Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

famciclovir 500 mg Tab [HMC]

Facility

$30.39

Service Code	NDC 00093811956
Hospital Charge Code	3803026
Hospital Revenue Code	250
Min. Negotiated Rate	$27.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.35
Rate for Payer: UnitedHealthcare Commercial	$28.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

famciclovir 500 mg Tab [HMC]

Facility

$30.39

Service Code	NDC 33342002607
Hospital Charge Code	3803026
Hospital Revenue Code	250
Min. Negotiated Rate	$27.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.35
Rate for Payer: UnitedHealthcare Commercial	$28.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

famciclovir 500 mg Tab [HMC]

Facility

$32.90

Service Code	NDC 60505324703
Hospital Charge Code	3803026
Hospital Revenue Code	250
Min. Negotiated Rate	$29.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.61
Rate for Payer: UnitedHealthcare Commercial	$31.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

famciclovir 500 mg Tab [HMC]

Facility

$32.90

Service Code	NDC 60505324703
Hospital Charge Code	3803026
Hospital Revenue Code	250
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$31.25
Rate for Payer: Aetna Commercial	$29.61
Rate for Payer: Humana Medicare Advantage	$13.82
Rate for Payer: UnitedHealthcare Commercial	$31.25
Rate for Payer: UnitedHealthcare Medicaid	$13.16
Rate for Payer: WPPA Medicare Advantage	$19.74

famciclovir 500 mg Tab [HMC]

Facility

$30.39

Service Code	NDC 00093811956
Hospital Charge Code	3803026
Hospital Revenue Code	250
Min. Negotiated Rate	$12.16
Max. Negotiated Rate	$28.87
Rate for Payer: Aetna Commercial	$27.35
Rate for Payer: Humana Medicare Advantage	$12.76
Rate for Payer: UnitedHealthcare Commercial	$28.87
Rate for Payer: UnitedHealthcare Medicaid	$12.16
Rate for Payer: WPPA Medicare Advantage	$18.23

famotidine 10 mg/mL IV Sol [HMC]

Facility

$20.40

Service Code	HCPCS S0028
Hospital Charge Code	3800681
Hospital Revenue Code	250
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.36
Rate for Payer: Aetna Commercial	$18.86
Rate for Payer: UnitedHealthcare Commercial	$19.91
Rate for Payer: UnitedHealthcare Commercial	$19.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

famotidine 10 mg/mL IV Sol [HMC]

Facility

$20.96

Service Code	HCPCS S0028
Hospital Charge Code	3800681
Hospital Revenue Code	250
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$19.91
Rate for Payer: Aetna Commercial	$18.86
Rate for Payer: Aetna Commercial	$18.36
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.12
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.12
Rate for Payer: Humana Medicare Advantage	$8.57
Rate for Payer: Humana Medicare Advantage	$8.80
Rate for Payer: UnitedHealthcare Commercial	$19.38
Rate for Payer: UnitedHealthcare Commercial	$19.91
Rate for Payer: UnitedHealthcare Medicaid	$8.16
Rate for Payer: UnitedHealthcare Medicaid	$8.38
Rate for Payer: WPPA Medicare Advantage	$12.58
Rate for Payer: WPPA Medicare Advantage	$12.24

famotidine 20 mg Tab [HMC]

Facility

$10.19

Service Code	NDC 62332000131
Hospital Charge Code	3805857
Hospital Revenue Code	250
Min. Negotiated Rate	$9.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.17
Rate for Payer: UnitedHealthcare Commercial	$9.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

famotidine 20 mg Tab [HMC]

Facility

$5.27

Service Code	NDC 00904719361
Hospital Charge Code	3805857
Hospital Revenue Code	250
Min. Negotiated Rate	$4.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.74
Rate for Payer: UnitedHealthcare Commercial	$5.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

famotidine 20 mg Tab [HMC]

Facility

$5.27

Service Code	NDC 00904719361
Hospital Charge Code	3805857
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$5.01
Rate for Payer: Aetna Commercial	$4.74
Rate for Payer: Humana Medicare Advantage	$2.21
Rate for Payer: UnitedHealthcare Commercial	$5.01
Rate for Payer: UnitedHealthcare Medicaid	$2.11
Rate for Payer: WPPA Medicare Advantage	$3.16

famotidine 20 mg Tab [HMC]

Facility

$10.19

Service Code	NDC 62332000131
Hospital Charge Code	3805857
Hospital Revenue Code	250
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$9.68
Rate for Payer: Aetna Commercial	$9.17
Rate for Payer: Humana Medicare Advantage	$4.28
Rate for Payer: UnitedHealthcare Commercial	$9.68
Rate for Payer: UnitedHealthcare Medicaid	$4.08
Rate for Payer: WPPA Medicare Advantage	$6.11

Fat Emul, 20% IV 250 mL [HMC]

Facility

$82.36

Service Code	NDC 00338051902
Hospital Charge Code	3174806
Hospital Revenue Code	250
Min. Negotiated Rate	$74.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$74.12
Rate for Payer: UnitedHealthcare Commercial	$78.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fat Emul, 20% IV 250 mL [HMC]

Facility

$82.36

Service Code	NDC 00338051902
Hospital Charge Code	3174806
Hospital Revenue Code	250
Min. Negotiated Rate	$32.94
Max. Negotiated Rate	$78.24
Rate for Payer: Aetna Commercial	$74.12
Rate for Payer: Humana Medicare Advantage	$34.59
Rate for Payer: UnitedHealthcare Commercial	$78.24
Rate for Payer: UnitedHealthcare Medicaid	$32.94
Rate for Payer: WPPA Medicare Advantage	$49.42

Fat Emul, 20% IV 500 mL [HMC]

Facility

$94.97

Service Code	NDC 00338051913
Hospital Charge Code	3174806
Hospital Revenue Code	250
Min. Negotiated Rate	$85.47
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$85.47
Rate for Payer: UnitedHealthcare Commercial	$90.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fat Emul, 20% IV 500 mL [HMC]

Facility

$94.97

Service Code	NDC 00338051913
Hospital Charge Code	3174806
Hospital Revenue Code	250
Min. Negotiated Rate	$37.99
Max. Negotiated Rate	$90.22
Rate for Payer: Aetna Commercial	$85.47
Rate for Payer: Humana Medicare Advantage	$39.89
Rate for Payer: UnitedHealthcare Commercial	$90.22
Rate for Payer: UnitedHealthcare Medicaid	$37.99
Rate for Payer: WPPA Medicare Advantage	$56.98

Fatty Acid Panel, Essential (C12-C22), Serum QST

Facility

$496.00

Service Code	HCPCS 82542
Hospital Charge Code	3552185
Hospital Revenue Code	300
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$471.20
Rate for Payer: Aetna Commercial	$446.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$194.29
Rate for Payer: Humana Medicare Advantage	$208.32
Rate for Payer: UnitedHealthcare Commercial	$471.20
Rate for Payer: UnitedHealthcare Medicaid	$20.48
Rate for Payer: WPPA Medicare Advantage	$297.60

Fatty Acid Panel, Essential (C12-C22), Serum QST

Facility

$496.00

Service Code	HCPCS 82725
Hospital Charge Code	3552185
Hospital Revenue Code	300
Min. Negotiated Rate	$446.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$446.40
Rate for Payer: UnitedHealthcare Commercial	$471.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fatty Acid Panel, Essential (C12-C22), Serum QST

Facility

$496.00

Service Code	HCPCS 82542
Hospital Charge Code	3552185
Hospital Revenue Code	300
Min. Negotiated Rate	$446.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$446.40
Rate for Payer: UnitedHealthcare Commercial	$471.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fatty Acid Panel, Essential (C12-C22), Serum QST

Facility

$496.00

Service Code	HCPCS 82725
Hospital Charge Code	3552185
Hospital Revenue Code	300
Min. Negotiated Rate	$15.95
Max. Negotiated Rate	$471.20
Rate for Payer: Aetna Commercial	$446.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.87
Rate for Payer: Humana Medicare Advantage	$208.32
Rate for Payer: UnitedHealthcare Commercial	$471.20
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: WPPA Medicare Advantage	$297.60

FDP QST

Facility

$99.00

Service Code	HCPCS 85362
Hospital Charge Code	3550403
Hospital Revenue Code	300
Min. Negotiated Rate	$89.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$89.10
Rate for Payer: UnitedHealthcare Commercial	$94.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FDP QST

Facility

$99.00

Service Code	HCPCS 85362
Hospital Charge Code	3550403
Hospital Revenue Code	300
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$94.05
Rate for Payer: Aetna Commercial	$89.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$42.27
Rate for Payer: Humana Medicare Advantage	$41.58
Rate for Payer: UnitedHealthcare Commercial	$94.05
Rate for Payer: UnitedHealthcare Medicaid	$6.89
Rate for Payer: WPPA Medicare Advantage	$59.40

febuxostat 40 mg Tab [HMC]

Facility

$14.00

Service Code	NDC 60687053821
Hospital Charge Code	3808428
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: UnitedHealthcare Commercial	$13.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

febuxostat 40 mg Tab [HMC]

Facility

$31.40

Service Code	NDC 64764091830
Hospital Charge Code	3808428
Hospital Revenue Code	250
Min. Negotiated Rate	$12.56
Max. Negotiated Rate	$29.83
Rate for Payer: Aetna Commercial	$28.26
Rate for Payer: Humana Medicare Advantage	$13.19
Rate for Payer: UnitedHealthcare Commercial	$29.83
Rate for Payer: UnitedHealthcare Medicaid	$12.56
Rate for Payer: WPPA Medicare Advantage	$18.84

febuxostat 40 mg Tab [HMC]

Facility

$14.00

Service Code	NDC 60687053821
Hospital Charge Code	3808428
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$13.30
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: Humana Medicare Advantage	$5.88
Rate for Payer: UnitedHealthcare Commercial	$13.30
Rate for Payer: UnitedHealthcare Medicaid	$5.60
Rate for Payer: WPPA Medicare Advantage	$8.40

febuxostat 40 mg Tab [HMC]

Facility

$31.40

Service Code	NDC 64764091830
Hospital Charge Code	3808428
Hospital Revenue Code	250
Min. Negotiated Rate	$28.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.26
Rate for Payer: UnitedHealthcare Commercial	$29.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges