Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

lithium 300 mg ER Tab [HMC]

Facility

$6.43

Service Code	NDC 68084064001
Hospital Charge Code	3800406
Hospital Revenue Code	250
Min. Negotiated Rate	$5.79
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.79
Rate for Payer: UnitedHealthcare Commercial	$6.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lithium 300 mg ER Tab [HMC]

Facility

$6.40

Service Code	NDC 51079018020
Hospital Charge Code	3800406
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

lithium 300 mg ER Tab [HMC]

Facility

$6.43

Service Code	NDC 68084064001
Hospital Charge Code	3800406
Hospital Revenue Code	250
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$6.11
Rate for Payer: Aetna Commercial	$5.79
Rate for Payer: Humana Medicare Advantage	$2.70
Rate for Payer: UnitedHealthcare Commercial	$6.11
Rate for Payer: UnitedHealthcare Medicaid	$2.57
Rate for Payer: WPPA Medicare Advantage	$3.86

Lithium QST

Facility

$45.00

Service Code	HCPCS 80178
Hospital Charge Code	3551112
Hospital Revenue Code	300
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$42.75
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$26.44
Rate for Payer: Humana Medicare Advantage	$18.90
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: UnitedHealthcare Medicaid	$6.61
Rate for Payer: WPPA Medicare Advantage	$27.00

Lithium QST

Facility

$45.00

Service Code	HCPCS 80178
Hospital Charge Code	3551112
Hospital Revenue Code	300
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Liver Fibrosis, FibroTst-ActiTst Pnl QST

Facility

$517.00

Service Code	HCPCS 81596
Hospital Charge Code	3551596
Hospital Revenue Code	300
Min. Negotiated Rate	$465.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$465.30
Rate for Payer: UnitedHealthcare Commercial	$491.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Liver Fibrosis, FibroTst-ActiTst Pnl QST

Facility

$517.00

Service Code	HCPCS 81596
Hospital Charge Code	3551596
Hospital Revenue Code	300
Min. Negotiated Rate	$206.80
Max. Negotiated Rate	$491.15
Rate for Payer: Aetna Commercial	$465.30
Rate for Payer: Humana Medicare Advantage	$217.14
Rate for Payer: UnitedHealthcare Commercial	$491.15
Rate for Payer: UnitedHealthcare Medicaid	$206.80
Rate for Payer: WPPA Medicare Advantage	$310.20

Liver Kidney Microsome Ab (IgG) QST

Facility

$114.00

Service Code	HCPCS 80076
Hospital Charge Code	3550536
Hospital Revenue Code	300
Min. Negotiated Rate	$8.17
Max. Negotiated Rate	$108.30
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.88
Rate for Payer: Humana Medicare Advantage	$47.88
Rate for Payer: UnitedHealthcare Commercial	$108.30
Rate for Payer: UnitedHealthcare Medicaid	$8.17
Rate for Payer: WPPA Medicare Advantage	$68.40

Liver Kidney Microsome Ab (IgG) QST

Facility

$114.00

Service Code	HCPCS 80076
Hospital Charge Code	3550536
Hospital Revenue Code	300
Min. Negotiated Rate	$102.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: UnitedHealthcare Commercial	$108.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT

Facility

$27,258.66

Service Code	MSDRG 005
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$27,258.66
Rate for Payer: UnitedHealthcare Medicaid	$27,258.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LIVER TRANSPLANT WITHOUT MCC

Facility

$12,263.22

Service Code	MSDRG 006
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,263.22
Rate for Payer: UnitedHealthcare Medicaid	$12,263.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

l-methylfolate 15 mg Tab [HMC]

Facility

$13.66

Service Code	NDC 51991080990
Hospital Charge Code	3800570
Hospital Revenue Code	250
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$12.98
Rate for Payer: Aetna Commercial	$12.29
Rate for Payer: Humana Medicare Advantage	$5.74
Rate for Payer: UnitedHealthcare Commercial	$12.98
Rate for Payer: UnitedHealthcare Medicaid	$5.46
Rate for Payer: WPPA Medicare Advantage	$8.20

l-methylfolate 15 mg Tab [HMC]

Facility

$13.66

Service Code	NDC 51991080990
Hospital Charge Code	3800570
Hospital Revenue Code	250
Min. Negotiated Rate	$12.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.29
Rate for Payer: UnitedHealthcare Commercial	$12.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC

Facility

$6,830.55

Service Code	MSDRG 496
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,830.55
Rate for Payer: UnitedHealthcare Medicaid	$6,830.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC

Facility

$13,724.64

Service Code	MSDRG 495
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$13,724.64
Rate for Payer: UnitedHealthcare Medicaid	$13,724.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC

Facility

$4,574.88

Service Code	MSDRG 497
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,574.88
Rate for Payer: UnitedHealthcare Medicaid	$4,574.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC

Facility

$11,437.20

Service Code	MSDRG 498
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,437.20
Rate for Payer: UnitedHealthcare Medicaid	$11,437.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC

Facility

$7,624.80

Service Code	MSDRG 499
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,624.80
Rate for Payer: UnitedHealthcare Medicaid	$7,624.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

loperamide 2 mg Cap [HMC]

Facility

$7.98

Service Code	NDC 50268048215
Hospital Charge Code	3808108
Hospital Revenue Code	250
Min. Negotiated Rate	$3.19
Max. Negotiated Rate	$7.58
Rate for Payer: Aetna Commercial	$7.18
Rate for Payer: Humana Medicare Advantage	$3.35
Rate for Payer: UnitedHealthcare Commercial	$7.58
Rate for Payer: UnitedHealthcare Medicaid	$3.19
Rate for Payer: WPPA Medicare Advantage	$4.79

loperamide 2 mg Cap [HMC]

Facility

$8.06

Service Code	NDC 60687022901
Hospital Charge Code	3808108
Hospital Revenue Code	250
Min. Negotiated Rate	$3.22
Max. Negotiated Rate	$7.66
Rate for Payer: Aetna Commercial	$7.25
Rate for Payer: Humana Medicare Advantage	$3.39
Rate for Payer: UnitedHealthcare Commercial	$7.66
Rate for Payer: UnitedHealthcare Medicaid	$3.22
Rate for Payer: WPPA Medicare Advantage	$4.84

loperamide 2 mg Cap [HMC]

Facility

$7.98

Service Code	NDC 50268048215
Hospital Charge Code	3808108
Hospital Revenue Code	250
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.18
Rate for Payer: UnitedHealthcare Commercial	$7.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

loperamide 2 mg Cap [HMC]

Facility

$7.62

Service Code	NDC 51079069020
Hospital Charge Code	3808108
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

loperamide 2 mg Cap [HMC]

Facility

$7.62

Service Code	NDC 51079069020
Hospital Charge Code	3808108
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

loperamide 2 mg Cap [HMC]

Facility

$8.06

Service Code	NDC 60687022901
Hospital Charge Code	3808108
Hospital Revenue Code	250
Min. Negotiated Rate	$7.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.25
Rate for Payer: UnitedHealthcare Commercial	$7.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

loratadine 10 mg Tab [HMC]

Facility

$5.90

Service Code	NDC 45802065065
Hospital Charge Code	3809701
Hospital Revenue Code	250
Min. Negotiated Rate	$5.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.31
Rate for Payer: UnitedHealthcare Commercial	$5.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges