Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

MINOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$3,526.47

Service Code	MSDRG 664
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,526.47
Rate for Payer: UnitedHealthcare Medicaid	$3,526.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MINOR SKIN DISORDERS WITH MCC

Facility

$7,084.71

Service Code	MSDRG 606
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,084.71
Rate for Payer: UnitedHealthcare Medicaid	$7,084.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MINOR SKIN DISORDERS WITHOUT MCC

Facility

$4,257.18

Service Code	MSDRG 607
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,257.18
Rate for Payer: UnitedHealthcare Medicaid	$4,257.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$5,686.83

Service Code	MSDRG 345
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,686.83
Rate for Payer: UnitedHealthcare Medicaid	$5,686.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$9,753.39

Service Code	MSDRG 344
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,753.39
Rate for Payer: UnitedHealthcare Medicaid	$9,753.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$4,479.57

Service Code	MSDRG 346
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,479.57
Rate for Payer: UnitedHealthcare Medicaid	$4,479.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mirabegron 25 mg [HMC]

Facility

$41.82

Service Code	NDC 00469260130
Hospital Charge Code	3800222
Hospital Revenue Code	250
Min. Negotiated Rate	$16.73
Max. Negotiated Rate	$39.73
Rate for Payer: Aetna Commercial	$37.64
Rate for Payer: Humana Medicare Advantage	$17.56
Rate for Payer: UnitedHealthcare Commercial	$39.73
Rate for Payer: UnitedHealthcare Medicaid	$16.73
Rate for Payer: WPPA Medicare Advantage	$25.09

mirabegron 25 mg [HMC]

Facility

$41.82

Service Code	NDC 00469260130
Hospital Charge Code	3800222
Hospital Revenue Code	250
Min. Negotiated Rate	$37.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$37.64
Rate for Payer: UnitedHealthcare Commercial	$39.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mirabegron 25 mg Tab [HMC]

Facility

$38.14

Service Code	NDC 70710115903
Hospital Charge Code	3800222
Hospital Revenue Code	250
Min. Negotiated Rate	$15.26
Max. Negotiated Rate	$36.23
Rate for Payer: Aetna Commercial	$34.33
Rate for Payer: Humana Medicare Advantage	$16.02
Rate for Payer: UnitedHealthcare Commercial	$36.23
Rate for Payer: UnitedHealthcare Medicaid	$15.26
Rate for Payer: WPPA Medicare Advantage	$22.88

mirabegron 25 mg Tab [HMC]

Facility

$38.14

Service Code	NDC 70710115903
Hospital Charge Code	3800222
Hospital Revenue Code	250
Min. Negotiated Rate	$34.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.33
Rate for Payer: UnitedHealthcare Commercial	$36.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mirtazapine 15 mg Tab [HMC]

Facility

$8.13

Service Code	NDC 68084011901
Hospital Charge Code	3803851
Hospital Revenue Code	250
Min. Negotiated Rate	$7.32
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.32
Rate for Payer: UnitedHealthcare Commercial	$7.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mirtazapine 15 mg Tab [HMC]

Facility

$8.13

Service Code	NDC 68084011901
Hospital Charge Code	3803851
Hospital Revenue Code	250
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$7.72
Rate for Payer: Aetna Commercial	$7.32
Rate for Payer: Humana Medicare Advantage	$3.41
Rate for Payer: UnitedHealthcare Commercial	$7.72
Rate for Payer: UnitedHealthcare Medicaid	$3.25
Rate for Payer: WPPA Medicare Advantage	$4.88

mirtazapine 15 mg Tab [HMC]

Facility

$13.58

Service Code	NDC 00904651961
Hospital Charge Code	3803851
Hospital Revenue Code	250
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$12.90
Rate for Payer: Aetna Commercial	$12.22
Rate for Payer: Humana Medicare Advantage	$5.70
Rate for Payer: UnitedHealthcare Commercial	$12.90
Rate for Payer: UnitedHealthcare Medicaid	$5.43
Rate for Payer: WPPA Medicare Advantage	$8.15

mirtazapine 15 mg Tab [HMC]

Facility

$13.58

Service Code	NDC 00904651961
Hospital Charge Code	3803851
Hospital Revenue Code	250
Min. Negotiated Rate	$12.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.22
Rate for Payer: UnitedHealthcare Commercial	$12.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC

Facility

$5,305.59

Service Code	MSDRG 640
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,305.59
Rate for Payer: UnitedHealthcare Medicaid	$5,305.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC

Facility

$4,670.19

Service Code	MSDRG 641
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,670.19
Rate for Payer: UnitedHealthcare Medicaid	$4,670.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Misc Test to Quest (Rmt) QST

Facility

$126.00

Service Code	HCPCS 80201
Hospital Charge Code	3550201
Hospital Revenue Code	300
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$113.40
Rate for Payer: UnitedHealthcare Commercial	$119.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Misc Test to Quest (Rmt) QST

Facility

$126.00

Service Code	HCPCS 80201
Hospital Charge Code	3550201
Hospital Revenue Code	300
Min. Negotiated Rate	$10.71
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna Commercial	$113.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.35
Rate for Payer: Humana Medicare Advantage	$52.92
Rate for Payer: UnitedHealthcare Commercial	$119.70
Rate for Payer: UnitedHealthcare Medicaid	$10.71
Rate for Payer: WPPA Medicare Advantage	$75.60

misoprostol 100 mcg Tab [HMC]

Facility

$7.47

Service Code	NDC 59762500701
Hospital Charge Code	3806962
Hospital Revenue Code	250
Min. Negotiated Rate	$6.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.72
Rate for Payer: UnitedHealthcare Commercial	$7.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

misoprostol 100 mcg Tab [HMC]

Facility

$12.44

Service Code	NDC 60687073501
Hospital Charge Code	3806962
Hospital Revenue Code	250
Min. Negotiated Rate	$4.98
Max. Negotiated Rate	$11.82
Rate for Payer: Aetna Commercial	$11.20
Rate for Payer: Humana Medicare Advantage	$5.22
Rate for Payer: UnitedHealthcare Commercial	$11.82
Rate for Payer: UnitedHealthcare Medicaid	$4.98
Rate for Payer: WPPA Medicare Advantage	$7.46

misoprostol 100 mcg Tab [HMC]

Facility

$7.94

Service Code	NDC 70954044310
Hospital Charge Code	3806962
Hospital Revenue Code	250
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.15
Rate for Payer: UnitedHealthcare Commercial	$7.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

misoprostol 100 mcg Tab [HMC]

Facility

$7.47

Service Code	NDC 59762500701
Hospital Charge Code	3806962
Hospital Revenue Code	250
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$7.10
Rate for Payer: Aetna Commercial	$6.72
Rate for Payer: Humana Medicare Advantage	$3.14
Rate for Payer: UnitedHealthcare Commercial	$7.10
Rate for Payer: UnitedHealthcare Medicaid	$2.99
Rate for Payer: WPPA Medicare Advantage	$4.48

misoprostol 100 mcg Tab [HMC]

Facility

$7.94

Service Code	NDC 70954044310
Hospital Charge Code	3806962
Hospital Revenue Code	250
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$7.54
Rate for Payer: Aetna Commercial	$7.15
Rate for Payer: Humana Medicare Advantage	$3.33
Rate for Payer: UnitedHealthcare Commercial	$7.54
Rate for Payer: UnitedHealthcare Medicaid	$3.18
Rate for Payer: WPPA Medicare Advantage	$4.76

misoprostol 100 mcg Tab [HMC]

Facility

$12.44

Service Code	NDC 60687073501
Hospital Charge Code	3806962
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.20
Rate for Payer: UnitedHealthcare Commercial	$11.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mitochondrial Ab w/Rfx Titer QST

Facility

$38.00

Service Code	HCPCS 86381
Hospital Charge Code	3556381
Hospital Revenue Code	300
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges