Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

tamsulosin 0.4 mg Oral Cap [HMC]

Facility

$6.60

Service Code	NDC 00904738361
Hospital Charge Code	3801772
Hospital Revenue Code	250
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.94
Rate for Payer: UnitedHealthcare Commercial	$6.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Tap Block

Facility

$627.00

Service Code	HCPCS 64486
Hospital Charge Code	3184486
Hospital Revenue Code	360
Min. Negotiated Rate	$564.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$564.30
Rate for Payer: UnitedHealthcare Commercial	$595.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Tap Block

Facility

$627.00

Service Code	HCPCS 64486
Hospital Charge Code	3184486
Hospital Revenue Code	360
Min. Negotiated Rate	$250.80
Max. Negotiated Rate	$595.65
Rate for Payer: Aetna Commercial	$564.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$263.34
Rate for Payer: UnitedHealthcare Commercial	$595.65
Rate for Payer: UnitedHealthcare Medicaid	$250.80
Rate for Payer: WPPA Medicare Advantage	$376.20

TAP Block Bilateral

Facility

$885.00

Service Code	HCPCS 64488
Hospital Charge Code	3154488
Hospital Revenue Code	360
Min. Negotiated Rate	$310.07
Max. Negotiated Rate	$840.75
Rate for Payer: Aetna Commercial	$796.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$371.70
Rate for Payer: UnitedHealthcare Commercial	$840.75
Rate for Payer: UnitedHealthcare Medicaid	$354.00
Rate for Payer: WPPA Medicare Advantage	$531.00

TAP Block Bilateral

Facility

$885.00

Service Code	HCPCS 64488
Hospital Charge Code	3154488
Hospital Revenue Code	360
Min. Negotiated Rate	$796.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$796.50
Rate for Payer: UnitedHealthcare Commercial	$840.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tbo-filgrastim 480 mcg/0.8 mL Sol [HMC]

Facility

$664.36

Service Code	HCPCS J1447
Hospital Charge Code	3850326
Hospital Revenue Code	250
Min. Negotiated Rate	$597.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$597.92
Rate for Payer: UnitedHealthcare Commercial	$631.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

tbo-filgrastim 480 mcg/0.8 mL Sol [HMC]

Facility

$664.36

Service Code	HCPCS J1447
Hospital Charge Code	3850326
Hospital Revenue Code	250
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$631.14
Rate for Payer: Aetna Commercial	$597.92
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.56
Rate for Payer: Humana Medicare Advantage	$279.03
Rate for Payer: UnitedHealthcare Commercial	$631.14
Rate for Payer: UnitedHealthcare Medicaid	$265.74
Rate for Payer: WPPA Medicare Advantage	$398.62

TB - Skin Test

Facility

$60.00

Service Code	HCPCS 86580
Hospital Charge Code	3807563
Hospital Revenue Code	300
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TB - Skin Test

Facility

$60.00

Service Code	HCPCS 86580
Hospital Charge Code	3807563
Hospital Revenue Code	300
Min. Negotiated Rate	$7.91
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$18.35
Rate for Payer: Humana Medicare Advantage	$25.20
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: UnitedHealthcare Medicaid	$7.91
Rate for Payer: WPPA Medicare Advantage	$36.00

Ted Stocking Knee LG-Long

Facility

$8.46

Hospital Charge Code	3256210
Hospital Revenue Code	270
Min. Negotiated Rate	$7.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ted Stocking Knee LG-Long

Facility

$8.46

Hospital Charge Code	3256210
Hospital Revenue Code	270
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$8.04
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: Humana Medicare Advantage	$3.55
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: UnitedHealthcare Medicaid	$3.38
Rate for Payer: WPPA Medicare Advantage	$5.08

Ted Stocking Knee LG-Reg

Facility

$8.46

Hospital Charge Code	3256208
Hospital Revenue Code	270
Min. Negotiated Rate	$7.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ted Stocking Knee LG-Reg

Facility

$8.46

Hospital Charge Code	3256208
Hospital Revenue Code	270
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$8.04
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: Humana Medicare Advantage	$3.55
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: UnitedHealthcare Medicaid	$3.38
Rate for Payer: WPPA Medicare Advantage	$5.08

Ted Stocking Knee MD-Long

Facility

$8.46

Hospital Charge Code	3256206
Hospital Revenue Code	270
Min. Negotiated Rate	$7.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ted Stocking Knee MD-Long

Facility

$8.46

Hospital Charge Code	3256206
Hospital Revenue Code	270
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$8.04
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: Humana Medicare Advantage	$3.55
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: UnitedHealthcare Medicaid	$3.38
Rate for Payer: WPPA Medicare Advantage	$5.08

Ted Stocking Knee MD-Reg

Facility

$8.82

Hospital Charge Code	3256204
Hospital Revenue Code	270
Min. Negotiated Rate	$7.94
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.94
Rate for Payer: UnitedHealthcare Commercial	$8.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ted Stocking Knee MD-Reg

Facility

$8.82

Hospital Charge Code	3256204
Hospital Revenue Code	270
Min. Negotiated Rate	$3.53
Max. Negotiated Rate	$8.38
Rate for Payer: Aetna Commercial	$7.94
Rate for Payer: Humana Medicare Advantage	$3.70
Rate for Payer: UnitedHealthcare Commercial	$8.38
Rate for Payer: UnitedHealthcare Medicaid	$3.53
Rate for Payer: WPPA Medicare Advantage	$5.29

Ted Stocking Knee SM-Long

Facility

$10.17

Hospital Charge Code	3256202
Hospital Revenue Code	270
Min. Negotiated Rate	$4.07
Max. Negotiated Rate	$9.66
Rate for Payer: Aetna Commercial	$9.15
Rate for Payer: Humana Medicare Advantage	$4.27
Rate for Payer: UnitedHealthcare Commercial	$9.66
Rate for Payer: UnitedHealthcare Medicaid	$4.07
Rate for Payer: WPPA Medicare Advantage	$6.10

Ted Stocking Knee SM-Long

Facility

$10.17

Hospital Charge Code	3256202
Hospital Revenue Code	270
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.15
Rate for Payer: UnitedHealthcare Commercial	$9.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ted Stocking Knee SM-Reg

Facility

$8.69

Hospital Charge Code	3256200
Hospital Revenue Code	270
Min. Negotiated Rate	$7.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.82
Rate for Payer: UnitedHealthcare Commercial	$8.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ted Stocking Knee SM-Reg

Facility

$8.69

Hospital Charge Code	3256200
Hospital Revenue Code	270
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$8.26
Rate for Payer: Aetna Commercial	$7.82
Rate for Payer: Humana Medicare Advantage	$3.65
Rate for Payer: UnitedHealthcare Commercial	$8.26
Rate for Payer: UnitedHealthcare Medicaid	$3.48
Rate for Payer: WPPA Medicare Advantage	$5.21

Ted Stocking Knee XL-Long

Facility

$8.46

Hospital Charge Code	3256214
Hospital Revenue Code	270
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$8.04
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: Humana Medicare Advantage	$3.55
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: UnitedHealthcare Medicaid	$3.38
Rate for Payer: WPPA Medicare Advantage	$5.08

Ted Stocking Knee XL-Long

Facility

$8.46

Hospital Charge Code	3256214
Hospital Revenue Code	270
Min. Negotiated Rate	$7.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ted Stocking Knee XL-Reg

Facility

$8.46

Hospital Charge Code	3256212
Hospital Revenue Code	270
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$8.04
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: Humana Medicare Advantage	$3.55
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: UnitedHealthcare Medicaid	$3.38
Rate for Payer: WPPA Medicare Advantage	$5.08

Ted Stocking Knee XL-Reg

Facility

$8.46

Hospital Charge Code	3256212
Hospital Revenue Code	270
Min. Negotiated Rate	$7.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.61
Rate for Payer: UnitedHealthcare Commercial	$8.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges