Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Walker Boot Low Small

Facility

$126.39

Hospital Charge Code	3259919
Hospital Revenue Code	270
Min. Negotiated Rate	$113.75
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$113.75
Rate for Payer: UnitedHealthcare Commercial	$120.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Walker Boot Low X-Large

Facility

$141.00

Hospital Charge Code	3259933
Hospital Revenue Code	270
Min. Negotiated Rate	$126.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$126.90
Rate for Payer: UnitedHealthcare Commercial	$133.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Walker Boot Low X-Large

Facility

$141.00

Hospital Charge Code	3259933
Hospital Revenue Code	270
Min. Negotiated Rate	$56.40
Max. Negotiated Rate	$133.95
Rate for Payer: Aetna Commercial	$126.90
Rate for Payer: Humana Medicare Advantage	$59.22
Rate for Payer: UnitedHealthcare Commercial	$133.95
Rate for Payer: UnitedHealthcare Medicaid	$56.40
Rate for Payer: WPPA Medicare Advantage	$84.60

Walker Boot Low X-Small

Facility

$126.00

Hospital Charge Code	3259931
Hospital Revenue Code	270
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna Commercial	$113.40
Rate for Payer: Humana Medicare Advantage	$52.92
Rate for Payer: UnitedHealthcare Commercial	$119.70
Rate for Payer: UnitedHealthcare Medicaid	$50.40
Rate for Payer: WPPA Medicare Advantage	$75.60

Walker Boot Low X-Small

Facility

$126.00

Hospital Charge Code	3259931
Hospital Revenue Code	270
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$113.40
Rate for Payer: UnitedHealthcare Commercial	$119.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Walker Boot Tall Large

Facility

$99.96

Hospital Charge Code	3259992
Hospital Revenue Code	270
Min. Negotiated Rate	$39.98
Max. Negotiated Rate	$94.96
Rate for Payer: Aetna Commercial	$89.96
Rate for Payer: Humana Medicare Advantage	$41.98
Rate for Payer: UnitedHealthcare Commercial	$94.96
Rate for Payer: UnitedHealthcare Medicaid	$39.98
Rate for Payer: WPPA Medicare Advantage	$59.98

Walker Boot Tall Large

Facility

$99.96

Hospital Charge Code	3259992
Hospital Revenue Code	270
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$89.96
Rate for Payer: UnitedHealthcare Commercial	$94.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Walker Boot Tall Medium

Facility

$99.96

Hospital Charge Code	3259993
Hospital Revenue Code	270
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$89.96
Rate for Payer: UnitedHealthcare Commercial	$94.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Walker Boot Tall Medium

Facility

$99.96

Hospital Charge Code	3259993
Hospital Revenue Code	270
Min. Negotiated Rate	$39.98
Max. Negotiated Rate	$94.96
Rate for Payer: Aetna Commercial	$89.96
Rate for Payer: Humana Medicare Advantage	$41.98
Rate for Payer: UnitedHealthcare Commercial	$94.96
Rate for Payer: UnitedHealthcare Medicaid	$39.98
Rate for Payer: WPPA Medicare Advantage	$59.98

Walker Boot Tall Small

Facility

$99.96

Hospital Charge Code	3259994
Hospital Revenue Code	270
Min. Negotiated Rate	$39.98
Max. Negotiated Rate	$94.96
Rate for Payer: Aetna Commercial	$89.96
Rate for Payer: Humana Medicare Advantage	$41.98
Rate for Payer: UnitedHealthcare Commercial	$94.96
Rate for Payer: UnitedHealthcare Medicaid	$39.98
Rate for Payer: WPPA Medicare Advantage	$59.98

Walker Boot Tall Small

Facility

$99.96

Hospital Charge Code	3259994
Hospital Revenue Code	270
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$89.96
Rate for Payer: UnitedHealthcare Commercial	$94.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Walker Boot Tall X-Large

Facility

$112.00

Service Code	HCPCS L4386
Hospital Charge Code	3259991
Hospital Revenue Code	274
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$100.80
Rate for Payer: UnitedHealthcare Commercial	$106.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Walker Boot Tall X-Large

Facility

$112.00

Service Code	HCPCS L4386
Hospital Charge Code	3259991
Hospital Revenue Code	274
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$106.40
Rate for Payer: Aetna Commercial	$100.80
Rate for Payer: Humana Medicare Advantage	$47.04
Rate for Payer: UnitedHealthcare Commercial	$106.40
Rate for Payer: UnitedHealthcare Medicaid	$44.80
Rate for Payer: WPPA Medicare Advantage	$67.20

Walker Boot Tall X-Small

Facility

$112.00

Hospital Charge Code	3259995
Hospital Revenue Code	270
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$106.40
Rate for Payer: Aetna Commercial	$100.80
Rate for Payer: Humana Medicare Advantage	$47.04
Rate for Payer: UnitedHealthcare Commercial	$106.40
Rate for Payer: UnitedHealthcare Medicaid	$44.80
Rate for Payer: WPPA Medicare Advantage	$67.20

Walker Boot Tall X-Small

Facility

$112.00

Hospital Charge Code	3259995
Hospital Revenue Code	270
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$100.80
Rate for Payer: UnitedHealthcare Commercial	$106.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Walnut (F256) IgE QST

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3556005
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$24.70
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$10.92
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$15.60

Walnut (F256) IgE QST

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3556005
Hospital Revenue Code	300
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

warfarin 2 mg Tab [HMC]

Facility

$6.90

Service Code	NDC 65162076210
Hospital Charge Code	3801120
Hospital Revenue Code	250
Min. Negotiated Rate	$2.76
Max. Negotiated Rate	$6.55
Rate for Payer: Aetna Commercial	$6.21
Rate for Payer: Humana Medicare Advantage	$2.90
Rate for Payer: UnitedHealthcare Commercial	$6.55
Rate for Payer: UnitedHealthcare Medicaid	$2.76
Rate for Payer: WPPA Medicare Advantage	$4.14

warfarin 2 mg Tab [HMC]

Facility

$6.93

Service Code	NDC 00832121201
Hospital Charge Code	3801120
Hospital Revenue Code	250
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.24
Rate for Payer: UnitedHealthcare Commercial	$6.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

warfarin 2 mg Tab [HMC]

Facility

$6.90

Service Code	NDC 65162076210
Hospital Charge Code	3801120
Hospital Revenue Code	250
Min. Negotiated Rate	$6.21
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.21
Rate for Payer: UnitedHealthcare Commercial	$6.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

warfarin 2 mg Tab [HMC]

Facility

$6.85

Service Code	NDC 62584098401
Hospital Charge Code	3801120
Hospital Revenue Code	250
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.17
Rate for Payer: UnitedHealthcare Commercial	$6.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

warfarin 2 mg Tab [HMC]

Facility

$6.85

Service Code	NDC 62584098401
Hospital Charge Code	3801120
Hospital Revenue Code	250
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$6.51
Rate for Payer: Aetna Commercial	$6.17
Rate for Payer: Humana Medicare Advantage	$2.88
Rate for Payer: UnitedHealthcare Commercial	$6.51
Rate for Payer: UnitedHealthcare Medicaid	$2.74
Rate for Payer: WPPA Medicare Advantage	$4.11

warfarin 2 mg Tab [HMC]

Facility

$6.93

Service Code	NDC 00832121201
Hospital Charge Code	3801120
Hospital Revenue Code	250
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$6.58
Rate for Payer: Aetna Commercial	$6.24
Rate for Payer: Humana Medicare Advantage	$2.91
Rate for Payer: UnitedHealthcare Commercial	$6.58
Rate for Payer: UnitedHealthcare Medicaid	$2.77
Rate for Payer: WPPA Medicare Advantage	$4.16

warfarin 5 mg Tab [HMC]

Facility

$7.02

Service Code	NDC 65162076610
Hospital Charge Code	3801146
Hospital Revenue Code	250
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$6.67
Rate for Payer: Aetna Commercial	$6.32
Rate for Payer: Humana Medicare Advantage	$2.95
Rate for Payer: UnitedHealthcare Commercial	$6.67
Rate for Payer: UnitedHealthcare Medicaid	$2.81
Rate for Payer: WPPA Medicare Advantage	$4.21

warfarin 5 mg Tab [HMC]

Facility

$7.06

Service Code	NDC 00832121601
Hospital Charge Code	3801146
Hospital Revenue Code	250
Min. Negotiated Rate	$6.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.35
Rate for Payer: UnitedHealthcare Commercial	$6.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges