Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

$40.69

Service Code	NDC 00121148800
Hospital Charge Code	3805559
Hospital Revenue Code	250
Min. Negotiated Rate	$36.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.62
Rate for Payer: UnitedHealthcare Commercial	$38.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

guaiFENesin 100 mg/5 mL Oral Liq [HMC]

Facility

$16.58

Service Code	NDC 54838011740
Hospital Charge Code	3805559
Hospital Revenue Code	250
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$15.75
Rate for Payer: Aetna Commercial	$14.92
Rate for Payer: Humana Medicare Advantage	$6.96
Rate for Payer: UnitedHealthcare Commercial	$15.75
Rate for Payer: UnitedHealthcare Medicaid	$6.63
Rate for Payer: WPPA Medicare Advantage	$9.95

guaiFENesin 600 mg ER Tab [HMC]

Facility

$8.01

Service Code	NDC 68084057201
Hospital Charge Code	3809822
Hospital Revenue Code	250
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$7.61
Rate for Payer: Aetna Commercial	$7.21
Rate for Payer: Humana Medicare Advantage	$3.36
Rate for Payer: UnitedHealthcare Commercial	$7.61
Rate for Payer: UnitedHealthcare Medicaid	$3.20
Rate for Payer: WPPA Medicare Advantage	$4.81

guaiFENesin 600 mg ER Tab [HMC]

Facility

$8.01

Service Code	NDC 68084057201
Hospital Charge Code	3809822
Hospital Revenue Code	250
Min. Negotiated Rate	$7.21
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.21
Rate for Payer: UnitedHealthcare Commercial	$7.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

guaiFENesin 600 mg ER Tab [HMC]

Facility

$6.33

Service Code	NDC 63824000850
Hospital Charge Code	3809822
Hospital Revenue Code	250
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: UnitedHealthcare Commercial	$6.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

guaiFENesin 600 mg ER Tab [HMC]

Facility

$6.33

Service Code	NDC 63824000850
Hospital Charge Code	3809822
Hospital Revenue Code	250
Min. Negotiated Rate	$2.53
Max. Negotiated Rate	$6.01
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Humana Medicare Advantage	$2.66
Rate for Payer: UnitedHealthcare Commercial	$6.01
Rate for Payer: UnitedHealthcare Medicaid	$2.53
Rate for Payer: WPPA Medicare Advantage	$3.80

Guide Wire .062 w/ Trocar Tip

Facility

$90.00

Hospital Charge Code	3258524
Hospital Revenue Code	270
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna Commercial	$81.00
Rate for Payer: Humana Medicare Advantage	$37.80
Rate for Payer: UnitedHealthcare Commercial	$85.50
Rate for Payer: UnitedHealthcare Medicaid	$36.00
Rate for Payer: WPPA Medicare Advantage	$54.00

Guide Wire .062 w/ Trocar Tip

Facility

$90.00

Hospital Charge Code	3258524
Hospital Revenue Code	270
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$81.00
Rate for Payer: UnitedHealthcare Commercial	$85.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Guidewire 1.1mm x 6 for Small Headed Impant Screws

Facility

$94.00

Hospital Charge Code	3258577
Hospital Revenue Code	270
Min. Negotiated Rate	$37.60
Max. Negotiated Rate	$89.30
Rate for Payer: Aetna Commercial	$84.60
Rate for Payer: Humana Medicare Advantage	$39.48
Rate for Payer: UnitedHealthcare Commercial	$89.30
Rate for Payer: UnitedHealthcare Medicaid	$37.60
Rate for Payer: WPPA Medicare Advantage	$56.40

Guidewire 1.1mm x 6 for Small Headed Impant Screws

Facility

$94.00

Hospital Charge Code	3258577
Hospital Revenue Code	270
Min. Negotiated Rate	$84.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$84.60
Rate for Payer: UnitedHealthcare Commercial	$89.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GULF FLOUNDER (F147) IgE Qst

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3552805
Hospital Revenue Code	300
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GULF FLOUNDER (F147) IgE Qst

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3552805
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$24.70
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$10.92
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$15.60

haemophilus b conjugate (PRP-T) vaccine IM Inj [HMC]

Facility

$48.93

Service Code	NDC 58160081811
Hospital Charge Code	3800058
Hospital Revenue Code	250
Min. Negotiated Rate	$44.04
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$44.04
Rate for Payer: UnitedHealthcare Commercial	$46.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

haemophilus b conjugate (PRP-T) vaccine IM Inj [HMC]

Facility

$71.65

Service Code	NDC 49281054505
Hospital Charge Code	3800058
Hospital Revenue Code	250
Min. Negotiated Rate	$28.66
Max. Negotiated Rate	$68.07
Rate for Payer: Aetna Commercial	$64.48
Rate for Payer: Humana Medicare Advantage	$30.09
Rate for Payer: UnitedHealthcare Commercial	$68.07
Rate for Payer: UnitedHealthcare Medicaid	$28.66
Rate for Payer: WPPA Medicare Advantage	$42.99

haemophilus b conjugate (PRP-T) vaccine IM Inj [HMC]

Facility

$71.65

Service Code	NDC 49281054505
Hospital Charge Code	3800058
Hospital Revenue Code	250
Min. Negotiated Rate	$64.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.48
Rate for Payer: UnitedHealthcare Commercial	$68.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

haemophilus b conjugate (PRP-T) vaccine IM Inj [HMC]

Facility

$48.93

Service Code	NDC 58160081811
Hospital Charge Code	3800058
Hospital Revenue Code	250
Min. Negotiated Rate	$19.57
Max. Negotiated Rate	$46.48
Rate for Payer: Aetna Commercial	$44.04
Rate for Payer: Humana Medicare Advantage	$20.55
Rate for Payer: UnitedHealthcare Commercial	$46.48
Rate for Payer: UnitedHealthcare Medicaid	$19.57
Rate for Payer: WPPA Medicare Advantage	$29.36

HALIBUT (f303) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552806
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$12.60

HALIBUT (f303) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552806
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

haloperidol 0.5 mg Tab [HMC]

Facility

$6.40

Service Code	NDC 00904738961
Hospital Charge Code	3809412
Hospital Revenue Code	250
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.76
Rate for Payer: UnitedHealthcare Commercial	$6.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

haloperidol 0.5 mg Tab [HMC]

Facility

$6.40

Service Code	NDC 00904738961
Hospital Charge Code	3809412
Hospital Revenue Code	250
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$6.08
Rate for Payer: Aetna Commercial	$5.76
Rate for Payer: Humana Medicare Advantage	$2.69
Rate for Payer: UnitedHealthcare Commercial	$6.08
Rate for Payer: UnitedHealthcare Medicaid	$2.56
Rate for Payer: WPPA Medicare Advantage	$3.84

haloperidol 0.5 mg Tab [HMC]

Facility

$6.04

Service Code	NDC 51079073320
Hospital Charge Code	3809412
Hospital Revenue Code	250
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.44
Rate for Payer: UnitedHealthcare Commercial	$5.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

haloperidol 0.5 mg Tab [HMC]

Facility

$6.04

Service Code	NDC 51079073320
Hospital Charge Code	3809412
Hospital Revenue Code	250
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$5.74
Rate for Payer: Aetna Commercial	$5.44
Rate for Payer: Humana Medicare Advantage	$2.54
Rate for Payer: UnitedHealthcare Commercial	$5.74
Rate for Payer: UnitedHealthcare Medicaid	$2.42
Rate for Payer: WPPA Medicare Advantage	$3.62

haloperidol 5 mg/mL Inj Sol [HMC]

Facility

$27.20

Service Code	HCPCS J1630
Hospital Charge Code	3801815
Hospital Revenue Code	250
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.48
Rate for Payer: Aetna Commercial	$37.40
Rate for Payer: Aetna Commercial	$37.89
Rate for Payer: UnitedHealthcare Commercial	$39.99
Rate for Payer: UnitedHealthcare Commercial	$25.84
Rate for Payer: UnitedHealthcare Commercial	$39.48
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

haloperidol 5 mg/mL Inj Sol [HMC]

Facility

$41.56

Service Code	HCPCS J1630
Hospital Charge Code	3801815
Hospital Revenue Code	250
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$39.48
Rate for Payer: Aetna Commercial	$37.40
Rate for Payer: Aetna Commercial	$24.48
Rate for Payer: Aetna Commercial	$37.89
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.62
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.62
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.62
Rate for Payer: Humana Medicare Advantage	$17.46
Rate for Payer: Humana Medicare Advantage	$11.42
Rate for Payer: Humana Medicare Advantage	$17.68
Rate for Payer: UnitedHealthcare Commercial	$39.48
Rate for Payer: UnitedHealthcare Commercial	$25.84
Rate for Payer: UnitedHealthcare Commercial	$39.99
Rate for Payer: UnitedHealthcare Medicaid	$16.62
Rate for Payer: UnitedHealthcare Medicaid	$10.88
Rate for Payer: UnitedHealthcare Medicaid	$16.84
Rate for Payer: WPPA Medicare Advantage	$16.32
Rate for Payer: WPPA Medicare Advantage	$25.26
Rate for Payer: WPPA Medicare Advantage	$24.94

Know your out-of-pocket cost for care.

All Charges