Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

lamoTRIgine 100 mg Tab [HMC]

Facility

$5.69

Service Code	NDC 68084031901
Hospital Charge Code	3800016
Hospital Revenue Code	250
Min. Negotiated Rate	$5.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.12
Rate for Payer: UnitedHealthcare Commercial	$5.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lamoTRIgine 100 mg Tab [HMC]

Facility

$19.48

Service Code	NDC 29300011201
Hospital Charge Code	3800016
Hospital Revenue Code	250
Min. Negotiated Rate	$17.53
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.53
Rate for Payer: UnitedHealthcare Commercial	$18.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lamoTRIgine 25 mg Tab [HMC]

Facility

$5.61

Service Code	NDC 00904700761
Hospital Charge Code	3808624
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

lamoTRIgine 25 mg Tab [HMC]

Facility

$40.47

Service Code	NDC 00173063302
Hospital Charge Code	3808624
Hospital Revenue Code	250
Min. Negotiated Rate	$36.42
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.42
Rate for Payer: UnitedHealthcare Commercial	$38.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lamoTRIgine 25 mg Tab [HMC]

Facility

$40.47

Service Code	NDC 00173063302
Hospital Charge Code	3808624
Hospital Revenue Code	250
Min. Negotiated Rate	$16.19
Max. Negotiated Rate	$38.45
Rate for Payer: Aetna Commercial	$36.42
Rate for Payer: Humana Medicare Advantage	$17.00
Rate for Payer: UnitedHealthcare Commercial	$38.45
Rate for Payer: UnitedHealthcare Medicaid	$16.19
Rate for Payer: WPPA Medicare Advantage	$24.28

lamoTRIgine 25 mg Tab [HMC]

Facility

$5.61

Service Code	NDC 00904700761
Hospital Charge Code	3808624
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

Lamotrigine QST

Facility

$131.00

Service Code	HCPCS 80175
Hospital Charge Code	3550299
Hospital Revenue Code	300
Min. Negotiated Rate	$36.45
Max. Negotiated Rate	$124.45
Rate for Payer: Aetna Commercial	$117.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.45
Rate for Payer: Humana Medicare Advantage	$55.02
Rate for Payer: UnitedHealthcare Commercial	$124.45
Rate for Payer: UnitedHealthcare Medicaid	$52.40
Rate for Payer: WPPA Medicare Advantage	$78.60

Lamotrigine QST

Facility

$131.00

Service Code	HCPCS 80175
Hospital Charge Code	3550299
Hospital Revenue Code	300
Min. Negotiated Rate	$117.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$117.90
Rate for Payer: UnitedHealthcare Commercial	$124.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lanolin 15.5%/Petrolatum 53.4% [HMC] 113 g Ointment

Facility

$29.32

Service Code	NDC 041100811240
Hospital Charge Code	3808539
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

Lanolin 15.5%/Petrolatum 53.4% [HMC] 113 g Ointment

Facility

$29.32

Service Code	NDC 041100811240
Hospital Charge Code	3808539
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

lanolin-mineral oil Top Lotion [HMC]

Facility

$39.38

Service Code	NDC 72140011019
Hospital Charge Code	3801520
Hospital Revenue Code	250
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$37.41
Rate for Payer: Aetna Commercial	$35.44
Rate for Payer: Humana Medicare Advantage	$16.54
Rate for Payer: UnitedHealthcare Commercial	$37.41
Rate for Payer: UnitedHealthcare Medicaid	$15.75
Rate for Payer: WPPA Medicare Advantage	$23.63

lanolin-mineral oil Top Lotion [HMC]

Facility

$39.38

Service Code	NDC 72140011019
Hospital Charge Code	3801520
Hospital Revenue Code	250
Min. Negotiated Rate	$35.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.44
Rate for Payer: UnitedHealthcare Commercial	$37.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lanolin topical - Cream [HMC]

Facility

$32.51

Service Code	NDC 44677010020
Hospital Charge Code	3809106
Hospital Revenue Code	257
Min. Negotiated Rate	$29.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.26
Rate for Payer: UnitedHealthcare Commercial	$30.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lanolin topical - Cream [HMC]

Facility

$32.51

Service Code	NDC 44677010020
Hospital Charge Code	3809106
Hospital Revenue Code	257
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$30.88
Rate for Payer: Aetna Commercial	$29.26
Rate for Payer: Humana Medicare Advantage	$13.65
Rate for Payer: UnitedHealthcare Commercial	$30.88
Rate for Payer: UnitedHealthcare Medicaid	$13.00
Rate for Payer: WPPA Medicare Advantage	$19.51

lansoprazole 30 mg DR Cap [HMC]

Facility

$19.74

Service Code	NDC 00378803077
Hospital Charge Code	3800089
Hospital Revenue Code	250
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna Commercial	$17.77
Rate for Payer: Humana Medicare Advantage	$8.29
Rate for Payer: UnitedHealthcare Commercial	$18.75
Rate for Payer: UnitedHealthcare Medicaid	$7.90
Rate for Payer: WPPA Medicare Advantage	$11.84

lansoprazole 30 mg DR Cap [HMC]

Facility

$19.74

Service Code	NDC 00378803077
Hospital Charge Code	3800089
Hospital Revenue Code	250
Min. Negotiated Rate	$17.77
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.77
Rate for Payer: UnitedHealthcare Commercial	$18.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC

Facility

$5,782.14

Service Code	MSDRG 418
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,782.14
Rate for Payer: UnitedHealthcare Medicaid	$5,782.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC

Facility

$6,099.84

Service Code	MSDRG 417
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,099.84
Rate for Payer: UnitedHealthcare Medicaid	$6,099.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$5,527.98

Service Code	MSDRG 419
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,527.98
Rate for Payer: UnitedHealthcare Medicaid	$5,527.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Laryngoscope MAC 2 Single-Use Blade & Handle

Facility

$32.72

Hospital Charge Code	3252510
Hospital Revenue Code	270
Min. Negotiated Rate	$29.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: UnitedHealthcare Commercial	$31.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Laryngoscope MAC 2 Single-Use Blade & Handle

Facility

$32.72

Hospital Charge Code	3252510
Hospital Revenue Code	270
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$31.08
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Humana Medicare Advantage	$13.74
Rate for Payer: UnitedHealthcare Commercial	$31.08
Rate for Payer: UnitedHealthcare Medicaid	$13.09
Rate for Payer: WPPA Medicare Advantage	$19.63

Laryngoscope MAC 3.5 Single-Use Blade & Handle

Facility

$32.72

Hospital Charge Code	3252513
Hospital Revenue Code	270
Min. Negotiated Rate	$29.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: UnitedHealthcare Commercial	$31.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Laryngoscope MAC 3.5 Single-Use Blade & Handle

Facility

$32.72

Hospital Charge Code	3252513
Hospital Revenue Code	270
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$31.08
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Humana Medicare Advantage	$13.74
Rate for Payer: UnitedHealthcare Commercial	$31.08
Rate for Payer: UnitedHealthcare Medicaid	$13.09
Rate for Payer: WPPA Medicare Advantage	$19.63

Laryngoscope MAC 3 Single-Use Blade & Handle

Facility

$32.72

Hospital Charge Code	3252511
Hospital Revenue Code	270
Min. Negotiated Rate	$29.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: UnitedHealthcare Commercial	$31.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Laryngoscope MAC 3 Single-Use Blade & Handle

Facility

$32.72

Hospital Charge Code	3252511
Hospital Revenue Code	270
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$31.08
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Humana Medicare Advantage	$13.74
Rate for Payer: UnitedHealthcare Commercial	$31.08
Rate for Payer: UnitedHealthcare Medicaid	$13.09
Rate for Payer: WPPA Medicare Advantage	$19.63

Know your out-of-pocket cost for care.

All Charges