Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC

Facility

$2,827.53

Service Code	MSDRG 806
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,827.53
Rate for Payer: UnitedHealthcare Medicaid	$2,827.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC

Facility

$3,113.46

Service Code	MSDRG 805
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,113.46
Rate for Payer: UnitedHealthcare Medicaid	$3,113.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC

Facility

$2,668.68

Service Code	MSDRG 807
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,668.68
Rate for Payer: UnitedHealthcare Medicaid	$2,668.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC

Facility

$4,384.26

Service Code	MSDRG 797
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,384.26
Rate for Payer: UnitedHealthcare Medicaid	$4,384.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC

Facility

$4,606.65

Service Code	MSDRG 796
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,606.65
Rate for Payer: UnitedHealthcare Medicaid	$4,606.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC

Facility

$4,161.87

Service Code	MSDRG 798
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,161.87
Rate for Payer: UnitedHealthcare Medicaid	$4,161.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Vaginal Gel - TRIMO-SAN 4oz Tube

Facility

$112.68

Hospital Charge Code	3258803
Hospital Revenue Code	270
Min. Negotiated Rate	$45.07
Max. Negotiated Rate	$107.05
Rate for Payer: Aetna Commercial	$101.41
Rate for Payer: Humana Medicare Advantage	$47.33
Rate for Payer: UnitedHealthcare Commercial	$107.05
Rate for Payer: UnitedHealthcare Medicaid	$45.07
Rate for Payer: WPPA Medicare Advantage	$67.61

Vaginal Gel - TRIMO-SAN 4oz Tube

Facility

$112.68

Hospital Charge Code	3258803
Hospital Revenue Code	270
Min. Negotiated Rate	$101.41
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.41
Rate for Payer: UnitedHealthcare Commercial	$107.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Vag Spec W/Light Medium

Facility

$15.30

Hospital Charge Code	3257345
Hospital Revenue Code	270
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.77
Rate for Payer: UnitedHealthcare Commercial	$14.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Vag Spec W/Light Medium

Facility

$15.30

Hospital Charge Code	3257345
Hospital Revenue Code	270
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$14.54
Rate for Payer: Aetna Commercial	$13.77
Rate for Payer: Humana Medicare Advantage	$6.43
Rate for Payer: UnitedHealthcare Commercial	$14.54
Rate for Payer: UnitedHealthcare Medicaid	$6.12
Rate for Payer: WPPA Medicare Advantage	$9.18

Vag Spec W/Light Small

Facility

$21.87

Hospital Charge Code	3257340
Hospital Revenue Code	270
Min. Negotiated Rate	$8.75
Max. Negotiated Rate	$20.78
Rate for Payer: Aetna Commercial	$19.68
Rate for Payer: Humana Medicare Advantage	$9.19
Rate for Payer: UnitedHealthcare Commercial	$20.78
Rate for Payer: UnitedHealthcare Medicaid	$8.75
Rate for Payer: WPPA Medicare Advantage	$13.12

Vag Spec W/Light Small

Facility

$21.87

Hospital Charge Code	3257340
Hospital Revenue Code	270
Min. Negotiated Rate	$19.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.68
Rate for Payer: UnitedHealthcare Commercial	$20.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valACYclovir 1 g Tab [HMC]

Facility

$29.02

Service Code	NDC 57237004390
Hospital Charge Code	3800558
Hospital Revenue Code	250
Min. Negotiated Rate	$26.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.12
Rate for Payer: UnitedHealthcare Commercial	$27.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valACYclovir 1 g Tab [HMC]

Facility

$30.28

Service Code	NDC 00378427693
Hospital Charge Code	3800558
Hospital Revenue Code	250
Min. Negotiated Rate	$27.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.25
Rate for Payer: UnitedHealthcare Commercial	$28.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valACYclovir 1 g Tab [HMC]

Facility

$20.49

Service Code	NDC 68084030921
Hospital Charge Code	3800558
Hospital Revenue Code	250
Min. Negotiated Rate	$18.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.44
Rate for Payer: UnitedHealthcare Commercial	$19.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valACYclovir 1 g Tab [HMC]

Facility

$22.42

Service Code	NDC 50268078915
Hospital Charge Code	3800558
Hospital Revenue Code	250
Min. Negotiated Rate	$20.18
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.18
Rate for Payer: UnitedHealthcare Commercial	$21.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valACYclovir 1 g Tab [HMC]

Facility

$29.02

Service Code	NDC 57237004390
Hospital Charge Code	3800558
Hospital Revenue Code	250
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$27.57
Rate for Payer: Aetna Commercial	$26.12
Rate for Payer: Humana Medicare Advantage	$12.19
Rate for Payer: UnitedHealthcare Commercial	$27.57
Rate for Payer: UnitedHealthcare Medicaid	$11.61
Rate for Payer: WPPA Medicare Advantage	$17.41

valACYclovir 1 g Tab [HMC]

Facility

$30.28

Service Code	NDC 00378427693
Hospital Charge Code	3800558
Hospital Revenue Code	250
Min. Negotiated Rate	$12.11
Max. Negotiated Rate	$28.77
Rate for Payer: Aetna Commercial	$27.25
Rate for Payer: Humana Medicare Advantage	$12.72
Rate for Payer: UnitedHealthcare Commercial	$28.77
Rate for Payer: UnitedHealthcare Medicaid	$12.11
Rate for Payer: WPPA Medicare Advantage	$18.17

valACYclovir 1 g Tab [HMC]

Facility

$20.49

Service Code	NDC 68084030921
Hospital Charge Code	3800558
Hospital Revenue Code	250
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$19.47
Rate for Payer: Aetna Commercial	$18.44
Rate for Payer: Humana Medicare Advantage	$8.61
Rate for Payer: UnitedHealthcare Commercial	$19.47
Rate for Payer: UnitedHealthcare Medicaid	$8.20
Rate for Payer: WPPA Medicare Advantage	$12.29

valACYclovir 1 g Tab [HMC]

Facility

$22.42

Service Code	NDC 50268078915
Hospital Charge Code	3800558
Hospital Revenue Code	250
Min. Negotiated Rate	$8.97
Max. Negotiated Rate	$21.30
Rate for Payer: Aetna Commercial	$20.18
Rate for Payer: Humana Medicare Advantage	$9.42
Rate for Payer: UnitedHealthcare Commercial	$21.30
Rate for Payer: UnitedHealthcare Medicaid	$8.97
Rate for Payer: WPPA Medicare Advantage	$13.45

valproic acid 100 mg/mL [HMC]

Facility

$45.12

Service Code	NDC 63323049405
Hospital Charge Code	3800339
Hospital Revenue Code	250
Min. Negotiated Rate	$40.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.61
Rate for Payer: UnitedHealthcare Commercial	$42.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valproic acid 100 mg/mL [HMC]

Facility

$51.12

Service Code	NDC 00143978510
Hospital Charge Code	3800339
Hospital Revenue Code	250
Min. Negotiated Rate	$46.01
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$46.01
Rate for Payer: UnitedHealthcare Commercial	$48.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valproic acid 100 mg/mL [HMC]

Facility

$51.12

Service Code	NDC 00143963710
Hospital Charge Code	3800339
Hospital Revenue Code	250
Min. Negotiated Rate	$46.01
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$46.01
Rate for Payer: UnitedHealthcare Commercial	$48.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valproic acid 100 mg/mL [HMC]

Facility

$45.12

Service Code	NDC 63323049405
Hospital Charge Code	3800339
Hospital Revenue Code	250
Min. Negotiated Rate	$18.05
Max. Negotiated Rate	$42.86
Rate for Payer: Aetna Commercial	$40.61
Rate for Payer: Humana Medicare Advantage	$18.95
Rate for Payer: UnitedHealthcare Commercial	$42.86
Rate for Payer: UnitedHealthcare Medicaid	$18.05
Rate for Payer: WPPA Medicare Advantage	$27.07

valproic acid 100 mg/mL [HMC]

Facility

$51.12

Service Code	NDC 00143963710
Hospital Charge Code	3800339
Hospital Revenue Code	250
Min. Negotiated Rate	$20.45
Max. Negotiated Rate	$48.56
Rate for Payer: Aetna Commercial	$46.01
Rate for Payer: Humana Medicare Advantage	$21.47
Rate for Payer: UnitedHealthcare Commercial	$48.56
Rate for Payer: UnitedHealthcare Medicaid	$20.45
Rate for Payer: WPPA Medicare Advantage	$30.67

Know your out-of-pocket cost for care.

All Charges