Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

ziprasidone 20 mg Cap [HMC]

Facility

$27.41

Service Code	NDC 00904626908
Hospital Charge Code	3800607
Hospital Revenue Code	250
Min. Negotiated Rate	$10.96
Max. Negotiated Rate	$26.04
Rate for Payer: Aetna Commercial	$24.67
Rate for Payer: Humana Medicare Advantage	$11.51
Rate for Payer: UnitedHealthcare Commercial	$26.04
Rate for Payer: UnitedHealthcare Medicaid	$10.96
Rate for Payer: WPPA Medicare Advantage	$16.45

ziprasidone 20 mg Pow [HMC]

Facility

$79.02

Service Code	HCPCS J3486
Hospital Charge Code	3804013
Hospital Revenue Code	250
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$75.07
Rate for Payer: Aetna Commercial	$71.12
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$13.15
Rate for Payer: Humana Medicare Advantage	$33.19
Rate for Payer: UnitedHealthcare Commercial	$75.07
Rate for Payer: UnitedHealthcare Medicaid	$9.15
Rate for Payer: WPPA Medicare Advantage	$47.41

ziprasidone 20 mg Pow [HMC]

Facility

$79.02

Service Code	HCPCS J3486
Hospital Charge Code	3804013
Hospital Revenue Code	250
Min. Negotiated Rate	$71.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$71.12
Rate for Payer: UnitedHealthcare Commercial	$75.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ziprasidone 20 mg Pow [HMC]

Facility

$79.02

Service Code	NDC 72266016042
Hospital Charge Code	3804013
Hospital Revenue Code	250
Min. Negotiated Rate	$71.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$71.12
Rate for Payer: UnitedHealthcare Commercial	$75.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ziprasidone 20 mg Pow [HMC]

Facility

$79.02

Service Code	NDC 72266016042
Hospital Charge Code	3804013
Hospital Revenue Code	250
Min. Negotiated Rate	$31.61
Max. Negotiated Rate	$75.07
Rate for Payer: Aetna Commercial	$71.12
Rate for Payer: Humana Medicare Advantage	$33.19
Rate for Payer: UnitedHealthcare Commercial	$75.07
Rate for Payer: UnitedHealthcare Medicaid	$31.61
Rate for Payer: WPPA Medicare Advantage	$47.41

zoledronic acid 4 mg/5 mL IV Sol [HMC]

Facility

$190.00

Service Code	HCPCS J3489
Hospital Charge Code	3850537
Hospital Revenue Code	250
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$180.50
Rate for Payer: Aetna Commercial	$171.00
Rate for Payer: Aetna Commercial	$1,140.70
Rate for Payer: Aetna Commercial	$538.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8.93
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8.93
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8.93
Rate for Payer: Humana Medicare Advantage	$79.80
Rate for Payer: Humana Medicare Advantage	$532.32
Rate for Payer: Humana Medicare Advantage	$251.16
Rate for Payer: UnitedHealthcare Commercial	$1,204.07
Rate for Payer: UnitedHealthcare Commercial	$180.50
Rate for Payer: UnitedHealthcare Commercial	$568.10
Rate for Payer: UnitedHealthcare Medicaid	$5.08
Rate for Payer: UnitedHealthcare Medicaid	$5.08
Rate for Payer: UnitedHealthcare Medicaid	$5.08
Rate for Payer: WPPA Medicare Advantage	$358.80
Rate for Payer: WPPA Medicare Advantage	$114.00
Rate for Payer: WPPA Medicare Advantage	$760.46

zoledronic acid 4 mg/5 mL IV Sol [HMC]

Facility

$1,267.44

Service Code	HCPCS J3489
Hospital Charge Code	3850537
Hospital Revenue Code	250
Min. Negotiated Rate	$1,140.70
Max. Negotiated Rate	$1,204.07
Rate for Payer: Aetna Commercial	$1,140.70
Rate for Payer: Aetna Commercial	$171.00
Rate for Payer: Aetna Commercial	$538.20
Rate for Payer: UnitedHealthcare Commercial	$568.10
Rate for Payer: UnitedHealthcare Commercial	$180.50
Rate for Payer: UnitedHealthcare Commercial	$1,204.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

zoledronic acid 5 mg/100 mL IV Sol [HMC]

Facility

$730.00

Service Code	NDC 63323096600
Hospital Charge Code	3852085
Hospital Revenue Code	250
Min. Negotiated Rate	$657.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$657.00
Rate for Payer: UnitedHealthcare Commercial	$693.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

zoledronic acid 5 mg/100 mL IV Sol [HMC]

Facility

$730.00

Service Code	NDC 63323096600
Hospital Charge Code	3852085
Hospital Revenue Code	250
Min. Negotiated Rate	$292.00
Max. Negotiated Rate	$693.50
Rate for Payer: Aetna Commercial	$657.00
Rate for Payer: Humana Medicare Advantage	$306.60
Rate for Payer: UnitedHealthcare Commercial	$693.50
Rate for Payer: UnitedHealthcare Medicaid	$292.00
Rate for Payer: WPPA Medicare Advantage	$438.00

zoledronic acid 5 mg/100 mL IV Sol [HMC]

Facility

$730.00

Service Code	HCPCS J3489
Hospital Charge Code	3852085
Hospital Revenue Code	250
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$693.50
Rate for Payer: Aetna Commercial	$657.00
Rate for Payer: Aetna Commercial	$1,764.81
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8.93
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8.93
Rate for Payer: Humana Medicare Advantage	$823.58
Rate for Payer: Humana Medicare Advantage	$306.60
Rate for Payer: UnitedHealthcare Commercial	$1,862.86
Rate for Payer: UnitedHealthcare Commercial	$693.50
Rate for Payer: UnitedHealthcare Medicaid	$5.08
Rate for Payer: UnitedHealthcare Medicaid	$5.08
Rate for Payer: WPPA Medicare Advantage	$438.00
Rate for Payer: WPPA Medicare Advantage	$1,176.54

zoledronic acid 5 mg/100 mL IV Sol [HMC]

Facility

$1,960.90

Service Code	HCPCS J3489
Hospital Charge Code	3852085
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,862.86
Rate for Payer: Aetna Commercial	$1,764.81
Rate for Payer: Aetna Commercial	$657.00
Rate for Payer: UnitedHealthcare Commercial	$693.50
Rate for Payer: UnitedHealthcare Commercial	$1,862.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Zoll CO2 Nasal Cannula w/O2 Adult

Facility

$53.00

Hospital Charge Code	3257252
Hospital Revenue Code	270
Min. Negotiated Rate	$21.20
Max. Negotiated Rate	$50.35
Rate for Payer: Aetna Commercial	$47.70
Rate for Payer: Humana Medicare Advantage	$22.26
Rate for Payer: UnitedHealthcare Commercial	$50.35
Rate for Payer: UnitedHealthcare Medicaid	$21.20
Rate for Payer: WPPA Medicare Advantage	$31.80

Zoll CO2 Nasal Cannula w/O2 Adult

Facility

$53.00

Hospital Charge Code	3257252
Hospital Revenue Code	270
Min. Negotiated Rate	$47.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$47.70
Rate for Payer: UnitedHealthcare Commercial	$50.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Zoll CO2 Nasal Cannula w/O2 Pediatric

Facility

$57.56

Hospital Charge Code	3257253
Hospital Revenue Code	270
Min. Negotiated Rate	$23.02
Max. Negotiated Rate	$54.68
Rate for Payer: Aetna Commercial	$51.80
Rate for Payer: Humana Medicare Advantage	$24.18
Rate for Payer: UnitedHealthcare Commercial	$54.68
Rate for Payer: UnitedHealthcare Medicaid	$23.02
Rate for Payer: WPPA Medicare Advantage	$34.54

Zoll CO2 Nasal Cannula w/O2 Pediatric

Facility

$57.56

Hospital Charge Code	3257253
Hospital Revenue Code	270
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.80
Rate for Payer: UnitedHealthcare Commercial	$54.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Zoll ETCO2 Tubing Adult or Pediatric

Facility

$40.00

Hospital Charge Code	3257254
Hospital Revenue Code	270
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.00
Rate for Payer: UnitedHealthcare Commercial	$38.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Zoll ETCO2 Tubing Adult or Pediatric

Facility

$40.00

Hospital Charge Code	3257254
Hospital Revenue Code	270
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$16.80
Rate for Payer: UnitedHealthcare Commercial	$38.00
Rate for Payer: UnitedHealthcare Medicaid	$16.00
Rate for Payer: WPPA Medicare Advantage	$24.00

Zoll ETCO2 Tubing Pediatric or Infant

Facility

$40.00

Hospital Charge Code	3257257
Hospital Revenue Code	270
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$16.80
Rate for Payer: UnitedHealthcare Commercial	$38.00
Rate for Payer: UnitedHealthcare Medicaid	$16.00
Rate for Payer: WPPA Medicare Advantage	$24.00

Zoll ETCO2 Tubing Pediatric or Infant

Facility

$40.00

Hospital Charge Code	3257257
Hospital Revenue Code	270
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.00
Rate for Payer: UnitedHealthcare Commercial	$38.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Zoll OneStep Complete Adult Defibrillator Pad R-Series

Facility

$254.56

Hospital Charge Code	3257250
Hospital Revenue Code	270
Min. Negotiated Rate	$101.82
Max. Negotiated Rate	$241.83
Rate for Payer: Aetna Commercial	$229.10
Rate for Payer: Humana Medicare Advantage	$106.92
Rate for Payer: UnitedHealthcare Commercial	$241.83
Rate for Payer: UnitedHealthcare Medicaid	$101.82
Rate for Payer: WPPA Medicare Advantage	$152.74

Zoll OneStep Complete Adult Defibrillator Pad R-Series

Facility

$254.56

Hospital Charge Code	3257250
Hospital Revenue Code	270
Min. Negotiated Rate	$229.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$229.10
Rate for Payer: UnitedHealthcare Commercial	$241.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Zoll OneStep Pediatric CPR Defibrillator Pad R-Series

Facility

$255.89

Hospital Charge Code	3257251
Hospital Revenue Code	270
Min. Negotiated Rate	$230.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$230.30
Rate for Payer: UnitedHealthcare Commercial	$243.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Zoll OneStep Pediatric CPR Defibrillator Pad R-Series

Facility

$255.89

Hospital Charge Code	3257251
Hospital Revenue Code	270
Min. Negotiated Rate	$102.36
Max. Negotiated Rate	$243.10
Rate for Payer: Aetna Commercial	$230.30
Rate for Payer: Humana Medicare Advantage	$107.47
Rate for Payer: UnitedHealthcare Commercial	$243.10
Rate for Payer: UnitedHealthcare Medicaid	$102.36
Rate for Payer: WPPA Medicare Advantage	$153.53

zolpidem 5 mg Tab [HMC]

Facility

$18.88

Service Code	NDC 13668000701
Hospital Charge Code	3800683
Hospital Revenue Code	250
Min. Negotiated Rate	$16.99
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.99
Rate for Payer: UnitedHealthcare Commercial	$17.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

zolpidem 5 mg Tab [HMC]

Facility

$18.86

Service Code	NDC 51079072420
Hospital Charge Code	3800683
Hospital Revenue Code	250
Min. Negotiated Rate	$16.97
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.97
Rate for Payer: UnitedHealthcare Commercial	$17.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges