Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

phenytoin 50 mg Chew Tab [HMC]

Facility

$12.67

Service Code	NDC 00071000740
Hospital Charge Code	3801310
Hospital Revenue Code	250
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: UnitedHealthcare Commercial	$12.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

phenytoin 50 mg Chew Tab [HMC]

Facility

$12.67

Service Code	NDC 00071000740
Hospital Charge Code	3801310
Hospital Revenue Code	250
Min. Negotiated Rate	$5.07
Max. Negotiated Rate	$12.04
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Humana Medicare Advantage	$5.32
Rate for Payer: UnitedHealthcare Commercial	$12.04
Rate for Payer: UnitedHealthcare Medicaid	$5.07
Rate for Payer: WPPA Medicare Advantage	$7.60

phenytoin 50 mg/mL Inj Sol 2 mL [HMC]

Facility

$33.20

Service Code	HCPCS J1165
Hospital Charge Code	3806565
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$31.54
Rate for Payer: Aetna Commercial	$29.88
Rate for Payer: Aetna Commercial	$24.26
Rate for Payer: Aetna Commercial	$25.64
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.81
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.81
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.81
Rate for Payer: Humana Medicare Advantage	$11.97
Rate for Payer: Humana Medicare Advantage	$11.32
Rate for Payer: Humana Medicare Advantage	$13.94
Rate for Payer: UnitedHealthcare Commercial	$31.54
Rate for Payer: UnitedHealthcare Commercial	$27.07
Rate for Payer: UnitedHealthcare Commercial	$25.61
Rate for Payer: UnitedHealthcare Medicaid	$0.60
Rate for Payer: UnitedHealthcare Medicaid	$0.60
Rate for Payer: UnitedHealthcare Medicaid	$0.60
Rate for Payer: WPPA Medicare Advantage	$16.18
Rate for Payer: WPPA Medicare Advantage	$17.09
Rate for Payer: WPPA Medicare Advantage	$19.92

phenytoin 50 mg/mL Inj Sol 2 mL [HMC]

Facility

$28.49

Service Code	HCPCS J1165
Hospital Charge Code	3806565
Hospital Revenue Code	250
Min. Negotiated Rate	$25.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.64
Rate for Payer: Aetna Commercial	$24.26
Rate for Payer: Aetna Commercial	$29.88
Rate for Payer: UnitedHealthcare Commercial	$31.54
Rate for Payer: UnitedHealthcare Commercial	$27.07
Rate for Payer: UnitedHealthcare Commercial	$25.61
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

phenytoin 50 mg/mL Inj Sol 5 mL [HMC]

Facility

$23.94

Service Code	HCPCS J1165
Hospital Charge Code	3806565
Hospital Revenue Code	250
Min. Negotiated Rate	$21.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.55
Rate for Payer: UnitedHealthcare Commercial	$22.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

phenytoin 50 mg/mL Inj Sol 5 mL [HMC]

Facility

$23.94

Service Code	HCPCS J1165
Hospital Charge Code	3806565
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$22.74
Rate for Payer: Aetna Commercial	$21.55
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.81
Rate for Payer: Humana Medicare Advantage	$10.05
Rate for Payer: UnitedHealthcare Commercial	$22.74
Rate for Payer: UnitedHealthcare Medicaid	$0.60
Rate for Payer: WPPA Medicare Advantage	$14.36

Phenytoin QST

Facility

$201.00

Service Code	HCPCS 80185
Hospital Charge Code	3550379
Hospital Revenue Code	300
Min. Negotiated Rate	$180.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$180.90
Rate for Payer: UnitedHealthcare Commercial	$190.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Phenytoin QST

Facility

$201.00

Service Code	HCPCS 80185
Hospital Charge Code	3550379
Hospital Revenue Code	300
Min. Negotiated Rate	$13.25
Max. Negotiated Rate	$190.95
Rate for Payer: Aetna Commercial	$180.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.39
Rate for Payer: Humana Medicare Advantage	$84.42
Rate for Payer: UnitedHealthcare Commercial	$190.95
Rate for Payer: UnitedHealthcare Medicaid	$13.25
Rate for Payer: WPPA Medicare Advantage	$120.60

Phosphatidylserine/Prothromb. Ab,IgG QST

Facility

$116.00

Service Code	HCPCS 83516
Hospital Charge Code	3551447
Hospital Revenue Code	300
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$110.20
Rate for Payer: Aetna Commercial	$104.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.34
Rate for Payer: Humana Medicare Advantage	$48.72
Rate for Payer: UnitedHealthcare Commercial	$110.20
Rate for Payer: UnitedHealthcare Medicaid	$10.00
Rate for Payer: WPPA Medicare Advantage	$69.60

Phosphatidylserine/Prothromb. Ab,IgG QST

Facility

$116.00

Service Code	HCPCS 83516
Hospital Charge Code	3551447
Hospital Revenue Code	300
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$104.40
Rate for Payer: UnitedHealthcare Commercial	$110.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Phosphatidylserine/Prothromb. Ab,IgM QST

Facility

$116.00

Service Code	HCPCS 83516
Hospital Charge Code	3552447
Hospital Revenue Code	300
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$110.20
Rate for Payer: Aetna Commercial	$104.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.34
Rate for Payer: Humana Medicare Advantage	$48.72
Rate for Payer: UnitedHealthcare Commercial	$110.20
Rate for Payer: UnitedHealthcare Medicaid	$10.00
Rate for Payer: WPPA Medicare Advantage	$69.60

Phosphatidylserine/Prothromb. Ab,IgM QST

Facility

$116.00

Service Code	HCPCS 83516
Hospital Charge Code	3552447
Hospital Revenue Code	300
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$104.40
Rate for Payer: UnitedHealthcare Commercial	$110.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Phospholipase A2 Receptor Abs QST

Facility

$89.00

Service Code	HCPCS 83698
Hospital Charge Code	3553698
Hospital Revenue Code	300
Min. Negotiated Rate	$80.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Phospholipase A2 Receptor Abs QST

Facility

$89.00

Service Code	HCPCS 83698
Hospital Charge Code	3553698
Hospital Revenue Code	300
Min. Negotiated Rate	$37.38
Max. Negotiated Rate	$204.15
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$204.15
Rate for Payer: Humana Medicare Advantage	$37.38
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: UnitedHealthcare Medicaid	$40.82
Rate for Payer: WPPA Medicare Advantage	$53.40

Phosphorus Level

Facility

$66.00

Service Code	HCPCS 84100
Hospital Charge Code	3550619
Hospital Revenue Code	300
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$59.40
Rate for Payer: UnitedHealthcare Commercial	$62.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Phosphorus Level

Facility

$66.00

Service Code	HCPCS 84100
Hospital Charge Code	3550619
Hospital Revenue Code	300
Min. Negotiated Rate	$4.74
Max. Negotiated Rate	$62.70
Rate for Payer: Aetna Commercial	$59.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$10.18
Rate for Payer: Humana Medicare Advantage	$27.72
Rate for Payer: UnitedHealthcare Commercial	$62.70
Rate for Payer: UnitedHealthcare Medicaid	$4.74
Rate for Payer: WPPA Medicare Advantage	$39.60

phytonadione 10 mg/mL Inj Sol [HMC]

Facility

$108.14

Service Code	HCPCS J3430
Hospital Charge Code	3807654
Hospital Revenue Code	250
Min. Negotiated Rate	$97.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$97.33
Rate for Payer: Aetna Commercial	$87.29
Rate for Payer: UnitedHealthcare Commercial	$92.14
Rate for Payer: UnitedHealthcare Commercial	$102.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

phytonadione 10 mg/mL Inj Sol [HMC]

Facility

$96.99

Service Code	NDC 69097070896
Hospital Charge Code	3807654
Hospital Revenue Code	250
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$92.14
Rate for Payer: Aetna Commercial	$87.29
Rate for Payer: Humana Medicare Advantage	$40.74
Rate for Payer: UnitedHealthcare Commercial	$92.14
Rate for Payer: UnitedHealthcare Medicaid	$38.80
Rate for Payer: WPPA Medicare Advantage	$58.19

phytonadione 10 mg/mL Inj Sol [HMC]

Facility

$96.99

Service Code	HCPCS J3430
Hospital Charge Code	3807654
Hospital Revenue Code	250
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$92.14
Rate for Payer: Aetna Commercial	$87.29
Rate for Payer: Aetna Commercial	$97.33
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.61
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.61
Rate for Payer: Humana Medicare Advantage	$40.74
Rate for Payer: Humana Medicare Advantage	$45.42
Rate for Payer: UnitedHealthcare Commercial	$102.73
Rate for Payer: UnitedHealthcare Commercial	$92.14
Rate for Payer: UnitedHealthcare Medicaid	$2.81
Rate for Payer: UnitedHealthcare Medicaid	$2.81
Rate for Payer: WPPA Medicare Advantage	$58.19
Rate for Payer: WPPA Medicare Advantage	$64.88

phytonadione 10 mg/mL Inj Sol [HMC]

Facility

$96.99

Service Code	NDC 69097070896
Hospital Charge Code	3807654
Hospital Revenue Code	250
Min. Negotiated Rate	$87.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$87.29
Rate for Payer: UnitedHealthcare Commercial	$92.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

phytonadione 1 mg/0.5 mL Inj Sol [HMC]

Facility

$35.30

Service Code	HCPCS J3430
Hospital Charge Code	3806607
Hospital Revenue Code	250
Min. Negotiated Rate	$31.77
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.77
Rate for Payer: Aetna Commercial	$33.37
Rate for Payer: UnitedHealthcare Commercial	$35.23
Rate for Payer: UnitedHealthcare Commercial	$33.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

phytonadione 1 mg/0.5 mL Inj Sol [HMC]

Facility

$37.08

Service Code	HCPCS J3430
Hospital Charge Code	3806607
Hospital Revenue Code	250
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$35.23
Rate for Payer: Aetna Commercial	$33.37
Rate for Payer: Aetna Commercial	$31.77
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.61
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.61
Rate for Payer: Humana Medicare Advantage	$15.57
Rate for Payer: Humana Medicare Advantage	$14.83
Rate for Payer: UnitedHealthcare Commercial	$33.53
Rate for Payer: UnitedHealthcare Commercial	$35.23
Rate for Payer: UnitedHealthcare Medicaid	$2.81
Rate for Payer: UnitedHealthcare Medicaid	$2.81
Rate for Payer: WPPA Medicare Advantage	$22.25
Rate for Payer: WPPA Medicare Advantage	$21.18

PICC 5fr Dual Lumen BioFlo Power Injectable Maximal Barrier Nursing Kit w/PASV

Facility

$733.43

Hospital Charge Code	3256653
Hospital Revenue Code	270
Min. Negotiated Rate	$293.37
Max. Negotiated Rate	$696.76
Rate for Payer: Aetna Commercial	$660.09
Rate for Payer: Humana Medicare Advantage	$308.04
Rate for Payer: UnitedHealthcare Commercial	$696.76
Rate for Payer: UnitedHealthcare Medicaid	$293.37
Rate for Payer: WPPA Medicare Advantage	$440.06

PICC 5fr Dual Lumen BioFlo Power Injectable Maximal Barrier Nursing Kit w/PASV

Facility

$733.43

Hospital Charge Code	3256653
Hospital Revenue Code	270
Min. Negotiated Rate	$660.09
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$660.09
Rate for Payer: UnitedHealthcare Commercial	$696.76
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PICC Line Insertion

Facility

$5,306.00

Service Code	HCPCS 36569
Hospital Charge Code	3150655
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,040.70
Rate for Payer: Aetna Commercial	$4,775.40
Rate for Payer: UnitedHealthcare Commercial	$5,040.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges