Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

nystatin Top 100,000 units/g Pwdr [HMC]

Facility

$42.46

Service Code	NDC 00832046515
Hospital Charge Code	3802861
Hospital Revenue Code	250
Min. Negotiated Rate	$16.98
Max. Negotiated Rate	$40.34
Rate for Payer: Aetna Commercial	$38.21
Rate for Payer: Humana Medicare Advantage	$17.83
Rate for Payer: UnitedHealthcare Commercial	$40.34
Rate for Payer: UnitedHealthcare Medicaid	$16.98
Rate for Payer: WPPA Medicare Advantage	$25.48

nystatin Top 100,000 units/g Pwdr [HMC]

Facility

$37.68

Service Code	NDC 00832046560
Hospital Charge Code	3802861
Hospital Revenue Code	250
Min. Negotiated Rate	$33.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.91
Rate for Payer: UnitedHealthcare Commercial	$35.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Oak (T7) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1018
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$16.20

Oak (T7) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1018
Hospital Revenue Code	300
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Oat (f7) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552814
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Oat (f7) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552814
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$12.60

OB Pad (Maternity) 4-3/10 X 12-1/4 Heavy Absorbancy

Facility

$4.37

Hospital Charge Code	3251472
Hospital Revenue Code	270
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.93
Rate for Payer: UnitedHealthcare Commercial	$4.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OB Pad (Maternity) 4-3/10 X 12-1/4 Heavy Absorbancy

Facility

$4.37

Hospital Charge Code	3251472
Hospital Revenue Code	270
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$4.15
Rate for Payer: Aetna Commercial	$3.93
Rate for Payer: Humana Medicare Advantage	$1.84
Rate for Payer: UnitedHealthcare Commercial	$4.15
Rate for Payer: UnitedHealthcare Medicaid	$1.75
Rate for Payer: WPPA Medicare Advantage	$2.62

OB Panel (Bill Only)

Facility

$621.00

Service Code	HCPCS 80081
Hospital Charge Code	3550081
Hospital Revenue Code	300
Min. Negotiated Rate	$74.86
Max. Negotiated Rate	$589.95
Rate for Payer: Aetna Commercial	$558.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$152.94
Rate for Payer: Humana Medicare Advantage	$260.82
Rate for Payer: UnitedHealthcare Commercial	$589.95
Rate for Payer: UnitedHealthcare Medicaid	$74.86
Rate for Payer: WPPA Medicare Advantage	$372.60

OB Panel (Bill Only)

Facility

$621.00

Service Code	HCPCS 80081
Hospital Charge Code	3550081
Hospital Revenue Code	300
Min. Negotiated Rate	$558.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$558.90
Rate for Payer: UnitedHealthcare Commercial	$589.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Occult Blood Screen

Facility

$45.00

Service Code	HCPCS 82272
Hospital Charge Code	3550577
Hospital Revenue Code	300
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$42.75
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$6.98
Rate for Payer: Humana Medicare Advantage	$18.90
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: UnitedHealthcare Medicaid	$3.86
Rate for Payer: WPPA Medicare Advantage	$27.00

Occult Blood Screen

Facility

$45.00

Service Code	HCPCS 82272
Hospital Charge Code	3550577
Hospital Revenue Code	300
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Occult Blood Screen 1

Facility

$45.00

Service Code	HCPCS 82274
Hospital Charge Code	3552813
Hospital Revenue Code	300
Min. Negotiated Rate	$13.53
Max. Negotiated Rate	$42.75
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$34.14
Rate for Payer: Humana Medicare Advantage	$18.90
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: UnitedHealthcare Medicaid	$13.53
Rate for Payer: WPPA Medicare Advantage	$27.00

Occult Blood Screen 1

Facility

$45.00

Service Code	HCPCS 82274
Hospital Charge Code	3552813
Hospital Revenue Code	300
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ocrelizumab 300 mg/10 mL Sol [HMC]

Facility

$4,731.45

Service Code	HCPCS J2350
Hospital Charge Code	3801010
Hospital Revenue Code	250
Min. Negotiated Rate	$59.32
Max. Negotiated Rate	$4,494.88
Rate for Payer: Aetna Commercial	$4,258.31
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$72.29
Rate for Payer: Humana Medicare Advantage	$1,987.21
Rate for Payer: UnitedHealthcare Commercial	$4,494.88
Rate for Payer: UnitedHealthcare Medicaid	$59.32
Rate for Payer: WPPA Medicare Advantage	$2,838.87

ocrelizumab 300 mg/10 mL Sol [HMC]

Facility

$4,731.45

Service Code	HCPCS J2350
Hospital Charge Code	3801010
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,494.88
Rate for Payer: Aetna Commercial	$4,258.31
Rate for Payer: UnitedHealthcare Commercial	$4,494.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

octreotide 100 mcg/mL Inj Sol [HMC]

Facility

$43.40

Service Code	HCPCS J2354
Hospital Charge Code	3852045
Hospital Revenue Code	250
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$41.23
Rate for Payer: Aetna Commercial	$39.06
Rate for Payer: Aetna Commercial	$39.94
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.44
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.44
Rate for Payer: Humana Medicare Advantage	$18.23
Rate for Payer: Humana Medicare Advantage	$18.64
Rate for Payer: UnitedHealthcare Commercial	$41.23
Rate for Payer: UnitedHealthcare Commercial	$42.16
Rate for Payer: UnitedHealthcare Medicaid	$17.75
Rate for Payer: UnitedHealthcare Medicaid	$17.36
Rate for Payer: WPPA Medicare Advantage	$26.04
Rate for Payer: WPPA Medicare Advantage	$26.63

octreotide 100 mcg/mL Inj Sol [HMC]

Facility

$43.40

Service Code	HCPCS J2354
Hospital Charge Code	3852045
Hospital Revenue Code	250
Min. Negotiated Rate	$39.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.06
Rate for Payer: Aetna Commercial	$39.94
Rate for Payer: UnitedHealthcare Commercial	$42.16
Rate for Payer: UnitedHealthcare Commercial	$41.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

octreotide 30 mg IM Inj [HMC]

Facility

$7,349.36

Service Code	HCPCS J2353
Hospital Charge Code	3852165
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,981.89
Rate for Payer: Aetna Commercial	$6,614.42
Rate for Payer: UnitedHealthcare Commercial	$6,981.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

octreotide 30 mg IM Inj [HMC]

Facility

$7,349.36

Service Code	HCPCS J2353
Hospital Charge Code	3852165
Hospital Revenue Code	250
Min. Negotiated Rate	$199.17
Max. Negotiated Rate	$6,981.89
Rate for Payer: Aetna Commercial	$6,614.42
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$259.42
Rate for Payer: Humana Medicare Advantage	$3,086.73
Rate for Payer: UnitedHealthcare Commercial	$6,981.89
Rate for Payer: UnitedHealthcare Medicaid	$199.17
Rate for Payer: WPPA Medicare Advantage	$4,409.62

octreotide 500 mcg/mL Inj Sol [HMC]

Facility

$109.44

Service Code	HCPCS J2354
Hospital Charge Code	3800651
Hospital Revenue Code	250
Min. Negotiated Rate	$98.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$98.50
Rate for Payer: Aetna Commercial	$77.06
Rate for Payer: UnitedHealthcare Commercial	$81.34
Rate for Payer: UnitedHealthcare Commercial	$103.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

octreotide 500 mcg/mL Inj Sol [HMC]

Facility

$85.62

Service Code	HCPCS J2354
Hospital Charge Code	3800651
Hospital Revenue Code	250
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$81.34
Rate for Payer: Aetna Commercial	$77.06
Rate for Payer: Aetna Commercial	$98.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.44
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.44
Rate for Payer: Humana Medicare Advantage	$45.96
Rate for Payer: Humana Medicare Advantage	$35.96
Rate for Payer: UnitedHealthcare Commercial	$103.97
Rate for Payer: UnitedHealthcare Commercial	$81.34
Rate for Payer: UnitedHealthcare Medicaid	$43.78
Rate for Payer: UnitedHealthcare Medicaid	$34.25
Rate for Payer: WPPA Medicare Advantage	$51.37
Rate for Payer: WPPA Medicare Advantage	$65.66

ocular lubricant Gel [HMC]

Facility

$39.80

Service Code	NDC 00023455430
Hospital Charge Code	3800720
Hospital Revenue Code	250
Min. Negotiated Rate	$35.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.82
Rate for Payer: UnitedHealthcare Commercial	$37.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ocular lubricant Gel [HMC]

Facility

$20.00

Service Code	NDC 70000008901
Hospital Charge Code	3800720
Hospital Revenue Code	250
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: Humana Medicare Advantage	$8.40
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: UnitedHealthcare Medicaid	$8.00
Rate for Payer: WPPA Medicare Advantage	$12.00

ocular lubricant Gel [HMC]

Facility

$20.00

Service Code	NDC 70000008901
Hospital Charge Code	3800720
Hospital Revenue Code	250
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges