Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

SUFentanil 50 mcg/mL IV Sol [HMC]

Facility

$40.59

Service Code	NDC 00409338221
Hospital Charge Code	3170440
Hospital Revenue Code	250
Min. Negotiated Rate	$16.24
Max. Negotiated Rate	$38.56
Rate for Payer: Aetna Commercial	$36.53
Rate for Payer: Humana Medicare Advantage	$17.05
Rate for Payer: UnitedHealthcare Commercial	$38.56
Rate for Payer: UnitedHealthcare Medicaid	$16.24
Rate for Payer: WPPA Medicare Advantage	$24.35

sugammadex 100 mg/mL [HMC]

Facility

$253.39

Service Code	NDC 00006542312
Hospital Charge Code	3800418
Hospital Revenue Code	250
Min. Negotiated Rate	$101.36
Max. Negotiated Rate	$240.72
Rate for Payer: Aetna Commercial	$228.05
Rate for Payer: Humana Medicare Advantage	$106.42
Rate for Payer: UnitedHealthcare Commercial	$240.72
Rate for Payer: UnitedHealthcare Medicaid	$101.36
Rate for Payer: WPPA Medicare Advantage	$152.03

sugammadex 100 mg/mL [HMC]

Facility

$253.39

Service Code	NDC 00006542312
Hospital Charge Code	3800418
Hospital Revenue Code	250
Min. Negotiated Rate	$228.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$228.05
Rate for Payer: UnitedHealthcare Commercial	$240.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [HMC]

Facility

$12.27

Service Code	NDC 49999064930
Hospital Charge Code	3807340
Hospital Revenue Code	250
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$11.66
Rate for Payer: Aetna Commercial	$11.04
Rate for Payer: Humana Medicare Advantage	$5.15
Rate for Payer: UnitedHealthcare Commercial	$11.66
Rate for Payer: UnitedHealthcare Medicaid	$4.91
Rate for Payer: WPPA Medicare Advantage	$7.36

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [HMC]

Facility

$6.12

Service Code	NDC 00904272561
Hospital Charge Code	3807340
Hospital Revenue Code	250
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.51
Rate for Payer: UnitedHealthcare Commercial	$5.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [HMC]

Facility

$12.27

Service Code	NDC 49999064930
Hospital Charge Code	3807340
Hospital Revenue Code	250
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.04
Rate for Payer: UnitedHealthcare Commercial	$11.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [HMC]

Facility

$6.12

Service Code	NDC 00904272561
Hospital Charge Code	3807340
Hospital Revenue Code	250
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$5.81
Rate for Payer: Aetna Commercial	$5.51
Rate for Payer: Humana Medicare Advantage	$2.57
Rate for Payer: UnitedHealthcare Commercial	$5.81
Rate for Payer: UnitedHealthcare Medicaid	$2.45
Rate for Payer: WPPA Medicare Advantage	$3.67

sulfaSALAzine 500 mg Tab [HMC]

Facility

$6.67

Service Code	NDC 50268073015
Hospital Charge Code	3807085
Hospital Revenue Code	250
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$6.34
Rate for Payer: Aetna Commercial	$6.00
Rate for Payer: Humana Medicare Advantage	$2.80
Rate for Payer: UnitedHealthcare Commercial	$6.34
Rate for Payer: UnitedHealthcare Medicaid	$2.67
Rate for Payer: WPPA Medicare Advantage	$4.00

sulfaSALAzine 500 mg Tab [HMC]

Facility

$5.73

Service Code	NDC 59762500005
Hospital Charge Code	3807085
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

sulfaSALAzine 500 mg Tab [HMC]

Facility

$5.73

Service Code	NDC 59762500005
Hospital Charge Code	3807085
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

sulfaSALAzine 500 mg Tab [HMC]

Facility

$6.67

Service Code	NDC 50268073015
Hospital Charge Code	3807085
Hospital Revenue Code	250
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.00
Rate for Payer: UnitedHealthcare Commercial	$6.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SUMAtriptan 50 mg Tab [HMC]

Facility

$30.14

Service Code	NDC 65862014736
Hospital Charge Code	3801897
Hospital Revenue Code	250
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$28.63
Rate for Payer: Aetna Commercial	$27.13
Rate for Payer: Humana Medicare Advantage	$12.66
Rate for Payer: UnitedHealthcare Commercial	$28.63
Rate for Payer: UnitedHealthcare Medicaid	$12.06
Rate for Payer: WPPA Medicare Advantage	$18.08

SUMAtriptan 50 mg Tab [HMC]

Facility

$30.14

Service Code	NDC 62756052169
Hospital Charge Code	3801897
Hospital Revenue Code	250
Min. Negotiated Rate	$27.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.13
Rate for Payer: UnitedHealthcare Commercial	$28.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SUMAtriptan 50 mg Tab [HMC]

Facility

$30.14

Service Code	NDC 65862014736
Hospital Charge Code	3801897
Hospital Revenue Code	250
Min. Negotiated Rate	$27.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.13
Rate for Payer: UnitedHealthcare Commercial	$28.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SUMAtriptan 50 mg Tab [HMC]

Facility

$30.14

Service Code	NDC 62756052169
Hospital Charge Code	3801897
Hospital Revenue Code	250
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$28.63
Rate for Payer: Aetna Commercial	$27.13
Rate for Payer: Humana Medicare Advantage	$12.66
Rate for Payer: UnitedHealthcare Commercial	$28.63
Rate for Payer: UnitedHealthcare Medicaid	$12.06
Rate for Payer: WPPA Medicare Advantage	$18.08

SUMAtriptan 50 mg Tab [HMC]

Facility

$30.14

Service Code	NDC 63304009819
Hospital Charge Code	3801897
Hospital Revenue Code	250
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$28.63
Rate for Payer: Aetna Commercial	$27.13
Rate for Payer: Humana Medicare Advantage	$12.66
Rate for Payer: UnitedHealthcare Commercial	$28.63
Rate for Payer: UnitedHealthcare Medicaid	$12.06
Rate for Payer: WPPA Medicare Advantage	$18.08

SUMAtriptan 50 mg Tab [HMC]

Facility

$30.14

Service Code	NDC 63304009819
Hospital Charge Code	3801897
Hospital Revenue Code	250
Min. Negotiated Rate	$27.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.13
Rate for Payer: UnitedHealthcare Commercial	$28.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SUMAtriptan 5 mg Nasal Spry [HMC]

Facility

$66.50

Service Code	NDC 66993008169
Hospital Charge Code	3800376
Hospital Revenue Code	250
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$63.17
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Humana Medicare Advantage	$27.93
Rate for Payer: UnitedHealthcare Commercial	$63.17
Rate for Payer: UnitedHealthcare Medicaid	$26.60
Rate for Payer: WPPA Medicare Advantage	$39.90

SUMAtriptan 5 mg Nasal Spry [HMC]

Facility

$43.89

Service Code	NDC 00781652406
Hospital Charge Code	3800376
Hospital Revenue Code	250
Min. Negotiated Rate	$17.56
Max. Negotiated Rate	$41.70
Rate for Payer: Aetna Commercial	$39.50
Rate for Payer: Humana Medicare Advantage	$18.43
Rate for Payer: UnitedHealthcare Commercial	$41.70
Rate for Payer: UnitedHealthcare Medicaid	$17.56
Rate for Payer: WPPA Medicare Advantage	$26.33

SUMAtriptan 5 mg Nasal Spry [HMC]

Facility

$43.89

Service Code	NDC 00781652406
Hospital Charge Code	3800376
Hospital Revenue Code	250
Min. Negotiated Rate	$39.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.50
Rate for Payer: UnitedHealthcare Commercial	$41.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SUMAtriptan 5 mg Nasal Spry [HMC]

Facility

$66.50

Service Code	NDC 66993008169
Hospital Charge Code	3800376
Hospital Revenue Code	250
Min. Negotiated Rate	$59.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: UnitedHealthcare Commercial	$63.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SUMAtriptan 6 mg/0.5 mL SubQ Sol [HMC]

Facility

$111.88

Service Code	HCPCS J3030
Hospital Charge Code	3808389
Hospital Revenue Code	250
Min. Negotiated Rate	$37.00
Max. Negotiated Rate	$106.29
Rate for Payer: Aetna Commercial	$100.69
Rate for Payer: Aetna Commercial	$41.76
Rate for Payer: Aetna Commercial	$132.75
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$93.26
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$93.26
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$93.26
Rate for Payer: Humana Medicare Advantage	$19.49
Rate for Payer: Humana Medicare Advantage	$46.99
Rate for Payer: Humana Medicare Advantage	$61.95
Rate for Payer: UnitedHealthcare Commercial	$106.29
Rate for Payer: UnitedHealthcare Commercial	$140.12
Rate for Payer: UnitedHealthcare Commercial	$44.08
Rate for Payer: UnitedHealthcare Medicaid	$37.00
Rate for Payer: UnitedHealthcare Medicaid	$37.00
Rate for Payer: UnitedHealthcare Medicaid	$37.00
Rate for Payer: WPPA Medicare Advantage	$67.13
Rate for Payer: WPPA Medicare Advantage	$27.84
Rate for Payer: WPPA Medicare Advantage	$88.50

SUMAtriptan 6 mg/0.5 mL SubQ Sol [HMC]

Facility

$46.40

Service Code	HCPCS J3030
Hospital Charge Code	3808389
Hospital Revenue Code	250
Min. Negotiated Rate	$41.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.76
Rate for Payer: Aetna Commercial	$100.69
Rate for Payer: Aetna Commercial	$132.75
Rate for Payer: UnitedHealthcare Commercial	$44.08
Rate for Payer: UnitedHealthcare Commercial	$140.12
Rate for Payer: UnitedHealthcare Commercial	$106.29
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

Surgical Clipper Blade General Purpose

Facility

$8.91

Hospital Charge Code	3259293
Hospital Revenue Code	270
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$8.46
Rate for Payer: Aetna Commercial	$8.02
Rate for Payer: Humana Medicare Advantage	$3.74
Rate for Payer: UnitedHealthcare Commercial	$8.46
Rate for Payer: UnitedHealthcare Medicaid	$3.56
Rate for Payer: WPPA Medicare Advantage	$5.35

Surgical Clipper Blade General Purpose

Facility

$8.91

Hospital Charge Code	3259293
Hospital Revenue Code	270
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.02
Rate for Payer: UnitedHealthcare Commercial	$8.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges