Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Fecal Fat, Qualitative QST

Facility

$28.00

Service Code	HCPCS 82705
Hospital Charge Code	3550405
Hospital Revenue Code	300
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$26.60
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$17.72
Rate for Payer: Humana Medicare Advantage	$11.76
Rate for Payer: UnitedHealthcare Commercial	$26.60
Rate for Payer: UnitedHealthcare Medicaid	$5.10
Rate for Payer: WPPA Medicare Advantage	$16.80

Fecal Fat, Qualitative QST

Facility

$28.00

Service Code	HCPCS 82705
Hospital Charge Code	3550405
Hospital Revenue Code	300
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: UnitedHealthcare Commercial	$26.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fecal Leukocyte Stain QST

Facility

$27.00

Service Code	HCPCS 89055
Hospital Charge Code	3559055
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

Fecal Leukocyte Stain QST

Facility

$27.00

Service Code	HCPCS 89055
Hospital Charge Code	3559055
Hospital Revenue Code	300
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.06
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$4.27
Rate for Payer: WPPA Medicare Advantage	$16.20

Feeding Tube 20fr MIC* Bolus G

Facility

$122.00

Hospital Charge Code	3256050
Hospital Revenue Code	270
Min. Negotiated Rate	$48.80
Max. Negotiated Rate	$115.90
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: Humana Medicare Advantage	$51.24
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: UnitedHealthcare Medicaid	$48.80
Rate for Payer: WPPA Medicare Advantage	$73.20

Feeding Tube 20fr MIC* Bolus G

Facility

$122.00

Hospital Charge Code	3256050
Hospital Revenue Code	270
Min. Negotiated Rate	$109.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FEEDING TUBE 5FR. INFANT

Facility

$7.07

Hospital Charge Code	3254542
Hospital Revenue Code	270
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.36
Rate for Payer: UnitedHealthcare Commercial	$6.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FEEDING TUBE 5FR. INFANT

Facility

$7.07

Hospital Charge Code	3254542
Hospital Revenue Code	270
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$6.72
Rate for Payer: Aetna Commercial	$6.36
Rate for Payer: Humana Medicare Advantage	$2.97
Rate for Payer: UnitedHealthcare Commercial	$6.72
Rate for Payer: UnitedHealthcare Medicaid	$2.83
Rate for Payer: WPPA Medicare Advantage	$4.24

FEEDING TUBE 8FR INFANT

Facility

$51.80

Hospital Charge Code	3254559
Hospital Revenue Code	270
Min. Negotiated Rate	$20.72
Max. Negotiated Rate	$49.21
Rate for Payer: Aetna Commercial	$46.62
Rate for Payer: Humana Medicare Advantage	$21.76
Rate for Payer: UnitedHealthcare Commercial	$49.21
Rate for Payer: UnitedHealthcare Medicaid	$20.72
Rate for Payer: WPPA Medicare Advantage	$31.08

FEEDING TUBE 8FR INFANT

Facility

$51.80

Hospital Charge Code	3254559
Hospital Revenue Code	270
Min. Negotiated Rate	$46.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$46.62
Rate for Payer: UnitedHealthcare Commercial	$49.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FEEDING TUBE JEJUNAL 12FR J-TUBE THAT PASSES THROUGH PEG TUBE

Facility

$583.00

Hospital Charge Code	3250649
Hospital Revenue Code	270
Min. Negotiated Rate	$233.20
Max. Negotiated Rate	$553.85
Rate for Payer: Aetna Commercial	$524.70
Rate for Payer: Humana Medicare Advantage	$244.86
Rate for Payer: UnitedHealthcare Commercial	$553.85
Rate for Payer: UnitedHealthcare Medicaid	$233.20
Rate for Payer: WPPA Medicare Advantage	$349.80

FEEDING TUBE JEJUNAL 12FR J-TUBE THAT PASSES THROUGH PEG TUBE

Facility

$583.00

Hospital Charge Code	3250649
Hospital Revenue Code	270
Min. Negotiated Rate	$524.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$524.70
Rate for Payer: UnitedHealthcare Commercial	$553.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Feeding Tube MIC G Gastro 24fr with Recessed Distal Tip 7-10ML Balloon

Facility

$114.00

Hospital Charge Code	3256037
Hospital Revenue Code	270
Min. Negotiated Rate	$45.60
Max. Negotiated Rate	$108.30
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: Humana Medicare Advantage	$47.88
Rate for Payer: UnitedHealthcare Commercial	$108.30
Rate for Payer: UnitedHealthcare Medicaid	$45.60
Rate for Payer: WPPA Medicare Advantage	$68.40

Feeding Tube MIC G Gastro 24fr with Recessed Distal Tip 7-10ML Balloon

Facility

$114.00

Hospital Charge Code	3256037
Hospital Revenue Code	270
Min. Negotiated Rate	$102.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: UnitedHealthcare Commercial	$108.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Feeding Tube MIC GJ 16 Fr x 30cm Gastric-Jejunal Feeding Tube Kit

Facility

$711.00

Hospital Charge Code	3256030
Hospital Revenue Code	270
Min. Negotiated Rate	$639.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$639.90
Rate for Payer: UnitedHealthcare Commercial	$675.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Feeding Tube MIC GJ 16 Fr x 30cm Gastric-Jejunal Feeding Tube Kit

Facility

$711.00

Hospital Charge Code	3256030
Hospital Revenue Code	270
Min. Negotiated Rate	$284.40
Max. Negotiated Rate	$675.45
Rate for Payer: Aetna Commercial	$639.90
Rate for Payer: Humana Medicare Advantage	$298.62
Rate for Payer: UnitedHealthcare Commercial	$675.45
Rate for Payer: UnitedHealthcare Medicaid	$284.40
Rate for Payer: WPPA Medicare Advantage	$426.60

Feeding Tube MIC GJ 22 Fr x 45cm Gastric-Jejunal Feeding Tube Kit

Facility

$704.00

Hospital Charge Code	3256033
Hospital Revenue Code	270
Min. Negotiated Rate	$281.60
Max. Negotiated Rate	$668.80
Rate for Payer: Aetna Commercial	$633.60
Rate for Payer: Humana Medicare Advantage	$295.68
Rate for Payer: UnitedHealthcare Commercial	$668.80
Rate for Payer: UnitedHealthcare Medicaid	$281.60
Rate for Payer: WPPA Medicare Advantage	$422.40

Feeding Tube MIC GJ 22 Fr x 45cm Gastric-Jejunal Feeding Tube Kit

Facility

$704.00

Hospital Charge Code	3256033
Hospital Revenue Code	270
Min. Negotiated Rate	$633.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$633.60
Rate for Payer: UnitedHealthcare Commercial	$668.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Feeding Tube MIC-KEY Button GJ Gastric-Jejunal Feeding Tube Kit 14Fr x 1.7 x22cm

Facility

$1,014.00

Hospital Charge Code	3256031
Hospital Revenue Code	270
Min. Negotiated Rate	$912.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$912.60
Rate for Payer: UnitedHealthcare Commercial	$963.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Feeding Tube MIC-KEY Button GJ Gastric-Jejunal Feeding Tube Kit 14Fr x 1.7 x22cm

Facility

$1,014.00

Hospital Charge Code	3256031
Hospital Revenue Code	270
Min. Negotiated Rate	$405.60
Max. Negotiated Rate	$963.30
Rate for Payer: Aetna Commercial	$912.60
Rate for Payer: Humana Medicare Advantage	$425.88
Rate for Payer: UnitedHealthcare Commercial	$963.30
Rate for Payer: UnitedHealthcare Medicaid	$405.60
Rate for Payer: WPPA Medicare Advantage	$608.40

Feeding Tube w/Stylet CORFLO Ultra-Lite NG 8fr 43 Nasogastric NG 2-Port Tube

Facility

$86.40

Hospital Charge Code	3256029
Hospital Revenue Code	270
Min. Negotiated Rate	$34.56
Max. Negotiated Rate	$82.08
Rate for Payer: Aetna Commercial	$77.76
Rate for Payer: Humana Medicare Advantage	$36.29
Rate for Payer: UnitedHealthcare Commercial	$82.08
Rate for Payer: UnitedHealthcare Medicaid	$34.56
Rate for Payer: WPPA Medicare Advantage	$51.84

Feeding Tube w/Stylet CORFLO Ultra-Lite NG 8fr 43 Nasogastric NG 2-Port Tube

Facility

$86.40

Hospital Charge Code	3256029
Hospital Revenue Code	270
Min. Negotiated Rate	$77.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$77.76
Rate for Payer: UnitedHealthcare Commercial	$82.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Feeding Tube Y-Style Jejunal 16fr Universal Fit

Facility

$409.00

Hospital Charge Code	3256032
Hospital Revenue Code	270
Min. Negotiated Rate	$163.60
Max. Negotiated Rate	$388.55
Rate for Payer: Aetna Commercial	$368.10
Rate for Payer: Humana Medicare Advantage	$171.78
Rate for Payer: UnitedHealthcare Commercial	$388.55
Rate for Payer: UnitedHealthcare Medicaid	$163.60
Rate for Payer: WPPA Medicare Advantage	$245.40

Feeding Tube Y-Style Jejunal 16fr Universal Fit

Facility

$409.00

Hospital Charge Code	3256032
Hospital Revenue Code	270
Min. Negotiated Rate	$368.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$368.10
Rate for Payer: UnitedHealthcare Commercial	$388.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

felodipine 5 mg ER Tab [HMC]

Facility

$9.53

Service Code	NDC 13668013301
Hospital Charge Code	3806865
Hospital Revenue Code	250
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.58
Rate for Payer: UnitedHealthcare Commercial	$9.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges