Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Thyroid Peroxidase Abs QST

Facility

$119.00

Service Code	HCPCS 86376
Hospital Charge Code	3552474
Hospital Revenue Code	300
Min. Negotiated Rate	$14.55
Max. Negotiated Rate	$113.05
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$50.96
Rate for Payer: Humana Medicare Advantage	$49.98
Rate for Payer: UnitedHealthcare Commercial	$113.05
Rate for Payer: UnitedHealthcare Medicaid	$14.55
Rate for Payer: WPPA Medicare Advantage	$71.40

Thyroid Peroxidase Abs QST

Facility

$119.00

Service Code	HCPCS 86376
Hospital Charge Code	3552474
Hospital Revenue Code	300
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: UnitedHealthcare Commercial	$113.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Thyroid Peroxidase Antibodies

Facility

$119.00

Service Code	HCPCS 86376
Hospital Charge Code	3552474
Hospital Revenue Code	300
Min. Negotiated Rate	$14.55
Max. Negotiated Rate	$113.05
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$50.96
Rate for Payer: Humana Medicare Advantage	$49.98
Rate for Payer: UnitedHealthcare Commercial	$113.05
Rate for Payer: UnitedHealthcare Medicaid	$14.55
Rate for Payer: WPPA Medicare Advantage	$71.40

Thyroid Peroxidase Antibodies

Facility

$119.00

Service Code	HCPCS 86376
Hospital Charge Code	3552474
Hospital Revenue Code	300
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: UnitedHealthcare Commercial	$113.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Thyroid Stimulating Hormone

Facility

$182.00

Service Code	HCPCS 84443
Hospital Charge Code	3551062
Hospital Revenue Code	300
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$172.90
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$43.97
Rate for Payer: Humana Medicare Advantage	$76.44
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: UnitedHealthcare Medicaid	$15.75
Rate for Payer: WPPA Medicare Advantage	$109.20

Thyroid Stimulating Hormone

Facility

$182.00

Service Code	HCPCS 84443
Hospital Charge Code	3551062
Hospital Revenue Code	300
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ticagrelor 90 mg Tab UD [HMC]

Facility

$27.56

Service Code	NDC 00186077739
Hospital Charge Code	3800707
Hospital Revenue Code	250
Min. Negotiated Rate	$11.02
Max. Negotiated Rate	$26.18
Rate for Payer: Aetna Commercial	$24.80
Rate for Payer: Humana Medicare Advantage	$11.58
Rate for Payer: UnitedHealthcare Commercial	$26.18
Rate for Payer: UnitedHealthcare Medicaid	$11.02
Rate for Payer: WPPA Medicare Advantage	$16.54

ticagrelor 90 mg Tab UD [HMC]

Facility

$27.56

Service Code	NDC 00186077739
Hospital Charge Code	3800707
Hospital Revenue Code	250
Min. Negotiated Rate	$24.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.80
Rate for Payer: UnitedHealthcare Commercial	$26.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tiotropium 18 mcg Inh Cap [HMC]

Facility

$29.34

Service Code	NDC 00597007575
Hospital Charge Code	3804037
Hospital Revenue Code	250
Min. Negotiated Rate	$26.41
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.41
Rate for Payer: UnitedHealthcare Commercial	$27.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tiotropium 18 mcg Inh Cap [HMC]

Facility

$25.48

Service Code	NDC 00597007541
Hospital Charge Code	3804037
Hospital Revenue Code	250
Min. Negotiated Rate	$10.19
Max. Negotiated Rate	$24.21
Rate for Payer: Aetna Commercial	$22.93
Rate for Payer: Humana Medicare Advantage	$10.70
Rate for Payer: UnitedHealthcare Commercial	$24.21
Rate for Payer: UnitedHealthcare Medicaid	$10.19
Rate for Payer: WPPA Medicare Advantage	$15.29

tiotropium 18 mcg Inh Cap [HMC]

Facility

$25.48

Service Code	NDC 00597007541
Hospital Charge Code	3804037
Hospital Revenue Code	250
Min. Negotiated Rate	$22.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.93
Rate for Payer: UnitedHealthcare Commercial	$24.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tiotropium 18 mcg Inh Cap [HMC]

Facility

$29.34

Service Code	NDC 00597007575
Hospital Charge Code	3804037
Hospital Revenue Code	250
Min. Negotiated Rate	$11.74
Max. Negotiated Rate	$27.87
Rate for Payer: Aetna Commercial	$26.41
Rate for Payer: Humana Medicare Advantage	$12.32
Rate for Payer: UnitedHealthcare Commercial	$27.87
Rate for Payer: UnitedHealthcare Medicaid	$11.74
Rate for Payer: WPPA Medicare Advantage	$17.60

Tissue Transglutaminase Ab, IgA QST

Facility

$61.00

Service Code	HCPCS 86364
Hospital Charge Code	3556364
Hospital Revenue Code	300
Min. Negotiated Rate	$7.49
Max. Negotiated Rate	$57.95
Rate for Payer: Aetna Commercial	$54.90
Rate for Payer: Humana Medicare Advantage	$25.62
Rate for Payer: UnitedHealthcare Commercial	$57.95
Rate for Payer: UnitedHealthcare Medicaid	$7.49
Rate for Payer: WPPA Medicare Advantage	$36.60

Tissue Transglutaminase Ab, IgA QST

Facility

$61.00

Service Code	HCPCS 86364
Hospital Charge Code	3556364
Hospital Revenue Code	300
Min. Negotiated Rate	$54.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.90
Rate for Payer: UnitedHealthcare Commercial	$57.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Tissue Transglutaminase Ab, IgG QST

Facility

$75.00

Service Code	HCPCS 86803
Hospital Charge Code	3552029
Hospital Revenue Code	300
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$71.25
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.09
Rate for Payer: Humana Medicare Advantage	$31.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: UnitedHealthcare Medicaid	$14.27
Rate for Payer: WPPA Medicare Advantage	$45.00

Tissue Transglutaminase Ab, IgG QST

Facility

$75.00

Service Code	HCPCS 86803
Hospital Charge Code	3552029
Hospital Revenue Code	300
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tiZANidine 2 mg Tab [HMC]

Facility

$10.25

Service Code	NDC 50268075915
Hospital Charge Code	3800120
Hospital Revenue Code	250
Min. Negotiated Rate	$9.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.22
Rate for Payer: UnitedHealthcare Commercial	$9.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tiZANidine 2 mg Tab [HMC]

Facility

$8.67

Service Code	NDC 00185003451
Hospital Charge Code	3800120
Hospital Revenue Code	250
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$8.24
Rate for Payer: Aetna Commercial	$7.80
Rate for Payer: Humana Medicare Advantage	$3.64
Rate for Payer: UnitedHealthcare Commercial	$8.24
Rate for Payer: UnitedHealthcare Medicaid	$3.47
Rate for Payer: WPPA Medicare Advantage	$5.20

tiZANidine 2 mg Tab [HMC]

Facility

$10.25

Service Code	NDC 50268075915
Hospital Charge Code	3800120
Hospital Revenue Code	250
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$9.74
Rate for Payer: Aetna Commercial	$9.22
Rate for Payer: Humana Medicare Advantage	$4.30
Rate for Payer: UnitedHealthcare Commercial	$9.74
Rate for Payer: UnitedHealthcare Medicaid	$4.10
Rate for Payer: WPPA Medicare Advantage	$6.15

tiZANidine 2 mg Tab [HMC]

Facility

$8.67

Service Code	NDC 00185003451
Hospital Charge Code	3800120
Hospital Revenue Code	250
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.80
Rate for Payer: UnitedHealthcare Commercial	$8.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tiZANidine 4 mg Tab [HMC]

Facility

$7.37

Service Code	NDC 68084064565
Hospital Charge Code	3809593
Hospital Revenue Code	250
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.63
Rate for Payer: UnitedHealthcare Commercial	$7.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tiZANidine 4 mg Tab [HMC]

Facility

$7.37

Service Code	NDC 68084064565
Hospital Charge Code	3809593
Hospital Revenue Code	250
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$7.00
Rate for Payer: Aetna Commercial	$6.63
Rate for Payer: Humana Medicare Advantage	$3.10
Rate for Payer: UnitedHealthcare Commercial	$7.00
Rate for Payer: UnitedHealthcare Medicaid	$2.95
Rate for Payer: WPPA Medicare Advantage	$4.42

tiZANidine 4 mg Tab [HMC]

Facility

$9.54

Service Code	NDC 50268076015
Hospital Charge Code	3809593
Hospital Revenue Code	250
Min. Negotiated Rate	$8.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.59
Rate for Payer: UnitedHealthcare Commercial	$9.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tiZANidine 4 mg Tab [HMC]

Facility

$9.54

Service Code	NDC 50268076015
Hospital Charge Code	3809593
Hospital Revenue Code	250
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$9.06
Rate for Payer: Aetna Commercial	$8.59
Rate for Payer: Humana Medicare Advantage	$4.01
Rate for Payer: UnitedHealthcare Commercial	$9.06
Rate for Payer: UnitedHealthcare Medicaid	$3.82
Rate for Payer: WPPA Medicare Advantage	$5.72

tiZANidine 4 mg Tab [HMC]

Facility

$10.29

Service Code	NDC 00904641861
Hospital Charge Code	3809593
Hospital Revenue Code	250
Min. Negotiated Rate	$9.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.26
Rate for Payer: UnitedHealthcare Commercial	$9.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges