Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Ostomy Hollister Skin Barrier Ring 2-3/4 - LARGE Flat

Facility

$2.50

Hospital Charge Code	3252283
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

Ostomy Hollister Skin Barrier Ring 2-3/4 - LARGE Flat

Facility

$2.50

Hospital Charge Code	3252283
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

Ostomy Paste 2.1oz Hollister

Facility

$5.00

Hospital Charge Code	3252254
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

Ostomy Paste 2.1oz Hollister

Facility

$5.00

Hospital Charge Code	3252254
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

Ostomy Pouch Ileostomy/Colostomy One-Piece Pouch with built-in Barrier 12 Cut to Fit up to 1.5 Sof

Facility

$5.00

Hospital Charge Code	3252234
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

Ostomy Pouch Ileostomy/Colostomy One-Piece Pouch with built-in Barrier 12 Cut to Fit up to 1.5 Sof

Facility

$5.00

Hospital Charge Code	3252234
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

Ostomy Pouch & Skin Barrier Kit 2-1/4 Clear Bag Flange Color Red 1-3/4 Stomas

Facility

$21.00

Hospital Charge Code	3252285
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$8.40
Rate for Payer: WPPA Medicare Advantage	$12.60

Ostomy Pouch & Skin Barrier Kit 2-1/4 Clear Bag Flange Color Red 1-3/4 Stomas

Facility

$21.00

Hospital Charge Code	3252285
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Pouch Urostomy One-Piece Pouch and Barrier Cut to Fit up to 1.5 Transparent

Facility

$6.00

Hospital Charge Code	3252233
Hospital Revenue Code	270
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$5.70
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: Humana Medicare Advantage	$2.52
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: WPPA Medicare Advantage	$3.60

Ostomy Pouch Urostomy One-Piece Pouch and Barrier Cut to Fit up to 1.5 Transparent

Facility

$6.00

Hospital Charge Code	3252233
Hospital Revenue Code	270
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Powder Stoma 1oz Hollister

Facility

$3.60

Hospital Charge Code	3252245
Hospital Revenue Code	270
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$3.42
Rate for Payer: Aetna Commercial	$3.24
Rate for Payer: Humana Medicare Advantage	$1.51
Rate for Payer: UnitedHealthcare Commercial	$3.42
Rate for Payer: UnitedHealthcare Medicaid	$1.44
Rate for Payer: WPPA Medicare Advantage	$2.16

Ostomy Powder Stoma 1oz Hollister

Facility

$3.60

Hospital Charge Code	3252245
Hospital Revenue Code	270
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.24
Rate for Payer: UnitedHealthcare Commercial	$3.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Rainlotus One-Piece Bag Cut-to-Fit

Facility

$6.30

Hospital Charge Code	3252239
Hospital Revenue Code	270
Min. Negotiated Rate	$5.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.67
Rate for Payer: UnitedHealthcare Commercial	$5.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ostomy Rainlotus One-Piece Bag Cut-to-Fit

Facility

$6.30

Hospital Charge Code	3252239
Hospital Revenue Code	270
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.99
Rate for Payer: Aetna Commercial	$5.67
Rate for Payer: Humana Medicare Advantage	$2.65
Rate for Payer: UnitedHealthcare Commercial	$5.99
Rate for Payer: UnitedHealthcare Medicaid	$2.52
Rate for Payer: WPPA Medicare Advantage	$3.78

OT ADL Training Assist Units

Facility

$128.00

Service Code	HCPCS 97535 GO
Hospital Charge Code	3970135
Hospital Revenue Code	430
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT ADL Training Assist Units

Facility

$128.00

Service Code	HCPCS 97535 GO
Hospital Charge Code	3970135
Hospital Revenue Code	430
Min. Negotiated Rate	$19.46
Max. Negotiated Rate	$121.60
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$34.17
Rate for Payer: Humana Medicare Advantage	$53.76
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: UnitedHealthcare Medicaid	$19.46
Rate for Payer: WPPA Medicare Advantage	$76.80

OT Attended E-Stim Assistant Units

Facility

$97.00

Service Code	HCPCS 97032 GO
Hospital Charge Code	3970260
Hospital Revenue Code	430
Min. Negotiated Rate	$87.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Attended E-Stim Assistant Units

Facility

$97.00

Service Code	HCPCS 97032 GO
Hospital Charge Code	3970260
Hospital Revenue Code	430
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$92.15
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$34.34
Rate for Payer: Humana Medicare Advantage	$40.74
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: UnitedHealthcare Medicaid	$8.58
Rate for Payer: WPPA Medicare Advantage	$58.20

OT Canalith Repositioning Assist Units

Facility

$191.00

Service Code	HCPCS 95992 GO
Hospital Charge Code	3970270
Hospital Revenue Code	430
Min. Negotiated Rate	$40.14
Max. Negotiated Rate	$181.45
Rate for Payer: Aetna Commercial	$171.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$40.14
Rate for Payer: Humana Medicare Advantage	$80.22
Rate for Payer: UnitedHealthcare Commercial	$181.45
Rate for Payer: UnitedHealthcare Medicaid	$76.40
Rate for Payer: WPPA Medicare Advantage	$114.60

OT Canalith Repositioning Assist Units

Facility

$191.00

Service Code	HCPCS 95992 GO
Hospital Charge Code	3970270
Hospital Revenue Code	430
Min. Negotiated Rate	$171.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$171.90
Rate for Payer: UnitedHealthcare Commercial	$181.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Canalith Repositioning Units

Facility

$191.00

Service Code	HCPCS 95992 GO
Hospital Charge Code	3970270
Hospital Revenue Code	430
Min. Negotiated Rate	$40.14
Max. Negotiated Rate	$181.45
Rate for Payer: Aetna Commercial	$171.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$40.14
Rate for Payer: Humana Medicare Advantage	$80.22
Rate for Payer: UnitedHealthcare Commercial	$181.45
Rate for Payer: UnitedHealthcare Medicaid	$76.40
Rate for Payer: WPPA Medicare Advantage	$114.60

OT Canalith Repositioning Units

Facility

$191.00

Service Code	HCPCS 95992 GO
Hospital Charge Code	3970270
Hospital Revenue Code	430
Min. Negotiated Rate	$171.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$171.90
Rate for Payer: UnitedHealthcare Commercial	$181.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Cog Ther Intervent, Addl 15 Min Asst

Facility

$160.00

Service Code	HCPCS 97130 GO
Hospital Charge Code	97130
Hospital Revenue Code	430
Min. Negotiated Rate	$144.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$144.00
Rate for Payer: UnitedHealthcare Commercial	$152.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Cog Ther Intervent, Addl 15 Min Asst

Facility

$160.00

Service Code	HCPCS 97130 GO
Hospital Charge Code	97130
Hospital Revenue Code	430
Min. Negotiated Rate	$50.50
Max. Negotiated Rate	$152.00
Rate for Payer: Aetna Commercial	$144.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$50.50
Rate for Payer: Humana Medicare Advantage	$67.20
Rate for Payer: UnitedHealthcare Commercial	$152.00
Rate for Payer: UnitedHealthcare Medicaid	$64.00
Rate for Payer: WPPA Medicare Advantage	$96.00

OT Cog Ther Intervent, Addl 15 Min Units

Facility

$160.00

Service Code	HCPCS 97130 GO
Hospital Charge Code	97130
Hospital Revenue Code	430
Min. Negotiated Rate	$50.50
Max. Negotiated Rate	$152.00
Rate for Payer: Aetna Commercial	$144.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$50.50
Rate for Payer: Humana Medicare Advantage	$67.20
Rate for Payer: UnitedHealthcare Commercial	$152.00
Rate for Payer: UnitedHealthcare Medicaid	$64.00
Rate for Payer: WPPA Medicare Advantage	$96.00

Know your out-of-pocket cost for care.

All Charges