Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

warfarin 5 mg Tab [HMC]

Facility

$7.02

Service Code	NDC 65162076610
Hospital Charge Code	3801146
Hospital Revenue Code	250
Min. Negotiated Rate	$6.32
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.32
Rate for Payer: UnitedHealthcare Commercial	$6.67
Rate for Payer: WPPA Medicare Advantage	$1,200.00

warfarin 5 mg Tab [HMC]

Facility

$7.06

Service Code	NDC 00832121601
Hospital Charge Code	3801146
Hospital Revenue Code	250
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$6.71
Rate for Payer: Aetna Commercial	$6.35
Rate for Payer: Humana Medicare Advantage	$2.97
Rate for Payer: UnitedHealthcare Commercial	$6.71
Rate for Payer: UnitedHealthcare Medicaid	$2.82
Rate for Payer: WPPA Medicare Advantage	$4.24

warfarin 5 mg Tab [HMC]

Facility

$6.93

Service Code	NDC 62584099401
Hospital Charge Code	3801146
Hospital Revenue Code	250
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.24
Rate for Payer: UnitedHealthcare Commercial	$6.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

warfarin 5 mg Tab [HMC]

Facility

$6.93

Service Code	NDC 62584099401
Hospital Charge Code	3801146
Hospital Revenue Code	250
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$6.58
Rate for Payer: Aetna Commercial	$6.24
Rate for Payer: Humana Medicare Advantage	$2.91
Rate for Payer: UnitedHealthcare Commercial	$6.58
Rate for Payer: UnitedHealthcare Medicaid	$2.77
Rate for Payer: WPPA Medicare Advantage	$4.16

Watermelon (RF329) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	3550755
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$16.20

Watermelon (RF329) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	3550755
Hospital Revenue Code	300
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

West Nile Virus Ab (IgG,IgM), CSF QST

Facility

$92.00

Service Code	HCPCS 86789
Hospital Charge Code	3556502
Hospital Revenue Code	300
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

West Nile Virus Ab (IgG,IgM), CSF QST

Facility

$92.00

Service Code	HCPCS 86789
Hospital Charge Code	3556502
Hospital Revenue Code	300
Min. Negotiated Rate	$14.39
Max. Negotiated Rate	$87.40
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$30.89
Rate for Payer: Humana Medicare Advantage	$38.64
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: UnitedHealthcare Medicaid	$14.39
Rate for Payer: WPPA Medicare Advantage	$55.20

West Nile Virus Ab (IgG,IgM) QST

Facility

$150.00

Service Code	HCPCS 86788
Hospital Charge Code	3556390
Hospital Revenue Code	300
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$135.00
Rate for Payer: UnitedHealthcare Commercial	$142.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

West Nile Virus Ab (IgG,IgM) QST

Facility

$150.00

Service Code	HCPCS 86788
Hospital Charge Code	3556390
Hospital Revenue Code	300
Min. Negotiated Rate	$16.85
Max. Negotiated Rate	$142.50
Rate for Payer: Aetna Commercial	$135.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.15
Rate for Payer: Humana Medicare Advantage	$63.00
Rate for Payer: UnitedHealthcare Commercial	$142.50
Rate for Payer: UnitedHealthcare Medicaid	$16.85
Rate for Payer: WPPA Medicare Advantage	$90.00

Wet Mount

Facility

$56.00

Service Code	HCPCS 87210
Hospital Charge Code	3551393
Hospital Revenue Code	300
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$53.20
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$16.38
Rate for Payer: Humana Medicare Advantage	$23.52
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: UnitedHealthcare Medicaid	$5.02
Rate for Payer: WPPA Medicare Advantage	$33.60

Wet Mount

Facility

$56.00

Service Code	HCPCS 87210
Hospital Charge Code	3551393
Hospital Revenue Code	300
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Wheat (F4) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552818
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Wheat (F4) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552818
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$12.60

Wheelchair Charge

Facility

$116.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	3970210
Hospital Revenue Code	430
Min. Negotiated Rate	$29.54
Max. Negotiated Rate	$110.20
Rate for Payer: Aetna Commercial	$104.40
Rate for Payer: Humana Medicare Advantage	$48.72
Rate for Payer: UnitedHealthcare Commercial	$110.20
Rate for Payer: UnitedHealthcare Medicaid	$29.54
Rate for Payer: WPPA Medicare Advantage	$69.60

Wheelchair Charge

Facility

$116.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	3970210
Hospital Revenue Code	430
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$104.40
Rate for Payer: UnitedHealthcare Commercial	$110.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

White Blood Cell Count

Facility

$38.00

Service Code	HCPCS 85048
Hospital Charge Code	3550171
Hospital Revenue Code	300
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$36.10
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$9.63
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: WPPA Medicare Advantage	$22.80

White Blood Cell Count

Facility

$38.00

Service Code	HCPCS 85048
Hospital Charge Code	3550171
Hospital Revenue Code	300
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

White Cell Count w/ Auto Diff

Facility

$38.00

Service Code	HCPCS 85048
Hospital Charge Code	3550171
Hospital Revenue Code	300
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

White Cell Count w/ Auto Diff

Facility

$38.00

Service Code	HCPCS 85048
Hospital Charge Code	3550171
Hospital Revenue Code	300
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$36.10
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$9.63
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: WPPA Medicare Advantage	$22.80

witch hazel topical 50% Pad [HMC]

Facility

$20.35

Service Code	NDC 41388000732
Hospital Charge Code	3800479
Hospital Revenue Code	257
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.32
Rate for Payer: UnitedHealthcare Commercial	$19.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

witch hazel topical 50% Pad [HMC]

Facility

$20.35

Service Code	NDC 41388000732
Hospital Charge Code	3800479
Hospital Revenue Code	257
Min. Negotiated Rate	$8.14
Max. Negotiated Rate	$19.33
Rate for Payer: Aetna Commercial	$18.32
Rate for Payer: Humana Medicare Advantage	$8.55
Rate for Payer: UnitedHealthcare Commercial	$19.33
Rate for Payer: UnitedHealthcare Medicaid	$8.14
Rate for Payer: WPPA Medicare Advantage	$12.21

Word Catheter Bartholin Gland Balloon Kit

Facility

$92.00

Hospital Charge Code	3258830
Hospital Revenue Code	270
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Word Catheter Bartholin Gland Balloon Kit

Facility

$92.00

Hospital Charge Code	3258830
Hospital Revenue Code	270
Min. Negotiated Rate	$36.80
Max. Negotiated Rate	$87.40
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: Humana Medicare Advantage	$38.64
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: UnitedHealthcare Medicaid	$36.80
Rate for Payer: WPPA Medicare Advantage	$55.20

Wound Cleanser Anasept 8oz Spray Bottle

Facility

$72.68

Hospital Charge Code	3259501
Hospital Revenue Code	270
Min. Negotiated Rate	$65.41
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$65.41
Rate for Payer: UnitedHealthcare Commercial	$69.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges