Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Mask Aerosol Adult

Facility

$2.50

Hospital Charge Code	3256794
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

Mask Aerosol Pediatric

Facility

$2.50

Hospital Charge Code	3254575
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

Mask Aerosol Pediatric

Facility

$2.50

Hospital Charge Code	3254575
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

Mask Aerosol Pediatric Dragon

Facility

$4.55

Hospital Charge Code	3254573
Hospital Revenue Code	270
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.09
Rate for Payer: UnitedHealthcare Commercial	$4.32
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Aerosol Pediatric Dragon

Facility

$4.55

Hospital Charge Code	3254573
Hospital Revenue Code	270
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$4.32
Rate for Payer: Aetna Commercial	$4.09
Rate for Payer: Humana Medicare Advantage	$1.91
Rate for Payer: UnitedHealthcare Commercial	$4.32
Rate for Payer: UnitedHealthcare Medicaid	$1.82
Rate for Payer: WPPA Medicare Advantage	$2.73

Mask CPAP Total Face PerforMax Large Adult

Facility

$125.69

Hospital Charge Code	3252001
Hospital Revenue Code	270
Min. Negotiated Rate	$113.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$113.12
Rate for Payer: UnitedHealthcare Commercial	$119.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask CPAP Total Face PerforMax Large Adult

Facility

$125.69

Hospital Charge Code	3252001
Hospital Revenue Code	270
Min. Negotiated Rate	$50.28
Max. Negotiated Rate	$119.41
Rate for Payer: Aetna Commercial	$113.12
Rate for Payer: Humana Medicare Advantage	$52.79
Rate for Payer: UnitedHealthcare Commercial	$119.41
Rate for Payer: UnitedHealthcare Medicaid	$50.28
Rate for Payer: WPPA Medicare Advantage	$75.41

Mask CPAP Total Face PerforMax Small Adult

Facility

$122.00

Hospital Charge Code	3252000
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

Mask CPAP Total Face PerforMax Small Adult

Facility

$122.00

Hospital Charge Code	3252000
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

Mask CPAP Total Face PerforMax X-Large Adult

Facility

$176.00

Hospital Charge Code	3252002
Hospital Revenue Code	270
Min. Negotiated Rate	$70.40
Max. Negotiated Rate	$167.20
Rate for Payer: Aetna Commercial	$158.40
Rate for Payer: Humana Medicare Advantage	$73.92
Rate for Payer: UnitedHealthcare Commercial	$167.20
Rate for Payer: UnitedHealthcare Medicaid	$70.40
Rate for Payer: WPPA Medicare Advantage	$105.60

Mask CPAP Total Face PerforMax X-Large Adult

Facility

$176.00

Hospital Charge Code	3252002
Hospital Revenue Code	270
Min. Negotiated Rate	$158.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$158.40
Rate for Payer: UnitedHealthcare Commercial	$167.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Cushion Infant

Facility

$13.00

Hospital Charge Code	3254106
Hospital Revenue Code	270
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.70
Rate for Payer: UnitedHealthcare Commercial	$12.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Cushion Infant

Facility

$13.00

Hospital Charge Code	3254106
Hospital Revenue Code	270
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$12.35
Rate for Payer: Aetna Commercial	$11.70
Rate for Payer: Humana Medicare Advantage	$5.46
Rate for Payer: UnitedHealthcare Commercial	$12.35
Rate for Payer: UnitedHealthcare Medicaid	$5.20
Rate for Payer: WPPA Medicare Advantage	$7.80

Mask Laryngeal I-Gel Size 1

Facility

$49.00

Hospital Charge Code	3251396
Hospital Revenue Code	270
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$44.10
Rate for Payer: UnitedHealthcare Commercial	$46.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Laryngeal I-Gel Size 1

Facility

$49.00

Hospital Charge Code	3251396
Hospital Revenue Code	270
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$46.55
Rate for Payer: Aetna Commercial	$44.10
Rate for Payer: Humana Medicare Advantage	$20.58
Rate for Payer: UnitedHealthcare Commercial	$46.55
Rate for Payer: UnitedHealthcare Medicaid	$19.60
Rate for Payer: WPPA Medicare Advantage	$29.40

Mask Laryngeal I-Gel Size 1.5

Facility

$78.08

Hospital Charge Code	3251397
Hospital Revenue Code	270
Min. Negotiated Rate	$70.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.27
Rate for Payer: UnitedHealthcare Commercial	$74.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Laryngeal I-Gel Size 1.5

Facility

$78.08

Hospital Charge Code	3251397
Hospital Revenue Code	270
Min. Negotiated Rate	$31.23
Max. Negotiated Rate	$74.18
Rate for Payer: Aetna Commercial	$70.27
Rate for Payer: Humana Medicare Advantage	$32.79
Rate for Payer: UnitedHealthcare Commercial	$74.18
Rate for Payer: UnitedHealthcare Medicaid	$31.23
Rate for Payer: WPPA Medicare Advantage	$46.85

Mask Laryngeal I-Gel Size 2

Facility

$78.08

Hospital Charge Code	3251399
Hospital Revenue Code	270
Min. Negotiated Rate	$70.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.27
Rate for Payer: UnitedHealthcare Commercial	$74.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Laryngeal I-Gel Size 2

Facility

$78.08

Hospital Charge Code	3251399
Hospital Revenue Code	270
Min. Negotiated Rate	$31.23
Max. Negotiated Rate	$74.18
Rate for Payer: Aetna Commercial	$70.27
Rate for Payer: Humana Medicare Advantage	$32.79
Rate for Payer: UnitedHealthcare Commercial	$74.18
Rate for Payer: UnitedHealthcare Medicaid	$31.23
Rate for Payer: WPPA Medicare Advantage	$46.85

Mask Laryngeal I-Gel Size 2.5

Facility

$78.08

Hospital Charge Code	3251406
Hospital Revenue Code	270
Min. Negotiated Rate	$31.23
Max. Negotiated Rate	$74.18
Rate for Payer: Aetna Commercial	$70.27
Rate for Payer: Humana Medicare Advantage	$32.79
Rate for Payer: UnitedHealthcare Commercial	$74.18
Rate for Payer: UnitedHealthcare Medicaid	$31.23
Rate for Payer: WPPA Medicare Advantage	$46.85

Mask Laryngeal I-Gel Size 2.5

Facility

$78.08

Hospital Charge Code	3251406
Hospital Revenue Code	270
Min. Negotiated Rate	$70.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.27
Rate for Payer: UnitedHealthcare Commercial	$74.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Laryngeal I-Gel Size 3

Facility

$76.19

Hospital Charge Code	3251400
Hospital Revenue Code	270
Min. Negotiated Rate	$68.57
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$68.57
Rate for Payer: UnitedHealthcare Commercial	$72.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Laryngeal I-Gel Size 3

Facility

$76.19

Hospital Charge Code	3251400
Hospital Revenue Code	270
Min. Negotiated Rate	$30.48
Max. Negotiated Rate	$72.38
Rate for Payer: Aetna Commercial	$68.57
Rate for Payer: Humana Medicare Advantage	$32.00
Rate for Payer: UnitedHealthcare Commercial	$72.38
Rate for Payer: UnitedHealthcare Medicaid	$30.48
Rate for Payer: WPPA Medicare Advantage	$45.71

Mask Laryngeal I-Gel Size 4

Facility

$83.16

Hospital Charge Code	3251402
Hospital Revenue Code	270
Min. Negotiated Rate	$74.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$74.84
Rate for Payer: UnitedHealthcare Commercial	$79.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Laryngeal I-Gel Size 4

Facility

$83.16

Hospital Charge Code	3251402
Hospital Revenue Code	270
Min. Negotiated Rate	$33.26
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$74.84
Rate for Payer: Humana Medicare Advantage	$34.93
Rate for Payer: UnitedHealthcare Commercial	$79.00
Rate for Payer: UnitedHealthcare Medicaid	$33.26
Rate for Payer: WPPA Medicare Advantage	$49.90

Know your out-of-pocket cost for care.

All Charges