Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

glycopyrrolate 1 mg Tab [HMC]

Facility

$8.94

Service Code	NDC 13107001401
Hospital Charge Code	3800057
Hospital Revenue Code	250
Min. Negotiated Rate	$3.58
Max. Negotiated Rate	$8.49
Rate for Payer: Aetna Commercial	$8.05
Rate for Payer: Humana Medicare Advantage	$3.75
Rate for Payer: UnitedHealthcare Commercial	$8.49
Rate for Payer: UnitedHealthcare Medicaid	$3.58
Rate for Payer: WPPA Medicare Advantage	$5.36

glycopyrrolate 1 mg Tab [HMC]

Facility

$8.94

Service Code	NDC 13107001401
Hospital Charge Code	3800057
Hospital Revenue Code	250
Min. Negotiated Rate	$8.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.05
Rate for Payer: UnitedHealthcare Commercial	$8.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00

glycopyrrolate 1 mg Tab [HMC]

Facility

$8.90

Service Code	NDC 00904670961
Hospital Charge Code	3800057
Hospital Revenue Code	250
Min. Negotiated Rate	$8.01
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.01
Rate for Payer: UnitedHealthcare Commercial	$8.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

glycopyrrolate 1 mg Tab [HMC]

Facility

$8.90

Service Code	NDC 00904670961
Hospital Charge Code	3800057
Hospital Revenue Code	250
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$8.46
Rate for Payer: Aetna Commercial	$8.01
Rate for Payer: Humana Medicare Advantage	$3.74
Rate for Payer: UnitedHealthcare Commercial	$8.46
Rate for Payer: UnitedHealthcare Medicaid	$3.56
Rate for Payer: WPPA Medicare Advantage	$5.34

golimumab 50 mg/4 mL [HMC]

Facility

$4,798.06

Service Code	HCPCS J1602
Hospital Charge Code	3850017
Hospital Revenue Code	250
Min. Negotiated Rate	$11.63
Max. Negotiated Rate	$4,558.16
Rate for Payer: Aetna Commercial	$4,318.25
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$14.52
Rate for Payer: Humana Medicare Advantage	$2,015.19
Rate for Payer: UnitedHealthcare Commercial	$4,558.16
Rate for Payer: UnitedHealthcare Medicaid	$11.63
Rate for Payer: WPPA Medicare Advantage	$2,878.84

golimumab 50 mg/4 mL [HMC]

Facility

$4,798.06

Service Code	HCPCS J1602
Hospital Charge Code	3850017
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,558.16
Rate for Payer: Aetna Commercial	$4,318.25
Rate for Payer: UnitedHealthcare Commercial	$4,558.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gown Patient Paper with 3 Armholes Reg/Lg Disposable No-Ties

Facility

$5.00

Hospital Charge Code	3250010
Hospital Revenue Code	270
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: Humana Medicare Advantage	$2.10
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: UnitedHealthcare Medicaid	$2.00
Rate for Payer: WPPA Medicare Advantage	$3.00

Gown Patient Paper with 3 Armholes Reg/Lg Disposable No-Ties

Facility

$5.00

Hospital Charge Code	3250010
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gram Stain QST

Facility

$32.00

Service Code	HCPCS 87205
Hospital Charge Code	3550460
Hospital Revenue Code	300
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna Commercial	$28.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$14.54
Rate for Payer: Humana Medicare Advantage	$13.44
Rate for Payer: UnitedHealthcare Commercial	$30.40
Rate for Payer: UnitedHealthcare Medicaid	$4.27
Rate for Payer: WPPA Medicare Advantage	$19.20

Gram Stain QST

Facility

$32.00

Service Code	HCPCS 87205
Hospital Charge Code	3550460
Hospital Revenue Code	300
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.80
Rate for Payer: UnitedHealthcare Commercial	$30.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Gray Foam Denser Padding Adaptable Foam Cushion 27x82x1/2 Lymphedema Program

Facility

$3.00

Hospital Charge Code	3254717
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

Gray Foam Denser Padding Adaptable Foam Cushion 27x82x1/2 Lymphedema Program

Facility

$3.00

Hospital Charge Code	3254717
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

Group B Strep (GeneXpert)

Facility

$264.00

Service Code	HCPCS 87653
Hospital Charge Code	3559040
Hospital Revenue Code	300
Min. Negotiated Rate	$237.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$237.60
Rate for Payer: UnitedHealthcare Commercial	$250.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Group B Strep (GeneXpert)

Facility

$264.00

Service Code	HCPCS 87653
Hospital Charge Code	3559040
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$250.80
Rate for Payer: Aetna Commercial	$237.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$75.31
Rate for Payer: Humana Medicare Advantage	$110.88
Rate for Payer: UnitedHealthcare Commercial	$250.80
Rate for Payer: UnitedHealthcare Medicaid	$35.09
Rate for Payer: WPPA Medicare Advantage	$158.40

Growth Hormone (GH) QST

Facility

$71.00

Service Code	HCPCS 83003
Hospital Charge Code	3553003
Hospital Revenue Code	300
Min. Negotiated Rate	$16.67
Max. Negotiated Rate	$67.45
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$58.95
Rate for Payer: Humana Medicare Advantage	$29.82
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: UnitedHealthcare Medicaid	$16.67
Rate for Payer: WPPA Medicare Advantage	$42.60

Growth Hormone (GH) QST

Facility

$71.00

Service Code	HCPCS 83003
Hospital Charge Code	3553003
Hospital Revenue Code	300
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.GTT 1 HR

Facility

$54.00

Service Code	HCPCS 82951
Hospital Charge Code	3550452
Hospital Revenue Code	300
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$48.72
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$12.87
Rate for Payer: WPPA Medicare Advantage	$32.40

.GTT 1 HR

Facility

$54.00

Service Code	HCPCS 82951
Hospital Charge Code	3550452
Hospital Revenue Code	300
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.GTT 2 HR

Facility

$54.00

Service Code	HCPCS 82951
Hospital Charge Code	3550452
Hospital Revenue Code	300
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.GTT 2 HR

Facility

$54.00

Service Code	HCPCS 82951
Hospital Charge Code	3550452
Hospital Revenue Code	300
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$48.72
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$12.87
Rate for Payer: WPPA Medicare Advantage	$32.40

.GTT 3 HR

Facility

$54.00

Service Code	HCPCS 82952
Hospital Charge Code	3551690
Hospital Revenue Code	300
Min. Negotiated Rate	$3.92
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$14.57
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$3.92
Rate for Payer: WPPA Medicare Advantage	$32.40

.GTT 3 HR

Facility

$54.00

Service Code	HCPCS 82952
Hospital Charge Code	3551690
Hospital Revenue Code	300
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

guaiFENesin 100 mg/5 mL Oral Liq [HMC]

Facility

$14.24

Service Code	NDC 00536118297
Hospital Charge Code	3805559
Hospital Revenue Code	250
Min. Negotiated Rate	$12.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.82
Rate for Payer: UnitedHealthcare Commercial	$13.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

guaiFENesin 100 mg/5 mL Oral Liq [HMC]

Facility

$40.69

Service Code	NDC 00121148800
Hospital Charge Code	3805559
Hospital Revenue Code	250
Min. Negotiated Rate	$16.28
Max. Negotiated Rate	$38.66
Rate for Payer: Aetna Commercial	$36.62
Rate for Payer: Humana Medicare Advantage	$17.09
Rate for Payer: UnitedHealthcare Commercial	$38.66
Rate for Payer: UnitedHealthcare Medicaid	$16.28
Rate for Payer: WPPA Medicare Advantage	$24.41

guaiFENesin 100 mg/5 mL Oral Liq [HMC]

Facility

$14.24

Service Code	NDC 00536118297
Hospital Charge Code	3805559
Hospital Revenue Code	250
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$13.53
Rate for Payer: Aetna Commercial	$12.82
Rate for Payer: Humana Medicare Advantage	$5.98
Rate for Payer: UnitedHealthcare Commercial	$13.53
Rate for Payer: UnitedHealthcare Medicaid	$5.70
Rate for Payer: WPPA Medicare Advantage	$8.54

Know your out-of-pocket cost for care.

All Charges