Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Blood Gas Arterial

Facility

$265.00

Service Code	HCPCS 82803
Hospital Charge Code	3550189
Hospital Revenue Code	300
Min. Negotiated Rate	$22.16
Max. Negotiated Rate	$251.75
Rate for Payer: Aetna Commercial	$238.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$68.05
Rate for Payer: Humana Medicare Advantage	$111.30
Rate for Payer: UnitedHealthcare Commercial	$251.75
Rate for Payer: UnitedHealthcare Medicaid	$22.16
Rate for Payer: WPPA Medicare Advantage	$159.00

Blood Gas Cord Venous

Facility

$265.00

Service Code	HCPCS 82803
Hospital Charge Code	3550189
Hospital Revenue Code	300
Min. Negotiated Rate	$22.16
Max. Negotiated Rate	$251.75
Rate for Payer: Aetna Commercial	$238.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$68.05
Rate for Payer: Humana Medicare Advantage	$111.30
Rate for Payer: UnitedHealthcare Commercial	$251.75
Rate for Payer: UnitedHealthcare Medicaid	$22.16
Rate for Payer: WPPA Medicare Advantage	$159.00

Blood Gas Cord Venous

Facility

$265.00

Service Code	HCPCS 82803
Hospital Charge Code	3550189
Hospital Revenue Code	300
Min. Negotiated Rate	$238.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$238.50
Rate for Payer: UnitedHealthcare Commercial	$251.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Blood Gas Draw Access Route

Facility

$43.00

Service Code	HCPCS 36416
Hospital Charge Code	3900630
Hospital Revenue Code	300
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$40.85
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4.42
Rate for Payer: Humana Medicare Advantage	$18.06
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: UnitedHealthcare Medicaid	$17.20
Rate for Payer: WPPA Medicare Advantage	$25.80

Blood Gas Draw Access Route

Facility

$43.00

Service Code	HCPCS 36416
Hospital Charge Code	3900630
Hospital Revenue Code	300
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Blood Urea Nitrogen

Facility

$54.00

Service Code	HCPCS 84520
Hospital Charge Code	3550197
Hospital Revenue Code	300
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8.47
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$3.95
Rate for Payer: WPPA Medicare Advantage	$32.40

Blood Urea Nitrogen

Facility

$54.00

Service Code	HCPCS 84520
Hospital Charge Code	3550197
Hospital Revenue Code	300
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BME Speed (TM) Implant Kit 11 x 10 mm

Facility

$2,431.00

Hospital Charge Code	3258327
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,309.45
Rate for Payer: Aetna Commercial	$2,187.90
Rate for Payer: UnitedHealthcare Commercial	$2,309.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BME Speed (TM) Implant Kit 11 x 10 mm

Facility

$2,431.00

Hospital Charge Code	3258327
Hospital Revenue Code	270
Min. Negotiated Rate	$972.40
Max. Negotiated Rate	$2,309.45
Rate for Payer: Aetna Commercial	$2,187.90
Rate for Payer: Humana Medicare Advantage	$1,021.02
Rate for Payer: UnitedHealthcare Commercial	$2,309.45
Rate for Payer: UnitedHealthcare Medicaid	$972.40
Rate for Payer: WPPA Medicare Advantage	$1,458.60

BME Speed (TM) Implant Kit 9 x 7 mm

Facility

$2,431.00

Hospital Charge Code	3258321
Hospital Revenue Code	270
Min. Negotiated Rate	$972.40
Max. Negotiated Rate	$2,309.45
Rate for Payer: Aetna Commercial	$2,187.90
Rate for Payer: Humana Medicare Advantage	$1,021.02
Rate for Payer: UnitedHealthcare Commercial	$2,309.45
Rate for Payer: UnitedHealthcare Medicaid	$972.40
Rate for Payer: WPPA Medicare Advantage	$1,458.60

BME Speed (TM) Implant Kit 9 x 7 mm

Facility

$2,431.00

Hospital Charge Code	3258321
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,309.45
Rate for Payer: Aetna Commercial	$2,187.90
Rate for Payer: UnitedHealthcare Commercial	$2,309.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Body plethysmography (throacic gas volume) - RT CHARGE PFT

Facility

$740.00

Service Code	HCPCS 94726
Hospital Charge Code	3912070
Hospital Revenue Code	460
Min. Negotiated Rate	$168.20
Max. Negotiated Rate	$703.00
Rate for Payer: Aetna Commercial	$666.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$297.32
Rate for Payer: Humana Medicare Advantage	$310.80
Rate for Payer: UnitedHealthcare Commercial	$703.00
Rate for Payer: UnitedHealthcare Medicaid	$168.20
Rate for Payer: WPPA Medicare Advantage	$444.00

Body plethysmography (throacic gas volume) - RT CHARGE PFT

Facility

$740.00

Service Code	HCPCS 94726
Hospital Charge Code	3912070
Hospital Revenue Code	460
Min. Negotiated Rate	$666.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$666.00
Rate for Payer: UnitedHealthcare Commercial	$703.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BONE BUR OVAL MEDIUM 4 X 8MM FOR USE WITH MICROPOWER & MICRO 100 DRILLS

Facility

$85.00

Hospital Charge Code	3254060
Hospital Revenue Code	270
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: UnitedHealthcare Commercial	$80.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BONE BUR OVAL MEDIUM 4 X 8MM FOR USE WITH MICROPOWER & MICRO 100 DRILLS

Facility

$85.00

Hospital Charge Code	3254060
Hospital Revenue Code	270
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$80.75
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: Humana Medicare Advantage	$35.70
Rate for Payer: UnitedHealthcare Commercial	$80.75
Rate for Payer: UnitedHealthcare Medicaid	$34.00
Rate for Payer: WPPA Medicare Advantage	$51.00

BONE BUR OVAL MEDIUM 5.5 X 10MM CARBIDE FOR USE W/ MICROPOWER & MICRO 100 DRILLS

Facility

$92.00

Hospital Charge Code	3254065
Hospital Revenue Code	270
Min. Negotiated Rate	$36.80
Max. Negotiated Rate	$87.40
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: Humana Medicare Advantage	$38.64
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: UnitedHealthcare Medicaid	$36.80
Rate for Payer: WPPA Medicare Advantage	$55.20

BONE BUR OVAL MEDIUM 5.5 X 10MM CARBIDE FOR USE W/ MICROPOWER & MICRO 100 DRILLS

Facility

$92.00

Hospital Charge Code	3254065
Hospital Revenue Code	270
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

Bone Burr 4.0 Stryker Precision Round

Facility

$1,128.25

Hospital Charge Code	3256022
Hospital Revenue Code	270
Min. Negotiated Rate	$451.30
Max. Negotiated Rate	$1,071.84
Rate for Payer: Aetna Commercial	$1,015.42
Rate for Payer: Humana Medicare Advantage	$473.87
Rate for Payer: UnitedHealthcare Commercial	$1,071.84
Rate for Payer: UnitedHealthcare Medicaid	$451.30
Rate for Payer: WPPA Medicare Advantage	$676.95

Bone Burr 4.0 Stryker Precision Round

Facility

$1,128.25

Hospital Charge Code	3256022
Hospital Revenue Code	270
Min. Negotiated Rate	$1,015.42
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,015.42
Rate for Payer: UnitedHealthcare Commercial	$1,071.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bone Burr 5.0 Stryker Precision Round

Facility

$616.00

Hospital Charge Code	3256023
Hospital Revenue Code	270
Min. Negotiated Rate	$554.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$554.40
Rate for Payer: UnitedHealthcare Commercial	$585.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bone Burr 5.0 Stryker Precision Round

Facility

$616.00

Hospital Charge Code	3256023
Hospital Revenue Code	270
Min. Negotiated Rate	$246.40
Max. Negotiated Rate	$585.20
Rate for Payer: Aetna Commercial	$554.40
Rate for Payer: Humana Medicare Advantage	$258.72
Rate for Payer: UnitedHealthcare Commercial	$585.20
Rate for Payer: UnitedHealthcare Medicaid	$246.40
Rate for Payer: WPPA Medicare Advantage	$369.60

Bone Cement Simplex P Full Dose

Facility

$1,242.00

Hospital Charge Code	3250491
Hospital Revenue Code	270
Min. Negotiated Rate	$1,117.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,117.80
Rate for Payer: UnitedHealthcare Commercial	$1,179.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bone Cement Simplex P Full Dose

Facility

$1,242.00

Hospital Charge Code	3250491
Hospital Revenue Code	270
Min. Negotiated Rate	$496.80
Max. Negotiated Rate	$1,179.90
Rate for Payer: Aetna Commercial	$1,117.80
Rate for Payer: Humana Medicare Advantage	$521.64
Rate for Payer: UnitedHealthcare Commercial	$1,179.90
Rate for Payer: UnitedHealthcare Medicaid	$496.80
Rate for Payer: WPPA Medicare Advantage	$745.20

BONE DISEASES AND ARTHROPATHIES WITH MCC

Facility

$7,942.50

Service Code	MSDRG 553
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,942.50
Rate for Payer: UnitedHealthcare Medicaid	$7,942.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BONE DISEASES AND ARTHROPATHIES WITHOUT MCC

Facility

$5,083.20

Service Code	MSDRG 554
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,083.20
Rate for Payer: UnitedHealthcare Medicaid	$5,083.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges