Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

gabapentin 300 mg Cap [HMC]

Facility

$5.59

Service Code	NDC 00904666661
Hospital Charge Code	3809123
Hospital Revenue Code	250
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$5.31
Rate for Payer: Aetna Commercial	$5.03
Rate for Payer: Humana Medicare Advantage	$2.35
Rate for Payer: UnitedHealthcare Commercial	$5.31
Rate for Payer: UnitedHealthcare Medicaid	$2.24
Rate for Payer: WPPA Medicare Advantage	$3.35

gabapentin 300 mg Cap [HMC]

Facility

$9.13

Service Code	NDC 60687059101
Hospital Charge Code	3809123
Hospital Revenue Code	250
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$8.67
Rate for Payer: Aetna Commercial	$8.22
Rate for Payer: Humana Medicare Advantage	$3.83
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicaid	$3.65
Rate for Payer: WPPA Medicare Advantage	$5.48

gabapentin 300 mg Cap [HMC]

Facility

$9.13

Service Code	NDC 60687059101
Hospital Charge Code	3809123
Hospital Revenue Code	250
Min. Negotiated Rate	$8.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.22
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 300 mg Cap [HMC]

Facility

$9.02

Service Code	NDC 67877022301
Hospital Charge Code	3809123
Hospital Revenue Code	250
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.12
Rate for Payer: UnitedHealthcare Commercial	$8.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 300 mg Cap [HMC]

Facility

$9.03

Service Code	NDC 65162010210
Hospital Charge Code	3809123
Hospital Revenue Code	250
Min. Negotiated Rate	$8.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.13
Rate for Payer: UnitedHealthcare Commercial	$8.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 300 mg Cap [HMC]

Facility

$9.03

Service Code	NDC 65162010210
Hospital Charge Code	3809123
Hospital Revenue Code	250
Min. Negotiated Rate	$3.61
Max. Negotiated Rate	$8.58
Rate for Payer: Aetna Commercial	$8.13
Rate for Payer: Humana Medicare Advantage	$3.79
Rate for Payer: UnitedHealthcare Commercial	$8.58
Rate for Payer: UnitedHealthcare Medicaid	$3.61
Rate for Payer: WPPA Medicare Advantage	$5.42

gabapentin 300 mg Cap [HMC]

Facility

$5.59

Service Code	NDC 63739090310
Hospital Charge Code	3809123
Hospital Revenue Code	250
Min. Negotiated Rate	$5.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.03
Rate for Payer: UnitedHealthcare Commercial	$5.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 300 mg Cap [HMC]

Facility

$9.02

Service Code	NDC 67877022301
Hospital Charge Code	3809123
Hospital Revenue Code	250
Min. Negotiated Rate	$3.61
Max. Negotiated Rate	$8.57
Rate for Payer: Aetna Commercial	$8.12
Rate for Payer: Humana Medicare Advantage	$3.79
Rate for Payer: UnitedHealthcare Commercial	$8.57
Rate for Payer: UnitedHealthcare Medicaid	$3.61
Rate for Payer: WPPA Medicare Advantage	$5.41

gabapentin 300 mg Cap [HMC]

Facility

$5.59

Service Code	NDC 63739090310
Hospital Charge Code	3809123
Hospital Revenue Code	250
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$5.31
Rate for Payer: Aetna Commercial	$5.03
Rate for Payer: Humana Medicare Advantage	$2.35
Rate for Payer: UnitedHealthcare Commercial	$5.31
Rate for Payer: UnitedHealthcare Medicaid	$2.24
Rate for Payer: WPPA Medicare Advantage	$3.35

gabapentin 300 mg Cap [HMC]

Facility

$5.59

Service Code	NDC 00904666661
Hospital Charge Code	3809123
Hospital Revenue Code	250
Min. Negotiated Rate	$5.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.03
Rate for Payer: UnitedHealthcare Commercial	$5.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 600 mg/24 hours [HMC]

Facility

$27.38

Service Code	NDC 13913000519
Hospital Charge Code	3800021
Hospital Revenue Code	250
Min. Negotiated Rate	$10.95
Max. Negotiated Rate	$26.01
Rate for Payer: Aetna Commercial	$24.64
Rate for Payer: Humana Medicare Advantage	$11.50
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicaid	$10.95
Rate for Payer: WPPA Medicare Advantage	$16.43

gabapentin 600 mg/24 hours [HMC]

Facility

$27.38

Service Code	NDC 13913000519
Hospital Charge Code	3800021
Hospital Revenue Code	250
Min. Negotiated Rate	$24.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.64
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 800 mg Tab [HMC]

Facility

$6.81

Service Code	NDC 00904710861
Hospital Charge Code	3800549
Hospital Revenue Code	250
Min. Negotiated Rate	$6.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.13
Rate for Payer: UnitedHealthcare Commercial	$6.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 800 mg Tab [HMC]

Facility

$14.09

Service Code	NDC 68382020501
Hospital Charge Code	3800549
Hospital Revenue Code	250
Min. Negotiated Rate	$5.64
Max. Negotiated Rate	$13.39
Rate for Payer: Aetna Commercial	$12.68
Rate for Payer: Humana Medicare Advantage	$5.92
Rate for Payer: UnitedHealthcare Commercial	$13.39
Rate for Payer: UnitedHealthcare Medicaid	$5.64
Rate for Payer: WPPA Medicare Advantage	$8.45

gabapentin 800 mg Tab [HMC]

Facility

$14.09

Service Code	NDC 68382020501
Hospital Charge Code	3800549
Hospital Revenue Code	250
Min. Negotiated Rate	$12.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.68
Rate for Payer: UnitedHealthcare Commercial	$13.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 800 mg Tab [HMC]

Facility

$6.81

Service Code	NDC 00904710861
Hospital Charge Code	3800549
Hospital Revenue Code	250
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$6.47
Rate for Payer: Aetna Commercial	$6.13
Rate for Payer: Humana Medicare Advantage	$2.86
Rate for Payer: UnitedHealthcare Commercial	$6.47
Rate for Payer: UnitedHealthcare Medicaid	$2.72
Rate for Payer: WPPA Medicare Advantage	$4.09

GAD-65 Ab QST

Facility

$334.00

Service Code	HCPCS 86341
Hospital Charge Code	3556341
Hospital Revenue Code	300
Min. Negotiated Rate	$79.87
Max. Negotiated Rate	$317.30
Rate for Payer: Aetna Commercial	$300.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$79.87
Rate for Payer: Humana Medicare Advantage	$140.28
Rate for Payer: UnitedHealthcare Commercial	$317.30
Rate for Payer: UnitedHealthcare Medicaid	$133.60
Rate for Payer: WPPA Medicare Advantage	$200.40

GAD-65 Ab QST

Facility

$334.00

Service Code	HCPCS 86341
Hospital Charge Code	3556341
Hospital Revenue Code	300
Min. Negotiated Rate	$300.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$300.60
Rate for Payer: UnitedHealthcare Commercial	$317.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gadoterate meglumine 376.9 mg/mL (0.5 mmol/mL) Sol [HMC]

Facility

$120.80

Service Code	HCPCS A7595
Hospital Charge Code	3750406
Hospital Revenue Code	250
Min. Negotiated Rate	$108.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$108.72
Rate for Payer: UnitedHealthcare Commercial	$114.76
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gadoterate meglumine 376.9 mg/mL (0.5 mmol/mL) Sol [HMC]

Facility

$120.80

Service Code	HCPCS A7595
Hospital Charge Code	3750406
Hospital Revenue Code	250
Min. Negotiated Rate	$48.32
Max. Negotiated Rate	$114.76
Rate for Payer: Aetna Commercial	$108.72
Rate for Payer: Humana Medicare Advantage	$50.74
Rate for Payer: UnitedHealthcare Commercial	$114.76
Rate for Payer: UnitedHealthcare Medicaid	$48.32
Rate for Payer: WPPA Medicare Advantage	$72.48

gadoteridol 279.3 mg/mL Sol [HMC]

Facility

$209.19

Service Code	HCPCS A9576
Hospital Charge Code	3750405
Hospital Revenue Code	250
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$198.73
Rate for Payer: Aetna Commercial	$188.27
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7.98
Rate for Payer: Humana Medicare Advantage	$87.86
Rate for Payer: UnitedHealthcare Commercial	$198.73
Rate for Payer: UnitedHealthcare Medicaid	$83.68
Rate for Payer: WPPA Medicare Advantage	$125.51

gadoteridol 279.3 mg/mL Sol [HMC]

Facility

$209.19

Service Code	HCPCS A9576
Hospital Charge Code	3750405
Hospital Revenue Code	250
Min. Negotiated Rate	$188.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$188.27
Rate for Payer: UnitedHealthcare Commercial	$198.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gait Training Charges

Facility

$112.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	3950135
Hospital Revenue Code	420
Min. Negotiated Rate	$24.24
Max. Negotiated Rate	$106.40
Rate for Payer: Aetna Commercial	$100.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$46.46
Rate for Payer: Humana Medicare Advantage	$47.04
Rate for Payer: UnitedHealthcare Commercial	$106.40
Rate for Payer: UnitedHealthcare Medicaid	$24.24
Rate for Payer: WPPA Medicare Advantage	$67.20

Gait Training Charges

Facility

$112.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	3950135
Hospital Revenue Code	420
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$100.80
Rate for Payer: UnitedHealthcare Commercial	$106.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

galantamine 4 mg Tab [HMC]

Facility

$17.60

Service Code	NDC 68084072921
Hospital Charge Code	3809346
Hospital Revenue Code	250
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.84
Rate for Payer: UnitedHealthcare Commercial	$16.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges