Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Bandage Conforming Gauze Mollelast 6cm x 4m Lymphedema Program

Facility

$3.00

Hospital Charge Code	3254720
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 6cm x 4m Lymphedema Program

Facility

$3.00

Hospital Charge Code	3254720
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

Bandage Foam Rubber Komprex 8cm x 2m x 1cm(10mm)(0.4) Lymphedema Program

Facility

$3.00

Hospital Charge Code	3254718
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

Bandage Foam Rubber Komprex 8cm x 2m x 1cm(10mm)(0.4) Lymphedema Program

Facility

$3.00

Hospital Charge Code	3254718
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 Short Stretch Rosidal K 10cm x 5m Lymphedema Program

Facility

$33.00

Hospital Charge Code	3254712
Hospital Revenue Code	270
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.70
Rate for Payer: UnitedHealthcare Commercial	$31.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bandage Short Stretch Rosidal K 10cm x 5m Lymphedema Program

Facility

$33.00

Hospital Charge Code	3254712
Hospital Revenue Code	270
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$31.35
Rate for Payer: Aetna Commercial	$29.70
Rate for Payer: Humana Medicare Advantage	$13.86
Rate for Payer: UnitedHealthcare Commercial	$31.35
Rate for Payer: UnitedHealthcare Medicaid	$13.20
Rate for Payer: WPPA Medicare Advantage	$19.80

Bandage Short Stretch Rosidal K 12cm x 5m Lymphedema Program

Facility

$37.00

Hospital Charge Code	3254713
Hospital Revenue Code	270
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.30
Rate for Payer: UnitedHealthcare Commercial	$35.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bandage Short Stretch Rosidal K 12cm x 5m Lymphedema Program

Facility

$37.00

Hospital Charge Code	3254713
Hospital Revenue Code	270
Min. Negotiated Rate	$14.80
Max. Negotiated Rate	$35.15
Rate for Payer: Aetna Commercial	$33.30
Rate for Payer: Humana Medicare Advantage	$15.54
Rate for Payer: UnitedHealthcare Commercial	$35.15
Rate for Payer: UnitedHealthcare Medicaid	$14.80
Rate for Payer: WPPA Medicare Advantage	$22.20

Bandage Short Stretch Rosidal K 6cm x 5m Lymphedema Program

Facility

$22.00

Hospital Charge Code	3254710
Hospital Revenue Code	270
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$20.90
Rate for Payer: Aetna Commercial	$19.80
Rate for Payer: Humana Medicare Advantage	$9.24
Rate for Payer: UnitedHealthcare Commercial	$20.90
Rate for Payer: UnitedHealthcare Medicaid	$8.80
Rate for Payer: WPPA Medicare Advantage	$13.20

Bandage Short Stretch Rosidal K 6cm x 5m Lymphedema Program

Facility

$22.00

Hospital Charge Code	3254710
Hospital Revenue Code	270
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.80
Rate for Payer: UnitedHealthcare Commercial	$20.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bandage Short Stretch Rosidal K 8cm x 5m Lymphedema Program

Facility

$27.00

Hospital Charge Code	3254711
Hospital Revenue Code	270
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

Bandage Short Stretch Rosidal K 8cm x 5m Lymphedema Program

Facility

$27.00

Hospital Charge Code	3254711
Hospital Revenue Code	270
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

Bandage Wide Width White Idealbinde 15cm x 5m Lymphedema Program

Facility

$45.00

Hospital Charge Code	3254714
Hospital Revenue Code	270
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$42.75
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: Humana Medicare Advantage	$18.90
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: WPPA Medicare Advantage	$27.00

Bandage Wide Width White Idealbinde 15cm x 5m Lymphedema Program

Facility

$45.00

Hospital Charge Code	3254714
Hospital Revenue Code	270
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BARLEY (F60) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552811
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

BARLEY (F60) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552811
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

Barley (F6) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552811
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

Barley (F6) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552811
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

Basic Metabolic Panel

Facility

$79.00

Service Code	HCPCS 80048
Hospital Charge Code	3551310
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

Basic Metabolic Panel

Facility

$79.00

Service Code	HCPCS 80048
Hospital Charge Code	3551310
Hospital Revenue Code	300
Min. Negotiated Rate	$8.46
Max. Negotiated Rate	$75.05
Rate for Payer: Aetna Commercial	$71.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$19.65
Rate for Payer: Humana Medicare Advantage	$33.18
Rate for Payer: UnitedHealthcare Commercial	$75.05
Rate for Payer: UnitedHealthcare Medicaid	$8.46
Rate for Payer: WPPA Medicare Advantage	$47.40

BCG 50 mg Intravesical Inj [HMC]

Facility

$325.78

Service Code	HCPCS J9030
Hospital Charge Code	3852030
Hospital Revenue Code	250
Min. Negotiated Rate	$293.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$293.20
Rate for Payer: UnitedHealthcare Commercial	$309.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BCG 50 mg Intravesical Inj [HMC]

Facility

$325.78

Service Code	HCPCS J9030
Hospital Charge Code	3852030
Hospital Revenue Code	250
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$309.49
Rate for Payer: Aetna Commercial	$293.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.68
Rate for Payer: Humana Medicare Advantage	$136.83
Rate for Payer: UnitedHealthcare Commercial	$309.49
Rate for Payer: UnitedHealthcare Medicaid	$3.28
Rate for Payer: WPPA Medicare Advantage	$195.47

BCR-ABL1 Gene Rearrangement, Qnt PCR QST

Facility

$546.00

Service Code	HCPCS 81206
Hospital Charge Code	3552061
Hospital Revenue Code	300
Min. Negotiated Rate	$193.89
Max. Negotiated Rate	$518.70
Rate for Payer: Aetna Commercial	$491.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$193.89
Rate for Payer: Humana Medicare Advantage	$229.32
Rate for Payer: UnitedHealthcare Commercial	$518.70
Rate for Payer: UnitedHealthcare Medicaid	$218.40
Rate for Payer: WPPA Medicare Advantage	$327.60

BCR-ABL1 Gene Rearrangement, Qnt PCR QST

Facility

$546.00

Service Code	HCPCS 81206
Hospital Charge Code	3552061
Hospital Revenue Code	300
Min. Negotiated Rate	$491.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$491.40
Rate for Payer: UnitedHealthcare Commercial	$518.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BD Bone Density DEXA App Skeleton

Facility

$149.00

Service Code	HCPCS 77081 TC
Hospital Charge Code	3690010
Hospital Revenue Code	320
Min. Negotiated Rate	$134.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$134.10
Rate for Payer: UnitedHealthcare Commercial	$141.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges