Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

etoposide 20 mg/mL IV Sol [HMC]

Facility

$44.11

Service Code	HCPCS J9181
Hospital Charge Code	3851420
Hospital Revenue Code	250
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$41.90
Rate for Payer: Aetna Commercial	$39.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.34
Rate for Payer: Humana Medicare Advantage	$18.53
Rate for Payer: UnitedHealthcare Commercial	$41.90
Rate for Payer: UnitedHealthcare Medicaid	$1.04
Rate for Payer: WPPA Medicare Advantage	$26.47

etoposide 20 mg/mL IV Sol [HMC]

Facility

$44.11

Service Code	HCPCS J9181
Hospital Charge Code	3851420
Hospital Revenue Code	250
Min. Negotiated Rate	$39.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.70
Rate for Payer: UnitedHealthcare Commercial	$41.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Eustachian Tube Dilation System Aera

Facility

$3,762.72

Hospital Charge Code	3259971
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,574.58
Rate for Payer: Aetna Commercial	$3,386.45
Rate for Payer: UnitedHealthcare Commercial	$3,574.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Eustachian Tube Dilation System Aera

Facility

$3,762.72

Hospital Charge Code	3259971
Hospital Revenue Code	270
Min. Negotiated Rate	$1,505.09
Max. Negotiated Rate	$3,574.58
Rate for Payer: Aetna Commercial	$3,386.45
Rate for Payer: Humana Medicare Advantage	$1,580.34
Rate for Payer: UnitedHealthcare Commercial	$3,574.58
Rate for Payer: UnitedHealthcare Medicaid	$1,505.09
Rate for Payer: WPPA Medicare Advantage	$2,257.63

Eval for Use/Fitting of Voice Prosthetic Dvc Chg

Facility

$228.00

Service Code	HCPCS 92597 GN
Hospital Charge Code	4052597
Hospital Revenue Code	444
Min. Negotiated Rate	$91.20
Max. Negotiated Rate	$216.60
Rate for Payer: Aetna Commercial	$205.20
Rate for Payer: Humana Medicare Advantage	$95.76
Rate for Payer: UnitedHealthcare Commercial	$216.60
Rate for Payer: UnitedHealthcare Medicaid	$91.20
Rate for Payer: WPPA Medicare Advantage	$136.80

Eval for Use/Fitting of Voice Prosthetic Dvc Chg

Facility

$228.00

Service Code	HCPCS 92597 GN
Hospital Charge Code	4052597
Hospital Revenue Code	444
Min. Negotiated Rate	$205.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$205.20
Rate for Payer: UnitedHealthcare Commercial	$216.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Eval of Oral and Pharyngeal Swallowing Fx Chg

Facility

$384.00

Service Code	HCPCS 92610 GN
Hospital Charge Code	4050206
Hospital Revenue Code	444
Min. Negotiated Rate	$345.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$345.60
Rate for Payer: UnitedHealthcare Commercial	$364.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Eval of Oral and Pharyngeal Swallowing Fx Chg

Facility

$384.00

Service Code	HCPCS 92610 GN
Hospital Charge Code	4050206
Hospital Revenue Code	444
Min. Negotiated Rate	$88.44
Max. Negotiated Rate	$364.80
Rate for Payer: Aetna Commercial	$345.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$128.71
Rate for Payer: Humana Medicare Advantage	$161.28
Rate for Payer: UnitedHealthcare Commercial	$364.80
Rate for Payer: UnitedHealthcare Medicaid	$88.44
Rate for Payer: WPPA Medicare Advantage	$230.40

Eval of Oral and Pharyngeal Swallowing Fx Min

Facility

$384.00

Service Code	HCPCS 92610 GN
Hospital Charge Code	4050206
Hospital Revenue Code	444
Min. Negotiated Rate	$88.44
Max. Negotiated Rate	$364.80
Rate for Payer: Aetna Commercial	$345.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$128.71
Rate for Payer: Humana Medicare Advantage	$161.28
Rate for Payer: UnitedHealthcare Commercial	$364.80
Rate for Payer: UnitedHealthcare Medicaid	$88.44
Rate for Payer: WPPA Medicare Advantage	$230.40

Eval of Oral and Pharyngeal Swallowing Fx Min

Facility

$384.00

Service Code	HCPCS 92610 GN
Hospital Charge Code	4050206
Hospital Revenue Code	444
Min. Negotiated Rate	$345.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$345.60
Rate for Payer: UnitedHealthcare Commercial	$364.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Excision Cyst Bladder

Facility

$4,786.00

Service Code	HCPCS 51500
Hospital Charge Code	3150828
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,546.70
Rate for Payer: Aetna Commercial	$4,307.40
Rate for Payer: UnitedHealthcare Commercial	$4,546.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Excision Cyst Bladder

Facility

$4,786.00

Service Code	HCPCS 51500
Hospital Charge Code	3150828
Hospital Revenue Code	360
Min. Negotiated Rate	$1,869.18
Max. Negotiated Rate	$4,546.70
Rate for Payer: Aetna Commercial	$4,307.40
Rate for Payer: Humana Medicare Advantage	$2,010.12
Rate for Payer: UnitedHealthcare Commercial	$4,546.70
Rate for Payer: UnitedHealthcare Medicaid	$1,869.18
Rate for Payer: WPPA Medicare Advantage	$2,871.60

Excision Cyst Eyelid

Facility

$1,353.00

Hospital Charge Code	3155004
Hospital Revenue Code	360
Min. Negotiated Rate	$541.20
Max. Negotiated Rate	$1,285.35
Rate for Payer: Aetna Commercial	$1,217.70
Rate for Payer: Humana Medicare Advantage	$568.26
Rate for Payer: UnitedHealthcare Commercial	$1,285.35
Rate for Payer: UnitedHealthcare Medicaid	$541.20
Rate for Payer: WPPA Medicare Advantage	$811.80

Excision Cyst Eyelid

Facility

$1,353.00

Hospital Charge Code	3155004
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,285.35
Rate for Payer: Aetna Commercial	$1,217.70
Rate for Payer: UnitedHealthcare Commercial	$1,285.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM

Facility

$2,531.05

Service Code	CPT 21555
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$2,531.05
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,104.84
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$2,531.05

exenatide 2 mg Pow [HMC]

Facility

$360.76

Service Code	NDC 00310653004
Hospital Charge Code	3800763
Hospital Revenue Code	250
Min. Negotiated Rate	$324.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$324.68
Rate for Payer: UnitedHealthcare Commercial	$342.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

exenatide 2 mg Pow [HMC]

Facility

$360.76

Service Code	NDC 00310653004
Hospital Charge Code	3800763
Hospital Revenue Code	250
Min. Negotiated Rate	$144.30
Max. Negotiated Rate	$342.72
Rate for Payer: Aetna Commercial	$324.68
Rate for Payer: Humana Medicare Advantage	$151.52
Rate for Payer: UnitedHealthcare Commercial	$342.72
Rate for Payer: UnitedHealthcare Medicaid	$144.30
Rate for Payer: WPPA Medicare Advantage	$216.46

exenatide 2 mg Pow [HMC]

Facility

$317.07

Service Code	NDC 00310652004
Hospital Charge Code	3800763
Hospital Revenue Code	250
Min. Negotiated Rate	$126.83
Max. Negotiated Rate	$301.22
Rate for Payer: Aetna Commercial	$285.36
Rate for Payer: Humana Medicare Advantage	$133.17
Rate for Payer: UnitedHealthcare Commercial	$301.22
Rate for Payer: UnitedHealthcare Medicaid	$126.83
Rate for Payer: WPPA Medicare Advantage	$190.24

exenatide 2 mg Pow [HMC]

Facility

$317.07

Service Code	NDC 00310652004
Hospital Charge Code	3800763
Hospital Revenue Code	250
Min. Negotiated Rate	$285.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$285.36
Rate for Payer: UnitedHealthcare Commercial	$301.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT

Facility

$12,453.84

Service Code	MSDRG 933
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,453.84
Rate for Payer: UnitedHealthcare Medicaid	$12,453.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT

Facility

$74,850.12

Service Code	MSDRG 927
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$74,850.12
Rate for Payer: UnitedHealthcare Medicaid	$74,850.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC

Facility

$10,674.72

Service Code	MSDRG 982
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,674.72
Rate for Payer: UnitedHealthcare Medicaid	$10,674.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$16,996.95

Service Code	MSDRG 981
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$16,996.95
Rate for Payer: UnitedHealthcare Medicaid	$16,996.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$6,417.54

Service Code	MSDRG 983
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,417.54
Rate for Payer: UnitedHealthcare Medicaid	$6,417.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EXTRACRANIAL PROCEDURES WITH CC

Facility

$5,909.22

Service Code	MSDRG 038
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,909.22
Rate for Payer: UnitedHealthcare Medicaid	$5,909.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges