Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Mitochondrial Ab w/Rfx Titer QST

Facility

$38.00

Service Code	HCPCS 86381
Hospital Charge Code	3556381
Hospital Revenue Code	300
Min. Negotiated Rate	$15.96
Max. Negotiated Rate	$47.72
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.72
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: UnitedHealthcare Medicaid	$16.54
Rate for Payer: WPPA Medicare Advantage	$22.80

modafinil 200 mg Tab [HMC]

Facility

$38.34

Service Code	NDC 55253080230
Hospital Charge Code	3806636
Hospital Revenue Code	250
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$36.42
Rate for Payer: Aetna Commercial	$34.51
Rate for Payer: Humana Medicare Advantage	$16.10
Rate for Payer: UnitedHealthcare Commercial	$36.42
Rate for Payer: UnitedHealthcare Medicaid	$15.34
Rate for Payer: WPPA Medicare Advantage	$23.00

modafinil 200 mg Tab [HMC]

Facility

$38.33

Service Code	NDC 62332038630
Hospital Charge Code	3806636
Hospital Revenue Code	250
Min. Negotiated Rate	$15.33
Max. Negotiated Rate	$36.41
Rate for Payer: Aetna Commercial	$34.50
Rate for Payer: Humana Medicare Advantage	$16.10
Rate for Payer: UnitedHealthcare Commercial	$36.41
Rate for Payer: UnitedHealthcare Medicaid	$15.33
Rate for Payer: WPPA Medicare Advantage	$23.00

modafinil 200 mg Tab [HMC]

Facility

$38.34

Service Code	NDC 55253080230
Hospital Charge Code	3806636
Hospital Revenue Code	250
Min. Negotiated Rate	$34.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.51
Rate for Payer: UnitedHealthcare Commercial	$36.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

modafinil 200 mg Tab [HMC]

Facility

$38.33

Service Code	NDC 62332038630
Hospital Charge Code	3806636
Hospital Revenue Code	250
Min. Negotiated Rate	$34.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.50
Rate for Payer: UnitedHealthcare Commercial	$36.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

moexipril 15 mg Tab [HMC]

Facility

$14.81

Service Code	NDC 00091371501
Hospital Charge Code	3800046
Hospital Revenue Code	250
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$14.07
Rate for Payer: Aetna Commercial	$13.33
Rate for Payer: Humana Medicare Advantage	$6.22
Rate for Payer: UnitedHealthcare Commercial	$14.07
Rate for Payer: UnitedHealthcare Medicaid	$5.92
Rate for Payer: WPPA Medicare Advantage	$8.89

moexipril 15 mg Tab [HMC]

Facility

$14.81

Service Code	NDC 00091371501
Hospital Charge Code	3800046
Hospital Revenue Code	250
Min. Negotiated Rate	$13.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.33
Rate for Payer: UnitedHealthcare Commercial	$14.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mold ID 1 QST

Facility

$72.00

Service Code	HCPCS 87107
Hospital Charge Code	3557107
Hospital Revenue Code	300
Min. Negotiated Rate	$10.32
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$38.54
Rate for Payer: Humana Medicare Advantage	$30.24
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$10.32
Rate for Payer: WPPA Medicare Advantage	$43.20

Mold ID 1 QST

Facility

$72.00

Service Code	HCPCS 87107
Hospital Charge Code	3557107
Hospital Revenue Code	300
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mometasone 220 mcg/inh Inh Aer Pwdr [HMC]

Facility

$330.31

Service Code	NDC 00085134107
Hospital Charge Code	3800357
Hospital Revenue Code	250
Min. Negotiated Rate	$297.28
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$297.28
Rate for Payer: UnitedHealthcare Commercial	$313.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mometasone 220 mcg/inh Inh Aer Pwdr [HMC]

Facility

$330.31

Service Code	NDC 00085134107
Hospital Charge Code	3800357
Hospital Revenue Code	250
Min. Negotiated Rate	$132.12
Max. Negotiated Rate	$313.79
Rate for Payer: Aetna Commercial	$297.28
Rate for Payer: Humana Medicare Advantage	$138.73
Rate for Payer: UnitedHealthcare Commercial	$313.79
Rate for Payer: UnitedHealthcare Medicaid	$132.12
Rate for Payer: WPPA Medicare Advantage	$198.19

mometasone Nasal 50 mcg/inh Spry [HMC]

Facility

$365.94

Service Code	NDC 60505083001
Hospital Charge Code	3803661
Hospital Revenue Code	250
Min. Negotiated Rate	$146.38
Max. Negotiated Rate	$347.64
Rate for Payer: Aetna Commercial	$329.35
Rate for Payer: Humana Medicare Advantage	$153.69
Rate for Payer: UnitedHealthcare Commercial	$347.64
Rate for Payer: UnitedHealthcare Medicaid	$146.38
Rate for Payer: WPPA Medicare Advantage	$219.56

mometasone Nasal 50 mcg/inh Spry [HMC]

Facility

$427.32

Service Code	NDC 00085128801
Hospital Charge Code	3803661
Hospital Revenue Code	250
Min. Negotiated Rate	$170.93
Max. Negotiated Rate	$405.95
Rate for Payer: Aetna Commercial	$384.59
Rate for Payer: Humana Medicare Advantage	$179.47
Rate for Payer: UnitedHealthcare Commercial	$405.95
Rate for Payer: UnitedHealthcare Medicaid	$170.93
Rate for Payer: WPPA Medicare Advantage	$256.39

mometasone Nasal 50 mcg/inh Spry [HMC]

Facility

$427.32

Service Code	NDC 00085128801
Hospital Charge Code	3803661
Hospital Revenue Code	250
Min. Negotiated Rate	$384.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$384.59
Rate for Payer: UnitedHealthcare Commercial	$405.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mometasone Nasal 50 mcg/inh Spry [HMC]

Facility

$365.94

Service Code	NDC 60505083001
Hospital Charge Code	3803661
Hospital Revenue Code	250
Min. Negotiated Rate	$329.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$329.35
Rate for Payer: UnitedHealthcare Commercial	$347.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mononucleosis Screen

Facility

$69.00

Service Code	HCPCS 86308
Hospital Charge Code	3550551
Hospital Revenue Code	300
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$62.10
Rate for Payer: UnitedHealthcare Commercial	$65.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mononucleosis Screen

Facility

$69.00

Service Code	HCPCS 86308
Hospital Charge Code	3550551
Hospital Revenue Code	300
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$65.55
Rate for Payer: Aetna Commercial	$62.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$19.50
Rate for Payer: Humana Medicare Advantage	$28.98
Rate for Payer: UnitedHealthcare Commercial	$65.55
Rate for Payer: UnitedHealthcare Medicaid	$5.18
Rate for Payer: WPPA Medicare Advantage	$41.40

montelukast 10 mg Tab [HMC]

Facility

$18.77

Service Code	NDC 68084087501
Hospital Charge Code	3802366
Hospital Revenue Code	250
Min. Negotiated Rate	$7.51
Max. Negotiated Rate	$17.83
Rate for Payer: Aetna Commercial	$16.89
Rate for Payer: Humana Medicare Advantage	$7.88
Rate for Payer: UnitedHealthcare Commercial	$17.83
Rate for Payer: UnitedHealthcare Medicaid	$7.51
Rate for Payer: WPPA Medicare Advantage	$11.26

montelukast 10 mg Tab [HMC]

Facility

$6.19

Service Code	NDC 00904680861
Hospital Charge Code	3802366
Hospital Revenue Code	250
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$5.88
Rate for Payer: Aetna Commercial	$5.57
Rate for Payer: Humana Medicare Advantage	$2.60
Rate for Payer: UnitedHealthcare Commercial	$5.88
Rate for Payer: UnitedHealthcare Medicaid	$2.48
Rate for Payer: WPPA Medicare Advantage	$3.71

montelukast 10 mg Tab [HMC]

Facility

$18.77

Service Code	NDC 68084087501
Hospital Charge Code	3802366
Hospital Revenue Code	250
Min. Negotiated Rate	$16.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.89
Rate for Payer: UnitedHealthcare Commercial	$17.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

montelukast 10 mg Tab [HMC]

Facility

$6.19

Service Code	NDC 00904680861
Hospital Charge Code	3802366
Hospital Revenue Code	250
Min. Negotiated Rate	$5.57
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.57
Rate for Payer: UnitedHealthcare Commercial	$5.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

montelukast 4 mg Chew Tab [HMC]

Facility

$15.98

Service Code	NDC 50268057315
Hospital Charge Code	3800610
Hospital Revenue Code	250
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$15.18
Rate for Payer: Aetna Commercial	$14.38
Rate for Payer: Humana Medicare Advantage	$6.71
Rate for Payer: UnitedHealthcare Commercial	$15.18
Rate for Payer: UnitedHealthcare Medicaid	$6.39
Rate for Payer: WPPA Medicare Advantage	$9.59

montelukast 4 mg Chew Tab [HMC]

Facility

$15.98

Service Code	NDC 50268057315
Hospital Charge Code	3800610
Hospital Revenue Code	250
Min. Negotiated Rate	$14.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$14.38
Rate for Payer: UnitedHealthcare Commercial	$15.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

montelukast 4 mg Chew Tab [HMC]

Facility

$17.57

Service Code	NDC 33342011007
Hospital Charge Code	3800610
Hospital Revenue Code	250
Min. Negotiated Rate	$15.81
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.81
Rate for Payer: UnitedHealthcare Commercial	$16.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

montelukast 4 mg Chew Tab [HMC]

Facility

$17.57

Service Code	NDC 33342011007
Hospital Charge Code	3800610
Hospital Revenue Code	250
Min. Negotiated Rate	$7.03
Max. Negotiated Rate	$16.69
Rate for Payer: Aetna Commercial	$15.81
Rate for Payer: Humana Medicare Advantage	$7.38
Rate for Payer: UnitedHealthcare Commercial	$16.69
Rate for Payer: UnitedHealthcare Medicaid	$7.03
Rate for Payer: WPPA Medicare Advantage	$10.54

Know your out-of-pocket cost for care.

All Charges