Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

THP Promethazine 12.5 mg (4 Tab) [HMC]

Facility

$31.75

Service Code	NDC 68084015401
Hospital Charge Code	3800168
Hospital Revenue Code	253
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.57
Rate for Payer: UnitedHealthcare Commercial	$30.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Sulfamethoxazole-Trimethoprim DS 800 mg-160 mg (4 Tab) [HMC]

Facility

$29.47

Service Code	NDC 00904272561
Hospital Charge Code	3807134
Hospital Revenue Code	253
Min. Negotiated Rate	$11.79
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.52
Rate for Payer: Humana Medicare Advantage	$12.38
Rate for Payer: UnitedHealthcare Commercial	$28.00
Rate for Payer: UnitedHealthcare Medicaid	$11.79
Rate for Payer: WPPA Medicare Advantage	$17.68

THP Sulfamethoxazole-Trimethoprim DS 800 mg-160 mg (4 Tab) [HMC]

Facility

$29.47

Service Code	NDC 00904272561
Hospital Charge Code	3807134
Hospital Revenue Code	253
Min. Negotiated Rate	$26.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.52
Rate for Payer: UnitedHealthcare Commercial	$28.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Tramadol 50 mg (4 Tab) [HMC]

Facility

$34.84

Service Code	NDC 62584055901
Hospital Charge Code	3803455
Hospital Revenue Code	253
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$33.10
Rate for Payer: Aetna Commercial	$31.36
Rate for Payer: Humana Medicare Advantage	$14.63
Rate for Payer: UnitedHealthcare Commercial	$33.10
Rate for Payer: UnitedHealthcare Medicaid	$13.94
Rate for Payer: WPPA Medicare Advantage	$20.90

THP Tramadol 50 mg (4 Tab) [HMC]

Facility

$34.84

Service Code	NDC 62584055901
Hospital Charge Code	3803455
Hospital Revenue Code	253
Min. Negotiated Rate	$31.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.36
Rate for Payer: UnitedHealthcare Commercial	$33.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP ulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp (120mL) [HMC]

Facility

$33.49

Service Code	NDC 54879000716
Hospital Charge Code	3807159
Hospital Revenue Code	253
Min. Negotiated Rate	$13.40
Max. Negotiated Rate	$31.82
Rate for Payer: Aetna Commercial	$30.14
Rate for Payer: Humana Medicare Advantage	$14.07
Rate for Payer: UnitedHealthcare Commercial	$31.82
Rate for Payer: UnitedHealthcare Medicaid	$13.40
Rate for Payer: WPPA Medicare Advantage	$20.09

THP ulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp (120mL) [HMC]

Facility

$33.49

Service Code	NDC 54879000716
Hospital Charge Code	3807159
Hospital Revenue Code	253
Min. Negotiated Rate	$30.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.14
Rate for Payer: UnitedHealthcare Commercial	$31.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Valacyclovir 1 gram (4 Tab) [HMC]

Facility

$75.50

Service Code	NDC 00378427693
Hospital Charge Code	3800325
Hospital Revenue Code	253
Min. Negotiated Rate	$30.20
Max. Negotiated Rate	$71.72
Rate for Payer: Aetna Commercial	$67.95
Rate for Payer: Humana Medicare Advantage	$31.71
Rate for Payer: UnitedHealthcare Commercial	$71.72
Rate for Payer: UnitedHealthcare Medicaid	$30.20
Rate for Payer: WPPA Medicare Advantage	$45.30

THP Valacyclovir 1 gram (4 Tab) [HMC]

Facility

$75.50

Service Code	NDC 00378427693
Hospital Charge Code	3800325
Hospital Revenue Code	253
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$67.95
Rate for Payer: UnitedHealthcare Commercial	$71.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Threshold Inspiratory Muscle Trainer IMT

Facility

$70.00

Hospital Charge Code	3250019
Hospital Revenue Code	270
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$66.50
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: Humana Medicare Advantage	$29.40
Rate for Payer: UnitedHealthcare Commercial	$66.50
Rate for Payer: UnitedHealthcare Medicaid	$28.00
Rate for Payer: WPPA Medicare Advantage	$42.00

Threshold Inspiratory Muscle Trainer IMT

Facility

$70.00

Hospital Charge Code	3250019
Hospital Revenue Code	270
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: UnitedHealthcare Commercial	$66.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

thrombin topical bovine 20,000 intl units Pow [HMC]

Facility

$547.42

Service Code	NDC 60793021721
Hospital Charge Code	3800397
Hospital Revenue Code	250
Min. Negotiated Rate	$492.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$492.68
Rate for Payer: UnitedHealthcare Commercial	$520.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

thrombin topical bovine 20,000 intl units Pow [HMC]

Facility

$547.42

Service Code	NDC 60793021721
Hospital Charge Code	3800397
Hospital Revenue Code	250
Min. Negotiated Rate	$218.97
Max. Negotiated Rate	$520.05
Rate for Payer: Aetna Commercial	$492.68
Rate for Payer: Humana Medicare Advantage	$229.92
Rate for Payer: UnitedHealthcare Commercial	$520.05
Rate for Payer: UnitedHealthcare Medicaid	$218.97
Rate for Payer: WPPA Medicare Advantage	$328.45

thrombin topical recombinant 5000 intl units Pow [HMC]

Facility

$159.32

Service Code	NDC 00338032201
Hospital Charge Code	3800051
Hospital Revenue Code	250
Min. Negotiated Rate	$63.73
Max. Negotiated Rate	$151.35
Rate for Payer: Aetna Commercial	$143.39
Rate for Payer: Humana Medicare Advantage	$66.91
Rate for Payer: UnitedHealthcare Commercial	$151.35
Rate for Payer: UnitedHealthcare Medicaid	$63.73
Rate for Payer: WPPA Medicare Advantage	$95.59

thrombin topical recombinant 5000 intl units Pow [HMC]

Facility

$159.32

Service Code	NDC 00338032201
Hospital Charge Code	3800051
Hospital Revenue Code	250
Min. Negotiated Rate	$143.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$143.39
Rate for Payer: UnitedHealthcare Commercial	$151.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THUMB SPICA 8 Left LG

Facility

$21.69

Service Code	HCPCS L3908
Hospital Charge Code	3259916
Hospital Revenue Code	274
Min. Negotiated Rate	$19.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.52
Rate for Payer: UnitedHealthcare Commercial	$20.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THUMB SPICA 8 Left LG

Facility

$21.69

Service Code	HCPCS L3908
Hospital Charge Code	3259916
Hospital Revenue Code	274
Min. Negotiated Rate	$9.11
Max. Negotiated Rate	$52.43
Rate for Payer: Aetna Commercial	$19.52
Rate for Payer: Humana Medicare Advantage	$9.11
Rate for Payer: UnitedHealthcare Commercial	$20.61
Rate for Payer: UnitedHealthcare Medicaid	$52.43
Rate for Payer: WPPA Medicare Advantage	$13.01

THUMB SPICA 8 Left MED

Facility

$34.92

Hospital Charge Code	3259914
Hospital Revenue Code	270
Min. Negotiated Rate	$31.43
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.43
Rate for Payer: UnitedHealthcare Commercial	$33.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THUMB SPICA 8 Left MED

Facility

$34.92

Hospital Charge Code	3259914
Hospital Revenue Code	270
Min. Negotiated Rate	$13.97
Max. Negotiated Rate	$33.17
Rate for Payer: Aetna Commercial	$31.43
Rate for Payer: Humana Medicare Advantage	$14.67
Rate for Payer: UnitedHealthcare Commercial	$33.17
Rate for Payer: UnitedHealthcare Medicaid	$13.97
Rate for Payer: WPPA Medicare Advantage	$20.95

THUMB SPICA 8 Left SM

Facility

$35.01

Hospital Charge Code	3259911
Hospital Revenue Code	270
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$33.26
Rate for Payer: Aetna Commercial	$31.51
Rate for Payer: Humana Medicare Advantage	$14.70
Rate for Payer: UnitedHealthcare Commercial	$33.26
Rate for Payer: UnitedHealthcare Medicaid	$14.00
Rate for Payer: WPPA Medicare Advantage	$21.01

THUMB SPICA 8 Left SM

Facility

$35.01

Hospital Charge Code	3259911
Hospital Revenue Code	270
Min. Negotiated Rate	$31.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.51
Rate for Payer: UnitedHealthcare Commercial	$33.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THUMB SPICA 8 Left X-LG

Facility

$39.00

Hospital Charge Code	3259918
Hospital Revenue Code	270
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$37.05
Rate for Payer: Aetna Commercial	$35.10
Rate for Payer: Humana Medicare Advantage	$16.38
Rate for Payer: UnitedHealthcare Commercial	$37.05
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: WPPA Medicare Advantage	$23.40

THUMB SPICA 8 Left X-LG

Facility

$39.00

Hospital Charge Code	3259918
Hospital Revenue Code	270
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.10
Rate for Payer: UnitedHealthcare Commercial	$37.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THUMB SPICA 8 Left X-Small

Facility

$34.00

Hospital Charge Code	3259909
Hospital Revenue Code	270
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$32.30
Rate for Payer: Aetna Commercial	$30.60
Rate for Payer: Humana Medicare Advantage	$14.28
Rate for Payer: UnitedHealthcare Commercial	$32.30
Rate for Payer: UnitedHealthcare Medicaid	$13.60
Rate for Payer: WPPA Medicare Advantage	$20.40

THUMB SPICA 8 Left X-Small

Facility

$34.00

Hospital Charge Code	3259909
Hospital Revenue Code	270
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.60
Rate for Payer: UnitedHealthcare Commercial	$32.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges