Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

amiodarone 200 mg Tab [HMC]

Facility

$6.82

Service Code	NDC 60687043701
Hospital Charge Code	3804255
Hospital Revenue Code	250
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$6.48
Rate for Payer: Aetna Commercial	$6.14
Rate for Payer: Humana Medicare Advantage	$2.86
Rate for Payer: UnitedHealthcare Commercial	$6.48
Rate for Payer: UnitedHealthcare Medicaid	$2.73
Rate for Payer: WPPA Medicare Advantage	$4.09

amiodarone 200 mg Tab [HMC]

Facility

$15.15

Service Code	NDC 65862073260
Hospital Charge Code	3804255
Hospital Revenue Code	250
Min. Negotiated Rate	$6.06
Max. Negotiated Rate	$14.39
Rate for Payer: Aetna Commercial	$13.63
Rate for Payer: Humana Medicare Advantage	$6.36
Rate for Payer: UnitedHealthcare Commercial	$14.39
Rate for Payer: UnitedHealthcare Medicaid	$6.06
Rate for Payer: WPPA Medicare Advantage	$9.09

amiodarone 200 mg Tab [HMC]

Facility

$15.15

Service Code	NDC 29300035916
Hospital Charge Code	3804255
Hospital Revenue Code	250
Min. Negotiated Rate	$13.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.63
Rate for Payer: UnitedHealthcare Commercial	$14.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amiodarone 200 mg Tab [HMC]

Facility

$15.15

Service Code	NDC 65862073260
Hospital Charge Code	3804255
Hospital Revenue Code	250
Min. Negotiated Rate	$13.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.63
Rate for Payer: UnitedHealthcare Commercial	$14.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amiodarone 360 mg/200 mL-D5% [HMC]

Facility

$120.74

Service Code	HCPCS J0282
Hospital Charge Code	3800235
Hospital Revenue Code	250
Min. Negotiated Rate	$108.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$108.67
Rate for Payer: UnitedHealthcare Commercial	$114.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amiodarone 360 mg/200 mL-D5% [HMC]

Facility

$120.74

Service Code	HCPCS J0282
Hospital Charge Code	3800235
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$114.70
Rate for Payer: Aetna Commercial	$108.67
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.57
Rate for Payer: Humana Medicare Advantage	$50.71
Rate for Payer: UnitedHealthcare Commercial	$114.70
Rate for Payer: UnitedHealthcare Medicaid	$0.41
Rate for Payer: WPPA Medicare Advantage	$72.44

amiodarone 50 mg/mL IV Sol [HMC]

Facility

$27.00

Service Code	HCPCS J0282
Hospital Charge Code	3804925
Hospital Revenue Code	250
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Aetna Commercial	$34.19
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Commercial	$36.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amiodarone 50 mg/mL IV Sol [HMC]

Facility

$37.99

Service Code	HCPCS J0282
Hospital Charge Code	3804925
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$36.09
Rate for Payer: Aetna Commercial	$34.19
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.57
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.57
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: UnitedHealthcare Commercial	$36.09
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$0.41
Rate for Payer: UnitedHealthcare Medicaid	$0.41
Rate for Payer: WPPA Medicare Advantage	$16.20
Rate for Payer: WPPA Medicare Advantage	$22.79

amitriptyline 10 mg Tab [HMC]

Facility

$6.49

Service Code	NDC 50268003715
Hospital Charge Code	3804263
Hospital Revenue Code	250
Min. Negotiated Rate	$5.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.84
Rate for Payer: UnitedHealthcare Commercial	$6.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amitriptyline 10 mg Tab [HMC]

Facility

$5.95

Service Code	NDC 16729017101
Hospital Charge Code	3804263
Hospital Revenue Code	250
Min. Negotiated Rate	$5.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.36
Rate for Payer: UnitedHealthcare Commercial	$5.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amitriptyline 10 mg Tab [HMC]

Facility

$5.95

Service Code	NDC 51079013120
Hospital Charge Code	3804263
Hospital Revenue Code	250
Min. Negotiated Rate	$5.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.36
Rate for Payer: UnitedHealthcare Commercial	$5.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amitriptyline 10 mg Tab [HMC]

Facility

$5.95

Service Code	NDC 51079013120
Hospital Charge Code	3804263
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$5.65
Rate for Payer: Aetna Commercial	$5.36
Rate for Payer: Humana Medicare Advantage	$2.50
Rate for Payer: UnitedHealthcare Commercial	$5.65
Rate for Payer: UnitedHealthcare Medicaid	$2.38
Rate for Payer: WPPA Medicare Advantage	$3.57

amitriptyline 10 mg Tab [HMC]

Facility

$6.49

Service Code	NDC 50268003715
Hospital Charge Code	3804263
Hospital Revenue Code	250
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$6.17
Rate for Payer: Aetna Commercial	$5.84
Rate for Payer: Humana Medicare Advantage	$2.73
Rate for Payer: UnitedHealthcare Commercial	$6.17
Rate for Payer: UnitedHealthcare Medicaid	$2.60
Rate for Payer: WPPA Medicare Advantage	$3.89

amitriptyline 10 mg Tab [HMC]

Facility

$5.95

Service Code	NDC 70710122501
Hospital Charge Code	3804263
Hospital Revenue Code	250
Min. Negotiated Rate	$5.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.36
Rate for Payer: UnitedHealthcare Commercial	$5.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amitriptyline 10 mg Tab [HMC]

Facility

$5.95

Service Code	NDC 16729017101
Hospital Charge Code	3804263
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$5.65
Rate for Payer: Aetna Commercial	$5.36
Rate for Payer: Humana Medicare Advantage	$2.50
Rate for Payer: UnitedHealthcare Commercial	$5.65
Rate for Payer: UnitedHealthcare Medicaid	$2.38
Rate for Payer: WPPA Medicare Advantage	$3.57

amitriptyline 10 mg Tab [HMC]

Facility

$5.95

Service Code	NDC 70710122501
Hospital Charge Code	3804263
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$5.65
Rate for Payer: Aetna Commercial	$5.36
Rate for Payer: Humana Medicare Advantage	$2.50
Rate for Payer: UnitedHealthcare Commercial	$5.65
Rate for Payer: UnitedHealthcare Medicaid	$2.38
Rate for Payer: WPPA Medicare Advantage	$3.57

amitriptyline 25 mg Tab [HMC]

Facility

$6.91

Service Code	NDC 00904020161
Hospital Charge Code	3804271
Hospital Revenue Code	250
Min. Negotiated Rate	$2.76
Max. Negotiated Rate	$6.56
Rate for Payer: Aetna Commercial	$6.22
Rate for Payer: Humana Medicare Advantage	$2.90
Rate for Payer: UnitedHealthcare Commercial	$6.56
Rate for Payer: UnitedHealthcare Medicaid	$2.76
Rate for Payer: WPPA Medicare Advantage	$4.15

amitriptyline 25 mg Tab [HMC]

Facility

$6.42

Service Code	NDC 00904741061
Hospital Charge Code	3804271
Hospital Revenue Code	250
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.78
Rate for Payer: UnitedHealthcare Commercial	$6.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amitriptyline 25 mg Tab [HMC]

Facility

$6.42

Service Code	NDC 00904741061
Hospital Charge Code	3804271
Hospital Revenue Code	250
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$6.10
Rate for Payer: Aetna Commercial	$5.78
Rate for Payer: Humana Medicare Advantage	$2.70
Rate for Payer: UnitedHealthcare Commercial	$6.10
Rate for Payer: UnitedHealthcare Medicaid	$2.57
Rate for Payer: WPPA Medicare Advantage	$3.85

amitriptyline 25 mg Tab [HMC]

Facility

$6.55

Service Code	NDC 00904718461
Hospital Charge Code	3804271
Hospital Revenue Code	250
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$6.22
Rate for Payer: Aetna Commercial	$5.89
Rate for Payer: Humana Medicare Advantage	$2.75
Rate for Payer: UnitedHealthcare Commercial	$6.22
Rate for Payer: UnitedHealthcare Medicaid	$2.62
Rate for Payer: WPPA Medicare Advantage	$3.93

amitriptyline 25 mg Tab [HMC]

Facility

$6.55

Service Code	NDC 00904718461
Hospital Charge Code	3804271
Hospital Revenue Code	250
Min. Negotiated Rate	$5.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.89
Rate for Payer: UnitedHealthcare Commercial	$6.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amitriptyline 25 mg Tab [HMC]

Facility

$6.91

Service Code	NDC 00904020161
Hospital Charge Code	3804271
Hospital Revenue Code	250
Min. Negotiated Rate	$6.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.22
Rate for Payer: UnitedHealthcare Commercial	$6.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amLODIPine 5 mg Tab [HMC]

Facility

$9.93

Service Code	NDC 00904637061
Hospital Charge Code	3809370
Hospital Revenue Code	250
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$9.43
Rate for Payer: Aetna Commercial	$8.94
Rate for Payer: Humana Medicare Advantage	$4.17
Rate for Payer: UnitedHealthcare Commercial	$9.43
Rate for Payer: UnitedHealthcare Medicaid	$3.97
Rate for Payer: WPPA Medicare Advantage	$5.96

amLODIPine 5 mg Tab [HMC]

Facility

$9.93

Service Code	NDC 00904637061
Hospital Charge Code	3809370
Hospital Revenue Code	250
Min. Negotiated Rate	$8.94
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.94
Rate for Payer: UnitedHealthcare Commercial	$9.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amLODIPine 5 mg Tab [HMC]

Facility

$10.37

Service Code	NDC 67877019890
Hospital Charge Code	3809370
Hospital Revenue Code	250
Min. Negotiated Rate	$4.15
Max. Negotiated Rate	$9.85
Rate for Payer: Aetna Commercial	$9.33
Rate for Payer: Humana Medicare Advantage	$4.36
Rate for Payer: UnitedHealthcare Commercial	$9.85
Rate for Payer: UnitedHealthcare Medicaid	$4.15
Rate for Payer: WPPA Medicare Advantage	$6.22

Know your out-of-pocket cost for care.

All Charges