Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

QUEtiapine 50 mg oral tablet [HMC]

Facility

$6.69

Service Code	NDC 00904663961
Hospital Charge Code	3807006
Hospital Revenue Code	250
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$6.36
Rate for Payer: Aetna Commercial	$6.02
Rate for Payer: Humana Medicare Advantage	$2.81
Rate for Payer: UnitedHealthcare Commercial	$6.36
Rate for Payer: UnitedHealthcare Medicaid	$2.68
Rate for Payer: WPPA Medicare Advantage	$4.01

QUEtiapine 50 mg oral tablet [HMC]

Facility

$21.42

Service Code	NDC 67877024901
Hospital Charge Code	3807006
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

QUEtiapine 50 mg oral tablet [HMC]

Facility

$6.69

Service Code	NDC 00904663961
Hospital Charge Code	3807006
Hospital Revenue Code	250
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.02
Rate for Payer: UnitedHealthcare Commercial	$6.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

QUICKCLIP PRO 230CM REPOSITIONABLE GI CLIP FIXING DEVICE LOWER GI SINGLE-USE

Facility

$593.00

Hospital Charge Code	3258250
Hospital Revenue Code	270
Min. Negotiated Rate	$237.20
Max. Negotiated Rate	$563.35
Rate for Payer: Aetna Commercial	$533.70
Rate for Payer: Humana Medicare Advantage	$249.06
Rate for Payer: UnitedHealthcare Commercial	$563.35
Rate for Payer: UnitedHealthcare Medicaid	$237.20
Rate for Payer: WPPA Medicare Advantage	$355.80

QUICKCLIP PRO 230CM REPOSITIONABLE GI CLIP FIXING DEVICE LOWER GI SINGLE-USE

Facility

$593.00

Hospital Charge Code	3258250
Hospital Revenue Code	270
Min. Negotiated Rate	$533.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$533.70
Rate for Payer: UnitedHealthcare Commercial	$563.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

QuickTrach Adult 4.0MM

Facility

$458.67

Hospital Charge Code	3251641
Hospital Revenue Code	270
Min. Negotiated Rate	$412.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$412.80
Rate for Payer: UnitedHealthcare Commercial	$435.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

QuickTrach Adult 4.0MM

Facility

$458.67

Hospital Charge Code	3251641
Hospital Revenue Code	270
Min. Negotiated Rate	$183.47
Max. Negotiated Rate	$435.74
Rate for Payer: Aetna Commercial	$412.80
Rate for Payer: Humana Medicare Advantage	$192.64
Rate for Payer: UnitedHealthcare Commercial	$435.74
Rate for Payer: UnitedHealthcare Medicaid	$183.47
Rate for Payer: WPPA Medicare Advantage	$275.20

QuickTrach Pediatric 2.0MM

Facility

$458.67

Hospital Charge Code	3251203
Hospital Revenue Code	270
Min. Negotiated Rate	$412.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$412.80
Rate for Payer: UnitedHealthcare Commercial	$435.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

QuickTrach Pediatric 2.0MM

Facility

$458.67

Hospital Charge Code	3251203
Hospital Revenue Code	270
Min. Negotiated Rate	$183.47
Max. Negotiated Rate	$435.74
Rate for Payer: Aetna Commercial	$412.80
Rate for Payer: Humana Medicare Advantage	$192.64
Rate for Payer: UnitedHealthcare Commercial	$435.74
Rate for Payer: UnitedHealthcare Medicaid	$183.47
Rate for Payer: WPPA Medicare Advantage	$275.20

quinapril 10 mg Tab [HMC]

Facility

$8.67

Service Code	NDC 68001018805
Hospital Charge Code	3809214
Hospital Revenue Code	250
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$8.24
Rate for Payer: Aetna Commercial	$7.80
Rate for Payer: Humana Medicare Advantage	$3.64
Rate for Payer: UnitedHealthcare Commercial	$8.24
Rate for Payer: UnitedHealthcare Medicaid	$3.47
Rate for Payer: WPPA Medicare Advantage	$5.20

quinapril 10 mg Tab [HMC]

