Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Lipid Panel

Facility

$104.00

Service Code	HCPCS 80061
Hospital Charge Code	3551336
Hospital Revenue Code	300
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$98.80
Rate for Payer: Aetna Commercial	$93.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$43.18
Rate for Payer: Humana Medicare Advantage	$43.68
Rate for Payer: UnitedHealthcare Commercial	$98.80
Rate for Payer: UnitedHealthcare Medicaid	$13.39
Rate for Payer: WPPA Medicare Advantage	$62.40

Lipid Panel

Facility

$104.00

Service Code	HCPCS 80061
Hospital Charge Code	3551336
Hospital Revenue Code	300
Min. Negotiated Rate	$93.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$93.60
Rate for Payer: UnitedHealthcare Commercial	$98.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lipoprotein Fractionation Quest Bill Only

Facility

$199.00

Service Code	HCPCS 83704
Hospital Charge Code	3553704
Hospital Revenue Code	300
Min. Negotiated Rate	$179.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$179.10
Rate for Payer: UnitedHealthcare Commercial	$189.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lipoprotein Fractionation Quest Bill Only

Facility

$199.00

Service Code	HCPCS 83704
Hospital Charge Code	3553704
Hospital Revenue Code	300
Min. Negotiated Rate	$31.49
Max. Negotiated Rate	$189.05
Rate for Payer: Aetna Commercial	$179.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$40.62
Rate for Payer: Humana Medicare Advantage	$83.58
Rate for Payer: UnitedHealthcare Commercial	$189.05
Rate for Payer: UnitedHealthcare Medicaid	$31.49
Rate for Payer: WPPA Medicare Advantage	$119.40

Lipoprotein Fract Ion Mobility QST

Facility

$105.00

Service Code	HCPCS 83704
Hospital Charge Code	3551792
Hospital Revenue Code	300
Min. Negotiated Rate	$31.49
Max. Negotiated Rate	$99.75
Rate for Payer: Aetna Commercial	$94.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$40.62
Rate for Payer: Humana Medicare Advantage	$44.10
Rate for Payer: UnitedHealthcare Commercial	$99.75
Rate for Payer: UnitedHealthcare Medicaid	$31.49
Rate for Payer: WPPA Medicare Advantage	$63.00

Lipoprotein Fract Ion Mobility QST

Facility

$105.00

Service Code	HCPCS 83704
Hospital Charge Code	3551792
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$94.50
Rate for Payer: UnitedHealthcare Commercial	$99.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

liraglutide 18 mg/3 mL [HMC]

Facility

$658.77

Service Code	NDC 00169406012
Hospital Charge Code	3800054
Hospital Revenue Code	250
Min. Negotiated Rate	$592.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$592.89
Rate for Payer: UnitedHealthcare Commercial	$625.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

liraglutide 18 mg/3 mL [HMC]

Facility

$509.16

Service Code	NDC 00169406013
Hospital Charge Code	3800054
Hospital Revenue Code	250
Min. Negotiated Rate	$458.24
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$458.24
Rate for Payer: UnitedHealthcare Commercial	$483.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

liraglutide 18 mg/3 mL [HMC]

Facility

$658.77

Service Code	NDC 00169406012
Hospital Charge Code	3800054
Hospital Revenue Code	250
Min. Negotiated Rate	$263.51
Max. Negotiated Rate	$625.83
Rate for Payer: Aetna Commercial	$592.89
Rate for Payer: Humana Medicare Advantage	$276.68
Rate for Payer: UnitedHealthcare Commercial	$625.83
Rate for Payer: UnitedHealthcare Medicaid	$263.51
Rate for Payer: WPPA Medicare Advantage	$395.26

liraglutide 18 mg/3 mL [HMC]

Facility

$509.16

Service Code	NDC 00169406013
Hospital Charge Code	3800054
Hospital Revenue Code	250
Min. Negotiated Rate	$203.66
Max. Negotiated Rate	$483.70
Rate for Payer: Aetna Commercial	$458.24
Rate for Payer: Humana Medicare Advantage	$213.85
Rate for Payer: UnitedHealthcare Commercial	$483.70
Rate for Payer: UnitedHealthcare Medicaid	$203.66
Rate for Payer: WPPA Medicare Advantage	$305.50

lisinopril 40 mg Tab [HMC]

Facility

$9.27

Service Code	NDC 68084006401
Hospital Charge Code	3809379
Hospital Revenue Code	250
Min. Negotiated Rate	$8.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.34
Rate for Payer: UnitedHealthcare Commercial	$8.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lisinopril 40 mg Tab [HMC]

Facility

$5.50

Service Code	NDC 00904720061
Hospital Charge Code	3809379
Hospital Revenue Code	250
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$5.22
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: Humana Medicare Advantage	$2.31
Rate for Payer: UnitedHealthcare Commercial	$5.22
Rate for Payer: UnitedHealthcare Medicaid	$2.20
Rate for Payer: WPPA Medicare Advantage	$3.30

lisinopril 40 mg Tab [HMC]

Facility

$5.50

Service Code	NDC 00904680061
Hospital Charge Code	3809379
Hospital Revenue Code	250
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$5.22
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: Humana Medicare Advantage	$2.31
Rate for Payer: UnitedHealthcare Commercial	$5.22
Rate for Payer: UnitedHealthcare Medicaid	$2.20
Rate for Payer: WPPA Medicare Advantage	$3.30

lisinopril 40 mg Tab [HMC]

Facility

$9.27

Service Code	NDC 68084006401
Hospital Charge Code	3809379
Hospital Revenue Code	250
Min. Negotiated Rate	$3.71
Max. Negotiated Rate	$8.81
Rate for Payer: Aetna Commercial	$8.34
Rate for Payer: Humana Medicare Advantage	$3.89
Rate for Payer: UnitedHealthcare Commercial	$8.81
Rate for Payer: UnitedHealthcare Medicaid	$3.71
Rate for Payer: WPPA Medicare Advantage	$5.56

lisinopril 40 mg Tab [HMC]

Facility

$5.50

Service Code	NDC 00904680061
Hospital Charge Code	3809379
Hospital Revenue Code	250
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: UnitedHealthcare Commercial	$5.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lisinopril 40 mg Tab [HMC]

Facility

$5.50

Service Code	NDC 00904720061
Hospital Charge Code	3809379
Hospital Revenue Code	250
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: UnitedHealthcare Commercial	$5.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lisinopril 5 mg Tab [HMC]

Facility

$7.62

Service Code	NDC 68084019601
Hospital Charge Code	3806442
Hospital Revenue Code	250
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$7.24
Rate for Payer: Aetna Commercial	$6.86
Rate for Payer: Humana Medicare Advantage	$3.20
Rate for Payer: UnitedHealthcare Commercial	$7.24
Rate for Payer: UnitedHealthcare Medicaid	$3.05
Rate for Payer: WPPA Medicare Advantage	$4.57

lisinopril 5 mg Tab [HMC]

Facility

$7.62

Service Code	NDC 68084019601
Hospital Charge Code	3806442
Hospital Revenue Code	250
Min. Negotiated Rate	$6.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.86
Rate for Payer: UnitedHealthcare Commercial	$7.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lisinopril 5 mg Tab [HMC]

Facility

$5.23

Service Code	NDC 00904679761
Hospital Charge Code	3806442
Hospital Revenue Code	250
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$4.97
Rate for Payer: Aetna Commercial	$4.71
Rate for Payer: Humana Medicare Advantage	$2.20
Rate for Payer: UnitedHealthcare Commercial	$4.97
Rate for Payer: UnitedHealthcare Medicaid	$2.09
Rate for Payer: WPPA Medicare Advantage	$3.14

lisinopril 5 mg Tab [HMC]

Facility

$5.23

Service Code	NDC 00904679761
Hospital Charge Code	3806442
Hospital Revenue Code	250
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.71
Rate for Payer: UnitedHealthcare Commercial	$4.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lithium 150 mg Cap [HMC]

Facility

$5.50

Service Code	NDC 00054252625
Hospital Charge Code	3806052
Hospital Revenue Code	250
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$5.22
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: Humana Medicare Advantage	$2.31
Rate for Payer: UnitedHealthcare Commercial	$5.22
Rate for Payer: UnitedHealthcare Medicaid	$2.20
Rate for Payer: WPPA Medicare Advantage	$3.30

lithium 150 mg Cap [HMC]

Facility

$5.50

Service Code	NDC 00054252625
Hospital Charge Code	3806052
Hospital Revenue Code	250
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: UnitedHealthcare Commercial	$5.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lithium 150 mg Cap [HMC]

Facility

$5.56

Service Code	NDC 00054852625
Hospital Charge Code	3806052
Hospital Revenue Code	250
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.00
Rate for Payer: UnitedHealthcare Commercial	$5.28
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lithium 150 mg Cap [HMC]

Facility

$5.56

Service Code	NDC 00054852625
Hospital Charge Code	3806052
Hospital Revenue Code	250
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$5.28
Rate for Payer: Aetna Commercial	$5.00
Rate for Payer: Humana Medicare Advantage	$2.34
Rate for Payer: UnitedHealthcare Commercial	$5.28
Rate for Payer: UnitedHealthcare Medicaid	$2.22
Rate for Payer: WPPA Medicare Advantage	$3.34

lithium 300 mg ER Tab [HMC]

Facility

$6.40

Service Code	NDC 51079018020
Hospital Charge Code	3800406
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

Know your out-of-pocket cost for care.

All Charges