Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

PICC Line Insertion

Facility

$5,306.00

Service Code	HCPCS 36569
Hospital Charge Code	3150655
Hospital Revenue Code	360
Min. Negotiated Rate	$773.97
Max. Negotiated Rate	$5,040.70
Rate for Payer: Aetna Commercial	$4,775.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$773.97
Rate for Payer: Humana Medicare Advantage	$2,228.52
Rate for Payer: UnitedHealthcare Commercial	$5,040.70
Rate for Payer: UnitedHealthcare Medicaid	$3,211.00
Rate for Payer: WPPA Medicare Advantage	$3,183.60

PICC Stabilization Device

Facility

$16.83

Hospital Charge Code	3258163
Hospital Revenue Code	270
Min. Negotiated Rate	$6.73
Max. Negotiated Rate	$15.99
Rate for Payer: Aetna Commercial	$15.15
Rate for Payer: Humana Medicare Advantage	$7.07
Rate for Payer: UnitedHealthcare Commercial	$15.99
Rate for Payer: UnitedHealthcare Medicaid	$6.73
Rate for Payer: WPPA Medicare Advantage	$10.10

PICC Stabilization Device

Facility

$16.83

Hospital Charge Code	3258163
Hospital Revenue Code	270
Min. Negotiated Rate	$15.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.15
Rate for Payer: UnitedHealthcare Commercial	$15.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PILLOW HIP ABDUCTION SMALL

Facility

$121.00

Hospital Charge Code	3259830
Hospital Revenue Code	270
Min. Negotiated Rate	$108.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$108.90
Rate for Payer: UnitedHealthcare Commercial	$114.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PILLOW HIP ABDUCTION SMALL

Facility

$121.00

Hospital Charge Code	3259830
Hospital Revenue Code	270
Min. Negotiated Rate	$48.40
Max. Negotiated Rate	$114.95
Rate for Payer: Aetna Commercial	$108.90
Rate for Payer: Humana Medicare Advantage	$50.82
Rate for Payer: UnitedHealthcare Commercial	$114.95
Rate for Payer: UnitedHealthcare Medicaid	$48.40
Rate for Payer: WPPA Medicare Advantage	$72.60

Pill Splitter/Cutter

Facility

$8.00

Hospital Charge Code	3250003
Hospital Revenue Code	270
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.20
Rate for Payer: UnitedHealthcare Commercial	$7.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pill Splitter/Cutter

Facility

$8.00

Hospital Charge Code	3250003
Hospital Revenue Code	270
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$7.60
Rate for Payer: Aetna Commercial	$7.20
Rate for Payer: Humana Medicare Advantage	$3.36
Rate for Payer: UnitedHealthcare Commercial	$7.60
Rate for Payer: UnitedHealthcare Medicaid	$3.20
Rate for Payer: WPPA Medicare Advantage	$4.80

pilocarpine 5 mg Tab [HMC]

Facility

$14.01

Service Code	NDC 68084092825
Hospital Charge Code	3800928
Hospital Revenue Code	250
Min. Negotiated Rate	$12.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.61
Rate for Payer: UnitedHealthcare Commercial	$13.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pilocarpine 5 mg Tab [HMC]

Facility

$11.07

Service Code	NDC 59212070510
Hospital Charge Code	3800928
Hospital Revenue Code	250
Min. Negotiated Rate	$9.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.96
Rate for Payer: UnitedHealthcare Commercial	$10.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pilocarpine 5 mg Tab [HMC]

Facility

$11.07

Service Code	NDC 59212070510
Hospital Charge Code	3800928
Hospital Revenue Code	250
Min. Negotiated Rate	$4.43
Max. Negotiated Rate	$10.52
Rate for Payer: Aetna Commercial	$9.96
Rate for Payer: Humana Medicare Advantage	$4.65
Rate for Payer: UnitedHealthcare Commercial	$10.52
Rate for Payer: UnitedHealthcare Medicaid	$4.43
Rate for Payer: WPPA Medicare Advantage	$6.64

pilocarpine 5 mg Tab [HMC]

Facility

$14.01

Service Code	NDC 68084092825
Hospital Charge Code	3800928
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$13.31
Rate for Payer: Aetna Commercial	$12.61
Rate for Payer: Humana Medicare Advantage	$5.88
Rate for Payer: UnitedHealthcare Commercial	$13.31
Rate for Payer: UnitedHealthcare Medicaid	$5.60
Rate for Payer: WPPA Medicare Advantage	$8.41

pilocarpine 5 mg Tab [HMC]

Facility

$6.47

Service Code	NDC 00574079201
Hospital Charge Code	3800928
Hospital Revenue Code	250
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.82
Rate for Payer: UnitedHealthcare Commercial	$6.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pilocarpine 5 mg Tab [HMC]

Facility

$6.47

Service Code	NDC 00574079201
Hospital Charge Code	3800928
Hospital Revenue Code	250
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$6.15
Rate for Payer: Aetna Commercial	$5.82
Rate for Payer: Humana Medicare Advantage	$2.72
Rate for Payer: UnitedHealthcare Commercial	$6.15
Rate for Payer: UnitedHealthcare Medicaid	$2.59
Rate for Payer: WPPA Medicare Advantage	$3.88

pindolol 5 mg Tab [HMC]

Facility

$8.96

Service Code	NDC 00378005201
Hospital Charge Code	3806623
Hospital Revenue Code	250
Min. Negotiated Rate	$3.58
Max. Negotiated Rate	$8.51
Rate for Payer: Aetna Commercial	$8.06
Rate for Payer: Humana Medicare Advantage	$3.76
Rate for Payer: UnitedHealthcare Commercial	$8.51
Rate for Payer: UnitedHealthcare Medicaid	$3.58
Rate for Payer: WPPA Medicare Advantage	$5.38

pindolol 5 mg Tab [HMC]

Facility

$8.96

Service Code	NDC 00378005201
Hospital Charge Code	3806623
Hospital Revenue Code	250
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.06
Rate for Payer: UnitedHealthcare Commercial	$8.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pioglitazone 15 mg Tab [HMC]

Facility

$22.51

Service Code	NDC 57237021930
Hospital Charge Code	3808009
Hospital Revenue Code	250
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$21.38
Rate for Payer: Aetna Commercial	$20.26
Rate for Payer: Humana Medicare Advantage	$9.45
Rate for Payer: UnitedHealthcare Commercial	$21.38
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: WPPA Medicare Advantage	$13.51

pioglitazone 15 mg Tab [HMC]

Facility

$36.09

Service Code	NDC 64764015104
Hospital Charge Code	3808009
Hospital Revenue Code	250
Min. Negotiated Rate	$32.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$32.48
Rate for Payer: UnitedHealthcare Commercial	$34.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pioglitazone 15 mg Tab [HMC]

Facility

$36.09

Service Code	NDC 64764015104
Hospital Charge Code	3808009
Hospital Revenue Code	250
Min. Negotiated Rate	$14.44
Max. Negotiated Rate	$34.29
Rate for Payer: Aetna Commercial	$32.48
Rate for Payer: Humana Medicare Advantage	$15.16
Rate for Payer: UnitedHealthcare Commercial	$34.29
Rate for Payer: UnitedHealthcare Medicaid	$14.44
Rate for Payer: WPPA Medicare Advantage	$21.65

pioglitazone 15 mg Tab [HMC]

Facility

$22.51

Service Code	NDC 57237021930
Hospital Charge Code	3808009
Hospital Revenue Code	250
Min. Negotiated Rate	$20.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.26
Rate for Payer: UnitedHealthcare Commercial	$21.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

piperacillin-tazobactam 2 g-0.25 g IV Inj [HMC]

Facility

$44.34

Service Code	HCPCS J2543
Hospital Charge Code	3802635
Hospital Revenue Code	250
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$42.12
Rate for Payer: Aetna Commercial	$39.91
Rate for Payer: Aetna Commercial	$32.05
Rate for Payer: Aetna Commercial	$48.15
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Humana Medicare Advantage	$18.62
Rate for Payer: Humana Medicare Advantage	$14.96
Rate for Payer: Humana Medicare Advantage	$22.47
Rate for Payer: UnitedHealthcare Commercial	$33.83
Rate for Payer: UnitedHealthcare Commercial	$42.12
Rate for Payer: UnitedHealthcare Commercial	$50.83
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: WPPA Medicare Advantage	$32.10
Rate for Payer: WPPA Medicare Advantage	$26.60
Rate for Payer: WPPA Medicare Advantage	$21.37

piperacillin-tazobactam 2 g-0.25 g IV Inj [HMC]

Facility

$53.50

Service Code	HCPCS J2543
Hospital Charge Code	3802635
Hospital Revenue Code	250
Min. Negotiated Rate	$48.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.15
Rate for Payer: Aetna Commercial	$32.05
Rate for Payer: Aetna Commercial	$39.91
Rate for Payer: UnitedHealthcare Commercial	$33.83
Rate for Payer: UnitedHealthcare Commercial	$42.12
Rate for Payer: UnitedHealthcare Commercial	$50.83
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

piperacillin-tazobactam 3 g-0.375 g IV Inj [HMC]

Facility

$65.39

Service Code	HCPCS J2543
Hospital Charge Code	3802648
Hospital Revenue Code	250
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$62.12
Rate for Payer: Aetna Commercial	$58.85
Rate for Payer: Aetna Commercial	$42.88
Rate for Payer: Aetna Commercial	$31.25
Rate for Payer: Aetna Commercial	$55.38
Rate for Payer: Aetna Commercial	$48.16
Rate for Payer: Aetna Commercial	$44.64
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Humana Medicare Advantage	$27.46
Rate for Payer: Humana Medicare Advantage	$14.58
Rate for Payer: Humana Medicare Advantage	$25.84
Rate for Payer: Humana Medicare Advantage	$22.47
Rate for Payer: Humana Medicare Advantage	$20.83
Rate for Payer: Humana Medicare Advantage	$20.01
Rate for Payer: UnitedHealthcare Commercial	$58.45
Rate for Payer: UnitedHealthcare Commercial	$47.12
Rate for Payer: UnitedHealthcare Commercial	$45.27
Rate for Payer: UnitedHealthcare Commercial	$32.98
Rate for Payer: UnitedHealthcare Commercial	$50.83
Rate for Payer: UnitedHealthcare Commercial	$62.12
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: WPPA Medicare Advantage	$39.23
Rate for Payer: WPPA Medicare Advantage	$20.83
Rate for Payer: WPPA Medicare Advantage	$28.59
Rate for Payer: WPPA Medicare Advantage	$29.76
Rate for Payer: WPPA Medicare Advantage	$32.11
Rate for Payer: WPPA Medicare Advantage	$36.92

piperacillin-tazobactam 3 g-0.375 g IV Inj [HMC]

Facility

$34.72

Service Code	HCPCS J2543
Hospital Charge Code	3802648
Hospital Revenue Code	250
Min. Negotiated Rate	$31.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.25
Rate for Payer: Aetna Commercial	$42.88
Rate for Payer: Aetna Commercial	$44.64
Rate for Payer: Aetna Commercial	$48.16
Rate for Payer: Aetna Commercial	$55.38
Rate for Payer: Aetna Commercial	$58.85
Rate for Payer: UnitedHealthcare Commercial	$62.12
Rate for Payer: UnitedHealthcare Commercial	$32.98
Rate for Payer: UnitedHealthcare Commercial	$50.83
Rate for Payer: UnitedHealthcare Commercial	$58.45
Rate for Payer: UnitedHealthcare Commercial	$45.27
Rate for Payer: UnitedHealthcare Commercial	$47.12
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
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

piperacillin-tazobactam 4 g-0.5 g IV Inj [HMC]

Facility

$53.50

Service Code	HCPCS J2543
Hospital Charge Code	3805066
Hospital Revenue Code	250
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$50.83
Rate for Payer: Aetna Commercial	$48.15
Rate for Payer: Aetna Commercial	$49.45
Rate for Payer: Aetna Commercial	$51.09
Rate for Payer: Aetna Commercial	$58.59
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.58
Rate for Payer: Humana Medicare Advantage	$27.34
Rate for Payer: Humana Medicare Advantage	$23.84
Rate for Payer: Humana Medicare Advantage	$23.07
Rate for Payer: Humana Medicare Advantage	$22.47
Rate for Payer: UnitedHealthcare Commercial	$61.84
Rate for Payer: UnitedHealthcare Commercial	$52.19
Rate for Payer: UnitedHealthcare Commercial	$50.83
Rate for Payer: UnitedHealthcare Commercial	$53.93
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: WPPA Medicare Advantage	$39.06
Rate for Payer: WPPA Medicare Advantage	$34.06
Rate for Payer: WPPA Medicare Advantage	$32.96
Rate for Payer: WPPA Medicare Advantage	$32.10

piperacillin-tazobactam 4 g-0.5 g IV Inj [HMC]

Facility

$53.50

Service Code	HCPCS J2543
Hospital Charge Code	3805066
Hospital Revenue Code	250
Min. Negotiated Rate	$48.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.15
Rate for Payer: Aetna Commercial	$58.59
Rate for Payer: Aetna Commercial	$49.45
Rate for Payer: Aetna Commercial	$51.09
Rate for Payer: UnitedHealthcare Commercial	$52.19
Rate for Payer: UnitedHealthcare Commercial	$61.84
Rate for Payer: UnitedHealthcare Commercial	$50.83
Rate for Payer: UnitedHealthcare Commercial	$53.93
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
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges