Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

tiZANidine 4 mg Tab [HMC]

Facility

$10.29

Service Code	NDC 00904641861
Hospital Charge Code	3809593
Hospital Revenue Code	250
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$9.78
Rate for Payer: Aetna Commercial	$9.26
Rate for Payer: Humana Medicare Advantage	$4.32
Rate for Payer: UnitedHealthcare Commercial	$9.78
Rate for Payer: UnitedHealthcare Medicaid	$4.12
Rate for Payer: WPPA Medicare Advantage	$6.17

tobramycin 40 mg/mL Inj Sol 2 mL [HMC]

Facility

$40.35

Service Code	HCPCS J3260
Hospital Charge Code	3809627
Hospital Revenue Code	250
Min. Negotiated Rate	$36.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.31
Rate for Payer: UnitedHealthcare Commercial	$38.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tobramycin 40 mg/mL Inj Sol 2 mL [HMC]

Facility

$40.35

Service Code	HCPCS J3260
Hospital Charge Code	3809627
Hospital Revenue Code	250
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$38.33
Rate for Payer: Aetna Commercial	$36.31
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.86
Rate for Payer: Humana Medicare Advantage	$16.95
Rate for Payer: UnitedHealthcare Commercial	$38.33
Rate for Payer: UnitedHealthcare Medicaid	$2.07
Rate for Payer: WPPA Medicare Advantage	$24.21

tobramycin 40 mg/mL Inj Sol 30 mL [HMC]

Facility

$59.34

Service Code	HCPCS J3260
Hospital Charge Code	3852230
Hospital Revenue Code	250
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$56.37
Rate for Payer: Aetna Commercial	$53.41
Rate for Payer: Aetna Commercial	$53.28
Rate for Payer: Aetna Commercial	$53.64
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.86
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.86
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.86
Rate for Payer: Humana Medicare Advantage	$24.92
Rate for Payer: Humana Medicare Advantage	$24.86
Rate for Payer: Humana Medicare Advantage	$25.03
Rate for Payer: UnitedHealthcare Commercial	$56.24
Rate for Payer: UnitedHealthcare Commercial	$56.37
Rate for Payer: UnitedHealthcare Commercial	$56.62
Rate for Payer: UnitedHealthcare Medicaid	$2.07
Rate for Payer: UnitedHealthcare Medicaid	$2.07
Rate for Payer: UnitedHealthcare Medicaid	$2.07
Rate for Payer: WPPA Medicare Advantage	$35.60
Rate for Payer: WPPA Medicare Advantage	$35.76
Rate for Payer: WPPA Medicare Advantage	$35.52

tobramycin 40 mg/mL Inj Sol 30 mL [HMC]

Facility

$59.60

Service Code	HCPCS J3260
Hospital Charge Code	3852230
Hospital Revenue Code	250
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$53.64
Rate for Payer: Aetna Commercial	$53.28
Rate for Payer: Aetna Commercial	$53.41
Rate for Payer: UnitedHealthcare Commercial	$56.37
Rate for Payer: UnitedHealthcare Commercial	$56.24
Rate for Payer: UnitedHealthcare Commercial	$56.62
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

tobramycin 40 mg/mL Inj Sol [HMC]

Facility

$35.34

Service Code	HCPCS J3260
Hospital Charge Code	3809627
Hospital Revenue Code	250
Min. Negotiated Rate	$31.81
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.81
Rate for Payer: UnitedHealthcare Commercial	$33.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tobramycin 40 mg/mL Inj Sol [HMC]

Facility

$35.34

Service Code	HCPCS J3260
Hospital Charge Code	3809627
Hospital Revenue Code	250
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$33.57
Rate for Payer: Aetna Commercial	$31.81
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.86
Rate for Payer: Humana Medicare Advantage	$14.84
Rate for Payer: UnitedHealthcare Commercial	$33.57
Rate for Payer: UnitedHealthcare Medicaid	$2.07
Rate for Payer: WPPA Medicare Advantage	$21.20

tobramycin 60 mg/mL Inh Sol [HMC]

Facility

$213.16

Service Code	HCPCS J7682
Hospital Charge Code	3800408
Hospital Revenue Code	250
Min. Negotiated Rate	$24.97
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna Commercial	$191.84
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$24.97
Rate for Payer: Humana Medicare Advantage	$89.53
Rate for Payer: UnitedHealthcare Commercial	$202.50
Rate for Payer: UnitedHealthcare Medicaid	$85.26
Rate for Payer: WPPA Medicare Advantage	$127.90

tobramycin 60 mg/mL Inh Sol [HMC]

Facility

$213.16

Service Code	HCPCS J7682
Hospital Charge Code	3800408
Hospital Revenue Code	250
Min. Negotiated Rate	$191.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$191.84
Rate for Payer: UnitedHealthcare Commercial	$202.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tocilizumab 162 mg/0.9 mL [HMC]

Facility

$2,134.66

Service Code	HCPCS J3262
Hospital Charge Code	3850061
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,027.93
Rate for Payer: Aetna Commercial	$1,921.19
Rate for Payer: UnitedHealthcare Commercial	$2,027.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tocilizumab 162 mg/0.9 mL [HMC]

Facility

$2,134.66

Service Code	HCPCS J3262
Hospital Charge Code	3850061
Hospital Revenue Code	250
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$2,027.93
Rate for Payer: Aetna Commercial	$1,921.19
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7.44
Rate for Payer: Humana Medicare Advantage	$896.56
Rate for Payer: UnitedHealthcare Commercial	$2,027.93
Rate for Payer: UnitedHealthcare Medicaid	$5.61
Rate for Payer: WPPA Medicare Advantage	$1,280.80

tocilizumab 20 mg/mL 20 mL[HMC]

Facility

$6,373.97

Service Code	HCPCS J3262
Hospital Charge Code	3852270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$6,055.27
Rate for Payer: Aetna Commercial	$5,736.57
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7.44
Rate for Payer: Humana Medicare Advantage	$2,677.07
Rate for Payer: UnitedHealthcare Commercial	$6,055.27
Rate for Payer: UnitedHealthcare Medicaid	$5.61
Rate for Payer: WPPA Medicare Advantage	$3,824.38

tocilizumab 20 mg/mL 20 mL[HMC]

Facility

$6,373.97

Service Code	HCPCS J3262
Hospital Charge Code	3852270
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,055.27
Rate for Payer: Aetna Commercial	$5,736.57
Rate for Payer: UnitedHealthcare Commercial	$6,055.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tocilizumab 20 mg/mL Sol 4mL [HMC]

Facility

$966.09

Service Code	HCPCS J3262
Hospital Charge Code	3852271
Hospital Revenue Code	250
Min. Negotiated Rate	$869.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$869.48
Rate for Payer: UnitedHealthcare Commercial	$917.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tocilizumab 20 mg/mL Sol 4mL [HMC]

Facility

$966.09

Service Code	HCPCS J3262
Hospital Charge Code	3852271
Hospital Revenue Code	250
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$917.79
Rate for Payer: Aetna Commercial	$869.48
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7.44
Rate for Payer: Humana Medicare Advantage	$405.76
Rate for Payer: UnitedHealthcare Commercial	$917.79
Rate for Payer: UnitedHealthcare Medicaid	$5.61
Rate for Payer: WPPA Medicare Advantage	$579.65

tocilizumab 20 mg/mL Sol 4mL [HMC]

Facility

$966.09

Service Code	HCPCS J3262
Hospital Charge Code	3852271
Hospital Revenue Code	636
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$917.79
Rate for Payer: Aetna Commercial	$869.48
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7.44
Rate for Payer: Humana Medicare Advantage	$405.76
Rate for Payer: UnitedHealthcare Commercial	$917.79
Rate for Payer: UnitedHealthcare Medicaid	$5.61
Rate for Payer: WPPA Medicare Advantage	$579.65

tocilizumab 20 mg/mL Sol 4mL [HMC]

Facility

$966.09

Service Code	HCPCS J3262
Hospital Charge Code	3852271
Hospital Revenue Code	636
Min. Negotiated Rate	$869.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$869.48
Rate for Payer: UnitedHealthcare Commercial	$917.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Toe Spacer Gel Medium

Facility

$5.00

Hospital Charge Code	3259250
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

Toe Spacer Gel Medium

Facility

$5.00

Hospital Charge Code	3259250
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

tolterodine 2 mg ERCap [HMC]

Facility

$29.10

Service Code	NDC 60687031921
Hospital Charge Code	3809569
Hospital Revenue Code	250
Min. Negotiated Rate	$26.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.19
Rate for Payer: UnitedHealthcare Commercial	$27.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tolterodine 2 mg ERCap [HMC]

Facility

$29.81

Service Code	NDC 70436016004
Hospital Charge Code	3809569
Hospital Revenue Code	250
Min. Negotiated Rate	$26.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.83
Rate for Payer: UnitedHealthcare Commercial	$28.32
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tolterodine 2 mg ERCap [HMC]

Facility

$25.09

Service Code	NDC 43975032203
Hospital Charge Code	3809569
Hospital Revenue Code	250
Min. Negotiated Rate	$22.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.58
Rate for Payer: UnitedHealthcare Commercial	$23.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tolterodine 2 mg ERCap [HMC]

Facility

$28.87

Service Code	NDC 59762004702
Hospital Charge Code	3809569
Hospital Revenue Code	250
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$27.43
Rate for Payer: Aetna Commercial	$25.98
Rate for Payer: Humana Medicare Advantage	$12.13
Rate for Payer: UnitedHealthcare Commercial	$27.43
Rate for Payer: UnitedHealthcare Medicaid	$11.55
Rate for Payer: WPPA Medicare Advantage	$17.32

tolterodine 2 mg ERCap [HMC]

Facility

$25.09

Service Code	NDC 43975032203
Hospital Charge Code	3809569
Hospital Revenue Code	250
Min. Negotiated Rate	$10.04
Max. Negotiated Rate	$23.84
Rate for Payer: Aetna Commercial	$22.58
Rate for Payer: Humana Medicare Advantage	$10.54
Rate for Payer: UnitedHealthcare Commercial	$23.84
Rate for Payer: UnitedHealthcare Medicaid	$10.04
Rate for Payer: WPPA Medicare Advantage	$15.05

tolterodine 2 mg ERCap [HMC]

Facility

$29.10

Service Code	NDC 60687031921
Hospital Charge Code	3809569
Hospital Revenue Code	250
Min. Negotiated Rate	$11.64
Max. Negotiated Rate	$27.64
Rate for Payer: Aetna Commercial	$26.19
Rate for Payer: Humana Medicare Advantage	$12.22
Rate for Payer: UnitedHealthcare Commercial	$27.64
Rate for Payer: UnitedHealthcare Medicaid	$11.64
Rate for Payer: WPPA Medicare Advantage	$17.46

Know your out-of-pocket cost for care.

All Charges