Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

oxybutynin 5 mg Tab [HMC]

Facility

$7.16

Service Code	NDC 00904702761
Hospital Charge Code	3806516
Hospital Revenue Code	250
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$6.80
Rate for Payer: Aetna Commercial	$6.44
Rate for Payer: Humana Medicare Advantage	$3.01
Rate for Payer: UnitedHealthcare Commercial	$6.80
Rate for Payer: UnitedHealthcare Medicaid	$2.86
Rate for Payer: WPPA Medicare Advantage	$4.30

oxyCODONE 10 mg ER Tab [HMC]

Facility

$21.42

Service Code	NDC 59011041020
Hospital Charge Code	3808884
Hospital Revenue Code	250
Min. Negotiated Rate	$19.28
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.28
Rate for Payer: UnitedHealthcare Commercial	$20.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxyCODONE 10 mg ER Tab [HMC]

Facility

$21.42

Service Code	NDC 59011041020
Hospital Charge Code	3808884
Hospital Revenue Code	250
Min. Negotiated Rate	$8.57
Max. Negotiated Rate	$20.35
Rate for Payer: Aetna Commercial	$19.28
Rate for Payer: Humana Medicare Advantage	$9.00
Rate for Payer: UnitedHealthcare Commercial	$20.35
Rate for Payer: UnitedHealthcare Medicaid	$8.57
Rate for Payer: WPPA Medicare Advantage	$12.85

oxyCODONE 15 mg Tab [HMC]

Facility

$12.11

Service Code	NDC 00406851562
Hospital Charge Code	3800032
Hospital Revenue Code	250
Min. Negotiated Rate	$4.84
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna Commercial	$10.90
Rate for Payer: Humana Medicare Advantage	$5.09
Rate for Payer: UnitedHealthcare Commercial	$11.50
Rate for Payer: UnitedHealthcare Medicaid	$4.84
Rate for Payer: WPPA Medicare Advantage	$7.27

oxyCODONE 15 mg Tab [HMC]

Facility

$12.11

Service Code	NDC 00406851562
Hospital Charge Code	3800032
Hospital Revenue Code	250
Min. Negotiated Rate	$10.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.90
Rate for Payer: UnitedHealthcare Commercial	$11.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxyCODONE 15 mg Tab [HMC]

Facility

$10.68

Service Code	NDC 00406851501
Hospital Charge Code	3800032
Hospital Revenue Code	250
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxyCODONE 15 mg Tab [HMC]

Facility

$7.14

Service Code	NDC 68094000561
Hospital Charge Code	3800032
Hospital Revenue Code	250
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.43
Rate for Payer: UnitedHealthcare Commercial	$6.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxyCODONE 15 mg Tab [HMC]

Facility

$7.14

Service Code	NDC 68094000561
Hospital Charge Code	3800032
Hospital Revenue Code	250
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$6.78
Rate for Payer: Aetna Commercial	$6.43
Rate for Payer: Humana Medicare Advantage	$3.00
Rate for Payer: UnitedHealthcare Commercial	$6.78
Rate for Payer: UnitedHealthcare Medicaid	$2.86
Rate for Payer: WPPA Medicare Advantage	$4.28

oxyCODONE 15 mg Tab [HMC]

Facility

$10.68

Service Code	NDC 00406851501
Hospital Charge Code	3800032
Hospital Revenue Code	250
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$10.15
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: Humana Medicare Advantage	$4.49
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: UnitedHealthcare Medicaid	$4.27
Rate for Payer: WPPA Medicare Advantage	$6.41

oxyCODONE 5 mg Tab [HMC]

Facility

$6.62

Service Code	NDC 68084035401
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$6.29
Rate for Payer: Aetna Commercial	$5.96
Rate for Payer: Humana Medicare Advantage	$2.78
Rate for Payer: UnitedHealthcare Commercial	$6.29
Rate for Payer: UnitedHealthcare Medicaid	$2.65
Rate for Payer: WPPA Medicare Advantage	$3.97

oxyCODONE 5 mg Tab [HMC]

Facility

$6.62

Service Code	NDC 00406055201
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$6.29
Rate for Payer: Aetna Commercial	$5.96
Rate for Payer: Humana Medicare Advantage	$2.78
Rate for Payer: UnitedHealthcare Commercial	$6.29
Rate for Payer: UnitedHealthcare Medicaid	$2.65
Rate for Payer: WPPA Medicare Advantage	$3.97

oxyCODONE 5 mg Tab [HMC]

Facility

$6.18

Service Code	NDC 00904696661
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$5.87
Rate for Payer: Aetna Commercial	$5.56
Rate for Payer: Humana Medicare Advantage	$2.60
Rate for Payer: UnitedHealthcare Commercial	$5.87
Rate for Payer: UnitedHealthcare Medicaid	$2.47
Rate for Payer: WPPA Medicare Advantage	$3.71

oxyCODONE 5 mg Tab [HMC]

Facility

$6.62

Service Code	NDC 65162004710
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.96
Rate for Payer: UnitedHealthcare Commercial	$6.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxyCODONE 5 mg Tab [HMC]

Facility

$6.86

Service Code	NDC 42858000110
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$6.52
Rate for Payer: Aetna Commercial	$6.17
Rate for Payer: Humana Medicare Advantage	$2.88
Rate for Payer: UnitedHealthcare Commercial	$6.52
Rate for Payer: UnitedHealthcare Medicaid	$2.74
Rate for Payer: WPPA Medicare Advantage	$4.12

oxyCODONE 5 mg Tab [HMC]

Facility

$6.62

Service Code	NDC 00406055262
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.96
Rate for Payer: UnitedHealthcare Commercial	$6.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxyCODONE 5 mg Tab [HMC]

Facility

$6.62

Service Code	NDC 65162004710
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$6.29
Rate for Payer: Aetna Commercial	$5.96
Rate for Payer: Humana Medicare Advantage	$2.78
Rate for Payer: UnitedHealthcare Commercial	$6.29
Rate for Payer: UnitedHealthcare Medicaid	$2.65
Rate for Payer: WPPA Medicare Advantage	$3.97

oxyCODONE 5 mg Tab [HMC]

Facility

$6.62

Service Code	NDC 00406055201
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.96
Rate for Payer: UnitedHealthcare Commercial	$6.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxyCODONE 5 mg Tab [HMC]

Facility

$6.62

Service Code	NDC 68084035401
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.96
Rate for Payer: UnitedHealthcare Commercial	$6.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxyCODONE 5 mg Tab [HMC]

Facility

$6.18

Service Code	NDC 00904696661
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$5.56
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.56
Rate for Payer: UnitedHealthcare Commercial	$5.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxyCODONE 5 mg Tab [HMC]

Facility

$6.86

Service Code	NDC 42858000110
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.17
Rate for Payer: UnitedHealthcare Commercial	$6.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxyCODONE 5 mg Tab [HMC]

Facility

$6.62

Service Code	NDC 00406055262
Hospital Charge Code	3805598
Hospital Revenue Code	250
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$6.29
Rate for Payer: Aetna Commercial	$5.96
Rate for Payer: Humana Medicare Advantage	$2.78
Rate for Payer: UnitedHealthcare Commercial	$6.29
Rate for Payer: UnitedHealthcare Medicaid	$2.65
Rate for Payer: WPPA Medicare Advantage	$3.97

Oxycodone Confirmation GC/MS, U QST

Facility

$69.00

Service Code	HCPCS 80361
Hospital Charge Code	3558036
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

Oxycodone Confirmation GC/MS, U QST

Facility

$69.00

Service Code	HCPCS 80361
Hospital Charge Code	3558036
Hospital Revenue Code	300
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$65.55
Rate for Payer: Aetna Commercial	$62.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$42.68
Rate for Payer: Humana Medicare Advantage	$28.98
Rate for Payer: UnitedHealthcare Commercial	$65.55
Rate for Payer: UnitedHealthcare Medicaid	$10.40
Rate for Payer: WPPA Medicare Advantage	$41.40

Oxygen Extension Tubing 14'

Facility

$2.50

Hospital Charge Code	3255028
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

Oxygen Extension Tubing 14'

Facility

$2.50

Hospital Charge Code	3255028
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

Know your out-of-pocket cost for care.

All Charges