Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Suture 6-0 Vicryl P-3

Facility

$16.00

Hospital Charge Code	3254985
Hospital Revenue Code	270
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$14.40
Rate for Payer: UnitedHealthcare Commercial	$15.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture 6-0 Vicryl P-3

Facility

$16.00

Hospital Charge Code	3254985
Hospital Revenue Code	270
Min. Negotiated Rate	$6.40
Max. Negotiated Rate	$15.20
Rate for Payer: Aetna Commercial	$14.40
Rate for Payer: Humana Medicare Advantage	$6.72
Rate for Payer: UnitedHealthcare Commercial	$15.20
Rate for Payer: UnitedHealthcare Medicaid	$6.40
Rate for Payer: WPPA Medicare Advantage	$9.60

Suture 7-0 Prolene P-1

Facility

$54.00

Hospital Charge Code	3258824
Hospital Revenue Code	270
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$21.60
Rate for Payer: WPPA Medicare Advantage	$32.40

Suture 7-0 Prolene P-1

Facility

$54.00

Hospital Charge Code	3258824
Hospital Revenue Code	270
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture Removal

Facility

$5.00

Hospital Charge Code	3253825
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture Removal

Facility

$5.00

Hospital Charge Code	3253825
Hospital Revenue Code	270
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: Humana Medicare Advantage	$2.10
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: UnitedHealthcare Medicaid	$2.00
Rate for Payer: WPPA Medicare Advantage	$3.00

Suture Removal w/Littauer Scissor Disposable Single-Use Tray

Facility

$2.75

Hospital Charge Code	3253830
Hospital Revenue Code	270
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$2.61
Rate for Payer: Aetna Commercial	$2.48
Rate for Payer: Humana Medicare Advantage	$1.16
Rate for Payer: UnitedHealthcare Commercial	$2.61
Rate for Payer: UnitedHealthcare Medicaid	$1.10
Rate for Payer: WPPA Medicare Advantage	$1.65

Suture Removal w/Littauer Scissor Disposable Single-Use Tray

Facility

$2.75

Hospital Charge Code	3253830
Hospital Revenue Code	270
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.48
Rate for Payer: UnitedHealthcare Commercial	$2.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

suvorexant 5 mg Tab UD [HMC]

Facility

$40.54

Service Code	NDC 00006000530
Hospital Charge Code	3800920
Hospital Revenue Code	250
Min. Negotiated Rate	$36.49
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.49
Rate for Payer: UnitedHealthcare Commercial	$38.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

suvorexant 5 mg Tab UD [HMC]

Facility

$40.54

Service Code	NDC 00006000530
Hospital Charge Code	3800920
Hospital Revenue Code	250
Min. Negotiated Rate	$16.22
Max. Negotiated Rate	$38.51
Rate for Payer: Aetna Commercial	$36.49
Rate for Payer: Humana Medicare Advantage	$17.03
Rate for Payer: UnitedHealthcare Commercial	$38.51
Rate for Payer: UnitedHealthcare Medicaid	$16.22
Rate for Payer: WPPA Medicare Advantage	$24.32

Sycamore (T11) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1023
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$16.20

Sycamore (T11) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1023
Hospital Revenue Code	300
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SYNCOPE AND COLLAPSE

Facility

$2,795.76

Service Code	MSDRG 312
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,795.76
Rate for Payer: UnitedHealthcare Medicaid	$2,795.76
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Syringe 60ml Enfit Oral Feeding Enteral Purple Sterile

Facility

$6.00

Hospital Charge Code	3254204
Hospital Revenue Code	270
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Syringe 60ml Enfit Oral Feeding Enteral Purple Sterile

Facility

$6.00

Hospital Charge Code	3254204
Hospital Revenue Code	270
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$5.70
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: Humana Medicare Advantage	$2.52
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: WPPA Medicare Advantage	$3.60

Syringe 6ml Enfit Oral Feeding Enteral Purple Sterile

Facility

$2.50

Hospital Charge Code	3254205
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

Syringe 6ml Enfit Oral Feeding Enteral Purple Sterile

Facility

$2.50

Hospital Charge Code	3254205
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

T3 Auto Ab QST

Facility

$242.00

Service Code	HCPCS 83519
Hospital Charge Code	3555199
Hospital Revenue Code	300
Min. Negotiated Rate	$15.64
Max. Negotiated Rate	$229.90
Rate for Payer: Aetna Commercial	$217.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.48
Rate for Payer: Humana Medicare Advantage	$101.64
Rate for Payer: UnitedHealthcare Commercial	$229.90
Rate for Payer: UnitedHealthcare Medicaid	$15.64
Rate for Payer: WPPA Medicare Advantage	$145.20

T3 Auto Ab QST

Facility

$242.00

Service Code	HCPCS 83519
Hospital Charge Code	3555199
Hospital Revenue Code	300
Min. Negotiated Rate	$217.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$217.80
Rate for Payer: UnitedHealthcare Commercial	$229.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

T3 Free

Facility

$276.00

Service Code	HCPCS 84481
Hospital Charge Code	3552391
Hospital Revenue Code	300
Min. Negotiated Rate	$248.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$248.40
Rate for Payer: UnitedHealthcare Commercial	$262.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

T3 Free

Facility

$276.00

Service Code	HCPCS 84481
Hospital Charge Code	3552391
Hospital Revenue Code	300
Min. Negotiated Rate	$16.94
Max. Negotiated Rate	$262.20
Rate for Payer: Aetna Commercial	$248.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$84.25
Rate for Payer: Humana Medicare Advantage	$115.92
Rate for Payer: UnitedHealthcare Commercial	$262.20
Rate for Payer: UnitedHealthcare Medicaid	$16.94
Rate for Payer: WPPA Medicare Advantage	$165.60

T3 Reverse, LC/MS/MS QST

Facility

$389.00

Service Code	HCPCS 84482
Hospital Charge Code	3552446
Hospital Revenue Code	300
Min. Negotiated Rate	$13.40
Max. Negotiated Rate	$369.55
Rate for Payer: Aetna Commercial	$350.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$82.92
Rate for Payer: Humana Medicare Advantage	$163.38
Rate for Payer: UnitedHealthcare Commercial	$369.55
Rate for Payer: UnitedHealthcare Medicaid	$13.40
Rate for Payer: WPPA Medicare Advantage	$233.40

T3 Reverse, LC/MS/MS QST

Facility

$389.00

Service Code	HCPCS 84482
Hospital Charge Code	3552446
Hospital Revenue Code	300
Min. Negotiated Rate	$350.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$350.10
Rate for Payer: UnitedHealthcare Commercial	$369.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

T3, Total QST

Facility

$149.00

Service Code	HCPCS 84480
Hospital Charge Code	3556455
Hospital Revenue Code	300
Min. Negotiated Rate	$14.18
Max. Negotiated Rate	$141.55
Rate for Payer: Aetna Commercial	$134.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.20
Rate for Payer: Humana Medicare Advantage	$62.58
Rate for Payer: UnitedHealthcare Commercial	$141.55
Rate for Payer: UnitedHealthcare Medicaid	$14.18
Rate for Payer: WPPA Medicare Advantage	$89.40

T3, Total QST

Facility

$149.00

Service Code	HCPCS 84480
Hospital Charge Code	3556455
Hospital Revenue Code	300
Min. Negotiated Rate	$134.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$134.10
Rate for Payer: UnitedHealthcare Commercial	$141.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges