Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

primidone 250 mg Tab [HMC]

Facility

$7.99

Service Code	NDC 53746054501
Hospital Charge Code	3800810
Hospital Revenue Code	250
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$7.59
Rate for Payer: Aetna Commercial	$7.19
Rate for Payer: Humana Medicare Advantage	$3.36
Rate for Payer: UnitedHealthcare Commercial	$7.59
Rate for Payer: UnitedHealthcare Medicaid	$3.20
Rate for Payer: WPPA Medicare Advantage	$4.79

primidone 250 mg Tab [HMC]

Facility

$7.99

Service Code	NDC 53746054501
Hospital Charge Code	3800810
Hospital Revenue Code	250
Min. Negotiated Rate	$7.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.19
Rate for Payer: UnitedHealthcare Commercial	$7.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

primidone 50 mg Tab [HMC]

Facility

$7.86

Service Code	NDC 50268068615
Hospital Charge Code	3802440
Hospital Revenue Code	250
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$7.47
Rate for Payer: Aetna Commercial	$7.07
Rate for Payer: Humana Medicare Advantage	$3.30
Rate for Payer: UnitedHealthcare Commercial	$7.47
Rate for Payer: UnitedHealthcare Medicaid	$3.14
Rate for Payer: WPPA Medicare Advantage	$4.72

primidone 50 mg Tab [HMC]

Facility

$6.48

Service Code	NDC 53746054401
Hospital Charge Code	3802440
Hospital Revenue Code	250
Min. Negotiated Rate	$5.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.83
Rate for Payer: UnitedHealthcare Commercial	$6.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

primidone 50 mg Tab [HMC]

Facility

$6.48

Service Code	NDC 53746054401
Hospital Charge Code	3802440
Hospital Revenue Code	250
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$6.16
Rate for Payer: Aetna Commercial	$5.83
Rate for Payer: Humana Medicare Advantage	$2.72
Rate for Payer: UnitedHealthcare Commercial	$6.16
Rate for Payer: UnitedHealthcare Medicaid	$2.59
Rate for Payer: WPPA Medicare Advantage	$3.89

primidone 50 mg Tab [HMC]

Facility

$7.92

Service Code	NDC 68084020201
Hospital Charge Code	3802440
Hospital Revenue Code	250
Min. Negotiated Rate	$7.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.13
Rate for Payer: UnitedHealthcare Commercial	$7.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

primidone 50 mg Tab [HMC]

Facility

$7.86

Service Code	NDC 50268068615
Hospital Charge Code	3802440
Hospital Revenue Code	250
Min. Negotiated Rate	$7.07
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.07
Rate for Payer: UnitedHealthcare Commercial	$7.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

primidone 50 mg Tab [HMC]

Facility

$7.92

Service Code	NDC 68084020201
Hospital Charge Code	3802440
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$7.52
Rate for Payer: Aetna Commercial	$7.13
Rate for Payer: Humana Medicare Advantage	$3.33
Rate for Payer: UnitedHealthcare Commercial	$7.52
Rate for Payer: UnitedHealthcare Medicaid	$3.17
Rate for Payer: WPPA Medicare Advantage	$4.75

PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS

Facility

$1,200.00

Service Code	MSDRG 998
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Probe Hemostasis Bicoag

Facility

$499.00

Hospital Charge Code	3254679
Hospital Revenue Code	270
Min. Negotiated Rate	$199.60
Max. Negotiated Rate	$474.05
Rate for Payer: Aetna Commercial	$449.10
Rate for Payer: Humana Medicare Advantage	$209.58
Rate for Payer: UnitedHealthcare Commercial	$474.05
Rate for Payer: UnitedHealthcare Medicaid	$199.60
Rate for Payer: WPPA Medicare Advantage	$299.40

Probe Hemostasis Bicoag

Facility

$499.00

Hospital Charge Code	3254679
Hospital Revenue Code	270
Min. Negotiated Rate	$449.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$449.10
Rate for Payer: UnitedHealthcare Commercial	$474.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Probe Prass Standard Monopolar Stimulator Flush Tip

Facility

$322.00

Hospital Charge Code	3250410
Hospital Revenue Code	270
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$305.90
Rate for Payer: Aetna Commercial	$289.80
Rate for Payer: Humana Medicare Advantage	$135.24
Rate for Payer: UnitedHealthcare Commercial	$305.90
Rate for Payer: UnitedHealthcare Medicaid	$128.80
Rate for Payer: WPPA Medicare Advantage	$193.20

Probe Prass Standard Monopolar Stimulator Flush Tip

Facility

$322.00

Hospital Charge Code	3250410
Hospital Revenue Code	270
Min. Negotiated Rate	$289.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$289.80
Rate for Payer: UnitedHealthcare Commercial	$305.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Probe Side by Side Bipolar Stimulation Xomed for NIM Response 3.0 Nerve Monitor

Facility

$362.00

Hospital Charge Code	3250412
Hospital Revenue Code	270
Min. Negotiated Rate	$144.80
Max. Negotiated Rate	$343.90
Rate for Payer: Aetna Commercial	$325.80
Rate for Payer: Humana Medicare Advantage	$152.04
Rate for Payer: UnitedHealthcare Commercial	$343.90
Rate for Payer: UnitedHealthcare Medicaid	$144.80
Rate for Payer: WPPA Medicare Advantage	$217.20

Probe Side by Side Bipolar Stimulation Xomed for NIM Response 3.0 Nerve Monitor

Facility

$362.00

Hospital Charge Code	3250412
Hospital Revenue Code	270
Min. Negotiated Rate	$325.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$325.80
Rate for Payer: UnitedHealthcare Commercial	$343.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

procainamide 100 mg/mL Inj Sol [HMC]

Facility

$185.60

Service Code	HCPCS J2690
Hospital Charge Code	3806698
Hospital Revenue Code	250
Min. Negotiated Rate	$77.95
Max. Negotiated Rate	$344.53
Rate for Payer: Aetna Commercial	$167.04
Rate for Payer: Aetna Commercial	$706.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$240.82
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$240.82
Rate for Payer: Humana Medicare Advantage	$77.95
Rate for Payer: Humana Medicare Advantage	$329.70
Rate for Payer: UnitedHealthcare Commercial	$176.32
Rate for Payer: UnitedHealthcare Commercial	$745.75
Rate for Payer: UnitedHealthcare Medicaid	$344.53
Rate for Payer: UnitedHealthcare Medicaid	$344.53
Rate for Payer: WPPA Medicare Advantage	$111.36
Rate for Payer: WPPA Medicare Advantage	$471.00

procainamide 100 mg/mL Inj Sol [HMC]

Facility

$185.60

Service Code	HCPCS J2690
Hospital Charge Code	3806698
Hospital Revenue Code	250
Min. Negotiated Rate	$167.04
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$167.04
Rate for Payer: Aetna Commercial	$706.50
Rate for Payer: UnitedHealthcare Commercial	$176.32
Rate for Payer: UnitedHealthcare Commercial	$745.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

procainamide 500 mg/mL Inj Sol [HMC]

Facility

$150.97

Service Code	HCPCS J2690
Hospital Charge Code	3806698
Hospital Revenue Code	250
Min. Negotiated Rate	$63.41
Max. Negotiated Rate	$344.53
Rate for Payer: Aetna Commercial	$135.87
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$240.82
Rate for Payer: Humana Medicare Advantage	$63.41
Rate for Payer: UnitedHealthcare Commercial	$143.42
Rate for Payer: UnitedHealthcare Medicaid	$344.53
Rate for Payer: WPPA Medicare Advantage	$90.58

procainamide 500 mg/mL Inj Sol [HMC]

Facility

$150.97

Service Code	HCPCS J2690
Hospital Charge Code	3806698
Hospital Revenue Code	250
Min. Negotiated Rate	$135.87
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$135.87
Rate for Payer: UnitedHealthcare Commercial	$143.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Procalcitonin

Facility

$179.00

Service Code	HCPCS 84145
Hospital Charge Code	3554145
Hospital Revenue Code	300
Min. Negotiated Rate	$161.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$161.10
Rate for Payer: UnitedHealthcare Commercial	$170.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Procalcitonin

Facility

$179.00

Service Code	HCPCS 84145
Hospital Charge Code	3554145
Hospital Revenue Code	300
Min. Negotiated Rate	$23.60
Max. Negotiated Rate	$170.05
Rate for Payer: Aetna Commercial	$161.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$91.94
Rate for Payer: Humana Medicare Advantage	$75.18
Rate for Payer: UnitedHealthcare Commercial	$170.05
Rate for Payer: UnitedHealthcare Medicaid	$23.60
Rate for Payer: WPPA Medicare Advantage	$107.40

prochlorperazine 25 mg Supp [HMC]

Facility

$30.16

Service Code	NDC 00574722612
Hospital Charge Code	3806714
Hospital Revenue Code	250
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$28.65
Rate for Payer: Aetna Commercial	$27.14
Rate for Payer: Humana Medicare Advantage	$12.67
Rate for Payer: UnitedHealthcare Commercial	$28.65
Rate for Payer: UnitedHealthcare Medicaid	$12.06
Rate for Payer: WPPA Medicare Advantage	$18.10

prochlorperazine 25 mg Supp [HMC]

Facility

$30.16

Service Code	NDC 00574722612
Hospital Charge Code	3806714
Hospital Revenue Code	250
Min. Negotiated Rate	$27.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.14
Rate for Payer: UnitedHealthcare Commercial	$28.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

prochlorperazine 5 mg Tab [HMC]

Facility

$22.61

Service Code	HCPCS Q0164
Hospital Charge Code	3804876
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$21.48
Rate for Payer: Aetna Commercial	$20.35
Rate for Payer: Aetna Commercial	$16.17
Rate for Payer: Aetna Commercial	$20.75
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.61
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.61
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.61
Rate for Payer: Humana Medicare Advantage	$9.50
Rate for Payer: Humana Medicare Advantage	$7.55
Rate for Payer: Humana Medicare Advantage	$9.69
Rate for Payer: UnitedHealthcare Commercial	$21.48
Rate for Payer: UnitedHealthcare Commercial	$17.07
Rate for Payer: UnitedHealthcare Commercial	$21.91
Rate for Payer: UnitedHealthcare Medicaid	$9.04
Rate for Payer: UnitedHealthcare Medicaid	$7.19
Rate for Payer: UnitedHealthcare Medicaid	$9.22
Rate for Payer: WPPA Medicare Advantage	$10.78
Rate for Payer: WPPA Medicare Advantage	$13.84
Rate for Payer: WPPA Medicare Advantage	$13.57

prochlorperazine 5 mg Tab [HMC]

Facility

$17.97

Service Code	HCPCS Q0164
Hospital Charge Code	3804876
Hospital Revenue Code	250
Min. Negotiated Rate	$16.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.17
Rate for Payer: Aetna Commercial	$20.35
Rate for Payer: Aetna Commercial	$20.75
Rate for Payer: UnitedHealthcare Commercial	$21.91
Rate for Payer: UnitedHealthcare Commercial	$17.07
Rate for Payer: UnitedHealthcare Commercial	$21.48
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

Know your out-of-pocket cost for care.

All Charges