Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

silver nitrate Top Stick [HMC]

Facility

$131.04

Service Code	NDC 12870000101
Hospital Charge Code	3803761
Hospital Revenue Code	250
Min. Negotiated Rate	$117.94
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$117.94
Rate for Payer: UnitedHealthcare Commercial	$124.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00

silver nitrate Top Stick [HMC]

Facility

$131.04

Service Code	NDC 12870000101
Hospital Charge Code	3803761
Hospital Revenue Code	250
Min. Negotiated Rate	$52.42
Max. Negotiated Rate	$124.49
Rate for Payer: Aetna Commercial	$117.94
Rate for Payer: Humana Medicare Advantage	$55.04
Rate for Payer: UnitedHealthcare Commercial	$124.49
Rate for Payer: UnitedHealthcare Medicaid	$52.42
Rate for Payer: WPPA Medicare Advantage	$78.62

silver sulfADIAZINE Top 1% Crm 400 g[HMC]

Facility

$105.85

Service Code	NDC 43598021040
Hospital Charge Code	3807480
Hospital Revenue Code	250
Min. Negotiated Rate	$95.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$95.27
Rate for Payer: UnitedHealthcare Commercial	$100.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

silver sulfADIAZINE Top 1% Crm 400 g[HMC]

Facility

$105.85

Service Code	NDC 43598021040
Hospital Charge Code	3807480
Hospital Revenue Code	250
Min. Negotiated Rate	$42.34
Max. Negotiated Rate	$100.56
Rate for Payer: Aetna Commercial	$95.27
Rate for Payer: Humana Medicare Advantage	$44.46
Rate for Payer: UnitedHealthcare Commercial	$100.56
Rate for Payer: UnitedHealthcare Medicaid	$42.34
Rate for Payer: WPPA Medicare Advantage	$63.51

silver sulfADIAZINE Top 1% Crm 85 g [HMC]

Facility

$56.79

Service Code	NDC 67877012485
Hospital Charge Code	3807464
Hospital Revenue Code	250
Min. Negotiated Rate	$51.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.11
Rate for Payer: UnitedHealthcare Commercial	$53.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

silver sulfADIAZINE Top 1% Crm 85 g [HMC]

Facility

$55.73

Service Code	NDC 43598021085
Hospital Charge Code	3807464
Hospital Revenue Code	250
Min. Negotiated Rate	$22.29
Max. Negotiated Rate	$52.94
Rate for Payer: Aetna Commercial	$50.16
Rate for Payer: Humana Medicare Advantage	$23.41
Rate for Payer: UnitedHealthcare Commercial	$52.94
Rate for Payer: UnitedHealthcare Medicaid	$22.29
Rate for Payer: WPPA Medicare Advantage	$33.44

silver sulfADIAZINE Top 1% Crm 85 g [HMC]

Facility

$55.73

Service Code	NDC 43598021085
Hospital Charge Code	3807464
Hospital Revenue Code	250
Min. Negotiated Rate	$50.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.16
Rate for Payer: UnitedHealthcare Commercial	$52.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

silver sulfADIAZINE Top 1% Crm 85 g [HMC]

Facility

$56.79

Service Code	NDC 67877012485
Hospital Charge Code	3807464
Hospital Revenue Code	250
Min. Negotiated Rate	$22.72
Max. Negotiated Rate	$53.95
Rate for Payer: Aetna Commercial	$51.11
Rate for Payer: Humana Medicare Advantage	$23.85
Rate for Payer: UnitedHealthcare Commercial	$53.95
Rate for Payer: UnitedHealthcare Medicaid	$22.72
Rate for Payer: WPPA Medicare Advantage	$34.07

simethicone 20 mg/0.3 mL Sus [HMC]

Facility

$10.07

Service Code	NDC 00904589430
Hospital Charge Code	3807100
Hospital Revenue Code	250
Min. Negotiated Rate	$9.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.06
Rate for Payer: UnitedHealthcare Commercial	$9.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

simethicone 20 mg/0.3 mL Sus [HMC]

Facility

$10.07

Service Code	NDC 00904589430
Hospital Charge Code	3807100
Hospital Revenue Code	250
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$9.57
Rate for Payer: Aetna Commercial	$9.06
Rate for Payer: Humana Medicare Advantage	$4.23
Rate for Payer: UnitedHealthcare Commercial	$9.57
Rate for Payer: UnitedHealthcare Medicaid	$4.03
Rate for Payer: WPPA Medicare Advantage	$6.04

simethicone 40 mg/0.6 mL Liq 30ml [HMC]

Facility

$20.10

Service Code	NDC 00536130375
Hospital Charge Code	3807100
Hospital Revenue Code	250
Min. Negotiated Rate	$8.04
Max. Negotiated Rate	$19.09
Rate for Payer: Aetna Commercial	$18.09
Rate for Payer: Humana Medicare Advantage	$8.44
Rate for Payer: UnitedHealthcare Commercial	$19.09
Rate for Payer: UnitedHealthcare Medicaid	$8.04
Rate for Payer: WPPA Medicare Advantage	$12.06

simethicone 40 mg/0.6 mL Liq 30ml [HMC]

Facility

$20.10

Service Code	NDC 00536130375
Hospital Charge Code	3807100
Hospital Revenue Code	250
Min. Negotiated Rate	$18.09
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.09
Rate for Payer: UnitedHealthcare Commercial	$19.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

simethicone 80 mg Chew Tab [HMC]

Facility

$5.13

Service Code	NDC 00904506860
Hospital Charge Code	3806947
Hospital Revenue Code	250
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$4.87
Rate for Payer: Aetna Commercial	$4.62
Rate for Payer: Humana Medicare Advantage	$2.15
Rate for Payer: UnitedHealthcare Commercial	$4.87
Rate for Payer: UnitedHealthcare Medicaid	$2.05
Rate for Payer: WPPA Medicare Advantage	$3.08

simethicone 80 mg Chew Tab [HMC]

Facility

$5.13

Service Code	NDC 00904506860
Hospital Charge Code	3806947
Hospital Revenue Code	250
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.62
Rate for Payer: UnitedHealthcare Commercial	$4.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

simethicone 80 mg Chew Tab [HMC]

Facility

$5.71

Service Code	NDC 77333081210
Hospital Charge Code	3806947
Hospital Revenue Code	250
Min. Negotiated Rate	$5.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.14
Rate for Payer: UnitedHealthcare Commercial	$5.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

simethicone 80 mg Chew Tab [HMC]

Facility

$5.71

Service Code	NDC 77333081210
Hospital Charge Code	3806947
Hospital Revenue Code	250
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$5.42
Rate for Payer: Aetna Commercial	$5.14
Rate for Payer: Humana Medicare Advantage	$2.40
Rate for Payer: UnitedHealthcare Commercial	$5.42
Rate for Payer: UnitedHealthcare Medicaid	$2.28
Rate for Payer: WPPA Medicare Advantage	$3.43

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$4,193.64

Service Code	MSDRG 194
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,193.64
Rate for Payer: UnitedHealthcare Medicaid	$4,193.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$4,574.88

Service Code	MSDRG 193
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,574.88
Rate for Payer: UnitedHealthcare Medicaid	$4,574.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$3,558.24

Service Code	MSDRG 195
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,558.24
Rate for Payer: UnitedHealthcare Medicaid	$3,558.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$14,804.82

Service Code	MSDRG 008
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,804.82
Rate for Payer: UnitedHealthcare Medicaid	$14,804.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS

Facility

$18,839.61

Service Code	MSDRG 019
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$18,839.61
Rate for Payer: UnitedHealthcare Medicaid	$18,839.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

simvastatin 10 mg Tab [HMC]

Facility

$13.37

Service Code	NDC 68084051101
Hospital Charge Code	3808232
Hospital Revenue Code	250
Min. Negotiated Rate	$12.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.03
Rate for Payer: UnitedHealthcare Commercial	$12.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

simvastatin 10 mg Tab [HMC]

Facility

$5.54

Service Code	NDC 63739057110
Hospital Charge Code	3808232
Hospital Revenue Code	250
Min. Negotiated Rate	$4.99
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.99
Rate for Payer: UnitedHealthcare Commercial	$5.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

simvastatin 10 mg Tab [HMC]

Facility

$13.37

Service Code	NDC 68084051101
Hospital Charge Code	3808232
Hospital Revenue Code	250
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$12.70
Rate for Payer: Aetna Commercial	$12.03
Rate for Payer: Humana Medicare Advantage	$5.62
Rate for Payer: UnitedHealthcare Commercial	$12.70
Rate for Payer: UnitedHealthcare Medicaid	$5.35
Rate for Payer: WPPA Medicare Advantage	$8.02

simvastatin 10 mg Tab [HMC]

Facility

$5.54

Service Code	NDC 63739057110
Hospital Charge Code	3808232
Hospital Revenue Code	250
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$5.26
Rate for Payer: Aetna Commercial	$4.99
Rate for Payer: Humana Medicare Advantage	$2.33
Rate for Payer: UnitedHealthcare Commercial	$5.26
Rate for Payer: UnitedHealthcare Medicaid	$2.22
Rate for Payer: WPPA Medicare Advantage	$3.32

Know your out-of-pocket cost for care.

All Charges