Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

filgrastim 480 mcg/1.6 mL Inj Sol [HMC]

Facility

$922.39

Service Code	HCPCS J1442
Hospital Charge Code	3850321
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$876.27
Rate for Payer: Aetna Commercial	$830.15
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.21
Rate for Payer: Humana Medicare Advantage	$387.40
Rate for Payer: UnitedHealthcare Commercial	$876.27
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$553.43

filgrastim 480 mcg/1.6 mL Inj Sol [HMC]

Facility

$922.39

Service Code	HCPCS J1442
Hospital Charge Code	3850321
Hospital Revenue Code	250
Min. Negotiated Rate	$830.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$830.15
Rate for Payer: UnitedHealthcare Commercial	$876.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

filgrastim ayow 300 mcg/0.5 mL Sol [HMC]

Facility

$306.20

Service Code	NDC 70121156807
Hospital Charge Code	3850323
Hospital Revenue Code	250
Min. Negotiated Rate	$275.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$275.58
Rate for Payer: UnitedHealthcare Commercial	$290.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

filgrastim ayow 300 mcg/0.5 mL Sol [HMC]

Facility

$306.20

Service Code	HCPCS J1442
Hospital Charge Code	3850323
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$290.89
Rate for Payer: Aetna Commercial	$275.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.21
Rate for Payer: Humana Medicare Advantage	$128.60
Rate for Payer: UnitedHealthcare Commercial	$290.89
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$183.72

filgrastim ayow 300 mcg/0.5 mL Sol [HMC]

Facility

$306.20

Service Code	HCPCS J1442
Hospital Charge Code	3850323
Hospital Revenue Code	250
Min. Negotiated Rate	$275.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$275.58
Rate for Payer: UnitedHealthcare Commercial	$290.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

filgrastim ayow 300 mcg/0.5 mL Sol [HMC]

Facility

$306.20

Service Code	NDC 70121156807
Hospital Charge Code	3850323
Hospital Revenue Code	250
Min. Negotiated Rate	$122.48
Max. Negotiated Rate	$290.89
Rate for Payer: Aetna Commercial	$275.58
Rate for Payer: Humana Medicare Advantage	$128.60
Rate for Payer: UnitedHealthcare Commercial	$290.89
Rate for Payer: UnitedHealthcare Medicaid	$122.48
Rate for Payer: WPPA Medicare Advantage	$183.72

filgrastim ayow 480 mcg/0.8 mL Sol [HMC]

Facility

$477.92

Service Code	HCPCS J1442
Hospital Charge Code	3850322
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$454.02
Rate for Payer: Aetna Commercial	$430.13
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.21
Rate for Payer: Humana Medicare Advantage	$200.73
Rate for Payer: UnitedHealthcare Commercial	$454.02
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$286.75

filgrastim ayow 480 mcg/0.8 mL Sol [HMC]

Facility

$477.92

Service Code	HCPCS J1442
Hospital Charge Code	3850322
Hospital Revenue Code	250
Min. Negotiated Rate	$430.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$430.13
Rate for Payer: UnitedHealthcare Commercial	$454.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

filgrastim sndz 300 mcg/0.5 mL Sol [HMC]

Facility

$668.46

Service Code	HCPCS Q5101
Hospital Charge Code	3850325
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$635.04
Rate for Payer: Aetna Commercial	$601.61
Rate for Payer: Aetna Commercial	$601.62
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.57
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.57
Rate for Payer: Humana Medicare Advantage	$280.75
Rate for Payer: Humana Medicare Advantage	$280.76
Rate for Payer: UnitedHealthcare Commercial	$635.04
Rate for Payer: UnitedHealthcare Commercial	$635.05
Rate for Payer: UnitedHealthcare Medicaid	$267.38
Rate for Payer: UnitedHealthcare Medicaid	$267.39
Rate for Payer: WPPA Medicare Advantage	$401.08
Rate for Payer: WPPA Medicare Advantage	$401.08

filgrastim sndz 300 mcg/0.5 mL Sol [HMC]

Facility

$668.47

Service Code	HCPCS Q5101
Hospital Charge Code	3850325
Hospital Revenue Code	250
Min. Negotiated Rate	$601.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$601.62
Rate for Payer: Aetna Commercial	$601.61
Rate for Payer: UnitedHealthcare Commercial	$635.04
Rate for Payer: UnitedHealthcare Commercial	$635.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

finasteride 5 mg Tab [HMC]

Facility

$19.06

Service Code	HCPCS S0138
Hospital Charge Code	3806896
Hospital Revenue Code	250
Min. Negotiated Rate	$17.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.15
Rate for Payer: Aetna Commercial	$19.06
Rate for Payer: Aetna Commercial	$27.51
Rate for Payer: UnitedHealthcare Commercial	$29.04
Rate for Payer: UnitedHealthcare Commercial	$18.11
Rate for Payer: UnitedHealthcare Commercial	$20.12
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

finasteride 5 mg Tab [HMC]

Facility

$21.18

Service Code	HCPCS S0138
Hospital Charge Code	3806896
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$20.12
Rate for Payer: Aetna Commercial	$19.06
Rate for Payer: Aetna Commercial	$17.15
Rate for Payer: Aetna Commercial	$27.51
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.17
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.17
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.17
Rate for Payer: Humana Medicare Advantage	$8.90
Rate for Payer: Humana Medicare Advantage	$8.01
Rate for Payer: Humana Medicare Advantage	$12.84
Rate for Payer: UnitedHealthcare Commercial	$20.12
Rate for Payer: UnitedHealthcare Commercial	$18.11
Rate for Payer: UnitedHealthcare Commercial	$29.04
Rate for Payer: UnitedHealthcare Medicaid	$8.47
Rate for Payer: UnitedHealthcare Medicaid	$7.62
Rate for Payer: UnitedHealthcare Medicaid	$12.23
Rate for Payer: WPPA Medicare Advantage	$11.44
Rate for Payer: WPPA Medicare Advantage	$18.34
Rate for Payer: WPPA Medicare Advantage	$12.71

FINE NEEDLE ASP

Facility

$252.00

Service Code	HCPCS 88162
Hospital Charge Code	3554085
Hospital Revenue Code	310
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FINE NEEDLE ASP

Facility

$252.00

Service Code	HCPCS 88162
Hospital Charge Code	3554085
Hospital Revenue Code	310
Min. Negotiated Rate	$87.96
Max. Negotiated Rate	$239.40
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$123.01
Rate for Payer: Humana Medicare Advantage	$105.84
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: UnitedHealthcare Medicaid	$87.96
Rate for Payer: WPPA Medicare Advantage	$151.20

FINE NEEDLE ASP EVAL

Facility

$300.00

Service Code	HCPCS 88172
Hospital Charge Code	3554090
Hospital Revenue Code	310
Min. Negotiated Rate	$42.79
Max. Negotiated Rate	$285.00
Rate for Payer: Aetna Commercial	$270.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$87.54
Rate for Payer: Humana Medicare Advantage	$126.00
Rate for Payer: UnitedHealthcare Commercial	$285.00
Rate for Payer: UnitedHealthcare Medicaid	$42.79
Rate for Payer: WPPA Medicare Advantage	$180.00

FINE NEEDLE ASP EVAL

Facility

$300.00

Service Code	HCPCS 88172
Hospital Charge Code	3554090
Hospital Revenue Code	310
Min. Negotiated Rate	$270.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$270.00
Rate for Payer: UnitedHealthcare Commercial	$285.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FINE NEEDLE ASP INTR & R

Facility

$462.00

Service Code	HCPCS 88173
Hospital Charge Code	3554095
Hospital Revenue Code	310
Min. Negotiated Rate	$122.17
Max. Negotiated Rate	$438.90
Rate for Payer: Aetna Commercial	$415.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$225.25
Rate for Payer: Humana Medicare Advantage	$194.04
Rate for Payer: UnitedHealthcare Commercial	$438.90
Rate for Payer: UnitedHealthcare Medicaid	$122.17
Rate for Payer: WPPA Medicare Advantage	$277.20

FINE NEEDLE ASP INTR & R

Facility

$462.00

Service Code	HCPCS 88173
Hospital Charge Code	3554095
Hospital Revenue Code	310
Min. Negotiated Rate	$415.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$415.80
Rate for Payer: UnitedHealthcare Commercial	$438.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FIRST HOUR OBSERVATION CHARGE

Facility

$551.00

Service Code	HCPCS G0378
Hospital Charge Code	3310026
Hospital Revenue Code	762
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$523.45
Rate for Payer: Aetna Commercial	$495.90
Rate for Payer: Humana Medicare Advantage	$231.42
Rate for Payer: UnitedHealthcare Commercial	$523.45
Rate for Payer: UnitedHealthcare Medicaid	$5.20
Rate for Payer: WPPA Medicare Advantage	$330.60

FIRST HOUR OBSERVATION CHARGE

Facility

$551.00

Service Code	HCPCS G0378
Hospital Charge Code	3310026
Hospital Revenue Code	762
Min. Negotiated Rate	$495.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$495.90
Rate for Payer: UnitedHealthcare Commercial	$523.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FISH, HER-2/NEU Bill Only

Facility

$688.00

Service Code	HCPCS 88377
Hospital Charge Code	3551480
Hospital Revenue Code	310
Min. Negotiated Rate	$619.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$619.20
Rate for Payer: UnitedHealthcare Commercial	$653.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FISH, HER-2/NEU Bill Only

Facility

$688.00

Service Code	HCPCS 88377
Hospital Charge Code	3551480
Hospital Revenue Code	310
Min. Negotiated Rate	$275.20
Max. Negotiated Rate	$653.60
Rate for Payer: Aetna Commercial	$619.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$418.90
Rate for Payer: Humana Medicare Advantage	$288.96
Rate for Payer: UnitedHealthcare Commercial	$653.60
Rate for Payer: UnitedHealthcare Medicaid	$275.20
Rate for Payer: WPPA Medicare Advantage	$412.80

Fish Oil omega-3 polyunsaturated fatty acid 1000 mg Cap [HMC]

Facility

$5.21

Service Code	NDC 00904404360
Hospital Charge Code	3800702
Hospital Revenue Code	250
Min. Negotiated Rate	$4.69
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.69
Rate for Payer: UnitedHealthcare Commercial	$4.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fish Oil omega-3 polyunsaturated fatty acid 1000 mg Cap [HMC]

Facility

$5.73

Service Code	NDC 77333030810
Hospital Charge Code	3800702
Hospital Revenue Code	250
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$5.44
Rate for Payer: Aetna Commercial	$5.16
Rate for Payer: Humana Medicare Advantage	$2.41
Rate for Payer: UnitedHealthcare Commercial	$5.44
Rate for Payer: UnitedHealthcare Medicaid	$2.29
Rate for Payer: WPPA Medicare Advantage	$3.44

Fish Oil omega-3 polyunsaturated fatty acid 1000 mg Cap [HMC]

Facility

$5.21

Service Code	NDC 00904404360
Hospital Charge Code	3800702
Hospital Revenue Code	250
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$4.95
Rate for Payer: Aetna Commercial	$4.69
Rate for Payer: Humana Medicare Advantage	$2.19
Rate for Payer: UnitedHealthcare Commercial	$4.95
Rate for Payer: UnitedHealthcare Medicaid	$2.08
Rate for Payer: WPPA Medicare Advantage	$3.13

Know your out-of-pocket cost for care.

All Charges