Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Port Smart CT-Injectable 7.5fr

Facility

$2,249.00

Service Code	HCPCS C1788
Hospital Charge Code	3251045
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,136.55
Rate for Payer: Aetna Commercial	$2,024.10
Rate for Payer: UnitedHealthcare Commercial	$2,136.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Port Smart CT-Injectable 7.5fr

Facility

$2,249.00

Service Code	HCPCS C1788
Hospital Charge Code	3251045
Hospital Revenue Code	278
Min. Negotiated Rate	$899.60
Max. Negotiated Rate	$2,136.55
Rate for Payer: Aetna Commercial	$2,024.10
Rate for Payer: Humana Medicare Advantage	$944.58
Rate for Payer: UnitedHealthcare Commercial	$2,136.55
Rate for Payer: UnitedHealthcare Medicaid	$899.60
Rate for Payer: WPPA Medicare Advantage	$1,349.40

Port Smart Low Profile 6.6fr

Facility

$906.00

Service Code	HCPCS C1781
Hospital Charge Code	3251047
Hospital Revenue Code	278
Min. Negotiated Rate	$815.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$815.40
Rate for Payer: UnitedHealthcare Commercial	$860.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Port Smart Low Profile 6.6fr

Facility

$906.00

Service Code	HCPCS C1781
Hospital Charge Code	3251047
Hospital Revenue Code	278
Min. Negotiated Rate	$362.40
Max. Negotiated Rate	$860.70
Rate for Payer: Aetna Commercial	$815.40
Rate for Payer: Humana Medicare Advantage	$380.52
Rate for Payer: UnitedHealthcare Commercial	$860.70
Rate for Payer: UnitedHealthcare Medicaid	$362.40
Rate for Payer: WPPA Medicare Advantage	$543.60

Port XCELA Low Profile Power Injectable 8fr

Facility

$772.00

Service Code	HCPCS C1781
Hospital Charge Code	3257668
Hospital Revenue Code	278
Min. Negotiated Rate	$694.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$694.80
Rate for Payer: UnitedHealthcare Commercial	$733.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Port XCELA Low Profile Power Injectable 8fr

Facility

$772.00

Service Code	HCPCS C1781
Hospital Charge Code	3257668
Hospital Revenue Code	278
Min. Negotiated Rate	$308.80
Max. Negotiated Rate	$733.40
Rate for Payer: Aetna Commercial	$694.80
Rate for Payer: Humana Medicare Advantage	$324.24
Rate for Payer: UnitedHealthcare Commercial	$733.40
Rate for Payer: UnitedHealthcare Medicaid	$308.80
Rate for Payer: WPPA Medicare Advantage	$463.20

Port XCELA Standard Power Injectable 8fr

Facility

$772.00

Service Code	HCPCS C1781
Hospital Charge Code	3257667
Hospital Revenue Code	278
Min. Negotiated Rate	$694.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$694.80
Rate for Payer: UnitedHealthcare Commercial	$733.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Port XCELA Standard Power Injectable 8fr

Facility

$772.00

Service Code	HCPCS C1781
Hospital Charge Code	3257667
Hospital Revenue Code	278
Min. Negotiated Rate	$308.80
Max. Negotiated Rate	$733.40
Rate for Payer: Aetna Commercial	$694.80
Rate for Payer: Humana Medicare Advantage	$324.24
Rate for Payer: UnitedHealthcare Commercial	$733.40
Rate for Payer: UnitedHealthcare Medicaid	$308.80
Rate for Payer: WPPA Medicare Advantage	$463.20

Positioner Ulnar Nerve

Facility

$11.00

Hospital Charge Code	3259238
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

Positioner Ulnar Nerve

Facility

$11.00

Hospital Charge Code	3259238
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

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC

Facility

$7,275.33

Service Code	MSDRG 862
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,275.33
Rate for Payer: UnitedHealthcare Medicaid	$7,275.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC

Facility

$3,971.25

Service Code	MSDRG 863
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,971.25
Rate for Payer: UnitedHealthcare Medicaid	$3,971.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC

Facility

$8,768.52

Service Code	MSDRG 857
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,768.52
Rate for Payer: UnitedHealthcare Medicaid	$8,768.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC

Facility

$18,617.22

Service Code	MSDRG 856
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$18,617.22
Rate for Payer: UnitedHealthcare Medicaid	$18,617.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$5,686.83

Service Code	MSDRG 858
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,686.83
Rate for Payer: UnitedHealthcare Medicaid	$5,686.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Post-Op Shoe Mens Large Size 10.5-12

Facility

$21.00

Service Code	HCPCS L3260
Hospital Charge Code	3256310
Hospital Revenue Code	274
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$50.00
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	$50.00
Rate for Payer: WPPA Medicare Advantage	$12.60

Post-Op Shoe Mens Large Size 10.5-12

Facility

$21.00

Service Code	HCPCS L3260
Hospital Charge Code	3256310
Hospital Revenue Code	274
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

Post-Op Shoe Mens Medium Size 8.5-10

Facility

$20.43

Service Code	HCPCS L3260
Hospital Charge Code	3256305
Hospital Revenue Code	274
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$18.39
Rate for Payer: Humana Medicare Advantage	$8.58
Rate for Payer: UnitedHealthcare Commercial	$19.41
Rate for Payer: UnitedHealthcare Medicaid	$50.00
Rate for Payer: WPPA Medicare Advantage	$12.26

Post-Op Shoe Mens Medium Size 8.5-10

Facility

$20.43

Service Code	HCPCS L3260
Hospital Charge Code	3256305
Hospital Revenue Code	274
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.39
Rate for Payer: UnitedHealthcare Commercial	$19.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Post-Op Shoe Mens Small Size 6-8

Facility

$21.00

Service Code	HCPCS L3260
Hospital Charge Code	3256300
Hospital Revenue Code	274
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$50.00
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	$50.00
Rate for Payer: WPPA Medicare Advantage	$12.60

Post-Op Shoe Mens Small Size 6-8

Facility

$21.00

Service Code	HCPCS L3260
Hospital Charge Code	3256300
Hospital Revenue Code	274
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

Post-Op Shoe Mens X-Large Size 12.5-14

Facility

$23.00

Hospital Charge Code	3256315
Hospital Revenue Code	270
Min. Negotiated Rate	$9.20
Max. Negotiated Rate	$21.85
Rate for Payer: Aetna Commercial	$20.70
Rate for Payer: Humana Medicare Advantage	$9.66
Rate for Payer: UnitedHealthcare Commercial	$21.85
Rate for Payer: UnitedHealthcare Medicaid	$9.20
Rate for Payer: WPPA Medicare Advantage	$13.80

Post-Op Shoe Mens X-Large Size 12.5-14

Facility

$23.00

Hospital Charge Code	3256315
Hospital Revenue Code	270
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.70
Rate for Payer: UnitedHealthcare Commercial	$21.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Post-Op Shoe Womens Large Size 8.5-10

Facility

$20.43

Service Code	HCPCS L3260
Hospital Charge Code	3256330
Hospital Revenue Code	274
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.39
Rate for Payer: UnitedHealthcare Commercial	$19.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Post-Op Shoe Womens Large Size 8.5-10

Facility

$20.43

Service Code	HCPCS L3260
Hospital Charge Code	3256330
Hospital Revenue Code	274
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$18.39
Rate for Payer: Humana Medicare Advantage	$8.58
Rate for Payer: UnitedHealthcare Commercial	$19.41
Rate for Payer: UnitedHealthcare Medicaid	$50.00
Rate for Payer: WPPA Medicare Advantage	$12.26

Know your out-of-pocket cost for care.

All Charges