Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Gavage Tube Infant 5FR

Facility

$3.00

Hospital Charge Code	3251043
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

Gavage Tube Infant 5FR

Facility

$3.00

Hospital Charge Code	3251043
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

gemfibrozil 600 mg Tab [HMC]

Facility

$11.94

Service Code	NDC 60687022401
Hospital Charge Code	3806749
Hospital Revenue Code	250
Min. Negotiated Rate	$10.75
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.75
Rate for Payer: UnitedHealthcare Commercial	$11.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gemfibrozil 600 mg Tab [HMC]

Facility

$12.29

Service Code	NDC 69097082103
Hospital Charge Code	3806749
Hospital Revenue Code	250
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$11.68
Rate for Payer: Aetna Commercial	$11.06
Rate for Payer: Humana Medicare Advantage	$5.16
Rate for Payer: UnitedHealthcare Commercial	$11.68
Rate for Payer: UnitedHealthcare Medicaid	$4.92
Rate for Payer: WPPA Medicare Advantage	$7.37

gemfibrozil 600 mg Tab [HMC]

Facility

$11.94

Service Code	NDC 60687022401
Hospital Charge Code	3806749
Hospital Revenue Code	250
Min. Negotiated Rate	$4.78
Max. Negotiated Rate	$11.34
Rate for Payer: Aetna Commercial	$10.75
Rate for Payer: Humana Medicare Advantage	$5.01
Rate for Payer: UnitedHealthcare Commercial	$11.34
Rate for Payer: UnitedHealthcare Medicaid	$4.78
Rate for Payer: WPPA Medicare Advantage	$7.16

gemfibrozil 600 mg Tab [HMC]

Facility

$12.29

Service Code	NDC 69097082103
Hospital Charge Code	3806749
Hospital Revenue Code	250
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.06
Rate for Payer: UnitedHealthcare Commercial	$11.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gentamicin 40 mg/mL Inj Sol 20 mL [HMC]

Facility

$39.99

Service Code	HCPCS J1580
Hospital Charge Code	3805500
Hospital Revenue Code	250
Min. Negotiated Rate	$35.99
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.99
Rate for Payer: UnitedHealthcare Commercial	$37.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gentamicin 40 mg/mL Inj Sol 20 mL [HMC]

Facility

$39.99

Service Code	HCPCS J1580
Hospital Charge Code	3805500
Hospital Revenue Code	250
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$37.99
Rate for Payer: Aetna Commercial	$35.99
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4.13
Rate for Payer: Humana Medicare Advantage	$16.80
Rate for Payer: UnitedHealthcare Commercial	$37.99
Rate for Payer: UnitedHealthcare Medicaid	$2.17
Rate for Payer: WPPA Medicare Advantage	$23.99

gentamicin 40 mg/mL Inj Sol 2 mL [HMC]

Facility

$36.70

Service Code	HCPCS J1580
Hospital Charge Code	3805500
Hospital Revenue Code	250
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$34.87
Rate for Payer: Aetna Commercial	$33.03
Rate for Payer: Aetna Commercial	$36.57
Rate for Payer: Aetna Commercial	$22.82
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4.13
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4.13
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4.13
Rate for Payer: Humana Medicare Advantage	$17.06
Rate for Payer: Humana Medicare Advantage	$10.65
Rate for Payer: Humana Medicare Advantage	$15.41
Rate for Payer: UnitedHealthcare Commercial	$38.60
Rate for Payer: UnitedHealthcare Commercial	$34.87
Rate for Payer: UnitedHealthcare Commercial	$24.09
Rate for Payer: UnitedHealthcare Medicaid	$2.17
Rate for Payer: UnitedHealthcare Medicaid	$2.17
Rate for Payer: UnitedHealthcare Medicaid	$2.17
Rate for Payer: WPPA Medicare Advantage	$24.38
Rate for Payer: WPPA Medicare Advantage	$15.22
Rate for Payer: WPPA Medicare Advantage	$22.02

gentamicin 40 mg/mL Inj Sol 2 mL [HMC]

Facility

$40.63

Service Code	HCPCS J1580
Hospital Charge Code	3805500
Hospital Revenue Code	250
Min. Negotiated Rate	$36.57
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.57
Rate for Payer: Aetna Commercial	$22.82
Rate for Payer: Aetna Commercial	$33.03
Rate for Payer: UnitedHealthcare Commercial	$24.09
Rate for Payer: UnitedHealthcare Commercial	$34.87
Rate for Payer: UnitedHealthcare Commercial	$38.60
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

gentamicin 40 mg/mL Sol

Facility

$36.50

Service Code	HCPCS J1580
Hospital Charge Code	3805500
Hospital Revenue Code	250
Min. Negotiated Rate	$32.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$32.85
Rate for Payer: UnitedHealthcare Commercial	$34.67
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gentamicin 40 mg/mL Sol

Facility

$36.50

Service Code	HCPCS J1580
Hospital Charge Code	3805500
Hospital Revenue Code	250
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$34.67
Rate for Payer: Aetna Commercial	$32.85
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4.13
Rate for Payer: Humana Medicare Advantage	$15.33
Rate for Payer: UnitedHealthcare Commercial	$34.67
Rate for Payer: UnitedHealthcare Medicaid	$2.17
Rate for Payer: WPPA Medicare Advantage	$21.90

gentamicin 80 mg/100 mL-0.9% Sol [HMC]

Facility

$38.94

Service Code	HCPCS J1580
Hospital Charge Code	3808638
Hospital Revenue Code	250
Min. Negotiated Rate	$35.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.05
Rate for Payer: UnitedHealthcare Commercial	$36.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gentamicin 80 mg/100 mL-0.9% Sol [HMC]

Facility

$38.94

Service Code	HCPCS J1580
Hospital Charge Code	3808638
Hospital Revenue Code	250
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$36.99
Rate for Payer: Aetna Commercial	$35.05
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4.13
Rate for Payer: Humana Medicare Advantage	$16.35
Rate for Payer: UnitedHealthcare Commercial	$36.99
Rate for Payer: UnitedHealthcare Medicaid	$2.17
Rate for Payer: WPPA Medicare Advantage	$23.36

gentamicin Ophth 0.3% Oint [HMC]

Facility

$72.58

Service Code	NDC 17478028435
Hospital Charge Code	3805476
Hospital Revenue Code	250
Min. Negotiated Rate	$65.32
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$65.32
Rate for Payer: UnitedHealthcare Commercial	$68.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gentamicin Ophth 0.3% Oint [HMC]

Facility

$72.58

Service Code	NDC 17478028435
Hospital Charge Code	3805476
Hospital Revenue Code	250
Min. Negotiated Rate	$29.03
Max. Negotiated Rate	$68.95
Rate for Payer: Aetna Commercial	$65.32
Rate for Payer: Humana Medicare Advantage	$30.48
Rate for Payer: UnitedHealthcare Commercial	$68.95
Rate for Payer: UnitedHealthcare Medicaid	$29.03
Rate for Payer: WPPA Medicare Advantage	$43.55

gentamicin Ophth 0.3% Sol [HMC]

Facility

$77.85

Service Code	NDC 24208058060
Hospital Charge Code	3801376
Hospital Revenue Code	250
Min. Negotiated Rate	$31.14
Max. Negotiated Rate	$73.96
Rate for Payer: Aetna Commercial	$70.06
Rate for Payer: Humana Medicare Advantage	$32.70
Rate for Payer: UnitedHealthcare Commercial	$73.96
Rate for Payer: UnitedHealthcare Medicaid	$31.14
Rate for Payer: WPPA Medicare Advantage	$46.71

gentamicin Ophth 0.3% Sol [HMC]

Facility

$30.50

Service Code	NDC 61314063305
Hospital Charge Code	3801376
Hospital Revenue Code	250
Min. Negotiated Rate	$12.20
Max. Negotiated Rate	$28.98
Rate for Payer: Aetna Commercial	$27.45
Rate for Payer: Humana Medicare Advantage	$12.81
Rate for Payer: UnitedHealthcare Commercial	$28.98
Rate for Payer: UnitedHealthcare Medicaid	$12.20
Rate for Payer: WPPA Medicare Advantage	$18.30

gentamicin Ophth 0.3% Sol [HMC]

Facility

$77.85

Service Code	NDC 24208058060
Hospital Charge Code	3801376
Hospital Revenue Code	250
Min. Negotiated Rate	$70.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.06
Rate for Payer: UnitedHealthcare Commercial	$73.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gentamicin Ophth 0.3% Sol [HMC]

Facility

$30.50

Service Code	NDC 61314063305
Hospital Charge Code	3801376
Hospital Revenue Code	250
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.45
Rate for Payer: UnitedHealthcare Commercial	$28.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gentamicin, Peak QST

Facility

$95.00

Service Code	HCPCS 80170
Hospital Charge Code	3550437
Hospital Revenue Code	300
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: UnitedHealthcare Commercial	$90.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gentamicin, Peak QST

Facility

$95.00

Service Code	HCPCS 80170
Hospital Charge Code	3550437
Hospital Revenue Code	300
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$90.25
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$57.41
Rate for Payer: Humana Medicare Advantage	$39.90
Rate for Payer: UnitedHealthcare Commercial	$90.25
Rate for Payer: UnitedHealthcare Medicaid	$16.38
Rate for Payer: WPPA Medicare Advantage	$57.00

Gentamicin, Trough QST

Facility

$153.00

Service Code	HCPCS 80170
Hospital Charge Code	3552714
Hospital Revenue Code	300
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$145.35
Rate for Payer: Aetna Commercial	$137.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$57.41
Rate for Payer: Humana Medicare Advantage	$64.26
Rate for Payer: UnitedHealthcare Commercial	$145.35
Rate for Payer: UnitedHealthcare Medicaid	$16.38
Rate for Payer: WPPA Medicare Advantage	$91.80

Gentamicin, Trough QST

Facility

$153.00

Service Code	HCPCS 80170
Hospital Charge Code	3552714
Hospital Revenue Code	300
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$137.70
Rate for Payer: UnitedHealthcare Commercial	$145.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Giardia Ag, EIA, Stool QST

Facility

$112.00

Service Code	HCPCS 87329
Hospital Charge Code	3550461
Hospital Revenue Code	300
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

Know your out-of-pocket cost for care.

All Charges