Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

ferrous sulfate 324 mg Tab UD [HMC]

Facility

$5.18

Service Code	NDC 00574060801
Hospital Charge Code	3801609
Hospital Revenue Code	250
Min. Negotiated Rate	$4.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.66
Rate for Payer: UnitedHealthcare Commercial	$4.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ferrous sulfate 324 mg Tab UD [HMC]

Facility

$5.18

Service Code	NDC 00574060801
Hospital Charge Code	3801609
Hospital Revenue Code	250
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$4.92
Rate for Payer: Aetna Commercial	$4.66
Rate for Payer: Humana Medicare Advantage	$2.18
Rate for Payer: UnitedHealthcare Commercial	$4.92
Rate for Payer: UnitedHealthcare Medicaid	$2.07
Rate for Payer: WPPA Medicare Advantage	$3.11

ferrous sulfate (as elemental iron) 15 mg/mL [HMC]

Facility

$46.25

Service Code	NDC 39328005750
Hospital Charge Code	3807549
Hospital Revenue Code	250
Min. Negotiated Rate	$41.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.62
Rate for Payer: UnitedHealthcare Commercial	$43.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ferrous sulfate (as elemental iron) 15 mg/mL [HMC]

Facility

$46.25

Service Code	NDC 39328005750
Hospital Charge Code	3807549
Hospital Revenue Code	250
Min. Negotiated Rate	$18.50
Max. Negotiated Rate	$43.94
Rate for Payer: Aetna Commercial	$41.62
Rate for Payer: Humana Medicare Advantage	$19.43
Rate for Payer: UnitedHealthcare Commercial	$43.94
Rate for Payer: UnitedHealthcare Medicaid	$18.50
Rate for Payer: WPPA Medicare Advantage	$27.75

ferumoxytol 30 mg/mL 17 mL Inj [HMC]

Facility

$2,095.93

Service Code	HCPCS Q0138
Hospital Charge Code	3800399
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$1,991.13
Rate for Payer: Aetna Commercial	$1,886.34
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.51
Rate for Payer: Humana Medicare Advantage	$880.29
Rate for Payer: UnitedHealthcare Commercial	$1,991.13
Rate for Payer: UnitedHealthcare Medicaid	$0.36
Rate for Payer: WPPA Medicare Advantage	$1,257.56

ferumoxytol 30 mg/mL 17 mL Inj [HMC]

Facility

$2,095.93

Service Code	HCPCS Q0138
Hospital Charge Code	3800399
Hospital Revenue Code	259
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,991.13
Rate for Payer: Aetna Commercial	$1,886.34
Rate for Payer: UnitedHealthcare Commercial	$1,991.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ferumoxytol 30 mg/mL 17 mLInj [HMC]

Facility

$1,639.63

Service Code	HCPCS Q0138
Hospital Charge Code	3800399
Hospital Revenue Code	259
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,557.65
Rate for Payer: Aetna Commercial	$1,475.67
Rate for Payer: UnitedHealthcare Commercial	$1,557.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ferumoxytol 30 mg/mL 17 mLInj [HMC]

Facility

$1,639.63

Service Code	HCPCS Q0138
Hospital Charge Code	3800399
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$1,557.65
Rate for Payer: Aetna Commercial	$1,475.67
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.51
Rate for Payer: Humana Medicare Advantage	$688.64
Rate for Payer: UnitedHealthcare Commercial	$1,557.65
Rate for Payer: UnitedHealthcare Medicaid	$0.36
Rate for Payer: WPPA Medicare Advantage	$983.78

fesoterodine 4 mg [HMC]

Facility

$35.12

Service Code	NDC 00069024230
Hospital Charge Code	3805044
Hospital Revenue Code	250
Min. Negotiated Rate	$14.05
Max. Negotiated Rate	$33.36
Rate for Payer: Aetna Commercial	$31.61
Rate for Payer: Humana Medicare Advantage	$14.75
Rate for Payer: UnitedHealthcare Commercial	$33.36
Rate for Payer: UnitedHealthcare Medicaid	$14.05
Rate for Payer: WPPA Medicare Advantage	$21.07

fesoterodine 4 mg [HMC]

Facility

$32.07

Service Code	NDC 67877006430
Hospital Charge Code	3805044
Hospital Revenue Code	250
Min. Negotiated Rate	$12.83
Max. Negotiated Rate	$30.47
Rate for Payer: Aetna Commercial	$28.86
Rate for Payer: Humana Medicare Advantage	$13.47
Rate for Payer: UnitedHealthcare Commercial	$30.47
Rate for Payer: UnitedHealthcare Medicaid	$12.83
Rate for Payer: WPPA Medicare Advantage	$19.24

fesoterodine 4 mg [HMC]

Facility

$32.07

Service Code	NDC 67877006430
Hospital Charge Code	3805044
Hospital Revenue Code	250
Min. Negotiated Rate	$28.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.86
Rate for Payer: UnitedHealthcare Commercial	$30.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fesoterodine 4 mg [HMC]

Facility

$35.12

Service Code	NDC 00069024230
Hospital Charge Code	3805044
Hospital Revenue Code	250
Min. Negotiated Rate	$31.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.61
Rate for Payer: UnitedHealthcare Commercial	$33.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fetal Non-Stress Test

Facility

$583.00

Service Code	HCPCS 59025
Hospital Charge Code	3290325
Hospital Revenue Code	761
Min. Negotiated Rate	$64.55
Max. Negotiated Rate	$553.85
Rate for Payer: Aetna Commercial	$524.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$359.77
Rate for Payer: Humana Medicare Advantage	$244.86
Rate for Payer: UnitedHealthcare Commercial	$553.85
Rate for Payer: UnitedHealthcare Medicaid	$64.55
Rate for Payer: WPPA Medicare Advantage	$349.80

Fetal Non-Stress Test

Facility

$583.00

Service Code	HCPCS 59025
Hospital Charge Code	3290325
Hospital Revenue Code	761
Min. Negotiated Rate	$524.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$524.70
Rate for Payer: UnitedHealthcare Commercial	$553.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FEVER AND INFLAMMATORY CONDITIONS

Facility

$3,526.47

Service Code	MSDRG 864
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,526.47
Rate for Payer: UnitedHealthcare Medicaid	$3,526.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fexofenadine 60 mg Tab [HMC]

Facility

$5.48

Service Code	NDC 00904719260
Hospital Charge Code	3802085
Hospital Revenue Code	250
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$5.21
Rate for Payer: Aetna Commercial	$4.93
Rate for Payer: Humana Medicare Advantage	$2.30
Rate for Payer: UnitedHealthcare Commercial	$5.21
Rate for Payer: UnitedHealthcare Medicaid	$2.19
Rate for Payer: WPPA Medicare Advantage	$3.29

fexofenadine 60 mg Tab [HMC]

Facility

$5.55

Service Code	NDC 55111078301
Hospital Charge Code	3802085
Hospital Revenue Code	250
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$5.27
Rate for Payer: Aetna Commercial	$5.00
Rate for Payer: Humana Medicare Advantage	$2.33
Rate for Payer: UnitedHealthcare Commercial	$5.27
Rate for Payer: UnitedHealthcare Medicaid	$2.22
Rate for Payer: WPPA Medicare Advantage	$3.33

fexofenadine 60 mg Tab [HMC]

Facility

$9.54

Service Code	NDC 51079054720
Hospital Charge Code	3802085
Hospital Revenue Code	250
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$9.06
Rate for Payer: Aetna Commercial	$8.59
Rate for Payer: Humana Medicare Advantage	$4.01
Rate for Payer: UnitedHealthcare Commercial	$9.06
Rate for Payer: UnitedHealthcare Medicaid	$3.82
Rate for Payer: WPPA Medicare Advantage	$5.72

fexofenadine 60 mg Tab [HMC]

Facility

$9.54

Service Code	NDC 51079054720
Hospital Charge Code	3802085
Hospital Revenue Code	250
Min. Negotiated Rate	$8.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.59
Rate for Payer: UnitedHealthcare Commercial	$9.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fexofenadine 60 mg Tab [HMC]

Facility

$5.55

Service Code	NDC 55111078301
Hospital Charge Code	3802085
Hospital Revenue Code	250
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.00
Rate for Payer: UnitedHealthcare Commercial	$5.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fexofenadine 60 mg Tab [HMC]

Facility

$5.48

Service Code	NDC 00904719260
Hospital Charge Code	3802085
Hospital Revenue Code	250
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.93
Rate for Payer: UnitedHealthcare Commercial	$5.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fibrinogen Activity, Clauss QST

Facility

$45.00

Service Code	HCPCS 85384
Hospital Charge Code	3550411
Hospital Revenue Code	300
Min. Negotiated Rate	$9.72
Max. Negotiated Rate	$42.75
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$25.65
Rate for Payer: Humana Medicare Advantage	$18.90
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: UnitedHealthcare Medicaid	$9.72
Rate for Payer: WPPA Medicare Advantage	$27.00

Fibrinogen Activity, Clauss QST

Facility

$45.00

Service Code	HCPCS 85384
Hospital Charge Code	3550411
Hospital Revenue Code	300
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

filgrastim 300 mcg/mL Inj Sol [HMC]

Facility

$586.70

Service Code	HCPCS J1442
Hospital Charge Code	3850065
Hospital Revenue Code	250
Min. Negotiated Rate	$528.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$528.03
Rate for Payer: UnitedHealthcare Commercial	$557.37
Rate for Payer: WPPA Medicare Advantage	$1,200.00

filgrastim 300 mcg/mL Inj Sol [HMC]

Facility

$586.70

Service Code	HCPCS J1442
Hospital Charge Code	3850065
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$557.37
Rate for Payer: Aetna Commercial	$528.03
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.21
Rate for Payer: Humana Medicare Advantage	$246.41
Rate for Payer: UnitedHealthcare Commercial	$557.37
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$352.02

Know your out-of-pocket cost for care.

All Charges