Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

oxymetazoline Nasal 0.05% Spry [HMC]

Facility

$25.38

Service Code	NDC 00904742730
Hospital Charge Code	3800488
Hospital Revenue Code	250
Min. Negotiated Rate	$22.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.84
Rate for Payer: UnitedHealthcare Commercial	$24.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxymetazoline Nasal 0.05% Spry [HMC]

Facility

$25.38

Service Code	NDC 00904676130
Hospital Charge Code	3800488
Hospital Revenue Code	250
Min. Negotiated Rate	$22.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.84
Rate for Payer: UnitedHealthcare Commercial	$24.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

oxymetazoline Nasal 0.05% Spry [HMC]

Facility

$25.38

Service Code	NDC 00904742730
Hospital Charge Code	3800488
Hospital Revenue Code	250
Min. Negotiated Rate	$10.15
Max. Negotiated Rate	$24.11
Rate for Payer: Aetna Commercial	$22.84
Rate for Payer: Humana Medicare Advantage	$10.66
Rate for Payer: UnitedHealthcare Commercial	$24.11
Rate for Payer: UnitedHealthcare Medicaid	$10.15
Rate for Payer: WPPA Medicare Advantage	$15.23

oxymetazoline Nasal 0.05% Spry [HMC]

Facility

$25.38

Service Code	NDC 00904676130
Hospital Charge Code	3800488
Hospital Revenue Code	250
Min. Negotiated Rate	$10.15
Max. Negotiated Rate	$24.11
Rate for Payer: Aetna Commercial	$22.84
Rate for Payer: Humana Medicare Advantage	$10.66
Rate for Payer: UnitedHealthcare Commercial	$24.11
Rate for Payer: UnitedHealthcare Medicaid	$10.15
Rate for Payer: WPPA Medicare Advantage	$15.23

oxytocin 10 intl units/mL Inj Sol [HMC]

Facility

$40.70

Service Code	HCPCS J2590
Hospital Charge Code	3806524
Hospital Revenue Code	250
Min. Negotiated Rate	$36.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.63
Rate for Payer: Aetna Commercial	$26.10
Rate for Payer: Aetna Commercial	$37.44
Rate for Payer: UnitedHealthcare Commercial	$38.66
Rate for Payer: UnitedHealthcare Commercial	$27.55
Rate for Payer: UnitedHealthcare Commercial	$39.52
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

oxytocin 10 intl units/mL Inj Sol [HMC]

Facility

$40.70

Service Code	HCPCS J2590
Hospital Charge Code	3806524
Hospital Revenue Code	250
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$38.66
Rate for Payer: Aetna Commercial	$36.63
Rate for Payer: Aetna Commercial	$26.10
Rate for Payer: Aetna Commercial	$37.44
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.05
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.05
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.05
Rate for Payer: Humana Medicare Advantage	$17.47
Rate for Payer: Humana Medicare Advantage	$12.18
Rate for Payer: Humana Medicare Advantage	$17.09
Rate for Payer: UnitedHealthcare Commercial	$39.52
Rate for Payer: UnitedHealthcare Commercial	$38.66
Rate for Payer: UnitedHealthcare Commercial	$27.55
Rate for Payer: UnitedHealthcare Medicaid	$0.87
Rate for Payer: UnitedHealthcare Medicaid	$0.87
Rate for Payer: UnitedHealthcare Medicaid	$0.87
Rate for Payer: WPPA Medicare Advantage	$24.42
Rate for Payer: WPPA Medicare Advantage	$17.40
Rate for Payer: WPPA Medicare Advantage	$24.96

Oyster (F290) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552829
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

Oyster (F290) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552829
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

P9612 Catheterize for urine spec ProFee

Facility

$298.00

Service Code	HCPCS P9612
Hospital Charge Code	3306001
Hospital Revenue Code	450
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

P9612 Catheterize for urine spec ProFee

Facility

$298.00

Service Code	HCPCS P9612
Hospital Charge Code	3306001
Hospital Revenue Code	450
Min. Negotiated Rate	$119.20
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$119.20
Rate for Payer: WPPA Medicare Advantage	$178.80

Pack C Section V

Facility

$118.41

Hospital Charge Code	3253593
Hospital Revenue Code	270
Min. Negotiated Rate	$47.36
Max. Negotiated Rate	$112.49
Rate for Payer: Aetna Commercial	$106.57
Rate for Payer: Humana Medicare Advantage	$49.73
Rate for Payer: UnitedHealthcare Commercial	$112.49
Rate for Payer: UnitedHealthcare Medicaid	$47.36
Rate for Payer: WPPA Medicare Advantage	$71.05

Pack C Section V

Facility

$118.41

Hospital Charge Code	3253593
Hospital Revenue Code	270
Min. Negotiated Rate	$106.57
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$106.57
Rate for Payer: UnitedHealthcare Commercial	$112.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pack EENT I Head and Neck

Facility

$46.00

Hospital Charge Code	3253596
Hospital Revenue Code	270
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.40
Rate for Payer: UnitedHealthcare Commercial	$43.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pack EENT I Head and Neck

Facility

$46.00

Hospital Charge Code	3253596
Hospital Revenue Code	270
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$43.70
Rate for Payer: Aetna Commercial	$41.40
Rate for Payer: Humana Medicare Advantage	$19.32
Rate for Payer: UnitedHealthcare Commercial	$43.70
Rate for Payer: UnitedHealthcare Medicaid	$18.40
Rate for Payer: WPPA Medicare Advantage	$27.60

Packing Strip Iodoform 1

Facility

$9.00

Hospital Charge Code	3253536
Hospital Revenue Code	270
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Packing Strip Iodoform 1

Facility

$9.00

Hospital Charge Code	3253536
Hospital Revenue Code	270
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$8.55
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: Humana Medicare Advantage	$3.78
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: WPPA Medicare Advantage	$5.40

Packing Strip Iodoform 1/2

Facility

$7.74

Hospital Charge Code	3255101
Hospital Revenue Code	270
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$7.35
Rate for Payer: Aetna Commercial	$6.97
Rate for Payer: Humana Medicare Advantage	$3.25
Rate for Payer: UnitedHealthcare Commercial	$7.35
Rate for Payer: UnitedHealthcare Medicaid	$3.10
Rate for Payer: WPPA Medicare Advantage	$4.64

Packing Strip Iodoform 1/2

Facility

$7.74

Hospital Charge Code	3255101
Hospital Revenue Code	270
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.97
Rate for Payer: UnitedHealthcare Commercial	$7.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Packing Strip Iodoform 1/4

Facility

$6.62

Hospital Charge Code	3259186
Hospital Revenue Code	270
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

Packing Strip Iodoform 1/4

Facility

$6.62

Hospital Charge Code	3259186
Hospital Revenue Code	270
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

Packing Strip Plain 1

Facility

$8.64

Hospital Charge Code	3254218
Hospital Revenue Code	270
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$8.21
Rate for Payer: Aetna Commercial	$7.78
Rate for Payer: Humana Medicare Advantage	$3.63
Rate for Payer: UnitedHealthcare Commercial	$8.21
Rate for Payer: UnitedHealthcare Medicaid	$3.46
Rate for Payer: WPPA Medicare Advantage	$5.18

Packing Strip Plain 1

Facility

$8.64

Hospital Charge Code	3254218
Hospital Revenue Code	270
Min. Negotiated Rate	$7.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.78
Rate for Payer: UnitedHealthcare Commercial	$8.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Packing Strip Plain 1/2

Facility

$7.92

Hospital Charge Code	3252123
Hospital Revenue Code	270
Min. Negotiated Rate	$7.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.13
Rate for Payer: UnitedHealthcare Commercial	$7.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Packing Strip Plain 1/2

Facility

$7.92

Hospital Charge Code	3252123
Hospital Revenue Code	270
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$7.52
Rate for Payer: Aetna Commercial	$7.13
Rate for Payer: Humana Medicare Advantage	$3.33
Rate for Payer: UnitedHealthcare Commercial	$7.52
Rate for Payer: UnitedHealthcare Medicaid	$3.17
Rate for Payer: WPPA Medicare Advantage	$4.75

Packing Strip Plain 1/4

Facility

$6.98

Hospital Charge Code	3254211
Hospital Revenue Code	270
Min. Negotiated Rate	$6.28
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.28
Rate for Payer: UnitedHealthcare Commercial	$6.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges