Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

ORBITAL PROCEDURES WITH CC/MCC

Facility

$8,228.43

Service Code	MSDRG 113
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,228.43
Rate for Payer: UnitedHealthcare Medicaid	$8,228.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ORBITAL PROCEDURES WITHOUT CC/MCC

Facility

$4,733.73

Service Code	MSDRG 114
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,733.73
Rate for Payer: UnitedHealthcare Medicaid	$4,733.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Organic Acids, Limited, Quantitative, Urine QSTSON

Facility

$707.00

Service Code	HCPCS 82542
Hospital Charge Code	3552542
Hospital Revenue Code	300
Min. Negotiated Rate	$636.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$636.30
Rate for Payer: UnitedHealthcare Commercial	$671.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Organic Acids, Limited, Quantitative, Urine QSTSON

Facility

$707.00

Service Code	HCPCS 82542
Hospital Charge Code	3552542
Hospital Revenue Code	300
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$671.65
Rate for Payer: Aetna Commercial	$636.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$194.29
Rate for Payer: Humana Medicare Advantage	$296.94
Rate for Payer: UnitedHealthcare Commercial	$671.65
Rate for Payer: UnitedHealthcare Medicaid	$20.48
Rate for Payer: WPPA Medicare Advantage	$424.20

ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY

Facility

$5,305.59

Service Code	MSDRG 884
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,305.59
Rate for Payer: UnitedHealthcare Medicaid	$5,305.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ORIGO Microdebrider Irrigation Line from Bien-Air used with TruDi ENT Navigation System

Facility

$78.75

Hospital Charge Code	3256114
Hospital Revenue Code	270
Min. Negotiated Rate	$70.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.88
Rate for Payer: UnitedHealthcare Commercial	$74.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ORIGO Microdebrider Irrigation Line from Bien-Air used with TruDi ENT Navigation System

Facility

$78.75

Hospital Charge Code	3256114
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$74.81
Rate for Payer: Aetna Commercial	$70.88
Rate for Payer: Humana Medicare Advantage	$33.08
Rate for Payer: UnitedHealthcare Commercial	$74.81
Rate for Payer: UnitedHealthcare Medicaid	$31.50
Rate for Payer: WPPA Medicare Advantage	$47.25

orphenadrine 100 mg ER Tab [HMC]

Facility

$11.92

Service Code	NDC 43386048024
Hospital Charge Code	3807025
Hospital Revenue Code	250
Min. Negotiated Rate	$10.73
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.73
Rate for Payer: UnitedHealthcare Commercial	$11.32
Rate for Payer: WPPA Medicare Advantage	$1,200.00

orphenadrine 100 mg ER Tab [HMC]

Facility

$11.92

Service Code	NDC 43386048024
Hospital Charge Code	3807025
Hospital Revenue Code	250
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$11.32
Rate for Payer: Aetna Commercial	$10.73
Rate for Payer: Humana Medicare Advantage	$5.01
Rate for Payer: UnitedHealthcare Commercial	$11.32
Rate for Payer: UnitedHealthcare Medicaid	$4.77
Rate for Payer: WPPA Medicare Advantage	$7.15

orphenadrine 30 mg/mL Inj Sol 2 ml [HMC]

Facility

$57.44

Service Code	NDC 00641618210
Hospital Charge Code	3852075
Hospital Revenue Code	250
Min. Negotiated Rate	$22.98
Max. Negotiated Rate	$54.57
Rate for Payer: Aetna Commercial	$51.70
Rate for Payer: Humana Medicare Advantage	$24.12
Rate for Payer: UnitedHealthcare Commercial	$54.57
Rate for Payer: UnitedHealthcare Medicaid	$22.98
Rate for Payer: WPPA Medicare Advantage	$34.46

orphenadrine 30 mg/mL Inj Sol 2 ml [HMC]

Facility

$57.44

Service Code	NDC 00641618210
Hospital Charge Code	3852075
Hospital Revenue Code	250
Min. Negotiated Rate	$51.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.70
Rate for Payer: UnitedHealthcare Commercial	$54.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

orphenadrine 30 mg/mL Inj Sol 2 mL [HMC]

Facility

$53.31

Service Code	HCPCS J2360
Hospital Charge Code	3852075
Hospital Revenue Code	250
Min. Negotiated Rate	$47.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$47.98
Rate for Payer: Aetna Commercial	$43.92
Rate for Payer: Aetna Commercial	$48.38
Rate for Payer: Aetna Commercial	$51.70
Rate for Payer: UnitedHealthcare Commercial	$50.64
Rate for Payer: UnitedHealthcare Commercial	$54.57
Rate for Payer: UnitedHealthcare Commercial	$51.06
Rate for Payer: UnitedHealthcare Commercial	$46.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

orphenadrine 30 mg/mL Inj Sol 2 mL [HMC]

Facility

$53.31

Service Code	HCPCS J2360
Hospital Charge Code	3852075
Hospital Revenue Code	250
Min. Negotiated Rate	$11.73
Max. Negotiated Rate	$50.64
Rate for Payer: Aetna Commercial	$47.98
Rate for Payer: Aetna Commercial	$48.38
Rate for Payer: Aetna Commercial	$43.92
Rate for Payer: Aetna Commercial	$51.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.73
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.73
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.73
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11.73
Rate for Payer: Humana Medicare Advantage	$20.50
Rate for Payer: Humana Medicare Advantage	$22.39
Rate for Payer: Humana Medicare Advantage	$24.12
Rate for Payer: Humana Medicare Advantage	$22.57
Rate for Payer: UnitedHealthcare Commercial	$54.57
Rate for Payer: UnitedHealthcare Commercial	$46.36
Rate for Payer: UnitedHealthcare Commercial	$50.64
Rate for Payer: UnitedHealthcare Commercial	$51.06
Rate for Payer: UnitedHealthcare Medicaid	$21.32
Rate for Payer: UnitedHealthcare Medicaid	$19.52
Rate for Payer: UnitedHealthcare Medicaid	$21.50
Rate for Payer: UnitedHealthcare Medicaid	$22.98
Rate for Payer: WPPA Medicare Advantage	$31.99
Rate for Payer: WPPA Medicare Advantage	$29.28
Rate for Payer: WPPA Medicare Advantage	$34.46
Rate for Payer: WPPA Medicare Advantage	$32.25

O.R. PROCEDURES FOR OBESITY WITH CC

Facility

$5,496.21

Service Code	MSDRG 620
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,496.21
Rate for Payer: UnitedHealthcare Medicaid	$5,496.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

O.R. PROCEDURES FOR OBESITY WITH MCC

Facility

$10,293.48

Service Code	MSDRG 619
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,293.48
Rate for Payer: UnitedHealthcare Medicaid	$10,293.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC

Facility

$5,146.74

Service Code	MSDRG 621
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,146.74
Rate for Payer: UnitedHealthcare Medicaid	$5,146.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC

Facility

$8,196.66

Service Code	MSDRG 940
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,196.66
Rate for Payer: UnitedHealthcare Medicaid	$8,196.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC

Facility

$12,708.00

Service Code	MSDRG 939
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,708.00
Rate for Payer: UnitedHealthcare Medicaid	$12,708.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC

Facility

$7,116.48

Service Code	MSDRG 941
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,116.48
Rate for Payer: UnitedHealthcare Medicaid	$7,116.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS

Facility

$13,534.02

Service Code	MSDRG 876
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$13,534.02
Rate for Payer: UnitedHealthcare Medicaid	$13,534.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ortho Glass 2

Facility

$11.25

Hospital Charge Code	3255558
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$10.69
Rate for Payer: Aetna Commercial	$10.12
Rate for Payer: Humana Medicare Advantage	$4.72
Rate for Payer: UnitedHealthcare Commercial	$10.69
Rate for Payer: UnitedHealthcare Medicaid	$4.50
Rate for Payer: WPPA Medicare Advantage	$6.75

Ortho Glass 2

Facility

$11.25

Hospital Charge Code	3255558
Hospital Revenue Code	270
Min. Negotiated Rate	$10.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.12
Rate for Payer: UnitedHealthcare Commercial	$10.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ortho Glass 3

Facility

$16.47

Hospital Charge Code	3255559
Hospital Revenue Code	270
Min. Negotiated Rate	$6.59
Max. Negotiated Rate	$15.65
Rate for Payer: Aetna Commercial	$14.82
Rate for Payer: Humana Medicare Advantage	$6.92
Rate for Payer: UnitedHealthcare Commercial	$15.65
Rate for Payer: UnitedHealthcare Medicaid	$6.59
Rate for Payer: WPPA Medicare Advantage	$9.88

Ortho Glass 3

Facility

$16.47

Hospital Charge Code	3255559
Hospital Revenue Code	270
Min. Negotiated Rate	$14.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$14.82
Rate for Payer: UnitedHealthcare Commercial	$15.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ortho Glass 4

Facility

$19.76

Hospital Charge Code	3255555
Hospital Revenue Code	270
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$18.77
Rate for Payer: Aetna Commercial	$17.78
Rate for Payer: Humana Medicare Advantage	$8.30
Rate for Payer: UnitedHealthcare Commercial	$18.77
Rate for Payer: UnitedHealthcare Medicaid	$7.90
Rate for Payer: WPPA Medicare Advantage	$11.86

Know your out-of-pocket cost for care.

All Charges