Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

escitalopram 10 mg Tab [HMC]

Facility

$18.14

Service Code	NDC 00904642661
Hospital Charge Code	3809452
Hospital Revenue Code	250
Min. Negotiated Rate	$16.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.33
Rate for Payer: UnitedHealthcare Commercial	$17.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00

escitalopram 10 mg Tab [HMC]

Facility

$17.96

Service Code	NDC 68084061701
Hospital Charge Code	3809452
Hospital Revenue Code	250
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.16
Rate for Payer: UnitedHealthcare Commercial	$17.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Eslicarbazapine QST

Facility

$156.00

Service Code	HCPCS 80299
Hospital Charge Code	3552999
Hospital Revenue Code	300
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$148.20
Rate for Payer: Aetna Commercial	$140.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$65.71
Rate for Payer: Humana Medicare Advantage	$65.52
Rate for Payer: UnitedHealthcare Commercial	$148.20
Rate for Payer: UnitedHealthcare Medicaid	$18.64
Rate for Payer: WPPA Medicare Advantage	$93.60

Eslicarbazapine QST

Facility

$156.00

Service Code	HCPCS 80299
Hospital Charge Code	3552999
Hospital Revenue Code	300
Min. Negotiated Rate	$140.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$140.40
Rate for Payer: UnitedHealthcare Commercial	$148.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

eslicarbazepine 800 mg Tab [HMC]

Facility

$53.49

Service Code	NDC 43598068730
Hospital Charge Code	3800994
Hospital Revenue Code	250
Min. Negotiated Rate	$21.40
Max. Negotiated Rate	$50.82
Rate for Payer: Aetna Commercial	$48.14
Rate for Payer: Humana Medicare Advantage	$22.47
Rate for Payer: UnitedHealthcare Commercial	$50.82
Rate for Payer: UnitedHealthcare Medicaid	$21.40
Rate for Payer: WPPA Medicare Advantage	$32.09

eslicarbazepine 800 mg Tab [HMC]

Facility

$53.49

Service Code	NDC 43598068730
Hospital Charge Code	3800994
Hospital Revenue Code	250
Min. Negotiated Rate	$48.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.14
Rate for Payer: UnitedHealthcare Commercial	$50.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

eslicarbazepine 800 mg Tab [HMC]

Facility

$55.83

Service Code	NDC 63402020830
Hospital Charge Code	3800994
Hospital Revenue Code	250
Min. Negotiated Rate	$50.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.25
Rate for Payer: UnitedHealthcare Commercial	$53.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

eslicarbazepine 800 mg Tab [HMC]

Facility

$55.83

Service Code	NDC 63402020830
Hospital Charge Code	3800994
Hospital Revenue Code	250
Min. Negotiated Rate	$22.33
Max. Negotiated Rate	$53.04
Rate for Payer: Aetna Commercial	$50.25
Rate for Payer: Humana Medicare Advantage	$23.45
Rate for Payer: UnitedHealthcare Commercial	$53.04
Rate for Payer: UnitedHealthcare Medicaid	$22.33
Rate for Payer: WPPA Medicare Advantage	$33.50

Eslicarbazepine QST

Facility

$156.00

Service Code	HCPCS 80299
Hospital Charge Code	3552999
Hospital Revenue Code	300
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$148.20
Rate for Payer: Aetna Commercial	$140.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$65.71
Rate for Payer: Humana Medicare Advantage	$65.52
Rate for Payer: UnitedHealthcare Commercial	$148.20
Rate for Payer: UnitedHealthcare Medicaid	$18.64
Rate for Payer: WPPA Medicare Advantage	$93.60

Eslicarbazepine QST

Facility

$156.00

Service Code	HCPCS 80299
Hospital Charge Code	3552999
Hospital Revenue Code	300
Min. Negotiated Rate	$140.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$140.40
Rate for Payer: UnitedHealthcare Commercial	$148.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC

Facility

$6,957.63

Service Code	MSDRG 391
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,957.63
Rate for Payer: UnitedHealthcare Medicaid	$6,957.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC

Facility

$3,494.70

Service Code	MSDRG 392
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,494.70
Rate for Payer: UnitedHealthcare Medicaid	$3,494.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Esophagogastroduodenoscopy

Facility

$1,896.00

Service Code	HCPCS 43235
Hospital Charge Code	3150318
Hospital Revenue Code	360
Min. Negotiated Rate	$293.65
Max. Negotiated Rate	$1,801.20
Rate for Payer: Aetna Commercial	$1,706.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,033.23
Rate for Payer: Humana Medicare Advantage	$796.32
Rate for Payer: UnitedHealthcare Commercial	$1,801.20
Rate for Payer: UnitedHealthcare Medicaid	$293.65
Rate for Payer: WPPA Medicare Advantage	$1,137.60

Esophagogastroduodenoscopy

Facility

$1,896.00

Service Code	HCPCS 43235
Hospital Charge Code	3150318
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,801.20
Rate for Payer: Aetna Commercial	$1,706.40
Rate for Payer: UnitedHealthcare Commercial	$1,801.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Esophagogastroduodenoscopy Foreign Body Removal

Facility

$2,402.00

Service Code	HCPCS 43247
Hospital Charge Code	3150322
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,281.90
Rate for Payer: Aetna Commercial	$2,161.80
Rate for Payer: UnitedHealthcare Commercial	$2,281.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Esophagogastroduodenoscopy Foreign Body Removal

Facility

$2,402.00

Service Code	HCPCS 43247
Hospital Charge Code	3150322
Hospital Revenue Code	360
Min. Negotiated Rate	$293.65
Max. Negotiated Rate	$2,281.90
Rate for Payer: Aetna Commercial	$2,161.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,308.96
Rate for Payer: Humana Medicare Advantage	$1,008.84
Rate for Payer: UnitedHealthcare Commercial	$2,281.90
Rate for Payer: UnitedHealthcare Medicaid	$293.65
Rate for Payer: WPPA Medicare Advantage	$1,441.20

ESR Alcor

Facility

$47.00

Service Code	HCPCS 85652
Hospital Charge Code	3550718
Hospital Revenue Code	300
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ESR Alcor

Facility

$47.00

Service Code	HCPCS 85652
Hospital Charge Code	3550718
Hospital Revenue Code	300
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$44.65
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$12.82
Rate for Payer: Humana Medicare Advantage	$19.74
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: UnitedHealthcare Medicaid	$2.70
Rate for Payer: WPPA Medicare Advantage	$28.20

estradiol 0.05 mg/24 hours weekly Transderm ER Film [HMC]

Facility

$28.21

Service Code	NDC 00378335099
Hospital Charge Code	3800176
Hospital Revenue Code	250
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$26.80
Rate for Payer: Aetna Commercial	$25.39
Rate for Payer: Humana Medicare Advantage	$11.85
Rate for Payer: UnitedHealthcare Commercial	$26.80
Rate for Payer: UnitedHealthcare Medicaid	$11.28
Rate for Payer: WPPA Medicare Advantage	$16.93

estradiol 0.05 mg/24 hours weekly Transderm ER Film [HMC]

Facility

$28.21

Service Code	NDC 00378335099
Hospital Charge Code	3800176
Hospital Revenue Code	250
Min. Negotiated Rate	$25.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.39
Rate for Payer: UnitedHealthcare Commercial	$26.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

estradiol 0.1 mg/24 hours weekly Transderm ER Film [HMC]

Facility

$50.78

Service Code	NDC 50419045204
Hospital Charge Code	3803844
Hospital Revenue Code	250
Min. Negotiated Rate	$45.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.70
Rate for Payer: UnitedHealthcare Commercial	$48.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

estradiol 0.1 mg/24 hours weekly Transderm ER Film [HMC]

Facility

$28.21

Service Code	NDC 00781710454
Hospital Charge Code	3803844
Hospital Revenue Code	250
Min. Negotiated Rate	$25.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.39
Rate for Payer: UnitedHealthcare Commercial	$26.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

estradiol 0.1 mg/24 hours weekly Transderm ER Film [HMC]

Facility

$28.21

Service Code	NDC 00781710454
Hospital Charge Code	3803844
Hospital Revenue Code	250
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$26.80
Rate for Payer: Aetna Commercial	$25.39
Rate for Payer: Humana Medicare Advantage	$11.85
Rate for Payer: UnitedHealthcare Commercial	$26.80
Rate for Payer: UnitedHealthcare Medicaid	$11.28
Rate for Payer: WPPA Medicare Advantage	$16.93

estradiol 0.1 mg/24 hours weekly Transderm ER Film [HMC]

Facility

$50.78

Service Code	NDC 50419045204
Hospital Charge Code	3803844
Hospital Revenue Code	250
Min. Negotiated Rate	$20.31
Max. Negotiated Rate	$48.24
Rate for Payer: Aetna Commercial	$45.70
Rate for Payer: Humana Medicare Advantage	$21.33
Rate for Payer: UnitedHealthcare Commercial	$48.24
Rate for Payer: UnitedHealthcare Medicaid	$20.31
Rate for Payer: WPPA Medicare Advantage	$30.47

estradiol 0.1 mg/g Vag Crm [HMC]

Facility

$578.55

Service Code	NDC 00430375414
Hospital Charge Code	3800266
Hospital Revenue Code	250
Min. Negotiated Rate	$231.42
Max. Negotiated Rate	$549.62
Rate for Payer: Aetna Commercial	$520.70
Rate for Payer: Humana Medicare Advantage	$242.99
Rate for Payer: UnitedHealthcare Commercial	$549.62
Rate for Payer: UnitedHealthcare Medicaid	$231.42
Rate for Payer: WPPA Medicare Advantage	$347.13

Know your out-of-pocket cost for care.

All Charges