Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Leukemia/Lymphoma Evaluation QST

Facility

$206.00

Service Code	HCPCS 88184
Hospital Charge Code	3559050
Hospital Revenue Code	300
Min. Negotiated Rate	$185.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Leukemia/Lymphoma Evaluation QST

Facility

$206.00

Service Code	HCPCS 88184
Hospital Charge Code	3559050
Hospital Revenue Code	300
Min. Negotiated Rate	$53.04
Max. Negotiated Rate	$195.70
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$174.50
Rate for Payer: Humana Medicare Advantage	$86.52
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: UnitedHealthcare Medicaid	$53.04
Rate for Payer: WPPA Medicare Advantage	$123.60

leuprolide 11.25 mg/3 months IM Inj, ER [HMC]

Facility

$9,282.93

Service Code	HCPCS J1950
Hospital Charge Code	3851430
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,818.78
Rate for Payer: Aetna Commercial	$8,354.64
Rate for Payer: UnitedHealthcare Commercial	$8,818.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

leuprolide 11.25 mg/3 months IM Inj, ER [HMC]

Facility

$9,282.93

Service Code	HCPCS J1950
Hospital Charge Code	3851430
Hospital Revenue Code	250
Min. Negotiated Rate	$1,763.87
Max. Negotiated Rate	$8,818.78
Rate for Payer: Aetna Commercial	$8,354.64
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,027.50
Rate for Payer: Humana Medicare Advantage	$3,898.83
Rate for Payer: UnitedHealthcare Commercial	$8,818.78
Rate for Payer: UnitedHealthcare Medicaid	$1,763.87
Rate for Payer: WPPA Medicare Advantage	$5,569.76

leuprolide 22.5 mg/3 months Kit [HMC]

Facility

$11,058.09

Service Code	HCPCS J9217
Hospital Charge Code	3800396
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,505.19
Rate for Payer: Aetna Commercial	$9,952.28
Rate for Payer: UnitedHealthcare Commercial	$10,505.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

leuprolide 22.5 mg/3 months Kit [HMC]

Facility

$11,058.09

Service Code	HCPCS J9217
Hospital Charge Code	3800396
Hospital Revenue Code	250
Min. Negotiated Rate	$170.78
Max. Negotiated Rate	$10,505.19
Rate for Payer: Aetna Commercial	$9,952.28
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$238.83
Rate for Payer: Humana Medicare Advantage	$4,644.40
Rate for Payer: UnitedHealthcare Commercial	$10,505.19
Rate for Payer: UnitedHealthcare Medicaid	$170.78
Rate for Payer: WPPA Medicare Advantage	$6,634.85

leuprolide 22.5 mg/3 months Powder

Facility

$2,459.12

Service Code	HCPCS J1954
Hospital Charge Code	3800999
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,336.16
Rate for Payer: Aetna Commercial	$2,213.21
Rate for Payer: UnitedHealthcare Commercial	$2,336.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

leuprolide 22.5 mg/3 months Powder

Facility

$2,459.12

Service Code	HCPCS J1954
Hospital Charge Code	3800999
Hospital Revenue Code	250
Min. Negotiated Rate	$346.47
Max. Negotiated Rate	$2,336.16
Rate for Payer: Aetna Commercial	$2,213.21
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$346.47
Rate for Payer: Humana Medicare Advantage	$1,032.83
Rate for Payer: UnitedHealthcare Commercial	$2,336.16
Rate for Payer: UnitedHealthcare Medicaid	$706.67
Rate for Payer: WPPA Medicare Advantage	$1,475.47

leuprolide 30 mg/4 months Kit [HMC]

Facility

$14,737.48

Service Code	HCPCS J9217
Hospital Charge Code	3850420
Hospital Revenue Code	250
Min. Negotiated Rate	$170.78
Max. Negotiated Rate	$14,000.61
Rate for Payer: Aetna Commercial	$13,263.73
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$238.83
Rate for Payer: Humana Medicare Advantage	$6,189.74
Rate for Payer: UnitedHealthcare Commercial	$14,000.61
Rate for Payer: UnitedHealthcare Medicaid	$170.78
Rate for Payer: WPPA Medicare Advantage	$8,842.49

leuprolide 30 mg/4 months Kit [HMC]

Facility

$14,737.48

Service Code	HCPCS J9217
Hospital Charge Code	3850420
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,000.61
Rate for Payer: Aetna Commercial	$13,263.73
Rate for Payer: UnitedHealthcare Commercial	$14,000.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

leuprolide 45 mg/6 months Kit [HMC]

Facility

$22,096.55

Service Code	HCPCS J9217
Hospital Charge Code	3852025
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$20,991.72
Rate for Payer: Aetna Commercial	$19,886.90
Rate for Payer: UnitedHealthcare Commercial	$20,991.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

leuprolide 45 mg/6 months Kit [HMC]

Facility

$22,096.55

Service Code	HCPCS J9217
Hospital Charge Code	3852025
Hospital Revenue Code	250
Min. Negotiated Rate	$170.78
Max. Negotiated Rate	$20,991.72
Rate for Payer: Aetna Commercial	$19,886.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$238.83
Rate for Payer: Humana Medicare Advantage	$9,280.55
Rate for Payer: UnitedHealthcare Commercial	$20,991.72
Rate for Payer: UnitedHealthcare Medicaid	$170.78
Rate for Payer: WPPA Medicare Advantage	$13,257.93

leuprolide 45 mg/6 months Pow Inj [HMC]

Facility

$4,898.24

Service Code	HCPCS J1951
Hospital Charge Code	3852027
Hospital Revenue Code	250
Min. Negotiated Rate	$139.88
Max. Negotiated Rate	$4,653.33
Rate for Payer: Aetna Commercial	$4,408.42
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$162.05
Rate for Payer: Humana Medicare Advantage	$2,057.26
Rate for Payer: UnitedHealthcare Commercial	$4,653.33
Rate for Payer: UnitedHealthcare Medicaid	$139.88
Rate for Payer: WPPA Medicare Advantage	$2,938.94

leuprolide 45 mg/6 months Pow Inj [HMC]

Facility

$4,898.24

Service Code	HCPCS J1951
Hospital Charge Code	3852027
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,653.33
Rate for Payer: Aetna Commercial	$4,408.42
Rate for Payer: UnitedHealthcare Commercial	$4,653.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

leuprolide 7.5 mg/month Kit [HMC]

Facility

$3,699.38

Service Code	HCPCS J9217
Hospital Charge Code	3850255
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,514.41
Rate for Payer: Aetna Commercial	$3,329.44
Rate for Payer: UnitedHealthcare Commercial	$3,514.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

leuprolide 7.5 mg/month Kit [HMC]

Facility

$3,699.38

Service Code	HCPCS J9217
Hospital Charge Code	3850255
Hospital Revenue Code	250
Min. Negotiated Rate	$170.78
Max. Negotiated Rate	$3,514.41
Rate for Payer: Aetna Commercial	$3,329.44
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$238.83
Rate for Payer: Humana Medicare Advantage	$1,553.74
Rate for Payer: UnitedHealthcare Commercial	$3,514.41
Rate for Payer: UnitedHealthcare Medicaid	$170.78
Rate for Payer: WPPA Medicare Advantage	$2,219.63

levalbuterol 0.31 mg/3 mL Inh Sol [HMC]

Facility

$21.72

Service Code	HCPCS J7614
Hospital Charge Code	3808135
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$20.63
Rate for Payer: Aetna Commercial	$19.55
Rate for Payer: Aetna Commercial	$19.13
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.31
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.31
Rate for Payer: Humana Medicare Advantage	$8.93
Rate for Payer: Humana Medicare Advantage	$9.12
Rate for Payer: UnitedHealthcare Commercial	$20.63
Rate for Payer: UnitedHealthcare Commercial	$20.20
Rate for Payer: UnitedHealthcare Medicaid	$0.08
Rate for Payer: UnitedHealthcare Medicaid	$0.08
Rate for Payer: WPPA Medicare Advantage	$12.76
Rate for Payer: WPPA Medicare Advantage	$13.03

levalbuterol 0.31 mg/3 mL Inh Sol [HMC]

Facility

$21.26

Service Code	HCPCS J7614
Hospital Charge Code	3808135
Hospital Revenue Code	250
Min. Negotiated Rate	$19.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.13
Rate for Payer: Aetna Commercial	$19.55
Rate for Payer: UnitedHealthcare Commercial	$20.20
Rate for Payer: UnitedHealthcare Commercial	$20.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levalbuterol 0.63 mg/3 mL Inh Sol [HMC]

Facility

$21.26

Service Code	HCPCS J7614
Hospital Charge Code	3807910
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$20.20
Rate for Payer: Aetna Commercial	$19.13
Rate for Payer: Aetna Commercial	$19.55
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.31
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.31
Rate for Payer: Humana Medicare Advantage	$8.93
Rate for Payer: Humana Medicare Advantage	$9.12
Rate for Payer: UnitedHealthcare Commercial	$20.20
Rate for Payer: UnitedHealthcare Commercial	$20.63
Rate for Payer: UnitedHealthcare Medicaid	$0.08
Rate for Payer: UnitedHealthcare Medicaid	$0.08
Rate for Payer: WPPA Medicare Advantage	$13.03
Rate for Payer: WPPA Medicare Advantage	$12.76

levalbuterol 0.63 mg/3 mL Inh Sol [HMC]

Facility

$21.26

Service Code	HCPCS J7614
Hospital Charge Code	3807910
Hospital Revenue Code	250
Min. Negotiated Rate	$19.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.13
Rate for Payer: Aetna Commercial	$19.55
Rate for Payer: UnitedHealthcare Commercial	$20.63
Rate for Payer: UnitedHealthcare Commercial	$20.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levalbuterol 1.25 mg/3 mL Inh Sol [HMC]

Facility

$14.00

Service Code	HCPCS J7614
Hospital Charge Code	3800324
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: Aetna Commercial	$19.56
Rate for Payer: Aetna Commercial	$19.13
Rate for Payer: Aetna Commercial	$19.55
Rate for Payer: UnitedHealthcare Commercial	$20.20
Rate for Payer: UnitedHealthcare Commercial	$20.64
Rate for Payer: UnitedHealthcare Commercial	$13.30
Rate for Payer: UnitedHealthcare Commercial	$20.63
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

levalbuterol 1.25 mg/3 mL Inh Sol [HMC]

Facility

$14.00

Service Code	HCPCS J7614
Hospital Charge Code	3800324
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$13.30
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: Aetna Commercial	$19.13
Rate for Payer: Aetna Commercial	$19.55
Rate for Payer: Aetna Commercial	$19.56
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.31
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.31
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.31
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.31
Rate for Payer: Humana Medicare Advantage	$9.13
Rate for Payer: Humana Medicare Advantage	$9.12
Rate for Payer: Humana Medicare Advantage	$8.93
Rate for Payer: Humana Medicare Advantage	$5.88
Rate for Payer: UnitedHealthcare Commercial	$20.64
Rate for Payer: UnitedHealthcare Commercial	$20.20
Rate for Payer: UnitedHealthcare Commercial	$13.30
Rate for Payer: UnitedHealthcare Commercial	$20.63
Rate for Payer: UnitedHealthcare Medicaid	$0.08
Rate for Payer: UnitedHealthcare Medicaid	$0.08
Rate for Payer: UnitedHealthcare Medicaid	$0.08
Rate for Payer: UnitedHealthcare Medicaid	$0.08
Rate for Payer: WPPA Medicare Advantage	$13.04
Rate for Payer: WPPA Medicare Advantage	$13.03
Rate for Payer: WPPA Medicare Advantage	$12.76
Rate for Payer: WPPA Medicare Advantage	$8.40

levETIRAcetam 100 mg/mL IV Sol 5 mL [HMC]

Facility

$33.75

Service Code	HCPCS J1953
Hospital Charge Code	3800132
Hospital Revenue Code	250
Min. Negotiated Rate	$30.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.38
Rate for Payer: Aetna Commercial	$33.75
Rate for Payer: UnitedHealthcare Commercial	$35.62
Rate for Payer: UnitedHealthcare Commercial	$32.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levETIRAcetam 100 mg/mL IV Sol 5 mL [HMC]

Facility

$37.50

Service Code	HCPCS J1953
Hospital Charge Code	3800132
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$35.62
Rate for Payer: Aetna Commercial	$33.75
Rate for Payer: Aetna Commercial	$30.38
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.11
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.11
Rate for Payer: Humana Medicare Advantage	$15.75
Rate for Payer: Humana Medicare Advantage	$14.18
Rate for Payer: UnitedHealthcare Commercial	$32.06
Rate for Payer: UnitedHealthcare Commercial	$35.62
Rate for Payer: UnitedHealthcare Medicaid	$0.04
Rate for Payer: UnitedHealthcare Medicaid	$0.04
Rate for Payer: WPPA Medicare Advantage	$22.50
Rate for Payer: WPPA Medicare Advantage	$20.25

levETIRAcetam 100 mg/mL Oral Sol [HMC]

Facility

$493.89

Service Code	NDC 00904726594
Hospital Charge Code	3800085
Hospital Revenue Code	250
Min. Negotiated Rate	$197.56
Max. Negotiated Rate	$469.20
Rate for Payer: Aetna Commercial	$444.50
Rate for Payer: Humana Medicare Advantage	$207.43
Rate for Payer: UnitedHealthcare Commercial	$469.20
Rate for Payer: UnitedHealthcare Medicaid	$197.56
Rate for Payer: WPPA Medicare Advantage	$296.33

Know your out-of-pocket cost for care.

All Charges