Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

pregabalin 25 mg oral capsule [HMC]

Facility

$26.07

Service Code	NDC 69238131009
Hospital Charge Code	3800229
Hospital Revenue Code	250
Min. Negotiated Rate	$10.43
Max. Negotiated Rate	$24.77
Rate for Payer: Aetna Commercial	$23.46
Rate for Payer: Humana Medicare Advantage	$10.95
Rate for Payer: UnitedHealthcare Commercial	$24.77
Rate for Payer: UnitedHealthcare Medicaid	$10.43
Rate for Payer: WPPA Medicare Advantage	$15.64

pregabalin 25 mg oral capsule [HMC]

Facility

$26.07

Service Code	NDC 69238131009
Hospital Charge Code	3800229
Hospital Revenue Code	250
Min. Negotiated Rate	$23.46
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.46
Rate for Payer: UnitedHealthcare Commercial	$24.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pregnancy Test Urine Qual

Facility

$93.00

Service Code	HCPCS 81025
Hospital Charge Code	3550650
Hospital Revenue Code	300
Min. Negotiated Rate	$83.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$83.70
Rate for Payer: UnitedHealthcare Commercial	$88.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pregnancy Test Urine Qual

Facility

$93.00

Service Code	HCPCS 81025
Hospital Charge Code	3550650
Hospital Revenue Code	300
Min. Negotiated Rate	$7.43
Max. Negotiated Rate	$88.35
Rate for Payer: Aetna Commercial	$83.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$27.14
Rate for Payer: Humana Medicare Advantage	$39.06
Rate for Payer: UnitedHealthcare Commercial	$88.35
Rate for Payer: UnitedHealthcare Medicaid	$7.43
Rate for Payer: WPPA Medicare Advantage	$55.80

Pregnenolone, LC/MS/MS QST

Facility

$177.00

Service Code	HCPCS 84140
Hospital Charge Code	3554140
Hospital Revenue Code	300
Min. Negotiated Rate	$159.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$159.30
Rate for Payer: UnitedHealthcare Commercial	$168.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pregnenolone, LC/MS/MS QST

Facility

$177.00

Service Code	HCPCS 84140
Hospital Charge Code	3554140
Hospital Revenue Code	300
Min. Negotiated Rate	$20.67
Max. Negotiated Rate	$168.15
Rate for Payer: Aetna Commercial	$159.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$62.53
Rate for Payer: Humana Medicare Advantage	$74.34
Rate for Payer: UnitedHealthcare Commercial	$168.15
Rate for Payer: UnitedHealthcare Medicaid	$20.67
Rate for Payer: WPPA Medicare Advantage	$106.20

PREMATURITY WITH MAJOR PROBLEMS

Facility

$1,200.00

Service Code	MSDRG 791
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PREMATURITY WITHOUT MAJOR PROBLEMS

Facility

$1,200.00

Service Code	MSDRG 792
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Preserve Hammertoe 2.8mm x 21mm 0 degree

Facility

$4,190.00

Service Code	HCPCS C1776
Hospital Charge Code	3258371
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,980.50
Rate for Payer: Aetna Commercial	$3,771.00
Rate for Payer: UnitedHealthcare Commercial	$3,980.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Preserve Hammertoe 2.8mm x 21mm 0 degree

Facility

$4,190.00

Service Code	HCPCS C1776
Hospital Charge Code	3258371
Hospital Revenue Code	278
Min. Negotiated Rate	$1,676.00
Max. Negotiated Rate	$3,980.50
Rate for Payer: Aetna Commercial	$3,771.00
Rate for Payer: Humana Medicare Advantage	$1,759.80
Rate for Payer: UnitedHealthcare Commercial	$3,980.50
Rate for Payer: UnitedHealthcare Medicaid	$1,676.00
Rate for Payer: WPPA Medicare Advantage	$2,514.00

Preserve Hammertoe 2.8mm x 21mm 10 degree

Facility

$4,190.00

Service Code	HCPCS C1776
Hospital Charge Code	3258372
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,980.50
Rate for Payer: Aetna Commercial	$3,771.00
Rate for Payer: UnitedHealthcare Commercial	$3,980.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Preserve Hammertoe 2.8mm x 21mm 10 degree

Facility

$4,190.00

Service Code	HCPCS C1776
Hospital Charge Code	3258372
Hospital Revenue Code	278
Min. Negotiated Rate	$1,676.00
Max. Negotiated Rate	$3,980.50
Rate for Payer: Aetna Commercial	$3,771.00
Rate for Payer: Humana Medicare Advantage	$1,759.80
Rate for Payer: UnitedHealthcare Commercial	$3,980.50
Rate for Payer: UnitedHealthcare Medicaid	$1,676.00
Rate for Payer: WPPA Medicare Advantage	$2,514.00

Preservision Eye Vitamins and Minerals Oral Cap [HMC]

Facility

$5.74

Service Code	NDC 24208069762
Hospital Charge Code	3800918
Hospital Revenue Code	250
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$5.45
Rate for Payer: Aetna Commercial	$5.17
Rate for Payer: Humana Medicare Advantage	$2.41
Rate for Payer: UnitedHealthcare Commercial	$5.45
Rate for Payer: UnitedHealthcare Medicaid	$2.30
Rate for Payer: WPPA Medicare Advantage	$3.44

Preservision Eye Vitamins and Minerals Oral Cap [HMC]

Facility

$5.74

Service Code	NDC 24208069762
Hospital Charge Code	3800918
Hospital Revenue Code	250
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.17
Rate for Payer: UnitedHealthcare Commercial	$5.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE

Facility

$335.58

Service Code	CPT 94640
Hospital Revenue Code	360
Min. Negotiated Rate	$69.09
Max. Negotiated Rate	$335.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$254.03
Rate for Payer: UnitedHealthcare Medicaid	$69.09
Rate for Payer: WPPA Medicare Advantage	$335.58

.Pre TR ABO/Rh

Facility

$63.00

Service Code	HCPCS 86900
Hospital Charge Code	3560081
Hospital Revenue Code	300
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.Pre TR ABO/Rh

Facility

$63.00

Service Code	HCPCS 86900
Hospital Charge Code	3560081
Hospital Revenue Code	300
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$210.75
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$210.75
Rate for Payer: Humana Medicare Advantage	$26.46
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: UnitedHealthcare Medicaid	$2.99
Rate for Payer: WPPA Medicare Advantage	$37.80

.Pre TR Antibody Screen Gel 2

Facility

$79.00

Service Code	HCPCS 86850
Hospital Charge Code	3560073
Hospital Revenue Code	300
Min. Negotiated Rate	$71.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$71.10
Rate for Payer: UnitedHealthcare Commercial	$75.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.Pre TR Antibody Screen Gel 2

Facility

$79.00

Service Code	HCPCS 86850
Hospital Charge Code	3560073
Hospital Revenue Code	300
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$91.28
Rate for Payer: Aetna Commercial	$71.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$91.28
Rate for Payer: Humana Medicare Advantage	$33.18
Rate for Payer: UnitedHealthcare Commercial	$75.05
Rate for Payer: UnitedHealthcare Medicaid	$8.30
Rate for Payer: WPPA Medicare Advantage	$47.40

.Pre TR Crossmatch

Facility

$113.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$101.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.Pre TR Crossmatch

Facility

$113.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$42.03
Max. Negotiated Rate	$107.35
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$42.03
Rate for Payer: Humana Medicare Advantage	$47.46
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: UnitedHealthcare Medicaid	$45.20
Rate for Payer: WPPA Medicare Advantage	$67.80

.Pre TR DAT IgG Gel

Facility

$151.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$135.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$135.90
Rate for Payer: UnitedHealthcare Commercial	$143.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.Pre TR DAT IgG Gel

Facility

$151.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$143.45
Rate for Payer: Aetna Commercial	$135.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.24
Rate for Payer: Humana Medicare Advantage	$63.42
Rate for Payer: UnitedHealthcare Commercial	$143.45
Rate for Payer: UnitedHealthcare Medicaid	$5.39
Rate for Payer: WPPA Medicare Advantage	$90.60

Primary Sapphire Infusion Set, Microbore, Yellow-Striped Tubing 117IN

Facility

$86.99

Hospital Charge Code	3259420
Hospital Revenue Code	270
Min. Negotiated Rate	$78.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$78.29
Rate for Payer: UnitedHealthcare Commercial	$82.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Primary Sapphire Infusion Set, Microbore, Yellow-Striped Tubing 117IN

Facility

$86.99

Hospital Charge Code	3259420
Hospital Revenue Code	270
Min. Negotiated Rate	$34.80
Max. Negotiated Rate	$82.64
Rate for Payer: Aetna Commercial	$78.29
Rate for Payer: Humana Medicare Advantage	$36.54
Rate for Payer: UnitedHealthcare Commercial	$82.64
Rate for Payer: UnitedHealthcare Medicaid	$34.80
Rate for Payer: WPPA Medicare Advantage	$52.19

Know your out-of-pocket cost for care.

All Charges