Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

furosemide 20 mg Tab [HMC]

Facility

$5.51

Service Code	NDC 68084001401
Hospital Charge Code	3805427
Hospital Revenue Code	250
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.96
Rate for Payer: UnitedHealthcare Commercial	$5.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00

furosemide 20 mg Tab [HMC]

Facility

$5.44

Service Code	NDC 51079007220
Hospital Charge Code	3805427
Hospital Revenue Code	250
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$5.17
Rate for Payer: Aetna Commercial	$4.90
Rate for Payer: Humana Medicare Advantage	$2.28
Rate for Payer: UnitedHealthcare Commercial	$5.17
Rate for Payer: UnitedHealthcare Medicaid	$2.18
Rate for Payer: WPPA Medicare Advantage	$3.26

furosemide 20 mg Tab [HMC]

Facility

$5.43

Service Code	NDC 43547040110
Hospital Charge Code	3805427
Hospital Revenue Code	250
Min. Negotiated Rate	$4.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.89
Rate for Payer: UnitedHealthcare Commercial	$5.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

furosemide 20 mg Tab [HMC]

Facility

$5.44

Service Code	NDC 51079007220
Hospital Charge Code	3805427
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.90
Rate for Payer: UnitedHealthcare Commercial	$5.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

furosemide 20 mg Tab [HMC]

Facility

$5.27

Service Code	NDC 00904717761
Hospital Charge Code	3805427
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$5.01
Rate for Payer: Aetna Commercial	$4.74
Rate for Payer: Humana Medicare Advantage	$2.21
Rate for Payer: UnitedHealthcare Commercial	$5.01
Rate for Payer: UnitedHealthcare Medicaid	$2.11
Rate for Payer: WPPA Medicare Advantage	$3.16

furosemide 20 mg Tab [HMC]

Facility

$5.43

Service Code	NDC 43547040110
Hospital Charge Code	3805427
Hospital Revenue Code	250
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$5.16
Rate for Payer: Aetna Commercial	$4.89
Rate for Payer: Humana Medicare Advantage	$2.28
Rate for Payer: UnitedHealthcare Commercial	$5.16
Rate for Payer: UnitedHealthcare Medicaid	$2.17
Rate for Payer: WPPA Medicare Advantage	$3.26

furosemide 20 mg Tab [HMC]

Facility

$5.51

Service Code	NDC 68084001401
Hospital Charge Code	3805427
Hospital Revenue Code	250
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$5.23
Rate for Payer: Aetna Commercial	$4.96
Rate for Payer: Humana Medicare Advantage	$2.31
Rate for Payer: UnitedHealthcare Commercial	$5.23
Rate for Payer: UnitedHealthcare Medicaid	$2.20
Rate for Payer: WPPA Medicare Advantage	$3.31

furosemide 20 mg Tab [HMC]

Facility

$5.27

Service Code	NDC 00904717761
Hospital Charge Code	3805427
Hospital Revenue Code	250
Min. Negotiated Rate	$4.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.74
Rate for Payer: UnitedHealthcare Commercial	$5.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

furosemide 40 mg Tab [HMC]

Facility

$5.28

Service Code	NDC 00904717861
Hospital Charge Code	3802151
Hospital Revenue Code	250
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: UnitedHealthcare Commercial	$5.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

furosemide 40 mg Tab [HMC]

Facility

$5.28

Service Code	NDC 00904717861
Hospital Charge Code	3802151
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$5.02
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Humana Medicare Advantage	$2.22
Rate for Payer: UnitedHealthcare Commercial	$5.02
Rate for Payer: UnitedHealthcare Medicaid	$2.11
Rate for Payer: WPPA Medicare Advantage	$3.17

furosemide 40 mg Tab [HMC]

Facility

$5.50

Service Code	NDC 51079007320
Hospital Charge Code	3802151
Hospital Revenue Code	250
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$5.22
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: Humana Medicare Advantage	$2.31
Rate for Payer: UnitedHealthcare Commercial	$5.22
Rate for Payer: UnitedHealthcare Medicaid	$2.20
Rate for Payer: WPPA Medicare Advantage	$3.30

furosemide 40 mg Tab [HMC]

Facility

$5.50

Service Code	NDC 51079007320
Hospital Charge Code	3802151
Hospital Revenue Code	250
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: UnitedHealthcare Commercial	$5.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

G0104 Colorectal cancer screening; flexible sigmoidoscopy

Facility

$1,778.00

Service Code	HCPCS G0104
Hospital Charge Code	3151040
Hospital Revenue Code	360
Min. Negotiated Rate	$567.46
Max. Negotiated Rate	$1,689.10
Rate for Payer: Aetna Commercial	$1,600.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$808.00
Rate for Payer: Humana Medicare Advantage	$746.76
Rate for Payer: UnitedHealthcare Commercial	$1,689.10
Rate for Payer: UnitedHealthcare Medicaid	$567.46
Rate for Payer: WPPA Medicare Advantage	$1,066.80

G0104 Colorectal cancer screening; flexible sigmoidoscopy

Facility

$1,778.00

Service Code	HCPCS G0104
Hospital Charge Code	3151040
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,689.10
Rate for Payer: Aetna Commercial	$1,600.20
Rate for Payer: UnitedHealthcare Commercial	$1,689.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

G0105 Colorectal cancer screening; colonoscopy on individual at high risk

Facility

$1,890.00

Service Code	HCPCS G0105
Hospital Charge Code	3150283
Hospital Revenue Code	360
Min. Negotiated Rate	$567.46
Max. Negotiated Rate	$1,795.50
Rate for Payer: Aetna Commercial	$1,701.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,006.97
Rate for Payer: Humana Medicare Advantage	$793.80
Rate for Payer: UnitedHealthcare Commercial	$1,795.50
Rate for Payer: UnitedHealthcare Medicaid	$567.46
Rate for Payer: WPPA Medicare Advantage	$1,134.00

G0105 Colorectal cancer screening; colonoscopy on individual at high risk

Facility

$1,890.00

Service Code	HCPCS G0105
Hospital Charge Code	3150283
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,795.50
Rate for Payer: Aetna Commercial	$1,701.00
Rate for Payer: UnitedHealthcare Commercial	$1,795.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

G0108 DIAB SELF-MGMT TRAIN-OP/30 MIN CHARGE

Facility

$56.00

Service Code	HCPCS G0108
Hospital Charge Code	3350300
Hospital Revenue Code	942
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

G0108 DIAB SELF-MGMT TRAIN-OP/30 MIN CHARGE

Facility

$56.00

Service Code	HCPCS G0108
Hospital Charge Code	3350300
Hospital Revenue Code	942
Min. Negotiated Rate	$23.52
Max. Negotiated Rate	$53.20
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$29.29
Rate for Payer: Humana Medicare Advantage	$23.52
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: UnitedHealthcare Medicaid	$40.26
Rate for Payer: WPPA Medicare Advantage	$33.60

G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

Facility

$1,890.00

Service Code	HCPCS G0121
Hospital Charge Code	3150282
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,795.50
Rate for Payer: Aetna Commercial	$1,701.00
Rate for Payer: UnitedHealthcare Commercial	$1,795.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

Facility

$1,890.00

Service Code	HCPCS G0121
Hospital Charge Code	3150282
Hospital Revenue Code	360
Min. Negotiated Rate	$567.46
Max. Negotiated Rate	$1,795.50
Rate for Payer: Aetna Commercial	$1,701.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,006.97
Rate for Payer: Humana Medicare Advantage	$793.80
Rate for Payer: UnitedHealthcare Commercial	$1,795.50
Rate for Payer: UnitedHealthcare Medicaid	$567.46
Rate for Payer: WPPA Medicare Advantage	$1,134.00

G0237 CR THER TX INCREASE STRENGTH; EA 15 MIN CHARGE

Facility

$128.00

Service Code	HCPCS G0237
Hospital Charge Code	SCCG023700
Hospital Revenue Code	943
Min. Negotiated Rate	$47.47
Max. Negotiated Rate	$121.60
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.47
Rate for Payer: Humana Medicare Advantage	$53.76
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: UnitedHealthcare Medicaid	$51.20
Rate for Payer: WPPA Medicare Advantage	$76.80

G0237 CR THER TX INCREASE STRENGTH; EA 15 MIN CHARGE

Facility

$128.00

Service Code	HCPCS G0237
Hospital Charge Code	SCCG023700
Hospital Revenue Code	943
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

G0238 CR THER TX TO IMPROVE FUNCTION;EA 15 MIN CHARGE

Facility

$128.00

Service Code	HCPCS G0238
Hospital Charge Code	3907001
Hospital Revenue Code	943
Min. Negotiated Rate	$47.47
Max. Negotiated Rate	$121.60
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.47
Rate for Payer: Humana Medicare Advantage	$53.76
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: UnitedHealthcare Medicaid	$51.20
Rate for Payer: WPPA Medicare Advantage	$76.80

G0238 CR THER TX TO IMPROVE FUNCTION;EA 15 MIN CHARGE

Facility

$128.00

Service Code	HCPCS G0238
Hospital Charge Code	3907001
Hospital Revenue Code	943
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

G0239 CR THER TX IMPROVE FUNCTION; 2+ PEOPLE CHARGE

Facility

$128.00

Service Code	HCPCS G0239
Hospital Charge Code	3860239
Hospital Revenue Code	943
Min. Negotiated Rate	$47.47
Max. Negotiated Rate	$121.60
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.47
Rate for Payer: Humana Medicare Advantage	$53.76
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: UnitedHealthcare Medicaid	$51.20
Rate for Payer: WPPA Medicare Advantage	$76.80

Know your out-of-pocket cost for care.

All Charges