Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

pentoxifylline 400 mg ER Tab [HMC]

Facility

$8.42

Service Code	NDC 60505003306
Hospital Charge Code	3800890
Hospital Revenue Code	250
Min. Negotiated Rate	$7.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.58
Rate for Payer: UnitedHealthcare Commercial	$8.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC

Facility

$14,773.05

Service Code	MSDRG 273
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,773.05
Rate for Payer: UnitedHealthcare Medicaid	$14,773.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC

Facility

$11,468.97

Service Code	MSDRG 274
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,468.97
Rate for Payer: UnitedHealthcare Medicaid	$11,468.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES

Facility

$11,087.73

Service Code	MSDRG 321
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,087.73
Rate for Payer: UnitedHealthcare Medicaid	$11,087.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$7,497.72

Service Code	MSDRG 322
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,497.72
Rate for Payer: UnitedHealthcare Medicaid	$7,497.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC

Facility

$7,815.42

Service Code	MSDRG 250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,815.42
Rate for Payer: UnitedHealthcare Medicaid	$7,815.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC

Facility

$5,369.13

Service Code	MSDRG 251
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,369.13
Rate for Payer: UnitedHealthcare Medicaid	$5,369.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC

Facility

$12,326.76

Service Code	MSDRG 359
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,326.76
Rate for Payer: UnitedHealthcare Medicaid	$12,326.76
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$8,641.44

Service Code	MSDRG 360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,641.44
Rate for Payer: UnitedHealthcare Medicaid	$8,641.44
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE

Facility

$8,673.21

Service Code	MSDRG 318
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,673.21
Rate for Payer: UnitedHealthcare Medicaid	$8,673.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Percutaneous Drainage Kit with Cath

Facility

$626.28

Hospital Charge Code	3252057
Hospital Revenue Code	270
Min. Negotiated Rate	$563.65
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$563.65
Rate for Payer: UnitedHealthcare Commercial	$594.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Percutaneous Drainage Kit with Cath

Facility

$626.28

Hospital Charge Code	3252057
Hospital Revenue Code	270
Min. Negotiated Rate	$250.51
Max. Negotiated Rate	$594.97
Rate for Payer: Aetna Commercial	$563.65
Rate for Payer: Humana Medicare Advantage	$263.04
Rate for Payer: UnitedHealthcare Commercial	$594.97
Rate for Payer: UnitedHealthcare Medicaid	$250.51
Rate for Payer: WPPA Medicare Advantage	$375.77

perflutren (lipid microspheres) Sus [HMC]

Facility

$623.63

Service Code	HCPCS Q9957
Hospital Charge Code	3629957
Hospital Revenue Code	250
Min. Negotiated Rate	$96.86
Max. Negotiated Rate	$592.45
Rate for Payer: Aetna Commercial	$561.27
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$96.86
Rate for Payer: Humana Medicare Advantage	$261.92
Rate for Payer: UnitedHealthcare Commercial	$592.45
Rate for Payer: UnitedHealthcare Medicaid	$249.45
Rate for Payer: WPPA Medicare Advantage	$374.18

perflutren (lipid microspheres) Sus [HMC]

Facility

$623.63

Service Code	HCPCS Q9957
Hospital Charge Code	3629957
Hospital Revenue Code	250
Min. Negotiated Rate	$561.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$561.27
Rate for Payer: UnitedHealthcare Commercial	$592.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pergolide 0.05 mg Tab [HMC]

Facility

$10.09

Service Code	NDC 00187083901
Hospital Charge Code	3809270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$9.59
Rate for Payer: Aetna Commercial	$9.08
Rate for Payer: Humana Medicare Advantage	$4.24
Rate for Payer: UnitedHealthcare Commercial	$9.59
Rate for Payer: UnitedHealthcare Medicaid	$4.04
Rate for Payer: WPPA Medicare Advantage	$6.05

pergolide 0.05 mg Tab [HMC]

Facility

$10.09

Service Code	NDC 00187083901
Hospital Charge Code	3809270
Hospital Revenue Code	250
Min. Negotiated Rate	$9.08
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.08
Rate for Payer: UnitedHealthcare Commercial	$9.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR

Facility

$8,006.04

Service Code	MSDRG 041
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,006.04
Rate for Payer: UnitedHealthcare Medicaid	$8,006.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC

Facility

$14,042.34

Service Code	MSDRG 040
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,042.34
Rate for Payer: UnitedHealthcare Medicaid	$14,042.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC

Facility

$6,290.46

Service Code	MSDRG 042
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,290.46
Rate for Payer: UnitedHealthcare Medicaid	$6,290.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERIPHERAL VASCULAR DISORDERS WITH CC

Facility

$4,701.96

Service Code	MSDRG 300
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,701.96
Rate for Payer: UnitedHealthcare Medicaid	$4,701.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERIPHERAL VASCULAR DISORDERS WITH MCC

Facility

$7,180.02

Service Code	MSDRG 299
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,180.02
Rate for Payer: UnitedHealthcare Medicaid	$7,180.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC

Facility

$3,145.23

Service Code	MSDRG 301
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,145.23
Rate for Payer: UnitedHealthcare Medicaid	$3,145.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERITONEAL ADHESIOLYSIS WITH CC

Facility

$7,974.27

Service Code	MSDRG 336
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,974.27
Rate for Payer: UnitedHealthcare Medicaid	$7,974.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERITONEAL ADHESIOLYSIS WITH MCC

Facility

$13,502.25

Service Code	MSDRG 335
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$13,502.25
Rate for Payer: UnitedHealthcare Medicaid	$13,502.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC

Facility

$5,813.91

Service Code	MSDRG 337
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,813.91
Rate for Payer: UnitedHealthcare Medicaid	$5,813.91
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges