Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

SEIZURES WITH MCC

Facility

$6,099.84

Service Code	MSDRG 100
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,099.84
Rate for Payer: UnitedHealthcare Medicaid	$6,099.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SEIZURES WITHOUT MCC

Facility

$3,717.09

Service Code	MSDRG 101
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,717.09
Rate for Payer: UnitedHealthcare Medicaid	$3,717.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

selegiline 5 mg Cap [HMC]

Facility

$11.91

Service Code	NDC 60505005501
Hospital Charge Code	3808372
Hospital Revenue Code	250
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$11.31
Rate for Payer: Aetna Commercial	$10.72
Rate for Payer: Humana Medicare Advantage	$5.00
Rate for Payer: UnitedHealthcare Commercial	$11.31
Rate for Payer: UnitedHealthcare Medicaid	$4.76
Rate for Payer: WPPA Medicare Advantage	$7.15

selegiline 5 mg Cap [HMC]

Facility

$11.91

Service Code	NDC 60505005501
Hospital Charge Code	3808372
Hospital Revenue Code	250
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.72
Rate for Payer: UnitedHealthcare Commercial	$11.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Selenium, WB QST

Facility

$134.00

Service Code	HCPCS 84255
Hospital Charge Code	3554255
Hospital Revenue Code	300
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$80.20
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$21.70
Rate for Payer: WPPA Medicare Advantage	$80.40

Selenium, WB QST

Facility

$134.00

Service Code	HCPCS 84255
Hospital Charge Code	3554255
Hospital Revenue Code	300
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Semen Analysis Post Vas

Facility

$87.00

Service Code	HCPCS 89321
Hospital Charge Code	3559045
Hospital Revenue Code	300
Min. Negotiated Rate	$78.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$78.30
Rate for Payer: UnitedHealthcare Commercial	$82.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Semen Analysis Post Vas

Facility

$87.00

Service Code	HCPCS 89321
Hospital Charge Code	3559045
Hospital Revenue Code	300
Min. Negotiated Rate	$34.80
Max. Negotiated Rate	$82.65
Rate for Payer: Aetna Commercial	$78.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$46.24
Rate for Payer: Humana Medicare Advantage	$36.54
Rate for Payer: UnitedHealthcare Commercial	$82.65
Rate for Payer: UnitedHealthcare Medicaid	$34.80
Rate for Payer: WPPA Medicare Advantage	$52.20

senna 8.6 mg Tab [HMC]

Facility

$5.23

Service Code	NDC 00904652261
Hospital Charge Code	3800039
Hospital Revenue Code	250
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.71
Rate for Payer: UnitedHealthcare Commercial	$4.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

senna 8.6 mg Tab [HMC]

Facility

$5.15

Service Code	NDC 00904725261
Hospital Charge Code	3800039
Hospital Revenue Code	250
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$4.89
Rate for Payer: Aetna Commercial	$4.63
Rate for Payer: Humana Medicare Advantage	$2.16
Rate for Payer: UnitedHealthcare Commercial	$4.89
Rate for Payer: UnitedHealthcare Medicaid	$2.06
Rate for Payer: WPPA Medicare Advantage	$3.09

senna 8.6 mg Tab [HMC]

Facility

$5.06

Service Code	NDC 00904725260
Hospital Charge Code	3800039
Hospital Revenue Code	250
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.55
Rate for Payer: UnitedHealthcare Commercial	$4.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

senna 8.6 mg Tab [HMC]

Facility

$5.15

Service Code	NDC 00904725261
Hospital Charge Code	3800039
Hospital Revenue Code	250
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.63
Rate for Payer: UnitedHealthcare Commercial	$4.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

senna 8.6 mg Tab [HMC]

Facility

$5.21

Service Code	NDC 46122057578
Hospital Charge Code	3800039
Hospital Revenue Code	250
Min. Negotiated Rate	$4.69
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.69
Rate for Payer: UnitedHealthcare Commercial	$4.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

senna 8.6 mg Tab [HMC]

Facility

$5.23

Service Code	NDC 00904652261
Hospital Charge Code	3800039
Hospital Revenue Code	250
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$4.97
Rate for Payer: Aetna Commercial	$4.71
Rate for Payer: Humana Medicare Advantage	$2.20
Rate for Payer: UnitedHealthcare Commercial	$4.97
Rate for Payer: UnitedHealthcare Medicaid	$2.09
Rate for Payer: WPPA Medicare Advantage	$3.14

senna 8.6 mg Tab [HMC]

Facility

$5.21

Service Code	NDC 46122057578
Hospital Charge Code	3800039
Hospital Revenue Code	250
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$4.95
Rate for Payer: Aetna Commercial	$4.69
Rate for Payer: Humana Medicare Advantage	$2.19
Rate for Payer: UnitedHealthcare Commercial	$4.95
Rate for Payer: UnitedHealthcare Medicaid	$2.08
Rate for Payer: WPPA Medicare Advantage	$3.13

senna 8.6 mg Tab [HMC]

Facility

$5.06

Service Code	NDC 00904725260
Hospital Charge Code	3800039
Hospital Revenue Code	250
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$4.81
Rate for Payer: Aetna Commercial	$4.55
Rate for Payer: Humana Medicare Advantage	$2.13
Rate for Payer: UnitedHealthcare Commercial	$4.81
Rate for Payer: UnitedHealthcare Medicaid	$2.02
Rate for Payer: WPPA Medicare Advantage	$3.04

Sensor Skin Temperature Probe Neonate Infant Warmer Giraffe & Panda iRes Dispsbl

Facility

$42.00

Hospital Charge Code	3257270
Hospital Revenue Code	270
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$39.90
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: Humana Medicare Advantage	$17.64
Rate for Payer: UnitedHealthcare Commercial	$39.90
Rate for Payer: UnitedHealthcare Medicaid	$16.80
Rate for Payer: WPPA Medicare Advantage	$25.20

Sensor Skin Temperature Probe Neonate Infant Warmer Giraffe & Panda iRes Dispsbl

Facility

$42.00

Hospital Charge Code	3257270
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: UnitedHealthcare Commercial	$39.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sensor Skin Temperature Sensor Adult 400 Series

Facility

$6.89

Hospital Charge Code	3257272
Hospital Revenue Code	270
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.20
Rate for Payer: UnitedHealthcare Commercial	$6.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sensor Skin Temperature Sensor Adult 400 Series

Facility

$6.89

Hospital Charge Code	3257272
Hospital Revenue Code	270
Min. Negotiated Rate	$2.76
Max. Negotiated Rate	$6.55
Rate for Payer: Aetna Commercial	$6.20
Rate for Payer: Humana Medicare Advantage	$2.89
Rate for Payer: UnitedHealthcare Commercial	$6.55
Rate for Payer: UnitedHealthcare Medicaid	$2.76
Rate for Payer: WPPA Medicare Advantage	$4.13

SEPTIC ARTHRITIS WITH CC

Facility

$7,402.41

Service Code	MSDRG 549
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,402.41
Rate for Payer: UnitedHealthcare Medicaid	$7,402.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SEPTIC ARTHRITIS WITH MCC

Facility

$11,850.21

Service Code	MSDRG 548
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,850.21
Rate for Payer: UnitedHealthcare Medicaid	$11,850.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SEPTIC ARTHRITIS WITHOUT CC/MCC

Facility

$5,369.13

Service Code	MSDRG 550
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,369.13
Rate for Payer: UnitedHealthcare Medicaid	$5,369.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS

Facility

$19,506.78

Service Code	MSDRG 870
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$19,506.78
Rate for Payer: UnitedHealthcare Medicaid	$19,506.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC

Facility

$7,942.50

Service Code	MSDRG 871
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,942.50
Rate for Payer: UnitedHealthcare Medicaid	$7,942.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges