Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Breast Shield 20mm Small Sterile

Facility

$19.62

Hospital Charge Code	3250466
Hospital Revenue Code	270
Min. Negotiated Rate	$17.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.66
Rate for Payer: UnitedHealthcare Commercial	$18.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Breast Shield 20mm Small Sterile

Facility

$19.62

Hospital Charge Code	3250466
Hospital Revenue Code	270
Min. Negotiated Rate	$7.85
Max. Negotiated Rate	$18.64
Rate for Payer: Aetna Commercial	$17.66
Rate for Payer: Humana Medicare Advantage	$8.24
Rate for Payer: UnitedHealthcare Commercial	$18.64
Rate for Payer: UnitedHealthcare Medicaid	$7.85
Rate for Payer: WPPA Medicare Advantage	$11.77

Breast Shield 24mm Medium Sterile

Facility

$19.98

Hospital Charge Code	3250467
Hospital Revenue Code	270
Min. Negotiated Rate	$7.99
Max. Negotiated Rate	$18.98
Rate for Payer: Aetna Commercial	$17.98
Rate for Payer: Humana Medicare Advantage	$8.39
Rate for Payer: UnitedHealthcare Commercial	$18.98
Rate for Payer: UnitedHealthcare Medicaid	$7.99
Rate for Payer: WPPA Medicare Advantage	$11.99

Breast Shield 24mm Medium Sterile

Facility

$19.98

Hospital Charge Code	3250467
Hospital Revenue Code	270
Min. Negotiated Rate	$17.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.98
Rate for Payer: UnitedHealthcare Commercial	$18.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Brief OB Knit Pant 2/pack

Facility

$4.86

Hospital Charge Code	3256851
Hospital Revenue Code	270
Min. Negotiated Rate	$4.37
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.37
Rate for Payer: UnitedHealthcare Commercial	$4.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Brief OB Knit Pant 2/pack

Facility

$4.86

Hospital Charge Code	3256851
Hospital Revenue Code	270
Min. Negotiated Rate	$1.94
Max. Negotiated Rate	$4.62
Rate for Payer: Aetna Commercial	$4.37
Rate for Payer: Humana Medicare Advantage	$2.04
Rate for Payer: UnitedHealthcare Commercial	$4.62
Rate for Payer: UnitedHealthcare Medicaid	$1.94
Rate for Payer: WPPA Medicare Advantage	$2.92

BRONCHITIS AND ASTHMA WITH CC/MCC

Facility

$3,844.17

Service Code	MSDRG 202
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,844.17
Rate for Payer: UnitedHealthcare Medicaid	$3,844.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BRONCHITIS AND ASTHMA WITHOUT CC/MCC

Facility

$2,859.30

Service Code	MSDRG 203
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,859.30
Rate for Payer: UnitedHealthcare Medicaid	$2,859.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Broncho Biopsy Forcep

Facility

$111.00

Hospital Charge Code	3258953
Hospital Revenue Code	270
Min. Negotiated Rate	$99.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$99.90
Rate for Payer: UnitedHealthcare Commercial	$105.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Broncho Biopsy Forcep

Facility

$111.00

Hospital Charge Code	3258953
Hospital Revenue Code	270
Min. Negotiated Rate	$44.40
Max. Negotiated Rate	$105.45
Rate for Payer: Aetna Commercial	$99.90
Rate for Payer: Humana Medicare Advantage	$46.62
Rate for Payer: UnitedHealthcare Commercial	$105.45
Rate for Payer: UnitedHealthcare Medicaid	$44.40
Rate for Payer: WPPA Medicare Advantage	$66.60

Bronchoscopy with Foreign Body Removal

Facility

$2,241.00

Service Code	HCPCS 31645
Hospital Charge Code	3150407
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,128.95
Rate for Payer: Aetna Commercial	$2,016.90
Rate for Payer: UnitedHealthcare Commercial	$2,128.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bronchoscopy with Foreign Body Removal

Facility

$2,241.00

Service Code	HCPCS 31645
Hospital Charge Code	3150407
Hospital Revenue Code	360
Min. Negotiated Rate	$549.83
Max. Negotiated Rate	$2,128.95
Rate for Payer: Aetna Commercial	$2,016.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,617.01
Rate for Payer: Humana Medicare Advantage	$941.22
Rate for Payer: UnitedHealthcare Commercial	$2,128.95
Rate for Payer: UnitedHealthcare Medicaid	$549.83
Rate for Payer: WPPA Medicare Advantage	$1,344.60

B-Type Natriuretic Peptide

Facility

$242.00

Service Code	HCPCS 83880
Hospital Charge Code	3556450
Hospital Revenue Code	300
Min. Negotiated Rate	$217.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$217.80
Rate for Payer: UnitedHealthcare Commercial	$229.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

B-Type Natriuretic Peptide

Facility

$242.00

Service Code	HCPCS 83880
Hospital Charge Code	3556450
Hospital Revenue Code	300
Min. Negotiated Rate	$33.37
Max. Negotiated Rate	$229.90
Rate for Payer: Aetna Commercial	$217.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$72.84
Rate for Payer: Humana Medicare Advantage	$101.64
Rate for Payer: UnitedHealthcare Commercial	$229.90
Rate for Payer: UnitedHealthcare Medicaid	$33.37
Rate for Payer: WPPA Medicare Advantage	$145.20

Bubble CPAP Kit for F&P Flexi Trunk Interface

Facility

$277.20

Hospital Charge Code	3254958
Hospital Revenue Code	270
Min. Negotiated Rate	$110.88
Max. Negotiated Rate	$263.34
Rate for Payer: Aetna Commercial	$249.48
Rate for Payer: Humana Medicare Advantage	$116.42
Rate for Payer: UnitedHealthcare Commercial	$263.34
Rate for Payer: UnitedHealthcare Medicaid	$110.88
Rate for Payer: WPPA Medicare Advantage	$166.32

Bubble CPAP Kit for F&P Flexi Trunk Interface

Facility

$277.20

Hospital Charge Code	3254958
Hospital Revenue Code	270
Min. Negotiated Rate	$249.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$249.48
Rate for Payer: UnitedHealthcare Commercial	$263.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

budesonide 0.25 mg/2 mL Inh Susp [HMC]

Facility

$26.47

Service Code	HCPCS J7633
Hospital Charge Code	3806445
Hospital Revenue Code	250
Min. Negotiated Rate	$6.55
Max. Negotiated Rate	$25.15
Rate for Payer: Aetna Commercial	$23.82
Rate for Payer: Aetna Commercial	$23.12
Rate for Payer: Aetna Commercial	$23.81
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$6.55
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$6.55
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$6.55
Rate for Payer: Humana Medicare Advantage	$11.12
Rate for Payer: Humana Medicare Advantage	$11.11
Rate for Payer: Humana Medicare Advantage	$10.79
Rate for Payer: UnitedHealthcare Commercial	$25.15
Rate for Payer: UnitedHealthcare Commercial	$25.14
Rate for Payer: UnitedHealthcare Commercial	$24.41
Rate for Payer: UnitedHealthcare Medicaid	$10.58
Rate for Payer: UnitedHealthcare Medicaid	$10.59
Rate for Payer: UnitedHealthcare Medicaid	$10.28
Rate for Payer: WPPA Medicare Advantage	$15.41
Rate for Payer: WPPA Medicare Advantage	$15.88
Rate for Payer: WPPA Medicare Advantage	$15.88

budesonide 0.25 mg/2 mL Inh Susp [HMC]

Facility

$25.69

Service Code	HCPCS J7633
Hospital Charge Code	3806445
Hospital Revenue Code	250
Min. Negotiated Rate	$23.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.12
Rate for Payer: Aetna Commercial	$23.81
Rate for Payer: Aetna Commercial	$23.82
Rate for Payer: UnitedHealthcare Commercial	$25.15
Rate for Payer: UnitedHealthcare Commercial	$25.14
Rate for Payer: UnitedHealthcare Commercial	$24.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

budesonide 0.25 mg/2 mL Sus [HMC]

Facility

$26.47

Service Code	HCPCS J7633
Hospital Charge Code	3806445
Hospital Revenue Code	250
Min. Negotiated Rate	$23.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.82
Rate for Payer: UnitedHealthcare Commercial	$25.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

budesonide 0.25 mg/2 mL Sus [HMC]

Facility

$26.47

Service Code	HCPCS J7633
Hospital Charge Code	3806445
Hospital Revenue Code	250
Min. Negotiated Rate	$6.55
Max. Negotiated Rate	$25.15
Rate for Payer: Aetna Commercial	$23.82
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$6.55
Rate for Payer: Humana Medicare Advantage	$11.12
Rate for Payer: UnitedHealthcare Commercial	$25.15
Rate for Payer: UnitedHealthcare Medicaid	$10.59
Rate for Payer: WPPA Medicare Advantage	$15.88

budesonide 0.5 mg/2 mL Inh Susp [HMC]

Facility

$26.62

Service Code	NDC 00115168974
Hospital Charge Code	3806946
Hospital Revenue Code	250
Min. Negotiated Rate	$23.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.96
Rate for Payer: UnitedHealthcare Commercial	$25.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

budesonide 0.5 mg/2 mL Inh Susp [HMC]

Facility

$26.62

Service Code	HCPCS J7626
Hospital Charge Code	3806946
Hospital Revenue Code	250
Min. Negotiated Rate	$23.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.96
Rate for Payer: Aetna Commercial	$24.12
Rate for Payer: Aetna Commercial	$25.61
Rate for Payer: UnitedHealthcare Commercial	$27.04
Rate for Payer: UnitedHealthcare Commercial	$25.29
Rate for Payer: UnitedHealthcare Commercial	$25.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

budesonide 0.5 mg/2 mL Inh Susp [HMC]

Facility

$26.80

Service Code	HCPCS J7626
Hospital Charge Code	3806946
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$25.46
Rate for Payer: Aetna Commercial	$24.12
Rate for Payer: Aetna Commercial	$23.96
Rate for Payer: Aetna Commercial	$25.61
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.55
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.55
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.55
Rate for Payer: Humana Medicare Advantage	$11.26
Rate for Payer: Humana Medicare Advantage	$11.18
Rate for Payer: Humana Medicare Advantage	$11.95
Rate for Payer: UnitedHealthcare Commercial	$25.29
Rate for Payer: UnitedHealthcare Commercial	$25.46
Rate for Payer: UnitedHealthcare Commercial	$27.04
Rate for Payer: UnitedHealthcare Medicaid	$1.05
Rate for Payer: UnitedHealthcare Medicaid	$1.05
Rate for Payer: UnitedHealthcare Medicaid	$1.05
Rate for Payer: WPPA Medicare Advantage	$17.08
Rate for Payer: WPPA Medicare Advantage	$16.08
Rate for Payer: WPPA Medicare Advantage	$15.97

budesonide 0.5 mg/2 mL Inh Susp [HMC]

Facility

$26.62

Service Code	NDC 00115168974
Hospital Charge Code	3806946
Hospital Revenue Code	250
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$25.29
Rate for Payer: Aetna Commercial	$23.96
Rate for Payer: Humana Medicare Advantage	$11.18
Rate for Payer: UnitedHealthcare Commercial	$25.29
Rate for Payer: UnitedHealthcare Medicaid	$10.65
Rate for Payer: WPPA Medicare Advantage	$15.97

budesonide-formoterol 160 mcg-4.5 mcg/inh Inh Aer w/adapter 6 g [HMC]

Facility

$437.33

Service Code	NDC 00186037028
Hospital Charge Code	3800193
Hospital Revenue Code	250
Min. Negotiated Rate	$393.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$393.60
Rate for Payer: UnitedHealthcare Commercial	$415.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges