Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

labetalol 100 mg Tab [HMC]

Facility

$6.20

Service Code	NDC 00904710961
Hospital Charge Code	3805930
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

labetalol 4 mL Soln-IV [HMC]

Facility

$20.00

Service Code	NDC 00409233924
Hospital Charge Code	3806411
Hospital Revenue Code	250
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

labetalol 4 mL Soln-IV [HMC]

Facility

$20.00

Service Code	NDC 00409233924
Hospital Charge Code	3806411
Hospital Revenue Code	250
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: Humana Medicare Advantage	$8.40
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: UnitedHealthcare Medicaid	$8.00
Rate for Payer: WPPA Medicare Advantage	$12.00

labetalol 5 mg/mL IV Sol 20 mL [HMC]

Facility

$48.80

Service Code	NDC 72266010201
Hospital Charge Code	3806411
Hospital Revenue Code	259
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$43.92
Rate for Payer: UnitedHealthcare Commercial	$46.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

labetalol 5 mg/mL IV Sol 20 mL [HMC]

Facility

$48.80

Service Code	NDC 72266010201
Hospital Charge Code	3806411
Hospital Revenue Code	259
Min. Negotiated Rate	$19.52
Max. Negotiated Rate	$46.36
Rate for Payer: Aetna Commercial	$43.92
Rate for Payer: Humana Medicare Advantage	$20.50
Rate for Payer: UnitedHealthcare Commercial	$46.36
Rate for Payer: UnitedHealthcare Medicaid	$19.52
Rate for Payer: WPPA Medicare Advantage	$29.28

labetalol 5 mg/mL IV Sol 20 mL [HMC]

Facility

$66.88

Service Code	NDC 17478042020
Hospital Charge Code	3806411
Hospital Revenue Code	259
Min. Negotiated Rate	$60.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$60.19
Rate for Payer: UnitedHealthcare Commercial	$63.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

labetalol 5 mg/mL IV Sol 20 mL [HMC]

Facility

$66.88

Service Code	NDC 17478042020
Hospital Charge Code	3806411
Hospital Revenue Code	259
Min. Negotiated Rate	$26.75
Max. Negotiated Rate	$63.54
Rate for Payer: Aetna Commercial	$60.19
Rate for Payer: Humana Medicare Advantage	$28.09
Rate for Payer: UnitedHealthcare Commercial	$63.54
Rate for Payer: UnitedHealthcare Medicaid	$26.75
Rate for Payer: WPPA Medicare Advantage	$40.13

labetalol 5 mg/mL IV Sol 4 mL [HMC]

Facility

$41.80

Service Code	NDC 00409233934
Hospital Charge Code	3806411
Hospital Revenue Code	250
Min. Negotiated Rate	$37.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$37.62
Rate for Payer: UnitedHealthcare Commercial	$39.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

labetalol 5 mg/mL IV Sol 4 mL [HMC]

Facility

$35.19

Service Code	NDC 36000032010
Hospital Charge Code	3806411
Hospital Revenue Code	250
Min. Negotiated Rate	$14.08
Max. Negotiated Rate	$33.43
Rate for Payer: Aetna Commercial	$31.67
Rate for Payer: Humana Medicare Advantage	$14.78
Rate for Payer: UnitedHealthcare Commercial	$33.43
Rate for Payer: UnitedHealthcare Medicaid	$14.08
Rate for Payer: WPPA Medicare Advantage	$21.11

labetalol 5 mg/mL IV Sol 4 mL [HMC]

Facility

$35.19

Service Code	NDC 36000032010
Hospital Charge Code	3806411
Hospital Revenue Code	250
Min. Negotiated Rate	$31.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.67
Rate for Payer: UnitedHealthcare Commercial	$33.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

labetalol 5 mg/mL IV Sol 4 mL [HMC]

Facility

$41.80

Service Code	NDC 00409233934
Hospital Charge Code	3806411
Hospital Revenue Code	250
Min. Negotiated Rate	$16.72
Max. Negotiated Rate	$39.71
Rate for Payer: Aetna Commercial	$37.62
Rate for Payer: Humana Medicare Advantage	$17.56
Rate for Payer: UnitedHealthcare Commercial	$39.71
Rate for Payer: UnitedHealthcare Medicaid	$16.72
Rate for Payer: WPPA Medicare Advantage	$25.08

labetalol 5 mg/mL IV Sol [HMC]

Facility

$43.76

Service Code	NDC 00409226720
Hospital Charge Code	3802346
Hospital Revenue Code	250
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$41.57
Rate for Payer: Aetna Commercial	$39.38
Rate for Payer: Humana Medicare Advantage	$18.38
Rate for Payer: UnitedHealthcare Commercial	$41.57
Rate for Payer: UnitedHealthcare Medicaid	$17.50
Rate for Payer: WPPA Medicare Advantage	$26.26

labetalol 5 mg/mL IV Sol [HMC]

Facility

$43.76

Service Code	NDC 00409226720
Hospital Charge Code	3802346
Hospital Revenue Code	250
Min. Negotiated Rate	$39.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.38
Rate for Payer: UnitedHealthcare Commercial	$41.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

labetalol 5 mg/mL Sol Inj 4 ml [HMC]

Facility

$35.19

Service Code	NDC 00143918310
Hospital Charge Code	3806411
Hospital Revenue Code	250
Min. Negotiated Rate	$31.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.67
Rate for Payer: UnitedHealthcare Commercial	$33.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

labetalol 5 mg/mL Sol Inj 4 ml [HMC]

Facility

$35.19

Service Code	NDC 00143918310
Hospital Charge Code	3806411
Hospital Revenue Code	250
Min. Negotiated Rate	$14.08
Max. Negotiated Rate	$33.43
Rate for Payer: Aetna Commercial	$31.67
Rate for Payer: Humana Medicare Advantage	$14.78
Rate for Payer: UnitedHealthcare Commercial	$33.43
Rate for Payer: UnitedHealthcare Medicaid	$14.08
Rate for Payer: WPPA Medicare Advantage	$21.11

LABOR 0-8 HOURS CHARGE

Facility

$1,226.00

Hospital Charge Code	3200075
Hospital Revenue Code	721
Min. Negotiated Rate	$490.40
Max. Negotiated Rate	$1,164.70
Rate for Payer: Aetna Commercial	$1,103.40
Rate for Payer: Humana Medicare Advantage	$514.92
Rate for Payer: UnitedHealthcare Commercial	$1,164.70
Rate for Payer: UnitedHealthcare Medicaid	$490.40
Rate for Payer: WPPA Medicare Advantage	$735.60

LABOR 0-8 HOURS CHARGE

Facility

$1,226.00

Hospital Charge Code	3200075
Hospital Revenue Code	721
Min. Negotiated Rate	$1,103.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,103.40
Rate for Payer: UnitedHealthcare Commercial	$1,164.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LABOR 8 OR MORE HOURS CHARGE

Facility

$1,484.00

Hospital Charge Code	3200080
Hospital Revenue Code	721
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,409.80
Rate for Payer: Aetna Commercial	$1,335.60
Rate for Payer: UnitedHealthcare Commercial	$1,409.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LABOR 8 OR MORE HOURS CHARGE

Facility

$1,484.00

Hospital Charge Code	3200080
Hospital Revenue Code	721
Min. Negotiated Rate	$593.60
Max. Negotiated Rate	$1,409.80
Rate for Payer: Aetna Commercial	$1,335.60
Rate for Payer: Humana Medicare Advantage	$623.28
Rate for Payer: UnitedHealthcare Commercial	$1,409.80
Rate for Payer: UnitedHealthcare Medicaid	$593.60
Rate for Payer: WPPA Medicare Advantage	$890.40

LABOR AND TRANSFER OUT CHARGE

Facility

$834.00

Hospital Charge Code	3200085
Hospital Revenue Code	721
Min. Negotiated Rate	$750.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$750.60
Rate for Payer: UnitedHealthcare Commercial	$792.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LABOR AND TRANSFER OUT CHARGE

Facility

$834.00

Hospital Charge Code	3200085
Hospital Revenue Code	721
Min. Negotiated Rate	$333.60
Max. Negotiated Rate	$792.30
Rate for Payer: Aetna Commercial	$750.60
Rate for Payer: Humana Medicare Advantage	$350.28
Rate for Payer: UnitedHealthcare Commercial	$792.30
Rate for Payer: UnitedHealthcare Medicaid	$333.60
Rate for Payer: WPPA Medicare Advantage	$500.40

LABOR ROOM CHARGE

Facility

$2,069.00

Hospital Charge Code	3200025
Hospital Revenue Code	720
Min. Negotiated Rate	$827.60
Max. Negotiated Rate	$1,965.55
Rate for Payer: Aetna Commercial	$1,862.10
Rate for Payer: Humana Medicare Advantage	$868.98
Rate for Payer: UnitedHealthcare Commercial	$1,965.55
Rate for Payer: UnitedHealthcare Medicaid	$827.60
Rate for Payer: WPPA Medicare Advantage	$1,241.40

LABOR ROOM CHARGE

Facility

$2,069.00

Hospital Charge Code	3200025
Hospital Revenue Code	720
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,965.55
Rate for Payer: Aetna Commercial	$1,862.10
Rate for Payer: UnitedHealthcare Commercial	$1,965.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Laceration Repair- Face,Ears,Eyelid, Nose, Lip, 12.6cm-20.0cm

Facility

$1,523.00

Service Code	HCPCS 12016
Hospital Charge Code	3300245
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,446.85
Rate for Payer: Aetna Commercial	$1,370.70
Rate for Payer: UnitedHealthcare Commercial	$1,446.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Laceration Repair- Face,Ears,Eyelid, Nose, Lip, 12.6cm-20.0cm

Facility

$1,523.00

Service Code	HCPCS 12016
Hospital Charge Code	3300245
Hospital Revenue Code	450
Min. Negotiated Rate	$370.66
Max. Negotiated Rate	$1,446.85
Rate for Payer: Aetna Commercial	$1,370.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$639.66
Rate for Payer: UnitedHealthcare Commercial	$1,446.85
Rate for Payer: UnitedHealthcare Medicaid	$370.66
Rate for Payer: WPPA Medicare Advantage	$913.80

Know your out-of-pocket cost for care.

All Charges