Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

oseltamivir 75 mg Cap [HMC]

Facility

$41.45

Service Code	NDC 00004080085
Hospital Charge Code	3800059
Hospital Revenue Code	250
Min. Negotiated Rate	$16.58
Max. Negotiated Rate	$39.38
Rate for Payer: Aetna Commercial	$37.30
Rate for Payer: Humana Medicare Advantage	$17.41
Rate for Payer: UnitedHealthcare Commercial	$39.38
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: WPPA Medicare Advantage	$24.87

oseltamivir 75 mg Cap [HMC]

Facility

$35.91

Service Code	NDC 68180067711
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

Osmolality (S) QST

Facility

$95.00

Service Code	HCPCS 83930
Hospital Charge Code	3552112
Hospital Revenue Code	300
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: UnitedHealthcare Commercial	$90.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Osmolality (S) QST

Facility

$95.00

Service Code	HCPCS 83930
Hospital Charge Code	3552112
Hospital Revenue Code	300
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$90.25
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$28.69
Rate for Payer: Humana Medicare Advantage	$39.90
Rate for Payer: UnitedHealthcare Commercial	$90.25
Rate for Payer: UnitedHealthcare Medicaid	$6.46
Rate for Payer: WPPA Medicare Advantage	$57.00

Osmolality (U) QST

Facility

$95.00

Service Code	HCPCS 83935
Hospital Charge Code	3552113
Hospital Revenue Code	300
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: UnitedHealthcare Commercial	$90.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Osmolality (U) QST

Facility

$95.00

Service Code	HCPCS 83935
Hospital Charge Code	3552113
Hospital Revenue Code	300
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$90.25
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.23
Rate for Payer: Humana Medicare Advantage	$39.90
Rate for Payer: UnitedHealthcare Commercial	$90.25
Rate for Payer: UnitedHealthcare Medicaid	$6.46
Rate for Payer: WPPA Medicare Advantage	$57.00

OSTEOMYELITIS WITH CC

Facility

$7,942.50

Service Code	MSDRG 540
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,942.50
Rate for Payer: UnitedHealthcare Medicaid	$7,942.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OSTEOMYELITIS WITH MCC

Facility

$12,072.60

Service Code	MSDRG 539
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,072.60
Rate for Payer: UnitedHealthcare Medicaid	$12,072.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OSTEOMYELITIS WITHOUT CC/MCC

Facility

$4,829.04

Service Code	MSDRG 541
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,829.04
Rate for Payer: UnitedHealthcare Medicaid	$4,829.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Adapt Stoma Barrier Expanding Paste, 0.5 oz. Tube

Facility

$2.50

Hospital Charge Code	3252252
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Adapt Stoma Barrier Expanding Paste, 0.5 oz. Tube

Facility

$2.50

Hospital Charge Code	3252252
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

Ostomy Barrier Ring Hollister Adapt Slim CeraRing 2 OD x 2.3 mm Thickness - Small-Thin

Facility

$3.00

Hospital Charge Code	3252232
Hospital Revenue Code	270
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Barrier Ring Hollister Adapt Slim CeraRing 2 OD x 2.3 mm Thickness - Small-Thin

Facility

$3.00

Hospital Charge Code	3252232
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Humana Medicare Advantage	$1.26
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: WPPA Medicare Advantage	$1.80

Ostomy Barrier Ring Hollister Adapt Slim CeraRing 4 OD x 2.3 mm Thickness - Large-Thin

Facility

$2.66

Hospital Charge Code	CDM
Hospital Revenue Code	270
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$2.53
Rate for Payer: Aetna Commercial	$2.39
Rate for Payer: Humana Medicare Advantage	$1.12
Rate for Payer: UnitedHealthcare Commercial	$2.53
Rate for Payer: UnitedHealthcare Medicaid	$1.06
Rate for Payer: WPPA Medicare Advantage	$1.60

Ostomy Barrier Ring Hollister Adapt Slim CeraRing 4 OD x 2.3 mm Thickness - Large-Thin

Facility

$2.66

Hospital Charge Code	CDM
Hospital Revenue Code	270
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.39
Rate for Payer: UnitedHealthcare Commercial	$2.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Barrier Ring Hollister Adapt Thick CeraRing 2 OD x 4.5 mm Thickness - Small-Thick

Facility

$2.66

Hospital Charge Code	3252237
Hospital Revenue Code	270
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$2.53
Rate for Payer: Aetna Commercial	$2.39
Rate for Payer: Humana Medicare Advantage	$1.12
Rate for Payer: UnitedHealthcare Commercial	$2.53
Rate for Payer: UnitedHealthcare Medicaid	$1.06
Rate for Payer: WPPA Medicare Advantage	$1.60

Ostomy Barrier Ring Hollister Adapt Thick CeraRing 2 OD x 4.5 mm Thickness - Small-Thick

Facility

$2.66

Hospital Charge Code	3252237
Hospital Revenue Code	270
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.39
Rate for Payer: UnitedHealthcare Commercial	$2.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Hollister Pouch 2-1/4 ULTRA CLEAR

Facility

$2.50

Hospital Charge Code	3254208
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

Ostomy Hollister Pouch 2-1/4 ULTRA CLEAR

Facility

$2.50

Hospital Charge Code	3254208
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Hollister Pouch 2-3/4 TRANSPARENT

Facility

$2.50

Hospital Charge Code	3254209
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Hollister Pouch 2-3/4 TRANSPARENT

Facility

$2.50

Hospital Charge Code	3254209
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

Ostomy Hollister Skin Barrier Ring 2-1/4 - MEDIUM

Facility

$2.50

Hospital Charge Code	3252282
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

Ostomy Hollister Skin Barrier Ring 2-1/4 - MEDIUM

Facility

$2.50

Hospital Charge Code	3252282
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Hollister Skin Barrier Ring 2-3/4 - LARGE Convex

Facility

$3.42

Hospital Charge Code	3252284
Hospital Revenue Code	270
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.08
Rate for Payer: UnitedHealthcare Commercial	$3.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Hollister Skin Barrier Ring 2-3/4 - LARGE Convex

Facility

$3.42

Hospital Charge Code	3252284
Hospital Revenue Code	270
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Commercial	$3.08
Rate for Payer: Humana Medicare Advantage	$1.44
Rate for Payer: UnitedHealthcare Commercial	$3.25
Rate for Payer: UnitedHealthcare Medicaid	$1.37
Rate for Payer: WPPA Medicare Advantage	$2.05

Know your out-of-pocket cost for care.

All Charges