Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Mastectomy Binder Bra Medium Theraport White

Facility

$92.00

Hospital Charge Code	3259810
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 X-Large Theraport White

Facility

$92.00

Hospital Charge Code	3259812
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 X-Large Theraport White

Facility

$92.00

Hospital Charge Code	3259812
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 FOR MALIGNANCY WITH CC/MCC

Facility

$6,290.46

Service Code	MSDRG 582
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,290.46
Rate for Payer: UnitedHealthcare Medicaid	$6,290.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC

Facility

$5,623.29

Service Code	MSDRG 583
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,623.29
Rate for Payer: UnitedHealthcare Medicaid	$5,623.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MAX VPC CANN DRILL 1.8MM

Facility

$592.20

Hospital Charge Code	3258132
Hospital Revenue Code	270
Min. Negotiated Rate	$236.88
Max. Negotiated Rate	$562.59
Rate for Payer: Aetna Commercial	$532.98
Rate for Payer: Humana Medicare Advantage	$248.72
Rate for Payer: UnitedHealthcare Commercial	$562.59
Rate for Payer: UnitedHealthcare Medicaid	$236.88
Rate for Payer: WPPA Medicare Advantage	$355.32

MAX VPC CANN DRILL 1.8MM

Facility

$592.20

Hospital Charge Code	3258132
Hospital Revenue Code	270
Min. Negotiated Rate	$532.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$532.98
Rate for Payer: UnitedHealthcare Commercial	$562.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mayo Medical Lab Consult Bill Only

Facility

$630.00

Service Code	HCPCS 88323
Hospital Charge Code	3558323
Hospital Revenue Code	310
Min. Negotiated Rate	$105.88
Max. Negotiated Rate	$598.50
Rate for Payer: Aetna Commercial	$567.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$164.91
Rate for Payer: Humana Medicare Advantage	$264.60
Rate for Payer: UnitedHealthcare Commercial	$598.50
Rate for Payer: UnitedHealthcare Medicaid	$105.88
Rate for Payer: WPPA Medicare Advantage	$378.00

Mayo Medical Lab Consult Bill Only

Facility

$630.00

Service Code	HCPCS 88323
Hospital Charge Code	3558323
Hospital Revenue Code	310
Min. Negotiated Rate	$567.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$567.00
Rate for Payer: UnitedHealthcare Commercial	$598.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mayo Medical Lab Immuno AB 1 Bill Only

Facility

$268.00

Service Code	HCPCS 88342
Hospital Charge Code	3554021
Hospital Revenue Code	310
Min. Negotiated Rate	$78.34
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$241.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$287.85
Rate for Payer: Humana Medicare Advantage	$112.56
Rate for Payer: UnitedHealthcare Commercial	$254.60
Rate for Payer: UnitedHealthcare Medicaid	$78.34
Rate for Payer: WPPA Medicare Advantage	$160.80

Mayo Medical Lab Immuno AB 1 Bill Only

Facility

$268.00

Service Code	HCPCS 88342
Hospital Charge Code	3554021
Hospital Revenue Code	310
Min. Negotiated Rate	$241.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$241.20
Rate for Payer: UnitedHealthcare Commercial	$254.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mayo Medical Lab Immuno AB 2 Bill Only

Facility

$268.00

Service Code	HCPCS 88341
Hospital Charge Code	3554022
Hospital Revenue Code	310
Min. Negotiated Rate	$68.50
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$241.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$287.85
Rate for Payer: Humana Medicare Advantage	$112.56
Rate for Payer: UnitedHealthcare Commercial	$254.60
Rate for Payer: UnitedHealthcare Medicaid	$68.50
Rate for Payer: WPPA Medicare Advantage	$160.80

Mayo Medical Lab Immuno AB 2 Bill Only

Facility

$268.00

Service Code	HCPCS 88341
Hospital Charge Code	3554022
Hospital Revenue Code	310
Min. Negotiated Rate	$241.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$241.20
Rate for Payer: UnitedHealthcare Commercial	$254.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mayo Miscellaneous Test SC

Facility

$183.00

Service Code	HCPCS 86255
Hospital Charge Code	3558625
Hospital Revenue Code	300
Min. Negotiated Rate	$164.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$164.70
Rate for Payer: UnitedHealthcare Commercial	$173.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mayo Miscellaneous Test SC

Facility

$183.00

Service Code	HCPCS 86255
Hospital Charge Code	3558625
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$173.85
Rate for Payer: Aetna Commercial	$164.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$49.98
Rate for Payer: Humana Medicare Advantage	$76.86
Rate for Payer: UnitedHealthcare Commercial	$173.85
Rate for Payer: UnitedHealthcare Medicaid	$12.05
Rate for Payer: WPPA Medicare Advantage	$109.80

MDI Panda Mask Small Yellow (Pocket Mask)

Facility

$38.00

Hospital Charge Code	3252037
Hospital Revenue Code	270
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MDI Panda Mask Small Yellow (Pocket Mask)

Facility

$38.00

Hospital Charge Code	3252037
Hospital Revenue Code	270
Min. Negotiated Rate	$15.20
Max. Negotiated Rate	$36.10
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: UnitedHealthcare Medicaid	$15.20
Rate for Payer: WPPA Medicare Advantage	$22.80

MDI Spacer Aerosol Chamber

Facility

$22.05

Hospital Charge Code	3252035
Hospital Revenue Code	270
Min. Negotiated Rate	$19.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.84
Rate for Payer: UnitedHealthcare Commercial	$20.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MDI Spacer Aerosol Chamber

Facility

$22.05

Hospital Charge Code	3252035
Hospital Revenue Code	270
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$20.95
Rate for Payer: Aetna Commercial	$19.84
Rate for Payer: Humana Medicare Advantage	$9.26
Rate for Payer: UnitedHealthcare Commercial	$20.95
Rate for Payer: UnitedHealthcare Medicaid	$8.82
Rate for Payer: WPPA Medicare Advantage	$13.23

MDI Spacer w/ Mask Large Blue

Facility

$79.00

Hospital Charge Code	3252039
Hospital Revenue Code	270
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

MDI Spacer w/ Mask Large Blue

Facility

$79.00

Hospital Charge Code	3252039
Hospital Revenue Code	270
Min. Negotiated Rate	$31.60
Max. Negotiated Rate	$75.05
Rate for Payer: Aetna Commercial	$71.10
Rate for Payer: Humana Medicare Advantage	$33.18
Rate for Payer: UnitedHealthcare Commercial	$75.05
Rate for Payer: UnitedHealthcare Medicaid	$31.60
Rate for Payer: WPPA Medicare Advantage	$47.40

MDI Spacer w/ Mask Medium Orange

Facility

$73.00

Hospital Charge Code	3252038
Hospital Revenue Code	270
Min. Negotiated Rate	$29.20
Max. Negotiated Rate	$69.35
Rate for Payer: Aetna Commercial	$65.70
Rate for Payer: Humana Medicare Advantage	$30.66
Rate for Payer: UnitedHealthcare Commercial	$69.35
Rate for Payer: UnitedHealthcare Medicaid	$29.20
Rate for Payer: WPPA Medicare Advantage	$43.80

MDI Spacer w/ Mask Medium Orange

Facility

$73.00

Hospital Charge Code	3252038
Hospital Revenue Code	270
Min. Negotiated Rate	$65.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$65.70
Rate for Payer: UnitedHealthcare Commercial	$69.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MEALS ON WHEELS-LUNCH

Facility

$5.00

Hospital Charge Code	5543207
Hospital Revenue Code	991
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

MEALS ON WHEELS-LUNCH

Facility

$5.00

Hospital Charge Code	5543207
Hospital Revenue Code	991
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

Know your out-of-pocket cost for care.

All Charges