Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

Facility

$11.40

Service Code	NDC 43598044874
Hospital Charge Code	3807796
Hospital Revenue Code	250
Min. Negotiated Rate	$10.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.26
Rate for Payer: UnitedHealthcare Commercial	$10.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

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	$11.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.44
Rate for Payer: UnitedHealthcare Commercial	$12.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

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

Facility

$11.40

Service Code	NDC 43598044874
Hospital Charge Code	3807796
Hospital Revenue Code	250
Min. Negotiated Rate	$4.56
Max. Negotiated Rate	$10.83
Rate for Payer: Aetna Commercial	$10.26
Rate for Payer: Humana Medicare Advantage	$4.79
Rate for Payer: UnitedHealthcare Commercial	$10.83
Rate for Payer: UnitedHealthcare Medicaid	$4.56
Rate for Payer: WPPA Medicare Advantage	$6.84

nicotine 7 mg/24 hr Transderm ER Film [HMC]

Facility

$12.17

Service Code	NDC 00536589453
Hospital Charge Code	3807978
Hospital Revenue Code	250
Min. Negotiated Rate	$10.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.95
Rate for Payer: UnitedHealthcare Commercial	$11.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

nicotine 7 mg/24 hr Transderm ER Film [HMC]

Facility

$12.17

Service Code	NDC 00536589453
Hospital Charge Code	3807978
Hospital Revenue Code	250
Min. Negotiated Rate	$4.87
Max. Negotiated Rate	$11.56
Rate for Payer: Aetna Commercial	$10.95
Rate for Payer: Humana Medicare Advantage	$5.11
Rate for Payer: UnitedHealthcare Commercial	$11.56
Rate for Payer: UnitedHealthcare Medicaid	$4.87
Rate for Payer: WPPA Medicare Advantage	$7.30

nicotine 7 mg/24 hr Transderm ER Film [HMC]

Facility

$11.43

Service Code	NDC 00536589488
Hospital Charge Code	3807978
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 7 mg/24 hr Transderm ER Film [HMC]

Facility

$11.43

Service Code	NDC 00536589488
Hospital Charge Code	3807978
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 and Cotinine, S/P QST

Facility

$150.00

Service Code	HCPCS 80323
Hospital Charge Code	3550323
Hospital Revenue Code	300
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$135.00
Rate for Payer: UnitedHealthcare Commercial	$142.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Nicotine and Cotinine, S/P QST

Facility

$150.00

Service Code	HCPCS 80323
Hospital Charge Code	3550323
Hospital Revenue Code	300
Min. Negotiated Rate	$11.86
Max. Negotiated Rate	$142.50
Rate for Payer: Aetna Commercial	$135.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.06
Rate for Payer: Humana Medicare Advantage	$63.00
Rate for Payer: UnitedHealthcare Commercial	$142.50
Rate for Payer: UnitedHealthcare Medicaid	$11.86
Rate for Payer: WPPA Medicare Advantage	$90.00

NIFEdipine 10 mg Cap [HMC]

Facility

$8.88

Service Code	NDC 00904722961
Hospital Charge Code	3806409
Hospital Revenue Code	250
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$8.44
Rate for Payer: Aetna Commercial	$7.99
Rate for Payer: Humana Medicare Advantage	$3.73
Rate for Payer: UnitedHealthcare Commercial	$8.44
Rate for Payer: UnitedHealthcare Medicaid	$3.55
Rate for Payer: WPPA Medicare Advantage	$5.33

NIFEdipine 10 mg Cap [HMC]

Facility

$8.88

Service Code	NDC 00904722961
Hospital Charge Code	3806409
Hospital Revenue Code	250
Min. Negotiated Rate	$7.99
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.99
Rate for Payer: UnitedHealthcare Commercial	$8.44
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NIFEdipine 10 mg Cap [HMC]

Facility

$6.38

Service Code	NDC 23155019401
Hospital Charge Code	3806409
Hospital Revenue Code	250
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.74
Rate for Payer: UnitedHealthcare Commercial	$6.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NIFEdipine 10 mg Cap [HMC]

Facility

$8.21

Service Code	NDC 00228249710
Hospital Charge Code	3806409
Hospital Revenue Code	250
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$7.80
Rate for Payer: Aetna Commercial	$7.39
Rate for Payer: Humana Medicare Advantage	$3.45
Rate for Payer: UnitedHealthcare Commercial	$7.80
Rate for Payer: UnitedHealthcare Medicaid	$3.28
Rate for Payer: WPPA Medicare Advantage	$4.93

NIFEdipine 10 mg Cap [HMC]

Facility

$6.38

Service Code	NDC 23155019401
Hospital Charge Code	3806409
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$6.06
Rate for Payer: Aetna Commercial	$5.74
Rate for Payer: Humana Medicare Advantage	$2.68
Rate for Payer: UnitedHealthcare Commercial	$6.06
Rate for Payer: UnitedHealthcare Medicaid	$2.55
Rate for Payer: WPPA Medicare Advantage	$3.83

NIFEdipine 10 mg Cap [HMC]

Facility

$8.21

Service Code	NDC 00228249710
Hospital Charge Code	3806409
Hospital Revenue Code	250
Min. Negotiated Rate	$7.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.39
Rate for Payer: UnitedHealthcare Commercial	$7.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NIFEdipine 30 mg ER Tab [HMC]

Facility

$8.94

Service Code	NDC 50268059715
Hospital Charge Code	3804172
Hospital Revenue Code	250
Min. Negotiated Rate	$8.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.05
Rate for Payer: UnitedHealthcare Commercial	$8.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NIFEdipine 30 mg ER Tab [HMC]

Facility

$8.46

Service Code	NDC 00904720806
Hospital Charge Code	3804172
Hospital Revenue Code	250
Min. Negotiated Rate	$7.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NIFEdipine 30 mg ER Tab [HMC]

Facility

$8.46

Service Code	NDC 00904720806
Hospital Charge Code	3804172
Hospital Revenue Code	250
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$8.04
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: Humana Medicare Advantage	$3.55
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: UnitedHealthcare Medicaid	$3.38
Rate for Payer: WPPA Medicare Advantage	$5.08

NIFEdipine 30 mg ER Tab [HMC]

Facility

$8.94

Service Code	NDC 50268059715
Hospital Charge Code	3804172
Hospital Revenue Code	250
Min. Negotiated Rate	$3.58
Max. Negotiated Rate	$8.49
Rate for Payer: Aetna Commercial	$8.05
Rate for Payer: Humana Medicare Advantage	$3.75
Rate for Payer: UnitedHealthcare Commercial	$8.49
Rate for Payer: UnitedHealthcare Medicaid	$3.58
Rate for Payer: WPPA Medicare Advantage	$5.36

Night Splint Alimed Classic Medium

Facility

$99.92

Service Code	HCPCS l4396
Hospital Charge Code	3251846
Hospital Revenue Code	270
Min. Negotiated Rate	$39.97
Max. Negotiated Rate	$94.92
Rate for Payer: Aetna Commercial	$89.93
Rate for Payer: Humana Medicare Advantage	$41.97
Rate for Payer: UnitedHealthcare Commercial	$94.92
Rate for Payer: UnitedHealthcare Medicaid	$39.97
Rate for Payer: WPPA Medicare Advantage	$59.95

Night Splint Alimed Classic Medium

Facility

$99.92

Service Code	HCPCS l4396
Hospital Charge Code	3251846
Hospital Revenue Code	270
Min. Negotiated Rate	$89.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$89.93
Rate for Payer: UnitedHealthcare Commercial	$94.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Night Splint Pro-Tec Foot Large

Facility

$129.00

Hospital Charge Code	3251843
Hospital Revenue Code	270
Min. Negotiated Rate	$51.60
Max. Negotiated Rate	$122.55
Rate for Payer: Aetna Commercial	$116.10
Rate for Payer: Humana Medicare Advantage	$54.18
Rate for Payer: UnitedHealthcare Commercial	$122.55
Rate for Payer: UnitedHealthcare Medicaid	$51.60
Rate for Payer: WPPA Medicare Advantage	$77.40

Night Splint Pro-Tec Foot Large

Facility

$129.00

Hospital Charge Code	3251843
Hospital Revenue Code	270
Min. Negotiated Rate	$116.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$116.10
Rate for Payer: UnitedHealthcare Commercial	$122.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Night Splint Pro-Tec Foot Small

Facility

$129.00

Hospital Charge Code	3251841
Hospital Revenue Code	270
Min. Negotiated Rate	$51.60
Max. Negotiated Rate	$122.55
Rate for Payer: Aetna Commercial	$116.10
Rate for Payer: Humana Medicare Advantage	$54.18
Rate for Payer: UnitedHealthcare Commercial	$122.55
Rate for Payer: UnitedHealthcare Medicaid	$51.60
Rate for Payer: WPPA Medicare Advantage	$77.40

Night Splint Pro-Tec Foot Small

Facility

$129.00

Hospital Charge Code	3251841
Hospital Revenue Code	270
Min. Negotiated Rate	$116.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$116.10
Rate for Payer: UnitedHealthcare Commercial	$122.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges