Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC

Facility

$12,835.08

Service Code	MSDRG 096
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,835.08
Rate for Payer: UnitedHealthcare Medicaid	$12,835.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bag Bile 19oz w/T-Tube Adapter 2 Latex Belts

Facility

$27.00

Hospital Charge Code	3255025
Hospital Revenue Code	370
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: WPPA Medicare Advantage	$16.20

Bag Bile 19oz w/T-Tube Adapter 2 Latex Belts

Facility

$27.00

Hospital Charge Code	3255025
Hospital Revenue Code	370
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BAG HYPERINFLATE INFANT

Facility

$64.00

Hospital Charge Code	3253548
Hospital Revenue Code	270
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BAG HYPERINFLATE INFANT

Facility

$64.00

Hospital Charge Code	3253548
Hospital Revenue Code	270
Min. Negotiated Rate	$25.60
Max. Negotiated Rate	$60.80
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: Humana Medicare Advantage	$26.88
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: UnitedHealthcare Medicaid	$25.60
Rate for Payer: WPPA Medicare Advantage	$38.40

Bag Pressure Infuser IV

Facility

$45.90

Hospital Charge Code	3256450
Hospital Revenue Code	270
Min. Negotiated Rate	$41.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.31
Rate for Payer: UnitedHealthcare Commercial	$43.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bag Pressure Infuser IV

Facility

$45.90

Hospital Charge Code	3256450
Hospital Revenue Code	270
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$43.60
Rate for Payer: Aetna Commercial	$41.31
Rate for Payer: Humana Medicare Advantage	$19.28
Rate for Payer: UnitedHealthcare Commercial	$43.60
Rate for Payer: UnitedHealthcare Medicaid	$18.36
Rate for Payer: WPPA Medicare Advantage	$27.54

Bag Resuscitator Adult Curaplex BVM with Universal Connector, 7ft O2 Tubing, Pop-off Valve, and Mask

Facility

$83.21

Hospital Charge Code	3251805
Hospital Revenue Code	270
Min. Negotiated Rate	$74.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$74.89
Rate for Payer: UnitedHealthcare Commercial	$79.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bag Resuscitator Adult Curaplex BVM with Universal Connector, 7ft O2 Tubing, Pop-off Valve, and Mask

Facility

$83.21

Hospital Charge Code	3251805
Hospital Revenue Code	270
Min. Negotiated Rate	$33.28
Max. Negotiated Rate	$79.05
Rate for Payer: Aetna Commercial	$74.89
Rate for Payer: Humana Medicare Advantage	$34.95
Rate for Payer: UnitedHealthcare Commercial	$79.05
Rate for Payer: UnitedHealthcare Medicaid	$33.28
Rate for Payer: WPPA Medicare Advantage	$49.93

Bag Resuscitator Adult Mask AMBU BVM

Facility

$33.26

Hospital Charge Code	3255549
Hospital Revenue Code	270
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$31.60
Rate for Payer: Aetna Commercial	$29.93
Rate for Payer: Humana Medicare Advantage	$13.97
Rate for Payer: UnitedHealthcare Commercial	$31.60
Rate for Payer: UnitedHealthcare Medicaid	$13.30
Rate for Payer: WPPA Medicare Advantage	$19.96

Bag Resuscitator Adult Mask AMBU BVM

Facility

$33.26

Hospital Charge Code	3255549
Hospital Revenue Code	270
Min. Negotiated Rate	$29.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.93
Rate for Payer: UnitedHealthcare Commercial	$31.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bag Resuscitator Infant Mask & Valve AMBU BVM

Facility

$83.00

Hospital Charge Code	3251802
Hospital Revenue Code	270
Min. Negotiated Rate	$33.20
Max. Negotiated Rate	$78.85
Rate for Payer: Aetna Commercial	$74.70
Rate for Payer: Humana Medicare Advantage	$34.86
Rate for Payer: UnitedHealthcare Commercial	$78.85
Rate for Payer: UnitedHealthcare Medicaid	$33.20
Rate for Payer: WPPA Medicare Advantage	$49.80

Bag Resuscitator Infant Mask & Valve AMBU BVM

Facility

$83.00

Hospital Charge Code	3251802
Hospital Revenue Code	270
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$74.70
Rate for Payer: UnitedHealthcare Commercial	$78.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bag Resuscitator Pediatric Mask AMBU BVM

Facility

$34.47

Hospital Charge Code	3251794
Hospital Revenue Code	270
Min. Negotiated Rate	$31.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.02
Rate for Payer: UnitedHealthcare Commercial	$32.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bag Resuscitator Pediatric Mask AMBU BVM

Facility

$34.47

Hospital Charge Code	3251794
Hospital Revenue Code	270
Min. Negotiated Rate	$13.79
Max. Negotiated Rate	$32.75
Rate for Payer: Aetna Commercial	$31.02
Rate for Payer: Humana Medicare Advantage	$14.48
Rate for Payer: UnitedHealthcare Commercial	$32.75
Rate for Payer: UnitedHealthcare Medicaid	$13.79
Rate for Payer: WPPA Medicare Advantage	$20.68

Bakri Balloon Catheter

Facility

$1,062.55

Service Code	HCPCS C1726
Hospital Charge Code	3257490
Hospital Revenue Code	278
Min. Negotiated Rate	$425.02
Max. Negotiated Rate	$1,009.42
Rate for Payer: Aetna Commercial	$956.29
Rate for Payer: Humana Medicare Advantage	$446.27
Rate for Payer: UnitedHealthcare Commercial	$1,009.42
Rate for Payer: UnitedHealthcare Medicaid	$425.02
Rate for Payer: WPPA Medicare Advantage	$637.53

Bakri Balloon Catheter

Facility

$1,062.55

Service Code	HCPCS C1726
Hospital Charge Code	3257490
Hospital Revenue Code	278
Min. Negotiated Rate	$956.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$956.29
Rate for Payer: UnitedHealthcare Commercial	$1,009.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

balsam Peru/castor oil/trypsin Top Oint [HMC]

Facility

$58.00

Service Code	NDC 58980079011
Hospital Charge Code	3800174
Hospital Revenue Code	250
Min. Negotiated Rate	$52.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$52.20
Rate for Payer: UnitedHealthcare Commercial	$55.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

balsam Peru/castor oil/trypsin Top Oint [HMC]

Facility

$58.00

Service Code	NDC 58980079011
Hospital Charge Code	3800174
Hospital Revenue Code	250
Min. Negotiated Rate	$23.20
Max. Negotiated Rate	$55.10
Rate for Payer: Aetna Commercial	$52.20
Rate for Payer: Humana Medicare Advantage	$24.36
Rate for Payer: UnitedHealthcare Commercial	$55.10
Rate for Payer: UnitedHealthcare Medicaid	$23.20
Rate for Payer: WPPA Medicare Advantage	$34.80

bamlanivimab 700 mg/20 mL [HMC]

Facility

$20.00

Service Code	HCPCS Q0245
Hospital Charge Code	3850207
Hospital Revenue Code	250
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bamlanivimab 700 mg/20 mL [HMC]

Facility

$20.00

Service Code	HCPCS Q0245
Hospital Charge Code	3850207
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.10
Rate for Payer: Humana Medicare Advantage	$8.40
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: UnitedHealthcare Medicaid	$8.00
Rate for Payer: WPPA Medicare Advantage	$12.00

Banana (F92) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552825
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Banana (F92) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552825
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$12.60

Bandage Conforming Gauze Mollelast 4cm x 4m Lymphedema Program

Facility

$3.00

Hospital Charge Code	3254719
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Humana Medicare Advantage	$1.26
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: WPPA Medicare Advantage	$1.80

Bandage Conforming Gauze Mollelast 4cm x 4m Lymphedema Program

Facility

$3.00

Hospital Charge Code	3254719
Hospital Revenue Code	270
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges