Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

pralidoxime 1 g IV Inj [HMC]

Facility

$176.06

Service Code	HCPCS J2730
Hospital Charge Code	3806904
Hospital Revenue Code	250
Min. Negotiated Rate	$158.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$158.45
Rate for Payer: UnitedHealthcare Commercial	$167.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pralidoxime 1 g IV Inj [HMC]

Facility

$176.06

Service Code	HCPCS J2730
Hospital Charge Code	3806904
Hospital Revenue Code	250
Min. Negotiated Rate	$70.42
Max. Negotiated Rate	$167.26
Rate for Payer: Aetna Commercial	$158.45
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$107.66
Rate for Payer: Humana Medicare Advantage	$73.95
Rate for Payer: UnitedHealthcare Commercial	$167.26
Rate for Payer: UnitedHealthcare Medicaid	$70.42
Rate for Payer: WPPA Medicare Advantage	$105.64

pramipexole 0.25 mg Tab [HMC]

Facility

$13.82

Service Code	NDC 13668009290
Hospital Charge Code	3800202
Hospital Revenue Code	250
Min. Negotiated Rate	$12.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.44
Rate for Payer: UnitedHealthcare Commercial	$13.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pramipexole 0.25 mg Tab [HMC]

Facility

$5.93

Service Code	NDC 00904670461
Hospital Charge Code	3800202
Hospital Revenue Code	250
Min. Negotiated Rate	$5.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.34
Rate for Payer: UnitedHealthcare Commercial	$5.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pramipexole 0.25 mg Tab [HMC]

Facility

$13.82

Service Code	NDC 13668009290
Hospital Charge Code	3800202
Hospital Revenue Code	250
Min. Negotiated Rate	$5.53
Max. Negotiated Rate	$13.13
Rate for Payer: Aetna Commercial	$12.44
Rate for Payer: Humana Medicare Advantage	$5.80
Rate for Payer: UnitedHealthcare Commercial	$13.13
Rate for Payer: UnitedHealthcare Medicaid	$5.53
Rate for Payer: WPPA Medicare Advantage	$8.29

pramipexole 0.25 mg Tab [HMC]

Facility

$5.93

Service Code	NDC 00904670461
Hospital Charge Code	3800202
Hospital Revenue Code	250
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$5.63
Rate for Payer: Aetna Commercial	$5.34
Rate for Payer: Humana Medicare Advantage	$2.49
Rate for Payer: UnitedHealthcare Commercial	$5.63
Rate for Payer: UnitedHealthcare Medicaid	$2.37
Rate for Payer: WPPA Medicare Advantage	$3.56

pramlintide 1000 mcg/mL SC Sol [HMC]

Facility

$391.90

Service Code	NDC 66780011502
Hospital Charge Code	3800706
Hospital Revenue Code	250
Min. Negotiated Rate	$352.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$352.71
Rate for Payer: UnitedHealthcare Commercial	$372.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pramlintide 1000 mcg/mL SC Sol [HMC]

Facility

$391.90

Service Code	NDC 66780011502
Hospital Charge Code	3800706
Hospital Revenue Code	250
Min. Negotiated Rate	$156.76
Max. Negotiated Rate	$372.31
Rate for Payer: Aetna Commercial	$352.71
Rate for Payer: Humana Medicare Advantage	$164.60
Rate for Payer: UnitedHealthcare Commercial	$372.31
Rate for Payer: UnitedHealthcare Medicaid	$156.76
Rate for Payer: WPPA Medicare Advantage	$235.14

pramoxine-zinc acetate topical 1%-0.1% Lot [HMC]

Facility

$28.24

Service Code	NDC 00904776021
Hospital Charge Code	3809783
Hospital Revenue Code	250
Min. Negotiated Rate	$25.42
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.42
Rate for Payer: UnitedHealthcare Commercial	$26.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pramoxine-zinc acetate topical 1%-0.1% Lot [HMC]

Facility

$29.26

Service Code	NDC 01875046606
Hospital Charge Code	3809783
Hospital Revenue Code	250
Min. Negotiated Rate	$26.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.33
Rate for Payer: UnitedHealthcare Commercial	$27.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pramoxine-zinc acetate topical 1%-0.1% Lot [HMC]

Facility

$29.26

Service Code	NDC 01875046606
Hospital Charge Code	3809783
Hospital Revenue Code	250
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$27.80
Rate for Payer: Aetna Commercial	$26.33
Rate for Payer: Humana Medicare Advantage	$12.29
Rate for Payer: UnitedHealthcare Commercial	$27.80
Rate for Payer: UnitedHealthcare Medicaid	$11.70
Rate for Payer: WPPA Medicare Advantage	$17.56

pramoxine-zinc acetate topical 1%-0.1% Lot [HMC]

Facility

$28.24

Service Code	NDC 00904776021
Hospital Charge Code	3809783
Hospital Revenue Code	250
Min. Negotiated Rate	$11.30
Max. Negotiated Rate	$26.83
Rate for Payer: Aetna Commercial	$25.42
Rate for Payer: Humana Medicare Advantage	$11.86
Rate for Payer: UnitedHealthcare Commercial	$26.83
Rate for Payer: UnitedHealthcare Medicaid	$11.30
Rate for Payer: WPPA Medicare Advantage	$16.94

prasugrel 10 mg Tab [HMC]

Facility

$41.72

Service Code	NDC 00002512330
Hospital Charge Code	3806352
Hospital Revenue Code	250
Min. Negotiated Rate	$37.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$37.55
Rate for Payer: UnitedHealthcare Commercial	$39.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

prasugrel 10 mg Tab [HMC]

Facility

$41.72

Service Code	NDC 00002512330
Hospital Charge Code	3806352
Hospital Revenue Code	250
Min. Negotiated Rate	$16.69
Max. Negotiated Rate	$39.63
Rate for Payer: Aetna Commercial	$37.55
Rate for Payer: Humana Medicare Advantage	$17.52
Rate for Payer: UnitedHealthcare Commercial	$39.63
Rate for Payer: UnitedHealthcare Medicaid	$16.69
Rate for Payer: WPPA Medicare Advantage	$25.03

prasugrel 10 mg Tab [HMC]

Facility

$38.01

Service Code	NDC 60505464303
Hospital Charge Code	3806352
Hospital Revenue Code	250
Min. Negotiated Rate	$34.21
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.21
Rate for Payer: UnitedHealthcare Commercial	$36.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

prasugrel 10 mg Tab [HMC]

Facility

$38.01

Service Code	NDC 60505464303
Hospital Charge Code	3806352
Hospital Revenue Code	250
Min. Negotiated Rate	$15.20
Max. Negotiated Rate	$36.11
Rate for Payer: Aetna Commercial	$34.21
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: UnitedHealthcare Commercial	$36.11
Rate for Payer: UnitedHealthcare Medicaid	$15.20
Rate for Payer: WPPA Medicare Advantage	$22.81

pravastatin 10 mg Tab [HMC]

Facility

$13.68

Service Code	NDC 00904589161
Hospital Charge Code	3809453
Hospital Revenue Code	250
Min. Negotiated Rate	$12.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.31
Rate for Payer: UnitedHealthcare Commercial	$13.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pravastatin 10 mg Tab [HMC]

Facility

$14.60

Service Code	NDC 60687016901
Hospital Charge Code	3809453
Hospital Revenue Code	250
Min. Negotiated Rate	$5.84
Max. Negotiated Rate	$13.87
Rate for Payer: Aetna Commercial	$13.14
Rate for Payer: Humana Medicare Advantage	$6.13
Rate for Payer: UnitedHealthcare Commercial	$13.87
Rate for Payer: UnitedHealthcare Medicaid	$5.84
Rate for Payer: WPPA Medicare Advantage	$8.76

pravastatin 10 mg Tab [HMC]

Facility

$13.68

Service Code	NDC 00904589161
Hospital Charge Code	3809453
Hospital Revenue Code	250
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.31
Rate for Payer: Humana Medicare Advantage	$5.75
Rate for Payer: UnitedHealthcare Commercial	$13.00
Rate for Payer: UnitedHealthcare Medicaid	$5.47
Rate for Payer: WPPA Medicare Advantage	$8.21

pravastatin 10 mg Tab [HMC]

Facility

$14.60

Service Code	NDC 60687016901
Hospital Charge Code	3809453
Hospital Revenue Code	250
Min. Negotiated Rate	$13.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.14
Rate for Payer: UnitedHealthcare Commercial	$13.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pravastatin 20 mg Tab [HMC]

Facility

$14.80

Service Code	NDC 51079045820
Hospital Charge Code	3800212
Hospital Revenue Code	250
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: UnitedHealthcare Commercial	$14.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pravastatin 20 mg Tab [HMC]

Facility

$14.80

Service Code	NDC 51079045820
Hospital Charge Code	3800212
Hospital Revenue Code	250
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$14.06
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: Humana Medicare Advantage	$6.22
Rate for Payer: UnitedHealthcare Commercial	$14.06
Rate for Payer: UnitedHealthcare Medicaid	$5.92
Rate for Payer: WPPA Medicare Advantage	$8.88

pravastatin 20 mg Tab [HMC]

Facility

$12.48

Service Code	NDC 00904589261
Hospital Charge Code	3800212
Hospital Revenue Code	250
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.23
Rate for Payer: UnitedHealthcare Commercial	$11.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pravastatin 20 mg Tab [HMC]

Facility

$12.48

Service Code	NDC 00904589261
Hospital Charge Code	3800212
Hospital Revenue Code	250
Min. Negotiated Rate	$4.99
Max. Negotiated Rate	$11.86
Rate for Payer: Aetna Commercial	$11.23
Rate for Payer: Humana Medicare Advantage	$5.24
Rate for Payer: UnitedHealthcare Commercial	$11.86
Rate for Payer: UnitedHealthcare Medicaid	$4.99
Rate for Payer: WPPA Medicare Advantage	$7.49

prazosin 5 mg Cap [HMC]

Facility

$17.92

Service Code	NDC 51079063220
Hospital Charge Code	3807382
Hospital Revenue Code	250
Min. Negotiated Rate	$7.17
Max. Negotiated Rate	$17.02
Rate for Payer: Aetna Commercial	$16.13
Rate for Payer: Humana Medicare Advantage	$7.53
Rate for Payer: UnitedHealthcare Commercial	$17.02
Rate for Payer: UnitedHealthcare Medicaid	$7.17
Rate for Payer: WPPA Medicare Advantage	$10.75

Know your out-of-pocket cost for care.

All Charges