Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Thoracentesis Tubing 30inch

Facility

$16.00

Hospital Charge Code	3257156
Hospital Revenue Code	270
Min. Negotiated Rate	$6.40
Max. Negotiated Rate	$15.20
Rate for Payer: Aetna Commercial	$14.40
Rate for Payer: Humana Medicare Advantage	$6.72
Rate for Payer: UnitedHealthcare Commercial	$15.20
Rate for Payer: UnitedHealthcare Medicaid	$6.40
Rate for Payer: WPPA Medicare Advantage	$9.60

Thora-Para Non-Valved Catheter Tray 5 Fr Thoracentesis/Paracentesis Drainage Full Kit

Facility

$122.19

Hospital Charge Code	3252158
Hospital Revenue Code	270
Min. Negotiated Rate	$48.88
Max. Negotiated Rate	$116.08
Rate for Payer: Aetna Commercial	$109.97
Rate for Payer: Humana Medicare Advantage	$51.32
Rate for Payer: UnitedHealthcare Commercial	$116.08
Rate for Payer: UnitedHealthcare Medicaid	$48.88
Rate for Payer: WPPA Medicare Advantage	$73.31

Thora-Para Non-Valved Catheter Tray 5 Fr Thoracentesis/Paracentesis Drainage Full Kit

Facility

$122.19

Hospital Charge Code	3252158
Hospital Revenue Code	270
Min. Negotiated Rate	$109.97
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$109.97
Rate for Payer: UnitedHealthcare Commercial	$116.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Acetaminophen-Codine 300 mg/30 mg (6 tabs) [HMC]

Facility

$31.51

Service Code	NDC 00093015001
Hospital Charge Code	3804438
Hospital Revenue Code	253
Min. Negotiated Rate	$28.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.36
Rate for Payer: UnitedHealthcare Commercial	$29.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Acetaminophen-Codine 300 mg/30 mg (6 tabs) [HMC]

Facility

$31.51

Service Code	NDC 00093015001
Hospital Charge Code	3804438
Hospital Revenue Code	253
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$29.93
Rate for Payer: Aetna Commercial	$28.36
Rate for Payer: Humana Medicare Advantage	$13.23
Rate for Payer: UnitedHealthcare Commercial	$29.93
Rate for Payer: UnitedHealthcare Medicaid	$12.60
Rate for Payer: WPPA Medicare Advantage	$18.91

THP Albuterol 0.083% 2.5 mg-3 mL Neb Soln ( 5 EA) [HMC]

Facility

$31.63

Service Code	NDC 76204020025
Hospital Charge Code	3809042
Hospital Revenue Code	253
Min. Negotiated Rate	$28.47
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.47
Rate for Payer: UnitedHealthcare Commercial	$30.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Albuterol 0.083% 2.5 mg-3 mL Neb Soln ( 5 EA) [HMC]

Facility

$31.63

Service Code	NDC 76204020025
Hospital Charge Code	3809042
Hospital Revenue Code	253
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$30.05
Rate for Payer: Aetna Commercial	$28.47
Rate for Payer: Humana Medicare Advantage	$13.28
Rate for Payer: UnitedHealthcare Commercial	$30.05
Rate for Payer: UnitedHealthcare Medicaid	$12.65
Rate for Payer: WPPA Medicare Advantage	$18.98

THP Alprazolam 0.25mg (4 tab) [HMC]

Facility

$32.92

Service Code	NDC 59762371901
Hospital Charge Code	3809163
Hospital Revenue Code	253
Min. Negotiated Rate	$13.17
Max. Negotiated Rate	$31.27
Rate for Payer: Aetna Commercial	$29.63
Rate for Payer: Humana Medicare Advantage	$13.83
Rate for Payer: UnitedHealthcare Commercial	$31.27
Rate for Payer: UnitedHealthcare Medicaid	$13.17
Rate for Payer: WPPA Medicare Advantage	$19.75

THP Alprazolam 0.25mg (4 tab) [HMC]

Facility

$32.92

Service Code	NDC 59762371901
Hospital Charge Code	3809163
Hospital Revenue Code	253
Min. Negotiated Rate	$29.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.63
Rate for Payer: UnitedHealthcare Commercial	$31.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Amoxicillin 250 mg (4 Tab) [HMC]

Facility

$28.15

Service Code	NDC 00093310793
Hospital Charge Code	3801590
Hospital Revenue Code	253
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.34
Rate for Payer: UnitedHealthcare Commercial	$26.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Amoxicillin 250 mg (4 Tab) [HMC]

Facility

$28.15

Service Code	NDC 00093310793
Hospital Charge Code	3801590
Hospital Revenue Code	253
Min. Negotiated Rate	$11.26
Max. Negotiated Rate	$26.74
Rate for Payer: Aetna Commercial	$25.34
Rate for Payer: Humana Medicare Advantage	$11.82
Rate for Payer: UnitedHealthcare Commercial	$26.74
Rate for Payer: UnitedHealthcare Medicaid	$11.26
Rate for Payer: WPPA Medicare Advantage	$16.89

THP Amoxicillin 400 mg/5ml 100 ml oral sol [HMC]

Facility

$49.53

Service Code	NDC 65862007101
Hospital Charge Code	3800140
Hospital Revenue Code	253
Min. Negotiated Rate	$44.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$44.58
Rate for Payer: UnitedHealthcare Commercial	$47.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Amoxicillin 400 mg/5ml 100 ml oral sol [HMC]

Facility

$49.53

Service Code	NDC 65862007101
Hospital Charge Code	3800140
Hospital Revenue Code	253
Min. Negotiated Rate	$19.81
Max. Negotiated Rate	$47.05
Rate for Payer: Aetna Commercial	$44.58
Rate for Payer: Humana Medicare Advantage	$20.80
Rate for Payer: UnitedHealthcare Commercial	$47.05
Rate for Payer: UnitedHealthcare Medicaid	$19.81
Rate for Payer: WPPA Medicare Advantage	$29.72

THP Amoxicillin 400 mg-5 mL Oral Susp 100 mL [HMC]

Facility

$49.53

Service Code	NDC 00093416173
Hospital Charge Code	3800140
Hospital Revenue Code	253
Min. Negotiated Rate	$44.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$44.58
Rate for Payer: UnitedHealthcare Commercial	$47.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Amoxicillin 400 mg-5 mL Oral Susp 100 mL [HMC]

Facility

$49.53

Service Code	NDC 00143988701
Hospital Charge Code	3800140
Hospital Revenue Code	253
Min. Negotiated Rate	$44.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$44.58
Rate for Payer: UnitedHealthcare Commercial	$47.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Amoxicillin 400 mg-5 mL Oral Susp 100 mL [HMC]

Facility

$49.53

Service Code	NDC 00093416173
Hospital Charge Code	3800140
Hospital Revenue Code	253
Min. Negotiated Rate	$19.81
Max. Negotiated Rate	$47.05
Rate for Payer: Aetna Commercial	$44.58
Rate for Payer: Humana Medicare Advantage	$20.80
Rate for Payer: UnitedHealthcare Commercial	$47.05
Rate for Payer: UnitedHealthcare Medicaid	$19.81
Rate for Payer: WPPA Medicare Advantage	$29.72

THP Amoxicillin 400 mg-5 mL Oral Susp 100 mL [HMC]

Facility

$49.53

Service Code	NDC 00143988701
Hospital Charge Code	3800140
Hospital Revenue Code	253
Min. Negotiated Rate	$19.81
Max. Negotiated Rate	$47.05
Rate for Payer: Aetna Commercial	$44.58
Rate for Payer: Humana Medicare Advantage	$20.80
Rate for Payer: UnitedHealthcare Commercial	$47.05
Rate for Payer: UnitedHealthcare Medicaid	$19.81
Rate for Payer: WPPA Medicare Advantage	$29.72

THP Amoxicillin-Clavulanate 400 mg-57 mg-5 mL Oral Susp 50 mL [HMC]

Facility

$60.15

Service Code	NDC 66685101200
Hospital Charge Code	3809510
Hospital Revenue Code	253
Min. Negotiated Rate	$24.06
Max. Negotiated Rate	$57.14
Rate for Payer: Aetna Commercial	$54.13
Rate for Payer: Humana Medicare Advantage	$25.26
Rate for Payer: UnitedHealthcare Commercial	$57.14
Rate for Payer: UnitedHealthcare Medicaid	$24.06
Rate for Payer: WPPA Medicare Advantage	$36.09

THP Amoxicillin-Clavulanate 400 mg-57 mg-5 mL Oral Susp 50 mL [HMC]

Facility

$60.15

Service Code	NDC 66685101200
Hospital Charge Code	3809510
Hospital Revenue Code	253
Min. Negotiated Rate	$54.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.13
Rate for Payer: UnitedHealthcare Commercial	$57.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Amoxicillin-Clavulanate 875 mg/125 mg (4 Tab) [HMC]

Facility

$45.20

Service Code	NDC 00781185220
Hospital Charge Code	3809544
Hospital Revenue Code	253
Min. Negotiated Rate	$40.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.68
Rate for Payer: UnitedHealthcare Commercial	$42.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Amoxicillin-Clavulanate 875 mg/125 mg (4 Tab) [HMC]

Facility

$45.20

Service Code	NDC 00781185220
Hospital Charge Code	3809544
Hospital Revenue Code	253
Min. Negotiated Rate	$18.08
Max. Negotiated Rate	$42.94
Rate for Payer: Aetna Commercial	$40.68
Rate for Payer: Humana Medicare Advantage	$18.98
Rate for Payer: UnitedHealthcare Commercial	$42.94
Rate for Payer: UnitedHealthcare Medicaid	$18.08
Rate for Payer: WPPA Medicare Advantage	$27.12

THP Azithromycin 200 mg-5 mL Oral Susp 15 mL [HMC]

Facility

$59.80

Service Code	NDC 59762312001
Hospital Charge Code	3803414
Hospital Revenue Code	253
Min. Negotiated Rate	$23.92
Max. Negotiated Rate	$56.81
Rate for Payer: Aetna Commercial	$53.82
Rate for Payer: Humana Medicare Advantage	$25.12
Rate for Payer: UnitedHealthcare Commercial	$56.81
Rate for Payer: UnitedHealthcare Medicaid	$23.92
Rate for Payer: WPPA Medicare Advantage	$35.88

THP Azithromycin 200 mg-5 mL Oral Susp 15 mL [HMC]

Facility

$59.80

Service Code	NDC 59762312001
Hospital Charge Code	3803414
Hospital Revenue Code	253
Min. Negotiated Rate	$53.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$53.82
Rate for Payer: UnitedHealthcare Commercial	$56.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Azithromycin 250 mg (6 Tab) [HMC]

Facility

$26.44

Service Code	NDC 00781808926
Hospital Charge Code	3806778
Hospital Revenue Code	253
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.80
Rate for Payer: UnitedHealthcare Commercial	$25.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Azithromycin 250 mg (6 Tab) [HMC]

Facility

$71.65

Service Code	NDC 51224002230
Hospital Charge Code	3806778
Hospital Revenue Code	253
Min. Negotiated Rate	$28.66
Max. Negotiated Rate	$68.07
Rate for Payer: Aetna Commercial	$64.48
Rate for Payer: Humana Medicare Advantage	$30.09
Rate for Payer: UnitedHealthcare Commercial	$68.07
Rate for Payer: UnitedHealthcare Medicaid	$28.66
Rate for Payer: WPPA Medicare Advantage	$42.99

Know your out-of-pocket cost for care.

All Charges