Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

metoprolol tartrate 25 mg Tab [HMC]

Facility

$5.73

Service Code	NDC 51079025520
Hospital Charge Code	3805081
Hospital Revenue Code	250
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.16
Rate for Payer: UnitedHealthcare Commercial	$5.44
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metoprolol tartrate 25 mg Tab [HMC]

Facility

$5.73

Service Code	NDC 62332011231
Hospital Charge Code	3805081
Hospital Revenue Code	250
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.16
Rate for Payer: UnitedHealthcare Commercial	$5.44
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metoprolol tartrate 25 mg Tab [HMC]

Facility

$5.73

Service Code	NDC 62332011231
Hospital Charge Code	3805081
Hospital Revenue Code	250
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$5.44
Rate for Payer: Aetna Commercial	$5.16
Rate for Payer: Humana Medicare Advantage	$2.41
Rate for Payer: UnitedHealthcare Commercial	$5.44
Rate for Payer: UnitedHealthcare Medicaid	$2.29
Rate for Payer: WPPA Medicare Advantage	$3.44

metoprolol tartrate 25 mg Tab [HMC]

Facility

$5.73

Service Code	NDC 51079025520
Hospital Charge Code	3805081
Hospital Revenue Code	250
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$5.44
Rate for Payer: Aetna Commercial	$5.16
Rate for Payer: Humana Medicare Advantage	$2.41
Rate for Payer: UnitedHealthcare Commercial	$5.44
Rate for Payer: UnitedHealthcare Medicaid	$2.29
Rate for Payer: WPPA Medicare Advantage	$3.44

metoprolol tartrate 50 mg Tab [HMC]

Facility

$5.38

Service Code	NDC 00904711861
Hospital Charge Code	3802630
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$5.11
Rate for Payer: Aetna Commercial	$4.84
Rate for Payer: Humana Medicare Advantage	$2.26
Rate for Payer: UnitedHealthcare Commercial	$5.11
Rate for Payer: UnitedHealthcare Medicaid	$2.15
Rate for Payer: WPPA Medicare Advantage	$3.23

metoprolol tartrate 50 mg Tab [HMC]

Facility

$6.72

Service Code	NDC 51079080120
Hospital Charge Code	3802630
Hospital Revenue Code	250
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.05
Rate for Payer: UnitedHealthcare Commercial	$6.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metoprolol tartrate 50 mg Tab [HMC]

Facility

$5.38

Service Code	NDC 00904711861
Hospital Charge Code	3802630
Hospital Revenue Code	250
Min. Negotiated Rate	$4.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.84
Rate for Payer: UnitedHealthcare Commercial	$5.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metoprolol tartrate 50 mg Tab [HMC]

Facility

$6.72

Service Code	NDC 51079080120
Hospital Charge Code	3802630
Hospital Revenue Code	250
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$6.38
Rate for Payer: Aetna Commercial	$6.05
Rate for Payer: Humana Medicare Advantage	$2.82
Rate for Payer: UnitedHealthcare Commercial	$6.38
Rate for Payer: UnitedHealthcare Medicaid	$2.69
Rate for Payer: WPPA Medicare Advantage	$4.03

metroNIDAZOLE 1 EA Tab

Facility

$35.08

Service Code	NDC 00904712661
Hospital Charge Code	3802155
Hospital Revenue Code	250
Min. Negotiated Rate	$14.03
Max. Negotiated Rate	$33.33
Rate for Payer: Aetna Commercial	$31.57
Rate for Payer: Humana Medicare Advantage	$14.73
Rate for Payer: UnitedHealthcare Commercial	$33.33
Rate for Payer: UnitedHealthcare Medicaid	$14.03
Rate for Payer: WPPA Medicare Advantage	$21.05

metroNIDAZOLE 1 EA Tab

Facility

$35.08

Service Code	NDC 00904712661
Hospital Charge Code	3802155
Hospital Revenue Code	250
Min. Negotiated Rate	$31.57
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.57
Rate for Payer: UnitedHealthcare Commercial	$33.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metroNIDAZOLE 250 mg Tab [HMC]

Facility

$6.43

Service Code	NDC 50268053415
Hospital Charge Code	3805337
Hospital Revenue Code	250
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$6.11
Rate for Payer: Aetna Commercial	$5.79
Rate for Payer: Humana Medicare Advantage	$2.70
Rate for Payer: UnitedHealthcare Commercial	$6.11
Rate for Payer: UnitedHealthcare Medicaid	$2.57
Rate for Payer: WPPA Medicare Advantage	$3.86

metroNIDAZOLE 250 mg Tab [HMC]

Facility

$6.43

Service Code	NDC 50268053415
Hospital Charge Code	3805337
Hospital Revenue Code	250
Min. Negotiated Rate	$5.79
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.79
Rate for Payer: UnitedHealthcare Commercial	$6.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metroNIDAZOLE 250 mg Tab [HMC]

Facility

$6.73

Service Code	NDC 00904145361
Hospital Charge Code	3805337
Hospital Revenue Code	250
Min. Negotiated Rate	$6.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.06
Rate for Payer: UnitedHealthcare Commercial	$6.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metroNIDAZOLE 250 mg Tab [HMC]

Facility

$6.73

Service Code	NDC 00904145361
Hospital Charge Code	3805337
Hospital Revenue Code	250
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$6.39
Rate for Payer: Aetna Commercial	$6.06
Rate for Payer: Humana Medicare Advantage	$2.83
Rate for Payer: UnitedHealthcare Commercial	$6.39
Rate for Payer: UnitedHealthcare Medicaid	$2.69
Rate for Payer: WPPA Medicare Advantage	$4.04

metroNIDAZOLE 500 mg/100 mL IV Sol [HMC]

Facility

$28.75

Service Code	HCPCS J1836
Hospital Charge Code	3806380
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$27.31
Rate for Payer: Aetna Commercial	$25.88
Rate for Payer: Aetna Commercial	$28.00
Rate for Payer: Aetna Commercial	$23.87
Rate for Payer: Aetna Commercial	$24.90
Rate for Payer: Humana Medicare Advantage	$11.14
Rate for Payer: Humana Medicare Advantage	$12.07
Rate for Payer: Humana Medicare Advantage	$13.07
Rate for Payer: Humana Medicare Advantage	$11.62
Rate for Payer: UnitedHealthcare Commercial	$25.19
Rate for Payer: UnitedHealthcare Commercial	$26.29
Rate for Payer: UnitedHealthcare Commercial	$27.31
Rate for Payer: UnitedHealthcare Commercial	$29.55
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: WPPA Medicare Advantage	$17.25
Rate for Payer: WPPA Medicare Advantage	$16.60
Rate for Payer: WPPA Medicare Advantage	$15.91
Rate for Payer: WPPA Medicare Advantage	$18.67

metroNIDAZOLE 500 mg/100 mL IV Sol [HMC]

Facility

$27.67

Service Code	HCPCS J1836
Hospital Charge Code	3806380
Hospital Revenue Code	250
Min. Negotiated Rate	$24.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.90
Rate for Payer: Aetna Commercial	$23.87
Rate for Payer: Aetna Commercial	$25.88
Rate for Payer: Aetna Commercial	$28.00
Rate for Payer: UnitedHealthcare Commercial	$26.29
Rate for Payer: UnitedHealthcare Commercial	$29.55
Rate for Payer: UnitedHealthcare Commercial	$27.31
Rate for Payer: UnitedHealthcare Commercial	$25.19
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
Rate for Payer: WPPA Medicare Advantage	$1,200.00

metroNIDAZOLE 500 mg Tab [HMC]

Facility

$7.53

Service Code	NDC 00904712661
Hospital Charge Code	3805338
Hospital Revenue Code	250
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$7.15
Rate for Payer: Aetna Commercial	$6.78
Rate for Payer: Humana Medicare Advantage	$3.16
Rate for Payer: UnitedHealthcare Commercial	$7.15
Rate for Payer: UnitedHealthcare Medicaid	$3.01
Rate for Payer: WPPA Medicare Advantage	$4.52

metroNIDAZOLE 500 mg Tab [HMC]

Facility

$7.53

Service Code	NDC 00904712661
Hospital Charge Code	3805338
Hospital Revenue Code	250
Min. Negotiated Rate	$6.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.78
Rate for Payer: UnitedHealthcare Commercial	$7.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mexiletine 150 mg Cap [HMC]

Facility

$12.61

Service Code	NDC 00093873901
Hospital Charge Code	3809685
Hospital Revenue Code	250
Min. Negotiated Rate	$11.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.35
Rate for Payer: UnitedHealthcare Commercial	$11.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mexiletine 150 mg Cap [HMC]

Facility

$12.61

Service Code	NDC 50742023901
Hospital Charge Code	3809685
Hospital Revenue Code	250
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$11.98
Rate for Payer: Aetna Commercial	$11.35
Rate for Payer: Humana Medicare Advantage	$5.30
Rate for Payer: UnitedHealthcare Commercial	$11.98
Rate for Payer: UnitedHealthcare Medicaid	$5.04
Rate for Payer: WPPA Medicare Advantage	$7.57

mexiletine 150 mg Cap [HMC]

Facility

$12.61

Service Code	NDC 50742023901
Hospital Charge Code	3809685
Hospital Revenue Code	250
Min. Negotiated Rate	$11.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.35
Rate for Payer: UnitedHealthcare Commercial	$11.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mexiletine 150 mg Cap [HMC]

Facility

$12.61

Service Code	NDC 00093873901
Hospital Charge Code	3809685
Hospital Revenue Code	250
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$11.98
Rate for Payer: Aetna Commercial	$11.35
Rate for Payer: Humana Medicare Advantage	$5.30
Rate for Payer: UnitedHealthcare Commercial	$11.98
Rate for Payer: UnitedHealthcare Medicaid	$5.04
Rate for Payer: WPPA Medicare Advantage	$7.57

MG Breast Tissue Specimen

Facility

$310.00

Service Code	HCPCS 76098 TC
Hospital Charge Code	3716098
Hospital Revenue Code	401
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$294.50
Rate for Payer: Aetna Commercial	$279.00
Rate for Payer: Humana Medicare Advantage	$130.20
Rate for Payer: UnitedHealthcare Commercial	$294.50
Rate for Payer: UnitedHealthcare Medicaid	$282.26
Rate for Payer: WPPA Medicare Advantage	$186.00

MG Breast Tissue Specimen

Facility

$310.00

Service Code	HCPCS 76098 TC
Hospital Charge Code	3716098
Hospital Revenue Code	401
Min. Negotiated Rate	$279.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$279.00
Rate for Payer: UnitedHealthcare Commercial	$294.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Diagnostic Bilateral w/ Tomo

Facility

$102.00

Service Code	HCPCS 77062 TC
Hospital Charge Code	3717062
Hospital Revenue Code	401
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges