Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Endomysial IgG Antibody Screen and Titer QST

Facility

$144.00

Service Code	HCPCS 86231
Hospital Charge Code	3556231
Hospital Revenue Code	300
Min. Negotiated Rate	$129.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$129.60
Rate for Payer: UnitedHealthcare Commercial	$136.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Endomysial IgG Antibody Screen and Titer QST

Facility

$144.00

Service Code	HCPCS 86231
Hospital Charge Code	3556231
Hospital Revenue Code	300
Min. Negotiated Rate	$7.86
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna Commercial	$129.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$22.67
Rate for Payer: Humana Medicare Advantage	$60.48
Rate for Payer: UnitedHealthcare Commercial	$136.80
Rate for Payer: UnitedHealthcare Medicaid	$7.86
Rate for Payer: WPPA Medicare Advantage	$86.40

Endo Overtube Esophageal Guardus Range 8.6 - 10.0mm

Facility

$614.00

Hospital Charge Code	3258952
Hospital Revenue Code	270
Min. Negotiated Rate	$245.60
Max. Negotiated Rate	$583.30
Rate for Payer: Aetna Commercial	$552.60
Rate for Payer: Humana Medicare Advantage	$257.88
Rate for Payer: UnitedHealthcare Commercial	$583.30
Rate for Payer: UnitedHealthcare Medicaid	$245.60
Rate for Payer: WPPA Medicare Advantage	$368.40

Endo Overtube Esophageal Guardus Range 8.6 - 10.0mm

Facility

$614.00

Hospital Charge Code	3258952
Hospital Revenue Code	270
Min. Negotiated Rate	$552.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$552.60
Rate for Payer: UnitedHealthcare Commercial	$583.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Endoscopy Oxygen Mask Medium Concentration without EtCO2 Sampling Line (POM Panoramic Oxygen Mask di

Facility

$47.00

Hospital Charge Code	3254950
Hospital Revenue Code	270
Min. Negotiated Rate	$18.80
Max. Negotiated Rate	$44.65
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: Humana Medicare Advantage	$19.74
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: UnitedHealthcare Medicaid	$18.80
Rate for Payer: WPPA Medicare Advantage	$28.20

Endoscopy Oxygen Mask Medium Concentration without EtCO2 Sampling Line (POM Panoramic Oxygen Mask di

Facility

$47.00

Hospital Charge Code	3254950
Hospital Revenue Code	270
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Endo Spider-Net Foreign Object Retrieval Device

Facility

$210.00

Hospital Charge Code	3257245
Hospital Revenue Code	270
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$189.00
Rate for Payer: UnitedHealthcare Commercial	$199.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Endo Spider-Net Foreign Object Retrieval Device

Facility

$210.00

Hospital Charge Code	3257245
Hospital Revenue Code	270
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$199.50
Rate for Payer: Aetna Commercial	$189.00
Rate for Payer: Humana Medicare Advantage	$88.20
Rate for Payer: UnitedHealthcare Commercial	$199.50
Rate for Payer: UnitedHealthcare Medicaid	$84.00
Rate for Payer: WPPA Medicare Advantage	$126.00

Endo Valves Air Water Suction Disposable 3-PC Set

Facility

$27.90

Hospital Charge Code	3254745
Hospital Revenue Code	270
Min. Negotiated Rate	$25.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.11
Rate for Payer: UnitedHealthcare Commercial	$26.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Endo Valves Air Water Suction Disposable 3-PC Set

Facility

$27.90

Hospital Charge Code	3254745
Hospital Revenue Code	270
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$26.50
Rate for Payer: Aetna Commercial	$25.11
Rate for Payer: Humana Medicare Advantage	$11.72
Rate for Payer: UnitedHealthcare Commercial	$26.50
Rate for Payer: UnitedHealthcare Medicaid	$11.16
Rate for Payer: WPPA Medicare Advantage	$16.74

ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES

Facility

$20,459.88

Service Code	MSDRG 213
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$20,459.88
Rate for Payer: UnitedHealthcare Medicaid	$20,459.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC

Facility

$21,953.07

Service Code	MSDRG 266
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$21,953.07
Rate for Payer: UnitedHealthcare Medicaid	$21,953.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC

Facility

$19,538.55

Service Code	MSDRG 267
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$19,538.55
Rate for Payer: UnitedHealthcare Medicaid	$19,538.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Enema Bag w/Soap

Facility

$4.50

Hospital Charge Code	3255002
Hospital Revenue Code	270
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.05
Rate for Payer: UnitedHealthcare Commercial	$4.28
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Enema Bag w/Soap

Facility

$4.50

Hospital Charge Code	3255002
Hospital Revenue Code	270
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$4.28
Rate for Payer: Aetna Commercial	$4.05
Rate for Payer: Humana Medicare Advantage	$1.89
Rate for Payer: UnitedHealthcare Commercial	$4.28
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: WPPA Medicare Advantage	$2.70

Enema Fleets

Facility

$8.24

Hospital Charge Code	3250920
Hospital Revenue Code	270
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$7.83
Rate for Payer: Aetna Commercial	$7.42
Rate for Payer: Humana Medicare Advantage	$3.46
Rate for Payer: UnitedHealthcare Commercial	$7.83
Rate for Payer: UnitedHealthcare Medicaid	$3.30
Rate for Payer: WPPA Medicare Advantage	$4.94

Enema Fleets

Facility

$8.24

Hospital Charge Code	3250920
Hospital Revenue Code	270
Min. Negotiated Rate	$7.42
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.42
Rate for Payer: UnitedHealthcare Commercial	$7.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

enoxaparin 100 mg/mL SubQ Sol [HMC]

Facility

$42.37

Service Code	HCPCS J1650
Hospital Charge Code	3804211
Hospital Revenue Code	250
Min. Negotiated Rate	$38.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.13
Rate for Payer: Aetna Commercial	$50.20
Rate for Payer: Aetna Commercial	$55.72
Rate for Payer: UnitedHealthcare Commercial	$58.81
Rate for Payer: UnitedHealthcare Commercial	$40.25
Rate for Payer: UnitedHealthcare Commercial	$52.99
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

enoxaparin 100 mg/mL SubQ Sol [HMC]

Facility

$55.78

Service Code	HCPCS J1650
Hospital Charge Code	3804211
Hospital Revenue Code	250
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$52.99
Rate for Payer: Aetna Commercial	$50.20
Rate for Payer: Aetna Commercial	$38.13
Rate for Payer: Aetna Commercial	$55.72
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.80
Rate for Payer: Humana Medicare Advantage	$23.43
Rate for Payer: Humana Medicare Advantage	$17.80
Rate for Payer: Humana Medicare Advantage	$26.00
Rate for Payer: UnitedHealthcare Commercial	$40.25
Rate for Payer: UnitedHealthcare Commercial	$52.99
Rate for Payer: UnitedHealthcare Commercial	$58.81
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: WPPA Medicare Advantage	$37.15
Rate for Payer: WPPA Medicare Advantage	$33.47
Rate for Payer: WPPA Medicare Advantage	$25.42

enoxaparin 30 mg/0.3 mL SC Sol [HMC]

Facility

$38.06

Service Code	HCPCS J1650
Hospital Charge Code	3800071
Hospital Revenue Code	250
Min. Negotiated Rate	$34.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.25
Rate for Payer: Aetna Commercial	$37.34
Rate for Payer: Aetna Commercial	$40.61
Rate for Payer: UnitedHealthcare Commercial	$42.86
Rate for Payer: UnitedHealthcare Commercial	$36.16
Rate for Payer: UnitedHealthcare Commercial	$39.42
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

enoxaparin 30 mg/0.3 mL SC Sol [HMC]

Facility

$41.49

Service Code	HCPCS J1650
Hospital Charge Code	3800071
Hospital Revenue Code	250
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$39.42
Rate for Payer: Aetna Commercial	$37.34
Rate for Payer: Aetna Commercial	$34.25
Rate for Payer: Aetna Commercial	$40.61
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.80
Rate for Payer: Humana Medicare Advantage	$17.43
Rate for Payer: Humana Medicare Advantage	$15.99
Rate for Payer: Humana Medicare Advantage	$18.95
Rate for Payer: UnitedHealthcare Commercial	$36.16
Rate for Payer: UnitedHealthcare Commercial	$39.42
Rate for Payer: UnitedHealthcare Commercial	$42.86
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: WPPA Medicare Advantage	$27.07
Rate for Payer: WPPA Medicare Advantage	$24.89
Rate for Payer: WPPA Medicare Advantage	$22.84

enoxaparin 40 mg/0.4 mL SC Sol [HMC]

Facility

$48.58

Service Code	NDC 63323056497
Hospital Charge Code	3809098
Hospital Revenue Code	250
Min. Negotiated Rate	$43.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$43.72
Rate for Payer: UnitedHealthcare Commercial	$46.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

enoxaparin 40 mg/0.4 mL SC Sol [HMC]

Facility

$48.58

Service Code	NDC 63323056497
Hospital Charge Code	3809098
Hospital Revenue Code	250
Min. Negotiated Rate	$19.43
Max. Negotiated Rate	$46.15
Rate for Payer: Aetna Commercial	$43.72
Rate for Payer: Humana Medicare Advantage	$20.40
Rate for Payer: UnitedHealthcare Commercial	$46.15
Rate for Payer: UnitedHealthcare Medicaid	$19.43
Rate for Payer: WPPA Medicare Advantage	$29.15

enoxaparin 40 mg/0.4 mL SC Sol [HMC]

Facility

$41.60

Service Code	HCPCS J1650
Hospital Charge Code	3809098
Hospital Revenue Code	250
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$39.52
Rate for Payer: Aetna Commercial	$37.44
Rate for Payer: Aetna Commercial	$43.72
Rate for Payer: Aetna Commercial	$37.87
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.80
Rate for Payer: Humana Medicare Advantage	$17.67
Rate for Payer: Humana Medicare Advantage	$20.40
Rate for Payer: Humana Medicare Advantage	$17.47
Rate for Payer: UnitedHealthcare Commercial	$39.98
Rate for Payer: UnitedHealthcare Commercial	$39.52
Rate for Payer: UnitedHealthcare Commercial	$46.15
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: UnitedHealthcare Medicaid	$0.53
Rate for Payer: WPPA Medicare Advantage	$24.96
Rate for Payer: WPPA Medicare Advantage	$25.25
Rate for Payer: WPPA Medicare Advantage	$29.15

enoxaparin 40 mg/0.4 mL SC Sol [HMC]

Facility

$41.60

Service Code	HCPCS J1650
Hospital Charge Code	3809098
Hospital Revenue Code	250
Min. Negotiated Rate	$37.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$37.44
Rate for Payer: Aetna Commercial	$37.87
Rate for Payer: Aetna Commercial	$43.72
Rate for Payer: UnitedHealthcare Commercial	$46.15
Rate for Payer: UnitedHealthcare Commercial	$39.98
Rate for Payer: UnitedHealthcare Commercial	$39.52
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

Know your out-of-pocket cost for care.

All Charges