Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Midline 5fr Bioflo Max Barrier

Facility

$600.00

Service Code	HCPCS C1751
Hospital Charge Code	3256658
Hospital Revenue Code	270
Min. Negotiated Rate	$540.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$540.00
Rate for Payer: UnitedHealthcare Commercial	$570.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

midodrine 5 mg Tab [HMC]

Facility

$17.47

Service Code	NDC 00245021211
Hospital Charge Code	3800194
Hospital Revenue Code	250
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$16.60
Rate for Payer: Aetna Commercial	$15.72
Rate for Payer: Humana Medicare Advantage	$7.34
Rate for Payer: UnitedHealthcare Commercial	$16.60
Rate for Payer: UnitedHealthcare Medicaid	$6.99
Rate for Payer: WPPA Medicare Advantage	$10.48

midodrine 5 mg Tab [HMC]

Facility

$8.12

Service Code	NDC 00904681861
Hospital Charge Code	3800194
Hospital Revenue Code	250
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$7.71
Rate for Payer: Aetna Commercial	$7.31
Rate for Payer: Humana Medicare Advantage	$3.41
Rate for Payer: UnitedHealthcare Commercial	$7.71
Rate for Payer: UnitedHealthcare Medicaid	$3.25
Rate for Payer: WPPA Medicare Advantage	$4.87

midodrine 5 mg Tab [HMC]

Facility

$8.12

Service Code	NDC 00904681861
Hospital Charge Code	3800194
Hospital Revenue Code	250
Min. Negotiated Rate	$7.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.31
Rate for Payer: UnitedHealthcare Commercial	$7.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

midodrine 5 mg Tab [HMC]

Facility

$17.47

Service Code	NDC 00245021211
Hospital Charge Code	3800194
Hospital Revenue Code	250
Min. Negotiated Rate	$15.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.72
Rate for Payer: UnitedHealthcare Commercial	$16.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

midodrine 5 mg Tab [HMC]

Facility

$6.52

Service Code	NDC 63739014510
Hospital Charge Code	3800194
Hospital Revenue Code	250
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.87
Rate for Payer: UnitedHealthcare Commercial	$6.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

midodrine 5 mg Tab [HMC]

Facility

$6.52

Service Code	NDC 63739014510
Hospital Charge Code	3800194
Hospital Revenue Code	250
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$6.19
Rate for Payer: Aetna Commercial	$5.87
Rate for Payer: Humana Medicare Advantage	$2.74
Rate for Payer: UnitedHealthcare Commercial	$6.19
Rate for Payer: UnitedHealthcare Medicaid	$2.61
Rate for Payer: WPPA Medicare Advantage	$3.91

milnacipran 12.5 mg Tab [HMC]

Facility

$29.37

Service Code	NDC 00456151260
Hospital Charge Code	3806345
Hospital Revenue Code	250
Min. Negotiated Rate	$26.43
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.43
Rate for Payer: UnitedHealthcare Commercial	$27.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

milnacipran 12.5 mg Tab [HMC]

Facility

$29.37

Service Code	NDC 00456151260
Hospital Charge Code	3806345
Hospital Revenue Code	250
Min. Negotiated Rate	$11.75
Max. Negotiated Rate	$27.90
Rate for Payer: Aetna Commercial	$26.43
Rate for Payer: Humana Medicare Advantage	$12.34
Rate for Payer: UnitedHealthcare Commercial	$27.90
Rate for Payer: UnitedHealthcare Medicaid	$11.75
Rate for Payer: WPPA Medicare Advantage	$17.62

mineral oil 30ml Liq UD [HMC]

Facility

$4.93

Service Code	NDC 48433020230
Hospital Charge Code	3805501
Hospital Revenue Code	257
Min. Negotiated Rate	$4.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.44
Rate for Payer: UnitedHealthcare Commercial	$4.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mineral oil 30ml Liq UD [HMC]

Facility

$4.93

Service Code	NDC 48433020230
Hospital Charge Code	3805501
Hospital Revenue Code	257
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$4.68
Rate for Payer: Aetna Commercial	$4.44
Rate for Payer: Humana Medicare Advantage	$2.07
Rate for Payer: UnitedHealthcare Commercial	$4.68
Rate for Payer: UnitedHealthcare Medicaid	$1.97
Rate for Payer: WPPA Medicare Advantage	$2.96

MiniBunion Capital Fragment Guide Kit Disposable

Facility

$1,865.00

Hospital Charge Code	3258347
Hospital Revenue Code	270
Min. Negotiated Rate	$746.00
Max. Negotiated Rate	$1,771.75
Rate for Payer: Aetna Commercial	$1,678.50
Rate for Payer: Humana Medicare Advantage	$783.30
Rate for Payer: UnitedHealthcare Commercial	$1,771.75
Rate for Payer: UnitedHealthcare Medicaid	$746.00
Rate for Payer: WPPA Medicare Advantage	$1,119.00

MiniBunion Capital Fragment Guide Kit Disposable

Facility

$1,865.00

Hospital Charge Code	3258347
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,771.75
Rate for Payer: Aetna Commercial	$1,678.50
Rate for Payer: UnitedHealthcare Commercial	$1,771.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MiniBunion Drill Kit Disposable

Facility

$1,973.00

Hospital Charge Code	3258349
Hospital Revenue Code	270
Min. Negotiated Rate	$789.20
Max. Negotiated Rate	$1,874.35
Rate for Payer: Aetna Commercial	$1,775.70
Rate for Payer: Humana Medicare Advantage	$828.66
Rate for Payer: UnitedHealthcare Commercial	$1,874.35
Rate for Payer: UnitedHealthcare Medicaid	$789.20
Rate for Payer: WPPA Medicare Advantage	$1,183.80

MiniBunion Drill Kit Disposable

Facility

$1,973.00

Hospital Charge Code	3258349
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,874.35
Rate for Payer: Aetna Commercial	$1,775.70
Rate for Payer: UnitedHealthcare Commercial	$1,874.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MiniBunion Instrument Kit Disposable

Facility

$3,164.00

Hospital Charge Code	3258348
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,005.80
Rate for Payer: Aetna Commercial	$2,847.60
Rate for Payer: UnitedHealthcare Commercial	$3,005.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MiniBunion Instrument Kit Disposable

Facility

$3,164.00

Hospital Charge Code	3258348
Hospital Revenue Code	270
Min. Negotiated Rate	$1,265.60
Max. Negotiated Rate	$3,005.80
Rate for Payer: Aetna Commercial	$2,847.60
Rate for Payer: Humana Medicare Advantage	$1,328.88
Rate for Payer: UnitedHealthcare Commercial	$3,005.80
Rate for Payer: UnitedHealthcare Medicaid	$1,265.60
Rate for Payer: WPPA Medicare Advantage	$1,898.40

Mini-Monster Cannulated Short Thread Screws Headless 3.0 X 24mm

Facility

$1,089.00

Hospital Charge Code	3258316
Hospital Revenue Code	270
Min. Negotiated Rate	$435.60
Max. Negotiated Rate	$1,034.55
Rate for Payer: Aetna Commercial	$980.10
Rate for Payer: Humana Medicare Advantage	$457.38
Rate for Payer: UnitedHealthcare Commercial	$1,034.55
Rate for Payer: UnitedHealthcare Medicaid	$435.60
Rate for Payer: WPPA Medicare Advantage	$653.40

Mini-Monster Cannulated Short Thread Screws Headless 3.0 X 24mm

Facility

$1,089.00

Hospital Charge Code	3258316
Hospital Revenue Code	270
Min. Negotiated Rate	$980.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$980.10
Rate for Payer: UnitedHealthcare Commercial	$1,034.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mini-Monster Cannulated Short Thread Screws Headless 3.0 X 28mm

Facility

$1,089.00

Hospital Charge Code	3258313
Hospital Revenue Code	270
Min. Negotiated Rate	$435.60
Max. Negotiated Rate	$1,034.55
Rate for Payer: Aetna Commercial	$980.10
Rate for Payer: Humana Medicare Advantage	$457.38
Rate for Payer: UnitedHealthcare Commercial	$1,034.55
Rate for Payer: UnitedHealthcare Medicaid	$435.60
Rate for Payer: WPPA Medicare Advantage	$653.40

Mini-Monster Cannulated Short Thread Screws Headless 3.0 X 28mm

Facility

$1,089.00

Hospital Charge Code	3258313
Hospital Revenue Code	270
Min. Negotiated Rate	$980.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$980.10
Rate for Payer: UnitedHealthcare Commercial	$1,034.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

minocycline 100 mg Cap [HMC]

Facility

$15.19

Service Code	NDC 00591569550
Hospital Charge Code	3806276
Hospital Revenue Code	250
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$14.43
Rate for Payer: Aetna Commercial	$13.67
Rate for Payer: Humana Medicare Advantage	$6.38
Rate for Payer: UnitedHealthcare Commercial	$14.43
Rate for Payer: UnitedHealthcare Medicaid	$6.08
Rate for Payer: WPPA Medicare Advantage	$9.11

minocycline 100 mg Cap [HMC]

Facility

$15.19

Service Code	NDC 00591569550
Hospital Charge Code	3806276
Hospital Revenue Code	250
Min. Negotiated Rate	$13.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.67
Rate for Payer: UnitedHealthcare Commercial	$14.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MINOR BLADDER PROCEDURES WITH CC

Facility

$5,114.97

Service Code	MSDRG 663
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,114.97
Rate for Payer: UnitedHealthcare Medicaid	$5,114.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MINOR BLADDER PROCEDURES WITH MCC

Facility

$10,325.25

Service Code	MSDRG 662
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,325.25
Rate for Payer: UnitedHealthcare Medicaid	$10,325.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges