Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Epic Pump 5ML/HR/270ML

Facility

$65.25

Hospital Charge Code	3253598
Hospital Revenue Code	270
Min. Negotiated Rate	$58.73
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$58.73
Rate for Payer: UnitedHealthcare Commercial	$61.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Epic Pump Pouches

Facility

$337.75

Hospital Charge Code	3253599
Hospital Revenue Code	270
Min. Negotiated Rate	$135.10
Max. Negotiated Rate	$320.86
Rate for Payer: Aetna Commercial	$303.98
Rate for Payer: Humana Medicare Advantage	$141.85
Rate for Payer: UnitedHealthcare Commercial	$320.86
Rate for Payer: UnitedHealthcare Medicaid	$135.10
Rate for Payer: WPPA Medicare Advantage	$202.65

Epic Pump Pouches

Facility

$337.75

Hospital Charge Code	3253599
Hospital Revenue Code	270
Min. Negotiated Rate	$303.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$303.98
Rate for Payer: UnitedHealthcare Commercial	$320.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Epidisc Otologic Lamina Repair Graft

Facility

$542.00

Service Code	HCPCS C1763
Hospital Charge Code	3257100
Hospital Revenue Code	278
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$514.90
Rate for Payer: Aetna Commercial	$487.80
Rate for Payer: Humana Medicare Advantage	$227.64
Rate for Payer: UnitedHealthcare Commercial	$514.90
Rate for Payer: UnitedHealthcare Medicaid	$216.80
Rate for Payer: WPPA Medicare Advantage	$325.20

Epidisc Otologic Lamina Repair Graft

Facility

$542.00

Service Code	HCPCS C1763
Hospital Charge Code	3257100
Hospital Revenue Code	278
Min. Negotiated Rate	$487.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$487.80
Rate for Payer: UnitedHealthcare Commercial	$514.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Epidural Steroid Injection Caudal

Facility

$1,164.00

Service Code	HCPCS 62322
Hospital Charge Code	3150501
Hospital Revenue Code	360
Min. Negotiated Rate	$377.15
Max. Negotiated Rate	$1,105.80
Rate for Payer: Aetna Commercial	$1,047.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$588.83
Rate for Payer: Humana Medicare Advantage	$488.88
Rate for Payer: UnitedHealthcare Commercial	$1,105.80
Rate for Payer: UnitedHealthcare Medicaid	$377.15
Rate for Payer: WPPA Medicare Advantage	$698.40

Epidural Steroid Injection Caudal

Facility

$1,164.00

Service Code	HCPCS 62322
Hospital Charge Code	3150501
Hospital Revenue Code	360
Min. Negotiated Rate	$1,047.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,047.60
Rate for Payer: UnitedHealthcare Commercial	$1,105.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Epidural Steroid Injection Cervical

Facility

$1,700.00

Service Code	HCPCS 62321
Hospital Charge Code	3152321
Hospital Revenue Code	360
Min. Negotiated Rate	$377.15
Max. Negotiated Rate	$1,615.00
Rate for Payer: Aetna Commercial	$1,530.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,141.80
Rate for Payer: Humana Medicare Advantage	$714.00
Rate for Payer: UnitedHealthcare Commercial	$1,615.00
Rate for Payer: UnitedHealthcare Medicaid	$377.15
Rate for Payer: WPPA Medicare Advantage	$1,020.00

Epidural Steroid Injection Cervical

Facility

$1,700.00

Service Code	HCPCS 62321
Hospital Charge Code	3152321
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,615.00
Rate for Payer: Aetna Commercial	$1,530.00
Rate for Payer: UnitedHealthcare Commercial	$1,615.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Epidural Steroid Injection w/Fluoro

Facility

$377.00

Service Code	HCPCS 77003
Hospital Charge Code	3700793
Hospital Revenue Code	320
Min. Negotiated Rate	$339.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$339.30
Rate for Payer: UnitedHealthcare Commercial	$358.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Epidural Steroid Injection w/Fluoro

Facility

$377.00

Service Code	HCPCS 77003
Hospital Charge Code	3700793
Hospital Revenue Code	320
Min. Negotiated Rate	$51.66
Max. Negotiated Rate	$358.15
Rate for Payer: Aetna Commercial	$339.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$235.09
Rate for Payer: Humana Medicare Advantage	$158.34
Rate for Payer: UnitedHealthcare Commercial	$358.15
Rate for Payer: UnitedHealthcare Medicaid	$51.66
Rate for Payer: WPPA Medicare Advantage	$226.20

Epidural Tray Continuous 19G Springwound Closed-Tip Catheter with Glass Slip LOR and 17G x 3.5 Need

Facility

$110.29

Hospital Charge Code	3256255
Hospital Revenue Code	270
Min. Negotiated Rate	$44.12
Max. Negotiated Rate	$104.78
Rate for Payer: Aetna Commercial	$99.26
Rate for Payer: Humana Medicare Advantage	$46.32
Rate for Payer: UnitedHealthcare Commercial	$104.78
Rate for Payer: UnitedHealthcare Medicaid	$44.12
Rate for Payer: WPPA Medicare Advantage	$66.17

Epidural Tray Continuous 19G Springwound Closed-Tip Catheter with Glass Slip LOR and 17G x 3.5 Need

Facility

$110.29

Hospital Charge Code	3256255
Hospital Revenue Code	270
Min. Negotiated Rate	$99.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$99.26
Rate for Payer: UnitedHealthcare Commercial	$104.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Epidural Tray Single Shot 18G x 3.5 Winged Tuohy Epidural Needle w/ Lidocaine

Facility

$61.25

Hospital Charge Code	3250556
Hospital Revenue Code	270
Min. Negotiated Rate	$55.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$55.12
Rate for Payer: UnitedHealthcare Commercial	$58.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Epidural Tray Single Shot 18G x 3.5 Winged Tuohy Epidural Needle w/ Lidocaine

Facility

$61.25

Hospital Charge Code	3250556
Hospital Revenue Code	270
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$58.19
Rate for Payer: Aetna Commercial	$55.12
Rate for Payer: Humana Medicare Advantage	$25.73
Rate for Payer: UnitedHealthcare Commercial	$58.19
Rate for Payer: UnitedHealthcare Medicaid	$24.50
Rate for Payer: WPPA Medicare Advantage	$36.75

Epidural Tray Single Shot 20G x 3.5 Winged Tuohy Epidural Needle w/ Lidocaine

Facility

$59.90

Hospital Charge Code	3250558
Hospital Revenue Code	270
Min. Negotiated Rate	$53.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$53.91
Rate for Payer: UnitedHealthcare Commercial	$56.91
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Epidural Tray Single Shot 20G x 3.5 Winged Tuohy Epidural Needle w/ Lidocaine

Facility

$59.90

Hospital Charge Code	3250558
Hospital Revenue Code	270
Min. Negotiated Rate	$23.96
Max. Negotiated Rate	$56.91
Rate for Payer: Aetna Commercial	$53.91
Rate for Payer: Humana Medicare Advantage	$25.16
Rate for Payer: UnitedHealthcare Commercial	$56.91
Rate for Payer: UnitedHealthcare Medicaid	$23.96
Rate for Payer: WPPA Medicare Advantage	$35.94

EPINEPHrine 0.1 mg/mL Inj Sol [HMC]

Facility

$50.00

Service Code	HCPCS J0171
Hospital Charge Code	3801542
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$47.50
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: Aetna Commercial	$38.04
Rate for Payer: Aetna Commercial	$35.29
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.05
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.05
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.05
Rate for Payer: Humana Medicare Advantage	$21.00
Rate for Payer: Humana Medicare Advantage	$17.75
Rate for Payer: Humana Medicare Advantage	$16.47
Rate for Payer: UnitedHealthcare Commercial	$40.16
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: UnitedHealthcare Commercial	$37.25
Rate for Payer: UnitedHealthcare Medicaid	$16.91
Rate for Payer: UnitedHealthcare Medicaid	$15.68
Rate for Payer: UnitedHealthcare Medicaid	$20.00
Rate for Payer: WPPA Medicare Advantage	$30.00
Rate for Payer: WPPA Medicare Advantage	$23.53
Rate for Payer: WPPA Medicare Advantage	$25.36

EPINEPHrine 0.1 mg/mL Inj Sol [HMC]

Facility

$50.00

Service Code	HCPCS J0171
Hospital Charge Code	3801542
Hospital Revenue Code	250
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: Aetna Commercial	$35.29
Rate for Payer: Aetna Commercial	$38.04
Rate for Payer: UnitedHealthcare Commercial	$37.25
Rate for Payer: UnitedHealthcare Commercial	$40.16
Rate for Payer: UnitedHealthcare Commercial	$47.50
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

EPINEPHrine 1 mg/mL Inj [HMC]

Facility

$55.90

Service Code	HCPCS JO171
Hospital Charge Code	3807432
Hospital Revenue Code	250
Min. Negotiated Rate	$22.36
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna Commercial	$50.31
Rate for Payer: Humana Medicare Advantage	$23.48
Rate for Payer: UnitedHealthcare Commercial	$53.10
Rate for Payer: UnitedHealthcare Medicaid	$22.36
Rate for Payer: WPPA Medicare Advantage	$33.54

EPINEPHrine 1 mg/mL Inj [HMC]

Facility

$55.90

Service Code	HCPCS JO171
Hospital Charge Code	3807432
Hospital Revenue Code	250
Min. Negotiated Rate	$50.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.31
Rate for Payer: UnitedHealthcare Commercial	$53.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EPINEPHrine 1 mg/mL preservative/sulfite-free [HMC]

Facility

$55.00

Service Code	HCPCS J0171
Hospital Charge Code	3807432
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$52.25
Rate for Payer: Aetna Commercial	$49.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.05
Rate for Payer: Humana Medicare Advantage	$23.10
Rate for Payer: UnitedHealthcare Commercial	$52.25
Rate for Payer: UnitedHealthcare Medicaid	$22.00
Rate for Payer: WPPA Medicare Advantage	$33.00

EPINEPHrine 1 mg/mL preservative/sulfite-free [HMC]

Facility

$55.00

Service Code	HCPCS J0171
Hospital Charge Code	3807432
Hospital Revenue Code	250
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$49.50
Rate for Payer: UnitedHealthcare Commercial	$52.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EPINEPHrine 30 mg/30 mL Sol [HMC]

Facility

$471.03

Service Code	HCPCS J0171
Hospital Charge Code	3807432
Hospital Revenue Code	250
Min. Negotiated Rate	$423.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$423.93
Rate for Payer: UnitedHealthcare Commercial	$447.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EPINEPHrine 30 mg/30 mL Sol [HMC]

Facility

$471.03

Service Code	HCPCS J0171
Hospital Charge Code	3807432
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$447.48
Rate for Payer: Aetna Commercial	$423.93
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.05
Rate for Payer: Humana Medicare Advantage	$197.83
Rate for Payer: UnitedHealthcare Commercial	$447.48
Rate for Payer: UnitedHealthcare Medicaid	$188.41
Rate for Payer: WPPA Medicare Advantage	$282.62

Know your out-of-pocket cost for care.

All Charges