Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

promethazine 50 mg/mL Sol [HMC]

Facility

$43.07

Service Code	HCPCS J2550
Hospital Charge Code	3806771
Hospital Revenue Code	250
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$40.92
Rate for Payer: Aetna Commercial	$38.76
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.99
Rate for Payer: Humana Medicare Advantage	$18.09
Rate for Payer: UnitedHealthcare Commercial	$40.92
Rate for Payer: UnitedHealthcare Medicaid	$3.97
Rate for Payer: WPPA Medicare Advantage	$25.84

promethazine 6.25 mg/5 mL Oral Syrup [HMC]

Facility

$11.01

Service Code	NDC 00121092716
Hospital Charge Code	3806763
Hospital Revenue Code	250
Min. Negotiated Rate	$9.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.91
Rate for Payer: UnitedHealthcare Commercial	$10.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

promethazine 6.25 mg/5 mL Oral Syrup [HMC]

Facility

$11.01

Service Code	HCPCS Q0169
Hospital Charge Code	3806763
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$10.46
Rate for Payer: Aetna Commercial	$9.91
Rate for Payer: Aetna Commercial	$9.87
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.25
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.25
Rate for Payer: Humana Medicare Advantage	$4.61
Rate for Payer: Humana Medicare Advantage	$4.62
Rate for Payer: UnitedHealthcare Commercial	$10.42
Rate for Payer: UnitedHealthcare Commercial	$10.46
Rate for Payer: UnitedHealthcare Medicaid	$4.39
Rate for Payer: UnitedHealthcare Medicaid	$4.40
Rate for Payer: WPPA Medicare Advantage	$6.61
Rate for Payer: WPPA Medicare Advantage	$6.58

promethazine 6.25 mg/5 mL Oral Syrup [HMC]

Facility

$10.97

Service Code	HCPCS Q0169
Hospital Charge Code	3806763
Hospital Revenue Code	250
Min. Negotiated Rate	$9.87
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.87
Rate for Payer: Aetna Commercial	$9.91
Rate for Payer: UnitedHealthcare Commercial	$10.46
Rate for Payer: UnitedHealthcare Commercial	$10.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

promethazine 6.25 mg/5 mL Oral Syrup [HMC]

Facility

$11.01

Service Code	NDC 00121092716
Hospital Charge Code	3806763
Hospital Revenue Code	250
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$10.46
Rate for Payer: Aetna Commercial	$9.91
Rate for Payer: Humana Medicare Advantage	$4.62
Rate for Payer: UnitedHealthcare Commercial	$10.46
Rate for Payer: UnitedHealthcare Medicaid	$4.40
Rate for Payer: WPPA Medicare Advantage	$6.61

propafenone 150 mg Tab [HMC]

Facility

$9.91

Service Code	NDC 62559023001
Hospital Charge Code	3809818
Hospital Revenue Code	250
Min. Negotiated Rate	$8.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.92
Rate for Payer: UnitedHealthcare Commercial	$9.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

propafenone 150 mg Tab [HMC]

Facility

$9.91

Service Code	NDC 59651025601
Hospital Charge Code	3809818
Hospital Revenue Code	250
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$9.41
Rate for Payer: Aetna Commercial	$8.92
Rate for Payer: Humana Medicare Advantage	$4.16
Rate for Payer: UnitedHealthcare Commercial	$9.41
Rate for Payer: UnitedHealthcare Medicaid	$3.96
Rate for Payer: WPPA Medicare Advantage	$5.95

propafenone 150 mg Tab [HMC]

Facility

$9.91

Service Code	NDC 62559023001
Hospital Charge Code	3809818
Hospital Revenue Code	250
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$9.41
Rate for Payer: Aetna Commercial	$8.92
Rate for Payer: Humana Medicare Advantage	$4.16
Rate for Payer: UnitedHealthcare Commercial	$9.41
Rate for Payer: UnitedHealthcare Medicaid	$3.96
Rate for Payer: WPPA Medicare Advantage	$5.95

propafenone 150 mg Tab [HMC]

Facility

$9.91

Service Code	NDC 59651025601
Hospital Charge Code	3809818
Hospital Revenue Code	250
Min. Negotiated Rate	$8.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.92
Rate for Payer: UnitedHealthcare Commercial	$9.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

propafenone 150 mg Tab [HMC]

Facility

$23.16

Service Code	NDC 00173079220
Hospital Charge Code	3809818
Hospital Revenue Code	250
Min. Negotiated Rate	$9.26
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.84
Rate for Payer: Humana Medicare Advantage	$9.73
Rate for Payer: UnitedHealthcare Commercial	$22.00
Rate for Payer: UnitedHealthcare Medicaid	$9.26
Rate for Payer: WPPA Medicare Advantage	$13.90

propafenone 150 mg Tab [HMC]

Facility

$7.81

Service Code	NDC 60687070901
Hospital Charge Code	3809818
Hospital Revenue Code	250
Min. Negotiated Rate	$7.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.03
Rate for Payer: UnitedHealthcare Commercial	$7.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

propafenone 150 mg Tab [HMC]

Facility

$7.81

Service Code	NDC 60687070901
Hospital Charge Code	3809818
Hospital Revenue Code	250
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$7.42
Rate for Payer: Aetna Commercial	$7.03
Rate for Payer: Humana Medicare Advantage	$3.28
Rate for Payer: UnitedHealthcare Commercial	$7.42
Rate for Payer: UnitedHealthcare Medicaid	$3.12
Rate for Payer: WPPA Medicare Advantage	$4.69

propafenone 150 mg Tab [HMC]

Facility

$23.16

Service Code	NDC 00173079220
Hospital Charge Code	3809818
Hospital Revenue Code	250
Min. Negotiated Rate	$20.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.84
Rate for Payer: UnitedHealthcare Commercial	$22.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

propofol 10 mg/mL EMU 100 mL [HMC]

Facility

$85.00

Service Code	HCPCS J2704
Hospital Charge Code	3170226
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$80.75
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: Aetna Commercial	$55.65
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.18
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.18
Rate for Payer: Humana Medicare Advantage	$25.97
Rate for Payer: Humana Medicare Advantage	$35.70
Rate for Payer: UnitedHealthcare Commercial	$58.74
Rate for Payer: UnitedHealthcare Commercial	$80.75
Rate for Payer: UnitedHealthcare Medicaid	$24.73
Rate for Payer: UnitedHealthcare Medicaid	$34.00
Rate for Payer: WPPA Medicare Advantage	$51.00
Rate for Payer: WPPA Medicare Advantage	$37.10

propofol 10 mg/mL EMU 100 mL [HMC]

Facility

$61.83

Service Code	HCPCS J2704
Hospital Charge Code	3170226
Hospital Revenue Code	250
Min. Negotiated Rate	$55.65
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$55.65
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: UnitedHealthcare Commercial	$80.75
Rate for Payer: UnitedHealthcare Commercial	$58.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

propofol 10 mg/mL IV Emul 20 mL [HMC]

Facility

$38.80

Service Code	HCPCS J2704
Hospital Charge Code	3170226
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$36.86
Rate for Payer: Aetna Commercial	$34.92
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.18
Rate for Payer: Humana Medicare Advantage	$16.30
Rate for Payer: UnitedHealthcare Commercial	$36.86
Rate for Payer: UnitedHealthcare Medicaid	$15.52
Rate for Payer: WPPA Medicare Advantage	$23.28

propofol 10 mg/mL IV Emul 20 mL [HMC]

Facility

$38.80

Service Code	HCPCS J2704
Hospital Charge Code	3170226
Hospital Revenue Code	250
Min. Negotiated Rate	$34.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.92
Rate for Payer: UnitedHealthcare Commercial	$36.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

propofol 10 mg/mL IV Emul 50 mL [HMC]

Facility

$60.40

Service Code	HCPCS J2704
Hospital Charge Code	3170229
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$57.38
Rate for Payer: Aetna Commercial	$54.36
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.18
Rate for Payer: Humana Medicare Advantage	$25.37
Rate for Payer: UnitedHealthcare Commercial	$57.38
Rate for Payer: UnitedHealthcare Medicaid	$24.16
Rate for Payer: WPPA Medicare Advantage	$36.24

propofol 10 mg/mL IV Emul 50 mL [HMC]

Facility

$60.40

Service Code	HCPCS J2704
Hospital Charge Code	3170229
Hospital Revenue Code	250
Min. Negotiated Rate	$54.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.36
Rate for Payer: UnitedHealthcare Commercial	$57.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

propranolol 10 mg Tab [HMC]

Facility

$5.90

Service Code	NDC 60687058701
Hospital Charge Code	3808173
Hospital Revenue Code	250
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$5.61
Rate for Payer: Aetna Commercial	$5.31
Rate for Payer: Humana Medicare Advantage	$2.48
Rate for Payer: UnitedHealthcare Commercial	$5.61
Rate for Payer: UnitedHealthcare Medicaid	$2.36
Rate for Payer: WPPA Medicare Advantage	$3.54

propranolol 10 mg Tab [HMC]

Facility

$6.05

Service Code	NDC 00904655061
Hospital Charge Code	3808173
Hospital Revenue Code	250
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.45
Rate for Payer: UnitedHealthcare Commercial	$5.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

propranolol 10 mg Tab [HMC]

Facility

$6.05

Service Code	NDC 00904655061
Hospital Charge Code	3808173
Hospital Revenue Code	250
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$5.75
Rate for Payer: Aetna Commercial	$5.45
Rate for Payer: Humana Medicare Advantage	$2.54
Rate for Payer: UnitedHealthcare Commercial	$5.75
Rate for Payer: UnitedHealthcare Medicaid	$2.42
Rate for Payer: WPPA Medicare Advantage	$3.63

propranolol 10 mg Tab [HMC]

Facility

$5.90

Service Code	NDC 60687058701
Hospital Charge Code	3808173
Hospital Revenue Code	250
Min. Negotiated Rate	$5.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.31
Rate for Payer: UnitedHealthcare Commercial	$5.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

propranolol 10 mg Tab [HMC]

Facility

$5.61

Service Code	NDC 51079027720
Hospital Charge Code	3808173
Hospital Revenue Code	250
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$5.33
Rate for Payer: Aetna Commercial	$5.05
Rate for Payer: Humana Medicare Advantage	$2.36
Rate for Payer: UnitedHealthcare Commercial	$5.33
Rate for Payer: UnitedHealthcare Medicaid	$2.24
Rate for Payer: WPPA Medicare Advantage	$3.37

propranolol 10 mg Tab [HMC]

Facility

$6.22

Service Code	NDC 69238207701
Hospital Charge Code	3808173
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.60
Rate for Payer: UnitedHealthcare Commercial	$5.91
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges