Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Kiwi IgE UNMC

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	3552884
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

Kling 1 Sterile Stretch Bandage Rolls

Facility

$3.00

Hospital Charge Code	3251268
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

Kling 1 Sterile Stretch Bandage Rolls

Facility

$3.00

Hospital Charge Code	3251268
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

Kling 2 Sterile Stretch Bandage Rolls

Facility

$2.50

Hospital Charge Code	3251266
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

Kling 2 Sterile Stretch Bandage Rolls

Facility

$2.50

Hospital Charge Code	3251266
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

Kling 3 Sterile Stretch Bandage Rolls

Facility

$2.50

Hospital Charge Code	3251274
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

Kling 3 Sterile Stretch Bandage Rolls

Facility

$2.50

Hospital Charge Code	3251274
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

Kling 4 Sterile Stretch Bandage Rolls

Facility

$2.50

Hospital Charge Code	3250622
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

Kling 4 Sterile Stretch Bandage Rolls

Facility

$2.50

Hospital Charge Code	3250622
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

Knee Brace Freestyle OA Left Lateral Small

Facility

$785.00

Hospital Charge Code	3251839
Hospital Revenue Code	270
Min. Negotiated Rate	$314.00
Max. Negotiated Rate	$745.75
Rate for Payer: Aetna Commercial	$706.50
Rate for Payer: Humana Medicare Advantage	$329.70
Rate for Payer: UnitedHealthcare Commercial	$745.75
Rate for Payer: UnitedHealthcare Medicaid	$314.00
Rate for Payer: WPPA Medicare Advantage	$471.00

Knee Brace Freestyle OA Left Lateral Small

Facility

$785.00

Hospital Charge Code	3251839
Hospital Revenue Code	270
Min. Negotiated Rate	$706.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$706.50
Rate for Payer: UnitedHealthcare Commercial	$745.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Brace Freestyle OA Left Medial Small

Facility

$785.00

Hospital Charge Code	3251838
Hospital Revenue Code	270
Min. Negotiated Rate	$314.00
Max. Negotiated Rate	$745.75
Rate for Payer: Aetna Commercial	$706.50
Rate for Payer: Humana Medicare Advantage	$329.70
Rate for Payer: UnitedHealthcare Commercial	$745.75
Rate for Payer: UnitedHealthcare Medicaid	$314.00
Rate for Payer: WPPA Medicare Advantage	$471.00

Knee Brace Freestyle OA Left Medial Small

Facility

$785.00

Hospital Charge Code	3251838
Hospital Revenue Code	270
Min. Negotiated Rate	$706.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$706.50
Rate for Payer: UnitedHealthcare Commercial	$745.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Brace Hinged Economy Small

Facility

$125.00

Hospital Charge Code	3251835
Hospital Revenue Code	274
Min. Negotiated Rate	$50.00
Max. Negotiated Rate	$118.75
Rate for Payer: Aetna Commercial	$112.50
Rate for Payer: Humana Medicare Advantage	$52.50
Rate for Payer: UnitedHealthcare Commercial	$118.75
Rate for Payer: UnitedHealthcare Medicaid	$50.00
Rate for Payer: WPPA Medicare Advantage	$75.00

Knee Brace Hinged Economy Small

Facility

$125.00

Hospital Charge Code	3251835
Hospital Revenue Code	274
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$112.50
Rate for Payer: UnitedHealthcare Commercial	$118.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Brace Hinged XL Rolyan Defender Cool Open Style

Facility

$315.00

Service Code	HCPCS L1832
Hospital Charge Code	3251832
Hospital Revenue Code	274
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$299.25
Rate for Payer: Aetna Commercial	$283.50
Rate for Payer: Humana Medicare Advantage	$132.30
Rate for Payer: UnitedHealthcare Commercial	$299.25
Rate for Payer: UnitedHealthcare Medicaid	$126.00
Rate for Payer: WPPA Medicare Advantage	$189.00

Knee Brace Hinged XL Rolyan Defender Cool Open Style

Facility

$315.00

Service Code	HCPCS L1832
Hospital Charge Code	3251832
Hospital Revenue Code	274
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$283.50
Rate for Payer: UnitedHealthcare Commercial	$299.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Brace RECOVER Lrg Airmesh Long Open-back Wraparound Breg

Facility

$320.00

Hospital Charge Code	3251829
Hospital Revenue Code	270
Min. Negotiated Rate	$128.00
Max. Negotiated Rate	$304.00
Rate for Payer: Aetna Commercial	$288.00
Rate for Payer: Humana Medicare Advantage	$134.40
Rate for Payer: UnitedHealthcare Commercial	$304.00
Rate for Payer: UnitedHealthcare Medicaid	$128.00
Rate for Payer: WPPA Medicare Advantage	$192.00

Knee Brace RECOVER Lrg Airmesh Long Open-back Wraparound Breg

Facility

$320.00

Hospital Charge Code	3251829
Hospital Revenue Code	270
Min. Negotiated Rate	$288.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$288.00
Rate for Payer: UnitedHealthcare Commercial	$304.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Brace Roadrunner Wraparound Medium Open Back Airmesh Breg

Facility

$303.00

Hospital Charge Code	3251831
Hospital Revenue Code	270
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

Knee Brace Roadrunner Wraparound Medium Open Back Airmesh Breg

Facility

$303.00

Hospital Charge Code	3251831
Hospital Revenue Code	270
Min. Negotiated Rate	$121.20
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$121.20
Rate for Payer: WPPA Medicare Advantage	$181.80

Knee Brace T-Scope Post-Op Premier Brace Standard Size

Facility

$308.00

Hospital Charge Code	3251830
Hospital Revenue Code	270
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$277.20
Rate for Payer: UnitedHealthcare Commercial	$292.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Brace T-Scope Post-Op Premier Brace Standard Size

Facility

$308.00

Hospital Charge Code	3251830
Hospital Revenue Code	270
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$292.60
Rate for Payer: Aetna Commercial	$277.20
Rate for Payer: Humana Medicare Advantage	$129.36
Rate for Payer: UnitedHealthcare Commercial	$292.60
Rate for Payer: UnitedHealthcare Medicaid	$123.20
Rate for Payer: WPPA Medicare Advantage	$184.80

Knee Immobilizer Large

Facility

$81.27

Service Code	HCPCS L1830
Hospital Charge Code	3250689
Hospital Revenue Code	274
Min. Negotiated Rate	$73.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$73.14
Rate for Payer: UnitedHealthcare Commercial	$77.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Immobilizer Large

Facility

$81.27

Service Code	HCPCS L1830
Hospital Charge Code	3250689
Hospital Revenue Code	274
Min. Negotiated Rate	$34.13
Max. Negotiated Rate	$77.21
Rate for Payer: Aetna Commercial	$73.14
Rate for Payer: Humana Medicare Advantage	$34.13
Rate for Payer: UnitedHealthcare Commercial	$77.21
Rate for Payer: UnitedHealthcare Medicaid	$52.70
Rate for Payer: WPPA Medicare Advantage	$48.76

Know your out-of-pocket cost for care.

All Charges