Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

DULoxetine 20 mg Cap [HMC]

Facility

$22.50

Service Code	NDC 60505299506
Hospital Charge Code	3800198
Hospital Revenue Code	250
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$21.38
Rate for Payer: Aetna Commercial	$20.25
Rate for Payer: Humana Medicare Advantage	$9.45
Rate for Payer: UnitedHealthcare Commercial	$21.38
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: WPPA Medicare Advantage	$13.50

DULoxetine 20 mg Cap [HMC]

Facility

$22.50

Service Code	NDC 68180029407
Hospital Charge Code	3800198
Hospital Revenue Code	250
Min. Negotiated Rate	$20.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.25
Rate for Payer: UnitedHealthcare Commercial	$21.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DULoxetine 20 mg Cap [HMC]

Facility

$22.50

Service Code	NDC 60505299506
Hospital Charge Code	3800198
Hospital Revenue Code	250
Min. Negotiated Rate	$20.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.25
Rate for Payer: UnitedHealthcare Commercial	$21.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DULoxetine 30 mg Cap DR [HMC]

Facility

$24.63

Service Code	NDC 68180029509
Hospital Charge Code	3800008
Hospital Revenue Code	250
Min. Negotiated Rate	$22.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.17
Rate for Payer: UnitedHealthcare Commercial	$23.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DULoxetine 30 mg Cap DR [HMC]

Facility

$10.17

Service Code	NDC 00904704461
Hospital Charge Code	3800008
Hospital Revenue Code	250
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.15
Rate for Payer: UnitedHealthcare Commercial	$9.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DULoxetine 30 mg Cap DR [HMC]

Facility

$24.63

Service Code	NDC 57237001890
Hospital Charge Code	3800008
Hospital Revenue Code	250
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna Commercial	$22.17
Rate for Payer: Humana Medicare Advantage	$10.34
Rate for Payer: UnitedHealthcare Commercial	$23.40
Rate for Payer: UnitedHealthcare Medicaid	$9.85
Rate for Payer: WPPA Medicare Advantage	$14.78

DULoxetine 30 mg Cap DR [HMC]

Facility

$10.17

Service Code	NDC 00904704461
Hospital Charge Code	3800008
Hospital Revenue Code	250
Min. Negotiated Rate	$4.07
Max. Negotiated Rate	$9.66
Rate for Payer: Aetna Commercial	$9.15
Rate for Payer: Humana Medicare Advantage	$4.27
Rate for Payer: UnitedHealthcare Commercial	$9.66
Rate for Payer: UnitedHealthcare Medicaid	$4.07
Rate for Payer: WPPA Medicare Advantage	$6.10

DULoxetine 30 mg Cap DR [HMC]

Facility

$24.25

Service Code	NDC 68084068301
Hospital Charge Code	3800008
Hospital Revenue Code	250
Min. Negotiated Rate	$21.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.82
Rate for Payer: UnitedHealthcare Commercial	$23.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DULoxetine 30 mg Cap DR [HMC]

Facility

$24.63

Service Code	NDC 57237001890
Hospital Charge Code	3800008
Hospital Revenue Code	250
Min. Negotiated Rate	$22.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.17
Rate for Payer: UnitedHealthcare Commercial	$23.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DULoxetine 30 mg Cap DR [HMC]

Facility

$24.63

Service Code	NDC 68180029509
Hospital Charge Code	3800008
Hospital Revenue Code	250
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna Commercial	$22.17
Rate for Payer: Humana Medicare Advantage	$10.34
Rate for Payer: UnitedHealthcare Commercial	$23.40
Rate for Payer: UnitedHealthcare Medicaid	$9.85
Rate for Payer: WPPA Medicare Advantage	$14.78

DULoxetine 30 mg Cap DR [HMC]

Facility

$24.25

Service Code	NDC 68084068301
Hospital Charge Code	3800008
Hospital Revenue Code	250
Min. Negotiated Rate	$9.70
Max. Negotiated Rate	$23.04
Rate for Payer: Aetna Commercial	$21.82
Rate for Payer: Humana Medicare Advantage	$10.19
Rate for Payer: UnitedHealthcare Commercial	$23.04
Rate for Payer: UnitedHealthcare Medicaid	$9.70
Rate for Payer: WPPA Medicare Advantage	$14.55

dutasteride 0.5 mg Cap [HMC]

Facility

$20.13

Service Code	NDC 31722013130
Hospital Charge Code	3800184
Hospital Revenue Code	250
Min. Negotiated Rate	$8.05
Max. Negotiated Rate	$19.12
Rate for Payer: Aetna Commercial	$18.12
Rate for Payer: Humana Medicare Advantage	$8.45
Rate for Payer: UnitedHealthcare Commercial	$19.12
Rate for Payer: UnitedHealthcare Medicaid	$8.05
Rate for Payer: WPPA Medicare Advantage	$12.08

dutasteride 0.5 mg Cap [HMC]

Facility

$20.13

Service Code	NDC 31722013130
Hospital Charge Code	3800184
Hospital Revenue Code	250
Min. Negotiated Rate	$18.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.12
Rate for Payer: UnitedHealthcare Commercial	$19.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dutasteride 0.5 mg Cap [HMC]

Facility

$27.92

Service Code	NDC 00173071215
Hospital Charge Code	3800184
Hospital Revenue Code	250
Min. Negotiated Rate	$25.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.13
Rate for Payer: UnitedHealthcare Commercial	$26.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dutasteride 0.5 mg Cap [HMC]

Facility

$27.92

Service Code	NDC 00173071215
Hospital Charge Code	3800184
Hospital Revenue Code	250
Min. Negotiated Rate	$11.17
Max. Negotiated Rate	$26.52
Rate for Payer: Aetna Commercial	$25.13
Rate for Payer: Humana Medicare Advantage	$11.73
Rate for Payer: UnitedHealthcare Commercial	$26.52
Rate for Payer: UnitedHealthcare Medicaid	$11.17
Rate for Payer: WPPA Medicare Advantage	$16.75

DynaFORCE MPJ Reamers Cup/Cone 20mm

Facility

$774.00

Hospital Charge Code	3258342
Hospital Revenue Code	270
Min. Negotiated Rate	$309.60
Max. Negotiated Rate	$735.30
Rate for Payer: Aetna Commercial	$696.60
Rate for Payer: Humana Medicare Advantage	$325.08
Rate for Payer: UnitedHealthcare Commercial	$735.30
Rate for Payer: UnitedHealthcare Medicaid	$309.60
Rate for Payer: WPPA Medicare Advantage	$464.40

DynaFORCE MPJ Reamers Cup/Cone 20mm

Facility

$774.00

Hospital Charge Code	3258342
Hospital Revenue Code	270
Min. Negotiated Rate	$696.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$696.60
Rate for Payer: UnitedHealthcare Commercial	$735.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DynaFORCE MPJ Reamers Cup/Cone 22mm

Facility

$774.00

Hospital Charge Code	3258331
Hospital Revenue Code	270
Min. Negotiated Rate	$309.60
Max. Negotiated Rate	$735.30
Rate for Payer: Aetna Commercial	$696.60
Rate for Payer: Humana Medicare Advantage	$325.08
Rate for Payer: UnitedHealthcare Commercial	$735.30
Rate for Payer: UnitedHealthcare Medicaid	$309.60
Rate for Payer: WPPA Medicare Advantage	$464.40

DynaFORCE MPJ Reamers Cup/Cone 22mm

Facility

$774.00

Hospital Charge Code	3258331
Hospital Revenue Code	270
Min. Negotiated Rate	$696.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$696.60
Rate for Payer: UnitedHealthcare Commercial	$735.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DynaFORCE Plate Sterile Instrument Kit

Facility

$1,355.00

Hospital Charge Code	3258332
Hospital Revenue Code	270
Min. Negotiated Rate	$542.00
Max. Negotiated Rate	$1,287.25
Rate for Payer: Aetna Commercial	$1,219.50
Rate for Payer: Humana Medicare Advantage	$569.10
Rate for Payer: UnitedHealthcare Commercial	$1,287.25
Rate for Payer: UnitedHealthcare Medicaid	$542.00
Rate for Payer: WPPA Medicare Advantage	$813.00

DynaFORCE Plate Sterile Instrument Kit

Facility

$1,355.00

Hospital Charge Code	3258332
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,287.25
Rate for Payer: Aetna Commercial	$1,219.50
Rate for Payer: UnitedHealthcare Commercial	$1,287.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DYSEQUILIBRIUM

Facility

$2,192.13

Service Code	MSDRG 149
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,192.13
Rate for Payer: UnitedHealthcare Medicaid	$2,192.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E0332 RBC CPD AS1 500 LR Irr

Facility

$571.00

Service Code	HCPCS P9016
Hospital Charge Code	3560180
Hospital Revenue Code	390
Min. Negotiated Rate	$513.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$513.90
Rate for Payer: UnitedHealthcare Commercial	$542.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E0332 RBC CPD AS1 500 LR Irr

Facility

$571.00

Service Code	HCPCS P9016
Hospital Charge Code	3560180
Hospital Revenue Code	390
Min. Negotiated Rate	$87.00
Max. Negotiated Rate	$542.45
Rate for Payer: Aetna Commercial	$513.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$534.34
Rate for Payer: Humana Medicare Advantage	$239.82
Rate for Payer: UnitedHealthcare Commercial	$542.45
Rate for Payer: UnitedHealthcare Medicaid	$87.00
Rate for Payer: WPPA Medicare Advantage	$342.60

E0336 RBC CPD AS1 500 LR

Facility

$571.00

Service Code	HCPCS P9016
Hospital Charge Code	3560180
Hospital Revenue Code	390
Min. Negotiated Rate	$87.00
Max. Negotiated Rate	$542.45
Rate for Payer: Aetna Commercial	$513.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$534.34
Rate for Payer: Humana Medicare Advantage	$239.82
Rate for Payer: UnitedHealthcare Commercial	$542.45
Rate for Payer: UnitedHealthcare Medicaid	$87.00
Rate for Payer: WPPA Medicare Advantage	$342.60

Know your out-of-pocket cost for care.

All Charges