Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

EPISTAXIS WITH MCC

Facility

$3,875.94

Service Code	MSDRG 150
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,875.94
Rate for Payer: UnitedHealthcare Medicaid	$3,875.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EPISTAXIS WITHOUT MCC

Facility

$2,128.59

Service Code	MSDRG 151
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,128.59
Rate for Payer: UnitedHealthcare Medicaid	$2,128.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

epoetin alfa 10,000 units/mL preservative-free Sol [HMC]

Facility

$318.44

Service Code	HCPCS J0885
Hospital Charge Code	3850405
Hospital Revenue Code	250
Min. Negotiated Rate	$7.74
Max. Negotiated Rate	$302.52
Rate for Payer: Aetna Commercial	$286.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$10.64
Rate for Payer: Humana Medicare Advantage	$133.74
Rate for Payer: UnitedHealthcare Commercial	$302.52
Rate for Payer: UnitedHealthcare Medicaid	$7.74
Rate for Payer: WPPA Medicare Advantage	$191.06

epoetin alfa 10,000 units/mL preservative-free Sol [HMC]

Facility

$318.44

Service Code	HCPCS J0885
Hospital Charge Code	3850405
Hospital Revenue Code	250
Min. Negotiated Rate	$286.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$286.60
Rate for Payer: UnitedHealthcare Commercial	$302.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

epoetin alfa 20,000 units/mL Inj Sol [HMC]

Facility

$616.88

Service Code	HCPCS J0885
Hospital Charge Code	3850404
Hospital Revenue Code	250
Min. Negotiated Rate	$555.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$555.19
Rate for Payer: Aetna Commercial	$883.89
Rate for Payer: UnitedHealthcare Commercial	$933.00
Rate for Payer: UnitedHealthcare Commercial	$586.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

epoetin alfa 20,000 units/mL Inj Sol [HMC]

Facility

$616.88

Service Code	HCPCS J0885
Hospital Charge Code	3850404
Hospital Revenue Code	250
Min. Negotiated Rate	$7.74
Max. Negotiated Rate	$586.04
Rate for Payer: Aetna Commercial	$555.19
Rate for Payer: Aetna Commercial	$883.89
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$10.64
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$10.64
Rate for Payer: Humana Medicare Advantage	$412.48
Rate for Payer: Humana Medicare Advantage	$259.09
Rate for Payer: UnitedHealthcare Commercial	$586.04
Rate for Payer: UnitedHealthcare Commercial	$933.00
Rate for Payer: UnitedHealthcare Medicaid	$7.74
Rate for Payer: UnitedHealthcare Medicaid	$7.74
Rate for Payer: WPPA Medicare Advantage	$589.26
Rate for Payer: WPPA Medicare Advantage	$370.13

Epstein Barr Virus Ab Panel QST

Facility

$118.00

Service Code	HCPCS 86664
Hospital Charge Code	3558666
Hospital Revenue Code	300
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$112.10
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$62.59
Rate for Payer: Humana Medicare Advantage	$49.56
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: UnitedHealthcare Medicaid	$13.00
Rate for Payer: WPPA Medicare Advantage	$70.80

Epstein Barr Virus Ab Panel QST

Facility

$118.00

Service Code	HCPCS 86664
Hospital Charge Code	3558666
Hospital Revenue Code	300
Min. Negotiated Rate	$106.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Epstein Barr Virus VCA antibody

Facility

$192.00

Service Code	HCPCS 86665
Hospital Charge Code	3558665
Hospital Revenue Code	300
Min. Negotiated Rate	$172.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$172.80
Rate for Payer: UnitedHealthcare Commercial	$182.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Epstein Barr Virus VCA antibody

Facility

$192.00

Service Code	HCPCS 86665
Hospital Charge Code	3558665
Hospital Revenue Code	300
Min. Negotiated Rate	$15.42
Max. Negotiated Rate	$182.40
Rate for Payer: Aetna Commercial	$172.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$64.87
Rate for Payer: Humana Medicare Advantage	$80.64
Rate for Payer: UnitedHealthcare Commercial	$182.40
Rate for Payer: UnitedHealthcare Medicaid	$15.42
Rate for Payer: WPPA Medicare Advantage	$115.20

eptinezumab jjmr 100 mg/mL Sol [HMC]

Facility

$2,701.00

Service Code	HCPCS J3032
Hospital Charge Code	3852066
Hospital Revenue Code	250
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$2,565.95
Rate for Payer: Aetna Commercial	$2,430.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.23
Rate for Payer: Humana Medicare Advantage	$1,134.42
Rate for Payer: UnitedHealthcare Commercial	$2,565.95
Rate for Payer: UnitedHealthcare Medicaid	$20.50
Rate for Payer: WPPA Medicare Advantage	$1,620.60

eptinezumab jjmr 100 mg/mL Sol [HMC]

Facility

$2,701.00

Service Code	HCPCS J3032
Hospital Charge Code	3852066
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,565.95
Rate for Payer: Aetna Commercial	$2,430.90
Rate for Payer: UnitedHealthcare Commercial	$2,565.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ertapenem 1 g Inj [HMC]

Facility

$164.00

Service Code	NDC 55150028209
Hospital Charge Code	3800795
Hospital Revenue Code	250
Min. Negotiated Rate	$147.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ertapenem 1 g Inj [HMC]

Facility

$164.00

Service Code	HCPCS J1335
Hospital Charge Code	3800795
Hospital Revenue Code	250
Min. Negotiated Rate	$147.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: Aetna Commercial	$236.83
Rate for Payer: Aetna Commercial	$180.00
Rate for Payer: Aetna Commercial	$207.66
Rate for Payer: UnitedHealthcare Commercial	$190.00
Rate for Payer: UnitedHealthcare Commercial	$249.98
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: UnitedHealthcare Commercial	$219.19
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
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ertapenem 1 g Inj [HMC]

Facility

$164.00

Service Code	HCPCS J1335
Hospital Charge Code	3800795
Hospital Revenue Code	250
Min. Negotiated Rate	$9.16
Max. Negotiated Rate	$155.80
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: Aetna Commercial	$180.00
Rate for Payer: Aetna Commercial	$207.66
Rate for Payer: Aetna Commercial	$236.83
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$17.97
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$17.97
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$17.97
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$17.97
Rate for Payer: Humana Medicare Advantage	$110.52
Rate for Payer: Humana Medicare Advantage	$96.91
Rate for Payer: Humana Medicare Advantage	$84.00
Rate for Payer: Humana Medicare Advantage	$68.88
Rate for Payer: UnitedHealthcare Commercial	$249.98
Rate for Payer: UnitedHealthcare Commercial	$190.00
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: UnitedHealthcare Commercial	$219.19
Rate for Payer: UnitedHealthcare Medicaid	$9.16
Rate for Payer: UnitedHealthcare Medicaid	$9.16
Rate for Payer: UnitedHealthcare Medicaid	$9.16
Rate for Payer: UnitedHealthcare Medicaid	$9.16
Rate for Payer: WPPA Medicare Advantage	$157.88
Rate for Payer: WPPA Medicare Advantage	$138.44
Rate for Payer: WPPA Medicare Advantage	$120.00
Rate for Payer: WPPA Medicare Advantage	$98.40

ertapenem 1 g Inj [HMC]

Facility

$164.00

Service Code	NDC 55150028209
Hospital Charge Code	3800795
Hospital Revenue Code	250
Min. Negotiated Rate	$65.60
Max. Negotiated Rate	$155.80
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: Humana Medicare Advantage	$68.88
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: UnitedHealthcare Medicaid	$65.60
Rate for Payer: WPPA Medicare Advantage	$98.40

erythromycin Ophth 0.5% Oint [HMC]

Facility

$38.62

Service Code	NDC 24208091019
Hospital Charge Code	3805336
Hospital Revenue Code	250
Min. Negotiated Rate	$15.45
Max. Negotiated Rate	$36.69
Rate for Payer: Aetna Commercial	$34.76
Rate for Payer: Humana Medicare Advantage	$16.22
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicaid	$15.45
Rate for Payer: WPPA Medicare Advantage	$23.17

erythromycin Ophth 0.5% Oint [HMC]

Facility

$35.22

Service Code	NDC 48102000811
Hospital Charge Code	3805336
Hospital Revenue Code	250
Min. Negotiated Rate	$14.09
Max. Negotiated Rate	$33.46
Rate for Payer: Aetna Commercial	$31.70
Rate for Payer: Humana Medicare Advantage	$14.79
Rate for Payer: UnitedHealthcare Commercial	$33.46
Rate for Payer: UnitedHealthcare Medicaid	$14.09
Rate for Payer: WPPA Medicare Advantage	$21.13

erythromycin Ophth 0.5% Oint [HMC]

Facility

$38.62

Service Code	NDC 24208091019
Hospital Charge Code	3805336
Hospital Revenue Code	250
Min. Negotiated Rate	$34.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.76
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

erythromycin Ophth 0.5% Oint [HMC]

Facility

$35.22

Service Code	NDC 48102000811
Hospital Charge Code	3805336
Hospital Revenue Code	250
Min. Negotiated Rate	$31.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.70
Rate for Payer: UnitedHealthcare Commercial	$33.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Erythropoietin QST

Facility

$116.00

Service Code	HCPCS 82668
Hospital Charge Code	3558266
Hospital Revenue Code	300
Min. Negotiated Rate	$18.79
Max. Negotiated Rate	$110.20
Rate for Payer: Aetna Commercial	$104.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$70.98
Rate for Payer: Humana Medicare Advantage	$48.72
Rate for Payer: UnitedHealthcare Commercial	$110.20
Rate for Payer: UnitedHealthcare Medicaid	$18.79
Rate for Payer: WPPA Medicare Advantage	$69.60

Erythropoietin QST

Facility

$116.00

Service Code	HCPCS 82668
Hospital Charge Code	3558266
Hospital Revenue Code	300
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$104.40
Rate for Payer: UnitedHealthcare Commercial	$110.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

escitalopram 10 mg Tab [HMC]

Facility

$17.96

Service Code	NDC 68084061701
Hospital Charge Code	3809452
Hospital Revenue Code	250
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.16
Rate for Payer: UnitedHealthcare Commercial	$17.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

escitalopram 10 mg Tab [HMC]

Facility

$17.96

Service Code	NDC 68084061701
Hospital Charge Code	3809452
Hospital Revenue Code	250
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$17.06
Rate for Payer: Aetna Commercial	$16.16
Rate for Payer: Humana Medicare Advantage	$7.54
Rate for Payer: UnitedHealthcare Commercial	$17.06
Rate for Payer: UnitedHealthcare Medicaid	$7.18
Rate for Payer: WPPA Medicare Advantage	$10.78

Know your out-of-pocket cost for care.

All Charges