Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

levocetirizine 5 mg oral tablet [HMC]

Facility

$14.23

Service Code	NDC 31722055190
Hospital Charge Code	3800731
Hospital Revenue Code	250
Min. Negotiated Rate	$12.81
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.81
Rate for Payer: UnitedHealthcare Commercial	$13.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levocetirizine 5 mg oral tablet [HMC]

Facility

$7.41

Service Code	NDC 41167351000
Hospital Charge Code	3800731
Hospital Revenue Code	250
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$7.04
Rate for Payer: Aetna Commercial	$6.67
Rate for Payer: Humana Medicare Advantage	$3.11
Rate for Payer: UnitedHealthcare Commercial	$7.04
Rate for Payer: UnitedHealthcare Medicaid	$2.96
Rate for Payer: WPPA Medicare Advantage	$4.45

levocetirizine 5 mg oral tablet [HMC]

Facility

$14.23

Service Code	NDC 31722055190
Hospital Charge Code	3800731
Hospital Revenue Code	250
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$13.52
Rate for Payer: Aetna Commercial	$12.81
Rate for Payer: Humana Medicare Advantage	$5.98
Rate for Payer: UnitedHealthcare Commercial	$13.52
Rate for Payer: UnitedHealthcare Medicaid	$5.69
Rate for Payer: WPPA Medicare Advantage	$8.54

levocetirizine 5 mg oral tablet [HMC]

Facility

$7.41

Service Code	NDC 41167351000
Hospital Charge Code	3800731
Hospital Revenue Code	250
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.67
Rate for Payer: UnitedHealthcare Commercial	$7.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levofloxacin 500 mg/100 mL IV Sol [HMC]

Facility

$39.38

Service Code	HCPCS J1956
Hospital Charge Code	3802333
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: Aetna Commercial	$34.43
Rate for Payer: Aetna Commercial	$44.64
Rate for Payer: Aetna Commercial	$49.66
Rate for Payer: UnitedHealthcare Commercial	$37.41
Rate for Payer: UnitedHealthcare Commercial	$52.42
Rate for Payer: UnitedHealthcare Commercial	$47.12
Rate for Payer: UnitedHealthcare Commercial	$36.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levofloxacin 500 mg/100 mL IV Sol [HMC]

Facility

$55.18

Service Code	HCPCS J1956
Hospital Charge Code	3802333
Hospital Revenue Code	250
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$52.42
Rate for Payer: Aetna Commercial	$49.66
Rate for Payer: Aetna Commercial	$34.43
Rate for Payer: Aetna Commercial	$44.64
Rate for Payer: Aetna Commercial	$35.44
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.45
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.45
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.45
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.45
Rate for Payer: Humana Medicare Advantage	$16.07
Rate for Payer: Humana Medicare Advantage	$23.18
Rate for Payer: Humana Medicare Advantage	$16.54
Rate for Payer: Humana Medicare Advantage	$20.83
Rate for Payer: UnitedHealthcare Commercial	$47.12
Rate for Payer: UnitedHealthcare Commercial	$36.35
Rate for Payer: UnitedHealthcare Commercial	$37.41
Rate for Payer: UnitedHealthcare Commercial	$52.42
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: WPPA Medicare Advantage	$23.63
Rate for Payer: WPPA Medicare Advantage	$29.76
Rate for Payer: WPPA Medicare Advantage	$22.96
Rate for Payer: WPPA Medicare Advantage	$33.11

levofloxacin 500 mg Tab [HMC]

Facility

$43.53

Service Code	NDC 65862053750
Hospital Charge Code	3801707
Hospital Revenue Code	250
Min. Negotiated Rate	$39.18
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.18
Rate for Payer: UnitedHealthcare Commercial	$41.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levofloxacin 500 mg Tab [HMC]

Facility

$38.64

Service Code	NDC 00904635261
Hospital Charge Code	3801707
Hospital Revenue Code	250
Min. Negotiated Rate	$34.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.78
Rate for Payer: UnitedHealthcare Commercial	$36.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levofloxacin 500 mg Tab [HMC]

Facility

$38.64

Service Code	NDC 00904635261
Hospital Charge Code	3801707
Hospital Revenue Code	250
Min. Negotiated Rate	$15.46
Max. Negotiated Rate	$36.71
Rate for Payer: Aetna Commercial	$34.78
Rate for Payer: Humana Medicare Advantage	$16.23
Rate for Payer: UnitedHealthcare Commercial	$36.71
Rate for Payer: UnitedHealthcare Medicaid	$15.46
Rate for Payer: WPPA Medicare Advantage	$23.18

levofloxacin 500 mg Tab [HMC]

Facility

$43.53

Service Code	NDC 65862053750
Hospital Charge Code	3801707
Hospital Revenue Code	250
Min. Negotiated Rate	$17.41
Max. Negotiated Rate	$41.35
Rate for Payer: Aetna Commercial	$39.18
Rate for Payer: Humana Medicare Advantage	$18.28
Rate for Payer: UnitedHealthcare Commercial	$41.35
Rate for Payer: UnitedHealthcare Medicaid	$17.41
Rate for Payer: WPPA Medicare Advantage	$26.12

levofloxacin 750 mg/150 mL IV Sol Premix [HMC]

Facility

$49.60

Service Code	HCPCS J1956
Hospital Charge Code	3806710
Hospital Revenue Code	250
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$47.12
Rate for Payer: Aetna Commercial	$44.64
Rate for Payer: Aetna Commercial	$51.12
Rate for Payer: Aetna Commercial	$32.90
Rate for Payer: Aetna Commercial	$35.95
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.45
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.45
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.45
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.45
Rate for Payer: Humana Medicare Advantage	$16.78
Rate for Payer: Humana Medicare Advantage	$20.83
Rate for Payer: Humana Medicare Advantage	$15.36
Rate for Payer: Humana Medicare Advantage	$23.86
Rate for Payer: UnitedHealthcare Commercial	$34.73
Rate for Payer: UnitedHealthcare Commercial	$37.95
Rate for Payer: UnitedHealthcare Commercial	$53.96
Rate for Payer: UnitedHealthcare Commercial	$47.12
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: WPPA Medicare Advantage	$21.94
Rate for Payer: WPPA Medicare Advantage	$29.76
Rate for Payer: WPPA Medicare Advantage	$34.08
Rate for Payer: WPPA Medicare Advantage	$23.97

levofloxacin 750 mg/150 mL IV Sol Premix [HMC]

Facility

$39.95

Service Code	HCPCS J1956
Hospital Charge Code	3806710
Hospital Revenue Code	250
Min. Negotiated Rate	$35.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.95
Rate for Payer: Aetna Commercial	$32.90
Rate for Payer: Aetna Commercial	$44.64
Rate for Payer: Aetna Commercial	$51.12
Rate for Payer: UnitedHealthcare Commercial	$34.73
Rate for Payer: UnitedHealthcare Commercial	$37.95
Rate for Payer: UnitedHealthcare Commercial	$47.12
Rate for Payer: UnitedHealthcare Commercial	$53.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levonorgestrel 1.5 mg Tab

Facility

$27.62

Service Code	NDC 00536143363
Hospital Charge Code	3801708
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$26.24
Rate for Payer: Aetna Commercial	$24.86
Rate for Payer: Humana Medicare Advantage	$11.60
Rate for Payer: UnitedHealthcare Commercial	$26.24
Rate for Payer: UnitedHealthcare Medicaid	$11.05
Rate for Payer: WPPA Medicare Advantage	$16.57

levonorgestrel 1.5 mg Tab

Facility

$27.62

Service Code	NDC 00536143363
Hospital Charge Code	3801708
Hospital Revenue Code	250
Min. Negotiated Rate	$24.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.86
Rate for Payer: UnitedHealthcare Commercial	$26.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 112 mcg (0.112 mg) Tab [HMC]

Facility

$7.44

Service Code	NDC 00904695461
Hospital Charge Code	3808793
Hospital Revenue Code	250
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$7.07
Rate for Payer: Aetna Commercial	$6.70
Rate for Payer: Humana Medicare Advantage	$3.12
Rate for Payer: UnitedHealthcare Commercial	$7.07
Rate for Payer: UnitedHealthcare Medicaid	$2.98
Rate for Payer: WPPA Medicare Advantage	$4.46

levothyroxine 112 mcg (0.112 mg) Tab [HMC]

Facility

$10.68

Service Code	NDC 00074929690
Hospital Charge Code	3808793
Hospital Revenue Code	250
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$10.15
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: Humana Medicare Advantage	$4.49
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: UnitedHealthcare Medicaid	$4.27
Rate for Payer: WPPA Medicare Advantage	$6.41

levothyroxine 112 mcg (0.112 mg) Tab [HMC]

Facility

$7.44

Service Code	NDC 00904695461
Hospital Charge Code	3808793
Hospital Revenue Code	250
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.70
Rate for Payer: UnitedHealthcare Commercial	$7.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 112 mcg (0.112 mg) Tab [HMC]

Facility

$10.68

Service Code	NDC 00074929690
Hospital Charge Code	3808793
Hospital Revenue Code	250
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 112 mcg Tab [HMC]

Facility

$6.95

Service Code	NDC 68180097009
Hospital Charge Code	3808793
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.25
Rate for Payer: UnitedHealthcare Commercial	$6.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 112 mcg Tab [HMC]

Facility

$6.95

Service Code	NDC 68180097009
Hospital Charge Code	3808793
Hospital Revenue Code	250
Min. Negotiated Rate	$2.78
Max. Negotiated Rate	$6.60
Rate for Payer: Aetna Commercial	$6.25
Rate for Payer: Humana Medicare Advantage	$2.92
Rate for Payer: UnitedHealthcare Commercial	$6.60
Rate for Payer: UnitedHealthcare Medicaid	$2.78
Rate for Payer: WPPA Medicare Advantage	$4.17

levothyroxine 125 mcg (0.125 mg) Tab [HMC]

Facility

$10.68

Service Code	NDC 00074706811
Hospital Charge Code	3807937
Hospital Revenue Code	250
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 125 mcg (0.125 mg) Tab [HMC]

Facility

$7.48

Service Code	NDC 00904695561
Hospital Charge Code	3807937
Hospital Revenue Code	250
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$7.11
Rate for Payer: Aetna Commercial	$6.73
Rate for Payer: Humana Medicare Advantage	$3.14
Rate for Payer: UnitedHealthcare Commercial	$7.11
Rate for Payer: UnitedHealthcare Medicaid	$2.99
Rate for Payer: WPPA Medicare Advantage	$4.49

levothyroxine 125 mcg (0.125 mg) Tab [HMC]

Facility

$10.68

Service Code	NDC 00074706811
Hospital Charge Code	3807937
Hospital Revenue Code	250
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$10.15
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: Humana Medicare Advantage	$4.49
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: UnitedHealthcare Medicaid	$4.27
Rate for Payer: WPPA Medicare Advantage	$6.41

levothyroxine 125 mcg (0.125 mg) Tab [HMC]

Facility

$7.48

Service Code	NDC 00904695561
Hospital Charge Code	3807937
Hospital Revenue Code	250
Min. Negotiated Rate	$6.73
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.73
Rate for Payer: UnitedHealthcare Commercial	$7.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 200 mcg (0.2 mg) Tab [HMC]

Facility

$8.60

Service Code	NDC 60687055201
Hospital Charge Code	3800454
Hospital Revenue Code	250
Min. Negotiated Rate	$7.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.74
Rate for Payer: UnitedHealthcare Commercial	$8.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges