Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Radiofrequency Lumbar Ablation w/Fluoro

Facility

$1,810.00

Service Code	HCPCS 64635
Hospital Charge Code	3154635
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,719.50
Rate for Payer: Aetna Commercial	$1,629.00
Rate for Payer: UnitedHealthcare Commercial	$1,719.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Radiofrequency Lumbar Ablation w/Fluoro

Facility

$1,810.00

Service Code	HCPCS 64635
Hospital Charge Code	3154635
Hospital Revenue Code	360
Min. Negotiated Rate	$609.97
Max. Negotiated Rate	$1,719.50
Rate for Payer: Aetna Commercial	$1,629.00
Rate for Payer: Humana Medicare Advantage	$760.20
Rate for Payer: UnitedHealthcare Commercial	$1,719.50
Rate for Payer: UnitedHealthcare Medicaid	$609.97
Rate for Payer: WPPA Medicare Advantage	$1,086.00

RADIOTHERAPY

Facility

$8,133.12

Service Code	MSDRG 849
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,133.12
Rate for Payer: UnitedHealthcare Medicaid	$8,133.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

raloxifene 60 mg Tab [HMC]

Facility

$22.82

Service Code	NDC 43598050501
Hospital Charge Code	3802564
Hospital Revenue Code	250
Min. Negotiated Rate	$9.13
Max. Negotiated Rate	$21.68
Rate for Payer: Aetna Commercial	$20.54
Rate for Payer: Humana Medicare Advantage	$9.58
Rate for Payer: UnitedHealthcare Commercial	$21.68
Rate for Payer: UnitedHealthcare Medicaid	$9.13
Rate for Payer: WPPA Medicare Advantage	$13.69

raloxifene 60 mg Tab [HMC]

Facility

$22.82

Service Code	NDC 69097082502
Hospital Charge Code	3802564
Hospital Revenue Code	250
Min. Negotiated Rate	$9.13
Max. Negotiated Rate	$21.68
Rate for Payer: Aetna Commercial	$20.54
Rate for Payer: Humana Medicare Advantage	$9.58
Rate for Payer: UnitedHealthcare Commercial	$21.68
Rate for Payer: UnitedHealthcare Medicaid	$9.13
Rate for Payer: WPPA Medicare Advantage	$13.69

raloxifene 60 mg Tab [HMC]

Facility

$22.82

Service Code	NDC 50268069415
Hospital Charge Code	3802564
Hospital Revenue Code	250
Min. Negotiated Rate	$9.13
Max. Negotiated Rate	$21.68
Rate for Payer: Aetna Commercial	$20.54
Rate for Payer: Humana Medicare Advantage	$9.58
Rate for Payer: UnitedHealthcare Commercial	$21.68
Rate for Payer: UnitedHealthcare Medicaid	$9.13
Rate for Payer: WPPA Medicare Advantage	$13.69

raloxifene 60 mg Tab [HMC]

Facility

$22.82

Service Code	NDC 69097082502
Hospital Charge Code	3802564
Hospital Revenue Code	250
Min. Negotiated Rate	$20.54
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.54
Rate for Payer: UnitedHealthcare Commercial	$21.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

raloxifene 60 mg Tab [HMC]

Facility

$22.82

Service Code	NDC 50268069415
Hospital Charge Code	3802564
Hospital Revenue Code	250
Min. Negotiated Rate	$20.54
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.54
Rate for Payer: UnitedHealthcare Commercial	$21.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

raloxifene 60 mg Tab [HMC]

Facility

$22.82

Service Code	NDC 43598050501
Hospital Charge Code	3802564
Hospital Revenue Code	250
Min. Negotiated Rate	$20.54
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.54
Rate for Payer: UnitedHealthcare Commercial	$21.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ramipril 5 mg Cap [HMC]

Facility

$10.40

Service Code	NDC 68001043000
Hospital Charge Code	3809156
Hospital Revenue Code	250
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$9.88
Rate for Payer: Aetna Commercial	$9.36
Rate for Payer: Humana Medicare Advantage	$4.37
Rate for Payer: UnitedHealthcare Commercial	$9.88
Rate for Payer: UnitedHealthcare Medicaid	$4.16
Rate for Payer: WPPA Medicare Advantage	$6.24

ramipril 5 mg Cap [HMC]

Facility

$10.68

Service Code	NDC 65862047601
Hospital Charge Code	3809156
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

ramipril 5 mg Cap [HMC]

Facility

$10.68

Service Code	NDC 65862047601
Hospital Charge Code	3809156
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

ramipril 5 mg Cap [HMC]

Facility

$10.68

Service Code	NDC 68180059001
Hospital Charge Code	3809156
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

ramipril 5 mg Cap [HMC]

Facility

$10.68

Service Code	NDC 68180059001
Hospital Charge Code	3809156
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

ramipril 5 mg Cap [HMC]

Facility

$10.40

Service Code	NDC 68001043000
Hospital Charge Code	3809156
Hospital Revenue Code	250
Min. Negotiated Rate	$9.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.36
Rate for Payer: UnitedHealthcare Commercial	$9.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

rasagiline 1 mg oral tablet [HMC]

Facility

$50.74

Service Code	NDC 68546022956
Hospital Charge Code	3800334
Hospital Revenue Code	250
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$48.20
Rate for Payer: Aetna Commercial	$45.67
Rate for Payer: Humana Medicare Advantage	$21.31
Rate for Payer: UnitedHealthcare Commercial	$48.20
Rate for Payer: UnitedHealthcare Medicaid	$20.30
Rate for Payer: WPPA Medicare Advantage	$30.44

rasagiline 1 mg oral tablet [HMC]

Facility

$29.98

Service Code	NDC 67877026030
Hospital Charge Code	3800334
Hospital Revenue Code	250
Min. Negotiated Rate	$26.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.98
Rate for Payer: UnitedHealthcare Commercial	$28.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

rasagiline 1 mg oral tablet [HMC]

Facility

$50.74

Service Code	NDC 68546022956
Hospital Charge Code	3800334
Hospital Revenue Code	250
Min. Negotiated Rate	$45.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.67
Rate for Payer: UnitedHealthcare Commercial	$48.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

rasagiline 1 mg oral tablet [HMC]

Facility

$29.98

Service Code	NDC 67877026030
Hospital Charge Code	3800334
Hospital Revenue Code	250
Min. Negotiated Rate	$11.99
Max. Negotiated Rate	$28.48
Rate for Payer: Aetna Commercial	$26.98
Rate for Payer: Humana Medicare Advantage	$12.59
Rate for Payer: UnitedHealthcare Commercial	$28.48
Rate for Payer: UnitedHealthcare Medicaid	$11.99
Rate for Payer: WPPA Medicare Advantage	$17.99

Rebella Screen

Facility

$54.00

Service Code	HCPCS 86762
Hospital Charge Code	3551633
Hospital Revenue Code	300
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Rebella Screen

Facility

$54.00

Service Code	HCPCS 86762
Hospital Charge Code	3551633
Hospital Revenue Code	300
Min. Negotiated Rate	$12.23
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$30.90
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$12.23
Rate for Payer: WPPA Medicare Advantage	$32.40

Rebella Screen IGM

Facility

$184.00

Service Code	HCPCS 86765
Hospital Charge Code	3552433
Hospital Revenue Code	300
Min. Negotiated Rate	$10.95
Max. Negotiated Rate	$174.80
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$68.27
Rate for Payer: Humana Medicare Advantage	$77.28
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: UnitedHealthcare Medicaid	$10.95
Rate for Payer: WPPA Medicare Advantage	$110.40

Rebella Screen IGM

Facility

$184.00

Service Code	HCPCS 86765
Hospital Charge Code	3552433
Hospital Revenue Code	300
Min. Negotiated Rate	$165.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RECTAL RESECTION WITH CC

Facility

$8,863.83

Service Code	MSDRG 333
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,863.83
Rate for Payer: UnitedHealthcare Medicaid	$8,863.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RECTAL RESECTION WITH MCC

Facility

$13,692.87

Service Code	MSDRG 332
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$13,692.87
Rate for Payer: UnitedHealthcare Medicaid	$13,692.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges