Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

ketorolac 30 mg/mL Inj Sol [HMC]

Facility

$30.50

Service Code	NDC 00338007225
Hospital Charge Code	3803893
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

ketorolac 30 mg/mL Inj Sol [HMC]

Facility

$30.50

Service Code	HCPCS J1885
Hospital Charge Code	3803893
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: Aetna Commercial	$26.54
Rate for Payer: Aetna Commercial	$22.70
Rate for Payer: Aetna Commercial	$39.16
Rate for Payer: Aetna Commercial	$24.05
Rate for Payer: UnitedHealthcare Commercial	$23.96
Rate for Payer: UnitedHealthcare Commercial	$41.33
Rate for Payer: UnitedHealthcare Commercial	$28.98
Rate for Payer: UnitedHealthcare Commercial	$25.38
Rate for Payer: UnitedHealthcare Commercial	$28.02
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
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ketorolac 30 mg/mL Inj Sol [HMC]

Facility

$30.50

Service Code	NDC 00338007225
Hospital Charge Code	3803893
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

ketorolac 60 mg/2 mL [HMC]

Facility

$27.44

Service Code	HCPCS J1885
Hospital Charge Code	3805906
Hospital Revenue Code	250
Min. Negotiated Rate	$24.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Commercial	$23.56
Rate for Payer: Aetna Commercial	$28.80
Rate for Payer: Aetna Commercial	$30.96
Rate for Payer: UnitedHealthcare Commercial	$26.07
Rate for Payer: UnitedHealthcare Commercial	$30.40
Rate for Payer: UnitedHealthcare Commercial	$32.68
Rate for Payer: UnitedHealthcare Commercial	$24.87
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
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ketorolac 60 mg/2 mL [HMC]

Facility

$32.00

Service Code	HCPCS J1885
Hospital Charge Code	3805906
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna Commercial	$28.80
Rate for Payer: Aetna Commercial	$23.56
Rate for Payer: Aetna Commercial	$30.96
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.90
Rate for Payer: Humana Medicare Advantage	$14.45
Rate for Payer: Humana Medicare Advantage	$11.00
Rate for Payer: Humana Medicare Advantage	$11.52
Rate for Payer: Humana Medicare Advantage	$13.44
Rate for Payer: UnitedHealthcare Commercial	$24.87
Rate for Payer: UnitedHealthcare Commercial	$32.68
Rate for Payer: UnitedHealthcare Commercial	$26.07
Rate for Payer: UnitedHealthcare Commercial	$30.40
Rate for Payer: UnitedHealthcare Medicaid	$0.33
Rate for Payer: UnitedHealthcare Medicaid	$0.33
Rate for Payer: UnitedHealthcare Medicaid	$0.33
Rate for Payer: UnitedHealthcare Medicaid	$0.33
Rate for Payer: WPPA Medicare Advantage	$16.46
Rate for Payer: WPPA Medicare Advantage	$20.64
Rate for Payer: WPPA Medicare Advantage	$19.20
Rate for Payer: WPPA Medicare Advantage	$15.71

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC

Facility

$6,163.38

Service Code	MSDRG 657
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,163.38
Rate for Payer: UnitedHealthcare Medicaid	$6,163.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC

Facility

$10,738.26

Service Code	MSDRG 656
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,738.26
Rate for Payer: UnitedHealthcare Medicaid	$10,738.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC

Facility

$5,242.05

Service Code	MSDRG 658
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,242.05
Rate for Payer: UnitedHealthcare Medicaid	$5,242.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC

Facility

$5,083.20

Service Code	MSDRG 660
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,083.20
Rate for Payer: UnitedHealthcare Medicaid	$5,083.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC

Facility

$8,577.90

Service Code	MSDRG 659
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,577.90
Rate for Payer: UnitedHealthcare Medicaid	$8,577.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC

Facility

$3,494.70

Service Code	MSDRG 661
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,494.70
Rate for Payer: UnitedHealthcare Medicaid	$3,494.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URINARY TRACT INFECTIONS WITH MCC

Facility

$6,576.39

Service Code	MSDRG 689
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,576.39
Rate for Payer: UnitedHealthcare Medicaid	$6,576.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC

Facility

$4,034.79

Service Code	MSDRG 690
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,034.79
Rate for Payer: UnitedHealthcare Medicaid	$4,034.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URINARY TRACT NEOPLASMS WITH CC

Facility

$4,447.80

Service Code	MSDRG 687
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,447.80
Rate for Payer: UnitedHealthcare Medicaid	$4,447.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC

Facility

$7,688.34

Service Code	MSDRG 686
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,688.34
Rate for Payer: UnitedHealthcare Medicaid	$7,688.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC

Facility

$3,367.62

Service Code	MSDRG 688
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,367.62
Rate for Payer: UnitedHealthcare Medicaid	$3,367.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC

Facility

$4,860.81

Service Code	MSDRG 695
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,860.81
Rate for Payer: UnitedHealthcare Medicaid	$4,860.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$2,922.84

Service Code	MSDRG 696
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

KIDNEY TRANSPLANT

Facility

$10,897.11

Service Code	MSDRG 652
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,897.11
Rate for Payer: UnitedHealthcare Medicaid	$10,897.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC

Facility

$15,853.23

Service Code	MSDRG 650
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$15,853.23
Rate for Payer: UnitedHealthcare Medicaid	$15,853.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC

Facility

$12,485.61

Service Code	MSDRG 651
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,485.61
Rate for Payer: UnitedHealthcare Medicaid	$12,485.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

King Airway LTS-D Purple Size #5

Facility

$169.00

Hospital Charge Code	3257715
Hospital Revenue Code	541
Min. Negotiated Rate	$67.60
Max. Negotiated Rate	$160.55
Rate for Payer: Aetna Commercial	$152.10
Rate for Payer: Humana Medicare Advantage	$70.98
Rate for Payer: UnitedHealthcare Commercial	$160.55
Rate for Payer: UnitedHealthcare Medicaid	$67.60
Rate for Payer: WPPA Medicare Advantage	$101.40

King Airway LTS-D Purple Size #5

Facility

$169.00

Hospital Charge Code	3257715
Hospital Revenue Code	541
Min. Negotiated Rate	$152.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$152.10
Rate for Payer: UnitedHealthcare Commercial	$160.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

King Airway LTS-D Red Size #4

Facility

$184.00

Hospital Charge Code	3257710
Hospital Revenue Code	541
Min. Negotiated Rate	$73.60
Max. Negotiated Rate	$174.80
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: Humana Medicare Advantage	$77.28
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: UnitedHealthcare Medicaid	$73.60
Rate for Payer: WPPA Medicare Advantage	$110.40

King Airway LTS-D Red Size #4

Facility

$184.00

Hospital Charge Code	3257710
Hospital Revenue Code	541
Min. Negotiated Rate	$165.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges