Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

HLA Typing For Celiac Disease QST

Facility

$864.00

Service Code	HCPCS 81382
Hospital Charge Code	3551382
Hospital Revenue Code	300
Min. Negotiated Rate	$777.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$777.60
Rate for Payer: UnitedHealthcare Commercial	$820.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HLA Typing For Celiac Disease QST

Facility

$864.00

Service Code	HCPCS 81382
Hospital Charge Code	3551382
Hospital Revenue Code	300
Min. Negotiated Rate	$149.16
Max. Negotiated Rate	$820.80
Rate for Payer: Aetna Commercial	$777.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$278.78
Rate for Payer: Humana Medicare Advantage	$362.88
Rate for Payer: UnitedHealthcare Commercial	$820.80
Rate for Payer: UnitedHealthcare Medicaid	$149.16
Rate for Payer: WPPA Medicare Advantage	$518.40

HMC Bag Resuscitator Adult Mask AMBU

Facility

$43.00

Hospital Charge Code	3255549
Hospital Revenue Code	270
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC Bag Resuscitator Adult Mask AMBU

Facility

$43.00

Hospital Charge Code	3255549
Hospital Revenue Code	270
Min. Negotiated Rate	$17.20
Max. Negotiated Rate	$40.85
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$18.06
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: UnitedHealthcare Medicaid	$17.20
Rate for Payer: WPPA Medicare Advantage	$25.80

HMC Bag Resuscitator Pediatric Mask AMBU

Facility

$97.00

Hospital Charge Code	3251794
Hospital Revenue Code	270
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$92.15
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: Humana Medicare Advantage	$40.74
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: UnitedHealthcare Medicaid	$38.80
Rate for Payer: WPPA Medicare Advantage	$58.20

HMC Bag Resuscitator Pediatric Mask AMBU

Facility

$97.00

Hospital Charge Code	3251794
Hospital Revenue Code	270
Min. Negotiated Rate	$87.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC Cannula O2 14' w/Ear Cushion

Facility

$8.00

Hospital Charge Code	3250516
Hospital Revenue Code	270
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$7.60
Rate for Payer: Aetna Commercial	$7.20
Rate for Payer: Humana Medicare Advantage	$3.36
Rate for Payer: UnitedHealthcare Commercial	$7.60
Rate for Payer: UnitedHealthcare Medicaid	$3.20
Rate for Payer: WPPA Medicare Advantage	$4.80

HMC Cannula O2 14' w/Ear Cushion

Facility

$8.00

Hospital Charge Code	3250516
Hospital Revenue Code	270
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.20
Rate for Payer: UnitedHealthcare Commercial	$7.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC Cannula O2 7' w/o Ear Cushion

Facility

$3.00

Hospital Charge Code	3250508
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

HMC Cannula O2 7' w/o Ear Cushion

Facility

$3.00

Hospital Charge Code	3250508
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

HMC Gauze 4 X 4 Sterile 16ply

Facility

$3.00

Hospital Charge Code	3255176
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

HMC Gauze 4 X 4 Sterile 16ply

Facility

$3.00

Hospital Charge Code	3255176
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

HMC IV CLV Male Port Adapter

Facility

$4.00

Hospital Charge Code	3259461
Hospital Revenue Code	270
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC IV CLV Male Port Adapter

Facility

$4.00

Hospital Charge Code	3259461
Hospital Revenue Code	270
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.80
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Humana Medicare Advantage	$1.68
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: UnitedHealthcare Medicaid	$1.60
Rate for Payer: WPPA Medicare Advantage	$2.40

HMC IVF NS 500 LC

Facility

$7.00

Service Code	HCPCS J7040 TC
Hospital Charge Code	3253999
Hospital Revenue Code	636
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: UnitedHealthcare Commercial	$6.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC IVF NS 500 LC

Facility

$7.00

Service Code	HCPCS J7040 TC
Hospital Charge Code	3253999
Hospital Revenue Code	636
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$6.65
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.68
Rate for Payer: Humana Medicare Advantage	$2.94
Rate for Payer: UnitedHealthcare Commercial	$6.65
Rate for Payer: UnitedHealthcare Medicaid	$1.29
Rate for Payer: WPPA Medicare Advantage	$4.20

HMC Kerlix 4 Sterile Bandage Rolls

Facility

$3.00

Hospital Charge Code	3253999
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

HMC Kerlix 4 Sterile Bandage Rolls

Facility

$3.00

Hospital Charge Code	3253999
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

HMC Mask O2 Nonrebreathing Adult

Facility

$4.00

Hospital Charge Code	3254955
Hospital Revenue Code	270
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.80
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Humana Medicare Advantage	$1.68
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: UnitedHealthcare Medicaid	$1.60
Rate for Payer: WPPA Medicare Advantage	$2.40

HMC Mask O2 Nonrebreathing Adult

Facility

$4.00

Hospital Charge Code	3254955
Hospital Revenue Code	270
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC Mask O2 Nonrebreathing Pediatric

Facility

$6.00

Hospital Charge Code	3254960
Hospital Revenue Code	270
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC Mask O2 Nonrebreathing Pediatric

Facility

$6.00

Hospital Charge Code	3254960
Hospital Revenue Code	270
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$5.70
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: Humana Medicare Advantage	$2.52
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: WPPA Medicare Advantage	$3.60

HMC MG Mammo Digital Screening Left

Facility

$303.00

Service Code	HCPCS 77067 LT
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC MG Mammo Digital Screening Left

Facility

$303.00

Service Code	HCPCS 77067 LT
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$161.00
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$72.25
Rate for Payer: WPPA Medicare Advantage	$181.80

HMC MG Mammo Digital Screening Right

Facility

$303.00

Service Code	HCPCS 77067 RT
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges