Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

OLANZapine 5 mg Dis Tab [HMC]

Facility

$33.55

Service Code	NDC 00093524565
Hospital Charge Code	3803408
Hospital Revenue Code	250
Min. Negotiated Rate	$30.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.20
Rate for Payer: UnitedHealthcare Commercial	$31.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OLANZapine 5 mg Dis Tab [HMC]

Facility

$33.55

Service Code	NDC 00093524565
Hospital Charge Code	3803408
Hospital Revenue Code	250
Min. Negotiated Rate	$13.42
Max. Negotiated Rate	$31.87
Rate for Payer: Aetna Commercial	$30.20
Rate for Payer: Humana Medicare Advantage	$14.09
Rate for Payer: UnitedHealthcare Commercial	$31.87
Rate for Payer: UnitedHealthcare Medicaid	$13.42
Rate for Payer: WPPA Medicare Advantage	$20.13

olmesartan 20 mg Tab [HMC]

Facility

$22.28

Service Code	NDC 00527242632
Hospital Charge Code	3805215
Hospital Revenue Code	250
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$21.17
Rate for Payer: Aetna Commercial	$20.05
Rate for Payer: Humana Medicare Advantage	$9.36
Rate for Payer: UnitedHealthcare Commercial	$21.17
Rate for Payer: UnitedHealthcare Medicaid	$8.91
Rate for Payer: WPPA Medicare Advantage	$13.37

olmesartan 20 mg Tab [HMC]

Facility

$22.28

Service Code	NDC 68462043730
Hospital Charge Code	3805215
Hospital Revenue Code	250
Min. Negotiated Rate	$20.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.05
Rate for Payer: UnitedHealthcare Commercial	$21.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

olmesartan 20 mg Tab [HMC]

Facility

$29.15

Service Code	NDC 65597010330
Hospital Charge Code	3805215
Hospital Revenue Code	250
Min. Negotiated Rate	$26.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.23
Rate for Payer: UnitedHealthcare Commercial	$27.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

olmesartan 20 mg Tab [HMC]

Facility

$22.28

Service Code	NDC 68462043790
Hospital Charge Code	3805215
Hospital Revenue Code	250
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$21.17
Rate for Payer: Aetna Commercial	$20.05
Rate for Payer: Humana Medicare Advantage	$9.36
Rate for Payer: UnitedHealthcare Commercial	$21.17
Rate for Payer: UnitedHealthcare Medicaid	$8.91
Rate for Payer: WPPA Medicare Advantage	$13.37

olmesartan 20 mg Tab [HMC]

Facility

$22.28

Service Code	NDC 68462043790
Hospital Charge Code	3805215
Hospital Revenue Code	250
Min. Negotiated Rate	$20.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.05
Rate for Payer: UnitedHealthcare Commercial	$21.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

olmesartan 20 mg Tab [HMC]

Facility

$22.28

Service Code	NDC 00527242632
Hospital Charge Code	3805215
Hospital Revenue Code	250
Min. Negotiated Rate	$20.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.05
Rate for Payer: UnitedHealthcare Commercial	$21.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

olmesartan 20 mg Tab [HMC]

Facility

$22.28

Service Code	NDC 68462043730
Hospital Charge Code	3805215
Hospital Revenue Code	250
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$21.17
Rate for Payer: Aetna Commercial	$20.05
Rate for Payer: Humana Medicare Advantage	$9.36
Rate for Payer: UnitedHealthcare Commercial	$21.17
Rate for Payer: UnitedHealthcare Medicaid	$8.91
Rate for Payer: WPPA Medicare Advantage	$13.37

olmesartan 20 mg Tab [HMC]

Facility

$29.15

Service Code	NDC 65597010330
Hospital Charge Code	3805215
Hospital Revenue Code	250
Min. Negotiated Rate	$11.66
Max. Negotiated Rate	$27.69
Rate for Payer: Aetna Commercial	$26.23
Rate for Payer: Humana Medicare Advantage	$12.24
Rate for Payer: UnitedHealthcare Commercial	$27.69
Rate for Payer: UnitedHealthcare Medicaid	$11.66
Rate for Payer: WPPA Medicare Advantage	$17.49

olodaterol-tiotropium 2.5 mcg-2.5 mcg/inh Aer [HMC]

Facility

$298.36

Service Code	NDC 00597015531
Hospital Charge Code	3800836
Hospital Revenue Code	250
Min. Negotiated Rate	$268.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$268.52
Rate for Payer: UnitedHealthcare Commercial	$283.44
Rate for Payer: WPPA Medicare Advantage	$1,200.00

olodaterol-tiotropium 2.5 mcg-2.5 mcg/inh Aer [HMC]

Facility

$298.36

Service Code	NDC 00597015531
Hospital Charge Code	3800836
Hospital Revenue Code	250
Min. Negotiated Rate	$119.34
Max. Negotiated Rate	$283.44
Rate for Payer: Aetna Commercial	$268.52
Rate for Payer: Humana Medicare Advantage	$125.31
Rate for Payer: UnitedHealthcare Commercial	$283.44
Rate for Payer: UnitedHealthcare Medicaid	$119.34
Rate for Payer: WPPA Medicare Advantage	$179.02

olodaterol-tiotropium 2.5 mcg-2.5 mcg/inh Aer [HMC]

Facility

$141.50

Service Code	NDC 00597015570
Hospital Charge Code	3800836
Hospital Revenue Code	250
Min. Negotiated Rate	$127.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$127.35
Rate for Payer: UnitedHealthcare Commercial	$134.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

olodaterol-tiotropium 2.5 mcg-2.5 mcg/inh Aer [HMC]

Facility

$141.50

Service Code	NDC 00597015570
Hospital Charge Code	3800836
Hospital Revenue Code	250
Min. Negotiated Rate	$56.60
Max. Negotiated Rate	$134.43
Rate for Payer: Aetna Commercial	$127.35
Rate for Payer: Humana Medicare Advantage	$59.43
Rate for Payer: UnitedHealthcare Commercial	$134.43
Rate for Payer: UnitedHealthcare Medicaid	$56.60
Rate for Payer: WPPA Medicare Advantage	$84.90

omalizumab 150 mg/mL Sol Inj [HMC]

Facility

$2,512.93

Service Code	HCPCS J2357
Hospital Charge Code	3850021
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,387.28
Rate for Payer: Aetna Commercial	$2,261.64
Rate for Payer: UnitedHealthcare Commercial	$2,387.28
Rate for Payer: WPPA Medicare Advantage	$1,200.00

omalizumab 150 mg/mL Sol Inj [HMC]

Facility

$2,512.93

Service Code	HCPCS J2357
Hospital Charge Code	3850021
Hospital Revenue Code	250
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$2,387.28
Rate for Payer: Aetna Commercial	$2,261.64
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.35
Rate for Payer: Humana Medicare Advantage	$1,055.43
Rate for Payer: UnitedHealthcare Commercial	$2,387.28
Rate for Payer: UnitedHealthcare Medicaid	$45.50
Rate for Payer: WPPA Medicare Advantage	$1,507.76

omalizumab 150 mg SubQ Inj [HMC]

Facility

$2,512.93

Service Code	HCPCS J2357
Hospital Charge Code	3850021
Hospital Revenue Code	250
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$2,387.28
Rate for Payer: Aetna Commercial	$2,261.64
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.35
Rate for Payer: Humana Medicare Advantage	$1,055.43
Rate for Payer: UnitedHealthcare Commercial	$2,387.28
Rate for Payer: UnitedHealthcare Medicaid	$45.50
Rate for Payer: WPPA Medicare Advantage	$1,507.76

omalizumab 150 mg SubQ Inj [HMC]

Facility

$2,512.93

Service Code	HCPCS J2357
Hospital Charge Code	3850021
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,387.28
Rate for Payer: Aetna Commercial	$2,261.64
Rate for Payer: UnitedHealthcare Commercial	$2,387.28
Rate for Payer: WPPA Medicare Advantage	$1,200.00

omalizumab 300 mg/2 mL Sol Inj [HMC]

Facility

$5,118.03

Service Code	HCPCS J2357
Hospital Charge Code	3850020
Hospital Revenue Code	250
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$4,862.13
Rate for Payer: Aetna Commercial	$4,606.23
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.35
Rate for Payer: Humana Medicare Advantage	$2,149.57
Rate for Payer: UnitedHealthcare Commercial	$4,862.13
Rate for Payer: UnitedHealthcare Medicaid	$45.50
Rate for Payer: WPPA Medicare Advantage	$3,070.82

omalizumab 300 mg/2 mL Sol Inj [HMC]

Facility

$5,118.03

Service Code	HCPCS J2357
Hospital Charge Code	3850020
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,862.13
Rate for Payer: Aetna Commercial	$4,606.23
Rate for Payer: UnitedHealthcare Commercial	$4,862.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

omalizumab 75 mg/0.5 mL [HMC]

Facility

$1,266.46

Service Code	HCPCS J2357
Hospital Charge Code	3850108
Hospital Revenue Code	250
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$1,203.14
Rate for Payer: Aetna Commercial	$1,139.81
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.35
Rate for Payer: Humana Medicare Advantage	$531.91
Rate for Payer: UnitedHealthcare Commercial	$1,203.14
Rate for Payer: UnitedHealthcare Medicaid	$45.50
Rate for Payer: WPPA Medicare Advantage	$759.88

omalizumab 75 mg/0.5 mL [HMC]

Facility

$1,266.46

Service Code	HCPCS J2357
Hospital Charge Code	3850108
Hospital Revenue Code	250
Min. Negotiated Rate	$1,139.81
Max. Negotiated Rate	$1,203.14
Rate for Payer: Aetna Commercial	$1,139.81
Rate for Payer: UnitedHealthcare Commercial	$1,203.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

omeprazole 20 mg Oral EC Cap [HMC]

Facility

$8.34

Service Code	NDC 68084012801
Hospital Charge Code	3806970
Hospital Revenue Code	250
Min. Negotiated Rate	$3.34
Max. Negotiated Rate	$7.92
Rate for Payer: Aetna Commercial	$7.51
Rate for Payer: Humana Medicare Advantage	$3.50
Rate for Payer: UnitedHealthcare Commercial	$7.92
Rate for Payer: UnitedHealthcare Medicaid	$3.34
Rate for Payer: WPPA Medicare Advantage	$5.00

omeprazole 20 mg Oral EC Cap [HMC]

Facility

$5.81

Service Code	NDC 00904691761
Hospital Charge Code	3806970
Hospital Revenue Code	250
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$5.52
Rate for Payer: Aetna Commercial	$5.23
Rate for Payer: Humana Medicare Advantage	$2.44
Rate for Payer: UnitedHealthcare Commercial	$5.52
Rate for Payer: UnitedHealthcare Medicaid	$2.32
Rate for Payer: WPPA Medicare Advantage	$3.49

omeprazole 20 mg Oral EC Cap [HMC]

Facility

$17.45

Service Code	NDC 70700015001
Hospital Charge Code	3806970
Hospital Revenue Code	250
Min. Negotiated Rate	$15.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.71
Rate for Payer: UnitedHealthcare Commercial	$16.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges