Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Ortho Glass 4

Facility

$19.76

Hospital Charge Code	3255555
Hospital Revenue Code	270
Min. Negotiated Rate	$17.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.78
Rate for Payer: UnitedHealthcare Commercial	$18.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ortho Glass 5

Facility

$23.40

Hospital Charge Code	3255556
Hospital Revenue Code	270
Min. Negotiated Rate	$21.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.06
Rate for Payer: UnitedHealthcare Commercial	$22.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ortho Glass 5

Facility

$23.40

Hospital Charge Code	3255556
Hospital Revenue Code	270
Min. Negotiated Rate	$9.36
Max. Negotiated Rate	$22.23
Rate for Payer: Aetna Commercial	$21.06
Rate for Payer: Humana Medicare Advantage	$9.83
Rate for Payer: UnitedHealthcare Commercial	$22.23
Rate for Payer: UnitedHealthcare Medicaid	$9.36
Rate for Payer: WPPA Medicare Advantage	$14.04

Ortho Glass 6

Facility

$27.68

Hospital Charge Code	3255557
Hospital Revenue Code	270
Min. Negotiated Rate	$11.07
Max. Negotiated Rate	$26.30
Rate for Payer: Aetna Commercial	$24.91
Rate for Payer: Humana Medicare Advantage	$11.63
Rate for Payer: UnitedHealthcare Commercial	$26.30
Rate for Payer: UnitedHealthcare Medicaid	$11.07
Rate for Payer: WPPA Medicare Advantage	$16.61

Ortho Glass 6

Facility

$27.68

Hospital Charge Code	3255557
Hospital Revenue Code	270
Min. Negotiated Rate	$24.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.91
Rate for Payer: UnitedHealthcare Commercial	$26.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Orthosis FootFlexor Ankle Foot Dorsal Flexion Support

Facility

$198.00

Hospital Charge Code	3251840
Hospital Revenue Code	270
Min. Negotiated Rate	$178.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$178.20
Rate for Payer: UnitedHealthcare Commercial	$188.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Orthosis FootFlexor Ankle Foot Dorsal Flexion Support

Facility

$198.00

Hospital Charge Code	3251840
Hospital Revenue Code	270
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$188.10
Rate for Payer: Aetna Commercial	$178.20
Rate for Payer: Humana Medicare Advantage	$83.16
Rate for Payer: UnitedHealthcare Commercial	$188.10
Rate for Payer: UnitedHealthcare Medicaid	$79.20
Rate for Payer: WPPA Medicare Advantage	$118.80

Orthotic Mgmt and Training Charges

Facility

$134.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	3950507
Hospital Revenue Code	420
Min. Negotiated Rate	$39.64
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$39.64
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$53.60
Rate for Payer: WPPA Medicare Advantage	$80.40

Orthotic Mgmt and Training Charges

Facility

$134.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	3950507
Hospital Revenue Code	420
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Orthotic Mgmt and Training Charges

Facility

$134.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	3970250
Hospital Revenue Code	430
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Orthotic Mgmt and Training Charges

Facility

$134.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	3970250
Hospital Revenue Code	430
Min. Negotiated Rate	$39.64
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$39.64
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$53.60
Rate for Payer: WPPA Medicare Advantage	$80.40

oseltamivir 30 mg Cap [HMC]

Facility

$33.36

Service Code	NDC 47781046813
Hospital Charge Code	3800061
Hospital Revenue Code	250
Min. Negotiated Rate	$13.34
Max. Negotiated Rate	$31.69
Rate for Payer: Aetna Commercial	$30.02
Rate for Payer: Humana Medicare Advantage	$14.01
Rate for Payer: UnitedHealthcare Commercial	$31.69
Rate for Payer: UnitedHealthcare Medicaid	$13.34
Rate for Payer: WPPA Medicare Advantage	$20.02

oseltamivir 30 mg Cap [HMC]

Facility

$33.36

Service Code	NDC 68180067511
Hospital Charge Code	3800061
Hospital Revenue Code	250
Min. Negotiated Rate	$13.34
Max. Negotiated Rate	$31.69
Rate for Payer: Aetna Commercial	$30.02
Rate for Payer: Humana Medicare Advantage	$14.01
Rate for Payer: UnitedHealthcare Commercial	$31.69
Rate for Payer: UnitedHealthcare Medicaid	$13.34
Rate for Payer: WPPA Medicare Advantage	$20.02

oseltamivir 30 mg Cap [HMC]

Facility

$33.36

Service Code	NDC 47781046813
Hospital Charge Code	3800061
Hospital Revenue Code	250
Min. Negotiated Rate	$30.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.02
Rate for Payer: UnitedHealthcare Commercial	$31.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oseltamivir 30 mg Cap [HMC]

Facility

$38.44

Service Code	NDC 00004080285
Hospital Charge Code	3800061
Hospital Revenue Code	250
Min. Negotiated Rate	$15.38
Max. Negotiated Rate	$36.52
Rate for Payer: Aetna Commercial	$34.60
Rate for Payer: Humana Medicare Advantage	$16.14
Rate for Payer: UnitedHealthcare Commercial	$36.52
Rate for Payer: UnitedHealthcare Medicaid	$15.38
Rate for Payer: WPPA Medicare Advantage	$23.06

oseltamivir 30 mg Cap [HMC]

Facility

$38.44

Service Code	NDC 00004080285
Hospital Charge Code	3800061
Hospital Revenue Code	250
Min. Negotiated Rate	$34.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.60
Rate for Payer: UnitedHealthcare Commercial	$36.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oseltamivir 30 mg Cap [HMC]

Facility

$33.36

Service Code	NDC 68180067511
Hospital Charge Code	3800061
Hospital Revenue Code	250
Min. Negotiated Rate	$30.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.02
Rate for Payer: UnitedHealthcare Commercial	$31.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oseltamivir 45 mg Cap [HMC]

Facility

$33.36

Service Code	NDC 68180067611
Hospital Charge Code	3800060
Hospital Revenue Code	250
Min. Negotiated Rate	$30.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.02
Rate for Payer: UnitedHealthcare Commercial	$31.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oseltamivir 45 mg Cap [HMC]

Facility

$33.36

Service Code	NDC 68180067611
Hospital Charge Code	3800060
Hospital Revenue Code	250
Min. Negotiated Rate	$13.34
Max. Negotiated Rate	$31.69
Rate for Payer: Aetna Commercial	$30.02
Rate for Payer: Humana Medicare Advantage	$14.01
Rate for Payer: UnitedHealthcare Commercial	$31.69
Rate for Payer: UnitedHealthcare Medicaid	$13.34
Rate for Payer: WPPA Medicare Advantage	$20.02

oseltamivir 45 mg Cap [HMC]

Facility

$38.44

Service Code	NDC 00004080185
Hospital Charge Code	3800060
Hospital Revenue Code	250
Min. Negotiated Rate	$15.38
Max. Negotiated Rate	$36.52
Rate for Payer: Aetna Commercial	$34.60
Rate for Payer: Humana Medicare Advantage	$16.14
Rate for Payer: UnitedHealthcare Commercial	$36.52
Rate for Payer: UnitedHealthcare Medicaid	$15.38
Rate for Payer: WPPA Medicare Advantage	$23.06

oseltamivir 45 mg Cap [HMC]

Facility

$38.44

Service Code	NDC 00004080185
Hospital Charge Code	3800060
Hospital Revenue Code	250
Min. Negotiated Rate	$34.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.60
Rate for Payer: UnitedHealthcare Commercial	$36.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oseltamivir 75 mg Cap [HMC]

Facility

$41.45

Service Code	NDC 00004080085
Hospital Charge Code	3800059
Hospital Revenue Code	250
Min. Negotiated Rate	$37.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$37.30
Rate for Payer: UnitedHealthcare Commercial	$39.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oseltamivir 75 mg Cap [HMC]

Facility

$35.91

Service Code	NDC 47781047013
Hospital Charge Code	3800059
Hospital Revenue Code	250
Min. Negotiated Rate	$32.32
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$32.32
Rate for Payer: UnitedHealthcare Commercial	$34.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oseltamivir 75 mg Cap [HMC]

Facility

$35.91

Service Code	NDC 68180067711
Hospital Charge Code	3800059
Hospital Revenue Code	250
Min. Negotiated Rate	$14.36
Max. Negotiated Rate	$34.11
Rate for Payer: Aetna Commercial	$32.32
Rate for Payer: Humana Medicare Advantage	$15.08
Rate for Payer: UnitedHealthcare Commercial	$34.11
Rate for Payer: UnitedHealthcare Medicaid	$14.36
Rate for Payer: WPPA Medicare Advantage	$21.55

oseltamivir 75 mg Cap [HMC]

Facility

$35.91

Service Code	NDC 47781047013
Hospital Charge Code	3800059
Hospital Revenue Code	250
Min. Negotiated Rate	$14.36
Max. Negotiated Rate	$34.11
Rate for Payer: Aetna Commercial	$32.32
Rate for Payer: Humana Medicare Advantage	$15.08
Rate for Payer: UnitedHealthcare Commercial	$34.11
Rate for Payer: UnitedHealthcare Medicaid	$14.36
Rate for Payer: WPPA Medicare Advantage	$21.55

Know your out-of-pocket cost for care.

All Charges