Facility

$8.67

Service Code	NDC 68001018805
Hospital Charge Code	3809214
Hospital Revenue Code	250
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.80
Rate for Payer: UnitedHealthcare Commercial	$8.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

rabies immune globulin, human 150 intl units/mL IM Sol 10 mL [HMC]

Facility

$5,107.79

Service Code	HCPCS 90376
Hospital Charge Code	3803589
Hospital Revenue Code	636
Min. Negotiated Rate	$371.02
Max. Negotiated Rate	$4,852.40
Rate for Payer: Aetna Commercial	$4,597.01
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$371.02
Rate for Payer: Humana Medicare Advantage	$2,145.27
Rate for Payer: UnitedHealthcare Commercial	$4,852.40
Rate for Payer: UnitedHealthcare Medicaid	$479.72
Rate for Payer: WPPA Medicare Advantage	$3,064.67

rabies immune globulin, human 150 intl units/mL IM Sol 10 mL [HMC]

Facility

$5,107.79

Service Code	HCPCS 90376
Hospital Charge Code	3803589
Hospital Revenue Code	636
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,852.40
Rate for Payer: Aetna Commercial	$4,597.01
Rate for Payer: UnitedHealthcare Commercial	$4,852.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

rabies immune globulin, human 150 intl units/mL IM Sol [HMC]

Facility

$1,144.13

Service Code	HCPCS 90376
Hospital Charge Code	3803589
Hospital Revenue Code	636
Min. Negotiated Rate	$1,029.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,029.72
Rate for Payer: Aetna Commercial	$1,024.59
Rate for Payer: Aetna Commercial	$1,484.32
Rate for Payer: UnitedHealthcare Commercial	$1,086.92
Rate for Payer: UnitedHealthcare Commercial	$1,081.51
Rate for Payer: UnitedHealthcare Commercial	$1,566.78
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

rabies immune globulin, human 150 intl units/mL IM Sol [HMC]

Facility

$1,144.13

Service Code	HCPCS 90376
Hospital Charge Code	3803589
Hospital Revenue Code	636
Min. Negotiated Rate	$371.02
Max. Negotiated Rate	$1,086.92
Rate for Payer: Aetna Commercial	$1,029.72
Rate for Payer: Aetna Commercial	$1,024.59
Rate for Payer: Aetna Commercial	$1,484.32
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$371.02
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$371.02
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$371.02
Rate for Payer: Humana Medicare Advantage	$692.68
Rate for Payer: Humana Medicare Advantage	$478.14
Rate for Payer: Humana Medicare Advantage	$480.53
Rate for Payer: UnitedHealthcare Commercial	$1,566.78
Rate for Payer: UnitedHealthcare Commercial	$1,086.92
Rate for Payer: UnitedHealthcare Commercial	$1,081.51
Rate for Payer: UnitedHealthcare Medicaid	$479.72
Rate for Payer: UnitedHealthcare Medicaid	$479.72
Rate for Payer: UnitedHealthcare Medicaid	$479.72
Rate for Payer: WPPA Medicare Advantage	$686.48
Rate for Payer: WPPA Medicare Advantage	$683.06
Rate for Payer: WPPA Medicare Advantage	$989.54

rabies vaccine, purified chick embryo cell 2.5 intl units Pow [HMC]

Facility

$702.28

Service Code	NDC 58160096412
Hospital Charge Code	3803597
Hospital Revenue Code	250
Min. Negotiated Rate	$280.91
Max. Negotiated Rate	$667.17
Rate for Payer: Aetna Commercial	$632.05
Rate for Payer: Humana Medicare Advantage	$294.96
Rate for Payer: UnitedHealthcare Commercial	$667.17
Rate for Payer: UnitedHealthcare Medicaid	$280.91
Rate for Payer: WPPA Medicare Advantage	$421.37

rabies vaccine, purified chick embryo cell 2.5 intl units Pow [HMC]

Facility

$765.04

Service Code	NDC 50632001001
Hospital Charge Code	3803597
Hospital Revenue Code	250
Min. Negotiated Rate	$306.02
Max. Negotiated Rate	$726.79
Rate for Payer: Aetna Commercial	$688.54
Rate for Payer: Humana Medicare Advantage	$321.32
Rate for Payer: UnitedHealthcare Commercial	$726.79
Rate for Payer: UnitedHealthcare Medicaid	$306.02
Rate for Payer: WPPA Medicare Advantage	$459.02

rabies vaccine, purified chick embryo cell 2.5 intl units Pow [HMC]

Facility

$702.28

Service Code	NDC 58160096412
Hospital Charge Code	3803597
Hospital Revenue Code	250
Min. Negotiated Rate	$632.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$632.05
Rate for Payer: UnitedHealthcare Commercial	$667.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

rabies vaccine, purified chick embryo cell 2.5 intl units Pow [HMC]

Facility

$765.04

Service Code	NDC 50632001001
Hospital Charge Code	3803597
Hospital Revenue Code	250
Min. Negotiated Rate	$688.54
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$688.54
Rate for Payer: UnitedHealthcare Commercial	$726.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

racepinephrine 2.25% UD [HMC]

Facility

$15.00

Service Code	NDC 00487590199
Hospital Charge Code	3809486
Hospital Revenue Code	250
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.50
Rate for Payer: UnitedHealthcare Commercial	$14.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

racepinephrine 2.25% UD [HMC]

Facility

$15.00

Service Code	NDC 00487590199
Hospital Charge Code	3809486
Hospital Revenue Code	250
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$14.25
Rate for Payer: Aetna Commercial	$13.50
Rate for Payer: Humana Medicare Advantage	$6.30
Rate for Payer: UnitedHealthcare Commercial	$14.25
Rate for Payer: UnitedHealthcare Medicaid	$6.00
Rate for Payer: WPPA Medicare Advantage	$9.00

Radiofrequency Ablation Thoracic w/Fluoro

Facility

$1,842.00

Service Code	HCPCS 64633
Hospital Charge Code	3154633
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,749.90
Rate for Payer: Aetna Commercial	$1,657.80
Rate for Payer: UnitedHealthcare Commercial	$1,749.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Radiofrequency Ablation Thoracic w/Fluoro

Facility

$1,842.00

Service Code	HCPCS 64633
Hospital Charge Code	3154633
Hospital Revenue Code	360
Min. Negotiated Rate	$353.46
Max. Negotiated Rate	$1,749.90
Rate for Payer: Aetna Commercial	$1,657.80
Rate for Payer: Humana Medicare Advantage	$773.64
Rate for Payer: UnitedHealthcare Commercial	$1,749.90
Rate for Payer: UnitedHealthcare Medicaid	$353.46
Rate for Payer: WPPA Medicare Advantage	$1,105.20

Radiofrequency Ablation w/fluro

Facility

$1,842.00

Service Code	HCPCS 64620
Hospital Charge Code	3154620
Hospital Revenue Code	360
Min. Negotiated Rate	$295.27
Max. Negotiated Rate	$1,749.90
Rate for Payer: Aetna Commercial	$1,657.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$551.00
Rate for Payer: Humana Medicare Advantage	$773.64
Rate for Payer: UnitedHealthcare Commercial	$1,749.90
Rate for Payer: UnitedHealthcare Medicaid	$295.27
Rate for Payer: WPPA Medicare Advantage	$1,105.20

Radiofrequency Ablation w/fluro

Facility

$1,842.00

Service Code	HCPCS 64620
Hospital Charge Code	3154620
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,749.90
Rate for Payer: Aetna Commercial	$1,657.80
Rate for Payer: UnitedHealthcare Commercial	$1,749.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges