Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Splint Cock-up Large Left

Facility

$36.81

Service Code	HCPCS L3984
Hospital Charge Code	3251985
Hospital Revenue Code	274
Min. Negotiated Rate	$14.72
Max. Negotiated Rate	$34.97
Rate for Payer: Aetna Commercial	$33.13
Rate for Payer: Humana Medicare Advantage	$15.46
Rate for Payer: UnitedHealthcare Commercial	$34.97
Rate for Payer: UnitedHealthcare Medicaid	$14.72
Rate for Payer: WPPA Medicare Advantage	$22.09

Splint Cock-up Large Right

Facility

$24.12

Service Code	HCPCS L3984
Hospital Charge Code	3251208
Hospital Revenue Code	274
Min. Negotiated Rate	$9.65
Max. Negotiated Rate	$22.91
Rate for Payer: Aetna Commercial	$21.71
Rate for Payer: Humana Medicare Advantage	$10.13
Rate for Payer: UnitedHealthcare Commercial	$22.91
Rate for Payer: UnitedHealthcare Medicaid	$9.65
Rate for Payer: WPPA Medicare Advantage	$14.47

Splint Cock-up Large Right

Facility

$24.12

Service Code	HCPCS L3984
Hospital Charge Code	3251208
Hospital Revenue Code	274
Min. Negotiated Rate	$21.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.71
Rate for Payer: UnitedHealthcare Commercial	$22.91
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Cock-up Medium Left

Facility

$30.56

Service Code	HCPCS L3984
Hospital Charge Code	3251182
Hospital Revenue Code	274
Min. Negotiated Rate	$12.22
Max. Negotiated Rate	$29.03
Rate for Payer: Aetna Commercial	$27.50
Rate for Payer: Humana Medicare Advantage	$12.84
Rate for Payer: UnitedHealthcare Commercial	$29.03
Rate for Payer: UnitedHealthcare Medicaid	$12.22
Rate for Payer: WPPA Medicare Advantage	$18.34

Splint Cock-up Medium Left

Facility

$30.56

Service Code	HCPCS L3984
Hospital Charge Code	3251182
Hospital Revenue Code	274
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.50
Rate for Payer: UnitedHealthcare Commercial	$29.03
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Cock-up Medium Right

Facility

$30.60

Service Code	HCPCS L3984
Hospital Charge Code	3251190
Hospital Revenue Code	274
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$29.07
Rate for Payer: Aetna Commercial	$27.54
Rate for Payer: Humana Medicare Advantage	$12.85
Rate for Payer: UnitedHealthcare Commercial	$29.07
Rate for Payer: UnitedHealthcare Medicaid	$12.24
Rate for Payer: WPPA Medicare Advantage	$18.36

Splint Cock-up Medium Right

Facility

$30.60

Service Code	HCPCS L3984
Hospital Charge Code	3251190
Hospital Revenue Code	274
Min. Negotiated Rate	$27.54
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.54
Rate for Payer: UnitedHealthcare Commercial	$29.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Cock-up Pediatric Left

Facility

$25.02

Service Code	HCPCS L3984
Hospital Charge Code	3250929
Hospital Revenue Code	274
Min. Negotiated Rate	$22.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.52
Rate for Payer: UnitedHealthcare Commercial	$23.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Cock-up Pediatric Left

Facility

$25.02

Service Code	HCPCS L3984
Hospital Charge Code	3250929
Hospital Revenue Code	274
Min. Negotiated Rate	$10.01
Max. Negotiated Rate	$23.77
Rate for Payer: Aetna Commercial	$22.52
Rate for Payer: Humana Medicare Advantage	$10.51
Rate for Payer: UnitedHealthcare Commercial	$23.77
Rate for Payer: UnitedHealthcare Medicaid	$10.01
Rate for Payer: WPPA Medicare Advantage	$15.01

Splint Cock-up Pediatric Right

Facility

$34.00

Service Code	HCPCS L3984
Hospital Charge Code	3250937
Hospital Revenue Code	274
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$32.30
Rate for Payer: Aetna Commercial	$30.60
Rate for Payer: Humana Medicare Advantage	$14.28
Rate for Payer: UnitedHealthcare Commercial	$32.30
Rate for Payer: UnitedHealthcare Medicaid	$13.60
Rate for Payer: WPPA Medicare Advantage	$20.40

Splint Cock-up Pediatric Right

Facility

$34.00

Service Code	HCPCS L3984
Hospital Charge Code	3250937
Hospital Revenue Code	274
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.60
Rate for Payer: UnitedHealthcare Commercial	$32.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Cock-up Small Left

Facility

$30.56

Service Code	HCPCS L3984
Hospital Charge Code	3251224
Hospital Revenue Code	274
Min. Negotiated Rate	$12.22
Max. Negotiated Rate	$29.03
Rate for Payer: Aetna Commercial	$27.50
Rate for Payer: Humana Medicare Advantage	$12.84
Rate for Payer: UnitedHealthcare Commercial	$29.03
Rate for Payer: UnitedHealthcare Medicaid	$12.22
Rate for Payer: WPPA Medicare Advantage	$18.34

Splint Cock-up Small Left

Facility

$30.56

Service Code	HCPCS L3984
Hospital Charge Code	3251224
Hospital Revenue Code	274
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.50
Rate for Payer: UnitedHealthcare Commercial	$29.03
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Cock-up Small Right

Facility

$30.33

Service Code	HCPCS L3984
Hospital Charge Code	3251216
Hospital Revenue Code	274
Min. Negotiated Rate	$12.13
Max. Negotiated Rate	$28.81
Rate for Payer: Aetna Commercial	$27.30
Rate for Payer: Humana Medicare Advantage	$12.74
Rate for Payer: UnitedHealthcare Commercial	$28.81
Rate for Payer: UnitedHealthcare Medicaid	$12.13
Rate for Payer: WPPA Medicare Advantage	$18.20

Splint Cock-up Small Right

Facility

$30.33

Service Code	HCPCS L3984
Hospital Charge Code	3251216
Hospital Revenue Code	274
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.30
Rate for Payer: UnitedHealthcare Commercial	$28.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Cock-up X-Large Left

Facility

$30.74

Service Code	HCPCS L3984
Hospital Charge Code	3250945
Hospital Revenue Code	274
Min. Negotiated Rate	$12.30
Max. Negotiated Rate	$29.20
Rate for Payer: Aetna Commercial	$27.67
Rate for Payer: Humana Medicare Advantage	$12.91
Rate for Payer: UnitedHealthcare Commercial	$29.20
Rate for Payer: UnitedHealthcare Medicaid	$12.30
Rate for Payer: WPPA Medicare Advantage	$18.44

Splint Cock-up X-Large Left

Facility

$30.74

Service Code	HCPCS L3984
Hospital Charge Code	3250945
Hospital Revenue Code	274
Min. Negotiated Rate	$27.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.67
Rate for Payer: UnitedHealthcare Commercial	$29.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Cock-up X-Large Right

Facility

$30.00

Service Code	HCPCS L3984
Hospital Charge Code	3250952
Hospital Revenue Code	274
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$28.50
Rate for Payer: Aetna Commercial	$27.00
Rate for Payer: Humana Medicare Advantage	$12.60
Rate for Payer: UnitedHealthcare Commercial	$28.50
Rate for Payer: UnitedHealthcare Medicaid	$12.00
Rate for Payer: WPPA Medicare Advantage	$18.00

Splint Cock-up X-Large Right

Facility

$30.00

Service Code	HCPCS L3984
Hospital Charge Code	3250952
Hospital Revenue Code	274
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.00
Rate for Payer: UnitedHealthcare Commercial	$28.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Cock-up X-Small Left 8

Facility

$43.00

Service Code	HCPCS L3984
Hospital Charge Code	3251174
Hospital Revenue Code	274
Min. Negotiated Rate	$17.20
Max. Negotiated Rate	$40.85
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$18.06
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: UnitedHealthcare Medicaid	$17.20
Rate for Payer: WPPA Medicare Advantage	$25.80

Splint Cock-up X-Small Left 8

Facility

$43.00

Service Code	HCPCS L3984
Hospital Charge Code	3251174
Hospital Revenue Code	274
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Cock-up X-Small Right 8

Facility

$43.88

Service Code	HCPCS L3984
Hospital Charge Code	3255184
Hospital Revenue Code	274
Min. Negotiated Rate	$17.55
Max. Negotiated Rate	$41.69
Rate for Payer: Aetna Commercial	$39.49
Rate for Payer: Humana Medicare Advantage	$18.43
Rate for Payer: UnitedHealthcare Commercial	$41.69
Rate for Payer: UnitedHealthcare Medicaid	$17.55
Rate for Payer: WPPA Medicare Advantage	$26.33

Splint Cock-up X-Small Right 8

Facility

$43.88

Service Code	HCPCS L3984
Hospital Charge Code	3255184
Hospital Revenue Code	274
Min. Negotiated Rate	$39.49
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.49
Rate for Payer: UnitedHealthcare Commercial	$41.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Doyle Open Lumen

Facility

$168.21

Hospital Charge Code	3259208
Hospital Revenue Code	270
Min. Negotiated Rate	$67.28
Max. Negotiated Rate	$159.80
Rate for Payer: Aetna Commercial	$151.39
Rate for Payer: Humana Medicare Advantage	$70.65
Rate for Payer: UnitedHealthcare Commercial	$159.80
Rate for Payer: UnitedHealthcare Medicaid	$67.28
Rate for Payer: WPPA Medicare Advantage	$100.93

Splint Doyle Open Lumen

Facility

$168.21

Hospital Charge Code	3259208
Hospital Revenue Code	270
Min. Negotiated Rate	$151.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$151.39
Rate for Payer: UnitedHealthcare Commercial	$159.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges