Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

EXTRACRANIAL PROCEDURES WITH MCC

Facility

$11,977.29

Service Code	MSDRG 037
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,977.29
Rate for Payer: UnitedHealthcare Medicaid	$11,977.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EXTRACRANIAL PROCEDURES WITHOUT CC/MCC

Facility

$4,288.95

Service Code	MSDRG 039
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,288.95
Rate for Payer: UnitedHealthcare Medicaid	$4,288.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$5,369.13

Service Code	MSDRG 115
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,369.13
Rate for Payer: UnitedHealthcare Medicaid	$5,369.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$1,200.00

Service Code	MSDRG 790
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Eye Pad

Facility

$2.50

Hospital Charge Code	3250979
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

Eye Pad

Facility

$2.50

Hospital Charge Code	3250979
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Eye Patch w/Strap

Facility

$19.26

Hospital Charge Code	3256349
Hospital Revenue Code	270
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$18.30
Rate for Payer: Aetna Commercial	$17.33
Rate for Payer: Humana Medicare Advantage	$8.09
Rate for Payer: UnitedHealthcare Commercial	$18.30
Rate for Payer: UnitedHealthcare Medicaid	$7.70
Rate for Payer: WPPA Medicare Advantage	$11.56

Eye Patch w/Strap

Facility

$19.26

Hospital Charge Code	3256349
Hospital Revenue Code	270
Min. Negotiated Rate	$17.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.33
Rate for Payer: UnitedHealthcare Commercial	$18.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Eye Protector Mask with Adhesive Foam Cushion Adult size for use in Surgery

Facility

$36.59

Hospital Charge Code	3250395
Hospital Revenue Code	270
Min. Negotiated Rate	$14.64
Max. Negotiated Rate	$34.76
Rate for Payer: Aetna Commercial	$32.93
Rate for Payer: Humana Medicare Advantage	$15.37
Rate for Payer: UnitedHealthcare Commercial	$34.76
Rate for Payer: UnitedHealthcare Medicaid	$14.64
Rate for Payer: WPPA Medicare Advantage	$21.95

Eye Protector Mask with Adhesive Foam Cushion Adult size for use in Surgery

Facility

$36.59

Hospital Charge Code	3250395
Hospital Revenue Code	270
Min. Negotiated Rate	$32.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$32.93
Rate for Payer: UnitedHealthcare Commercial	$34.76
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ezetimibe 10 mg Tab [HMC]

Facility

$27.59

Service Code	NDC 50228037930
Hospital Charge Code	3804120
Hospital Revenue Code	250
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$26.21
Rate for Payer: Aetna Commercial	$24.83
Rate for Payer: Humana Medicare Advantage	$11.59
Rate for Payer: UnitedHealthcare Commercial	$26.21
Rate for Payer: UnitedHealthcare Medicaid	$11.04
Rate for Payer: WPPA Medicare Advantage	$16.55

ezetimibe 10 mg Tab [HMC]

Facility

$27.59

Service Code	NDC 50228037930
Hospital Charge Code	3804120
Hospital Revenue Code	250
Min. Negotiated Rate	$24.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.83
Rate for Payer: UnitedHealthcare Commercial	$26.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ezetimibe 10 mg Tab [HMC]

Facility

$25.57

Service Code	NDC 67877049030
Hospital Charge Code	3804120
Hospital Revenue Code	250
Min. Negotiated Rate	$10.23
Max. Negotiated Rate	$24.29
Rate for Payer: Aetna Commercial	$23.01
Rate for Payer: Humana Medicare Advantage	$10.74
Rate for Payer: UnitedHealthcare Commercial	$24.29
Rate for Payer: UnitedHealthcare Medicaid	$10.23
Rate for Payer: WPPA Medicare Advantage	$15.34

ezetimibe 10 mg Tab [HMC]

Facility

$25.57

Service Code	NDC 67877049030
Hospital Charge Code	3804120
Hospital Revenue Code	250
Min. Negotiated Rate	$23.01
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.01
Rate for Payer: UnitedHealthcare Commercial	$24.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EZ-IO Stabilizer

Facility

$85.00

Hospital Charge Code	3259850
Hospital Revenue Code	270
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: UnitedHealthcare Commercial	$80.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EZ-IO Stabilizer

Facility

$85.00

Hospital Charge Code	3259850
Hospital Revenue Code	270
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$80.75
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: Humana Medicare Advantage	$35.70
Rate for Payer: UnitedHealthcare Commercial	$80.75
Rate for Payer: UnitedHealthcare Medicaid	$34.00
Rate for Payer: WPPA Medicare Advantage	$51.00

EZPAP Nebulizer w/Manometer Disposable

Facility

$84.92

Hospital Charge Code	3251576
Hospital Revenue Code	270
Min. Negotiated Rate	$76.43
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$76.43
Rate for Payer: UnitedHealthcare Commercial	$80.67
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EZPAP Nebulizer w/Manometer Disposable

Facility

$84.92

Hospital Charge Code	3251576
Hospital Revenue Code	270
Min. Negotiated Rate	$33.97
Max. Negotiated Rate	$80.67
Rate for Payer: Aetna Commercial	$76.43
Rate for Payer: Humana Medicare Advantage	$35.67
Rate for Payer: UnitedHealthcare Commercial	$80.67
Rate for Payer: UnitedHealthcare Medicaid	$33.97
Rate for Payer: WPPA Medicare Advantage	$50.95

FACE TENT

Facility

$3.00

Hospital Charge Code	3254583
Hospital Revenue Code	270
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FACE TENT

Facility

$3.00

Hospital Charge Code	3254583
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Humana Medicare Advantage	$1.26
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: WPPA Medicare Advantage	$1.80

Factor VIII Activity, Clotting QST

Facility

$53.00

Service Code	HCPCS 85240
Hospital Charge Code	3555613
Hospital Revenue Code	300
Min. Negotiated Rate	$17.90
Max. Negotiated Rate	$88.47
Rate for Payer: Aetna Commercial	$47.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$88.47
Rate for Payer: Humana Medicare Advantage	$22.26
Rate for Payer: UnitedHealthcare Commercial	$50.35
Rate for Payer: UnitedHealthcare Medicaid	$17.90
Rate for Payer: WPPA Medicare Advantage	$31.80

Factor VIII Activity, Clotting QST

Facility

$53.00

Service Code	HCPCS 85240
Hospital Charge Code	3555613
Hospital Revenue Code	300
Min. Negotiated Rate	$47.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$47.70
Rate for Payer: UnitedHealthcare Commercial	$50.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Factor V (Leiden) Mutation Analysis QST

Facility

$460.00

Service Code	HCPCS 81241
Hospital Charge Code	3555105
Hospital Revenue Code	300
Min. Negotiated Rate	$175.14
Max. Negotiated Rate	$437.00
Rate for Payer: Aetna Commercial	$414.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$175.14
Rate for Payer: Humana Medicare Advantage	$193.20
Rate for Payer: UnitedHealthcare Commercial	$437.00
Rate for Payer: UnitedHealthcare Medicaid	$184.00
Rate for Payer: WPPA Medicare Advantage	$276.00

Factor V (Leiden) Mutation Analysis QST

Facility

$460.00

Service Code	HCPCS 81241
Hospital Charge Code	3555105
Hospital Revenue Code	300
Min. Negotiated Rate	$414.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$414.00
Rate for Payer: UnitedHealthcare Commercial	$437.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

famciclovir 500 mg Tab [HMC]

Facility

$30.39

Service Code	NDC 00093811956
Hospital Charge Code	3803026
Hospital Revenue Code	250
Min. Negotiated Rate	$27.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.35
Rate for Payer: UnitedHealthcare Commercial	$28.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges