Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Packing Strip Plain 1/4

Facility

$6.98

Hospital Charge Code	3254211
Hospital Revenue Code	270
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$6.63
Rate for Payer: Aetna Commercial	$6.28
Rate for Payer: Humana Medicare Advantage	$2.93
Rate for Payer: UnitedHealthcare Commercial	$6.63
Rate for Payer: UnitedHealthcare Medicaid	$2.79
Rate for Payer: WPPA Medicare Advantage	$4.19

PACK LAPOROTOMY III

Facility

$34.83

Hospital Charge Code	3255978
Hospital Revenue Code	270
Min. Negotiated Rate	$31.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: UnitedHealthcare Commercial	$33.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PACK LAPOROTOMY III

Facility

$34.83

Hospital Charge Code	3255978
Hospital Revenue Code	270
Min. Negotiated Rate	$13.93
Max. Negotiated Rate	$33.09
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Humana Medicare Advantage	$14.63
Rate for Payer: UnitedHealthcare Commercial	$33.09
Rate for Payer: UnitedHealthcare Medicaid	$13.93
Rate for Payer: WPPA Medicare Advantage	$20.90

Pack OB III

Facility

$50.72

Hospital Charge Code	3253594
Hospital Revenue Code	270
Min. Negotiated Rate	$45.65
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.65
Rate for Payer: UnitedHealthcare Commercial	$48.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pack OB III

Facility

$50.72

Hospital Charge Code	3253594
Hospital Revenue Code	270
Min. Negotiated Rate	$20.29
Max. Negotiated Rate	$48.18
Rate for Payer: Aetna Commercial	$45.65
Rate for Payer: Humana Medicare Advantage	$21.30
Rate for Payer: UnitedHealthcare Commercial	$48.18
Rate for Payer: UnitedHealthcare Medicaid	$20.29
Rate for Payer: WPPA Medicare Advantage	$30.43

Pack Universal I

Facility

$79.00

Hospital Charge Code	3253595
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

Pack Universal I

Facility

$79.00

Hospital Charge Code	3253595
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

PACK VI LITHOTOMYPERI/GYN

Facility

$38.43

Hospital Charge Code	3255481
Hospital Revenue Code	270
Min. Negotiated Rate	$15.37
Max. Negotiated Rate	$36.51
Rate for Payer: Aetna Commercial	$34.59
Rate for Payer: Humana Medicare Advantage	$16.14
Rate for Payer: UnitedHealthcare Commercial	$36.51
Rate for Payer: UnitedHealthcare Medicaid	$15.37
Rate for Payer: WPPA Medicare Advantage	$23.06

PACK VI LITHOTOMYPERI/GYN

Facility

$38.43

Hospital Charge Code	3255481
Hospital Revenue Code	270
Min. Negotiated Rate	$34.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.59
Rate for Payer: UnitedHealthcare Commercial	$36.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Padding Soft Rolls Cellona Synthetic 10cm x 3m Lymphedema Program

Facility

$11.00

Hospital Charge Code	3254715
Hospital Revenue Code	270
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$10.45
Rate for Payer: Aetna Commercial	$9.90
Rate for Payer: Humana Medicare Advantage	$4.62
Rate for Payer: UnitedHealthcare Commercial	$10.45
Rate for Payer: UnitedHealthcare Medicaid	$4.40
Rate for Payer: WPPA Medicare Advantage	$6.60

Padding Soft Rolls Cellona Synthetic 10cm x 3m Lymphedema Program

Facility

$11.00

Hospital Charge Code	3254715
Hospital Revenue Code	270
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.90
Rate for Payer: UnitedHealthcare Commercial	$10.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Padding Soft Rolls Cellona Synthetic 15cm x 3m Lymphedema Program

Facility

$15.00

Hospital Charge Code	3254716
Hospital Revenue Code	270
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$14.25
Rate for Payer: Aetna Commercial	$13.50
Rate for Payer: Humana Medicare Advantage	$6.30
Rate for Payer: UnitedHealthcare Commercial	$14.25
Rate for Payer: UnitedHealthcare Medicaid	$6.00
Rate for Payer: WPPA Medicare Advantage	$9.00

Padding Soft Rolls Cellona Synthetic 15cm x 3m Lymphedema Program

Facility

$15.00

Hospital Charge Code	3254716
Hospital Revenue Code	270
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.50
Rate for Payer: UnitedHealthcare Commercial	$14.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pad Felt Protective Foot Insert w/Adhesive Large Size 106

Facility

$3.00

Hospital Charge Code	3250230
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

Pad Felt Protective Foot Insert w/Adhesive Large Size 106

Facility

$3.00

Hospital Charge Code	3250230
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

paliperidone 156 mg/mL [HMC]

Facility

$4,194.54

Service Code	HCPCS J2426
Hospital Charge Code	3850023
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,984.81
Rate for Payer: Aetna Commercial	$3,775.09
Rate for Payer: UnitedHealthcare Commercial	$3,984.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

paliperidone 156 mg/mL [HMC]

Facility

$4,194.54

Service Code	HCPCS J2426
Hospital Charge Code	3850023
Hospital Revenue Code	250
Min. Negotiated Rate	$15.11
Max. Negotiated Rate	$3,984.81
Rate for Payer: Aetna Commercial	$3,775.09
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$18.42
Rate for Payer: Humana Medicare Advantage	$1,761.71
Rate for Payer: UnitedHealthcare Commercial	$3,984.81
Rate for Payer: UnitedHealthcare Medicaid	$15.11
Rate for Payer: WPPA Medicare Advantage	$2,516.72

palonosetron 0.25 mg/5 mL Inj [HMC]

Facility

$529.62

Service Code	HCPCS J2469
Hospital Charge Code	3807903
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$503.14
Rate for Payer: Aetna Commercial	$476.66
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.45
Rate for Payer: Humana Medicare Advantage	$222.44
Rate for Payer: UnitedHealthcare Commercial	$503.14
Rate for Payer: UnitedHealthcare Medicaid	$0.35
Rate for Payer: WPPA Medicare Advantage	$317.77

palonosetron 0.25 mg/5 mL Inj [HMC]

Facility

$529.62

Service Code	HCPCS J2469
Hospital Charge Code	3807903
Hospital Revenue Code	250
Min. Negotiated Rate	$476.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$476.66
Rate for Payer: UnitedHealthcare Commercial	$503.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC

Facility

$9,340.38

Service Code	MSDRG 406
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,340.38
Rate for Payer: UnitedHealthcare Medicaid	$9,340.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC

Facility

$17,632.35

Service Code	MSDRG 405
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$17,632.35
Rate for Payer: UnitedHealthcare Medicaid	$17,632.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC

Facility

$7,148.25

Service Code	MSDRG 407
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,148.25
Rate for Payer: UnitedHealthcare Medicaid	$7,148.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PANCREAS TRANSPLANT

Facility

$18,966.69

Service Code	MSDRG 010
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$18,966.69
Rate for Payer: UnitedHealthcare Medicaid	$18,966.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pancreatic Elastase-1 QST

Facility

$444.00

Service Code	HCPCS 82656
Hospital Charge Code	3558265
Hospital Revenue Code	300
Min. Negotiated Rate	$399.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$399.60
Rate for Payer: UnitedHealthcare Commercial	$421.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pancreatic Elastase-1 QST

Facility

$444.00

Service Code	HCPCS 82656
Hospital Charge Code	3558265
Hospital Revenue Code	300
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$421.80
Rate for Payer: Aetna Commercial	$399.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$25.51
Rate for Payer: Humana Medicare Advantage	$186.48
Rate for Payer: UnitedHealthcare Commercial	$421.80
Rate for Payer: UnitedHealthcare Medicaid	$11.53
Rate for Payer: WPPA Medicare Advantage	$266.40

Know your out-of-pocket cost for care.

All Charges