Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

NG Tube 18 FR Salem Sump

Facility

$8.37

Hospital Charge Code	3254450
Hospital Revenue Code	270
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

NG Tube 18 FR Salem Sump

Facility

$8.37

Hospital Charge Code	3254450
Hospital Revenue Code	270
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

NG Tube 6 FR Salem Sump

Facility

$24.53

Hospital Charge Code	3254451
Hospital Revenue Code	270
Min. Negotiated Rate	$22.08
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.08
Rate for Payer: UnitedHealthcare Commercial	$23.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NG Tube 6 FR Salem Sump

Facility

$24.53

Hospital Charge Code	3254451
Hospital Revenue Code	270
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$23.30
Rate for Payer: Aetna Commercial	$22.08
Rate for Payer: Humana Medicare Advantage	$10.30
Rate for Payer: UnitedHealthcare Commercial	$23.30
Rate for Payer: UnitedHealthcare Medicaid	$9.81
Rate for Payer: WPPA Medicare Advantage	$14.72

NG Tube 8 FR Salem Sump

Facility

$51.00

Hospital Charge Code	3254452
Hospital Revenue Code	270
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$48.45
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: Humana Medicare Advantage	$21.42
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: WPPA Medicare Advantage	$30.60

NG Tube 8 FR Salem Sump

Facility

$51.00

Hospital Charge Code	3254452
Hospital Revenue Code	270
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NG Tube Anti-Reflux Valve

Facility

$13.46

Hospital Charge Code	3254455
Hospital Revenue Code	270
Min. Negotiated Rate	$12.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.11
Rate for Payer: UnitedHealthcare Commercial	$12.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NG Tube Anti-Reflux Valve

Facility

$13.46

Hospital Charge Code	3254455
Hospital Revenue Code	270
Min. Negotiated Rate	$5.38
Max. Negotiated Rate	$12.79
Rate for Payer: Aetna Commercial	$12.11
Rate for Payer: Humana Medicare Advantage	$5.65
Rate for Payer: UnitedHealthcare Commercial	$12.79
Rate for Payer: UnitedHealthcare Medicaid	$5.38
Rate for Payer: WPPA Medicare Advantage	$8.08

niacin 250 mg Tab [HMC]

Facility

$5.11

Service Code	NDC 40985022849
Hospital Charge Code	3800152
Hospital Revenue Code	250
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$4.85
Rate for Payer: Aetna Commercial	$4.60
Rate for Payer: Humana Medicare Advantage	$2.15
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: UnitedHealthcare Medicaid	$2.04
Rate for Payer: WPPA Medicare Advantage	$3.07

niacin 250 mg Tab [HMC]

Facility

$5.11

Service Code	NDC 40985022849
Hospital Charge Code	3800152
Hospital Revenue Code	250
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.60
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

niacin 500 mg ER Tab [HMC]

Facility

$17.71

Service Code	NDC 59651001890
Hospital Charge Code	3800150
Hospital Revenue Code	250
Min. Negotiated Rate	$15.94
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.94
Rate for Payer: UnitedHealthcare Commercial	$16.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

niacin 500 mg ER Tab [HMC]

Facility

$18.04

Service Code	NDC 65162032109
Hospital Charge Code	3800150
Hospital Revenue Code	250
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$17.14
Rate for Payer: Aetna Commercial	$16.24
Rate for Payer: Humana Medicare Advantage	$7.58
Rate for Payer: UnitedHealthcare Commercial	$17.14
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: WPPA Medicare Advantage	$10.82

niacin 500 mg ER Tab [HMC]

Facility

$17.71

Service Code	NDC 59651001890
Hospital Charge Code	3800150
Hospital Revenue Code	250
Min. Negotiated Rate	$7.08
Max. Negotiated Rate	$16.82
Rate for Payer: Aetna Commercial	$15.94
Rate for Payer: Humana Medicare Advantage	$7.44
Rate for Payer: UnitedHealthcare Commercial	$16.82
Rate for Payer: UnitedHealthcare Medicaid	$7.08
Rate for Payer: WPPA Medicare Advantage	$10.63

niacin 500 mg ER Tab [HMC]

Facility

$18.04

Service Code	NDC 65162032109
Hospital Charge Code	3800150
Hospital Revenue Code	250
Min. Negotiated Rate	$16.24
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.24
Rate for Payer: UnitedHealthcare Commercial	$17.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

niCARdipine 2.5 mg/mL Inj Sol [HMC]

Facility

$54.40

Service Code	NDC 55150018311
Hospital Charge Code	3800257
Hospital Revenue Code	250
Min. Negotiated Rate	$21.76
Max. Negotiated Rate	$51.68
Rate for Payer: Aetna Commercial	$48.96
Rate for Payer: Humana Medicare Advantage	$22.85
Rate for Payer: UnitedHealthcare Commercial	$51.68
Rate for Payer: UnitedHealthcare Medicaid	$21.76
Rate for Payer: WPPA Medicare Advantage	$32.64

niCARdipine 2.5 mg/mL Inj Sol [HMC]

Facility

$56.26

Service Code	NDC 00143959310
Hospital Charge Code	3800257
Hospital Revenue Code	250
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$53.45
Rate for Payer: Aetna Commercial	$50.63
Rate for Payer: Humana Medicare Advantage	$23.63
Rate for Payer: UnitedHealthcare Commercial	$53.45
Rate for Payer: UnitedHealthcare Medicaid	$22.50
Rate for Payer: WPPA Medicare Advantage	$33.76

niCARdipine 2.5 mg/mL Inj Sol [HMC]

Facility

$54.40

Service Code	NDC 55150018311
Hospital Charge Code	3800257
Hospital Revenue Code	250
Min. Negotiated Rate	$48.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.96
Rate for Payer: UnitedHealthcare Commercial	$51.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

niCARdipine 2.5 mg/mL Inj Sol [HMC]

Facility

$56.26

Service Code	NDC 00143959310
Hospital Charge Code	3800257
Hospital Revenue Code	250
Min. Negotiated Rate	$50.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.63
Rate for Payer: UnitedHealthcare Commercial	$53.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

nicotine 14 mg/24 hr Transderm ER Film [HMC]

Facility

$11.43

Service Code	NDC 00536589588
Hospital Charge Code	3800774
Hospital Revenue Code	250
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$10.86
Rate for Payer: Aetna Commercial	$10.29
Rate for Payer: Humana Medicare Advantage	$4.80
Rate for Payer: UnitedHealthcare Commercial	$10.86
Rate for Payer: UnitedHealthcare Medicaid	$4.57
Rate for Payer: WPPA Medicare Advantage	$6.86

nicotine 14 mg/24 hr Transderm ER Film [HMC]

Facility

$11.43

Service Code	NDC 00536589588
Hospital Charge Code	3800774
Hospital Revenue Code	250
Min. Negotiated Rate	$10.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.29
Rate for Payer: UnitedHealthcare Commercial	$10.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

nicotine 14 mg/24 hr Transderm ER Film [HMC]

Facility

$19.72

Service Code	NDC 00135019502
Hospital Charge Code	3800774
Hospital Revenue Code	250
Min. Negotiated Rate	$17.75
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.75
Rate for Payer: UnitedHealthcare Commercial	$18.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

nicotine 14 mg/24 hr Transderm ER Film [HMC]

Facility

$19.72

Service Code	NDC 00135019502
Hospital Charge Code	3800774
Hospital Revenue Code	250
Min. Negotiated Rate	$7.89
Max. Negotiated Rate	$18.73
Rate for Payer: Aetna Commercial	$17.75
Rate for Payer: Humana Medicare Advantage	$8.28
Rate for Payer: UnitedHealthcare Commercial	$18.73
Rate for Payer: UnitedHealthcare Medicaid	$7.89
Rate for Payer: WPPA Medicare Advantage	$11.83

nicotine 21 mg/24 hr Transderm ER Film [HMC]

Facility

$11.43

Service Code	NDC 00536589688
Hospital Charge Code	3807796
Hospital Revenue Code	250
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$10.86
Rate for Payer: Aetna Commercial	$10.29
Rate for Payer: Humana Medicare Advantage	$4.80
Rate for Payer: UnitedHealthcare Commercial	$10.86
Rate for Payer: UnitedHealthcare Medicaid	$4.57
Rate for Payer: WPPA Medicare Advantage	$6.86

nicotine 21 mg/24 hr Transderm ER Film [HMC]

Facility

$12.71

Service Code	NDC 60505709000
Hospital Charge Code	3807796
Hospital Revenue Code	250
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$12.07
Rate for Payer: Aetna Commercial	$11.44
Rate for Payer: Humana Medicare Advantage	$5.34
Rate for Payer: UnitedHealthcare Commercial	$12.07
Rate for Payer: UnitedHealthcare Medicaid	$5.08
Rate for Payer: WPPA Medicare Advantage	$7.63

nicotine 21 mg/24 hr Transderm ER Film [HMC]

Facility

$11.43

Service Code	NDC 00536589688
Hospital Charge Code	3807796
Hospital Revenue Code	250
Min. Negotiated Rate	$10.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.29
Rate for Payer: UnitedHealthcare Commercial	$10.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges