Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

telmisartan 80 mg Tab [HMC]

Facility

$18.80

Service Code	NDC 00378292293
Hospital Charge Code	3803786
Hospital Revenue Code	250
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.92
Rate for Payer: UnitedHealthcare Commercial	$17.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

telmisartan 80 mg Tab [HMC]

Facility

$18.95

Service Code	NDC 67877048430
Hospital Charge Code	3803786
Hospital Revenue Code	250
Min. Negotiated Rate	$7.58
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.05
Rate for Payer: Humana Medicare Advantage	$7.96
Rate for Payer: UnitedHealthcare Commercial	$18.00
Rate for Payer: UnitedHealthcare Medicaid	$7.58
Rate for Payer: WPPA Medicare Advantage	$11.37

telmisartan 80 mg Tab [HMC]

Facility

$18.95

Service Code	NDC 67877048430
Hospital Charge Code	3803786
Hospital Revenue Code	250
Min. Negotiated Rate	$17.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.05
Rate for Payer: UnitedHealthcare Commercial	$18.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

telmisartan 80 mg Tab [HMC]

Facility

$19.02

Service Code	NDC 00597004137
Hospital Charge Code	3803786
Hospital Revenue Code	250
Min. Negotiated Rate	$17.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: UnitedHealthcare Commercial	$18.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

telmisartan 80 mg Tab [HMC]

Facility

$19.02

Service Code	NDC 00597004137
Hospital Charge Code	3803786
Hospital Revenue Code	250
Min. Negotiated Rate	$7.61
Max. Negotiated Rate	$18.07
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: Humana Medicare Advantage	$7.99
Rate for Payer: UnitedHealthcare Commercial	$18.07
Rate for Payer: UnitedHealthcare Medicaid	$7.61
Rate for Payer: WPPA Medicare Advantage	$11.41

telmisartan 80 mg Tab [HMC]

Facility

$18.80

Service Code	NDC 00378292293
Hospital Charge Code	3803786
Hospital Revenue Code	250
Min. Negotiated Rate	$7.52
Max. Negotiated Rate	$17.86
Rate for Payer: Aetna Commercial	$16.92
Rate for Payer: Humana Medicare Advantage	$7.90
Rate for Payer: UnitedHealthcare Commercial	$17.86
Rate for Payer: UnitedHealthcare Medicaid	$7.52
Rate for Payer: WPPA Medicare Advantage	$11.28

temazepam 15 mg Cap [HMC]

Facility

$7.20

Service Code	NDC 00228207610
Hospital Charge Code	3807365
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.48
Rate for Payer: UnitedHealthcare Commercial	$6.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

temazepam 15 mg Cap [HMC]

Facility

$7.20

Service Code	NDC 00228207610
Hospital Charge Code	3807365
Hospital Revenue Code	250
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$6.84
Rate for Payer: Aetna Commercial	$6.48
Rate for Payer: Humana Medicare Advantage	$3.02
Rate for Payer: UnitedHealthcare Commercial	$6.84
Rate for Payer: UnitedHealthcare Medicaid	$2.88
Rate for Payer: WPPA Medicare Advantage	$4.32

TENDONITIS, MYOSITIS AND BURSITIS WITH MCC

Facility

$9,117.99

Service Code	MSDRG 557
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,117.99
Rate for Payer: UnitedHealthcare Medicaid	$9,117.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC

Facility

$5,464.44

Service Code	MSDRG 558
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,464.44
Rate for Payer: UnitedHealthcare Medicaid	$5,464.44
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tenecteplase 50 mg IV Inj [HMC]

Facility

$16,437.96

Service Code	HCPCS J3101
Hospital Charge Code	3803521
Hospital Revenue Code	250
Min. Negotiated Rate	$186.97
Max. Negotiated Rate	$15,616.06
Rate for Payer: Aetna Commercial	$14,794.16
Rate for Payer: Aetna Commercial	$6,926.36
Rate for Payer: Aetna Commercial	$15,681.83
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$196.97
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$196.97
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$196.97
Rate for Payer: Humana Medicare Advantage	$7,318.19
Rate for Payer: Humana Medicare Advantage	$3,232.30
Rate for Payer: Humana Medicare Advantage	$6,903.94
Rate for Payer: UnitedHealthcare Commercial	$16,553.04
Rate for Payer: UnitedHealthcare Commercial	$15,616.06
Rate for Payer: UnitedHealthcare Commercial	$7,311.16
Rate for Payer: UnitedHealthcare Medicaid	$186.97
Rate for Payer: UnitedHealthcare Medicaid	$186.97
Rate for Payer: UnitedHealthcare Medicaid	$186.97
Rate for Payer: WPPA Medicare Advantage	$9,862.78
Rate for Payer: WPPA Medicare Advantage	$10,454.55
Rate for Payer: WPPA Medicare Advantage	$4,617.58

tenecteplase 50 mg IV Inj [HMC]

Facility

$16,437.96

Service Code	HCPCS J3101
Hospital Charge Code	3803521
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$15,616.06
Rate for Payer: Aetna Commercial	$14,794.16
Rate for Payer: Aetna Commercial	$15,681.83
Rate for Payer: Aetna Commercial	$6,926.36
Rate for Payer: UnitedHealthcare Commercial	$7,311.16
Rate for Payer: UnitedHealthcare Commercial	$16,553.04
Rate for Payer: UnitedHealthcare Commercial	$15,616.06
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

terazosin 1 mg Cap [HMC]

Facility

$9.82

Service Code	NDC 50268076415
Hospital Charge Code	3807381
Hospital Revenue Code	250
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$9.33
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: Humana Medicare Advantage	$4.12
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: UnitedHealthcare Medicaid	$3.93
Rate for Payer: WPPA Medicare Advantage	$5.89

terazosin 1 mg Cap [HMC]

Facility

$9.82

Service Code	NDC 00093433601
Hospital Charge Code	3807381
Hospital Revenue Code	250
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$9.33
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: Humana Medicare Advantage	$4.12
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: UnitedHealthcare Medicaid	$3.93
Rate for Payer: WPPA Medicare Advantage	$5.89

terazosin 1 mg Cap [HMC]

Facility

$9.82

Service Code	NDC 59746038306
Hospital Charge Code	3807381
Hospital Revenue Code	250
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

terazosin 1 mg Cap [HMC]

Facility

$9.82

Service Code	NDC 00093433601
Hospital Charge Code	3807381
Hospital Revenue Code	250
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

terazosin 1 mg Cap [HMC]

Facility

$9.82

Service Code	NDC 50268076415
Hospital Charge Code	3807381
Hospital Revenue Code	250
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

terazosin 1 mg Cap [HMC]

Facility

$9.82

Service Code	NDC 59746038306
Hospital Charge Code	3807381
Hospital Revenue Code	250
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$9.33
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: Humana Medicare Advantage	$4.12
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: UnitedHealthcare Medicaid	$3.93
Rate for Payer: WPPA Medicare Advantage	$5.89

terazosin 5 mg Cap [HMC]

Facility

$9.82

Service Code	NDC 50268076615
Hospital Charge Code	3806269
Hospital Revenue Code	250
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$9.33
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: Humana Medicare Advantage	$4.12
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: UnitedHealthcare Medicaid	$3.93
Rate for Payer: WPPA Medicare Advantage	$5.89

terazosin 5 mg Cap [HMC]

Facility

$9.82

Service Code	NDC 59746038506
Hospital Charge Code	3806269
Hospital Revenue Code	250
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$9.33
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: Humana Medicare Advantage	$4.12
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: UnitedHealthcare Medicaid	$3.93
Rate for Payer: WPPA Medicare Advantage	$5.89

terazosin 5 mg Cap [HMC]

Facility

$9.82

Service Code	NDC 50268076615
Hospital Charge Code	3806269
Hospital Revenue Code	250
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

terazosin 5 mg Cap [HMC]

Facility

$9.82

Service Code	NDC 59746038506
Hospital Charge Code	3806269
Hospital Revenue Code	250
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: UnitedHealthcare Commercial	$9.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

terbinafine 250 mg Tab

Facility

$31.15

Service Code	NDC 69097085907
Hospital Charge Code	3852141
Hospital Revenue Code	250
Min. Negotiated Rate	$28.04
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.04
Rate for Payer: UnitedHealthcare Commercial	$29.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

terbinafine 250 mg Tab

Facility

$31.15

Service Code	NDC 69097085907
Hospital Charge Code	3852141
Hospital Revenue Code	250
Min. Negotiated Rate	$12.46
Max. Negotiated Rate	$29.59
Rate for Payer: Aetna Commercial	$28.04
Rate for Payer: Humana Medicare Advantage	$13.08
Rate for Payer: UnitedHealthcare Commercial	$29.59
Rate for Payer: UnitedHealthcare Medicaid	$12.46
Rate for Payer: WPPA Medicare Advantage	$18.69

terbutaline 1 mg/mL Inj Sol [HMC]

Facility

$44.00

Service Code	HCPCS J3105
Hospital Charge Code	3800619
Hospital Revenue Code	250
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$41.80
Rate for Payer: Aetna Commercial	$39.60
Rate for Payer: Aetna Commercial	$25.02
Rate for Payer: Aetna Commercial	$49.91
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7.83
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7.83
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7.83
Rate for Payer: Humana Medicare Advantage	$18.48
Rate for Payer: Humana Medicare Advantage	$11.68
Rate for Payer: Humana Medicare Advantage	$23.29
Rate for Payer: UnitedHealthcare Commercial	$26.41
Rate for Payer: UnitedHealthcare Commercial	$41.80
Rate for Payer: UnitedHealthcare Commercial	$52.69
Rate for Payer: UnitedHealthcare Medicaid	$2.47
Rate for Payer: UnitedHealthcare Medicaid	$2.47
Rate for Payer: UnitedHealthcare Medicaid	$2.47
Rate for Payer: WPPA Medicare Advantage	$33.28
Rate for Payer: WPPA Medicare Advantage	$26.40
Rate for Payer: WPPA Medicare Advantage	$16.68

Know your out-of-pocket cost for care.

All Charges