Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

MG MAMMOGRAM 2D SCREENING BILATERAL Add-On

Facility

$303.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG MAMMOGRAM 2D SCREENING BILATERAL Add-On

Facility

$303.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$161.00
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$72.25
Rate for Payer: WPPA Medicare Advantage	$181.80

MG Mammo Screening Bilateral w/ Tomo

Facility

$102.00

Service Code	HCPCS 77063 TC
Hospital Charge Code	3717063
Hospital Revenue Code	403
Min. Negotiated Rate	$15.67
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$80.10
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$15.67
Rate for Payer: WPPA Medicare Advantage	$61.20

MG Mammo Screening Bilateral w/ Tomo

Facility

$102.00

Service Code	HCPCS 77063 TC
Hospital Charge Code	3717063
Hospital Revenue Code	403
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Screening Left w/ Tomo

Facility

$102.00

Service Code	HCPCS 77063 LT
Hospital Charge Code	3717063
Hospital Revenue Code	403
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Screening Left w/ Tomo

Facility

$102.00

Service Code	HCPCS 77063 LT
Hospital Charge Code	3717063
Hospital Revenue Code	403
Min. Negotiated Rate	$15.67
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$80.10
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$15.67
Rate for Payer: WPPA Medicare Advantage	$61.20

MG Mammo Screening Right w/ Tomo

Facility

$102.00

Service Code	HCPCS 77063 RT
Hospital Charge Code	3717063
Hospital Revenue Code	403
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Screening Right w/ Tomo

Facility

$102.00

Service Code	HCPCS 77063 RT
Hospital Charge Code	3717063
Hospital Revenue Code	403
Min. Negotiated Rate	$15.67
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$80.10
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$15.67
Rate for Payer: WPPA Medicare Advantage	$61.20

micafungin 1 mg/mL-NaCl 0.9% Sol [HMC]

Facility

$200.08

Service Code	HCPCS J2248
Hospital Charge Code	3808420
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$190.08
Rate for Payer: Aetna Commercial	$180.07
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.40
Rate for Payer: Humana Medicare Advantage	$84.03
Rate for Payer: UnitedHealthcare Commercial	$190.08
Rate for Payer: UnitedHealthcare Medicaid	$0.25
Rate for Payer: WPPA Medicare Advantage	$120.05

micafungin 1 mg/mL-NaCl 0.9% Sol [HMC]

Facility

$200.08

Service Code	HCPCS J2248
Hospital Charge Code	3808420
Hospital Revenue Code	250
Min. Negotiated Rate	$180.07
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$180.07
Rate for Payer: UnitedHealthcare Commercial	$190.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

miconazole 2% Vag Crm w/Appl [HMC]

Facility

$36.50

Service Code	NDC 00904773457
Hospital Charge Code	3800151
Hospital Revenue Code	250
Min. Negotiated Rate	$14.60
Max. Negotiated Rate	$34.67
Rate for Payer: Aetna Commercial	$32.85
Rate for Payer: Humana Medicare Advantage	$15.33
Rate for Payer: UnitedHealthcare Commercial	$34.67
Rate for Payer: UnitedHealthcare Medicaid	$14.60
Rate for Payer: WPPA Medicare Advantage	$21.90

miconazole 2% Vag Crm w/Appl [HMC]

Facility

$36.50

Service Code	NDC 00904773457
Hospital Charge Code	3800151
Hospital Revenue Code	250
Min. Negotiated Rate	$32.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$32.85
Rate for Payer: UnitedHealthcare Commercial	$34.67
Rate for Payer: WPPA Medicare Advantage	$1,200.00

midazolam 1 mg/mL Inj Sol [HMC]

Facility

$23.90

Service Code	NDC 00641605725
Hospital Charge Code	3170358
Hospital Revenue Code	250
Min. Negotiated Rate	$9.56
Max. Negotiated Rate	$22.70
Rate for Payer: Aetna Commercial	$21.51
Rate for Payer: Humana Medicare Advantage	$10.04
Rate for Payer: UnitedHealthcare Commercial	$22.70
Rate for Payer: UnitedHealthcare Medicaid	$9.56
Rate for Payer: WPPA Medicare Advantage	$14.34

midazolam 1 mg/mL Inj Sol [HMC]

Facility

$23.90

Service Code	NDC 00641605725
Hospital Charge Code	3170358
Hospital Revenue Code	250
Min. Negotiated Rate	$21.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.51
Rate for Payer: UnitedHealthcare Commercial	$22.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

midazolam 1 mg/mL Inj Sol [HMC]

Facility

$23.84

Service Code	HCPCS J2250
Hospital Charge Code	3170358
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$22.65
Rate for Payer: Aetna Commercial	$21.46
Rate for Payer: Aetna Commercial	$21.51
Rate for Payer: Aetna Commercial	$22.74
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.18
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.18
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.18
Rate for Payer: Humana Medicare Advantage	$10.04
Rate for Payer: Humana Medicare Advantage	$10.01
Rate for Payer: Humana Medicare Advantage	$10.61
Rate for Payer: UnitedHealthcare Commercial	$24.01
Rate for Payer: UnitedHealthcare Commercial	$22.65
Rate for Payer: UnitedHealthcare Commercial	$22.70
Rate for Payer: UnitedHealthcare Medicaid	$10.11
Rate for Payer: UnitedHealthcare Medicaid	$9.56
Rate for Payer: UnitedHealthcare Medicaid	$9.54
Rate for Payer: WPPA Medicare Advantage	$14.30
Rate for Payer: WPPA Medicare Advantage	$14.34
Rate for Payer: WPPA Medicare Advantage	$15.16

midazolam 1 mg/mL Inj Sol [HMC]

Facility

$23.90

Service Code	HCPCS J2250
Hospital Charge Code	3170358
Hospital Revenue Code	250
Min. Negotiated Rate	$21.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.51
Rate for Payer: Aetna Commercial	$21.46
Rate for Payer: Aetna Commercial	$22.74
Rate for Payer: UnitedHealthcare Commercial	$24.01
Rate for Payer: UnitedHealthcare Commercial	$22.70
Rate for Payer: UnitedHealthcare Commercial	$22.65
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

midazolam 1 mg/mL preservative-free 5 mL Sol [HMC]

Facility

$27.58

Service Code	HCPCS J2250
Hospital Charge Code	3170390
Hospital Revenue Code	250
Min. Negotiated Rate	$24.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.82
Rate for Payer: UnitedHealthcare Commercial	$26.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

midazolam 1 mg/mL preservative-free 5 mL Sol [HMC]

Facility

$27.58

Service Code	HCPCS J2250
Hospital Charge Code	3170390
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$26.20
Rate for Payer: Aetna Commercial	$24.82
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.18
Rate for Payer: Humana Medicare Advantage	$11.58
Rate for Payer: UnitedHealthcare Commercial	$26.20
Rate for Payer: UnitedHealthcare Medicaid	$11.03
Rate for Payer: WPPA Medicare Advantage	$16.55

midazolam 5 mg/inh Spr [HMC]

Facility

$780.79

Service Code	NDC 50474050015
Hospital Charge Code	3800068
Hospital Revenue Code	250
Min. Negotiated Rate	$312.32
Max. Negotiated Rate	$741.75
Rate for Payer: Aetna Commercial	$702.71
Rate for Payer: Humana Medicare Advantage	$327.93
Rate for Payer: UnitedHealthcare Commercial	$741.75
Rate for Payer: UnitedHealthcare Medicaid	$312.32
Rate for Payer: WPPA Medicare Advantage	$468.47

midazolam 5 mg/inh Spr [HMC]

Facility

$780.79

Service Code	NDC 50474050015
Hospital Charge Code	3800068
Hospital Revenue Code	250
Min. Negotiated Rate	$702.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$702.71
Rate for Payer: UnitedHealthcare Commercial	$741.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

midazolam 5 mg/mL Inj Sol [HMC]

Facility

$27.20

Service Code	HCPCS J2250
Hospital Charge Code	3800067
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: UnitedHealthcare Commercial	$25.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

midazolam 5 mg/mL Inj Sol [HMC]

Facility

$27.20

Service Code	NDC 00641606125
Hospital Charge Code	3800067
Hospital Revenue Code	250
Min. Negotiated Rate	$10.88
Max. Negotiated Rate	$25.84
Rate for Payer: Aetna Commercial	$24.48
Rate for Payer: Humana Medicare Advantage	$11.42
Rate for Payer: UnitedHealthcare Commercial	$25.84
Rate for Payer: UnitedHealthcare Medicaid	$10.88
Rate for Payer: WPPA Medicare Advantage	$16.32

midazolam 5 mg/mL Inj Sol [HMC]

Facility

$27.20

Service Code	HCPCS J2250
Hospital Charge Code	3800067
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$25.84
Rate for Payer: Aetna Commercial	$24.48
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.18
Rate for Payer: Humana Medicare Advantage	$11.42
Rate for Payer: UnitedHealthcare Commercial	$25.84
Rate for Payer: UnitedHealthcare Medicaid	$10.88
Rate for Payer: WPPA Medicare Advantage	$16.32

midazolam 5 mg/mL Inj Sol [HMC]

Facility

$27.20

Service Code	NDC 00641606125
Hospital Charge Code	3800067
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: UnitedHealthcare Commercial	$25.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Midline 5fr Bioflo Max Barrier

Facility

$600.00

Service Code	HCPCS C1751
Hospital Charge Code	3256658
Hospital Revenue Code	270
Min. Negotiated Rate	$240.00
Max. Negotiated Rate	$570.00
Rate for Payer: Aetna Commercial	$540.00
Rate for Payer: Humana Medicare Advantage	$252.00
Rate for Payer: UnitedHealthcare Commercial	$570.00
Rate for Payer: UnitedHealthcare Medicaid	$240.00
Rate for Payer: WPPA Medicare Advantage	$360.00

Know your out-of-pocket cost for care.

All Charges