Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Rickettsia Typhi IgG QST

Facility

$207.00

Service Code	HCPCS 86757
Hospital Charge Code	3552771
Hospital Revenue Code	300
Min. Negotiated Rate	$186.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$186.30
Rate for Payer: UnitedHealthcare Commercial	$196.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Rickettsia Typhi IgG QST

Facility

$207.00

Service Code	HCPCS 86757
Hospital Charge Code	3552771
Hospital Revenue Code	300
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$196.65
Rate for Payer: Aetna Commercial	$186.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$126.53
Rate for Payer: Humana Medicare Advantage	$86.94
Rate for Payer: UnitedHealthcare Commercial	$196.65
Rate for Payer: UnitedHealthcare Medicaid	$19.35
Rate for Payer: WPPA Medicare Advantage	$124.20

Rickettsia Typhi IgM QST

Facility

$207.00

Service Code	HCPCS 86757
Hospital Charge Code	3552771-1
Hospital Revenue Code	300
Min. Negotiated Rate	$186.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$186.30
Rate for Payer: UnitedHealthcare Commercial	$196.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Rickettsia Typhi IgM QST

Facility

$207.00

Service Code	HCPCS 86757
Hospital Charge Code	3552771-1
Hospital Revenue Code	300
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$196.65
Rate for Payer: Aetna Commercial	$186.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$126.53
Rate for Payer: Humana Medicare Advantage	$86.94
Rate for Payer: UnitedHealthcare Commercial	$196.65
Rate for Payer: UnitedHealthcare Medicaid	$19.35
Rate for Payer: WPPA Medicare Advantage	$124.20

rifampin 300 mg Cap [HMC]

Facility

$11.05

Service Code	NDC 61748001830
Hospital Charge Code	3806020
Hospital Revenue Code	250
Min. Negotiated Rate	$9.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.95
Rate for Payer: UnitedHealthcare Commercial	$10.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

rifampin 300 mg Cap [HMC]

Facility

$11.05

Service Code	NDC 61748001830
Hospital Charge Code	3806020
Hospital Revenue Code	250
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$10.50
Rate for Payer: Aetna Commercial	$9.95
Rate for Payer: Humana Medicare Advantage	$4.64
Rate for Payer: UnitedHealthcare Commercial	$10.50
Rate for Payer: UnitedHealthcare Medicaid	$4.42
Rate for Payer: WPPA Medicare Advantage	$6.63

rifAXIMin 550 mg Tab UD [HMC]

Facility

$70.34

Service Code	NDC 65649030303
Hospital Charge Code	3800133
Hospital Revenue Code	250
Min. Negotiated Rate	$63.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.31
Rate for Payer: UnitedHealthcare Commercial	$66.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

rifAXIMin 550 mg Tab UD [HMC]

Facility

$70.34

Service Code	NDC 65649030303
Hospital Charge Code	3800133
Hospital Revenue Code	250
Min. Negotiated Rate	$28.14
Max. Negotiated Rate	$66.82
Rate for Payer: Aetna Commercial	$63.31
Rate for Payer: Humana Medicare Advantage	$29.54
Rate for Payer: UnitedHealthcare Commercial	$66.82
Rate for Payer: UnitedHealthcare Medicaid	$28.14
Rate for Payer: WPPA Medicare Advantage	$42.20

risankizumab-rzaa 60 mg/mL Sol [HMC]

Facility

$21,782.67

Service Code	HCPCS J2327
Hospital Charge Code	3800256
Hospital Revenue Code	250
Min. Negotiated Rate	$14.93
Max. Negotiated Rate	$20,693.54
Rate for Payer: Aetna Commercial	$19,604.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$19.77
Rate for Payer: Humana Medicare Advantage	$9,148.72
Rate for Payer: UnitedHealthcare Commercial	$20,693.54
Rate for Payer: UnitedHealthcare Medicaid	$14.93
Rate for Payer: WPPA Medicare Advantage	$13,069.60

risankizumab-rzaa 60 mg/mL Sol [HMC]

Facility

$21,782.67

Service Code	HCPCS J2327
Hospital Charge Code	3800256
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$20,693.54
Rate for Payer: Aetna Commercial	$19,604.40
Rate for Payer: UnitedHealthcare Commercial	$20,693.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

risperiDONE 0.25 mg Tab [HMC]

Facility

$16.70

Service Code	NDC 68382011214
Hospital Charge Code	3803802
Hospital Revenue Code	250
Min. Negotiated Rate	$15.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.03
Rate for Payer: UnitedHealthcare Commercial	$15.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

risperiDONE 0.25 mg Tab [HMC]

Facility

$5.86

Service Code	NDC 00904736061
Hospital Charge Code	3803802
Hospital Revenue Code	250
Min. Negotiated Rate	$5.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.27
Rate for Payer: UnitedHealthcare Commercial	$5.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

risperiDONE 0.25 mg Tab [HMC]

Facility

$5.86

Service Code	NDC 00904736061
Hospital Charge Code	3803802
Hospital Revenue Code	250
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$5.57
Rate for Payer: Aetna Commercial	$5.27
Rate for Payer: Humana Medicare Advantage	$2.46
Rate for Payer: UnitedHealthcare Commercial	$5.57
Rate for Payer: UnitedHealthcare Medicaid	$2.34
Rate for Payer: WPPA Medicare Advantage	$3.52

risperiDONE 0.25 mg Tab [HMC]

Facility

$15.74

Service Code	NDC 00904635761
Hospital Charge Code	3803802
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$14.95
Rate for Payer: Aetna Commercial	$14.17
Rate for Payer: Humana Medicare Advantage	$6.61
Rate for Payer: UnitedHealthcare Commercial	$14.95
Rate for Payer: UnitedHealthcare Medicaid	$6.30
Rate for Payer: WPPA Medicare Advantage	$9.44

risperiDONE 0.25 mg Tab [HMC]

Facility

$15.74

Service Code	NDC 00904635761
Hospital Charge Code	3803802
Hospital Revenue Code	250
Min. Negotiated Rate	$14.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$14.17
Rate for Payer: UnitedHealthcare Commercial	$14.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

risperiDONE 0.25 mg Tab [HMC]

Facility

$16.70

Service Code	NDC 68382011214
Hospital Charge Code	3803802
Hospital Revenue Code	250
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$15.87
Rate for Payer: Aetna Commercial	$15.03
Rate for Payer: Humana Medicare Advantage	$7.01
Rate for Payer: UnitedHealthcare Commercial	$15.87
Rate for Payer: UnitedHealthcare Medicaid	$6.68
Rate for Payer: WPPA Medicare Advantage	$10.02

risperiDONE 0.25 mg Tab [HMC]

Facility

$16.70

Service Code	NDC 43547033906
Hospital Charge Code	3803802
Hospital Revenue Code	250
Min. Negotiated Rate	$15.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.03
Rate for Payer: UnitedHealthcare Commercial	$15.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

risperiDONE 0.25 mg Tab [HMC]

Facility

$16.70

Service Code	NDC 43547033906
Hospital Charge Code	3803802
Hospital Revenue Code	250
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$15.87
Rate for Payer: Aetna Commercial	$15.03
Rate for Payer: Humana Medicare Advantage	$7.01
Rate for Payer: UnitedHealthcare Commercial	$15.87
Rate for Payer: UnitedHealthcare Medicaid	$6.68
Rate for Payer: WPPA Medicare Advantage	$10.02

risperiDONE 1 mg Tab [HMC]

Facility

$18.69

Service Code	NDC 00904635961
Hospital Charge Code	3802028
Hospital Revenue Code	250
Min. Negotiated Rate	$16.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.82
Rate for Payer: UnitedHealthcare Commercial	$17.76
Rate for Payer: WPPA Medicare Advantage	$1,200.00

risperiDONE 1 mg Tab [HMC]

Facility

$18.62

Service Code	NDC 68084027201
Hospital Charge Code	3802028
Hospital Revenue Code	250
Min. Negotiated Rate	$16.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.76
Rate for Payer: UnitedHealthcare Commercial	$17.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

risperiDONE 1 mg Tab [HMC]

Facility

$18.69

Service Code	NDC 00904635961
Hospital Charge Code	3802028
Hospital Revenue Code	250
Min. Negotiated Rate	$7.48
Max. Negotiated Rate	$17.76
Rate for Payer: Aetna Commercial	$16.82
Rate for Payer: Humana Medicare Advantage	$7.85
Rate for Payer: UnitedHealthcare Commercial	$17.76
Rate for Payer: UnitedHealthcare Medicaid	$7.48
Rate for Payer: WPPA Medicare Advantage	$11.21

risperiDONE 1 mg Tab [HMC]

Facility

$6.28

Service Code	NDC 00904736261
Hospital Charge Code	3802028
Hospital Revenue Code	250
Min. Negotiated Rate	$5.65
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.65
Rate for Payer: UnitedHealthcare Commercial	$5.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

risperiDONE 1 mg Tab [HMC]

Facility

$18.62

Service Code	NDC 68084027201
Hospital Charge Code	3802028
Hospital Revenue Code	250
Min. Negotiated Rate	$7.45
Max. Negotiated Rate	$17.69
Rate for Payer: Aetna Commercial	$16.76
Rate for Payer: Humana Medicare Advantage	$7.82
Rate for Payer: UnitedHealthcare Commercial	$17.69
Rate for Payer: UnitedHealthcare Medicaid	$7.45
Rate for Payer: WPPA Medicare Advantage	$11.17

risperiDONE 1 mg Tab [HMC]

Facility

$6.28

Service Code	NDC 00904736261
Hospital Charge Code	3802028
Hospital Revenue Code	250
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$5.97
Rate for Payer: Aetna Commercial	$5.65
Rate for Payer: Humana Medicare Advantage	$2.64
Rate for Payer: UnitedHealthcare Commercial	$5.97
Rate for Payer: UnitedHealthcare Medicaid	$2.51
Rate for Payer: WPPA Medicare Advantage	$3.77

Rituxan Sensitivity (CD20) QST

Facility

$151.00

Service Code	HCPCS 86356
Hospital Charge Code	3550981
Hospital Revenue Code	300
Min. Negotiated Rate	$135.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$135.90
Rate for Payer: UnitedHealthcare Commercial	$143.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges