Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Bone Marrow Biopsy Tray w/o needle

Facility

$63.00

Hospital Charge Code	3254050
Hospital Revenue Code	270
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bone Marrow Biopsy Tray w/o needle

Facility

$63.00

Hospital Charge Code	3254050
Hospital Revenue Code	270
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$59.85
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: Humana Medicare Advantage	$26.46
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: UnitedHealthcare Medicaid	$25.20
Rate for Payer: WPPA Medicare Advantage	$37.80

Bone Planer 8mm

Facility

$774.00

Hospital Charge Code	3258374
Hospital Revenue Code	270
Min. Negotiated Rate	$696.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$696.60
Rate for Payer: UnitedHealthcare Commercial	$735.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bone Planer 8mm

Facility

$774.00

Hospital Charge Code	3258374
Hospital Revenue Code	270
Min. Negotiated Rate	$309.60
Max. Negotiated Rate	$735.30
Rate for Payer: Aetna Commercial	$696.60
Rate for Payer: Humana Medicare Advantage	$325.08
Rate for Payer: UnitedHealthcare Commercial	$735.30
Rate for Payer: UnitedHealthcare Medicaid	$309.60
Rate for Payer: WPPA Medicare Advantage	$464.40

Bone Putty Fibergraft BG Matrix Small 3cc 25mm X 25mm X 5mm

Facility

$4,301.00

Hospital Charge Code	3250492
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,085.95
Rate for Payer: Aetna Commercial	$3,870.90
Rate for Payer: UnitedHealthcare Commercial	$4,085.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bone Putty Fibergraft BG Matrix Small 3cc 25mm X 25mm X 5mm

Facility

$4,301.00

Hospital Charge Code	3250492
Hospital Revenue Code	270
Min. Negotiated Rate	$1,720.40
Max. Negotiated Rate	$4,085.95
Rate for Payer: Aetna Commercial	$3,870.90
Rate for Payer: Humana Medicare Advantage	$1,806.42
Rate for Payer: UnitedHealthcare Commercial	$4,085.95
Rate for Payer: UnitedHealthcare Medicaid	$1,720.40
Rate for Payer: WPPA Medicare Advantage	$2,580.60

Bonnet (22-25cm)

Facility

$52.20

Hospital Charge Code	3254956
Hospital Revenue Code	270
Min. Negotiated Rate	$20.88
Max. Negotiated Rate	$49.59
Rate for Payer: Aetna Commercial	$46.98
Rate for Payer: Humana Medicare Advantage	$21.92
Rate for Payer: UnitedHealthcare Commercial	$49.59
Rate for Payer: UnitedHealthcare Medicaid	$20.88
Rate for Payer: WPPA Medicare Advantage	$31.32

Bonnet (22-25cm)

Facility

$52.20

Hospital Charge Code	3254956
Hospital Revenue Code	270
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$46.98
Rate for Payer: UnitedHealthcare Commercial	$49.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bonnet (29-36cm)

Facility

$52.20

Hospital Charge Code	3254957
Hospital Revenue Code	270
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$46.98
Rate for Payer: UnitedHealthcare Commercial	$49.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bonnet (29-36cm)

Facility

$52.20

Hospital Charge Code	3254957
Hospital Revenue Code	270
Min. Negotiated Rate	$20.88
Max. Negotiated Rate	$49.59
Rate for Payer: Aetna Commercial	$46.98
Rate for Payer: Humana Medicare Advantage	$21.92
Rate for Payer: UnitedHealthcare Commercial	$49.59
Rate for Payer: UnitedHealthcare Medicaid	$20.88
Rate for Payer: WPPA Medicare Advantage	$31.32

Bordetella Pertussis/ Parapertussis QST

Facility

$403.00

Service Code	HCPCS 87798
Hospital Charge Code	3557798
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$382.85
Rate for Payer: Aetna Commercial	$362.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$185.64
Rate for Payer: Humana Medicare Advantage	$169.26
Rate for Payer: UnitedHealthcare Commercial	$382.85
Rate for Payer: UnitedHealthcare Medicaid	$35.09
Rate for Payer: WPPA Medicare Advantage	$241.80

Bordetella Pertussis/ Parapertussis QST

Facility

$403.00

Service Code	HCPCS 87798
Hospital Charge Code	3557798
Hospital Revenue Code	300
Min. Negotiated Rate	$362.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$362.70
Rate for Payer: UnitedHealthcare Commercial	$382.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bortezomib 3.5 mg IV Inj [HMC]

Facility

$2,905.40

Service Code	HCPCS J9041
Hospital Charge Code	3852235
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,760.13
Rate for Payer: Aetna Commercial	$2,614.86
Rate for Payer: UnitedHealthcare Commercial	$2,760.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bortezomib 3.5 mg IV Inj [HMC]

Facility

$2,905.40

Service Code	HCPCS J9041
Hospital Charge Code	3852235
Hospital Revenue Code	250
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$2,760.13
Rate for Payer: Aetna Commercial	$2,614.86
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.67
Rate for Payer: Humana Medicare Advantage	$1,220.27
Rate for Payer: UnitedHealthcare Commercial	$2,760.13
Rate for Payer: UnitedHealthcare Medicaid	$2.68
Rate for Payer: WPPA Medicare Advantage	$1,743.24

BOTOX

Facility

$284.00

Service Code	HCPCS 64611
Hospital Charge Code	3354611
Hospital Revenue Code	761
Min. Negotiated Rate	$255.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$255.60
Rate for Payer: UnitedHealthcare Commercial	$269.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BOTOX

Facility

$284.00

Service Code	HCPCS 64611
Hospital Charge Code	3354611
Hospital Revenue Code	761
Min. Negotiated Rate	$113.60
Max. Negotiated Rate	$269.80
Rate for Payer: Aetna Commercial	$255.60
Rate for Payer: Humana Medicare Advantage	$119.28
Rate for Payer: UnitedHealthcare Commercial	$269.80
Rate for Payer: UnitedHealthcare Medicaid	$113.60
Rate for Payer: WPPA Medicare Advantage	$170.40

Brace Back TLSO Universal Adjustable

Facility

$718.00

Hospital Charge Code	3251850
Hospital Revenue Code	270
Min. Negotiated Rate	$287.20
Max. Negotiated Rate	$682.10
Rate for Payer: Aetna Commercial	$646.20
Rate for Payer: Humana Medicare Advantage	$301.56
Rate for Payer: UnitedHealthcare Commercial	$682.10
Rate for Payer: UnitedHealthcare Medicaid	$287.20
Rate for Payer: WPPA Medicare Advantage	$430.80

Brace Back TLSO Universal Adjustable

Facility

$718.00

Hospital Charge Code	3251850
Hospital Revenue Code	270
Min. Negotiated Rate	$646.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$646.20
Rate for Payer: UnitedHealthcare Commercial	$682.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Brace Back TLSO Vista 464 Universal Adjustable Fit

Facility

$911.00

Hospital Charge Code	3251851
Hospital Revenue Code	270
Min. Negotiated Rate	$364.40
Max. Negotiated Rate	$865.45
Rate for Payer: Aetna Commercial	$819.90
Rate for Payer: Humana Medicare Advantage	$382.62
Rate for Payer: UnitedHealthcare Commercial	$865.45
Rate for Payer: UnitedHealthcare Medicaid	$364.40
Rate for Payer: WPPA Medicare Advantage	$546.60

Brace Back TLSO Vista 464 Universal Adjustable Fit

Facility

$911.00

Hospital Charge Code	3251851
Hospital Revenue Code	270
Min. Negotiated Rate	$819.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$819.90
Rate for Payer: UnitedHealthcare Commercial	$865.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Brace Hip Abduction Centron Medium

Facility

$793.00

Hospital Charge Code	3251855
Hospital Revenue Code	270
Min. Negotiated Rate	$713.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$713.70
Rate for Payer: UnitedHealthcare Commercial	$753.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Brace Hip Abduction Centron Medium

Facility

$793.00

Hospital Charge Code	3251855
Hospital Revenue Code	270
Min. Negotiated Rate	$317.20
Max. Negotiated Rate	$753.35
Rate for Payer: Aetna Commercial	$713.70
Rate for Payer: Humana Medicare Advantage	$333.06
Rate for Payer: UnitedHealthcare Commercial	$753.35
Rate for Payer: UnitedHealthcare Medicaid	$317.20
Rate for Payer: WPPA Medicare Advantage	$475.80

Brace Hip Abduction T-Scope Left Std Size

Facility

$901.00

Hospital Charge Code	3251852
Hospital Revenue Code	270
Min. Negotiated Rate	$810.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$810.90
Rate for Payer: UnitedHealthcare Commercial	$855.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Brace Hip Abduction T-Scope Left Std Size

Facility

$901.00

Hospital Charge Code	3251852
Hospital Revenue Code	270
Min. Negotiated Rate	$360.40
Max. Negotiated Rate	$855.95
Rate for Payer: Aetna Commercial	$810.90
Rate for Payer: Humana Medicare Advantage	$378.42
Rate for Payer: UnitedHealthcare Commercial	$855.95
Rate for Payer: UnitedHealthcare Medicaid	$360.40
Rate for Payer: WPPA Medicare Advantage	$540.60

Brace Lower Spine Ascend SI 621 Belt Medium

Facility

$159.25

Hospital Charge Code	3255850
Hospital Revenue Code	270
Min. Negotiated Rate	$143.32
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$143.32
Rate for Payer: UnitedHealthcare Commercial	$151.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges