Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

magnesium sulfate 50% Inj Sol 10 mL [HMC]

Facility

$34.82

Service Code	HCPCS J3475
Hospital Charge Code	3808410
Hospital Revenue Code	250
Min. Negotiated Rate	$31.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.34
Rate for Payer: Aetna Commercial	$27.34
Rate for Payer: UnitedHealthcare Commercial	$28.86
Rate for Payer: UnitedHealthcare Commercial	$33.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

magnesium sulfate 50% Inj Sol 10 mL [HMC]

Facility

$30.38

Service Code	HCPCS J3475
Hospital Charge Code	3808410
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$28.86
Rate for Payer: Aetna Commercial	$27.34
Rate for Payer: Aetna Commercial	$31.34
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.83
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.83
Rate for Payer: Humana Medicare Advantage	$14.62
Rate for Payer: Humana Medicare Advantage	$12.76
Rate for Payer: UnitedHealthcare Commercial	$33.08
Rate for Payer: UnitedHealthcare Commercial	$28.86
Rate for Payer: UnitedHealthcare Medicaid	$0.41
Rate for Payer: UnitedHealthcare Medicaid	$0.41
Rate for Payer: WPPA Medicare Advantage	$18.23
Rate for Payer: WPPA Medicare Advantage	$20.89

magnesium sulfate 50% Inj Sol 2 mL [HMC]

Facility

$27.20

Service Code	HCPCS J3475
Hospital Charge Code	3802417
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$25.84
Rate for Payer: Aetna Commercial	$24.48
Rate for Payer: Aetna Commercial	$30.26
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.83
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.83
Rate for Payer: Humana Medicare Advantage	$14.12
Rate for Payer: Humana Medicare Advantage	$11.42
Rate for Payer: UnitedHealthcare Commercial	$31.94
Rate for Payer: UnitedHealthcare Commercial	$25.84
Rate for Payer: UnitedHealthcare Medicaid	$0.41
Rate for Payer: UnitedHealthcare Medicaid	$0.41
Rate for Payer: WPPA Medicare Advantage	$20.17
Rate for Payer: WPPA Medicare Advantage	$16.32

magnesium sulfate 50% Inj Sol 2 mL [HMC]

Facility

$27.20

Service Code	HCPCS J3475
Hospital Charge Code	3802417
Hospital Revenue Code	250
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.48
Rate for Payer: Aetna Commercial	$30.26
Rate for Payer: UnitedHealthcare Commercial	$31.94
Rate for Payer: UnitedHealthcare Commercial	$25.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

magnesium sulfate 50% Sol 20 mL [HMC]

Facility

$37.36

Service Code	HCPCS J3475
Hospital Charge Code	3808410
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$35.49
Rate for Payer: Aetna Commercial	$33.62
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.83
Rate for Payer: Humana Medicare Advantage	$15.69
Rate for Payer: UnitedHealthcare Commercial	$35.49
Rate for Payer: UnitedHealthcare Medicaid	$0.41
Rate for Payer: WPPA Medicare Advantage	$22.42

magnesium sulfate 50% Sol 20 mL [HMC]

Facility

$37.36

Service Code	HCPCS J3475
Hospital Charge Code	3808410
Hospital Revenue Code	250
Min. Negotiated Rate	$33.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.62
Rate for Payer: UnitedHealthcare Commercial	$35.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Magnetic Instrument Pad, Sterile 10 x 16in Blue

Facility

$12.11

Hospital Charge Code	3250234
Hospital Revenue Code	270
Min. Negotiated Rate	$4.84
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna Commercial	$10.90
Rate for Payer: Humana Medicare Advantage	$5.09
Rate for Payer: UnitedHealthcare Commercial	$11.50
Rate for Payer: UnitedHealthcare Medicaid	$4.84
Rate for Payer: WPPA Medicare Advantage	$7.27

Magnetic Instrument Pad, Sterile 10 x 16in Blue

Facility

$12.11

Hospital Charge Code	3250234
Hospital Revenue Code	270
Min. Negotiated Rate	$10.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.90
Rate for Payer: UnitedHealthcare Commercial	$11.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR BLADDER PROCEDURES WITH CC

Facility

$9,435.69

Service Code	MSDRG 654
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,435.69
Rate for Payer: UnitedHealthcare Medicaid	$9,435.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR BLADDER PROCEDURES WITH MCC

Facility

$17,505.27

Service Code	MSDRG 653
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$17,505.27
Rate for Payer: UnitedHealthcare Medicaid	$17,505.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$7,148.25

Service Code	MSDRG 655
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,148.25
Rate for Payer: UnitedHealthcare Medicaid	$7,148.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR CHEST PROCEDURES WITH CC

Facility

$8,832.06

Service Code	MSDRG 164
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,832.06
Rate for Payer: UnitedHealthcare Medicaid	$8,832.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR CHEST PROCEDURES WITH MCC

Facility

$15,694.38

Service Code	MSDRG 163
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$15,694.38
Rate for Payer: UnitedHealthcare Medicaid	$15,694.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR CHEST PROCEDURES WITHOUT CC/MCC

Facility

$6,703.47

Service Code	MSDRG 165
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,703.47
Rate for Payer: UnitedHealthcare Medicaid	$6,703.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR CHEST TRAUMA WITH CC

Facility

$4,098.33

Service Code	MSDRG 184
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,098.33
Rate for Payer: UnitedHealthcare Medicaid	$4,098.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR CHEST TRAUMA WITH MCC

Facility

$5,909.22

Service Code	MSDRG 183
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,909.22
Rate for Payer: UnitedHealthcare Medicaid	$5,909.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR CHEST TRAUMA WITHOUT CC/MCC

Facility

$3,049.92

Service Code	MSDRG 185
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,049.92
Rate for Payer: UnitedHealthcare Medicaid	$3,049.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR ESOPHAGEAL DISORDERS WITH CC

Facility

$4,606.65

Service Code	MSDRG 369
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,606.65
Rate for Payer: UnitedHealthcare Medicaid	$4,606.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR ESOPHAGEAL DISORDERS WITH MCC

Facility

$7,338.87

Service Code	MSDRG 368
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,338.87
Rate for Payer: UnitedHealthcare Medicaid	$7,338.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC

Facility

$3,240.54

Service Code	MSDRG 370
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,240.54
Rate for Payer: UnitedHealthcare Medicaid	$3,240.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC

Facility

$4,098.33

Service Code	MSDRG 372
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,098.33
Rate for Payer: UnitedHealthcare Medicaid	$4,098.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC

Facility

$8,196.66

Service Code	MSDRG 371
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,196.66
Rate for Payer: UnitedHealthcare Medicaid	$8,196.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC

Facility

$3,049.92

Service Code	MSDRG 373
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,049.92
Rate for Payer: UnitedHealthcare Medicaid	$3,049.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR HEAD AND NECK PROCEDURES WITH CC

Facility

$4,098.33

Service Code	MSDRG 141
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,098.33
Rate for Payer: UnitedHealthcare Medicaid	$4,098.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAJOR HEAD AND NECK PROCEDURES WITH MCC

Facility

$8,006.04

Service Code	MSDRG 140
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,006.04
Rate for Payer: UnitedHealthcare Medicaid	$8,006.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges