Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Vitamin B Complex Tab [HMC]

Facility

$5.03

Service Code	NDC 10135012010
Hospital Charge Code	3808351
Hospital Revenue Code	250
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$4.78
Rate for Payer: Aetna Commercial	$4.53
Rate for Payer: Humana Medicare Advantage	$2.11
Rate for Payer: UnitedHealthcare Commercial	$4.78
Rate for Payer: UnitedHealthcare Medicaid	$2.01
Rate for Payer: WPPA Medicare Advantage	$3.02

Vitamin B Complex Tab [HMC]

Facility

$5.00

Service Code	NDC 40985022282
Hospital Charge Code	3808351
Hospital Revenue Code	250
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: Humana Medicare Advantage	$2.10
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: UnitedHealthcare Medicaid	$2.00
Rate for Payer: WPPA Medicare Advantage	$3.00

Vitamin B Complex Tab [HMC]

Facility

$5.03

Service Code	NDC 10135012010
Hospital Charge Code	3808351
Hospital Revenue Code	250
Min. Negotiated Rate	$4.53
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.53
Rate for Payer: UnitedHealthcare Commercial	$4.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Vitamin B Complex Tab [HMC]

Facility

$5.00

Service Code	NDC 40985022282
Hospital Charge Code	3808351
Hospital Revenue Code	250
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Vitamin D 25 Hydroxy Level

Facility

$359.00

Service Code	HCPCS 82306
Hospital Charge Code	3557110
Hospital Revenue Code	300
Min. Negotiated Rate	$25.16
Max. Negotiated Rate	$341.05
Rate for Payer: Aetna Commercial	$323.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$218.43
Rate for Payer: Humana Medicare Advantage	$150.78
Rate for Payer: UnitedHealthcare Commercial	$341.05
Rate for Payer: UnitedHealthcare Medicaid	$25.16
Rate for Payer: WPPA Medicare Advantage	$215.40

Vitamin D 25 Hydroxy Level

Facility

$359.00

Service Code	HCPCS 82306
Hospital Charge Code	3557110
Hospital Revenue Code	300
Min. Negotiated Rate	$323.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$323.10
Rate for Payer: UnitedHealthcare Commercial	$341.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

vitamin E 180 mg Cap UD [HMC]

Facility

$5.77

Service Code	NDC 77333095110
Hospital Charge Code	3807465
Hospital Revenue Code	257
Min. Negotiated Rate	$5.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.19
Rate for Payer: UnitedHealthcare Commercial	$5.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

vitamin E 180 mg Cap UD [HMC]

Facility

$5.77

Service Code	NDC 77333095110
Hospital Charge Code	3807465
Hospital Revenue Code	257
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$5.48
Rate for Payer: Aetna Commercial	$5.19
Rate for Payer: Humana Medicare Advantage	$2.42
Rate for Payer: UnitedHealthcare Commercial	$5.48
Rate for Payer: UnitedHealthcare Medicaid	$2.31
Rate for Payer: WPPA Medicare Advantage	$3.46

vitamin E 400 intl units Cap [HMC]

Facility

$5.33

Service Code	NDC 00904027461
Hospital Charge Code	3807465
Hospital Revenue Code	250
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$5.06
Rate for Payer: Aetna Commercial	$4.80
Rate for Payer: Humana Medicare Advantage	$2.24
Rate for Payer: UnitedHealthcare Commercial	$5.06
Rate for Payer: UnitedHealthcare Medicaid	$2.13
Rate for Payer: WPPA Medicare Advantage	$3.20

vitamin E 400 intl units Cap [HMC]

Facility

$5.33

Service Code	NDC 00904027461
Hospital Charge Code	3807465
Hospital Revenue Code	250
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.80
Rate for Payer: UnitedHealthcare Commercial	$5.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Vitamin E (Tocopherol) QST

Facility

$151.00

Service Code	HCPCS 84446
Hospital Charge Code	3554446
Hospital Revenue Code	300
Min. Negotiated Rate	$14.18
Max. Negotiated Rate	$143.45
Rate for Payer: Aetna Commercial	$135.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$56.23
Rate for Payer: Humana Medicare Advantage	$63.42
Rate for Payer: UnitedHealthcare Commercial	$143.45
Rate for Payer: UnitedHealthcare Medicaid	$14.18
Rate for Payer: WPPA Medicare Advantage	$90.60

Vitamin E (Tocopherol) QST

Facility

$151.00

Service Code	HCPCS 84446
Hospital Charge Code	3554446
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

Vitamin K QST

Facility

$390.00

Service Code	HCPCS 84597
Hospital Charge Code	3556430
Hospital Revenue Code	300
Min. Negotiated Rate	$13.72
Max. Negotiated Rate	$370.50
Rate for Payer: Aetna Commercial	$351.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.33
Rate for Payer: Humana Medicare Advantage	$163.80
Rate for Payer: UnitedHealthcare Commercial	$370.50
Rate for Payer: UnitedHealthcare Medicaid	$13.72
Rate for Payer: WPPA Medicare Advantage	$234.00

Vitamin K QST

Facility

$390.00

Service Code	HCPCS 84597
Hospital Charge Code	3556430
Hospital Revenue Code	300
Min. Negotiated Rate	$351.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$351.00
Rate for Payer: UnitedHealthcare Commercial	$370.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VMA, U24 w/o Creat QST

Facility

$50.00

Service Code	HCPCS 84585
Hospital Charge Code	3550934
Hospital Revenue Code	300
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VMA, U24 w/o Creat QST

Facility

$50.00

Service Code	HCPCS 84585
Hospital Charge Code	3550934
Hospital Revenue Code	300
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$60.95
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$60.95
Rate for Payer: Humana Medicare Advantage	$21.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: UnitedHealthcare Medicaid	$15.50
Rate for Payer: WPPA Medicare Advantage	$30.00

Von Willebrand Screen QST

Facility

$534.00

Service Code	HCPCS 85240
Hospital Charge Code	3550759
Hospital Revenue Code	300
Min. Negotiated Rate	$480.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$480.60
Rate for Payer: UnitedHealthcare Commercial	$507.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Von Willebrand Screen QST

Facility

$534.00

Service Code	HCPCS 85240
Hospital Charge Code	3550759
Hospital Revenue Code	300
Min. Negotiated Rate	$17.90
Max. Negotiated Rate	$507.30
Rate for Payer: Aetna Commercial	$480.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$88.47
Rate for Payer: Humana Medicare Advantage	$224.28
Rate for Payer: UnitedHealthcare Commercial	$507.30
Rate for Payer: UnitedHealthcare Medicaid	$17.90
Rate for Payer: WPPA Medicare Advantage	$320.40

VPC SCREW 2.5X24MM

Facility

$822.50

Hospital Charge Code	3258130
Hospital Revenue Code	270
Min. Negotiated Rate	$740.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$740.25
Rate for Payer: UnitedHealthcare Commercial	$781.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VPC SCREW 2.5X24MM

Facility

$822.50

Hospital Charge Code	3258130
Hospital Revenue Code	270
Min. Negotiated Rate	$329.00
Max. Negotiated Rate	$781.38
Rate for Payer: Aetna Commercial	$740.25
Rate for Payer: Humana Medicare Advantage	$345.45
Rate for Payer: UnitedHealthcare Commercial	$781.38
Rate for Payer: UnitedHealthcare Medicaid	$329.00
Rate for Payer: WPPA Medicare Advantage	$493.50

Walker Boot Low Large

Facility

$99.96

Hospital Charge Code	3259922
Hospital Revenue Code	270
Min. Negotiated Rate	$39.98
Max. Negotiated Rate	$94.96
Rate for Payer: Aetna Commercial	$89.96
Rate for Payer: Humana Medicare Advantage	$41.98
Rate for Payer: UnitedHealthcare Commercial	$94.96
Rate for Payer: UnitedHealthcare Medicaid	$39.98
Rate for Payer: WPPA Medicare Advantage	$59.98

Walker Boot Low Large

Facility

$99.96

Hospital Charge Code	3259922
Hospital Revenue Code	270
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$89.96
Rate for Payer: UnitedHealthcare Commercial	$94.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Walker Boot Low Medium

Facility

$128.24

Hospital Charge Code	3259920
Hospital Revenue Code	270
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$121.83
Rate for Payer: Aetna Commercial	$115.42
Rate for Payer: Humana Medicare Advantage	$53.86
Rate for Payer: UnitedHealthcare Commercial	$121.83
Rate for Payer: UnitedHealthcare Medicaid	$51.30
Rate for Payer: WPPA Medicare Advantage	$76.94

Walker Boot Low Medium

Facility

$128.24

Hospital Charge Code	3259920
Hospital Revenue Code	270
Min. Negotiated Rate	$115.42
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$115.42
Rate for Payer: UnitedHealthcare Commercial	$121.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Walker Boot Low Small

Facility

$126.39

Hospital Charge Code	3259919
Hospital Revenue Code	270
Min. Negotiated Rate	$50.56
Max. Negotiated Rate	$120.07
Rate for Payer: Aetna Commercial	$113.75
Rate for Payer: Humana Medicare Advantage	$53.08
Rate for Payer: UnitedHealthcare Commercial	$120.07
Rate for Payer: UnitedHealthcare Medicaid	$50.56
Rate for Payer: WPPA Medicare Advantage	$75.83

Know your out-of-pocket cost for care.

All Charges