Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

simvastatin 40 mg Tab [HMC]

Facility

$5.62

Service Code	NDC 63739057310
Hospital Charge Code	3809347
Hospital Revenue Code	250
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$5.34
Rate for Payer: Aetna Commercial	$5.06
Rate for Payer: Humana Medicare Advantage	$2.36
Rate for Payer: UnitedHealthcare Commercial	$5.34
Rate for Payer: UnitedHealthcare Medicaid	$2.25
Rate for Payer: WPPA Medicare Advantage	$3.37

simvastatin 40 mg Tab [HMC]

Facility

$19.71

Service Code	NDC 70377000414
Hospital Charge Code	3809347
Hospital Revenue Code	250
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$18.72
Rate for Payer: Aetna Commercial	$17.74
Rate for Payer: Humana Medicare Advantage	$8.28
Rate for Payer: UnitedHealthcare Commercial	$18.72
Rate for Payer: UnitedHealthcare Medicaid	$7.88
Rate for Payer: WPPA Medicare Advantage	$11.83

simvastatin 40 mg Tab [HMC]

Facility

$19.76

Service Code	NDC 60687021001
Hospital Charge Code	3809347
Hospital Revenue Code	250
Min. Negotiated Rate	$17.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.78
Rate for Payer: UnitedHealthcare Commercial	$18.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

simvastatin 40 mg Tab [HMC]

Facility

$19.76

Service Code	NDC 60687021001
Hospital Charge Code	3809347
Hospital Revenue Code	250
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$18.77
Rate for Payer: Aetna Commercial	$17.78
Rate for Payer: Humana Medicare Advantage	$8.30
Rate for Payer: UnitedHealthcare Commercial	$18.77
Rate for Payer: UnitedHealthcare Medicaid	$7.90
Rate for Payer: WPPA Medicare Advantage	$11.86

simvastatin 40 mg Tab [HMC]

Facility

$5.62

Service Code	NDC 63739057310
Hospital Charge Code	3809347
Hospital Revenue Code	250
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.06
Rate for Payer: UnitedHealthcare Commercial	$5.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

simvastatin 40 mg Tab [HMC]

Facility

$19.71

Service Code	NDC 70377000414
Hospital Charge Code	3809347
Hospital Revenue Code	250
Min. Negotiated Rate	$17.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.74
Rate for Payer: UnitedHealthcare Commercial	$18.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$15,217.83

Service Code	MSDRG 402
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$15,217.83
Rate for Payer: UnitedHealthcare Medicaid	$15,217.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$20,173.95

Service Code	MSDRG 450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$20,173.95
Rate for Payer: UnitedHealthcare Medicaid	$20,173.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$12,231.45

Service Code	MSDRG 451
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,231.45
Rate for Payer: UnitedHealthcare Medicaid	$12,231.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility

$4,066.56

Service Code	MSDRG 135
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,066.56
Rate for Payer: UnitedHealthcare Medicaid	$4,066.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility

$1,906.20

Service Code	MSDRG 136
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,906.20
Rate for Payer: UnitedHealthcare Medicaid	$1,906.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sitaGLIPtin 50 mg oral tablet [HMC]

Facility

$27.92

Service Code	NDC 00006011231
Hospital Charge Code	3800306
Hospital Revenue Code	250
Min. Negotiated Rate	$25.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.13
Rate for Payer: UnitedHealthcare Commercial	$26.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sitaGLIPtin 50 mg oral tablet [HMC]

Facility

$27.92

Service Code	NDC 00006011231
Hospital Charge Code	3800306
Hospital Revenue Code	250
Min. Negotiated Rate	$11.17
Max. Negotiated Rate	$26.52
Rate for Payer: Aetna Commercial	$25.13
Rate for Payer: Humana Medicare Advantage	$11.73
Rate for Payer: UnitedHealthcare Commercial	$26.52
Rate for Payer: UnitedHealthcare Medicaid	$11.17
Rate for Payer: WPPA Medicare Advantage	$16.75

sitaGLIPtin 50 mg oral tablet [HMC]

Facility

$27.92

Service Code	NDC 00006011228
Hospital Charge Code	3800306
Hospital Revenue Code	250
Min. Negotiated Rate	$25.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.13
Rate for Payer: UnitedHealthcare Commercial	$26.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sitaGLIPtin 50 mg oral tablet [HMC]

Facility

$27.92

Service Code	NDC 00006011228
Hospital Charge Code	3800306
Hospital Revenue Code	250
Min. Negotiated Rate	$11.17
Max. Negotiated Rate	$26.52
Rate for Payer: Aetna Commercial	$25.13
Rate for Payer: Humana Medicare Advantage	$11.73
Rate for Payer: UnitedHealthcare Commercial	$26.52
Rate for Payer: UnitedHealthcare Medicaid	$11.17
Rate for Payer: WPPA Medicare Advantage	$16.75

Sitz Bath

Facility

$10.76

Hospital Charge Code	3251860
Hospital Revenue Code	270
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$10.22
Rate for Payer: Aetna Commercial	$9.68
Rate for Payer: Humana Medicare Advantage	$4.52
Rate for Payer: UnitedHealthcare Commercial	$10.22
Rate for Payer: UnitedHealthcare Medicaid	$4.30
Rate for Payer: WPPA Medicare Advantage	$6.46

Sitz Bath

Facility

$10.76

Hospital Charge Code	3251860
Hospital Revenue Code	270
Min. Negotiated Rate	$9.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.68
Rate for Payer: UnitedHealthcare Commercial	$10.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sjogren's Antibodies (SS-A,SS-B) QST

Facility

$103.00

Service Code	HCPCS 86235
Hospital Charge Code	3556401
Hospital Revenue Code	300
Min. Negotiated Rate	$92.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$92.70
Rate for Payer: UnitedHealthcare Commercial	$97.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sjogren's Antibodies (SS-A,SS-B) QST

Facility

$103.00

Service Code	HCPCS 86235
Hospital Charge Code	3556401
Hospital Revenue Code	300
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$97.85
Rate for Payer: Aetna Commercial	$92.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$52.26
Rate for Payer: Humana Medicare Advantage	$43.26
Rate for Payer: UnitedHealthcare Commercial	$97.85
Rate for Payer: UnitedHealthcare Medicaid	$17.93
Rate for Payer: WPPA Medicare Advantage	$61.80

S Kappa Light Chain, Free QST

Facility

$119.00

Service Code	HCPCS 83521
Hospital Charge Code	3553521
Hospital Revenue Code	300
Min. Negotiated Rate	$32.39
Max. Negotiated Rate	$113.05
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$32.39
Rate for Payer: Humana Medicare Advantage	$49.98
Rate for Payer: UnitedHealthcare Commercial	$113.05
Rate for Payer: UnitedHealthcare Medicaid	$47.60
Rate for Payer: WPPA Medicare Advantage	$71.40

S Kappa Light Chain, Free QST

Facility

$119.00

Service Code	HCPCS 83521
Hospital Charge Code	3553521
Hospital Revenue Code	300
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: UnitedHealthcare Commercial	$113.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN DEBRIDEMENT WITH CC

Facility

$5,496.21

Service Code	MSDRG 571
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,496.21
Rate for Payer: UnitedHealthcare Medicaid	$5,496.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN DEBRIDEMENT WITH MCC

Facility

$9,594.54

Service Code	MSDRG 570
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,594.54
Rate for Payer: UnitedHealthcare Medicaid	$9,594.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN DEBRIDEMENT WITHOUT CC/MCC

Facility

$3,748.86

Service Code	MSDRG 572
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,748.86
Rate for Payer: UnitedHealthcare Medicaid	$3,748.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Skin Graft Blade Dermatome Blade Zimmer Air 8801

Facility

$193.00

Hospital Charge Code	3259630
Hospital Revenue Code	270
Min. Negotiated Rate	$77.20
Max. Negotiated Rate	$183.35
Rate for Payer: Aetna Commercial	$173.70
Rate for Payer: Humana Medicare Advantage	$81.06
Rate for Payer: UnitedHealthcare Commercial	$183.35
Rate for Payer: UnitedHealthcare Medicaid	$77.20
Rate for Payer: WPPA Medicare Advantage	$115.80

Know your out-of-pocket cost for care.

All Charges