sol MDV 20 mL [HMC]

Facility

$37.68

Service Code	NDC 63323048227
Hospital Charge Code	3803950
Hospital Revenue Code	259
Min. Negotiated Rate	$15.07
Max. Negotiated Rate	$35.80
Rate for Payer: Aetna Commercial	$33.91
Rate for Payer: Humana Medicare Advantage	$15.83
Rate for Payer: UnitedHealthcare Commercial	$35.80
Rate for Payer: UnitedHealthcare Medicaid	$15.07
Rate for Payer: WPPA Medicare Advantage	$22.61

epinephrine-lidocaine 1:100000-1% Sol MDV 20 mL [HMC]

Facility

$37.68

Service Code	NDC 63323048227
Hospital Charge Code	3803950
Hospital Revenue Code	250
Min. Negotiated Rate	$15.07
Max. Negotiated Rate	$35.80
Rate for Payer: Aetna Commercial	$33.91
Rate for Payer: Humana Medicare Advantage	$15.83
Rate for Payer: UnitedHealthcare Commercial	$35.80
Rate for Payer: UnitedHealthcare Medicaid	$15.07
Rate for Payer: WPPA Medicare Advantage	$22.61

epinephrine-lidocaine 1:100000-1% Sol MDV 20 mL [HMC]

Facility

$37.68

Service Code	NDC 63323048227
Hospital Charge Code	3803950
Hospital Revenue Code	259
Min. Negotiated Rate	$33.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.91
Rate for Payer: UnitedHealthcare Commercial	$35.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

epinephrine-lidocaine 1:100000-1% Sol MDV 20 mL [HMC]

Facility

$37.68

Service Code	NDC 63323048227
Hospital Charge Code	3803950
Hospital Revenue Code	250
Min. Negotiated Rate	$33.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.91
Rate for Payer: UnitedHealthcare Commercial	$35.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

epinephrine-lidocaine 1:100000-2% Sol MDV 20 mL [HMC]

Facility

$40.03

Service Code	NDC 00409318201
Hospital Charge Code	3170023
Hospital Revenue Code	250
Min. Negotiated Rate	$16.01
Max. Negotiated Rate	$38.03
Rate for Payer: Aetna Commercial	$36.03
Rate for Payer: Humana Medicare Advantage	$16.81
Rate for Payer: UnitedHealthcare Commercial	$38.03
Rate for Payer: UnitedHealthcare Medicaid	$16.01
Rate for Payer: WPPA Medicare Advantage	$24.02

epinephrine-lidocaine 1:100000-2% Sol MDV 20 mL [HMC]

Facility

$40.03

Service Code	NDC 00409318201
Hospital Charge Code	3170023
Hospital Revenue Code	250
Min. Negotiated Rate	$36.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.03
Rate for Payer: UnitedHealthcare Commercial	$38.03
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 10 mL [HMC]

Facility

$56.97

Service Code	NDC 63323048917
Hospital Charge Code	3808579
Hospital Revenue Code	250
Min. Negotiated Rate	$51.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.27
Rate for Payer: UnitedHealthcare Commercial	$54.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 10 mL [HMC]

Facility

$56.97

Service Code	NDC 63323048917
Hospital Charge Code	3808579
Hospital Revenue Code	250
Min. Negotiated Rate	$22.79
Max. Negotiated Rate	$54.12
Rate for Payer: Aetna Commercial	$51.27
Rate for Payer: Humana Medicare Advantage	$23.93
Rate for Payer: UnitedHealthcare Commercial	$54.12
Rate for Payer: UnitedHealthcare Medicaid	$22.79
Rate for Payer: WPPA Medicare Advantage	$34.18

EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 20 mL [HMC]

Facility

$57.10

Service Code	NDC 63323048927
Hospital Charge Code	3808579
Hospital Revenue Code	250
Min. Negotiated Rate	$51.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.39
Rate for Payer: UnitedHealthcare Commercial	$54.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 20 mL [HMC]

Facility

$38.17

Service Code	NDC 00409318301
Hospital Charge Code	3808579
Hospital Revenue Code	250
Min. Negotiated Rate	$15.27
Max. Negotiated Rate	$36.26
Rate for Payer: Aetna Commercial	$34.35
Rate for Payer: Humana Medicare Advantage	$16.03
Rate for Payer: UnitedHealthcare Commercial	$36.26
Rate for Payer: UnitedHealthcare Medicaid	$15.27
Rate for Payer: WPPA Medicare Advantage	$22.90

EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 20 mL [HMC]

Facility

$57.10

Service Code	NDC 63323048927
Hospital Charge Code	3808579
Hospital Revenue Code	250
Min. Negotiated Rate	$22.84
Max. Negotiated Rate	$54.24
Rate for Payer: Aetna Commercial	$51.39
Rate for Payer: Humana Medicare Advantage	$23.98
Rate for Payer: UnitedHealthcare Commercial	$54.24
Rate for Payer: UnitedHealthcare Medicaid	$22.84
Rate for Payer: WPPA Medicare Advantage	$34.26

EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 20 mL [HMC]

Facility

$38.17

Service Code	NDC 00409318301
Hospital Charge Code	3808579
Hospital Revenue Code	250
Min. Negotiated Rate	$34.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.35
Rate for Payer: UnitedHealthcare Commercial	$36.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

epinephrine/lidocaine/tetracaine topical 0.05%-4%-0.5% Gel [HMC]

Facility

$48.24

Service Code	NDC 70092161144
Hospital Charge Code	3801552
Hospital Revenue Code	250
Min. Negotiated Rate	$43.42
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$43.42
Rate for Payer: UnitedHealthcare Commercial	$45.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

epinephrine/lidocaine/tetracaine topical 0.05%-4%-0.5% Gel [HMC]

Facility

$48.24

Service Code	NDC 70092161144
Hospital Charge Code	3801552
Hospital Revenue Code	250
Min. Negotiated Rate	$19.30
Max. Negotiated Rate	$45.83
Rate for Payer: Aetna Commercial	$43.42
Rate for Payer: Humana Medicare Advantage	$20.26
Rate for Payer: UnitedHealthcare Commercial	$45.83
Rate for Payer: UnitedHealthcare Medicaid	$19.30
Rate for Payer: WPPA Medicare Advantage	$28.94

EPINEPHrine topical nasal 30 mg/ 30 mL Sol [HMC]

Facility

$425.92

Service Code	NDC 42023010301
Hospital Charge Code	3801315
Hospital Revenue Code	250
Min. Negotiated Rate	$383.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$383.33
Rate for Payer: UnitedHealthcare Commercial	$404.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EPINEPHrine topical nasal 30 mg/ 30 mL Sol [HMC]

Facility

$425.92

Service Code	NDC 42023010301
Hospital Charge Code	3801315
Hospital Revenue Code	250
Min. Negotiated Rate	$170.37
Max. Negotiated Rate	$404.62
Rate for Payer: Aetna Commercial	$383.33
Rate for Payer: Humana Medicare Advantage	$178.89
Rate for Payer: UnitedHealthcare Commercial	$404.62
Rate for Payer: UnitedHealthcare Medicaid	$170.37
Rate for Payer: WPPA Medicare Advantage	$255.55

EPINEPHrine topical nasal 30 mg/ 30 mL Sol [HMC]

Facility

$376.40

Service Code	NDC 54288015401
Hospital Charge Code	3801315
Hospital Revenue Code	250
Min. Negotiated Rate	$338.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$338.76
Rate for Payer: UnitedHealthcare Commercial	$357.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EPINEPHrine topical nasal 30 mg/ 30 mL Sol [HMC]

Facility

$376.40

Service Code	NDC 54288015401
Hospital Charge Code	3801315
Hospital Revenue Code	250
Min. Negotiated Rate	$150.56
Max. Negotiated Rate	$357.58
Rate for Payer: Aetna Commercial	$338.76
Rate for Payer: Humana Medicare Advantage	$158.09
Rate for Payer: UnitedHealthcare Commercial	$357.58
Rate for Payer: UnitedHealthcare Medicaid	$150.56
Rate for Payer: WPPA Medicare Advantage	$225.84

EpiPatch Otologic Repair Patch for Tympanic Membrane (Ear Drum)

Facility

$625.00

Hospital Charge Code	3257105
Hospital Revenue Code	270
Min. Negotiated Rate	$562.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$562.50
Rate for Payer: UnitedHealthcare Commercial	$593.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EpiPatch Otologic Repair Patch for Tympanic Membrane (Ear Drum)

Facility

$625.00

Hospital Charge Code	3257105
Hospital Revenue Code	270
Min. Negotiated Rate	$250.00
Max. Negotiated Rate	$593.75
Rate for Payer: Aetna Commercial	$562.50
Rate for Payer: Humana Medicare Advantage	$262.50
Rate for Payer: UnitedHealthcare Commercial	$593.75
Rate for Payer: UnitedHealthcare Medicaid	$250.00
Rate for Payer: WPPA Medicare Advantage	$375.00

Episiotomy Transcribed

Facility

$432.00

Service Code	HCPCS 59300
Hospital Charge Code	3209300
Hospital Revenue Code	729
Min. Negotiated Rate	$388.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$388.80
Rate for Payer: UnitedHealthcare Commercial	$410.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Episiotomy Transcribed

Facility

$432.00

Service Code	HCPCS 59300
Hospital Charge Code	3209300
Hospital Revenue Code	729
Min. Negotiated Rate	$181.44
Max. Negotiated Rate	$1,012.78
Rate for Payer: Aetna Commercial	$388.80
Rate for Payer: Humana Medicare Advantage	$181.44
Rate for Payer: UnitedHealthcare Commercial	$410.40
Rate for Payer: UnitedHealthcare Medicaid	$1,012.78
Rate for Payer: WPPA Medicare Advantage	$259.20

Epistaxis Balloon Cath

Facility

$204.86

Hospital Charge Code	3257685
Hospital Revenue Code	270
Min. Negotiated Rate	$81.94
Max. Negotiated Rate	$194.62
Rate for Payer: Aetna Commercial	$184.37
Rate for Payer: Humana Medicare Advantage	$86.04
Rate for Payer: UnitedHealthcare Commercial	$194.62
Rate for Payer: UnitedHealthcare Medicaid	$81.94
Rate for Payer: WPPA Medicare Advantage	$122.92

Know your out-of-pocket cost for care.

All Charges