Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

clotrimazole 10 mg Loz [HMC]

Facility

$9.82

Service Code	NDC 00574010770
Hospital Charge Code	3806194
Hospital Revenue Code	250
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

clotrimazole 10 mg Loz [HMC]

Facility

$15.31

Service Code	NDC 00054814622
Hospital Charge Code	3806194
Hospital Revenue Code	250
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$14.54
Rate for Payer: Aetna Commercial	$13.78
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	$9.19

clotrimazole 10 mg Loz [HMC]

Facility

$15.31

Service Code	NDC 00054814622
Hospital Charge Code	3806194
Hospital Revenue Code	250
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.78
Rate for Payer: UnitedHealthcare Commercial	$14.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

clotrimazole 10 mg Loz [HMC]

Facility

$9.82

Service Code	NDC 00574010770
Hospital Charge Code	3806194
Hospital Revenue Code	250
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$9.33
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: Humana Medicare Advantage	$4.12
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: UnitedHealthcare Medicaid	$3.93
Rate for Payer: WPPA Medicare Advantage	$5.89

clotrimazole 10 mg Loz [HMC]

Facility

$9.29

Service Code	NDC 00574010777
Hospital Charge Code	3806194
Hospital Revenue Code	250
Min. Negotiated Rate	$3.72
Max. Negotiated Rate	$8.83
Rate for Payer: Aetna Commercial	$8.36
Rate for Payer: Humana Medicare Advantage	$3.90
Rate for Payer: UnitedHealthcare Commercial	$8.83
Rate for Payer: UnitedHealthcare Medicaid	$3.72
Rate for Payer: WPPA Medicare Advantage	$5.57

clotrimazole 10 mg Loz [HMC]

Facility

$9.29

Service Code	NDC 00574010777
Hospital Charge Code	3806194
Hospital Revenue Code	250
Min. Negotiated Rate	$8.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.36
Rate for Payer: UnitedHealthcare Commercial	$8.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

clotrimazole Top 1% Crm [HMC]

Facility

$34.88

Service Code	NDC 51672200201
Hospital Charge Code	3804891
Hospital Revenue Code	250
Min. Negotiated Rate	$31.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.39
Rate for Payer: UnitedHealthcare Commercial	$33.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

clotrimazole Top 1% Crm [HMC]

Facility

$49.91

Service Code	NDC 51672127501
Hospital Charge Code	3804891
Hospital Revenue Code	250
Min. Negotiated Rate	$19.96
Max. Negotiated Rate	$47.41
Rate for Payer: Aetna Commercial	$44.92
Rate for Payer: Humana Medicare Advantage	$20.96
Rate for Payer: UnitedHealthcare Commercial	$47.41
Rate for Payer: UnitedHealthcare Medicaid	$19.96
Rate for Payer: WPPA Medicare Advantage	$29.95

clotrimazole Top 1% Crm [HMC]

Facility

$34.88

Service Code	NDC 51672200201
Hospital Charge Code	3804891
Hospital Revenue Code	250
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$33.14
Rate for Payer: Aetna Commercial	$31.39
Rate for Payer: Humana Medicare Advantage	$14.65
Rate for Payer: UnitedHealthcare Commercial	$33.14
Rate for Payer: UnitedHealthcare Medicaid	$13.95
Rate for Payer: WPPA Medicare Advantage	$20.93

clotrimazole Top 1% Crm [HMC]

Facility

$30.48

Service Code	NDC 45802043401
Hospital Charge Code	3804891
Hospital Revenue Code	250
Min. Negotiated Rate	$12.19
Max. Negotiated Rate	$28.96
Rate for Payer: Aetna Commercial	$27.43
Rate for Payer: Humana Medicare Advantage	$12.80
Rate for Payer: UnitedHealthcare Commercial	$28.96
Rate for Payer: UnitedHealthcare Medicaid	$12.19
Rate for Payer: WPPA Medicare Advantage	$18.29

clotrimazole Top 1% Crm [HMC]

Facility

$30.48

Service Code	NDC 45802043401
Hospital Charge Code	3804891
Hospital Revenue Code	250
Min. Negotiated Rate	$27.43
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.43
Rate for Payer: UnitedHealthcare Commercial	$28.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

clotrimazole Top 1% Crm [HMC]

Facility

$49.91

Service Code	NDC 51672127501
Hospital Charge Code	3804891
Hospital Revenue Code	250
Min. Negotiated Rate	$44.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$44.92
Rate for Payer: UnitedHealthcare Commercial	$47.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CMV IgG Avidity Index QST

Facility

$145.00

Service Code	HCPCS 86645
Hospital Charge Code	3558665
Hospital Revenue Code	300
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$130.50
Rate for Payer: UnitedHealthcare Commercial	$137.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CMV IgG Avidity Index QST

Facility

$145.00

Service Code	HCPCS 86645
Hospital Charge Code	3558665
Hospital Revenue Code	300
Min. Negotiated Rate	$14.32
Max. Negotiated Rate	$137.75
Rate for Payer: Aetna Commercial	$130.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$72.11
Rate for Payer: Humana Medicare Advantage	$60.90
Rate for Payer: UnitedHealthcare Commercial	$137.75
Rate for Payer: UnitedHealthcare Medicaid	$14.32
Rate for Payer: WPPA Medicare Advantage	$87.00

CO2 Detector Adult Easy Cap

Facility

$43.56

Hospital Charge Code	3256703
Hospital Revenue Code	270
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.20
Rate for Payer: UnitedHealthcare Commercial	$41.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CO2 Detector Adult Easy Cap

Facility

$43.56

Hospital Charge Code	3256703
Hospital Revenue Code	270
Min. Negotiated Rate	$17.42
Max. Negotiated Rate	$41.38
Rate for Payer: Aetna Commercial	$39.20
Rate for Payer: Humana Medicare Advantage	$18.30
Rate for Payer: UnitedHealthcare Commercial	$41.38
Rate for Payer: UnitedHealthcare Medicaid	$17.42
Rate for Payer: WPPA Medicare Advantage	$26.14

CO2 Detector Pediatric Pedi Cap

Facility

$41.00

Hospital Charge Code	3256412
Hospital Revenue Code	270
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.90
Rate for Payer: UnitedHealthcare Commercial	$38.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CO2 Detector Pediatric Pedi Cap

Facility

$41.00

Hospital Charge Code	3256412
Hospital Revenue Code	270
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$38.95
Rate for Payer: Aetna Commercial	$36.90
Rate for Payer: Humana Medicare Advantage	$17.22
Rate for Payer: UnitedHealthcare Commercial	$38.95
Rate for Payer: UnitedHealthcare Medicaid	$16.40
Rate for Payer: WPPA Medicare Advantage	$24.60

COAGULATION DISORDERS

Facility

$6,767.01

Service Code	MSDRG 813
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,767.01
Rate for Payer: UnitedHealthcare Medicaid	$6,767.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cobalt, Blood QST

Facility

$74.00

Service Code	HCPCS 83018
Hospital Charge Code	3553018
Hospital Revenue Code	300
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cobalt, Blood QST

Facility

$74.00

Service Code	HCPCS 83018
Hospital Charge Code	3553018
Hospital Revenue Code	300
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$70.30
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.97
Rate for Payer: Humana Medicare Advantage	$31.08
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: UnitedHealthcare Medicaid	$19.20
Rate for Payer: WPPA Medicare Advantage	$44.40

Coblation ARIS turbinate reduction wand-Adult

Facility

$824.00

Hospital Charge Code	3252139
Hospital Revenue Code	270
Min. Negotiated Rate	$741.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$741.60
Rate for Payer: UnitedHealthcare Commercial	$782.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Coblation ARIS turbinate reduction wand-Adult

Facility

$824.00

Hospital Charge Code	3252139
Hospital Revenue Code	270
Min. Negotiated Rate	$329.60
Max. Negotiated Rate	$782.80
Rate for Payer: Aetna Commercial	$741.60
Rate for Payer: Humana Medicare Advantage	$346.08
Rate for Payer: UnitedHealthcare Commercial	$782.80
Rate for Payer: UnitedHealthcare Medicaid	$329.60
Rate for Payer: WPPA Medicare Advantage	$494.40

Coblation HALO tonsil wand-Pediatric

Facility

$919.85

Hospital Charge Code	3252143
Hospital Revenue Code	270
Min. Negotiated Rate	$827.87
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$827.87
Rate for Payer: UnitedHealthcare Commercial	$873.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Coblation HALO tonsil wand-Pediatric

Facility

$919.85

Hospital Charge Code	3252143
Hospital Revenue Code	270
Min. Negotiated Rate	$367.94
Max. Negotiated Rate	$873.86
Rate for Payer: Aetna Commercial	$827.87
Rate for Payer: Humana Medicare Advantage	$386.34
Rate for Payer: UnitedHealthcare Commercial	$873.86
Rate for Payer: UnitedHealthcare Medicaid	$367.94
Rate for Payer: WPPA Medicare Advantage	$551.91

Know your out-of-pocket cost for care.

All Charges