Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

leflunomide 20 mg Tab [HMC]

Facility

$37.81

Service Code	NDC 60505250301
Hospital Charge Code	3800007
Hospital Revenue Code	250
Min. Negotiated Rate	$34.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.03
Rate for Payer: UnitedHealthcare Commercial	$35.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

leflunomide 20 mg Tab [HMC]

Facility

$37.81

Service Code	NDC 60505250301
Hospital Charge Code	3800007
Hospital Revenue Code	250
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$35.92
Rate for Payer: Aetna Commercial	$34.03
Rate for Payer: Humana Medicare Advantage	$15.88
Rate for Payer: UnitedHealthcare Commercial	$35.92
Rate for Payer: UnitedHealthcare Medicaid	$15.12
Rate for Payer: WPPA Medicare Advantage	$22.69

leflunomide 20 mg Tab [HMC]

Facility

$37.85

Service Code	NDC 23155004403
Hospital Charge Code	3800007
Hospital Revenue Code	250
Min. Negotiated Rate	$34.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.06
Rate for Payer: UnitedHealthcare Commercial	$35.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Leg Bag Connector Tube

Facility

$5.00

Hospital Charge Code	3250004
Hospital Revenue Code	270
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: Humana Medicare Advantage	$2.10
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: UnitedHealthcare Medicaid	$2.00
Rate for Payer: WPPA Medicare Advantage	$3.00

Leg Bag Connector Tube

Facility

$5.00

Hospital Charge Code	3250004
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Leg Bag Large Bard 32oz w/Drain Tube & Clamp w/1 Pair Latex Straps

Facility

$21.00

Hospital Charge Code	3250006
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Leg Bag Large Bard 32oz w/Drain Tube & Clamp w/1 Pair Latex Straps

Facility

$21.00

Hospital Charge Code	3250006
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$8.40
Rate for Payer: WPPA Medicare Advantage	$12.60

Leg Bag Large Kendall 25oz w/Extension Tube

Facility

$22.00

Hospital Charge Code	3257117
Hospital Revenue Code	270
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.80
Rate for Payer: UnitedHealthcare Commercial	$20.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Leg Bag Large Kendall 25oz w/Extension Tube

Facility

$22.00

Hospital Charge Code	3257117
Hospital Revenue Code	270
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$20.90
Rate for Payer: Aetna Commercial	$19.80
Rate for Payer: Humana Medicare Advantage	$9.24
Rate for Payer: UnitedHealthcare Commercial	$20.90
Rate for Payer: UnitedHealthcare Medicaid	$8.80
Rate for Payer: WPPA Medicare Advantage	$13.20

Leg Bag UA Medium 19oz w/Rubber Cap Valve w/1 Pair Latex Straps

Facility

$7.52

Hospital Charge Code	3253643
Hospital Revenue Code	270
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$7.14
Rate for Payer: Aetna Commercial	$6.77
Rate for Payer: Humana Medicare Advantage	$3.16
Rate for Payer: UnitedHealthcare Commercial	$7.14
Rate for Payer: UnitedHealthcare Medicaid	$3.01
Rate for Payer: WPPA Medicare Advantage	$4.51

Leg Bag UA Medium 19oz w/Rubber Cap Valve w/1 Pair Latex Straps

Facility

$7.52

Hospital Charge Code	3253643
Hospital Revenue Code	270
Min. Negotiated Rate	$6.77
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.77
Rate for Payer: UnitedHealthcare Commercial	$7.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Legionella Ag, EIA, U QST

Facility

$238.00

Service Code	HCPCS 87541
Hospital Charge Code	3551163
Hospital Revenue Code	300
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$214.20
Rate for Payer: UnitedHealthcare Commercial	$226.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Legionella Ag, EIA, U QST

Facility

$238.00

Service Code	HCPCS 87541
Hospital Charge Code	3551163
Hospital Revenue Code	300
Min. Negotiated Rate	$29.83
Max. Negotiated Rate	$226.10
Rate for Payer: Aetna Commercial	$214.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$75.32
Rate for Payer: Humana Medicare Advantage	$99.96
Rate for Payer: UnitedHealthcare Commercial	$226.10
Rate for Payer: UnitedHealthcare Medicaid	$29.83
Rate for Payer: WPPA Medicare Advantage	$142.80

Leg Strap Fabric

Facility

$9.00

Hospital Charge Code	3256514
Hospital Revenue Code	270
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$8.55
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: Humana Medicare Advantage	$3.78
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: WPPA Medicare Advantage	$5.40

Leg Strap Fabric

Facility

$9.00

Hospital Charge Code	3256514
Hospital Revenue Code	270
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Leg Strap Foam Velcro

Facility

$4.28

Hospital Charge Code	3256513
Hospital Revenue Code	270
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.85
Rate for Payer: UnitedHealthcare Commercial	$4.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Leg Strap Foam Velcro

Facility

$4.28

Hospital Charge Code	3256513
Hospital Revenue Code	270
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$4.07
Rate for Payer: Aetna Commercial	$3.85
Rate for Payer: Humana Medicare Advantage	$1.80
Rate for Payer: UnitedHealthcare Commercial	$4.07
Rate for Payer: UnitedHealthcare Medicaid	$1.71
Rate for Payer: WPPA Medicare Advantage	$2.57

letrozole 2.5 mg Tab [HMC]

Facility

$41.10

Service Code	NDC 50268047615
Hospital Charge Code	3800458
Hospital Revenue Code	250
Min. Negotiated Rate	$16.44
Max. Negotiated Rate	$39.05
Rate for Payer: Aetna Commercial	$36.99
Rate for Payer: Humana Medicare Advantage	$17.26
Rate for Payer: UnitedHealthcare Commercial	$39.05
Rate for Payer: UnitedHealthcare Medicaid	$16.44
Rate for Payer: WPPA Medicare Advantage	$24.66

letrozole 2.5 mg Tab [HMC]

Facility

$41.10

Service Code	NDC 16729003410
Hospital Charge Code	3800458
Hospital Revenue Code	250
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.99
Rate for Payer: UnitedHealthcare Commercial	$39.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

letrozole 2.5 mg Tab [HMC]

Facility

$41.23

Service Code	NDC 51991075933
Hospital Charge Code	3800458
Hospital Revenue Code	250
Min. Negotiated Rate	$16.49
Max. Negotiated Rate	$39.17
Rate for Payer: Aetna Commercial	$37.11
Rate for Payer: Humana Medicare Advantage	$17.32
Rate for Payer: UnitedHealthcare Commercial	$39.17
Rate for Payer: UnitedHealthcare Medicaid	$16.49
Rate for Payer: WPPA Medicare Advantage	$24.74

letrozole 2.5 mg Tab [HMC]

Facility

$41.10

Service Code	NDC 16729003410
Hospital Charge Code	3800458
Hospital Revenue Code	250
Min. Negotiated Rate	$16.44
Max. Negotiated Rate	$39.05
Rate for Payer: Aetna Commercial	$36.99
Rate for Payer: Humana Medicare Advantage	$17.26
Rate for Payer: UnitedHealthcare Commercial	$39.05
Rate for Payer: UnitedHealthcare Medicaid	$16.44
Rate for Payer: WPPA Medicare Advantage	$24.66

letrozole 2.5 mg Tab [HMC]

Facility

$41.23

Service Code	NDC 51991075933
Hospital Charge Code	3800458
Hospital Revenue Code	250
Min. Negotiated Rate	$37.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$37.11
Rate for Payer: UnitedHealthcare Commercial	$39.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

letrozole 2.5 mg Tab [HMC]

Facility

$41.10

Service Code	NDC 50268047615
Hospital Charge Code	3800458
Hospital Revenue Code	250
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.99
Rate for Payer: UnitedHealthcare Commercial	$39.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

leucovorin 100 mg IV Inj [HMC]

Facility

$56.00

Service Code	HCPCS J0640
Hospital Charge Code	3850081
Hospital Revenue Code	250
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

leucovorin 100 mg IV Inj [HMC]

Facility

$56.00

Service Code	HCPCS J0640
Hospital Charge Code	3850081
Hospital Revenue Code	250
Min. Negotiated Rate	$3.84
Max. Negotiated Rate	$53.20
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$6.60
Rate for Payer: Humana Medicare Advantage	$23.52
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: UnitedHealthcare Medicaid	$3.84
Rate for Payer: WPPA Medicare Advantage	$33.60

Know your out-of-pocket cost for care.

All Charges