Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Splint Finger Baseball Toad Large

Facility

$7.11

Service Code	HCPCS L3927
Hospital Charge Code	3251331
Hospital Revenue Code	274
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$45.98
Rate for Payer: Aetna Commercial	$6.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.98
Rate for Payer: Humana Medicare Advantage	$2.99
Rate for Payer: UnitedHealthcare Commercial	$6.75
Rate for Payer: UnitedHealthcare Medicaid	$29.82
Rate for Payer: WPPA Medicare Advantage	$4.27

Splint Finger Baseball Toad Large

Facility

$7.11

Service Code	HCPCS L3927
Hospital Charge Code	3251331
Hospital Revenue Code	274
Min. Negotiated Rate	$6.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.40
Rate for Payer: UnitedHealthcare Commercial	$6.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Finger Baseball Toad Medium

Facility

$9.00

Service Code	HCPCS L3927
Hospital Charge Code	3251349
Hospital Revenue Code	274
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$45.98
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.98
Rate for Payer: Humana Medicare Advantage	$3.78
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: UnitedHealthcare Medicaid	$29.82
Rate for Payer: WPPA Medicare Advantage	$5.40

Splint Finger Baseball Toad Medium

Facility

$9.00

Service Code	HCPCS L3927
Hospital Charge Code	3251349
Hospital Revenue Code	274
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Finger Baseball Toad Small

Facility

$8.51

Service Code	HCPCS L3927
Hospital Charge Code	3251166
Hospital Revenue Code	274
Min. Negotiated Rate	$3.57
Max. Negotiated Rate	$45.98
Rate for Payer: Aetna Commercial	$7.66
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.98
Rate for Payer: Humana Medicare Advantage	$3.57
Rate for Payer: UnitedHealthcare Commercial	$8.08
Rate for Payer: UnitedHealthcare Medicaid	$29.82
Rate for Payer: WPPA Medicare Advantage	$5.11

Splint Finger Baseball Toad Small

Facility

$8.51

Service Code	HCPCS L3927
Hospital Charge Code	3251166
Hospital Revenue Code	274
Min. Negotiated Rate	$7.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.66
Rate for Payer: UnitedHealthcare Commercial	$8.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Finger Fold 1-1/4 -SMALL

Facility

$5.09

Service Code	HCPCS L3927
Hospital Charge Code	3251356
Hospital Revenue Code	274
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$45.98
Rate for Payer: Aetna Commercial	$4.58
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.98
Rate for Payer: Humana Medicare Advantage	$2.14
Rate for Payer: UnitedHealthcare Commercial	$4.84
Rate for Payer: UnitedHealthcare Medicaid	$29.82
Rate for Payer: WPPA Medicare Advantage	$3.05

Splint Finger Fold 1-1/4 -SMALL

Facility

$5.09

Service Code	HCPCS L3927
Hospital Charge Code	3251356
Hospital Revenue Code	274
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.58
Rate for Payer: UnitedHealthcare Commercial	$4.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Finger Fold 2- MED

Facility

$4.41

Service Code	HCPCS L3927
Hospital Charge Code	3251364
Hospital Revenue Code	274
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$45.98
Rate for Payer: Aetna Commercial	$3.97
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.98
Rate for Payer: Humana Medicare Advantage	$1.85
Rate for Payer: UnitedHealthcare Commercial	$4.19
Rate for Payer: UnitedHealthcare Medicaid	$29.82
Rate for Payer: WPPA Medicare Advantage	$2.65

Splint Finger Fold 2- MED

Facility

$4.41

Service Code	HCPCS L3927
Hospital Charge Code	3251364
Hospital Revenue Code	274
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.97
Rate for Payer: UnitedHealthcare Commercial	$4.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Finger Fold 3-1/2- XL

Facility

$3.20

Service Code	HCPCS L3927
Hospital Charge Code	3251398
Hospital Revenue Code	274
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$45.98
Rate for Payer: Aetna Commercial	$2.88
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.98
Rate for Payer: Humana Medicare Advantage	$1.34
Rate for Payer: UnitedHealthcare Commercial	$3.04
Rate for Payer: UnitedHealthcare Medicaid	$29.82
Rate for Payer: WPPA Medicare Advantage	$1.92

Splint Finger Fold 3-1/2- XL

Facility

$3.20

Service Code	HCPCS L3927
Hospital Charge Code	3251398
Hospital Revenue Code	274
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.88
Rate for Payer: UnitedHealthcare Commercial	$3.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Finger Fold 3- LG

Facility

$4.37

Service Code	HCPCS L3927
Hospital Charge Code	3251380
Hospital Revenue Code	274
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$45.98
Rate for Payer: Aetna Commercial	$3.93
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.98
Rate for Payer: Humana Medicare Advantage	$1.84
Rate for Payer: UnitedHealthcare Commercial	$4.15
Rate for Payer: UnitedHealthcare Medicaid	$29.82
Rate for Payer: WPPA Medicare Advantage	$2.62

Splint Finger Fold 3- LG

Facility

$4.37

Service Code	HCPCS L3927
Hospital Charge Code	3251380
Hospital Revenue Code	274
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.93
Rate for Payer: UnitedHealthcare Commercial	$4.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Finger Gutter 1-5/8

Facility

$9.00

Service Code	HCPCS L3927
Hospital Charge Code	3254856
Hospital Revenue Code	274
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Finger Gutter 1-5/8

Facility

$9.00

Service Code	HCPCS L3927
Hospital Charge Code	3254856
Hospital Revenue Code	274
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$45.98
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.98
Rate for Payer: Humana Medicare Advantage	$3.78
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: UnitedHealthcare Medicaid	$29.82
Rate for Payer: WPPA Medicare Advantage	$5.40

Splint Finger Gutter 2-5/8

Facility

$5.04

Service Code	HCPCS L3927
Hospital Charge Code	3251372
Hospital Revenue Code	274
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$45.98
Rate for Payer: Aetna Commercial	$4.54
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.98
Rate for Payer: Humana Medicare Advantage	$2.12
Rate for Payer: UnitedHealthcare Commercial	$4.79
Rate for Payer: UnitedHealthcare Medicaid	$29.82
Rate for Payer: WPPA Medicare Advantage	$3.02

Splint Finger Gutter 2-5/8

Facility

$5.04

Service Code	HCPCS L3927
Hospital Charge Code	3251372
Hospital Revenue Code	274
Min. Negotiated Rate	$4.54
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.54
Rate for Payer: UnitedHealthcare Commercial	$4.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Finger Gutter 6

Facility

$5.04

Service Code	HCPCS L3927
Hospital Charge Code	3254849
Hospital Revenue Code	274
Min. Negotiated Rate	$4.54
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.54
Rate for Payer: UnitedHealthcare Commercial	$4.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Finger Gutter 6

Facility

$5.04

Service Code	HCPCS L3927
Hospital Charge Code	3254849
Hospital Revenue Code	274
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$45.98
Rate for Payer: Aetna Commercial	$4.54
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.98
Rate for Payer: Humana Medicare Advantage	$2.12
Rate for Payer: UnitedHealthcare Commercial	$4.79
Rate for Payer: UnitedHealthcare Medicaid	$29.82
Rate for Payer: WPPA Medicare Advantage	$3.02

Splint Sam 4-1/2 X 36 Roll Orange/Blue

Facility

$64.80

Hospital Charge Code	3254430
Hospital Revenue Code	541
Min. Negotiated Rate	$58.32
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$58.32
Rate for Payer: UnitedHealthcare Commercial	$61.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Splint Sam 4-1/2 X 36 Roll Orange/Blue

Facility

$64.80

Hospital Charge Code	3254430
Hospital Revenue Code	541
Min. Negotiated Rate	$25.92
Max. Negotiated Rate	$61.56
Rate for Payer: Aetna Commercial	$58.32
Rate for Payer: Humana Medicare Advantage	$27.22
Rate for Payer: UnitedHealthcare Commercial	$61.56
Rate for Payer: UnitedHealthcare Medicaid	$25.92
Rate for Payer: WPPA Medicare Advantage	$38.88

Sponge Drain 4 X 4 Sterile 16ply

Facility

$2.50

Hospital Charge Code	3259491
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

Sponge Drain 4 X 4 Sterile 16ply

Facility

$2.50

Hospital Charge Code	3259491
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

Sponge Vaginal Packing 4 x 36 Sterile X-Ray Detectable Gauze

Facility

$3.02

Hospital Charge Code	3253592
Hospital Revenue Code	270
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.72
Rate for Payer: UnitedHealthcare Commercial	$2.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges