Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

galantamine 4 mg Tab [HMC]

Facility

$14.55

Service Code	NDC 70436000406
Hospital Charge Code	3809346
Hospital Revenue Code	250
Min. Negotiated Rate	$13.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.10
Rate for Payer: UnitedHealthcare Commercial	$13.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

galantamine 4 mg Tab [HMC]

Facility

$14.55

Service Code	NDC 70436000406
Hospital Charge Code	3809346
Hospital Revenue Code	250
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$13.82
Rate for Payer: Aetna Commercial	$13.10
Rate for Payer: Humana Medicare Advantage	$6.11
Rate for Payer: UnitedHealthcare Commercial	$13.82
Rate for Payer: UnitedHealthcare Medicaid	$5.82
Rate for Payer: WPPA Medicare Advantage	$8.73

Galectin-3 REF

Facility

$129.00

Service Code	HCPCS 82777
Hospital Charge Code	3552777
Hospital Revenue Code	300
Min. Negotiated Rate	$34.48
Max. Negotiated Rate	$122.55
Rate for Payer: Aetna Commercial	$116.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$34.48
Rate for Payer: Humana Medicare Advantage	$54.18
Rate for Payer: UnitedHealthcare Commercial	$122.55
Rate for Payer: UnitedHealthcare Medicaid	$37.61
Rate for Payer: WPPA Medicare Advantage	$77.40

Galectin-3 REF

Facility

$129.00

Service Code	HCPCS 82777
Hospital Charge Code	3552777
Hospital Revenue Code	300
Min. Negotiated Rate	$116.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$116.10
Rate for Payer: UnitedHealthcare Commercial	$122.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gamma Glutamyl Transferase

Facility

$28.00

Service Code	HCPCS 82977
Hospital Charge Code	3551203
Hospital Revenue Code	300
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: UnitedHealthcare Commercial	$26.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gamma Glutamyl Transferase

Facility

$28.00

Service Code	HCPCS 82977
Hospital Charge Code	3551203
Hospital Revenue Code	300
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$26.60
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.45
Rate for Payer: Humana Medicare Advantage	$11.76
Rate for Payer: UnitedHealthcare Commercial	$26.60
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: WPPA Medicare Advantage	$16.80

Gastrin QST

Facility

$75.00

Service Code	HCPCS 82308
Hospital Charge Code	3550478
Hospital Revenue Code	300
Min. Negotiated Rate	$22.77
Max. Negotiated Rate	$102.28
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$102.28
Rate for Payer: Humana Medicare Advantage	$31.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: UnitedHealthcare Medicaid	$22.77
Rate for Payer: WPPA Medicare Advantage	$45.00

Gastrin QST

Facility

$75.00

Service Code	HCPCS 82308
Hospital Charge Code	3550478
Hospital Revenue Code	300
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GASTROINTESTINAL HEMORRHAGE WITH CC

Facility

$4,797.27

Service Code	MSDRG 378
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,797.27
Rate for Payer: UnitedHealthcare Medicaid	$4,797.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GASTROINTESTINAL HEMORRHAGE WITH MCC

Facility

$8,450.82

Service Code	MSDRG 377
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,450.82
Rate for Payer: UnitedHealthcare Medicaid	$8,450.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC

Facility

$2,922.84

Service Code	MSDRG 379
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,922.84
Rate for Payer: UnitedHealthcare Medicaid	$2,922.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GASTROINTESTINAL OBSTRUCTION WITH CC

Facility

$4,352.49

Service Code	MSDRG 389
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,352.49
Rate for Payer: UnitedHealthcare Medicaid	$4,352.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GASTROINTESTINAL OBSTRUCTION WITH MCC

Facility

$4,384.26

Service Code	MSDRG 388
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,384.26
Rate for Payer: UnitedHealthcare Medicaid	$4,384.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC

Facility

$2,954.61

Service Code	MSDRG 390
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,954.61
Rate for Payer: UnitedHealthcare Medicaid	$2,954.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gastrointestinal Pathogen Panel, Real-Time PCR QST

Facility

$687.00

Service Code	HCPCS 87506
Hospital Charge Code	3557506
Hospital Revenue Code	300
Min. Negotiated Rate	$246.88
Max. Negotiated Rate	$652.65
Rate for Payer: Aetna Commercial	$618.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$465.73
Rate for Payer: Humana Medicare Advantage	$288.54
Rate for Payer: UnitedHealthcare Commercial	$652.65
Rate for Payer: UnitedHealthcare Medicaid	$246.88
Rate for Payer: WPPA Medicare Advantage	$412.20

Gastrointestinal Pathogen Panel, Real-Time PCR QST

Facility

$687.00

Service Code	HCPCS 87506
Hospital Charge Code	3557506
Hospital Revenue Code	300
Min. Negotiated Rate	$618.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$618.30
Rate for Payer: UnitedHealthcare Commercial	$652.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gauze 2 X 2 Sterile 8ply

Facility

$2.50

Hospital Charge Code	3251035
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gauze 2 X 2 Sterile 8ply

Facility

$2.50

Hospital Charge Code	3251035
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

Gauze 4 X 4 Sterile 16ply

Facility

$2.50

Hospital Charge Code	3255176
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gauze 4 X 4 Sterile 16ply

Facility

$2.50

Hospital Charge Code	3255176
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

Gauze 4 X 4 Sterile 8ply

Facility

$2.50

Hospital Charge Code	3251780
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

Gauze 4 X 4 Sterile 8ply

Facility

$2.50

Hospital Charge Code	3251780
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gauze XRay Detectable 4 X 4 Sterile

Facility

$3.00

Hospital Charge Code	3251787
Hospital Revenue Code	270
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gauze XRay Detectable 4 X 4 Sterile

Facility

$3.00

Hospital Charge Code	3251787
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Humana Medicare Advantage	$1.26
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: WPPA Medicare Advantage	$1.80

Know your out-of-pocket cost for care.

All Charges