Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

PT Vasopneumatic Devices Units

Facility

$197.00

Service Code	HCPCS 97016 GP
Hospital Charge Code	3957016
Hospital Revenue Code	420
Min. Negotiated Rate	$177.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$177.30
Rate for Payer: UnitedHealthcare Commercial	$187.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Vasopneumatic Devices Units

Facility

$197.00

Service Code	HCPCS 97016 GP
Hospital Charge Code	3957016
Hospital Revenue Code	420
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$187.15
Rate for Payer: Aetna Commercial	$177.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.33
Rate for Payer: Humana Medicare Advantage	$82.74
Rate for Payer: UnitedHealthcare Commercial	$187.15
Rate for Payer: UnitedHealthcare Medicaid	$16.50
Rate for Payer: WPPA Medicare Advantage	$118.20

PT Whirlpool, Fluidotherapy Assist Units

Facility

$72.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	3950176
Hospital Revenue Code	420
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Whirlpool, Fluidotherapy Assist Units

Facility

$72.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	3950176
Hospital Revenue Code	420
Min. Negotiated Rate	$14.41
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.33
Rate for Payer: Humana Medicare Advantage	$30.24
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$14.41
Rate for Payer: WPPA Medicare Advantage	$43.20

PT Whirlpool, Fluidotherapy Units

Facility

$72.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	3950176
Hospital Revenue Code	420
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Whirlpool, Fluidotherapy Units

Facility

$72.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	3950176
Hospital Revenue Code	420
Min. Negotiated Rate	$14.41
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.33
Rate for Payer: Humana Medicare Advantage	$30.24
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$14.41
Rate for Payer: WPPA Medicare Advantage	$43.20

Pudendal Block Tray 10cc

Facility

$55.00

Hospital Charge Code	3257970
Hospital Revenue Code	270
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$49.50
Rate for Payer: UnitedHealthcare Commercial	$52.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pudendal Block Tray 10cc

Facility

$55.00

Hospital Charge Code	3257970
Hospital Revenue Code	270
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$52.25
Rate for Payer: Aetna Commercial	$49.50
Rate for Payer: Humana Medicare Advantage	$23.10
Rate for Payer: UnitedHealthcare Commercial	$52.25
Rate for Payer: UnitedHealthcare Medicaid	$22.00
Rate for Payer: WPPA Medicare Advantage	$33.00

PULMONARY EDEMA AND RESPIRATORY FAILURE

Facility

$4,638.42

Service Code	MSDRG 189
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,638.42
Rate for Payer: UnitedHealthcare Medicaid	$4,638.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE

Facility

$5,305.59

Service Code	MSDRG 175
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,305.59
Rate for Payer: UnitedHealthcare Medicaid	$5,305.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PULMONARY EMBOLISM WITHOUT MCC

Facility

$3,113.46

Service Code	MSDRG 176
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,113.46
Rate for Payer: UnitedHealthcare Medicaid	$3,113.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PULSE OXIMETRY CONTINUOUS CHARGE

Facility

$119.00

Service Code	HCPCS 93041
Hospital Charge Code	3259129
Hospital Revenue Code	730
Min. Negotiated Rate	$19.82
Max. Negotiated Rate	$113.05
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$73.10
Rate for Payer: Humana Medicare Advantage	$49.98
Rate for Payer: UnitedHealthcare Commercial	$113.05
Rate for Payer: UnitedHealthcare Medicaid	$19.82
Rate for Payer: WPPA Medicare Advantage	$71.40

PULSE OXIMETRY CONTINUOUS CHARGE

Facility

$119.00

Service Code	HCPCS 93041
Hospital Charge Code	3259129
Hospital Revenue Code	730
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: UnitedHealthcare Commercial	$113.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pulse Oximetry Overnight Study

Facility

$538.00

Service Code	HCPCS 94762
Hospital Charge Code	3900480
Hospital Revenue Code	460
Min. Negotiated Rate	$50.60
Max. Negotiated Rate	$511.10
Rate for Payer: Aetna Commercial	$484.20
Rate for Payer: Aetna Commercial	$460.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$65.16
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$65.16
Rate for Payer: Humana Medicare Advantage	$215.04
Rate for Payer: Humana Medicare Advantage	$225.96
Rate for Payer: UnitedHealthcare Commercial	$486.40
Rate for Payer: UnitedHealthcare Commercial	$511.10
Rate for Payer: UnitedHealthcare Medicaid	$50.60
Rate for Payer: UnitedHealthcare Medicaid	$50.60
Rate for Payer: WPPA Medicare Advantage	$322.80
Rate for Payer: WPPA Medicare Advantage	$307.20

Pulse Oximetry Overnight Study

Facility

$512.00

Service Code	HCPCS 94762
Hospital Charge Code	3900480
Hospital Revenue Code	460
Min. Negotiated Rate	$460.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$460.80
Rate for Payer: Aetna Commercial	$484.20
Rate for Payer: UnitedHealthcare Commercial	$511.10
Rate for Payer: UnitedHealthcare Commercial	$486.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pulse Oximetry POC

Facility

$118.00

Service Code	HCPCS 94760
Hospital Charge Code	3290120
Hospital Revenue Code	761
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$112.10
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$9.13
Rate for Payer: Humana Medicare Advantage	$49.56
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: UnitedHealthcare Medicaid	$9.03
Rate for Payer: WPPA Medicare Advantage	$70.80

Pulse Oximetry POC

Facility

$118.00

Service Code	HCPCS 94760
Hospital Charge Code	3290120
Hospital Revenue Code	761
Min. Negotiated Rate	$106.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PULSE OXIMETRY SINGLE CHARGE

Facility

$118.00

Service Code	HCPCS 94760
Hospital Charge Code	3900037
Hospital Revenue Code	460
Min. Negotiated Rate	$106.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PULSE OXIMETRY SINGLE CHARGE

Facility

$118.00

Service Code	HCPCS 94760
Hospital Charge Code	3900037
Hospital Revenue Code	460
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$112.10
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$9.13
Rate for Payer: Humana Medicare Advantage	$49.56
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: UnitedHealthcare Medicaid	$9.03
Rate for Payer: WPPA Medicare Advantage	$70.80

PureWick Female External Catheter - Newer Version

Facility

$47.61

Hospital Charge Code	3258540
Hospital Revenue Code	270
Min. Negotiated Rate	$19.04
Max. Negotiated Rate	$45.23
Rate for Payer: Aetna Commercial	$42.85
Rate for Payer: Humana Medicare Advantage	$20.00
Rate for Payer: UnitedHealthcare Commercial	$45.23
Rate for Payer: UnitedHealthcare Medicaid	$19.04
Rate for Payer: WPPA Medicare Advantage	$28.57

PureWick Female External Catheter - Newer Version

Facility

$47.61

Hospital Charge Code	3258540
Hospital Revenue Code	270
Min. Negotiated Rate	$42.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.85
Rate for Payer: UnitedHealthcare Commercial	$45.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PureWick Male External Catheter

Facility

$70.61

Hospital Charge Code	3258542
Hospital Revenue Code	270
Min. Negotiated Rate	$28.24
Max. Negotiated Rate	$67.08
Rate for Payer: Aetna Commercial	$63.55
Rate for Payer: Humana Medicare Advantage	$29.66
Rate for Payer: UnitedHealthcare Commercial	$67.08
Rate for Payer: UnitedHealthcare Medicaid	$28.24
Rate for Payer: WPPA Medicare Advantage	$42.37

PureWick Male External Catheter

Facility

$70.61

Hospital Charge Code	3258542
Hospital Revenue Code	270
Min. Negotiated Rate	$63.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.55
Rate for Payer: UnitedHealthcare Commercial	$67.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pyridostigmine 60 mg Tab [HMC]

Facility

$8.67

Service Code	NDC 68682030210
Hospital Charge Code	3800109
Hospital Revenue Code	250
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.80
Rate for Payer: UnitedHealthcare Commercial	$8.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pyridostigmine 60 mg Tab [HMC]

Facility

$8.67

Service Code	NDC 68682030210
Hospital Charge Code	3800109
Hospital Revenue Code	250
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$8.24
Rate for Payer: Aetna Commercial	$7.80
Rate for Payer: Humana Medicare Advantage	$3.64
Rate for Payer: UnitedHealthcare Commercial	$8.24
Rate for Payer: UnitedHealthcare Medicaid	$3.47
Rate for Payer: WPPA Medicare Advantage	$5.20

Know your out-of-pocket cost for care.

All Charges