Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

tolterodine 2 mg ERCap [HMC]

Facility

$29.81

Service Code	NDC 70436016004
Hospital Charge Code	3809569
Hospital Revenue Code	250
Min. Negotiated Rate	$11.92
Max. Negotiated Rate	$28.32
Rate for Payer: Aetna Commercial	$26.83
Rate for Payer: Humana Medicare Advantage	$12.52
Rate for Payer: UnitedHealthcare Commercial	$28.32
Rate for Payer: UnitedHealthcare Medicaid	$11.92
Rate for Payer: WPPA Medicare Advantage	$17.89

tolterodine 2 mg ERCap [HMC]

Facility

$28.87

Service Code	NDC 59762004702
Hospital Charge Code	3809569
Hospital Revenue Code	250
Min. Negotiated Rate	$25.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.98
Rate for Payer: UnitedHealthcare Commercial	$27.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tolterodine 2 mg ERCap [HMC]

Facility

$32.11

Service Code	NDC 00904659204
Hospital Charge Code	3809569
Hospital Revenue Code	250
Min. Negotiated Rate	$12.84
Max. Negotiated Rate	$30.50
Rate for Payer: Aetna Commercial	$28.90
Rate for Payer: Humana Medicare Advantage	$13.49
Rate for Payer: UnitedHealthcare Commercial	$30.50
Rate for Payer: UnitedHealthcare Medicaid	$12.84
Rate for Payer: WPPA Medicare Advantage	$19.27

tolterodine 2 mg ERCap [HMC]

Facility

$32.11

Service Code	NDC 00904659204
Hospital Charge Code	3809569
Hospital Revenue Code	250
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.90
Rate for Payer: UnitedHealthcare Commercial	$30.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Tomato (f25) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552821
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Tomato (f25) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552821
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$12.60

topiramate 200 mg Tab [HMC]

Facility

$8.37

Service Code	NDC 68084034521
Hospital Charge Code	3800224
Hospital Revenue Code	250
Min. Negotiated Rate	$7.53
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.53
Rate for Payer: UnitedHealthcare Commercial	$7.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

topiramate 200 mg Tab [HMC]

Facility

$22.68

Service Code	NDC 68462011060
Hospital Charge Code	3800224
Hospital Revenue Code	250
Min. Negotiated Rate	$20.41
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.41
Rate for Payer: UnitedHealthcare Commercial	$21.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

topiramate 200 mg Tab [HMC]

Facility

$8.37

Service Code	NDC 68084034521
Hospital Charge Code	3800224
Hospital Revenue Code	250
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$7.95
Rate for Payer: Aetna Commercial	$7.53
Rate for Payer: Humana Medicare Advantage	$3.52
Rate for Payer: UnitedHealthcare Commercial	$7.95
Rate for Payer: UnitedHealthcare Medicaid	$3.35
Rate for Payer: WPPA Medicare Advantage	$5.02

topiramate 200 mg Tab [HMC]

Facility

$22.68

Service Code	NDC 68462011060
Hospital Charge Code	3800224
Hospital Revenue Code	250
Min. Negotiated Rate	$9.07
Max. Negotiated Rate	$21.55
Rate for Payer: Aetna Commercial	$20.41
Rate for Payer: Humana Medicare Advantage	$9.53
Rate for Payer: UnitedHealthcare Commercial	$21.55
Rate for Payer: UnitedHealthcare Medicaid	$9.07
Rate for Payer: WPPA Medicare Advantage	$13.61

topiramate 25 mg Tab [HMC]

Facility

$11.65

Service Code	NDC 68462010860
Hospital Charge Code	3809254
Hospital Revenue Code	250
Min. Negotiated Rate	$4.66
Max. Negotiated Rate	$11.07
Rate for Payer: Aetna Commercial	$10.48
Rate for Payer: Humana Medicare Advantage	$4.89
Rate for Payer: UnitedHealthcare Commercial	$11.07
Rate for Payer: UnitedHealthcare Medicaid	$4.66
Rate for Payer: WPPA Medicare Advantage	$6.99

topiramate 25 mg Tab [HMC]

Facility

$5.99

Service Code	NDC 00904692861
Hospital Charge Code	3809254
Hospital Revenue Code	250
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$5.69
Rate for Payer: Aetna Commercial	$5.39
Rate for Payer: Humana Medicare Advantage	$2.52
Rate for Payer: UnitedHealthcare Commercial	$5.69
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: WPPA Medicare Advantage	$3.59

topiramate 25 mg Tab [HMC]

Facility

$11.65

Service Code	NDC 68462010860
Hospital Charge Code	3809254
Hospital Revenue Code	250
Min. Negotiated Rate	$10.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.48
Rate for Payer: UnitedHealthcare Commercial	$11.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

topiramate 25 mg Tab [HMC]

Facility

$5.99

Service Code	NDC 00904692861
Hospital Charge Code	3809254
Hospital Revenue Code	250
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.39
Rate for Payer: UnitedHealthcare Commercial	$5.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Topirmate

Facility

$126.00

Service Code	HCPCS 80201
Hospital Charge Code	3550201
Hospital Revenue Code	300
Min. Negotiated Rate	$10.71
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna Commercial	$113.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.35
Rate for Payer: Humana Medicare Advantage	$52.92
Rate for Payer: UnitedHealthcare Commercial	$119.70
Rate for Payer: UnitedHealthcare Medicaid	$10.71
Rate for Payer: WPPA Medicare Advantage	$75.60

Topirmate

Facility

$126.00

Service Code	HCPCS 80201
Hospital Charge Code	3550201
Hospital Revenue Code	300
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$113.40
Rate for Payer: UnitedHealthcare Commercial	$119.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

torsemide 20 mg Tab [HMC]

Facility

$7.46

Service Code	NDC 65862012701
Hospital Charge Code	3800410
Hospital Revenue Code	250
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$7.09
Rate for Payer: Aetna Commercial	$6.71
Rate for Payer: Humana Medicare Advantage	$3.13
Rate for Payer: UnitedHealthcare Commercial	$7.09
Rate for Payer: UnitedHealthcare Medicaid	$2.98
Rate for Payer: WPPA Medicare Advantage	$4.48

torsemide 20 mg Tab [HMC]

Facility

$6.27

Service Code	NDC 00904728306
Hospital Charge Code	3800410
Hospital Revenue Code	250
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$5.96
Rate for Payer: Aetna Commercial	$5.64
Rate for Payer: Humana Medicare Advantage	$2.63
Rate for Payer: UnitedHealthcare Commercial	$5.96
Rate for Payer: UnitedHealthcare Medicaid	$2.51
Rate for Payer: WPPA Medicare Advantage	$3.76

torsemide 20 mg Tab [HMC]

Facility

$7.46

Service Code	NDC 65862012701
Hospital Charge Code	3800410
Hospital Revenue Code	250
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.71
Rate for Payer: UnitedHealthcare Commercial	$7.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

torsemide 20 mg Tab [HMC]

Facility

$6.27

Service Code	NDC 00904728306
Hospital Charge Code	3800410
Hospital Revenue Code	250
Min. Negotiated Rate	$5.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.64
Rate for Payer: UnitedHealthcare Commercial	$5.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

torsemide 20 mg Tab [HMC]

Facility

$7.46

Service Code	NDC 31722053101
Hospital Charge Code	3800410
Hospital Revenue Code	250
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$7.09
Rate for Payer: Aetna Commercial	$6.71
Rate for Payer: Humana Medicare Advantage	$3.13
Rate for Payer: UnitedHealthcare Commercial	$7.09
Rate for Payer: UnitedHealthcare Medicaid	$2.98
Rate for Payer: WPPA Medicare Advantage	$4.48

torsemide 20 mg Tab [HMC]

Facility

$7.46

Service Code	NDC 31722053101
Hospital Charge Code	3800410
Hospital Revenue Code	250
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.71
Rate for Payer: UnitedHealthcare Commercial	$7.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Total Contact Cast Large Boot

Facility

$335.00

Hospital Charge Code	3254102
Hospital Revenue Code	270
Min. Negotiated Rate	$301.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$301.50
Rate for Payer: UnitedHealthcare Commercial	$318.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Total Contact Cast Large Boot

Facility

$335.00

Hospital Charge Code	3254102
Hospital Revenue Code	270
Min. Negotiated Rate	$134.00
Max. Negotiated Rate	$318.25
Rate for Payer: Aetna Commercial	$301.50
Rate for Payer: Humana Medicare Advantage	$140.70
Rate for Payer: UnitedHealthcare Commercial	$318.25
Rate for Payer: UnitedHealthcare Medicaid	$134.00
Rate for Payer: WPPA Medicare Advantage	$201.00

Total Contact Cast Regular Boot

Facility

$270.00

Hospital Charge Code	3254101
Hospital Revenue Code	270
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$256.50
Rate for Payer: Aetna Commercial	$243.00
Rate for Payer: Humana Medicare Advantage	$113.40
Rate for Payer: UnitedHealthcare Commercial	$256.50
Rate for Payer: UnitedHealthcare Medicaid	$108.00
Rate for Payer: WPPA Medicare Advantage	$162.00

Know your out-of-pocket cost for care.

All Charges