Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

GlideScope Spectrum QC MAC S4

Facility

$142.80

Hospital Charge Code	3254115
Hospital Revenue Code	270
Min. Negotiated Rate	$128.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$128.52
Rate for Payer: UnitedHealthcare Commercial	$135.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GlideScope Spectrum QC MAC S4

Facility

$142.80

Hospital Charge Code	3254115
Hospital Revenue Code	270
Min. Negotiated Rate	$57.12
Max. Negotiated Rate	$135.66
Rate for Payer: Aetna Commercial	$128.52
Rate for Payer: Humana Medicare Advantage	$59.98
Rate for Payer: UnitedHealthcare Commercial	$135.66
Rate for Payer: UnitedHealthcare Medicaid	$57.12
Rate for Payer: WPPA Medicare Advantage	$85.68

glimepiride 2 mg Tab [HMC]

Facility

$7.65

Service Code	NDC 68084032601
Hospital Charge Code	3801410
Hospital Revenue Code	250
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$7.27
Rate for Payer: Aetna Commercial	$6.88
Rate for Payer: Humana Medicare Advantage	$3.21
Rate for Payer: UnitedHealthcare Commercial	$7.27
Rate for Payer: UnitedHealthcare Medicaid	$3.06
Rate for Payer: WPPA Medicare Advantage	$4.59

glimepiride 2 mg Tab [HMC]

Facility

$7.65

Service Code	NDC 50268035915
Hospital Charge Code	3801410
Hospital Revenue Code	250
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$7.27
Rate for Payer: Aetna Commercial	$6.88
Rate for Payer: Humana Medicare Advantage	$3.21
Rate for Payer: UnitedHealthcare Commercial	$7.27
Rate for Payer: UnitedHealthcare Medicaid	$3.06
Rate for Payer: WPPA Medicare Advantage	$4.59

glimepiride 2 mg Tab [HMC]

Facility

$7.65

Service Code	NDC 68084032601
Hospital Charge Code	3801410
Hospital Revenue Code	250
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.88
Rate for Payer: UnitedHealthcare Commercial	$7.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

glimepiride 2 mg Tab [HMC]

Facility

$7.65

Service Code	NDC 50268035915
Hospital Charge Code	3801410
Hospital Revenue Code	250
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.88
Rate for Payer: UnitedHealthcare Commercial	$7.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

glipiZIDE 5 mg Tab [HMC]

Facility

$6.20

Service Code	NDC 00904663761
Hospital Charge Code	3804934
Hospital Revenue Code	250
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$5.89
Rate for Payer: Aetna Commercial	$5.58
Rate for Payer: Humana Medicare Advantage	$2.60
Rate for Payer: UnitedHealthcare Commercial	$5.89
Rate for Payer: UnitedHealthcare Medicaid	$2.48
Rate for Payer: WPPA Medicare Advantage	$3.72

glipiZIDE 5 mg Tab [HMC]

Facility

$6.09

Service Code	NDC 60505014100
Hospital Charge Code	3804934
Hospital Revenue Code	250
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$5.79
Rate for Payer: Aetna Commercial	$5.48
Rate for Payer: Humana Medicare Advantage	$2.56
Rate for Payer: UnitedHealthcare Commercial	$5.79
Rate for Payer: UnitedHealthcare Medicaid	$2.44
Rate for Payer: WPPA Medicare Advantage	$3.65

glipiZIDE 5 mg Tab [HMC]

Facility

$6.09

Service Code	NDC 60505014100
Hospital Charge Code	3804934
Hospital Revenue Code	250
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.48
Rate for Payer: UnitedHealthcare Commercial	$5.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

glipiZIDE 5 mg Tab [HMC]

Facility

$6.20

Service Code	NDC 00904663761
Hospital Charge Code	3804934
Hospital Revenue Code	250
Min. Negotiated Rate	$5.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.58
Rate for Payer: UnitedHealthcare Commercial	$5.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Glomerular Basement Membrane Ab, IgG QST

Facility

$297.00

Service Code	HCPCS 83520
Hospital Charge Code	3550257
Hospital Revenue Code	300
Min. Negotiated Rate	$36.48
Max. Negotiated Rate	$282.15
Rate for Payer: Aetna Commercial	$267.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.48
Rate for Payer: Humana Medicare Advantage	$124.74
Rate for Payer: UnitedHealthcare Commercial	$282.15
Rate for Payer: UnitedHealthcare Medicaid	$118.80
Rate for Payer: WPPA Medicare Advantage	$178.20

Glomerular Basement Membrane Ab, IgG QST

Facility

$297.00

Service Code	HCPCS 83520
Hospital Charge Code	3550257
Hospital Revenue Code	300
Min. Negotiated Rate	$267.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$267.30
Rate for Payer: UnitedHealthcare Commercial	$282.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

glucagon 1 mg Inj [HMC]

Facility

$524.00

Service Code	HCPCS J1610
Hospital Charge Code	3801740
Hospital Revenue Code	250
Min. Negotiated Rate	$164.86
Max. Negotiated Rate	$497.80
Rate for Payer: Aetna Commercial	$471.60
Rate for Payer: Aetna Commercial	$471.28
Rate for Payer: Aetna Commercial	$472.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$244.75
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$244.75
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$244.75
Rate for Payer: Humana Medicare Advantage	$220.68
Rate for Payer: Humana Medicare Advantage	$219.93
Rate for Payer: Humana Medicare Advantage	$220.08
Rate for Payer: UnitedHealthcare Commercial	$499.17
Rate for Payer: UnitedHealthcare Commercial	$497.80
Rate for Payer: UnitedHealthcare Commercial	$497.46
Rate for Payer: UnitedHealthcare Medicaid	$164.86
Rate for Payer: UnitedHealthcare Medicaid	$164.86
Rate for Payer: UnitedHealthcare Medicaid	$164.86
Rate for Payer: WPPA Medicare Advantage	$314.40
Rate for Payer: WPPA Medicare Advantage	$314.18
Rate for Payer: WPPA Medicare Advantage	$315.26

glucagon 1 mg Inj [HMC]

Facility

$524.00

Service Code	HCPCS J1610
Hospital Charge Code	3801740
Hospital Revenue Code	250
Min. Negotiated Rate	$471.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$471.60
Rate for Payer: Aetna Commercial	$471.28
Rate for Payer: Aetna Commercial	$472.90
Rate for Payer: UnitedHealthcare Commercial	$497.80
Rate for Payer: UnitedHealthcare Commercial	$497.46
Rate for Payer: UnitedHealthcare Commercial	$499.17
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

glucosamine 500 mg Cap UD [HMC]

Facility

$5.21

Service Code	NDC 43292055857
Hospital Charge Code	3804110
Hospital Revenue Code	257
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

glucosamine 500 mg Cap UD [HMC]

Facility

$5.21

Service Code	NDC 43292055857
Hospital Charge Code	3804110
Hospital Revenue Code	257
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

glucosamine 500 mg Cap UD [HMC]

Facility

$6.39

Service Code	NDC 50268037515
Hospital Charge Code	3804110
Hospital Revenue Code	257
Min. Negotiated Rate	$5.75
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.75
Rate for Payer: UnitedHealthcare Commercial	$6.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

glucosamine 500 mg Cap UD [HMC]

Facility

$6.39

Service Code	NDC 50268037515
Hospital Charge Code	3804110
Hospital Revenue Code	257
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$6.07
Rate for Payer: Aetna Commercial	$5.75
Rate for Payer: Humana Medicare Advantage	$2.68
Rate for Payer: UnitedHealthcare Commercial	$6.07
Rate for Payer: UnitedHealthcare Medicaid	$2.56
Rate for Payer: WPPA Medicare Advantage	$3.83

Glucose 1 Hour Post Prandial

Facility

$208.00

Service Code	HCPCS 82950
Hospital Charge Code	3552573
Hospital Revenue Code	300
Min. Negotiated Rate	$187.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: UnitedHealthcare Commercial	$197.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Glucose 1 Hour Post Prandial

Facility

$208.00

Service Code	HCPCS 82950
Hospital Charge Code	3552573
Hospital Revenue Code	300
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$197.60
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$20.08
Rate for Payer: Humana Medicare Advantage	$87.36
Rate for Payer: UnitedHealthcare Commercial	$197.60
Rate for Payer: UnitedHealthcare Medicaid	$4.75
Rate for Payer: WPPA Medicare Advantage	$124.80

glucose 40% Oral gel [HMC]

Facility

$30.76

Service Code	NDC 00574006930
Hospital Charge Code	3802606
Hospital Revenue Code	250
Min. Negotiated Rate	$12.30
Max. Negotiated Rate	$29.22
Rate for Payer: Aetna Commercial	$27.68
Rate for Payer: Humana Medicare Advantage	$12.92
Rate for Payer: UnitedHealthcare Commercial	$29.22
Rate for Payer: UnitedHealthcare Medicaid	$12.30
Rate for Payer: WPPA Medicare Advantage	$18.46

glucose 40% Oral gel [HMC]

Facility

$30.76

Service Code	NDC 00574006930
Hospital Charge Code	3802606
Hospital Revenue Code	250
Min. Negotiated Rate	$27.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.68
Rate for Payer: UnitedHealthcare Commercial	$29.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

glucose 50% IV Sol 50 mL [HMC]

Facility

$59.12

Service Code	NDC 00409751716
Hospital Charge Code	3801302
Hospital Revenue Code	250
Min. Negotiated Rate	$53.21
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$53.21
Rate for Payer: UnitedHealthcare Commercial	$56.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

glucose 50% IV Sol 50 mL [HMC]

Facility

$53.16

Service Code	NDC 76329330201
Hospital Charge Code	3801302
Hospital Revenue Code	250
Min. Negotiated Rate	$21.26
Max. Negotiated Rate	$50.50
Rate for Payer: Aetna Commercial	$47.84
Rate for Payer: Humana Medicare Advantage	$22.33
Rate for Payer: UnitedHealthcare Commercial	$50.50
Rate for Payer: UnitedHealthcare Medicaid	$21.26
Rate for Payer: WPPA Medicare Advantage	$31.90

glucose 50% IV Sol 50 mL [HMC]

Facility

$53.16

Service Code	NDC 76329330201
Hospital Charge Code	3801302
Hospital Revenue Code	250
Min. Negotiated Rate	$47.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$47.84
Rate for Payer: UnitedHealthcare Commercial	$50.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges