Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Mask Laryngeal I-Gel Size 5

Facility

$71.00

Hospital Charge Code	3251404
Hospital Revenue Code	270
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Laryngeal I-Gel Size 5

Facility

$71.00

Hospital Charge Code	3251404
Hospital Revenue Code	270
Min. Negotiated Rate	$28.40
Max. Negotiated Rate	$67.45
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: Humana Medicare Advantage	$29.82
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: UnitedHealthcare Medicaid	$28.40
Rate for Payer: WPPA Medicare Advantage	$42.60

Mask Multi Venturi

Facility

$5.00

Hospital Charge Code	3251365
Hospital Revenue Code	270
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: Humana Medicare Advantage	$2.10
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: UnitedHealthcare Medicaid	$2.00
Rate for Payer: WPPA Medicare Advantage	$3.00

Mask Multi Venturi

Facility

$5.00

Hospital Charge Code	3251365
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask O2 Nonrebreathing Adult

Facility

$4.41

Hospital Charge Code	3254955
Hospital Revenue Code	270
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.97
Rate for Payer: UnitedHealthcare Commercial	$4.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask O2 Nonrebreathing Adult

Facility

$4.41

Hospital Charge Code	3254955
Hospital Revenue Code	270
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.19
Rate for Payer: Aetna Commercial	$3.97
Rate for Payer: Humana Medicare Advantage	$1.85
Rate for Payer: UnitedHealthcare Commercial	$4.19
Rate for Payer: UnitedHealthcare Medicaid	$1.76
Rate for Payer: WPPA Medicare Advantage	$2.65

Mask O2 Nonrebreathing Pediatric

Facility

$8.00

Hospital Charge Code	3254960
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

Mask O2 Nonrebreathing Pediatric

Facility

$8.00

Hospital Charge Code	3254960
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

Mask Oxygen Adult

Facility

$2.66

Hospital Charge Code	3251340
Hospital Revenue Code	270
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$2.53
Rate for Payer: Aetna Commercial	$2.39
Rate for Payer: Humana Medicare Advantage	$1.12
Rate for Payer: UnitedHealthcare Commercial	$2.53
Rate for Payer: UnitedHealthcare Medicaid	$1.06
Rate for Payer: WPPA Medicare Advantage	$1.60

Mask Oxygen Adult

Facility

$2.66

Hospital Charge Code	3251340
Hospital Revenue Code	270
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.39
Rate for Payer: UnitedHealthcare Commercial	$2.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Oxygen Infant

Facility

$4.00

Hospital Charge Code	3255960
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

Mask Oxygen Infant

Facility

$4.00

Hospital Charge Code	3255960
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

Mask Oxygen OxyKid OxyMask w/8ft Tubing

Facility

$19.13

Hospital Charge Code	3255950
Hospital Revenue Code	270
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$18.17
Rate for Payer: Aetna Commercial	$17.22
Rate for Payer: Humana Medicare Advantage	$8.03
Rate for Payer: UnitedHealthcare Commercial	$18.17
Rate for Payer: UnitedHealthcare Medicaid	$7.65
Rate for Payer: WPPA Medicare Advantage	$11.48

Mask Oxygen OxyKid OxyMask w/8ft Tubing

Facility

$19.13

Hospital Charge Code	3255950
Hospital Revenue Code	270
Min. Negotiated Rate	$17.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.22
Rate for Payer: UnitedHealthcare Commercial	$18.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Oxygen OxyMask w/7ft Tubing

Facility

$17.60

Hospital Charge Code	3255955
Hospital Revenue Code	270
Min. Negotiated Rate	$7.04
Max. Negotiated Rate	$16.72
Rate for Payer: Aetna Commercial	$15.84
Rate for Payer: Humana Medicare Advantage	$7.39
Rate for Payer: UnitedHealthcare Commercial	$16.72
Rate for Payer: UnitedHealthcare Medicaid	$7.04
Rate for Payer: WPPA Medicare Advantage	$10.56

Mask Oxygen OxyMask w/7ft Tubing

Facility

$17.60

Hospital Charge Code	3255955
Hospital Revenue Code	270
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.84
Rate for Payer: UnitedHealthcare Commercial	$16.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Oxygen Pediatric

Facility

$3.00

Hospital Charge Code	3251357
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

Mask Oxygen Pediatric

Facility

$3.00

Hospital Charge Code	3251357
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

Mask Tracheostomy Adult

Facility

$2.79

Hospital Charge Code	3252231
Hospital Revenue Code	270
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.51
Rate for Payer: UnitedHealthcare Commercial	$2.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Tracheostomy Adult

Facility

$2.79

Hospital Charge Code	3252231
Hospital Revenue Code	270
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$2.65
Rate for Payer: Aetna Commercial	$2.51
Rate for Payer: Humana Medicare Advantage	$1.17
Rate for Payer: UnitedHealthcare Commercial	$2.65
Rate for Payer: UnitedHealthcare Medicaid	$1.12
Rate for Payer: WPPA Medicare Advantage	$1.67

Massage Charge Units

Facility

$110.00

Service Code	HCPCS 97124 GP
Hospital Charge Code	3957124
Hospital Revenue Code	420
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$99.00
Rate for Payer: UnitedHealthcare Commercial	$104.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Massage Charge Units

Facility

$110.00

Service Code	HCPCS 97124 GP
Hospital Charge Code	3957124
Hospital Revenue Code	420
Min. Negotiated Rate	$11.41
Max. Negotiated Rate	$104.50
Rate for Payer: Aetna Commercial	$99.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$42.42
Rate for Payer: Humana Medicare Advantage	$46.20
Rate for Payer: UnitedHealthcare Commercial	$104.50
Rate for Payer: UnitedHealthcare Medicaid	$11.41
Rate for Payer: WPPA Medicare Advantage	$66.00

Mastectomy Binder Bra Large Theraport White

Facility

$92.00

Hospital Charge Code	3259811
Hospital Revenue Code	270
Min. Negotiated Rate	$36.80
Max. Negotiated Rate	$87.40
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: Humana Medicare Advantage	$38.64
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: UnitedHealthcare Medicaid	$36.80
Rate for Payer: WPPA Medicare Advantage	$55.20

Mastectomy Binder Bra Large Theraport White

Facility

$92.00

Hospital Charge Code	3259811
Hospital Revenue Code	270
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mastectomy Binder Bra Medium Theraport White

Facility

$92.00

Hospital Charge Code	3259810
Hospital Revenue Code	270
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges