Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

melatonin 3 mg Tab [HMC]

Facility

$6.18

Service Code	NDC 50268052415
Hospital Charge Code	3809585
Hospital Revenue Code	250
Min. Negotiated Rate	$5.56
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.56
Rate for Payer: UnitedHealthcare Commercial	$5.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

melatonin 3 mg Tab [HMC]

Facility

$6.18

Service Code	NDC 50268052415
Hospital Charge Code	3809585
Hospital Revenue Code	250
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$5.87
Rate for Payer: Aetna Commercial	$5.56
Rate for Payer: Humana Medicare Advantage	$2.60
Rate for Payer: UnitedHealthcare Commercial	$5.87
Rate for Payer: UnitedHealthcare Medicaid	$2.47
Rate for Payer: WPPA Medicare Advantage	$3.71

melatonin 5 mg Tab [HMC]

Facility

$5.15

Service Code	NDC 87701040814
Hospital Charge Code	3800264
Hospital Revenue Code	250
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$4.89
Rate for Payer: Aetna Commercial	$4.63
Rate for Payer: Humana Medicare Advantage	$2.16
Rate for Payer: UnitedHealthcare Commercial	$4.89
Rate for Payer: UnitedHealthcare Medicaid	$2.06
Rate for Payer: WPPA Medicare Advantage	$3.09

melatonin 5 mg Tab [HMC]

Facility

$5.77

Service Code	NDC 20555003901
Hospital Charge Code	3800264
Hospital Revenue Code	250
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$5.48
Rate for Payer: Aetna Commercial	$5.19
Rate for Payer: Humana Medicare Advantage	$2.42
Rate for Payer: UnitedHealthcare Commercial	$5.48
Rate for Payer: UnitedHealthcare Medicaid	$2.31
Rate for Payer: WPPA Medicare Advantage	$3.46

melatonin 5 mg Tab [HMC]

Facility

$5.15

Service Code	NDC 87701040814
Hospital Charge Code	3800264
Hospital Revenue Code	250
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.63
Rate for Payer: UnitedHealthcare Commercial	$4.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

melatonin 5 mg Tab [HMC]

Facility

$5.77

Service Code	NDC 20555003901
Hospital Charge Code	3800264
Hospital Revenue Code	250
Min. Negotiated Rate	$5.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.19
Rate for Payer: UnitedHealthcare Commercial	$5.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

meloxicam 7.5 mg Tab [HMC]

Facility

$14.29

Service Code	NDC 50268052515
Hospital Charge Code	3803596
Hospital Revenue Code	250
Min. Negotiated Rate	$12.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.86
Rate for Payer: UnitedHealthcare Commercial	$13.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

meloxicam 7.5 mg Tab [HMC]

Facility

$14.51

Service Code	NDC 68382005001
Hospital Charge Code	3803596
Hospital Revenue Code	250
Min. Negotiated Rate	$5.80
Max. Negotiated Rate	$13.78
Rate for Payer: Aetna Commercial	$13.06
Rate for Payer: Humana Medicare Advantage	$6.09
Rate for Payer: UnitedHealthcare Commercial	$13.78
Rate for Payer: UnitedHealthcare Medicaid	$5.80
Rate for Payer: WPPA Medicare Advantage	$8.71

meloxicam 7.5 mg Tab [HMC]

Facility

$14.29

Service Code	NDC 50268052515
Hospital Charge Code	3803596
Hospital Revenue Code	250
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$13.58
Rate for Payer: Aetna Commercial	$12.86
Rate for Payer: Humana Medicare Advantage	$6.00
Rate for Payer: UnitedHealthcare Commercial	$13.58
Rate for Payer: UnitedHealthcare Medicaid	$5.72
Rate for Payer: WPPA Medicare Advantage	$8.57

meloxicam 7.5 mg Tab [HMC]

Facility

$14.51

Service Code	NDC 68382005001
Hospital Charge Code	3803596
Hospital Revenue Code	250
Min. Negotiated Rate	$13.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.06
Rate for Payer: UnitedHealthcare Commercial	$13.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

memantine 10 mg Tab [HMC]

Facility

$27.24

Service Code	NDC 00456321063
Hospital Charge Code	3800605
Hospital Revenue Code	250
Min. Negotiated Rate	$10.90
Max. Negotiated Rate	$25.88
Rate for Payer: Aetna Commercial	$24.52
Rate for Payer: Humana Medicare Advantage	$11.44
Rate for Payer: UnitedHealthcare Commercial	$25.88
Rate for Payer: UnitedHealthcare Medicaid	$10.90
Rate for Payer: WPPA Medicare Advantage	$16.34

memantine 10 mg Tab [HMC]

Facility

$20.26

Service Code	NDC 68180023007
Hospital Charge Code	3800605
Hospital Revenue Code	250
Min. Negotiated Rate	$18.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.23
Rate for Payer: UnitedHealthcare Commercial	$19.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

memantine 10 mg Tab [HMC]

Facility

$6.62

Service Code	NDC 00904650606
Hospital Charge Code	3800605
Hospital Revenue Code	250
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.96
Rate for Payer: UnitedHealthcare Commercial	$6.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

memantine 10 mg Tab [HMC]

Facility

$6.62

Service Code	NDC 00904650606
Hospital Charge Code	3800605
Hospital Revenue Code	250
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$6.29
Rate for Payer: Aetna Commercial	$5.96
Rate for Payer: Humana Medicare Advantage	$2.78
Rate for Payer: UnitedHealthcare Commercial	$6.29
Rate for Payer: UnitedHealthcare Medicaid	$2.65
Rate for Payer: WPPA Medicare Advantage	$3.97

memantine 10 mg Tab [HMC]

Facility

$20.26

Service Code	NDC 68180023007
Hospital Charge Code	3800605
Hospital Revenue Code	250
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$19.25
Rate for Payer: Aetna Commercial	$18.23
Rate for Payer: Humana Medicare Advantage	$8.51
Rate for Payer: UnitedHealthcare Commercial	$19.25
Rate for Payer: UnitedHealthcare Medicaid	$8.10
Rate for Payer: WPPA Medicare Advantage	$12.16

memantine 10 mg Tab [HMC]

Facility

$27.24

Service Code	NDC 00456321063
Hospital Charge Code	3800605
Hospital Revenue Code	250
Min. Negotiated Rate	$24.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.52
Rate for Payer: UnitedHealthcare Commercial	$25.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

memantine 28 mg [HMC]

Facility

$35.53

Service Code	NDC 65162078503
Hospital Charge Code	3800216
Hospital Revenue Code	250
Min. Negotiated Rate	$14.21
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna Commercial	$31.98
Rate for Payer: Humana Medicare Advantage	$14.92
Rate for Payer: UnitedHealthcare Commercial	$33.75
Rate for Payer: UnitedHealthcare Medicaid	$14.21
Rate for Payer: WPPA Medicare Advantage	$21.32

memantine 28 mg [HMC]

Facility

$35.53

Service Code	NDC 65162078503
Hospital Charge Code	3800216
Hospital Revenue Code	250
Min. Negotiated Rate	$31.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.98
Rate for Payer: UnitedHealthcare Commercial	$33.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

memantine 7 mg [HMC]

Facility

$14.34

Service Code	NDC 00904673461
Hospital Charge Code	3800216
Hospital Revenue Code	250
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$13.62
Rate for Payer: Aetna Commercial	$12.91
Rate for Payer: Humana Medicare Advantage	$6.02
Rate for Payer: UnitedHealthcare Commercial	$13.62
Rate for Payer: UnitedHealthcare Medicaid	$5.74
Rate for Payer: WPPA Medicare Advantage	$8.60

memantine 7 mg [HMC]

Facility

$35.53

Service Code	NDC 65162078203
Hospital Charge Code	3800216
Hospital Revenue Code	250
Min. Negotiated Rate	$31.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.98
Rate for Payer: UnitedHealthcare Commercial	$33.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

memantine 7 mg [HMC]

Facility

$35.56

Service Code	NDC 70436005404
Hospital Charge Code	3800216
Hospital Revenue Code	250
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$32.00
Rate for Payer: UnitedHealthcare Commercial	$33.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

memantine 7 mg [HMC]

Facility

$35.56

Service Code	NDC 70436005404
Hospital Charge Code	3800216
Hospital Revenue Code	250
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$33.78
Rate for Payer: Aetna Commercial	$32.00
Rate for Payer: Humana Medicare Advantage	$14.94
Rate for Payer: UnitedHealthcare Commercial	$33.78
Rate for Payer: UnitedHealthcare Medicaid	$14.22
Rate for Payer: WPPA Medicare Advantage	$21.34

memantine 7 mg [HMC]

Facility

$14.34

Service Code	NDC 00904673461
Hospital Charge Code	3800216
Hospital Revenue Code	250
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.91
Rate for Payer: UnitedHealthcare Commercial	$13.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

memantine 7 mg [HMC]

Facility

$35.53

Service Code	NDC 65162078203
Hospital Charge Code	3800216
Hospital Revenue Code	250
Min. Negotiated Rate	$14.21
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna Commercial	$31.98
Rate for Payer: Humana Medicare Advantage	$14.92
Rate for Payer: UnitedHealthcare Commercial	$33.75
Rate for Payer: UnitedHealthcare Medicaid	$14.21
Rate for Payer: WPPA Medicare Advantage	$21.32

MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC

Facility

$2,827.53

Service Code	MSDRG 760
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,827.53
Rate for Payer: UnitedHealthcare Medicaid	$2,827.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges