Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Aerosol Drainage Bag 750cc w/Y Adapter 22mm OD

Facility

$5.00

Hospital Charge Code	3251630
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AFB Identification LC

Facility

$92.00

Service Code	HCPCS 87118
Hospital Charge Code	3551229
Hospital Revenue Code	300
Min. Negotiated Rate	$12.42
Max. Negotiated Rate	$87.40
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$37.48
Rate for Payer: Humana Medicare Advantage	$38.64
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: UnitedHealthcare Medicaid	$12.42
Rate for Payer: WPPA Medicare Advantage	$55.20

AFB Identification LC

Facility

$92.00

Service Code	HCPCS 87118
Hospital Charge Code	3551229
Hospital Revenue Code	300
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC

Facility

$8,609.67

Service Code	MSDRG 560
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,609.67
Rate for Payer: UnitedHealthcare Medicaid	$8,609.67
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$11,437.20

Service Code	MSDRG 559
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,437.20
Rate for Payer: UnitedHealthcare Medicaid	$11,437.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC

Facility

$4,924.35

Service Code	MSDRG 561
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,924.35
Rate for Payer: UnitedHealthcare Medicaid	$4,924.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AFTERCARE WITH CC/MCC

Facility

$12,199.68

Service Code	MSDRG 949
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,199.68
Rate for Payer: UnitedHealthcare Medicaid	$12,199.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AFTERCARE WITHOUT CC/MCC

Facility

$4,447.80

Service Code	MSDRG 950
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,447.80
Rate for Payer: UnitedHealthcare Medicaid	$4,447.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AICD GENERATOR PROCEDURES

Facility

$16,361.55

Service Code	MSDRG 245
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$16,361.55
Rate for Payer: UnitedHealthcare Medicaid	$16,361.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AICD LEAD PROCEDURES

Facility

$12,962.16

Service Code	MSDRG 265
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,962.16
Rate for Payer: UnitedHealthcare Medicaid	$12,962.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Air Splint Adult Half Leg for Oral Inflation

Facility

$57.00

Hospital Charge Code	3257650
Hospital Revenue Code	270
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$54.15
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Humana Medicare Advantage	$23.94
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: UnitedHealthcare Medicaid	$22.80
Rate for Payer: WPPA Medicare Advantage	$34.20

Air Splint Adult Half Leg for Oral Inflation

Facility

$57.00

Hospital Charge Code	3257650
Hospital Revenue Code	270
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Air Splint Foot & Ankle for Oral Inflation

Facility

$44.00

Hospital Charge Code	3257655
Hospital Revenue Code	270
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$41.80
Rate for Payer: Aetna Commercial	$39.60
Rate for Payer: Humana Medicare Advantage	$18.48
Rate for Payer: UnitedHealthcare Commercial	$41.80
Rate for Payer: UnitedHealthcare Medicaid	$17.60
Rate for Payer: WPPA Medicare Advantage	$26.40

Air Splint Foot & Ankle for Oral Inflation

Facility

$44.00

Hospital Charge Code	3257655
Hospital Revenue Code	270
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.60
Rate for Payer: UnitedHealthcare Commercial	$41.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Air Splint Full Leg & Foot for Oral Inflation

Facility

$62.00

Hospital Charge Code	3257645
Hospital Revenue Code	270
Min. Negotiated Rate	$24.80
Max. Negotiated Rate	$58.90
Rate for Payer: Aetna Commercial	$55.80
Rate for Payer: Humana Medicare Advantage	$26.04
Rate for Payer: UnitedHealthcare Commercial	$58.90
Rate for Payer: UnitedHealthcare Medicaid	$24.80
Rate for Payer: WPPA Medicare Advantage	$37.20

Air Splint Full Leg & Foot for Oral Inflation

Facility

$62.00

Hospital Charge Code	3257645
Hospital Revenue Code	270
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$55.80
Rate for Payer: UnitedHealthcare Commercial	$58.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Air Splint Half Arm for Oral Inflation

Facility

$46.00

Hospital Charge Code	3257635
Hospital Revenue Code	270
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$43.70
Rate for Payer: Aetna Commercial	$41.40
Rate for Payer: Humana Medicare Advantage	$19.32
Rate for Payer: UnitedHealthcare Commercial	$43.70
Rate for Payer: UnitedHealthcare Medicaid	$18.40
Rate for Payer: WPPA Medicare Advantage	$27.60

Air Splint Half Arm for Oral Inflation

Facility

$46.00

Hospital Charge Code	3257635
Hospital Revenue Code	270
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.40
Rate for Payer: UnitedHealthcare Commercial	$43.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Air Splint Hand & Wrist for Oral Inflation

Facility

$39.00

Hospital Charge Code	3257640
Hospital Revenue Code	270
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.10
Rate for Payer: UnitedHealthcare Commercial	$37.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Air Splint Hand & Wrist for Oral Inflation

Facility

$39.00

Hospital Charge Code	3257640
Hospital Revenue Code	270
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$37.05
Rate for Payer: Aetna Commercial	$35.10
Rate for Payer: Humana Medicare Advantage	$16.38
Rate for Payer: UnitedHealthcare Commercial	$37.05
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: WPPA Medicare Advantage	$23.40

Airway King LTS-D Supraglottic Purple Size 5

Facility

$144.31

Hospital Charge Code	3257715
Hospital Revenue Code	541
Min. Negotiated Rate	$129.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$129.88
Rate for Payer: UnitedHealthcare Commercial	$137.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Airway King LTS-D Supraglottic Purple Size 5

Facility

$144.31

Hospital Charge Code	3257715
Hospital Revenue Code	541
Min. Negotiated Rate	$57.72
Max. Negotiated Rate	$137.09
Rate for Payer: Aetna Commercial	$129.88
Rate for Payer: Humana Medicare Advantage	$60.61
Rate for Payer: UnitedHealthcare Commercial	$137.09
Rate for Payer: UnitedHealthcare Medicaid	$57.72
Rate for Payer: WPPA Medicare Advantage	$86.59

Airway King LTS-D Supraglottic Red Size 4

Facility

$144.31

Hospital Charge Code	3257710
Hospital Revenue Code	541
Min. Negotiated Rate	$129.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$129.88
Rate for Payer: UnitedHealthcare Commercial	$137.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Airway King LTS-D Supraglottic Red Size 4

Facility

$144.31

Hospital Charge Code	3257710
Hospital Revenue Code	541
Min. Negotiated Rate	$57.72
Max. Negotiated Rate	$137.09
Rate for Payer: Aetna Commercial	$129.88
Rate for Payer: Humana Medicare Advantage	$60.61
Rate for Payer: UnitedHealthcare Commercial	$137.09
Rate for Payer: UnitedHealthcare Medicaid	$57.72
Rate for Payer: WPPA Medicare Advantage	$86.59

Airway King LTS-D Supraglottic Yellow Size 3

Facility

$149.80

Hospital Charge Code	3257705
Hospital Revenue Code	541
Min. Negotiated Rate	$59.92
Max. Negotiated Rate	$142.31
Rate for Payer: Aetna Commercial	$134.82
Rate for Payer: Humana Medicare Advantage	$62.92
Rate for Payer: UnitedHealthcare Commercial	$142.31
Rate for Payer: UnitedHealthcare Medicaid	$59.92
Rate for Payer: WPPA Medicare Advantage	$89.88

Know your out-of-pocket cost for care.

All Charges