Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

estradiol 1 mg Tab [HMC]

Facility

$6.14

Service Code	NDC 00378145401
Hospital Charge Code	3808777
Hospital Revenue Code	250
Min. Negotiated Rate	$5.53
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.53
Rate for Payer: UnitedHealthcare Commercial	$5.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

estradiol 1 mg Tab [HMC]

Facility

$7.04

Service Code	NDC 00555088602
Hospital Charge Code	3808777
Hospital Revenue Code	250
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: UnitedHealthcare Commercial	$6.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

estradiol 1 mg Tab [HMC]

Facility

$7.04

Service Code	NDC 00555088602
Hospital Charge Code	3808777
Hospital Revenue Code	250
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$6.69
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: Humana Medicare Advantage	$2.96
Rate for Payer: UnitedHealthcare Commercial	$6.69
Rate for Payer: UnitedHealthcare Medicaid	$2.82
Rate for Payer: WPPA Medicare Advantage	$4.22

estradiol 1 mg Tab [HMC]

Facility

$7.04

Service Code	NDC 51862033301
Hospital Charge Code	3808777
Hospital Revenue Code	250
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: UnitedHealthcare Commercial	$6.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

estradiol 1 mg Tab [HMC]

Facility

$7.04

Service Code	NDC 70954056510
Hospital Charge Code	3808777
Hospital Revenue Code	250
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: UnitedHealthcare Commercial	$6.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

estradiol 1 mg Tab [HMC]

Facility

$7.04

Service Code	NDC 51862033301
Hospital Charge Code	3808777
Hospital Revenue Code	250
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$6.69
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: Humana Medicare Advantage	$2.96
Rate for Payer: UnitedHealthcare Commercial	$6.69
Rate for Payer: UnitedHealthcare Medicaid	$2.82
Rate for Payer: WPPA Medicare Advantage	$4.22

estradiol 1 mg Tab [HMC]

Facility

$6.14

Service Code	NDC 00378145401
Hospital Charge Code	3808777
Hospital Revenue Code	250
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$5.83
Rate for Payer: Aetna Commercial	$5.53
Rate for Payer: Humana Medicare Advantage	$2.58
Rate for Payer: UnitedHealthcare Commercial	$5.83
Rate for Payer: UnitedHealthcare Medicaid	$2.46
Rate for Payer: WPPA Medicare Advantage	$3.68

estradiol 1 mg Tab [HMC]

Facility

$7.04

Service Code	NDC 70954056510
Hospital Charge Code	3808777
Hospital Revenue Code	250
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$6.69
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: Humana Medicare Advantage	$2.96
Rate for Payer: UnitedHealthcare Commercial	$6.69
Rate for Payer: UnitedHealthcare Medicaid	$2.82
Rate for Payer: WPPA Medicare Advantage	$4.22

Estradiol Level

Facility

$206.00

Service Code	HCPCS 82670
Hospital Charge Code	3552409
Hospital Revenue Code	300
Min. Negotiated Rate	$27.94
Max. Negotiated Rate	$195.70
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$125.19
Rate for Payer: Humana Medicare Advantage	$86.52
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: UnitedHealthcare Medicaid	$27.94
Rate for Payer: WPPA Medicare Advantage	$123.60

Estradiol Level

Facility

$206.00

Service Code	HCPCS 82670
Hospital Charge Code	3552409
Hospital Revenue Code	300
Min. Negotiated Rate	$185.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

estradiol topical 10 mcg Tab [HMC]

Facility

$30.52

Service Code	NDC 00169517603
Hospital Charge Code	3800623
Hospital Revenue Code	250
Min. Negotiated Rate	$12.21
Max. Negotiated Rate	$28.99
Rate for Payer: Aetna Commercial	$27.47
Rate for Payer: Humana Medicare Advantage	$12.82
Rate for Payer: UnitedHealthcare Commercial	$28.99
Rate for Payer: UnitedHealthcare Medicaid	$12.21
Rate for Payer: WPPA Medicare Advantage	$18.31

estradiol topical 10 mcg Tab [HMC]

Facility

$30.52

Service Code	NDC 00169517603
Hospital Charge Code	3800623
Hospital Revenue Code	250
Min. Negotiated Rate	$27.47
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.47
Rate for Payer: UnitedHealthcare Commercial	$28.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Estrogen, Total, S QST

Facility

$139.00

Service Code	HCPCS 82672
Hospital Charge Code	3550395
Hospital Revenue Code	300
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$132.05
Rate for Payer: Aetna Commercial	$125.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$84.51
Rate for Payer: Humana Medicare Advantage	$58.38
Rate for Payer: UnitedHealthcare Commercial	$132.05
Rate for Payer: UnitedHealthcare Medicaid	$21.70
Rate for Payer: WPPA Medicare Advantage	$83.40

Estrogen, Total, S QST

Facility

$139.00

Service Code	HCPCS 82672
Hospital Charge Code	3550395
Hospital Revenue Code	300
Min. Negotiated Rate	$125.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$125.10
Rate for Payer: UnitedHealthcare Commercial	$132.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Estrone, LC/MS/MS QST

Facility

$321.00

Service Code	HCPCS 82679
Hospital Charge Code	3552679
Hospital Revenue Code	300
Min. Negotiated Rate	$288.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$288.90
Rate for Payer: UnitedHealthcare Commercial	$304.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Estrone, LC/MS/MS QST

Facility

$321.00

Service Code	HCPCS 82679
Hospital Charge Code	3552679
Hospital Revenue Code	300
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$304.95
Rate for Payer: Aetna Commercial	$288.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$62.10
Rate for Payer: Humana Medicare Advantage	$134.82
Rate for Payer: UnitedHealthcare Commercial	$304.95
Rate for Payer: UnitedHealthcare Medicaid	$21.00
Rate for Payer: WPPA Medicare Advantage	$192.60

eszopiclone 1 mg Tab [HMC]

Facility

$29.32

Service Code	NDC 33342029907
Hospital Charge Code	3808614
Hospital Revenue Code	250
Min. Negotiated Rate	$26.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.39
Rate for Payer: UnitedHealthcare Commercial	$27.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

eszopiclone 1 mg Tab [HMC]

Facility

$28.35

Service Code	NDC 65862096701
Hospital Charge Code	3808614
Hospital Revenue Code	250
Min. Negotiated Rate	$11.34
Max. Negotiated Rate	$26.93
Rate for Payer: Aetna Commercial	$25.52
Rate for Payer: Humana Medicare Advantage	$11.91
Rate for Payer: UnitedHealthcare Commercial	$26.93
Rate for Payer: UnitedHealthcare Medicaid	$11.34
Rate for Payer: WPPA Medicare Advantage	$17.01

eszopiclone 1 mg Tab [HMC]

Facility

$29.32

Service Code	NDC 33342029907
Hospital Charge Code	3808614
Hospital Revenue Code	250
Min. Negotiated Rate	$11.73
Max. Negotiated Rate	$27.85
Rate for Payer: Aetna Commercial	$26.39
Rate for Payer: Humana Medicare Advantage	$12.31
Rate for Payer: UnitedHealthcare Commercial	$27.85
Rate for Payer: UnitedHealthcare Medicaid	$11.73
Rate for Payer: WPPA Medicare Advantage	$17.59

eszopiclone 1 mg Tab [HMC]

Facility

$33.14

Service Code	NDC 63402019030
Hospital Charge Code	3808614
Hospital Revenue Code	250
Min. Negotiated Rate	$29.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.83
Rate for Payer: UnitedHealthcare Commercial	$31.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

eszopiclone 1 mg Tab [HMC]

Facility

$28.35

Service Code	NDC 65862096701
Hospital Charge Code	3808614
Hospital Revenue Code	250
Min. Negotiated Rate	$25.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.52
Rate for Payer: UnitedHealthcare Commercial	$26.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00

eszopiclone 1 mg Tab [HMC]

Facility

$33.14

Service Code	NDC 63402019030
Hospital Charge Code	3808614
Hospital Revenue Code	250
Min. Negotiated Rate	$13.26
Max. Negotiated Rate	$31.48
Rate for Payer: Aetna Commercial	$29.83
Rate for Payer: Humana Medicare Advantage	$13.92
Rate for Payer: UnitedHealthcare Commercial	$31.48
Rate for Payer: UnitedHealthcare Medicaid	$13.26
Rate for Payer: WPPA Medicare Advantage	$19.88

etoposide 20 mg/mL IV Sol 25 mL [HMC]

Facility

$101.18

Service Code	HCPCS J9181
Hospital Charge Code	3850355
Hospital Revenue Code	250
Min. Negotiated Rate	$91.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.06
Rate for Payer: UnitedHealthcare Commercial	$96.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

etoposide 20 mg/mL IV Sol 25 mL [HMC]

Facility

$101.18

Service Code	HCPCS J9181
Hospital Charge Code	3850355
Hospital Revenue Code	250
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$96.12
Rate for Payer: Aetna Commercial	$91.06
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.34
Rate for Payer: Humana Medicare Advantage	$42.50
Rate for Payer: UnitedHealthcare Commercial	$96.12
Rate for Payer: UnitedHealthcare Medicaid	$1.04
Rate for Payer: WPPA Medicare Advantage	$60.71

Know your out-of-pocket cost for care.

All Charges