Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Knee Immobilizer Medium

Facility

$70.29

Service Code	HCPCS L1830
Hospital Charge Code	3250697
Hospital Revenue Code	274
Min. Negotiated Rate	$29.52
Max. Negotiated Rate	$66.78
Rate for Payer: Aetna Commercial	$63.26
Rate for Payer: Humana Medicare Advantage	$29.52
Rate for Payer: UnitedHealthcare Commercial	$66.78
Rate for Payer: UnitedHealthcare Medicaid	$52.70
Rate for Payer: WPPA Medicare Advantage	$42.17

Knee Immobilizer Medium

Facility

$70.29

Service Code	HCPCS L1830
Hospital Charge Code	3250697
Hospital Revenue Code	274
Min. Negotiated Rate	$63.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.26
Rate for Payer: UnitedHealthcare Commercial	$66.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Immobilizer Pediatric Large

Facility

$60.00

Service Code	HCPCS L1830
Hospital Charge Code	3250696
Hospital Revenue Code	274
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Immobilizer Pediatric Large

Facility

$60.00

Service Code	HCPCS L1830
Hospital Charge Code	3250696
Hospital Revenue Code	274
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: Humana Medicare Advantage	$25.20
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: UnitedHealthcare Medicaid	$52.70
Rate for Payer: WPPA Medicare Advantage	$36.00

Knee Immobilizer Pediatric Medium

Facility

$67.00

Service Code	HCPCS L1830
Hospital Charge Code	3250695
Hospital Revenue Code	274
Min. Negotiated Rate	$28.14
Max. Negotiated Rate	$63.65
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: Humana Medicare Advantage	$28.14
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: UnitedHealthcare Medicaid	$52.70
Rate for Payer: WPPA Medicare Advantage	$40.20

Knee Immobilizer Pediatric Medium

Facility

$67.00

Service Code	HCPCS L1830
Hospital Charge Code	3250695
Hospital Revenue Code	274
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Immobilizer Pediatric Small

Facility

$67.00

Service Code	HCPCS L1830
Hospital Charge Code	3250694
Hospital Revenue Code	274
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Immobilizer Pediatric Small

Facility

$67.00

Service Code	HCPCS L1830
Hospital Charge Code	3250694
Hospital Revenue Code	274
Min. Negotiated Rate	$28.14
Max. Negotiated Rate	$63.65
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: Humana Medicare Advantage	$28.14
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: UnitedHealthcare Medicaid	$52.70
Rate for Payer: WPPA Medicare Advantage	$40.20

Knee Immobilizer Small

Facility

$122.78

Hospital Charge Code	3250705
Hospital Revenue Code	274
Min. Negotiated Rate	$110.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$110.50
Rate for Payer: UnitedHealthcare Commercial	$116.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Immobilizer Small

Facility

$122.78

Hospital Charge Code	3250705
Hospital Revenue Code	274
Min. Negotiated Rate	$49.11
Max. Negotiated Rate	$116.64
Rate for Payer: Aetna Commercial	$110.50
Rate for Payer: Humana Medicare Advantage	$51.57
Rate for Payer: UnitedHealthcare Commercial	$116.64
Rate for Payer: UnitedHealthcare Medicaid	$49.11
Rate for Payer: WPPA Medicare Advantage	$73.67

Knee Immobilizer X-Large

Facility

$81.27

Hospital Charge Code	3250713
Hospital Revenue Code	270
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 X-Large

Facility

$81.27

Hospital Charge Code	3250713
Hospital Revenue Code	270
Min. Negotiated Rate	$32.51
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	$32.51
Rate for Payer: WPPA Medicare Advantage	$48.76

Knee Immobilizer XX-Large

Facility

$94.00

Hospital Charge Code	3251282
Hospital Revenue Code	270
Min. Negotiated Rate	$84.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$84.60
Rate for Payer: UnitedHealthcare Commercial	$89.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Knee Immobilizer XX-Large

Facility

$94.00

Hospital Charge Code	3251282
Hospital Revenue Code	270
Min. Negotiated Rate	$37.60
Max. Negotiated Rate	$89.30
Rate for Payer: Aetna Commercial	$84.60
Rate for Payer: Humana Medicare Advantage	$39.48
Rate for Payer: UnitedHealthcare Commercial	$89.30
Rate for Payer: UnitedHealthcare Medicaid	$37.60
Rate for Payer: WPPA Medicare Advantage	$56.40

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC

Facility

$6,703.47

Service Code	MSDRG 488
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,703.47
Rate for Payer: UnitedHealthcare Medicaid	$6,703.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$4,225.41

Service Code	MSDRG 489
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,225.41
Rate for Payer: UnitedHealthcare Medicaid	$4,225.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC

Facility

$7,910.73

Service Code	MSDRG 486
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,910.73
Rate for Payer: UnitedHealthcare Medicaid	$7,910.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC

Facility

$12,231.45

Service Code	MSDRG 485
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,231.45
Rate for Payer: UnitedHealthcare Medicaid	$12,231.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$5,940.99

Service Code	MSDRG 487
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,940.99
Rate for Payer: UnitedHealthcare Medicaid	$5,940.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KOH Prep (Hair, Skin, Nails)

Facility

$64.00

Service Code	HCPCS 87220
Hospital Charge Code	3551377
Hospital Revenue Code	300
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

KOH Prep (Hair, Skin, Nails)

Facility

$64.00

Service Code	HCPCS 87220
Hospital Charge Code	3551377
Hospital Revenue Code	300
Min. Negotiated Rate	$3.90
Max. Negotiated Rate	$60.80
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$18.06
Rate for Payer: Humana Medicare Advantage	$26.88
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: UnitedHealthcare Medicaid	$3.90
Rate for Payer: WPPA Medicare Advantage	$38.40

K-Wire 0.9 X 150mm Blunt/Trocar

Facility

$184.00

Hospital Charge Code	3258597
Hospital Revenue Code	270
Min. Negotiated Rate	$73.60
Max. Negotiated Rate	$174.80
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: Humana Medicare Advantage	$77.28
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: UnitedHealthcare Medicaid	$73.60
Rate for Payer: WPPA Medicare Advantage	$110.40

K-Wire 0.9 X 150mm Blunt/Trocar

Facility

$184.00

Hospital Charge Code	3258597
Hospital Revenue Code	270
Min. Negotiated Rate	$165.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

K-Wire 1.1 X 150mm Blunt/Trocar

Facility

$165.00

Hospital Charge Code	3258585
Hospital Revenue Code	270
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$148.50
Rate for Payer: UnitedHealthcare Commercial	$156.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

K-Wire 1.1 X 150mm Blunt/Trocar

Facility

$165.00

Hospital Charge Code	3258585
Hospital Revenue Code	270
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$156.75
Rate for Payer: Aetna Commercial	$148.50
Rate for Payer: Humana Medicare Advantage	$69.30
Rate for Payer: UnitedHealthcare Commercial	$156.75
Rate for Payer: UnitedHealthcare Medicaid	$66.00
Rate for Payer: WPPA Medicare Advantage	$99.00

Know your out-of-pocket cost for care.

All Charges