Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

omeprazole 20 mg Oral EC Cap [HMC]

Facility

$8.34

Service Code	NDC 68084012801
Hospital Charge Code	3806970
Hospital Revenue Code	250
Min. Negotiated Rate	$7.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.51
Rate for Payer: UnitedHealthcare Commercial	$7.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

omeprazole 20 mg Oral EC Cap [HMC]

Facility

$5.81

Service Code	NDC 00904691761
Hospital Charge Code	3806970
Hospital Revenue Code	250
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.23
Rate for Payer: UnitedHealthcare Commercial	$5.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

omeprazole 20 mg Oral EC Cap [HMC]

Facility

$17.45

Service Code	NDC 70700015001
Hospital Charge Code	3806970
Hospital Revenue Code	250
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$16.58
Rate for Payer: Aetna Commercial	$15.71
Rate for Payer: Humana Medicare Advantage	$7.33
Rate for Payer: UnitedHealthcare Commercial	$16.58
Rate for Payer: UnitedHealthcare Medicaid	$6.98
Rate for Payer: WPPA Medicare Advantage	$10.47

onabotulinumtoxinA 100 units Pow [HMC]

Facility

$1,496.00

Service Code	HCPCS J0585
Hospital Charge Code	3800946
Hospital Revenue Code	636
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$1,421.20
Rate for Payer: Aetna Commercial	$1,346.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8.13
Rate for Payer: Humana Medicare Advantage	$628.32
Rate for Payer: UnitedHealthcare Commercial	$1,421.20
Rate for Payer: UnitedHealthcare Medicaid	$6.51
Rate for Payer: WPPA Medicare Advantage	$897.60

onabotulinumtoxinA 100 units Pow [HMC]

Facility

$1,496.00

Service Code	HCPCS J0585
Hospital Charge Code	3800946
Hospital Revenue Code	636
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,421.20
Rate for Payer: Aetna Commercial	$1,346.40
Rate for Payer: UnitedHealthcare Commercial	$1,421.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

onabotulinumtoxinA 200 units Pow [HMC]

Facility

$1,958.00

Service Code	HCPCS J0585
Hospital Charge Code	3800948
Hospital Revenue Code	259
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,860.10
Rate for Payer: Aetna Commercial	$1,762.20
Rate for Payer: UnitedHealthcare Commercial	$1,860.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

onabotulinumtoxinA 200 units Pow [HMC]

Facility

$1,958.00

Service Code	HCPCS J0585
Hospital Charge Code	3800948
Hospital Revenue Code	259
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$1,860.10
Rate for Payer: Aetna Commercial	$1,762.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8.13
Rate for Payer: Humana Medicare Advantage	$822.36
Rate for Payer: UnitedHealthcare Commercial	$1,860.10
Rate for Payer: UnitedHealthcare Medicaid	$6.51
Rate for Payer: WPPA Medicare Advantage	$1,174.80

ondansetron 2 mg/mL Inj Sol 2 mL [HMC]

Facility

$25.70

Service Code	HCPCS J2405
Hospital Charge Code	3807902
Hospital Revenue Code	250
Min. Negotiated Rate	$23.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.13
Rate for Payer: Aetna Commercial	$22.64
Rate for Payer: Aetna Commercial	$20.70
Rate for Payer: Aetna Commercial	$28.80
Rate for Payer: Aetna Commercial	$21.24
Rate for Payer: UnitedHealthcare Commercial	$21.85
Rate for Payer: UnitedHealthcare Commercial	$30.40
Rate for Payer: UnitedHealthcare Commercial	$24.41
Rate for Payer: UnitedHealthcare Commercial	$22.42
Rate for Payer: UnitedHealthcare Commercial	$23.90
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
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ondansetron 2 mg/mL Inj Sol 2 mL [HMC]

Facility

$25.70

Service Code	HCPCS J2405
Hospital Charge Code	3807902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$24.41
Rate for Payer: Aetna Commercial	$23.13
Rate for Payer: Aetna Commercial	$20.70
Rate for Payer: Aetna Commercial	$22.64
Rate for Payer: Aetna Commercial	$21.24
Rate for Payer: Aetna Commercial	$28.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.13
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.13
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.13
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.13
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.13
Rate for Payer: Humana Medicare Advantage	$9.91
Rate for Payer: Humana Medicare Advantage	$9.66
Rate for Payer: Humana Medicare Advantage	$10.57
Rate for Payer: Humana Medicare Advantage	$10.79
Rate for Payer: Humana Medicare Advantage	$13.44
Rate for Payer: UnitedHealthcare Commercial	$22.42
Rate for Payer: UnitedHealthcare Commercial	$23.90
Rate for Payer: UnitedHealthcare Commercial	$30.40
Rate for Payer: UnitedHealthcare Commercial	$24.41
Rate for Payer: UnitedHealthcare Commercial	$21.85
Rate for Payer: UnitedHealthcare Medicaid	$0.09
Rate for Payer: UnitedHealthcare Medicaid	$0.09
Rate for Payer: UnitedHealthcare Medicaid	$0.09
Rate for Payer: UnitedHealthcare Medicaid	$0.09
Rate for Payer: UnitedHealthcare Medicaid	$0.09
Rate for Payer: WPPA Medicare Advantage	$15.10
Rate for Payer: WPPA Medicare Advantage	$14.16
Rate for Payer: WPPA Medicare Advantage	$13.80
Rate for Payer: WPPA Medicare Advantage	$15.42
Rate for Payer: WPPA Medicare Advantage	$19.20

ondansetron 2 mg/mL Sol Inj 2ml [HMC]

Facility

$22.76

Service Code	HCPCS J2405
Hospital Charge Code	3807902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$21.62
Rate for Payer: Aetna Commercial	$20.48
Rate for Payer: Aetna Commercial	$23.23
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.13
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.13
Rate for Payer: Humana Medicare Advantage	$9.56
Rate for Payer: Humana Medicare Advantage	$10.84
Rate for Payer: UnitedHealthcare Commercial	$24.52
Rate for Payer: UnitedHealthcare Commercial	$21.62
Rate for Payer: UnitedHealthcare Medicaid	$0.09
Rate for Payer: UnitedHealthcare Medicaid	$0.09
Rate for Payer: WPPA Medicare Advantage	$15.49
Rate for Payer: WPPA Medicare Advantage	$13.66

ondansetron 2 mg/mL Sol Inj 2ml [HMC]

Facility

$22.76

Service Code	HCPCS J2405
Hospital Charge Code	3807902
Hospital Revenue Code	250
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.48
Rate for Payer: Aetna Commercial	$23.23
Rate for Payer: UnitedHealthcare Commercial	$24.52
Rate for Payer: UnitedHealthcare Commercial	$21.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ondansetron 4 mg/5 mL Oral Sol [HMC]

Facility

$42.38

Service Code	NDC 65162069179
Hospital Charge Code	3800764
Hospital Revenue Code	250
Min. Negotiated Rate	$38.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.14
Rate for Payer: UnitedHealthcare Commercial	$40.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ondansetron 4 mg/5 mL Oral Sol [HMC]

Facility

$42.27

Service Code	HCPCS Q0162
Hospital Charge Code	3800764
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$40.16
Rate for Payer: Aetna Commercial	$38.04
Rate for Payer: Aetna Commercial	$38.14
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.27
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.27
Rate for Payer: Humana Medicare Advantage	$17.80
Rate for Payer: Humana Medicare Advantage	$17.75
Rate for Payer: UnitedHealthcare Commercial	$40.26
Rate for Payer: UnitedHealthcare Commercial	$40.16
Rate for Payer: UnitedHealthcare Medicaid	$16.91
Rate for Payer: UnitedHealthcare Medicaid	$16.95
Rate for Payer: WPPA Medicare Advantage	$25.43
Rate for Payer: WPPA Medicare Advantage	$25.36

ondansetron 4 mg/5 mL Oral Sol [HMC]

Facility

$42.38

Service Code	HCPCS Q0162
Hospital Charge Code	3800764
Hospital Revenue Code	250
Min. Negotiated Rate	$38.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.14
Rate for Payer: Aetna Commercial	$38.04
Rate for Payer: UnitedHealthcare Commercial	$40.16
Rate for Payer: UnitedHealthcare Commercial	$40.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ondansetron 4 mg/5 mL Oral Sol [HMC]

Facility

$42.38

Service Code	NDC 65162069179
Hospital Charge Code	3800764
Hospital Revenue Code	250
Min. Negotiated Rate	$16.95
Max. Negotiated Rate	$40.26
Rate for Payer: Aetna Commercial	$38.14
Rate for Payer: Humana Medicare Advantage	$17.80
Rate for Payer: UnitedHealthcare Commercial	$40.26
Rate for Payer: UnitedHealthcare Medicaid	$16.95
Rate for Payer: WPPA Medicare Advantage	$25.43

ondansetron 4 mg Dis Tab [HMC]

Facility

$28.11

Service Code	HCPCS Q0162
Hospital Charge Code	3805608
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$26.70
Rate for Payer: Aetna Commercial	$25.30
Rate for Payer: Aetna Commercial	$24.55
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.27
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.27
Rate for Payer: Humana Medicare Advantage	$11.46
Rate for Payer: Humana Medicare Advantage	$11.81
Rate for Payer: UnitedHealthcare Commercial	$25.92
Rate for Payer: UnitedHealthcare Commercial	$26.70
Rate for Payer: UnitedHealthcare Medicaid	$10.91
Rate for Payer: UnitedHealthcare Medicaid	$11.24
Rate for Payer: WPPA Medicare Advantage	$16.87
Rate for Payer: WPPA Medicare Advantage	$16.37

ondansetron 4 mg Dis Tab [HMC]

Facility

$27.28

Service Code	HCPCS Q0162
Hospital Charge Code	3805608
Hospital Revenue Code	250
Min. Negotiated Rate	$24.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.55
Rate for Payer: Aetna Commercial	$25.30
Rate for Payer: UnitedHealthcare Commercial	$26.70
Rate for Payer: UnitedHealthcare Commercial	$25.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ophthalmic Burr Tip 1mm

Facility

$48.29

Hospital Charge Code	3256026
Hospital Revenue Code	270
Min. Negotiated Rate	$43.46
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$43.46
Rate for Payer: UnitedHealthcare Commercial	$45.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ophthalmic Burr Tip 1mm

Facility

$48.29

Hospital Charge Code	3256026
Hospital Revenue Code	270
Min. Negotiated Rate	$19.32
Max. Negotiated Rate	$45.88
Rate for Payer: Aetna Commercial	$43.46
Rate for Payer: Humana Medicare Advantage	$20.28
Rate for Payer: UnitedHealthcare Commercial	$45.88
Rate for Payer: UnitedHealthcare Medicaid	$19.32
Rate for Payer: WPPA Medicare Advantage	$28.97

ophthalmic irrigation, extraocular - Sol 4oz [HMC]

Facility

$27.26

Service Code	NDC 10119000252
Hospital Charge Code	3802655
Hospital Revenue Code	257
Min. Negotiated Rate	$10.90
Max. Negotiated Rate	$25.90
Rate for Payer: Aetna Commercial	$24.53
Rate for Payer: Humana Medicare Advantage	$11.45
Rate for Payer: UnitedHealthcare Commercial	$25.90
Rate for Payer: UnitedHealthcare Medicaid	$10.90
Rate for Payer: WPPA Medicare Advantage	$16.36

ophthalmic irrigation, extraocular - Sol 4oz [HMC]

Facility

$27.26

Service Code	NDC 10119000252
Hospital Charge Code	3802655
Hospital Revenue Code	257
Min. Negotiated Rate	$24.53
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.53
Rate for Payer: UnitedHealthcare Commercial	$25.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Optispec Gynecology illuminator

Facility

$26.00

Hospital Charge Code	3257343
Hospital Revenue Code	270
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$24.70
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: Humana Medicare Advantage	$10.92
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: UnitedHealthcare Medicaid	$10.40
Rate for Payer: WPPA Medicare Advantage	$15.60

Optispec Gynecology illuminator

Facility

$26.00

Hospital Charge Code	3257343
Hospital Revenue Code	270
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Orange (f33) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552826
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

Orange (f33) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552826
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

Know your out-of-pocket cost for care.

All Charges