Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Post-Op Shoe Womens Medium Size 6.5-8

Facility

$20.00

Service Code	HCPCS L3260
Hospital Charge Code	3256325
Hospital Revenue Code	274
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: Humana Medicare Advantage	$8.40
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: UnitedHealthcare Medicaid	$50.00
Rate for Payer: WPPA Medicare Advantage	$12.00

Post-Op Shoe Womens Medium Size 6.5-8

Facility

$20.00

Service Code	HCPCS L3260
Hospital Charge Code	3256325
Hospital Revenue Code	274
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Post-Op Shoe Womens Small Size 4-6

Facility

$21.00

Service Code	HCPCS L3260
Hospital Charge Code	3256320
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 Womens Small Size 4-6

Facility

$21.00

Service Code	HCPCS L3260
Hospital Charge Code	3256320
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 Surgical Bra Size L - 36-38, B-D

Facility

$108.89

Hospital Charge Code	3256342
Hospital Revenue Code	270
Min. Negotiated Rate	$43.56
Max. Negotiated Rate	$103.45
Rate for Payer: Aetna Commercial	$98.00
Rate for Payer: Humana Medicare Advantage	$45.73
Rate for Payer: UnitedHealthcare Commercial	$103.45
Rate for Payer: UnitedHealthcare Medicaid	$43.56
Rate for Payer: WPPA Medicare Advantage	$65.33

Post-Op Surgical Bra Size L - 36-38, B-D

Facility

$108.89

Hospital Charge Code	3256342
Hospital Revenue Code	270
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$98.00
Rate for Payer: UnitedHealthcare Commercial	$103.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Post-Op Surgical Bra Size XL - 38-44, B-D

Facility

$137.06

Hospital Charge Code	3256343
Hospital Revenue Code	270
Min. Negotiated Rate	$123.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$123.35
Rate for Payer: UnitedHealthcare Commercial	$130.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Post-Op Surgical Bra Size XL - 38-44, B-D

Facility

$137.06

Hospital Charge Code	3256343
Hospital Revenue Code	270
Min. Negotiated Rate	$54.82
Max. Negotiated Rate	$130.21
Rate for Payer: Aetna Commercial	$123.35
Rate for Payer: Humana Medicare Advantage	$57.57
Rate for Payer: UnitedHealthcare Commercial	$130.21
Rate for Payer: UnitedHealthcare Medicaid	$54.82
Rate for Payer: WPPA Medicare Advantage	$82.24

POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES

Facility

$5,877.45

Service Code	MSDRG 769
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,877.45
Rate for Payer: UnitedHealthcare Medicaid	$5,877.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES

Facility

$2,350.98

Service Code	MSDRG 776
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,350.98
Rate for Payer: UnitedHealthcare Medicaid	$2,350.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.Post TR ABO/Rh

Facility

$63.00

Service Code	HCPCS 86900
Hospital Charge Code	3560081
Hospital Revenue Code	300
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.Post TR ABO/Rh

Facility

$63.00

Service Code	HCPCS 86900
Hospital Charge Code	3560081
Hospital Revenue Code	300
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$210.75
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$210.75
Rate for Payer: Humana Medicare Advantage	$26.46
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: UnitedHealthcare Medicaid	$2.99
Rate for Payer: WPPA Medicare Advantage	$37.80

.Post TR Antibody Screen Gel 2

Facility

$79.00

Service Code	HCPCS 86850
Hospital Charge Code	3560073
Hospital Revenue Code	300
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

.Post TR Antibody Screen Gel 2

Facility

$79.00

Service Code	HCPCS 86850
Hospital Charge Code	3560073
Hospital Revenue Code	300
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$91.28
Rate for Payer: Aetna Commercial	$71.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$91.28
Rate for Payer: Humana Medicare Advantage	$33.18
Rate for Payer: UnitedHealthcare Commercial	$75.05
Rate for Payer: UnitedHealthcare Medicaid	$8.30
Rate for Payer: WPPA Medicare Advantage	$47.40

.Post TR Crossmatch

Facility

$113.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$42.03
Max. Negotiated Rate	$107.35
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$42.03
Rate for Payer: Humana Medicare Advantage	$47.46
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: UnitedHealthcare Medicaid	$45.20
Rate for Payer: WPPA Medicare Advantage	$67.80

.Post TR Crossmatch

Facility

$113.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$101.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.Post TR DAT IgG Gel

Facility

$151.00

Service Code	HCPCS 86880
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$135.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$135.90
Rate for Payer: UnitedHealthcare Commercial	$143.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.Post TR DAT IgG Gel

Facility

$151.00

Service Code	HCPCS 86880
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$143.45
Rate for Payer: Aetna Commercial	$135.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.24
Rate for Payer: Humana Medicare Advantage	$63.42
Rate for Payer: UnitedHealthcare Commercial	$143.45
Rate for Payer: UnitedHealthcare Medicaid	$5.39
Rate for Payer: WPPA Medicare Advantage	$90.60

Post Vasectomy Semen MAYO

Facility

$87.00

Service Code	HCPCS 89321
Hospital Charge Code	3559045
Hospital Revenue Code	300
Min. Negotiated Rate	$78.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$78.30
Rate for Payer: UnitedHealthcare Commercial	$82.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Post Vasectomy Semen MAYO

Facility

$87.00

Service Code	HCPCS 89321
Hospital Charge Code	3559045
Hospital Revenue Code	300
Min. Negotiated Rate	$34.80
Max. Negotiated Rate	$82.65
Rate for Payer: Aetna Commercial	$78.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$46.24
Rate for Payer: Humana Medicare Advantage	$36.54
Rate for Payer: UnitedHealthcare Commercial	$82.65
Rate for Payer: UnitedHealthcare Medicaid	$34.80
Rate for Payer: WPPA Medicare Advantage	$52.20

potassium chloride 10 mEq/100 mL Sol [HMC]

Facility

$37.86

Service Code	HCPCS J3480
Hospital Charge Code	3802447
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$35.97
Rate for Payer: Aetna Commercial	$34.07
Rate for Payer: Aetna Commercial	$39.31
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.15
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.15
Rate for Payer: Humana Medicare Advantage	$18.35
Rate for Payer: Humana Medicare Advantage	$15.90
Rate for Payer: UnitedHealthcare Commercial	$41.50
Rate for Payer: UnitedHealthcare Commercial	$35.97
Rate for Payer: UnitedHealthcare Medicaid	$0.12
Rate for Payer: UnitedHealthcare Medicaid	$0.12
Rate for Payer: WPPA Medicare Advantage	$26.21
Rate for Payer: WPPA Medicare Advantage	$22.72

potassium chloride 10 mEq/100 mL Sol [HMC]

Facility

$37.86

Service Code	HCPCS J3480
Hospital Charge Code	3802447
Hospital Revenue Code	250
Min. Negotiated Rate	$34.07
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.07
Rate for Payer: Aetna Commercial	$39.31
Rate for Payer: UnitedHealthcare Commercial	$41.50
Rate for Payer: UnitedHealthcare Commercial	$35.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

potassium chloride 10 mEq Cap ER [HMC]

Facility

$7.77

Service Code	NDC 00904754361
Hospital Charge Code	3808250
Hospital Revenue Code	250
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.99
Rate for Payer: UnitedHealthcare Commercial	$7.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

potassium chloride 10 mEq Cap ER [HMC]

Facility

$7.77

Service Code	NDC 00904754361
Hospital Charge Code	3808250
Hospital Revenue Code	250
Min. Negotiated Rate	$3.11
Max. Negotiated Rate	$7.38
Rate for Payer: Aetna Commercial	$6.99
Rate for Payer: Humana Medicare Advantage	$3.26
Rate for Payer: UnitedHealthcare Commercial	$7.38
Rate for Payer: UnitedHealthcare Medicaid	$3.11
Rate for Payer: WPPA Medicare Advantage	$4.66

potassium chloride 10 mEq Cap [HMC]

Facility

$9.24

Service Code	NDC 70010014801
Hospital Charge Code	3808250
Hospital Revenue Code	250
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.32
Rate for Payer: UnitedHealthcare Commercial	$8.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges