Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

fluticasone-salmeterol 250 mcg-50 mcg Inh Pwdr [HMC]

Facility

$265.81

Service Code	NDC 00173069604
Hospital Charge Code	3807951
Hospital Revenue Code	250
Min. Negotiated Rate	$239.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$239.23
Rate for Payer: UnitedHealthcare Commercial	$252.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluticasone-salmeterol 250 mcg-50 mcg Inh Pwdr [HMC]

Facility

$265.81

Service Code	NDC 00173069604
Hospital Charge Code	3807951
Hospital Revenue Code	250
Min. Negotiated Rate	$106.32
Max. Negotiated Rate	$252.52
Rate for Payer: Aetna Commercial	$239.23
Rate for Payer: Humana Medicare Advantage	$111.64
Rate for Payer: UnitedHealthcare Commercial	$252.52
Rate for Payer: UnitedHealthcare Medicaid	$106.32
Rate for Payer: WPPA Medicare Advantage	$159.49

fluticasone-salmeterol 250 mcg-50 mcg Inh Pwdr [HMC]

Facility

$161.46

Service Code	NDC 00054032756
Hospital Charge Code	3807951
Hospital Revenue Code	250
Min. Negotiated Rate	$145.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$145.31
Rate for Payer: UnitedHealthcare Commercial	$153.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluticasone-salmeterol 250 mcg-50 mcg Inh Pwdr [HMC]

Facility

$161.46

Service Code	NDC 00054032756
Hospital Charge Code	3807951
Hospital Revenue Code	250
Min. Negotiated Rate	$64.58
Max. Negotiated Rate	$153.39
Rate for Payer: Aetna Commercial	$145.31
Rate for Payer: Humana Medicare Advantage	$67.81
Rate for Payer: UnitedHealthcare Commercial	$153.39
Rate for Payer: UnitedHealthcare Medicaid	$64.58
Rate for Payer: WPPA Medicare Advantage	$96.88

fluticasone-salmeterol 500 mcg-50 mcg Inh Pwdr [HMC]

Facility

$420.63

Service Code	NDC 00173069704
Hospital Charge Code	3800398
Hospital Revenue Code	250
Min. Negotiated Rate	$378.57
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$378.57
Rate for Payer: UnitedHealthcare Commercial	$399.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fluticasone-salmeterol 500 mcg-50 mcg Inh Pwdr [HMC]

Facility

$420.63

Service Code	NDC 00173069704
Hospital Charge Code	3800398
Hospital Revenue Code	250
Min. Negotiated Rate	$168.25
Max. Negotiated Rate	$399.60
Rate for Payer: Aetna Commercial	$378.57
Rate for Payer: Humana Medicare Advantage	$176.66
Rate for Payer: UnitedHealthcare Commercial	$399.60
Rate for Payer: UnitedHealthcare Medicaid	$168.25
Rate for Payer: WPPA Medicare Advantage	$252.38

fluticasone/umeclidinium/vilanterol 100 mcg-62.5 mcg-25 mcg/inh Pow [HMC]

Facility

$516.53

Service Code	NDC 00173088714
Hospital Charge Code	3800656
Hospital Revenue Code	250
Min. Negotiated Rate	$206.61
Max. Negotiated Rate	$490.70
Rate for Payer: Aetna Commercial	$464.88
Rate for Payer: Humana Medicare Advantage	$216.94
Rate for Payer: UnitedHealthcare Commercial	$490.70
Rate for Payer: UnitedHealthcare Medicaid	$206.61
Rate for Payer: WPPA Medicare Advantage	$309.92

fluticasone/umeclidinium/vilanterol 100 mcg-62.5 mcg-25 mcg/inh Pow [HMC]

Facility

$516.53

Service Code	NDC 00173088714
Hospital Charge Code	3800656
Hospital Revenue Code	250
Min. Negotiated Rate	$464.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$464.88
Rate for Payer: UnitedHealthcare Commercial	$490.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Flutter PEP Device Acapella Pediatric Blue

Facility

$172.00

Hospital Charge Code	3254320
Hospital Revenue Code	270
Min. Negotiated Rate	$68.80
Max. Negotiated Rate	$163.40
Rate for Payer: Aetna Commercial	$154.80
Rate for Payer: Humana Medicare Advantage	$72.24
Rate for Payer: UnitedHealthcare Commercial	$163.40
Rate for Payer: UnitedHealthcare Medicaid	$68.80
Rate for Payer: WPPA Medicare Advantage	$103.20

Flutter PEP Device Acapella Pediatric Blue

Facility

$172.00

Hospital Charge Code	3254320
Hospital Revenue Code	270
Min. Negotiated Rate	$154.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$154.80
Rate for Payer: UnitedHealthcare Commercial	$163.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Flutter PEP Device (previously Acapella Adult Green)

Facility

$148.19

Hospital Charge Code	3254325
Hospital Revenue Code	270
Min. Negotiated Rate	$133.37
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$133.37
Rate for Payer: UnitedHealthcare Commercial	$140.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Flutter PEP Device (previously Acapella Adult Green)

Facility

$148.19

Hospital Charge Code	3254325
Hospital Revenue Code	270
Min. Negotiated Rate	$59.28
Max. Negotiated Rate	$140.78
Rate for Payer: Aetna Commercial	$133.37
Rate for Payer: Humana Medicare Advantage	$62.24
Rate for Payer: UnitedHealthcare Commercial	$140.78
Rate for Payer: UnitedHealthcare Medicaid	$59.28
Rate for Payer: WPPA Medicare Advantage	$88.91

fluvoxaMINE 100 mg Tab [HMC]

Facility

$12.89

Service Code	NDC 62559016001
Hospital Charge Code	3800210
Hospital Revenue Code	250
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$12.25
Rate for Payer: Aetna Commercial	$11.60
Rate for Payer: Humana Medicare Advantage	$5.41
Rate for Payer: UnitedHealthcare Commercial	$12.25
Rate for Payer: UnitedHealthcare Medicaid	$5.16
Rate for Payer: WPPA Medicare Advantage	$7.73

fluvoxaMINE 100 mg Tab [HMC]

Facility

$12.89

Service Code	NDC 62559016001
Hospital Charge Code	3800210
Hospital Revenue Code	250
Min. Negotiated Rate	$11.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.60
Rate for Payer: UnitedHealthcare Commercial	$12.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Folate Level

Facility

$103.00

Service Code	HCPCS 82746
Hospital Charge Code	3550429
Hospital Revenue Code	300
Min. Negotiated Rate	$92.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$92.70
Rate for Payer: UnitedHealthcare Commercial	$97.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Folate Level

Facility

$103.00

Service Code	HCPCS 82746
Hospital Charge Code	3550429
Hospital Revenue Code	300
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$97.85
Rate for Payer: Aetna Commercial	$92.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$61.81
Rate for Payer: Humana Medicare Advantage	$43.26
Rate for Payer: UnitedHealthcare Commercial	$97.85
Rate for Payer: UnitedHealthcare Medicaid	$14.70
Rate for Payer: WPPA Medicare Advantage	$61.80

Folate, RBC QST

Facility

$103.00

Service Code	HCPCS 82746
Hospital Charge Code	3550429
Hospital Revenue Code	300
Min. Negotiated Rate	$92.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$92.70
Rate for Payer: UnitedHealthcare Commercial	$97.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Folate, RBC QST

Facility

$103.00

Service Code	HCPCS 82746
Hospital Charge Code	3550429
Hospital Revenue Code	300
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$97.85
Rate for Payer: Aetna Commercial	$92.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$61.81
Rate for Payer: Humana Medicare Advantage	$43.26
Rate for Payer: UnitedHealthcare Commercial	$97.85
Rate for Payer: UnitedHealthcare Medicaid	$14.70
Rate for Payer: WPPA Medicare Advantage	$61.80

folic acid 1 mg Tab [HMC]

Facility

$5.61

Service Code	NDC 00904722461
Hospital Charge Code	3801666
Hospital Revenue Code	250
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.05
Rate for Payer: UnitedHealthcare Commercial	$5.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

folic acid 1 mg Tab [HMC]

Facility

$5.61

Service Code	NDC 00904722461
Hospital Charge Code	3801666
Hospital Revenue Code	250
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$5.33
Rate for Payer: Aetna Commercial	$5.05
Rate for Payer: Humana Medicare Advantage	$2.36
Rate for Payer: UnitedHealthcare Commercial	$5.33
Rate for Payer: UnitedHealthcare Medicaid	$2.24
Rate for Payer: WPPA Medicare Advantage	$3.37

folic acid 1 mg Tab [HMC]

Facility

$5.57

Service Code	NDC 62584089701
Hospital Charge Code	3801666
Hospital Revenue Code	250
Min. Negotiated Rate	$5.01
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.01
Rate for Payer: UnitedHealthcare Commercial	$5.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

folic acid 1 mg Tab [HMC]

Facility

$5.57

Service Code	NDC 62584089701
Hospital Charge Code	3801666
Hospital Revenue Code	250
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$5.29
Rate for Payer: Aetna Commercial	$5.01
Rate for Payer: Humana Medicare Advantage	$2.34
Rate for Payer: UnitedHealthcare Commercial	$5.29
Rate for Payer: UnitedHealthcare Medicaid	$2.23
Rate for Payer: WPPA Medicare Advantage	$3.34

folic acid 5 mg/mL Inj Sol [HMC]

Facility

$85.62

Service Code	NDC 39822110001
Hospital Charge Code	3803708
Hospital Revenue Code	250
Min. Negotiated Rate	$34.25
Max. Negotiated Rate	$81.34
Rate for Payer: Aetna Commercial	$77.06
Rate for Payer: Humana Medicare Advantage	$35.96
Rate for Payer: UnitedHealthcare Commercial	$81.34
Rate for Payer: UnitedHealthcare Medicaid	$34.25
Rate for Payer: WPPA Medicare Advantage	$51.37

folic acid 5 mg/mL Inj Sol [HMC]

Facility

$85.62

Service Code	NDC 39822110001
Hospital Charge Code	3803708
Hospital Revenue Code	250
Min. Negotiated Rate	$77.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$77.06
Rate for Payer: UnitedHealthcare Commercial	$81.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

folic acid 5 mg/mL Inj Sol [HMC]

Facility

$120.93

Service Code	NDC 63323018410
Hospital Charge Code	3803708
Hospital Revenue Code	250
Min. Negotiated Rate	$108.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$108.84
Rate for Payer: UnitedHealthcare Commercial	$114.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges