Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Electrode Natus Gold Cup EEG 1.5 meter (59) lead (12 per Pack) w/ 1.5mm Female Connector

Facility

$318.00

Hospital Charge Code	3253875
Hospital Revenue Code	270
Min. Negotiated Rate	$127.20
Max. Negotiated Rate	$302.10
Rate for Payer: Aetna Commercial	$286.20
Rate for Payer: Humana Medicare Advantage	$133.56
Rate for Payer: UnitedHealthcare Commercial	$302.10
Rate for Payer: UnitedHealthcare Medicaid	$127.20
Rate for Payer: WPPA Medicare Advantage	$190.80

Electrode Natus Gold Cup EEG 2.5 meter (98) lead (12 per Pack) w/ 1.5mm Female Connector

Facility

$494.10

Hospital Charge Code	3253876
Hospital Revenue Code	270
Min. Negotiated Rate	$197.64
Max. Negotiated Rate	$469.39
Rate for Payer: Aetna Commercial	$444.69
Rate for Payer: Humana Medicare Advantage	$207.52
Rate for Payer: UnitedHealthcare Commercial	$469.39
Rate for Payer: UnitedHealthcare Medicaid	$197.64
Rate for Payer: WPPA Medicare Advantage	$296.46

Electrode Natus Gold Cup EEG 2.5 meter (98) lead (12 per Pack) w/ 1.5mm Female Connector

Facility

$494.10

Hospital Charge Code	3253876
Hospital Revenue Code	270
Min. Negotiated Rate	$444.69
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$444.69
Rate for Payer: UnitedHealthcare Commercial	$469.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Electrode Prass Paired 18mm Xomed for NIM Response 3.0 Nerve Monitoring System

Facility

$363.00

Hospital Charge Code	3250411
Hospital Revenue Code	270
Min. Negotiated Rate	$326.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$326.70
Rate for Payer: UnitedHealthcare Commercial	$344.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Electrode Prass Paired 18mm Xomed for NIM Response 3.0 Nerve Monitoring System

Facility

$363.00

Hospital Charge Code	3250411
Hospital Revenue Code	270
Min. Negotiated Rate	$145.20
Max. Negotiated Rate	$344.85
Rate for Payer: Aetna Commercial	$326.70
Rate for Payer: Humana Medicare Advantage	$152.46
Rate for Payer: UnitedHealthcare Commercial	$344.85
Rate for Payer: UnitedHealthcare Medicaid	$145.20
Rate for Payer: WPPA Medicare Advantage	$217.80

Electrode Spiral Fetal

Facility

$15.21

Hospital Charge Code	3250995
Hospital Revenue Code	270
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$14.45
Rate for Payer: Aetna Commercial	$13.69
Rate for Payer: Humana Medicare Advantage	$6.39
Rate for Payer: UnitedHealthcare Commercial	$14.45
Rate for Payer: UnitedHealthcare Medicaid	$6.08
Rate for Payer: WPPA Medicare Advantage	$9.13

Electrode Spiral Fetal

Facility

$15.21

Hospital Charge Code	3250995
Hospital Revenue Code	270
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.69
Rate for Payer: UnitedHealthcare Commercial	$14.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Electrolyte Panel

Facility

$75.00

Service Code	HCPCS 80051
Hospital Charge Code	3550569
Hospital Revenue Code	300
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Electrolyte Panel

Facility

$75.00

Service Code	HCPCS 80051
Hospital Charge Code	3550569
Hospital Revenue Code	300
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$71.25
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$19.65
Rate for Payer: Humana Medicare Advantage	$31.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: UnitedHealthcare Medicaid	$6.00
Rate for Payer: WPPA Medicare Advantage	$45.00

electrolyte replacement Oral Sol 1000 mL [HMC]

Facility

$30.15

Service Code	NDC 00074517530
Hospital Charge Code	3806532
Hospital Revenue Code	250
Min. Negotiated Rate	$27.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.14
Rate for Payer: UnitedHealthcare Commercial	$28.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

electrolyte replacement Oral Sol 1000 mL [HMC]

Facility

$30.15

Service Code	NDC 00074517530
Hospital Charge Code	3806532
Hospital Revenue Code	250
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$28.64
Rate for Payer: Aetna Commercial	$27.14
Rate for Payer: Humana Medicare Advantage	$12.66
Rate for Payer: UnitedHealthcare Commercial	$28.64
Rate for Payer: UnitedHealthcare Medicaid	$12.06
Rate for Payer: WPPA Medicare Advantage	$18.09

Elm (T8) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1012
Hospital Revenue Code	300
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

Elm (T8) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1012
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$16.20

emollients, topical [HMC]

Facility

$39.37

Service Code	NDC 72140011015
Hospital Charge Code	3801520
Hospital Revenue Code	250
Min. Negotiated Rate	$35.43
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.43
Rate for Payer: UnitedHealthcare Commercial	$37.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

emollients, topical [HMC]

Facility

$39.37

Service Code	NDC 72140011015
Hospital Charge Code	3801520
Hospital Revenue Code	250
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$37.40
Rate for Payer: Aetna Commercial	$35.43
Rate for Payer: Humana Medicare Advantage	$16.54
Rate for Payer: UnitedHealthcare Commercial	$37.40
Rate for Payer: UnitedHealthcare Medicaid	$15.75
Rate for Payer: WPPA Medicare Advantage	$23.62

emollients, Top Stick [HMC]

Facility

$22.80

Service Code	NDC 00573192524
Hospital Charge Code	3809619
Hospital Revenue Code	250
Min. Negotiated Rate	$20.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.52
Rate for Payer: UnitedHealthcare Commercial	$21.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

emollients, Top Stick [HMC]

Facility

$22.80

Service Code	NDC 00573192524
Hospital Charge Code	3809619
Hospital Revenue Code	250
Min. Negotiated Rate	$9.12
Max. Negotiated Rate	$21.66
Rate for Payer: Aetna Commercial	$20.52
Rate for Payer: Humana Medicare Advantage	$9.58
Rate for Payer: UnitedHealthcare Commercial	$21.66
Rate for Payer: UnitedHealthcare Medicaid	$9.12
Rate for Payer: WPPA Medicare Advantage	$13.68

EMPLOYEE MEALS (NON-P/R)

Facility

$4.00

Hospital Charge Code	5545541
Hospital Revenue Code	991
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EMPLOYEE MEALS (NON-P/R)

Facility

$4.00

Hospital Charge Code	5545541
Hospital Revenue Code	991
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.80
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Humana Medicare Advantage	$1.68
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: UnitedHealthcare Medicaid	$1.60
Rate for Payer: WPPA Medicare Advantage	$2.40

Empty Glass Evacuated Bottle 1000ML only Spike-able

Facility

$91.88

Hospital Charge Code	3257081
Hospital Revenue Code	270
Min. Negotiated Rate	$82.69
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$82.69
Rate for Payer: UnitedHealthcare Commercial	$87.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Empty Glass Evacuated Bottle 1000ML only Spike-able

Facility

$91.88

Hospital Charge Code	3257081
Hospital Revenue Code	270
Min. Negotiated Rate	$36.75
Max. Negotiated Rate	$87.29
Rate for Payer: Aetna Commercial	$82.69
Rate for Payer: Humana Medicare Advantage	$38.59
Rate for Payer: UnitedHealthcare Commercial	$87.29
Rate for Payer: UnitedHealthcare Medicaid	$36.75
Rate for Payer: WPPA Medicare Advantage	$55.13

Empty Plastic Evacuated Bottle 1325ml Spike-able & Luer-Lock Connections

Facility

$49.50

Hospital Charge Code	3257080
Hospital Revenue Code	270
Min. Negotiated Rate	$44.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$44.55
Rate for Payer: UnitedHealthcare Commercial	$47.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Empty Plastic Evacuated Bottle 1325ml Spike-able & Luer-Lock Connections

Facility

$49.50

Hospital Charge Code	3257080
Hospital Revenue Code	270
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$47.02
Rate for Payer: Aetna Commercial	$44.55
Rate for Payer: Humana Medicare Advantage	$20.79
Rate for Payer: UnitedHealthcare Commercial	$47.02
Rate for Payer: UnitedHealthcare Medicaid	$19.80
Rate for Payer: WPPA Medicare Advantage	$29.70

enalapril 1.25 mg/mL IV Sol [HMC]

Facility

$39.11

Service Code	NDC 00143978710
Hospital Charge Code	3802603
Hospital Revenue Code	250
Min. Negotiated Rate	$35.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.20
Rate for Payer: UnitedHealthcare Commercial	$37.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

enalapril 1.25 mg/mL IV Sol [HMC]

Facility

$39.11

Service Code	NDC 00143978710
Hospital Charge Code	3802603
Hospital Revenue Code	250
Min. Negotiated Rate	$15.64
Max. Negotiated Rate	$37.15
Rate for Payer: Aetna Commercial	$35.20
Rate for Payer: Humana Medicare Advantage	$16.43
Rate for Payer: UnitedHealthcare Commercial	$37.15
Rate for Payer: UnitedHealthcare Medicaid	$15.64
Rate for Payer: WPPA Medicare Advantage	$23.47

Know your out-of-pocket cost for care.

All Charges