Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

THP Dexamethasone 4 mg (6 Tab) [HMC]

Facility

$43.05

Service Code	NDC 00054817525
Hospital Charge Code	3800861
Hospital Revenue Code	253
Min. Negotiated Rate	$38.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.74
Rate for Payer: UnitedHealthcare Commercial	$40.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Doxycycline 100 mg (4 Tab) [HMC]

Facility

$47.35

Service Code	NDC 62584069321
Hospital Charge Code	3807753
Hospital Revenue Code	253
Min. Negotiated Rate	$42.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.62
Rate for Payer: UnitedHealthcare Commercial	$44.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Doxycycline 100 mg (4 Tab) [HMC]

Facility

$47.35

Service Code	NDC 62584069321
Hospital Charge Code	3807753
Hospital Revenue Code	253
Min. Negotiated Rate	$18.94
Max. Negotiated Rate	$44.98
Rate for Payer: Aetna Commercial	$42.62
Rate for Payer: Humana Medicare Advantage	$19.89
Rate for Payer: UnitedHealthcare Commercial	$44.98
Rate for Payer: UnitedHealthcare Medicaid	$18.94
Rate for Payer: WPPA Medicare Advantage	$28.41

THP Furosemide 20 mg (4 Tab) [HMC]

Facility

$27.04

Service Code	NDC 68084001401
Hospital Charge Code	3805419
Hospital Revenue Code	253
Min. Negotiated Rate	$10.82
Max. Negotiated Rate	$25.69
Rate for Payer: Aetna Commercial	$24.34
Rate for Payer: Humana Medicare Advantage	$11.36
Rate for Payer: UnitedHealthcare Commercial	$25.69
Rate for Payer: UnitedHealthcare Medicaid	$10.82
Rate for Payer: WPPA Medicare Advantage	$16.22

THP Furosemide 20 mg (4 Tab) [HMC]

Facility

$27.04

Service Code	NDC 68084001401
Hospital Charge Code	3805419
Hospital Revenue Code	253
Min. Negotiated Rate	$24.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.34
Rate for Payer: UnitedHealthcare Commercial	$25.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Hydrocodone-Acetaminophen 5 mg-325 mg (6 Tab) [HMC]

Facility

$39.31

Service Code	NDC 00406012362
Hospital Charge Code	3802150
Hospital Revenue Code	253
Min. Negotiated Rate	$15.72
Max. Negotiated Rate	$37.34
Rate for Payer: Aetna Commercial	$35.38
Rate for Payer: Humana Medicare Advantage	$16.51
Rate for Payer: UnitedHealthcare Commercial	$37.34
Rate for Payer: UnitedHealthcare Medicaid	$15.72
Rate for Payer: WPPA Medicare Advantage	$23.59

THP Hydrocodone-Acetaminophen 5 mg-325 mg (6 Tab) [HMC]

Facility

$39.31

Service Code	NDC 00406012362
Hospital Charge Code	3802150
Hospital Revenue Code	253
Min. Negotiated Rate	$35.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.38
Rate for Payer: UnitedHealthcare Commercial	$37.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Hydroxyzine 25 mg (4 Tab) [HMC]

Facility

$35.95

Service Code	NDC 00093506101
Hospital Charge Code	3807571
Hospital Revenue Code	253
Min. Negotiated Rate	$14.38
Max. Negotiated Rate	$34.15
Rate for Payer: Aetna Commercial	$32.35
Rate for Payer: Humana Medicare Advantage	$15.10
Rate for Payer: UnitedHealthcare Commercial	$34.15
Rate for Payer: UnitedHealthcare Medicaid	$14.38
Rate for Payer: WPPA Medicare Advantage	$21.57

THP Hydroxyzine 25 mg (4 Tab) [HMC]

Facility

$35.95

Service Code	NDC 00093506101
Hospital Charge Code	3807571
Hospital Revenue Code	253
Min. Negotiated Rate	$32.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$32.35
Rate for Payer: UnitedHealthcare Commercial	$34.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Ipratropium-Albuterol 0.5 mg-3 mg-3 mL Inh Soln (5 EA) [HMC]

Facility

$28.00

Service Code	NDC 00487020101
Hospital Charge Code	3800531
Hospital Revenue Code	253
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: UnitedHealthcare Commercial	$26.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Ipratropium-Albuterol 0.5 mg-3 mg-3 mL Inh Soln (5 EA) [HMC]

Facility

$28.00

Service Code	NDC 00487020101
Hospital Charge Code	3800531
Hospital Revenue Code	253
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$26.60
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Humana Medicare Advantage	$11.76
Rate for Payer: UnitedHealthcare Commercial	$26.60
Rate for Payer: UnitedHealthcare Medicaid	$11.20
Rate for Payer: WPPA Medicare Advantage	$16.80

THP Levalbuterol Inh Soln 1.25 mg-3 mL (5 EA) [HMC]

Facility

$47.30

Service Code	NDC 66993002327
Hospital Charge Code	3808426
Hospital Revenue Code	253
Min. Negotiated Rate	$18.92
Max. Negotiated Rate	$44.94
Rate for Payer: Aetna Commercial	$42.57
Rate for Payer: Humana Medicare Advantage	$19.87
Rate for Payer: UnitedHealthcare Commercial	$44.94
Rate for Payer: UnitedHealthcare Medicaid	$18.92
Rate for Payer: WPPA Medicare Advantage	$28.38

THP Levalbuterol Inh Soln 1.25 mg-3 mL (5 EA) [HMC]

Facility

$47.30

Service Code	NDC 66993002327
Hospital Charge Code	3808426
Hospital Revenue Code	253
Min. Negotiated Rate	$42.57
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.57
Rate for Payer: UnitedHealthcare Commercial	$44.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Levetiracetam 500 mg (4 Tab) [HMC]

Facility

$50.30

Service Code	NDC 00904605261
Hospital Charge Code	3800330
Hospital Revenue Code	253
Min. Negotiated Rate	$45.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.27
Rate for Payer: UnitedHealthcare Commercial	$47.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Levetiracetam 500 mg (4 Tab) [HMC]

Facility

$50.30

Service Code	NDC 00904605261
Hospital Charge Code	3800330
Hospital Revenue Code	253
Min. Negotiated Rate	$20.12
Max. Negotiated Rate	$47.78
Rate for Payer: Aetna Commercial	$45.27
Rate for Payer: Humana Medicare Advantage	$21.13
Rate for Payer: UnitedHealthcare Commercial	$47.78
Rate for Payer: UnitedHealthcare Medicaid	$20.12
Rate for Payer: WPPA Medicare Advantage	$30.18

THP Levofloxacin 500 mg (4 Tab) [HMC]

Facility

$102.06

Service Code	NDC 65862053750
Hospital Charge Code	3805498
Hospital Revenue Code	253
Min. Negotiated Rate	$91.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.85
Rate for Payer: UnitedHealthcare Commercial	$96.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Levofloxacin 500 mg (4 Tab) [HMC]

Facility

$102.06

Service Code	NDC 65862053750
Hospital Charge Code	3805498
Hospital Revenue Code	253
Min. Negotiated Rate	$40.82
Max. Negotiated Rate	$96.96
Rate for Payer: Aetna Commercial	$91.85
Rate for Payer: Humana Medicare Advantage	$42.87
Rate for Payer: UnitedHealthcare Commercial	$96.96
Rate for Payer: UnitedHealthcare Medicaid	$40.82
Rate for Payer: WPPA Medicare Advantage	$61.24

THP Lorazepam 0.5 mg (4 Tab) [HMC]

Facility

$32.71

Service Code	NDC 00591024001
Hospital Charge Code	3802168
Hospital Revenue Code	253
Min. Negotiated Rate	$29.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.44
Rate for Payer: UnitedHealthcare Commercial	$31.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Lorazepam 0.5 mg (4 Tab) [HMC]

Facility

$32.71

Service Code	NDC 00591024001
Hospital Charge Code	3802168
Hospital Revenue Code	253
Min. Negotiated Rate	$13.08
Max. Negotiated Rate	$31.07
Rate for Payer: Aetna Commercial	$29.44
Rate for Payer: Humana Medicare Advantage	$13.74
Rate for Payer: UnitedHealthcare Commercial	$31.07
Rate for Payer: UnitedHealthcare Medicaid	$13.08
Rate for Payer: WPPA Medicare Advantage	$19.63

THP Meclizine 25 mg (4 Tab) [HMC]

Facility

$35.29

Service Code	NDC 51079009020
Hospital Charge Code	3809037
Hospital Revenue Code	253
Min. Negotiated Rate	$31.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.76
Rate for Payer: UnitedHealthcare Commercial	$33.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Meclizine 25 mg (4 Tab) [HMC]

Facility

$35.29

Service Code	NDC 51079009020
Hospital Charge Code	3809037
Hospital Revenue Code	253
Min. Negotiated Rate	$14.12
Max. Negotiated Rate	$33.53
Rate for Payer: Aetna Commercial	$31.76
Rate for Payer: Humana Medicare Advantage	$14.82
Rate for Payer: UnitedHealthcare Commercial	$33.53
Rate for Payer: UnitedHealthcare Medicaid	$14.12
Rate for Payer: WPPA Medicare Advantage	$21.17

THP Methocarbamol 500 mg (4 Tab) [HMC]

Facility

$31.09

Service Code	NDC 76385012301
Hospital Charge Code	3802067
Hospital Revenue Code	253
Min. Negotiated Rate	$12.44
Max. Negotiated Rate	$29.54
Rate for Payer: Aetna Commercial	$27.98
Rate for Payer: Humana Medicare Advantage	$13.06
Rate for Payer: UnitedHealthcare Commercial	$29.54
Rate for Payer: UnitedHealthcare Medicaid	$12.44
Rate for Payer: WPPA Medicare Advantage	$18.65

THP Methocarbamol 500 mg (4 Tab) [HMC]

Facility

$31.09

Service Code	NDC 76385012301
Hospital Charge Code	3802067
Hospital Revenue Code	253
Min. Negotiated Rate	$27.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.98
Rate for Payer: UnitedHealthcare Commercial	$29.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Metronidazole 250 mg (4 Tab) [HMC]

Facility

$31.90

Service Code	NDC 00904145361
Hospital Charge Code	000000
Hospital Revenue Code	253
Min. Negotiated Rate	$28.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.71
Rate for Payer: UnitedHealthcare Commercial	$30.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Metronidazole 250 mg (4 Tab) [HMC]

Facility

$31.90

Service Code	NDC 00904145361
Hospital Charge Code	000000
Hospital Revenue Code	253
Min. Negotiated Rate	$12.76
Max. Negotiated Rate	$30.30
Rate for Payer: Aetna Commercial	$28.71
Rate for Payer: Humana Medicare Advantage	$13.40
Rate for Payer: UnitedHealthcare Commercial	$30.30
Rate for Payer: UnitedHealthcare Medicaid	$12.76
Rate for Payer: WPPA Medicare Advantage	$19.14

Know your out-of-pocket cost for care.

All Charges