Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Mesh SurgiMesh Easy Plug

Facility

$919.00

Service Code	HCPCS C1781
Hospital Charge Code	3254565
Hospital Revenue Code	278
Min. Negotiated Rate	$367.60
Max. Negotiated Rate	$873.05
Rate for Payer: Aetna Commercial	$827.10
Rate for Payer: Humana Medicare Advantage	$385.98
Rate for Payer: UnitedHealthcare Commercial	$873.05
Rate for Payer: UnitedHealthcare Medicaid	$367.60
Rate for Payer: WPPA Medicare Advantage	$551.40

Mesh Surgimesh WN - Universal Size

Facility

$1,063.00

Hospital Charge Code	3253870
Hospital Revenue Code	270
Min. Negotiated Rate	$956.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mesh Surgimesh WN - Universal Size

Facility

$1,063.00

Hospital Charge Code	3253870
Hospital Revenue Code	270
Min. Negotiated Rate	$425.20
Max. Negotiated Rate	$1,009.85
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: Humana Medicare Advantage	$446.46
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: UnitedHealthcare Medicaid	$425.20
Rate for Payer: WPPA Medicare Advantage	$637.80

MetaNeb Circuit w/Nebulizer Disposable

Facility

$283.00

Hospital Charge Code	3255050
Hospital Revenue Code	270
Min. Negotiated Rate	$113.20
Max. Negotiated Rate	$268.85
Rate for Payer: Aetna Commercial	$254.70
Rate for Payer: Humana Medicare Advantage	$118.86
Rate for Payer: UnitedHealthcare Commercial	$268.85
Rate for Payer: UnitedHealthcare Medicaid	$113.20
Rate for Payer: WPPA Medicare Advantage	$169.80

MetaNeb Circuit w/Nebulizer Disposable

Facility

$283.00

Hospital Charge Code	3255050
Hospital Revenue Code	270
Min. Negotiated Rate	$254.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$254.70
Rate for Payer: UnitedHealthcare Commercial	$268.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Metanephrines, Fract, Free, LC/MS/MS QST

Facility

$354.00

Service Code	HCPCS 83835
Hospital Charge Code	3553835
Hospital Revenue Code	300
Min. Negotiated Rate	$16.94
Max. Negotiated Rate	$336.30
Rate for Payer: Aetna Commercial	$318.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$65.77
Rate for Payer: Humana Medicare Advantage	$148.68
Rate for Payer: UnitedHealthcare Commercial	$336.30
Rate for Payer: UnitedHealthcare Medicaid	$16.94
Rate for Payer: WPPA Medicare Advantage	$212.40

Metanephrines, Fract, Free, LC/MS/MS QST

Facility

$354.00

Service Code	HCPCS 83835
Hospital Charge Code	3553835
Hospital Revenue Code	300
Min. Negotiated Rate	$318.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$318.60
Rate for Payer: UnitedHealthcare Commercial	$336.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Metanephrines, Fract. LC/MS/MS, U24 QST

Facility

$295.00

Service Code	HCPCS 83835
Hospital Charge Code	3551948
Hospital Revenue Code	300
Min. Negotiated Rate	$16.94
Max. Negotiated Rate	$280.25
Rate for Payer: Aetna Commercial	$265.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$65.77
Rate for Payer: Humana Medicare Advantage	$123.90
Rate for Payer: UnitedHealthcare Commercial	$280.25
Rate for Payer: UnitedHealthcare Medicaid	$16.94
Rate for Payer: WPPA Medicare Advantage	$177.00

Metanephrines, Fract. LC/MS/MS, U24 QST

Facility

$295.00

Service Code	HCPCS 83835
Hospital Charge Code	3551948
Hospital Revenue Code	300
Min. Negotiated Rate	$265.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$265.50
Rate for Payer: UnitedHealthcare Commercial	$280.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metFORMIN 500 mg ER Tab [HMC]

Facility

$7.24

Service Code	NDC 62756014201
Hospital Charge Code	3802306
Hospital Revenue Code	250
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$6.88
Rate for Payer: Aetna Commercial	$6.52
Rate for Payer: Humana Medicare Advantage	$3.04
Rate for Payer: UnitedHealthcare Commercial	$6.88
Rate for Payer: UnitedHealthcare Medicaid	$2.90
Rate for Payer: WPPA Medicare Advantage	$4.34

metFORMIN 500 mg ER Tab [HMC]

Facility

$6.87

Service Code	NDC 50268055015
Hospital Charge Code	3802306
Hospital Revenue Code	250
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.18
Rate for Payer: UnitedHealthcare Commercial	$6.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metFORMIN 500 mg ER Tab [HMC]

Facility

$7.32

Service Code	NDC 67877041301
Hospital Charge Code	3802306
Hospital Revenue Code	250
Min. Negotiated Rate	$2.93
Max. Negotiated Rate	$6.95
Rate for Payer: Aetna Commercial	$6.59
Rate for Payer: Humana Medicare Advantage	$3.07
Rate for Payer: UnitedHealthcare Commercial	$6.95
Rate for Payer: UnitedHealthcare Medicaid	$2.93
Rate for Payer: WPPA Medicare Advantage	$4.39

metFORMIN 500 mg ER Tab [HMC]

Facility

$7.24

Service Code	NDC 62756014201
Hospital Charge Code	3802306
Hospital Revenue Code	250
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.52
Rate for Payer: UnitedHealthcare Commercial	$6.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metFORMIN 500 mg ER Tab [HMC]

Facility

$7.56

Service Code	NDC 70010049109
Hospital Charge Code	3802306
Hospital Revenue Code	250
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$7.18
Rate for Payer: Aetna Commercial	$6.80
Rate for Payer: Humana Medicare Advantage	$3.18
Rate for Payer: UnitedHealthcare Commercial	$7.18
Rate for Payer: UnitedHealthcare Medicaid	$3.02
Rate for Payer: WPPA Medicare Advantage	$4.54

metFORMIN 500 mg ER Tab [HMC]

Facility

$7.32

Service Code	NDC 67877041301
Hospital Charge Code	3802306
Hospital Revenue Code	250
Min. Negotiated Rate	$6.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.59
Rate for Payer: UnitedHealthcare Commercial	$6.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metFORMIN 500 mg ER Tab [HMC]

Facility

$6.87

Service Code	NDC 50268055015
Hospital Charge Code	3802306
Hospital Revenue Code	250
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$6.53
Rate for Payer: Aetna Commercial	$6.18
Rate for Payer: Humana Medicare Advantage	$2.89
Rate for Payer: UnitedHealthcare Commercial	$6.53
Rate for Payer: UnitedHealthcare Medicaid	$2.75
Rate for Payer: WPPA Medicare Advantage	$4.12

metFORMIN 500 mg ER Tab [HMC]

Facility

$7.56

Service Code	NDC 70010049109
Hospital Charge Code	3802306
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.80
Rate for Payer: UnitedHealthcare Commercial	$7.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metFORMIN 500 mg Tab [HMC]

Facility

$5.23

Service Code	NDC 00904668961
Hospital Charge Code	3809545
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

metFORMIN 500 mg Tab [HMC]

Facility

$5.23

Service Code	NDC 00904716261
Hospital Charge Code	3809545
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

metFORMIN 500 mg Tab [HMC]

Facility

$7.10

Service Code	NDC 60687015501
Hospital Charge Code	3809545
Hospital Revenue Code	250
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$6.75
Rate for Payer: Aetna Commercial	$6.39
Rate for Payer: Humana Medicare Advantage	$2.98
Rate for Payer: UnitedHealthcare Commercial	$6.75
Rate for Payer: UnitedHealthcare Medicaid	$2.84
Rate for Payer: WPPA Medicare Advantage	$4.26

metFORMIN 500 mg Tab [HMC]

Facility

$7.10

Service Code	NDC 60687015501
Hospital Charge Code	3809545
Hospital Revenue Code	250
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.39
Rate for Payer: UnitedHealthcare Commercial	$6.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metFORMIN 500 mg Tab [HMC]

Facility

$5.23

Service Code	NDC 00904716261
Hospital Charge Code	3809545
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

metFORMIN 500 mg Tab [HMC]

Facility

$5.23

Service Code	NDC 00904668961
Hospital Charge Code	3809545
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

metFORMIN 750 mg ER Tab [HMC]

Facility

$8.59

Service Code	NDC 67877041401
Hospital Charge Code	3800673
Hospital Revenue Code	250
Min. Negotiated Rate	$7.73
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.73
Rate for Payer: UnitedHealthcare Commercial	$8.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metFORMIN 750 mg ER Tab [HMC]

Facility

$8.59

Service Code	NDC 76385012901
Hospital Charge Code	3800673
Hospital Revenue Code	250
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$8.16
Rate for Payer: Aetna Commercial	$7.73
Rate for Payer: Humana Medicare Advantage	$3.61
Rate for Payer: UnitedHealthcare Commercial	$8.16
Rate for Payer: UnitedHealthcare Medicaid	$3.44
Rate for Payer: WPPA Medicare Advantage	$5.15

Know your out-of-pocket cost for care.

All Charges