Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC

Facility

$4,701.96

Service Code	MSDRG 872
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,701.96
Rate for Payer: UnitedHealthcare Medicaid	$4,701.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sertraline 25 mg Tab [HMC]

Facility

$6.25

Service Code	NDC 00904692461
Hospital Charge Code	3800660
Hospital Revenue Code	250
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$5.94
Rate for Payer: Aetna Commercial	$5.62
Rate for Payer: Humana Medicare Advantage	$2.62
Rate for Payer: UnitedHealthcare Commercial	$5.94
Rate for Payer: UnitedHealthcare Medicaid	$2.50
Rate for Payer: WPPA Medicare Advantage	$3.75

sertraline 25 mg Tab [HMC]

Facility

$6.33

Service Code	NDC 50268076815
Hospital Charge Code	3800660
Hospital Revenue Code	250
Min. Negotiated Rate	$2.53
Max. Negotiated Rate	$6.01
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Humana Medicare Advantage	$2.66
Rate for Payer: UnitedHealthcare Commercial	$6.01
Rate for Payer: UnitedHealthcare Medicaid	$2.53
Rate for Payer: WPPA Medicare Advantage	$3.80

sertraline 25 mg Tab [HMC]

Facility

$6.22

Service Code	NDC 60687023101
Hospital Charge Code	3800660
Hospital Revenue Code	250
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$5.91
Rate for Payer: Aetna Commercial	$5.60
Rate for Payer: Humana Medicare Advantage	$2.61
Rate for Payer: UnitedHealthcare Commercial	$5.91
Rate for Payer: UnitedHealthcare Medicaid	$2.49
Rate for Payer: WPPA Medicare Advantage	$3.73

sertraline 25 mg Tab [HMC]

Facility

$6.25

Service Code	NDC 00904692461
Hospital Charge Code	3800660
Hospital Revenue Code	250
Min. Negotiated Rate	$5.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.62
Rate for Payer: UnitedHealthcare Commercial	$5.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sertraline 25 mg Tab [HMC]

Facility

$13.14

Service Code	NDC 69097083312
Hospital Charge Code	3800660
Hospital Revenue Code	250
Min. Negotiated Rate	$5.26
Max. Negotiated Rate	$12.48
Rate for Payer: Aetna Commercial	$11.83
Rate for Payer: Humana Medicare Advantage	$5.52
Rate for Payer: UnitedHealthcare Commercial	$12.48
Rate for Payer: UnitedHealthcare Medicaid	$5.26
Rate for Payer: WPPA Medicare Advantage	$7.88

sertraline 25 mg Tab [HMC]

Facility

$6.22

Service Code	NDC 60687023101
Hospital Charge Code	3800660
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.60
Rate for Payer: UnitedHealthcare Commercial	$5.91
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sertraline 25 mg Tab [HMC]

Facility

$6.33

Service Code	NDC 50268076815
Hospital Charge Code	3800660
Hospital Revenue Code	250
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: UnitedHealthcare Commercial	$6.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sertraline 25 mg Tab [HMC]

Facility

$13.14

Service Code	NDC 69097083312
Hospital Charge Code	3800660
Hospital Revenue Code	250
Min. Negotiated Rate	$11.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.83
Rate for Payer: UnitedHealthcare Commercial	$12.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sertraline 50 mg Tab [HMC]

Facility

$6.21

Service Code	NDC 60687024201
Hospital Charge Code	3807704
Hospital Revenue Code	250
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$5.90
Rate for Payer: Aetna Commercial	$5.59
Rate for Payer: Humana Medicare Advantage	$2.61
Rate for Payer: UnitedHealthcare Commercial	$5.90
Rate for Payer: UnitedHealthcare Medicaid	$2.48
Rate for Payer: WPPA Medicare Advantage	$3.73

sertraline 50 mg Tab [HMC]

Facility

$6.45

Service Code	NDC 00904692561
Hospital Charge Code	3807704
Hospital Revenue Code	250
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$6.13
Rate for Payer: Aetna Commercial	$5.80
Rate for Payer: Humana Medicare Advantage	$2.71
Rate for Payer: UnitedHealthcare Commercial	$6.13
Rate for Payer: UnitedHealthcare Medicaid	$2.58
Rate for Payer: WPPA Medicare Advantage	$3.87

sertraline 50 mg Tab [HMC]

Facility

$6.45

Service Code	NDC 00904692561
Hospital Charge Code	3807704
Hospital Revenue Code	250
Min. Negotiated Rate	$5.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.80
Rate for Payer: UnitedHealthcare Commercial	$6.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sertraline 50 mg Tab [HMC]

Facility

$6.21

Service Code	NDC 60687024201
Hospital Charge Code	3807704
Hospital Revenue Code	250
Min. Negotiated Rate	$5.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.59
Rate for Payer: UnitedHealthcare Commercial	$5.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sevoflurane 100% Liq [HMC]

Facility

$322.50

Service Code	NDC 00781616086
Hospital Charge Code	3170275
Hospital Revenue Code	370
Min. Negotiated Rate	$290.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$290.25
Rate for Payer: UnitedHealthcare Commercial	$306.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sevoflurane 100% Liq [HMC]

Facility

$561.56

Service Code	NDC 00074445651
Hospital Charge Code	3170275
Hospital Revenue Code	370
Min. Negotiated Rate	$224.62
Max. Negotiated Rate	$533.48
Rate for Payer: Aetna Commercial	$505.40
Rate for Payer: Humana Medicare Advantage	$235.86
Rate for Payer: UnitedHealthcare Commercial	$533.48
Rate for Payer: UnitedHealthcare Medicaid	$224.62
Rate for Payer: WPPA Medicare Advantage	$336.94

sevoflurane 100% Liq [HMC]

Facility

$261.60

Service Code	NDC 66794001525
Hospital Charge Code	3170275
Hospital Revenue Code	370
Min. Negotiated Rate	$235.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$235.44
Rate for Payer: UnitedHealthcare Commercial	$248.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sevoflurane 100% Liq [HMC]

Facility

$261.60

Service Code	NDC 66794001525
Hospital Charge Code	3170275
Hospital Revenue Code	370
Min. Negotiated Rate	$104.64
Max. Negotiated Rate	$248.52
Rate for Payer: Aetna Commercial	$235.44
Rate for Payer: Humana Medicare Advantage	$109.87
Rate for Payer: UnitedHealthcare Commercial	$248.52
Rate for Payer: UnitedHealthcare Medicaid	$104.64
Rate for Payer: WPPA Medicare Advantage	$156.96

sevoflurane 100% Liq [HMC]

Facility

$561.56

Service Code	NDC 00074445651
Hospital Charge Code	3170275
Hospital Revenue Code	370
Min. Negotiated Rate	$505.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$505.40
Rate for Payer: UnitedHealthcare Commercial	$533.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sevoflurane 100% Liq [HMC]

Facility

$322.50

Service Code	NDC 00781616086
Hospital Charge Code	3170275
Hospital Revenue Code	370
Min. Negotiated Rate	$129.00
Max. Negotiated Rate	$306.38
Rate for Payer: Aetna Commercial	$290.25
Rate for Payer: Humana Medicare Advantage	$135.45
Rate for Payer: UnitedHealthcare Commercial	$306.38
Rate for Payer: UnitedHealthcare Medicaid	$129.00
Rate for Payer: WPPA Medicare Advantage	$193.50

SEVOFLURANE (ULTANE) PER 15 MIN

Facility

$132.00

Hospital Charge Code	3170275
Hospital Revenue Code	370
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SEVOFLURANE (ULTANE) PER 15 MIN

Facility

$132.00

Hospital Charge Code	3170275
Hospital Revenue Code	370
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$125.40
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: Humana Medicare Advantage	$55.44
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: UnitedHealthcare Medicaid	$52.80
Rate for Payer: WPPA Medicare Advantage	$79.20

Sex Hormone Binding Globulin QST

Facility

$243.00

Service Code	HCPCS 84270
Hospital Charge Code	3554270
Hospital Revenue Code	300
Min. Negotiated Rate	$218.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$218.70
Rate for Payer: UnitedHealthcare Commercial	$230.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sex Hormone Binding Globulin QST

Facility

$243.00

Service Code	HCPCS 84270
Hospital Charge Code	3554270
Hospital Revenue Code	300
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$230.85
Rate for Payer: Aetna Commercial	$218.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$128.86
Rate for Payer: Humana Medicare Advantage	$102.06
Rate for Payer: UnitedHealthcare Commercial	$230.85
Rate for Payer: UnitedHealthcare Medicaid	$18.47
Rate for Payer: WPPA Medicare Advantage	$145.80

Sheet Burn 60 X 96

Facility

$13.00

Hospital Charge Code	3250625
Hospital Revenue Code	270
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$12.35
Rate for Payer: Aetna Commercial	$11.70
Rate for Payer: Humana Medicare Advantage	$5.46
Rate for Payer: UnitedHealthcare Commercial	$12.35
Rate for Payer: UnitedHealthcare Medicaid	$5.20
Rate for Payer: WPPA Medicare Advantage	$7.80

Sheet Burn 60 X 96

Facility

$13.00

Hospital Charge Code	3250625
Hospital Revenue Code	270
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.70
Rate for Payer: UnitedHealthcare Commercial	$12.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges