Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Brace Lower Spine Ascend SI 621 Belt Medium

Facility

$159.25

Hospital Charge Code	3255850
Hospital Revenue Code	270
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$151.29
Rate for Payer: Aetna Commercial	$143.32
Rate for Payer: Humana Medicare Advantage	$66.89
Rate for Payer: UnitedHealthcare Commercial	$151.29
Rate for Payer: UnitedHealthcare Medicaid	$63.70
Rate for Payer: WPPA Medicare Advantage	$95.55

Brace Over the Shoulder Medium for Humeral Fracture

Facility

$189.21

Service Code	HCPCS L3980
Hospital Charge Code	3251858
Hospital Revenue Code	270
Min. Negotiated Rate	$79.47
Max. Negotiated Rate	$317.08
Rate for Payer: Aetna Commercial	$170.29
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$259.35
Rate for Payer: Humana Medicare Advantage	$79.47
Rate for Payer: UnitedHealthcare Commercial	$179.75
Rate for Payer: UnitedHealthcare Medicaid	$317.08
Rate for Payer: WPPA Medicare Advantage	$113.53

Brace Over the Shoulder Medium for Humeral Fracture

Facility

$189.21

Service Code	HCPCS L3980
Hospital Charge Code	3251858
Hospital Revenue Code	270
Min. Negotiated Rate	$170.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$170.29
Rate for Payer: UnitedHealthcare Commercial	$179.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Brace Over the Shoulder Small for Humeral Fracture

Facility

$189.21

Service Code	HCPCS L3980
Hospital Charge Code	3251857
Hospital Revenue Code	270
Min. Negotiated Rate	$170.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$170.29
Rate for Payer: UnitedHealthcare Commercial	$179.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Brace Over the Shoulder Small for Humeral Fracture

Facility

$189.21

Service Code	HCPCS L3980
Hospital Charge Code	3251857
Hospital Revenue Code	270
Min. Negotiated Rate	$79.47
Max. Negotiated Rate	$317.08
Rate for Payer: Aetna Commercial	$170.29
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$259.35
Rate for Payer: Humana Medicare Advantage	$79.47
Rate for Payer: UnitedHealthcare Commercial	$179.75
Rate for Payer: UnitedHealthcare Medicaid	$317.08
Rate for Payer: WPPA Medicare Advantage	$113.53

Brace Shoulder SlingShot 2 Size Medium

Facility

$175.00

Hospital Charge Code	3251856
Hospital Revenue Code	270
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$166.25
Rate for Payer: Aetna Commercial	$157.50
Rate for Payer: Humana Medicare Advantage	$73.50
Rate for Payer: UnitedHealthcare Commercial	$166.25
Rate for Payer: UnitedHealthcare Medicaid	$70.00
Rate for Payer: WPPA Medicare Advantage	$105.00

Brace Shoulder SlingShot 2 Size Medium

Facility

$175.00

Hospital Charge Code	3251856
Hospital Revenue Code	270
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$157.50
Rate for Payer: UnitedHealthcare Commercial	$166.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BRAF Mutation Analysis

Facility

$735.00

Service Code	HCPCS 81210
Hospital Charge Code	3551210
Hospital Revenue Code	310
Min. Negotiated Rate	$661.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$661.50
Rate for Payer: UnitedHealthcare Commercial	$698.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BRAF Mutation Analysis

Facility

$735.00

Service Code	HCPCS 81210
Hospital Charge Code	3551210
Hospital Revenue Code	310
Min. Negotiated Rate	$294.00
Max. Negotiated Rate	$698.25
Rate for Payer: Aetna Commercial	$661.50
Rate for Payer: Humana Medicare Advantage	$308.70
Rate for Payer: UnitedHealthcare Commercial	$698.25
Rate for Payer: UnitedHealthcare Medicaid	$294.00
Rate for Payer: WPPA Medicare Advantage	$441.00

Brazil Nut (F18) IgE QST

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3556004
Hospital Revenue Code	300
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Brazil Nut (F18) IgE QST

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3556004
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$24.70
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$10.92
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$15.60

BRCavantage, Comprehensive QST

Facility

$3,544.00

Service Code	HCPCS 81162
Hospital Charge Code	3558116
Hospital Revenue Code	300
Min. Negotiated Rate	$1,417.60
Max. Negotiated Rate	$3,366.80
Rate for Payer: Aetna Commercial	$3,189.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,340.68
Rate for Payer: Humana Medicare Advantage	$1,488.48
Rate for Payer: UnitedHealthcare Commercial	$3,366.80
Rate for Payer: UnitedHealthcare Medicaid	$1,417.60
Rate for Payer: WPPA Medicare Advantage	$2,126.40

BRCavantage, Comprehensive QST

Facility

$3,544.00

Service Code	HCPCS 81162
Hospital Charge Code	3558116
Hospital Revenue Code	300
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,366.80
Rate for Payer: Aetna Commercial	$3,189.60
Rate for Payer: UnitedHealthcare Commercial	$3,366.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC

Facility

$6,989.40

Service Code	MSDRG 584
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,989.40
Rate for Payer: UnitedHealthcare Medicaid	$6,989.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC

Facility

$6,290.46

Service Code	MSDRG 585
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,290.46
Rate for Payer: UnitedHealthcare Medicaid	$6,290.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Breast Marker Biopsy Tumark Q-Shape Clip 18G x 10cm

Facility

$202.00

Hospital Charge Code	3255665
Hospital Revenue Code	270
Min. Negotiated Rate	$181.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$181.80
Rate for Payer: UnitedHealthcare Commercial	$191.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Breast Marker Biopsy Tumark Q-Shape Clip 18G x 10cm

Facility

$202.00

Hospital Charge Code	3255665
Hospital Revenue Code	270
Min. Negotiated Rate	$80.80
Max. Negotiated Rate	$191.90
Rate for Payer: Aetna Commercial	$181.80
Rate for Payer: Humana Medicare Advantage	$84.84
Rate for Payer: UnitedHealthcare Commercial	$191.90
Rate for Payer: UnitedHealthcare Medicaid	$80.80
Rate for Payer: WPPA Medicare Advantage	$121.20

Breast Pads

Facility

$6.03

Hospital Charge Code	3250441
Hospital Revenue Code	270
Min. Negotiated Rate	$2.41
Max. Negotiated Rate	$5.73
Rate for Payer: Aetna Commercial	$5.43
Rate for Payer: Humana Medicare Advantage	$2.53
Rate for Payer: UnitedHealthcare Commercial	$5.73
Rate for Payer: UnitedHealthcare Medicaid	$2.41
Rate for Payer: WPPA Medicare Advantage	$3.62

Breast Pads

Facility

$6.03

Hospital Charge Code	3250441
Hospital Revenue Code	270
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.43
Rate for Payer: UnitedHealthcare Commercial	$5.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Breast Pump Kit Combo Manual & Electric Symphony & Harmony Double Duet

Facility

$113.00

Hospital Charge Code	3250468
Hospital Revenue Code	270
Min. Negotiated Rate	$101.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Breast Pump Kit Combo Manual & Electric Symphony & Harmony Double Duet

Facility

$113.00

Hospital Charge Code	3250468
Hospital Revenue Code	270
Min. Negotiated Rate	$45.20
Max. Negotiated Rate	$107.35
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: Humana Medicare Advantage	$47.46
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: UnitedHealthcare Medicaid	$45.20
Rate for Payer: WPPA Medicare Advantage	$67.80

Breast Shell Inverted

Facility

$40.23

Hospital Charge Code	3259517
Hospital Revenue Code	270
Min. Negotiated Rate	$16.09
Max. Negotiated Rate	$38.22
Rate for Payer: Aetna Commercial	$36.21
Rate for Payer: Humana Medicare Advantage	$16.90
Rate for Payer: UnitedHealthcare Commercial	$38.22
Rate for Payer: UnitedHealthcare Medicaid	$16.09
Rate for Payer: WPPA Medicare Advantage	$24.14

Breast Shell Inverted

Facility

$40.23

Hospital Charge Code	3259517
Hospital Revenue Code	270
Min. Negotiated Rate	$36.21
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.21
Rate for Payer: UnitedHealthcare Commercial	$38.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Breast Shell Sore

Facility

$42.30

Hospital Charge Code	3259520
Hospital Revenue Code	270
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$40.19
Rate for Payer: Aetna Commercial	$38.07
Rate for Payer: Humana Medicare Advantage	$17.77
Rate for Payer: UnitedHealthcare Commercial	$40.19
Rate for Payer: UnitedHealthcare Medicaid	$16.92
Rate for Payer: WPPA Medicare Advantage	$25.38

Breast Shell Sore

Facility

$42.30

Hospital Charge Code	3259520
Hospital Revenue Code	270
Min. Negotiated Rate	$38.07
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.07
Rate for Payer: UnitedHealthcare Commercial	$40.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges