Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Laryngoscope MAC 4 Single-Use Blade & Handle

Facility

$32.72

Hospital Charge Code	3252512
Hospital Revenue Code	270
Min. Negotiated Rate	$29.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: UnitedHealthcare Commercial	$31.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Laryngoscope MAC 4 Single-Use Blade & Handle

Facility

$32.72

Hospital Charge Code	3252512
Hospital Revenue Code	270
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$31.08
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Humana Medicare Advantage	$13.74
Rate for Payer: UnitedHealthcare Commercial	$31.08
Rate for Payer: UnitedHealthcare Medicaid	$13.09
Rate for Payer: WPPA Medicare Advantage	$19.63

latanoprost Ophth 0.005% Sol [HMC]

Facility

$148.25

Service Code	NDC 61314054701
Hospital Charge Code	3807878
Hospital Revenue Code	250
Min. Negotiated Rate	$59.30
Max. Negotiated Rate	$140.84
Rate for Payer: Aetna Commercial	$133.43
Rate for Payer: Humana Medicare Advantage	$62.27
Rate for Payer: UnitedHealthcare Commercial	$140.84
Rate for Payer: UnitedHealthcare Medicaid	$59.30
Rate for Payer: WPPA Medicare Advantage	$88.95

latanoprost Ophth 0.005% Sol [HMC]

Facility

$448.15

Service Code	NDC 00013830304
Hospital Charge Code	3807878
Hospital Revenue Code	250
Min. Negotiated Rate	$179.26
Max. Negotiated Rate	$425.74
Rate for Payer: Aetna Commercial	$403.33
Rate for Payer: Humana Medicare Advantage	$188.22
Rate for Payer: UnitedHealthcare Commercial	$425.74
Rate for Payer: UnitedHealthcare Medicaid	$179.26
Rate for Payer: WPPA Medicare Advantage	$268.89

latanoprost Ophth 0.005% Sol [HMC]

Facility

$148.25

Service Code	NDC 61314054701
Hospital Charge Code	3807878
Hospital Revenue Code	250
Min. Negotiated Rate	$133.43
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$133.43
Rate for Payer: UnitedHealthcare Commercial	$140.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

latanoprost Ophth 0.005% Sol [HMC]

Facility

$448.15

Service Code	NDC 00013830304
Hospital Charge Code	3807878
Hospital Revenue Code	250
Min. Negotiated Rate	$403.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$403.33
Rate for Payer: UnitedHealthcare Commercial	$425.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Latera 20mm Absorbable Nasal Implant System

Facility

$4,790.00

Hospital Charge Code	3256120
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,550.50
Rate for Payer: Aetna Commercial	$4,311.00
Rate for Payer: UnitedHealthcare Commercial	$4,550.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Latera 20mm Absorbable Nasal Implant System

Facility

$4,790.00

Hospital Charge Code	3256120
Hospital Revenue Code	270
Min. Negotiated Rate	$1,916.00
Max. Negotiated Rate	$4,550.50
Rate for Payer: Aetna Commercial	$4,311.00
Rate for Payer: Humana Medicare Advantage	$2,011.80
Rate for Payer: UnitedHealthcare Commercial	$4,550.50
Rate for Payer: UnitedHealthcare Medicaid	$1,916.00
Rate for Payer: WPPA Medicare Advantage	$2,874.00

Latera 24mm Absorbable Nasal Implant System

Facility

$4,790.00

Hospital Charge Code	3256121
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,550.50
Rate for Payer: Aetna Commercial	$4,311.00
Rate for Payer: UnitedHealthcare Commercial	$4,550.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Latera 24mm Absorbable Nasal Implant System

Facility

$4,790.00

Hospital Charge Code	3256121
Hospital Revenue Code	270
Min. Negotiated Rate	$1,916.00
Max. Negotiated Rate	$4,550.50
Rate for Payer: Aetna Commercial	$4,311.00
Rate for Payer: Humana Medicare Advantage	$2,011.80
Rate for Payer: UnitedHealthcare Commercial	$4,550.50
Rate for Payer: UnitedHealthcare Medicaid	$1,916.00
Rate for Payer: WPPA Medicare Advantage	$2,874.00

Latex (K82) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	3552927
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$16.20

Latex (K82) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	3552927
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

LD, Pleural Fl QST

Facility

$79.00

Service Code	HCPCS 84155
Hospital Charge Code	3552615
Hospital Revenue Code	300
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$75.05
Rate for Payer: Aetna Commercial	$71.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8.64
Rate for Payer: Humana Medicare Advantage	$33.18
Rate for Payer: UnitedHealthcare Commercial	$75.05
Rate for Payer: UnitedHealthcare Medicaid	$3.67
Rate for Payer: WPPA Medicare Advantage	$47.40

LD, Pleural Fl QST

Facility

$79.00

Service Code	HCPCS 84155
Hospital Charge Code	3552615
Hospital Revenue Code	300
Min. Negotiated Rate	$71.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$71.10
Rate for Payer: UnitedHealthcare Commercial	$75.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lead, Capillary QST

Facility

$47.00

Service Code	HCPCS 83655
Hospital Charge Code	3552334
Hospital Revenue Code	300
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lead, Capillary QST

Facility

$47.00

Service Code	HCPCS 83655
Hospital Charge Code	3552334
Hospital Revenue Code	300
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$44.65
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$24.36
Rate for Payer: Humana Medicare Advantage	$19.74
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: UnitedHealthcare Medicaid	$11.70
Rate for Payer: WPPA Medicare Advantage	$28.20

Lead Hand Alumi Large

Facility

$122.96

Hospital Charge Code	3259924
Hospital Revenue Code	270
Min. Negotiated Rate	$110.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$110.66
Rate for Payer: UnitedHealthcare Commercial	$116.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lead Hand Alumi Large

Facility

$122.96

Hospital Charge Code	3259924
Hospital Revenue Code	270
Min. Negotiated Rate	$49.18
Max. Negotiated Rate	$116.81
Rate for Payer: Aetna Commercial	$110.66
Rate for Payer: Humana Medicare Advantage	$51.64
Rate for Payer: UnitedHealthcare Commercial	$116.81
Rate for Payer: UnitedHealthcare Medicaid	$49.18
Rate for Payer: WPPA Medicare Advantage	$73.78

Lead QST

Facility

$47.00

Service Code	HCPCS 83655
Hospital Charge Code	3552334
Hospital Revenue Code	300
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lead QST

Facility

$47.00

Service Code	HCPCS 83655
Hospital Charge Code	3552334
Hospital Revenue Code	300
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$44.65
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$24.36
Rate for Payer: Humana Medicare Advantage	$19.74
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: UnitedHealthcare Medicaid	$11.70
Rate for Payer: WPPA Medicare Advantage	$28.20

Least Incompatible - XM AHG Gel Interp

Facility

$108.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$97.20
Rate for Payer: UnitedHealthcare Commercial	$102.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Least Incompatible - XM AHG Gel Interp

Facility

$108.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$42.03
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna Commercial	$97.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$42.03
Rate for Payer: Humana Medicare Advantage	$45.36
Rate for Payer: UnitedHealthcare Commercial	$102.60
Rate for Payer: UnitedHealthcare Medicaid	$43.20
Rate for Payer: WPPA Medicare Advantage	$64.80

leflunomide 20 mg Tab [HMC]

Facility

$8.00

Service Code	NDC 00093017456
Hospital Charge Code	3800007
Hospital Revenue Code	250
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

leflunomide 20 mg Tab [HMC]

Facility

$37.85

Service Code	NDC 23155004403
Hospital Charge Code	3800007
Hospital Revenue Code	250
Min. Negotiated Rate	$15.14
Max. Negotiated Rate	$35.96
Rate for Payer: Aetna Commercial	$34.06
Rate for Payer: Humana Medicare Advantage	$15.90
Rate for Payer: UnitedHealthcare Commercial	$35.96
Rate for Payer: UnitedHealthcare Medicaid	$15.14
Rate for Payer: WPPA Medicare Advantage	$22.71

leflunomide 20 mg Tab [HMC]

Facility

$8.00

Service Code	NDC 00093017456
Hospital Charge Code	3800007
Hospital Revenue Code	250
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

Know your out-of-pocket cost for care.

All Charges