Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

FLUoxetine 10 mg Cap [HMC]

Facility

$12.26

Service Code	NDC 00904578461
Hospital Charge Code	3800543
Hospital Revenue Code	250
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.03
Rate for Payer: UnitedHealthcare Commercial	$11.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FLUoxetine 10 mg Cap [HMC]

Facility

$5.42

Service Code	NDC 00904734561
Hospital Charge Code	3800543
Hospital Revenue Code	250
Min. Negotiated Rate	$4.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.88
Rate for Payer: UnitedHealthcare Commercial	$5.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FLUoxetine 10 mg Cap [HMC]

Facility

$12.79

Service Code	NDC 50111064701
Hospital Charge Code	3800543
Hospital Revenue Code	250
Min. Negotiated Rate	$5.12
Max. Negotiated Rate	$12.15
Rate for Payer: Aetna Commercial	$11.51
Rate for Payer: Humana Medicare Advantage	$5.37
Rate for Payer: UnitedHealthcare Commercial	$12.15
Rate for Payer: UnitedHealthcare Medicaid	$5.12
Rate for Payer: WPPA Medicare Advantage	$7.67

FLUoxetine 10 mg Cap [HMC]

Facility

$12.79

Service Code	NDC 50111064701
Hospital Charge Code	3800543
Hospital Revenue Code	250
Min. Negotiated Rate	$11.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.51
Rate for Payer: UnitedHealthcare Commercial	$12.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FLUoxetine 10 mg Cap [HMC]

Facility

$5.42

Service Code	NDC 00904734561
Hospital Charge Code	3800543
Hospital Revenue Code	250
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$5.15
Rate for Payer: Aetna Commercial	$4.88
Rate for Payer: Humana Medicare Advantage	$2.28
Rate for Payer: UnitedHealthcare Commercial	$5.15
Rate for Payer: UnitedHealthcare Medicaid	$2.17
Rate for Payer: WPPA Medicare Advantage	$3.25

FLUoxetine 20 mg Cap UD [HMC]

Facility

$5.34

Service Code	NDC 00904734661
Hospital Charge Code	3806012
Hospital Revenue Code	250
Min. Negotiated Rate	$4.81
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.81
Rate for Payer: UnitedHealthcare Commercial	$5.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FLUoxetine 20 mg Cap UD [HMC]

Facility

$12.45

Service Code	NDC 00904578561
Hospital Charge Code	3806012
Hospital Revenue Code	250
Min. Negotiated Rate	$11.21
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.21
Rate for Payer: UnitedHealthcare Commercial	$11.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FLUoxetine 20 mg Cap UD [HMC]

Facility

$13.00

Service Code	NDC 65862019301
Hospital Charge Code	3806012
Hospital Revenue Code	250
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$12.35
Rate for Payer: Aetna Commercial	$11.70
Rate for Payer: Humana Medicare Advantage	$5.46
Rate for Payer: UnitedHealthcare Commercial	$12.35
Rate for Payer: UnitedHealthcare Medicaid	$5.20
Rate for Payer: WPPA Medicare Advantage	$7.80

FLUoxetine 20 mg Cap UD [HMC]

Facility

$5.34

Service Code	NDC 00904734661
Hospital Charge Code	3806012
Hospital Revenue Code	250
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$5.07
Rate for Payer: Aetna Commercial	$4.81
Rate for Payer: Humana Medicare Advantage	$2.24
Rate for Payer: UnitedHealthcare Commercial	$5.07
Rate for Payer: UnitedHealthcare Medicaid	$2.14
Rate for Payer: WPPA Medicare Advantage	$3.20

FLUoxetine 20 mg Cap UD [HMC]

Facility

$12.45

Service Code	NDC 00904578561
Hospital Charge Code	3806012
Hospital Revenue Code	250
Min. Negotiated Rate	$4.98
Max. Negotiated Rate	$11.83
Rate for Payer: Aetna Commercial	$11.21
Rate for Payer: Humana Medicare Advantage	$5.23
Rate for Payer: UnitedHealthcare Commercial	$11.83
Rate for Payer: UnitedHealthcare Medicaid	$4.98
Rate for Payer: WPPA Medicare Advantage	$7.47

FLUoxetine 20 mg Cap UD [HMC]

Facility

$13.00

Service Code	NDC 65862019301
Hospital Charge Code	3806012
Hospital Revenue Code	250
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.70
Rate for Payer: UnitedHealthcare Commercial	$12.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Flu (regular)

Facility

$49.00

Service Code	HCPCS 90674
Hospital Charge Code	3802705
Hospital Revenue Code	636
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$46.55
Rate for Payer: Aetna Commercial	$44.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$42.80
Rate for Payer: Humana Medicare Advantage	$20.58
Rate for Payer: UnitedHealthcare Commercial	$46.55
Rate for Payer: UnitedHealthcare Medicaid	$19.60
Rate for Payer: WPPA Medicare Advantage	$29.40

Flu (regular)

Facility

$49.00

Service Code	HCPCS 90674
Hospital Charge Code	3802705
Hospital Revenue Code	636
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$44.10
Rate for Payer: UnitedHealthcare Commercial	$46.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluticasone CFC free 110 mcg/inh Inh Aer w/adapter [HMC]

Facility

$463.61

Service Code	NDC 00173071920
Hospital Charge Code	3803109
Hospital Revenue Code	250
Min. Negotiated Rate	$185.44
Max. Negotiated Rate	$440.43
Rate for Payer: Aetna Commercial	$417.25
Rate for Payer: Humana Medicare Advantage	$194.72
Rate for Payer: UnitedHealthcare Commercial	$440.43
Rate for Payer: UnitedHealthcare Medicaid	$185.44
Rate for Payer: WPPA Medicare Advantage	$278.17

fluticasone CFC free 110 mcg/inh Inh Aer w/adapter [HMC]

Facility

$463.61

Service Code	NDC 00173071920
Hospital Charge Code	3803109
Hospital Revenue Code	250
Min. Negotiated Rate	$417.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$417.25
Rate for Payer: UnitedHealthcare Commercial	$440.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluticasone CFC free 110 mcg/inh Inh Aer w/adapter [HMC]

Facility

$441.43

Service Code	NDC 66993007996
Hospital Charge Code	3803109
Hospital Revenue Code	250
Min. Negotiated Rate	$397.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$397.29
Rate for Payer: UnitedHealthcare Commercial	$419.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluticasone CFC free 110 mcg/inh Inh Aer w/adapter [HMC]

Facility

$441.43

Service Code	NDC 66993007996
Hospital Charge Code	3803109
Hospital Revenue Code	250
Min. Negotiated Rate	$176.57
Max. Negotiated Rate	$419.36
Rate for Payer: Aetna Commercial	$397.29
Rate for Payer: Humana Medicare Advantage	$185.40
Rate for Payer: UnitedHealthcare Commercial	$419.36
Rate for Payer: UnitedHealthcare Medicaid	$176.57
Rate for Payer: WPPA Medicare Advantage	$264.86

fluticasone CFC free 44 mcg/inh Inh Aer w/adapter [HMC]

Facility

$351.36

Service Code	NDC 00173071820
Hospital Charge Code	3800358
Hospital Revenue Code	250
Min. Negotiated Rate	$316.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$316.22
Rate for Payer: UnitedHealthcare Commercial	$333.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluticasone CFC free 44 mcg/inh Inh Aer w/adapter [HMC]

Facility

$351.36

Service Code	NDC 00173071820
Hospital Charge Code	3800358
Hospital Revenue Code	250
Min. Negotiated Rate	$140.54
Max. Negotiated Rate	$333.79
Rate for Payer: Aetna Commercial	$316.22
Rate for Payer: Humana Medicare Advantage	$147.57
Rate for Payer: UnitedHealthcare Commercial	$333.79
Rate for Payer: UnitedHealthcare Medicaid	$140.54
Rate for Payer: WPPA Medicare Advantage	$210.82

fluticasone Nasal 0.05 mg/inh Spry 16 g [HMC]

Facility

$135.10

Service Code	NDC 60505084703
Hospital Charge Code	3809628
Hospital Revenue Code	250
Min. Negotiated Rate	$121.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$121.59
Rate for Payer: UnitedHealthcare Commercial	$128.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluticasone Nasal 0.05 mg/inh Spry 16 g [HMC]

Facility

$135.10

Service Code	NDC 60505084703
Hospital Charge Code	3809628
Hospital Revenue Code	250
Min. Negotiated Rate	$54.04
Max. Negotiated Rate	$128.34
Rate for Payer: Aetna Commercial	$121.59
Rate for Payer: Humana Medicare Advantage	$56.74
Rate for Payer: UnitedHealthcare Commercial	$128.34
Rate for Payer: UnitedHealthcare Medicaid	$54.04
Rate for Payer: WPPA Medicare Advantage	$81.06

fluticasone Nasal 0.05 mg/inh Spry [HMC]

Facility

$135.10

Service Code	NDC 60505082901
Hospital Charge Code	3809628
Hospital Revenue Code	250
Min. Negotiated Rate	$121.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$121.59
Rate for Payer: UnitedHealthcare Commercial	$128.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluticasone Nasal 0.05 mg/inh Spry [HMC]

Facility

$135.10

Service Code	NDC 60505082901
Hospital Charge Code	3809628
Hospital Revenue Code	250
Min. Negotiated Rate	$54.04
Max. Negotiated Rate	$128.34
Rate for Payer: Aetna Commercial	$121.59
Rate for Payer: Humana Medicare Advantage	$56.74
Rate for Payer: UnitedHealthcare Commercial	$128.34
Rate for Payer: UnitedHealthcare Medicaid	$54.04
Rate for Payer: WPPA Medicare Advantage	$81.06

fluticasone-salmeterol 115 mcg-21 mcg Inh Aer w/adapter [HMC]

Facility

$658.17

Service Code	NDC 00173071620
Hospital Charge Code	3800719
Hospital Revenue Code	250
Min. Negotiated Rate	$592.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$592.35
Rate for Payer: UnitedHealthcare Commercial	$625.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluticasone-salmeterol 115 mcg-21 mcg Inh Aer w/adapter [HMC]

Facility

$658.17

Service Code	NDC 00173071620
Hospital Charge Code	3800719
Hospital Revenue Code	250
Min. Negotiated Rate	$263.27
Max. Negotiated Rate	$625.26
Rate for Payer: Aetna Commercial	$592.35
Rate for Payer: Humana Medicare Advantage	$276.43
Rate for Payer: UnitedHealthcare Commercial	$625.26
Rate for Payer: UnitedHealthcare Medicaid	$263.27
Rate for Payer: WPPA Medicare Advantage	$394.90

Know your out-of-pocket cost for care.

All Charges