Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Fish Oil omega-3 polyunsaturated fatty acid 1000 mg Cap [HMC]

Facility

$5.73

Service Code	NDC 77333030810
Hospital Charge Code	3800702
Hospital Revenue Code	250
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.16
Rate for Payer: UnitedHealthcare Commercial	$5.44
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fixation Device Absorbatack 20 Short Abstack20S

Facility

$1,041.73

Service Code	HCPCS C1713
Hospital Charge Code	3258942
Hospital Revenue Code	278
Min. Negotiated Rate	$416.69
Max. Negotiated Rate	$989.64
Rate for Payer: Aetna Commercial	$937.56
Rate for Payer: Humana Medicare Advantage	$437.53
Rate for Payer: UnitedHealthcare Commercial	$989.64
Rate for Payer: UnitedHealthcare Medicaid	$416.69
Rate for Payer: WPPA Medicare Advantage	$625.04

Fixation Device Absorbatack 20 Short Abstack20S

Facility

$1,041.73

Service Code	HCPCS C1713
Hospital Charge Code	3258942
Hospital Revenue Code	278
Min. Negotiated Rate	$937.56
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$937.56
Rate for Payer: UnitedHealthcare Commercial	$989.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fixation Device Absorbatack 30 Endo Abstack30X

Facility

$1,501.00

Hospital Charge Code	3258945
Hospital Revenue Code	270
Min. Negotiated Rate	$600.40
Max. Negotiated Rate	$1,425.95
Rate for Payer: Aetna Commercial	$1,350.90
Rate for Payer: Humana Medicare Advantage	$630.42
Rate for Payer: UnitedHealthcare Commercial	$1,425.95
Rate for Payer: UnitedHealthcare Medicaid	$600.40
Rate for Payer: WPPA Medicare Advantage	$900.60

Fixation Device Absorbatack 30 Endo Abstack30X

Facility

$1,501.00

Hospital Charge Code	3258945
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,425.95
Rate for Payer: Aetna Commercial	$1,350.90
Rate for Payer: UnitedHealthcare Commercial	$1,425.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fixation Device Stat Tack 5mm

Facility

$612.00

Hospital Charge Code	3258949
Hospital Revenue Code	270
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$581.40
Rate for Payer: Aetna Commercial	$550.80
Rate for Payer: Humana Medicare Advantage	$257.04
Rate for Payer: UnitedHealthcare Commercial	$581.40
Rate for Payer: UnitedHealthcare Medicaid	$244.80
Rate for Payer: WPPA Medicare Advantage	$367.20

Fixation Device Stat Tack 5mm

Facility

$612.00

Hospital Charge Code	3258949
Hospital Revenue Code	270
Min. Negotiated Rate	$550.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$550.80
Rate for Payer: UnitedHealthcare Commercial	$581.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fixed Ankle Walker Boot Tall Medium

Facility

$107.00

Hospital Charge Code	3251820
Hospital Revenue Code	270
Min. Negotiated Rate	$96.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$96.30
Rate for Payer: UnitedHealthcare Commercial	$101.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fixed Ankle Walker Boot Tall Medium

Facility

$107.00

Hospital Charge Code	3251820
Hospital Revenue Code	270
Min. Negotiated Rate	$42.80
Max. Negotiated Rate	$101.65
Rate for Payer: Aetna Commercial	$96.30
Rate for Payer: Humana Medicare Advantage	$44.94
Rate for Payer: UnitedHealthcare Commercial	$101.65
Rate for Payer: UnitedHealthcare Medicaid	$42.80
Rate for Payer: WPPA Medicare Advantage	$64.20

flecainide 50 mg Tab [HMC]

Facility

$17.16

Service Code	NDC 50268032015
Hospital Charge Code	3801210
Hospital Revenue Code	250
Min. Negotiated Rate	$6.86
Max. Negotiated Rate	$16.30
Rate for Payer: Aetna Commercial	$15.44
Rate for Payer: Humana Medicare Advantage	$7.21
Rate for Payer: UnitedHealthcare Commercial	$16.30
Rate for Payer: UnitedHealthcare Medicaid	$6.86
Rate for Payer: WPPA Medicare Advantage	$10.30

flecainide 50 mg Tab [HMC]

Facility

$11.06

Service Code	NDC 00054001021
Hospital Charge Code	3801210
Hospital Revenue Code	250
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$10.51
Rate for Payer: Aetna Commercial	$9.95
Rate for Payer: Humana Medicare Advantage	$4.65
Rate for Payer: UnitedHealthcare Commercial	$10.51
Rate for Payer: UnitedHealthcare Medicaid	$4.42
Rate for Payer: WPPA Medicare Advantage	$6.64

flecainide 50 mg Tab [HMC]

Facility

$11.06

Service Code	NDC 00054001021
Hospital Charge Code	3801210
Hospital Revenue Code	250
Min. Negotiated Rate	$9.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.95
Rate for Payer: UnitedHealthcare Commercial	$10.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

flecainide 50 mg Tab [HMC]

Facility

$17.16

Service Code	NDC 50268032015
Hospital Charge Code	3801210
Hospital Revenue Code	250
Min. Negotiated Rate	$15.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.44
Rate for Payer: UnitedHealthcare Commercial	$16.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FlexiTrunk Nasal Tubing 100mm

Facility

$62.10

Hospital Charge Code	3254952
Hospital Revenue Code	270
Min. Negotiated Rate	$55.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$55.89
Rate for Payer: UnitedHealthcare Commercial	$58.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FlexiTrunk Nasal Tubing 100mm

Facility

$62.10

Hospital Charge Code	3254952
Hospital Revenue Code	270
Min. Negotiated Rate	$24.84
Max. Negotiated Rate	$58.99
Rate for Payer: Aetna Commercial	$55.89
Rate for Payer: Humana Medicare Advantage	$26.08
Rate for Payer: UnitedHealthcare Commercial	$58.99
Rate for Payer: UnitedHealthcare Medicaid	$24.84
Rate for Payer: WPPA Medicare Advantage	$37.26

FlexiTrunk Nasal Tubing 70mm

Facility

$62.10

Hospital Charge Code	3254951
Hospital Revenue Code	270
Min. Negotiated Rate	$55.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$55.89
Rate for Payer: UnitedHealthcare Commercial	$58.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FlexiTrunk Nasal Tubing 70mm

Facility

$62.10

Hospital Charge Code	3254951
Hospital Revenue Code	270
Min. Negotiated Rate	$24.84
Max. Negotiated Rate	$58.99
Rate for Payer: Aetna Commercial	$55.89
Rate for Payer: Humana Medicare Advantage	$26.08
Rate for Payer: UnitedHealthcare Commercial	$58.99
Rate for Payer: UnitedHealthcare Medicaid	$24.84
Rate for Payer: WPPA Medicare Advantage	$37.26

fluconazole 100 mg Tab

Facility

$29.27

Service Code	NDC 00904650061
Hospital Charge Code	3806673
Hospital Revenue Code	250
Min. Negotiated Rate	$26.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.34
Rate for Payer: UnitedHealthcare Commercial	$27.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluconazole 100 mg Tab

Facility

$29.27

Service Code	NDC 00904650061
Hospital Charge Code	3806673
Hospital Revenue Code	250
Min. Negotiated Rate	$11.71
Max. Negotiated Rate	$27.81
Rate for Payer: Aetna Commercial	$26.34
Rate for Payer: Humana Medicare Advantage	$12.29
Rate for Payer: UnitedHealthcare Commercial	$27.81
Rate for Payer: UnitedHealthcare Medicaid	$11.71
Rate for Payer: WPPA Medicare Advantage	$17.56

fluconazole 100 mg Tab [HMC]

Facility

$26.88

Service Code	NDC 00172541110
Hospital Charge Code	3806673
Hospital Revenue Code	250
Min. Negotiated Rate	$24.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.19
Rate for Payer: UnitedHealthcare Commercial	$25.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluconazole 100 mg Tab [HMC]

Facility

$27.01

Service Code	NDC 68462010230
Hospital Charge Code	3806673
Hospital Revenue Code	250
Min. Negotiated Rate	$24.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.31
Rate for Payer: UnitedHealthcare Commercial	$25.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluconazole 100 mg Tab [HMC]

Facility

$27.01

Service Code	NDC 68462010230
Hospital Charge Code	3806673
Hospital Revenue Code	250
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$25.66
Rate for Payer: Aetna Commercial	$24.31
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.66
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: WPPA Medicare Advantage	$16.21

fluconazole 100 mg Tab [HMC]

Facility

$27.01

Service Code	NDC 68001025204
Hospital Charge Code	3806673
Hospital Revenue Code	250
Min. Negotiated Rate	$24.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.31
Rate for Payer: UnitedHealthcare Commercial	$25.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluconazole 100 mg Tab [HMC]

Facility

$27.01

Service Code	NDC 68001025204
Hospital Charge Code	3806673
Hospital Revenue Code	250
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$25.66
Rate for Payer: Aetna Commercial	$24.31
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.66
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: WPPA Medicare Advantage	$16.21

fluconazole 100 mg Tab [HMC]

Facility

$26.88

Service Code	NDC 00172541110
Hospital Charge Code	3806673
Hospital Revenue Code	250
Min. Negotiated Rate	$10.75
Max. Negotiated Rate	$25.54
Rate for Payer: Aetna Commercial	$24.19
Rate for Payer: Humana Medicare Advantage	$11.29
Rate for Payer: UnitedHealthcare Commercial	$25.54
Rate for Payer: UnitedHealthcare Medicaid	$10.75
Rate for Payer: WPPA Medicare Advantage	$16.13

Know your out-of-pocket cost for care.

All Charges