Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

MEALS ON WHEELS-LUNCH.

Facility

$3.00

Hospital Charge Code	5543208
Hospital Revenue Code	991
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MEALS ON WHEELS-LUNCH.

Facility

$3.00

Hospital Charge Code	5543208
Hospital Revenue Code	991
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Humana Medicare Advantage	$1.26
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: WPPA Medicare Advantage	$1.80

MEALS ON WHEELS-SUPPER

Facility

$4.00

Hospital Charge Code	5543306
Hospital Revenue Code	991
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MEALS ON WHEELS-SUPPER

Facility

$4.00

Hospital Charge Code	5543306
Hospital Revenue Code	991
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.80
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Humana Medicare Advantage	$1.68
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: UnitedHealthcare Medicaid	$1.60
Rate for Payer: WPPA Medicare Advantage	$2.40

Measles Ab (IgG) QST

Facility

$54.00

Service Code	HCPCS 86762
Hospital Charge Code	3551633
Hospital Revenue Code	300
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Measles Ab (IgG) QST

Facility

$54.00

Service Code	HCPCS 86762
Hospital Charge Code	3551633
Hospital Revenue Code	300
Min. Negotiated Rate	$12.23
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$30.90
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$12.23
Rate for Payer: WPPA Medicare Advantage	$32.40

measles/mumps/rubella virus vaccine SubQ Inj [HMC]

Facility

$191.36

Service Code	NDC 00006468100
Hospital Charge Code	3800115
Hospital Revenue Code	250
Min. Negotiated Rate	$76.54
Max. Negotiated Rate	$181.79
Rate for Payer: Aetna Commercial	$172.22
Rate for Payer: Humana Medicare Advantage	$80.37
Rate for Payer: UnitedHealthcare Commercial	$181.79
Rate for Payer: UnitedHealthcare Medicaid	$76.54
Rate for Payer: WPPA Medicare Advantage	$114.82

measles/mumps/rubella virus vaccine SubQ Inj [HMC]

Facility

$191.36

Service Code	NDC 00006468100
Hospital Charge Code	3800115
Hospital Revenue Code	250
Min. Negotiated Rate	$172.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$172.22
Rate for Payer: UnitedHealthcare Commercial	$181.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

meclizine 25 mg Tab [HMC]

Facility

$7.61

Service Code	NDC 00904651761
Hospital Charge Code	3806169
Hospital Revenue Code	250
Min. Negotiated Rate	$6.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.85
Rate for Payer: UnitedHealthcare Commercial	$7.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00

meclizine 25 mg Tab [HMC]

Facility

$7.57

Service Code	NDC 68084049101
Hospital Charge Code	3806169
Hospital Revenue Code	250
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$7.19
Rate for Payer: Aetna Commercial	$6.81
Rate for Payer: Humana Medicare Advantage	$3.18
Rate for Payer: UnitedHealthcare Commercial	$7.19
Rate for Payer: UnitedHealthcare Medicaid	$3.03
Rate for Payer: WPPA Medicare Advantage	$4.54

meclizine 25 mg Tab [HMC]

Facility

$7.61

Service Code	NDC 00904651761
Hospital Charge Code	3806169
Hospital Revenue Code	250
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$7.23
Rate for Payer: Aetna Commercial	$6.85
Rate for Payer: Humana Medicare Advantage	$3.20
Rate for Payer: UnitedHealthcare Commercial	$7.23
Rate for Payer: UnitedHealthcare Medicaid	$3.04
Rate for Payer: WPPA Medicare Advantage	$4.57

meclizine 25 mg Tab [HMC]

Facility

$7.57

Service Code	NDC 51079009020
Hospital Charge Code	3806169
Hospital Revenue Code	250
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$7.19
Rate for Payer: Aetna Commercial	$6.81
Rate for Payer: Humana Medicare Advantage	$3.18
Rate for Payer: UnitedHealthcare Commercial	$7.19
Rate for Payer: UnitedHealthcare Medicaid	$3.03
Rate for Payer: WPPA Medicare Advantage	$4.54

meclizine 25 mg Tab [HMC]

Facility

$7.52

Service Code	NDC 60687073065
Hospital Charge Code	3806169
Hospital Revenue Code	250
Min. Negotiated Rate	$6.77
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.77
Rate for Payer: UnitedHealthcare Commercial	$7.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

meclizine 25 mg Tab [HMC]

Facility

$7.52

Service Code	NDC 60687073065
Hospital Charge Code	3806169
Hospital Revenue Code	250
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$7.14
Rate for Payer: Aetna Commercial	$6.77
Rate for Payer: Humana Medicare Advantage	$3.16
Rate for Payer: UnitedHealthcare Commercial	$7.14
Rate for Payer: UnitedHealthcare Medicaid	$3.01
Rate for Payer: WPPA Medicare Advantage	$4.51

meclizine 25 mg Tab [HMC]

Facility

$7.57

Service Code	NDC 51079009020
Hospital Charge Code	3806169
Hospital Revenue Code	250
Min. Negotiated Rate	$6.81
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.81
Rate for Payer: UnitedHealthcare Commercial	$7.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

meclizine 25 mg Tab [HMC]

Facility

$7.57

Service Code	NDC 68084049101
Hospital Charge Code	3806169
Hospital Revenue Code	250
Min. Negotiated Rate	$6.81
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.81
Rate for Payer: UnitedHealthcare Commercial	$7.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MECONIUM ASPIRATOR

Facility

$441.00

Hospital Charge Code	3256174
Hospital Revenue Code	270
Min. Negotiated Rate	$396.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$396.90
Rate for Payer: UnitedHealthcare Commercial	$418.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MECONIUM ASPIRATOR

Facility

$441.00

Hospital Charge Code	3256174
Hospital Revenue Code	270
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$418.95
Rate for Payer: Aetna Commercial	$396.90
Rate for Payer: Humana Medicare Advantage	$185.22
Rate for Payer: UnitedHealthcare Commercial	$418.95
Rate for Payer: UnitedHealthcare Medicaid	$176.40
Rate for Payer: WPPA Medicare Advantage	$264.60

MEDICAL BACK PROBLEMS WITH MCC

Facility

$10,261.71

Service Code	MSDRG 551
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,261.71
Rate for Payer: UnitedHealthcare Medicaid	$10,261.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MEDICAL BACK PROBLEMS WITHOUT MCC

Facility

$4,860.81

Service Code	MSDRG 552
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,860.81
Rate for Payer: UnitedHealthcare Medicaid	$4,860.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Medication Charge

Facility

$138.00

Service Code	HCPCS 90707
Hospital Charge Code	3800115
Hospital Revenue Code	636
Min. Negotiated Rate	$57.96
Max. Negotiated Rate	$131.54
Rate for Payer: Aetna Commercial	$124.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$131.54
Rate for Payer: Humana Medicare Advantage	$57.96
Rate for Payer: UnitedHealthcare Commercial	$131.10
Rate for Payer: UnitedHealthcare Medicaid	$70.92
Rate for Payer: WPPA Medicare Advantage	$82.80

Medication Charge

Facility

$138.00

Service Code	HCPCS 90707
Hospital Charge Code	3800115
Hospital Revenue Code	636
Min. Negotiated Rate	$124.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$124.20
Rate for Payer: UnitedHealthcare Commercial	$131.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Med Pump Refill Program

Facility

$231.00

Service Code	HCPCS 62368
Hospital Charge Code	3192368
Hospital Revenue Code	360
Min. Negotiated Rate	$97.02
Max. Negotiated Rate	$219.45
Rate for Payer: Aetna Commercial	$207.90
Rate for Payer: Humana Medicare Advantage	$97.02
Rate for Payer: UnitedHealthcare Commercial	$219.45
Rate for Payer: UnitedHealthcare Medicaid	$140.13
Rate for Payer: WPPA Medicare Advantage	$138.60

Med Pump Refill Program

Facility

$231.00

Service Code	HCPCS 62368
Hospital Charge Code	3192368
Hospital Revenue Code	360
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$207.90
Rate for Payer: UnitedHealthcare Commercial	$219.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

medroxyPROGESTERone 150 mg/mL IM Susp [HMC]

Facility

$118.91

Service Code	HCPCS J1050
Hospital Charge Code	3800609
Hospital Revenue Code	250
Min. Negotiated Rate	$107.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$107.02
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: Aetna Commercial	$131.40
Rate for Payer: UnitedHealthcare Commercial	$138.70
Rate for Payer: UnitedHealthcare Commercial	$112.96
Rate for Payer: UnitedHealthcare Commercial	$113.05
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

Know your out-of-pocket cost for care.

All Charges