Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

isosorbide dinitrate 10 mg Tab [HMC]

Facility

$10.76

Service Code	NDC 00904215161
Hospital Charge Code	3802003
Hospital Revenue Code	250
Min. Negotiated Rate	$9.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.68
Rate for Payer: UnitedHealthcare Commercial	$10.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

isosorbide dinitrate 10 mg Tab [HMC]

Facility

$7.29

Service Code	NDC 00904661961
Hospital Charge Code	3802003
Hospital Revenue Code	250
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$6.93
Rate for Payer: Aetna Commercial	$6.56
Rate for Payer: Humana Medicare Advantage	$3.06
Rate for Payer: UnitedHealthcare Commercial	$6.93
Rate for Payer: UnitedHealthcare Medicaid	$2.92
Rate for Payer: WPPA Medicare Advantage	$4.37

isosorbide mononitrate 30 mg ER Tab [HMC]

Facility

$10.03

Service Code	NDC 68084043501
Hospital Charge Code	3806382
Hospital Revenue Code	250
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.03
Rate for Payer: UnitedHealthcare Commercial	$9.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

isosorbide mononitrate 30 mg ER Tab [HMC]

Facility

$10.03

Service Code	NDC 68084043501
Hospital Charge Code	3806382
Hospital Revenue Code	250
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$9.53
Rate for Payer: Aetna Commercial	$9.03
Rate for Payer: Humana Medicare Advantage	$4.21
Rate for Payer: UnitedHealthcare Commercial	$9.53
Rate for Payer: UnitedHealthcare Medicaid	$4.01
Rate for Payer: WPPA Medicare Advantage	$6.02

isosorbide mononitrate 30 mg ER Tab [HMC]

Facility

$9.98

Service Code	NDC 00904644961
Hospital Charge Code	3806382
Hospital Revenue Code	250
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.98
Rate for Payer: UnitedHealthcare Commercial	$9.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

isosorbide mononitrate 30 mg ER Tab [HMC]

Facility

$9.98

Service Code	NDC 00904644961
Hospital Charge Code	3806382
Hospital Revenue Code	250
Min. Negotiated Rate	$3.99
Max. Negotiated Rate	$9.48
Rate for Payer: Aetna Commercial	$8.98
Rate for Payer: Humana Medicare Advantage	$4.19
Rate for Payer: UnitedHealthcare Commercial	$9.48
Rate for Payer: UnitedHealthcare Medicaid	$3.99
Rate for Payer: WPPA Medicare Advantage	$5.99

isosorbide mononitrate 30 mg Tab

Facility

$8.18

Service Code	NDC 50742017505
Hospital Charge Code	3806382
Hospital Revenue Code	250
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$7.77
Rate for Payer: Aetna Commercial	$7.36
Rate for Payer: Humana Medicare Advantage	$3.44
Rate for Payer: UnitedHealthcare Commercial	$7.77
Rate for Payer: UnitedHealthcare Medicaid	$3.27
Rate for Payer: WPPA Medicare Advantage	$4.91

isosorbide mononitrate 30 mg Tab

Facility

$8.18

Service Code	NDC 50742017505
Hospital Charge Code	3806382
Hospital Revenue Code	250
Min. Negotiated Rate	$7.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.36
Rate for Payer: UnitedHealthcare Commercial	$7.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

isosorbide mononitrate 60 mg ER Tab [HMC]

Facility

$11.08

Service Code	NDC 00904645061
Hospital Charge Code	3802267
Hospital Revenue Code	250
Min. Negotiated Rate	$4.43
Max. Negotiated Rate	$10.53
Rate for Payer: Aetna Commercial	$9.97
Rate for Payer: Humana Medicare Advantage	$4.65
Rate for Payer: UnitedHealthcare Commercial	$10.53
Rate for Payer: UnitedHealthcare Medicaid	$4.43
Rate for Payer: WPPA Medicare Advantage	$6.65

isosorbide mononitrate 60 mg ER Tab [HMC]

Facility

$11.17

Service Code	NDC 68084043601
Hospital Charge Code	3802267
Hospital Revenue Code	250
Min. Negotiated Rate	$10.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.05
Rate for Payer: UnitedHealthcare Commercial	$10.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

isosorbide mononitrate 60 mg ER Tab [HMC]

Facility

$11.08

Service Code	NDC 00904645061
Hospital Charge Code	3802267
Hospital Revenue Code	250
Min. Negotiated Rate	$9.97
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.97
Rate for Payer: UnitedHealthcare Commercial	$10.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

isosorbide mononitrate 60 mg ER Tab [HMC]

Facility

$11.17

Service Code	NDC 68084043601
Hospital Charge Code	3802267
Hospital Revenue Code	250
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$10.61
Rate for Payer: Aetna Commercial	$10.05
Rate for Payer: Humana Medicare Advantage	$4.69
Rate for Payer: UnitedHealthcare Commercial	$10.61
Rate for Payer: UnitedHealthcare Medicaid	$4.47
Rate for Payer: WPPA Medicare Advantage	$6.70

i-Stat Troponin

Facility

$226.00

Service Code	HCPCS 84484
Hospital Charge Code	3554484
Hospital Revenue Code	300
Min. Negotiated Rate	$12.47
Max. Negotiated Rate	$214.70
Rate for Payer: Aetna Commercial	$203.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$68.59
Rate for Payer: Humana Medicare Advantage	$94.92
Rate for Payer: UnitedHealthcare Commercial	$214.70
Rate for Payer: UnitedHealthcare Medicaid	$12.47
Rate for Payer: WPPA Medicare Advantage	$135.60

i-Stat Troponin

Facility

$226.00

Service Code	HCPCS 84484
Hospital Charge Code	3554484
Hospital Revenue Code	300
Min. Negotiated Rate	$203.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$203.40
Rate for Payer: UnitedHealthcare Commercial	$214.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IUD Kyleena

Facility

$1,519.00

Hospital Charge Code	3254620
Hospital Revenue Code	270
Min. Negotiated Rate	$607.60
Max. Negotiated Rate	$1,443.05
Rate for Payer: Aetna Commercial	$1,367.10
Rate for Payer: Humana Medicare Advantage	$637.98
Rate for Payer: UnitedHealthcare Commercial	$1,443.05
Rate for Payer: UnitedHealthcare Medicaid	$607.60
Rate for Payer: WPPA Medicare Advantage	$911.40

IUD Kyleena

Facility

$1,519.00

Hospital Charge Code	3254620
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,443.05
Rate for Payer: Aetna Commercial	$1,367.10
Rate for Payer: UnitedHealthcare Commercial	$1,443.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IUD Liletta

Facility

$1,863.46

Hospital Charge Code	3259146
Hospital Revenue Code	270
Min. Negotiated Rate	$745.38
Max. Negotiated Rate	$1,770.29
Rate for Payer: Aetna Commercial	$1,677.11
Rate for Payer: Humana Medicare Advantage	$782.65
Rate for Payer: UnitedHealthcare Commercial	$1,770.29
Rate for Payer: UnitedHealthcare Medicaid	$745.38
Rate for Payer: WPPA Medicare Advantage	$1,118.08

IUD Liletta

Facility

$1,863.46

Hospital Charge Code	3259146
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,770.29
Rate for Payer: Aetna Commercial	$1,677.11
Rate for Payer: UnitedHealthcare Commercial	$1,770.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IUD Mirena

Facility

$666.80

Hospital Charge Code	3259147
Hospital Revenue Code	270
Min. Negotiated Rate	$266.72
Max. Negotiated Rate	$633.46
Rate for Payer: Aetna Commercial	$600.12
Rate for Payer: Humana Medicare Advantage	$280.06
Rate for Payer: UnitedHealthcare Commercial	$633.46
Rate for Payer: UnitedHealthcare Medicaid	$266.72
Rate for Payer: WPPA Medicare Advantage	$400.08

IUD Mirena

Facility

$666.80

Hospital Charge Code	3259147
Hospital Revenue Code	270
Min. Negotiated Rate	$600.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$600.12
Rate for Payer: UnitedHealthcare Commercial	$633.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IUD Nexplanon

Facility

$1,102.42

Hospital Charge Code	3251084
Hospital Revenue Code	270
Min. Negotiated Rate	$440.97
Max. Negotiated Rate	$1,047.30
Rate for Payer: Aetna Commercial	$992.18
Rate for Payer: Humana Medicare Advantage	$463.02
Rate for Payer: UnitedHealthcare Commercial	$1,047.30
Rate for Payer: UnitedHealthcare Medicaid	$440.97
Rate for Payer: WPPA Medicare Advantage	$661.45

IUD Nexplanon

Facility

$1,102.42

Hospital Charge Code	3251084
Hospital Revenue Code	270
Min. Negotiated Rate	$992.18
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$992.18
Rate for Payer: UnitedHealthcare Commercial	$1,047.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IUD Paragard

Facility

$783.00

Hospital Charge Code	3251433
Hospital Revenue Code	270
Min. Negotiated Rate	$313.20
Max. Negotiated Rate	$743.85
Rate for Payer: Aetna Commercial	$704.70
Rate for Payer: Humana Medicare Advantage	$328.86
Rate for Payer: UnitedHealthcare Commercial	$743.85
Rate for Payer: UnitedHealthcare Medicaid	$313.20
Rate for Payer: WPPA Medicare Advantage	$469.80

IUD Paragard

Facility

$783.00

Hospital Charge Code	3251433
Hospital Revenue Code	270
Min. Negotiated Rate	$704.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$704.70
Rate for Payer: UnitedHealthcare Commercial	$743.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IUD Skyla

Facility

$1,218.00

Hospital Charge Code	3254619
Hospital Revenue Code	270
Min. Negotiated Rate	$487.20
Max. Negotiated Rate	$1,157.10
Rate for Payer: Aetna Commercial	$1,096.20
Rate for Payer: Humana Medicare Advantage	$511.56
Rate for Payer: UnitedHealthcare Commercial	$1,157.10
Rate for Payer: UnitedHealthcare Medicaid	$487.20
Rate for Payer: WPPA Medicare Advantage	$730.80

Know your out-of-pocket cost for care.

All Charges