Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Yes - OT Unattended Electrical Therapy Charge

Facility

$84.00

Service Code	HCPCS 97014 GO
Hospital Charge Code	3970115
Hospital Revenue Code	430
Min. Negotiated Rate	$14.75
Max. Negotiated Rate	$79.80
Rate for Payer: Aetna Commercial	$75.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.31
Rate for Payer: Humana Medicare Advantage	$35.28
Rate for Payer: UnitedHealthcare Commercial	$79.80
Rate for Payer: UnitedHealthcare Medicaid	$14.75
Rate for Payer: WPPA Medicare Advantage	$50.40

Yes - Paraffin Bath Charge

Facility

$67.00

Service Code	HCPCS 97018 GP
Hospital Charge Code	3950150
Hospital Revenue Code	420
Min. Negotiated Rate	$13.96
Max. Negotiated Rate	$63.65
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.23
Rate for Payer: Humana Medicare Advantage	$28.14
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: UnitedHealthcare Medicaid	$13.96
Rate for Payer: WPPA Medicare Advantage	$40.20

Yes - Paraffin Bath Charge

Facility

$67.00

Service Code	HCPCS 97018 GP
Hospital Charge Code	3950150
Hospital Revenue Code	420
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Yes - SLP Speech-Gen Dev Prog and Mod

Facility

$168.00

Service Code	HCPCS 92609 GN
Hospital Charge Code	4052609
Hospital Revenue Code	444
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$151.20
Rate for Payer: UnitedHealthcare Commercial	$159.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Yes - SLP Speech-Gen Dev Prog and Mod

Facility

$168.00

Service Code	HCPCS 92609 GN
Hospital Charge Code	4052609
Hospital Revenue Code	444
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$159.60
Rate for Payer: Aetna Commercial	$151.20
Rate for Payer: Humana Medicare Advantage	$70.56
Rate for Payer: UnitedHealthcare Commercial	$159.60
Rate for Payer: UnitedHealthcare Medicaid	$67.20
Rate for Payer: WPPA Medicare Advantage	$100.80

Yes - Unattended Electrical Therapy Charge

Facility

$75.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	3950840
Hospital Revenue Code	420
Min. Negotiated Rate	$14.75
Max. Negotiated Rate	$71.25
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.31
Rate for Payer: Humana Medicare Advantage	$31.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: UnitedHealthcare Medicaid	$14.75
Rate for Payer: WPPA Medicare Advantage	$45.00

Yes - Unattended Electrical Therapy Charge

Facility

$75.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	3950840
Hospital Revenue Code	420
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Yes - Vasopneumatic Device Charge

Facility

$197.00

Service Code	HCPCS 97016 GO
Hospital Charge Code	3977016
Hospital Revenue Code	430
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$187.15
Rate for Payer: Aetna Commercial	$177.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.33
Rate for Payer: Humana Medicare Advantage	$82.74
Rate for Payer: UnitedHealthcare Commercial	$187.15
Rate for Payer: UnitedHealthcare Medicaid	$16.50
Rate for Payer: WPPA Medicare Advantage	$118.20

Yes - Vasopneumatic Device Charge

Facility

$197.00

Service Code	HCPCS 97016 GO
Hospital Charge Code	3977016
Hospital Revenue Code	430
Min. Negotiated Rate	$177.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$177.30
Rate for Payer: UnitedHealthcare Commercial	$187.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Yes - Vasopneumatic Device Charge

Facility

$197.00

Service Code	HCPCS 97016 GP
Hospital Charge Code	3957016
Hospital Revenue Code	420
Min. Negotiated Rate	$177.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$177.30
Rate for Payer: UnitedHealthcare Commercial	$187.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Yes - Vasopneumatic Device Charge

Facility

$197.00

Service Code	HCPCS 97016 GP
Hospital Charge Code	3957016
Hospital Revenue Code	420
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$187.15
Rate for Payer: Aetna Commercial	$177.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.33
Rate for Payer: Humana Medicare Advantage	$82.74
Rate for Payer: UnitedHealthcare Commercial	$187.15
Rate for Payer: UnitedHealthcare Medicaid	$16.50
Rate for Payer: WPPA Medicare Advantage	$118.20

Yes - Whirlpool Extremity Charge

Facility

$74.00

Service Code	HCPCS 97022 GO
Hospital Charge Code	3977022
Hospital Revenue Code	430
Min. Negotiated Rate	$14.41
Max. Negotiated Rate	$70.30
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.33
Rate for Payer: Humana Medicare Advantage	$31.08
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: UnitedHealthcare Medicaid	$14.41
Rate for Payer: WPPA Medicare Advantage	$44.40

Yes - Whirlpool Extremity Charge

Facility

$74.00

Service Code	HCPCS 97022 GO
Hospital Charge Code	3977022
Hospital Revenue Code	430
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Yes - Whirlpool Full Body Charge

Facility

$72.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	3950176
Hospital Revenue Code	420
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Yes - Whirlpool Full Body Charge

Facility

$72.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	3950176
Hospital Revenue Code	420
Min. Negotiated Rate	$14.41
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.33
Rate for Payer: Humana Medicare Advantage	$30.24
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$14.41
Rate for Payer: WPPA Medicare Advantage	$43.20

zafirlukast 20 mg Tab [HMC]

Facility

$15.33

Service Code	NDC 68084005921
Hospital Charge Code	3800703
Hospital Revenue Code	250
Min. Negotiated Rate	$13.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.80
Rate for Payer: UnitedHealthcare Commercial	$14.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

zafirlukast 20 mg Tab [HMC]

Facility

$11.49

Service Code	NDC 55111062660
Hospital Charge Code	3800703
Hospital Revenue Code	250
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.34
Rate for Payer: UnitedHealthcare Commercial	$10.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

zafirlukast 20 mg Tab [HMC]

Facility

$17.29

Service Code	NDC 31722000860
Hospital Charge Code	3800703
Hospital Revenue Code	250
Min. Negotiated Rate	$15.56
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.56
Rate for Payer: UnitedHealthcare Commercial	$16.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

zafirlukast 20 mg Tab [HMC]

Facility

$17.29

Service Code	NDC 31722000860
Hospital Charge Code	3800703
Hospital Revenue Code	250
Min. Negotiated Rate	$6.92
Max. Negotiated Rate	$16.43
Rate for Payer: Aetna Commercial	$15.56
Rate for Payer: Humana Medicare Advantage	$7.26
Rate for Payer: UnitedHealthcare Commercial	$16.43
Rate for Payer: UnitedHealthcare Medicaid	$6.92
Rate for Payer: WPPA Medicare Advantage	$10.37

zafirlukast 20 mg Tab [HMC]

Facility

$15.33

Service Code	NDC 68084005921
Hospital Charge Code	3800703
Hospital Revenue Code	250
Min. Negotiated Rate	$6.13
Max. Negotiated Rate	$14.56
Rate for Payer: Aetna Commercial	$13.80
Rate for Payer: Humana Medicare Advantage	$6.44
Rate for Payer: UnitedHealthcare Commercial	$14.56
Rate for Payer: UnitedHealthcare Medicaid	$6.13
Rate for Payer: WPPA Medicare Advantage	$9.20

zafirlukast 20 mg Tab [HMC]

Facility

$11.49

Service Code	NDC 55111062660
Hospital Charge Code	3800703
Hospital Revenue Code	250
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$10.92
Rate for Payer: Aetna Commercial	$10.34
Rate for Payer: Humana Medicare Advantage	$4.83
Rate for Payer: UnitedHealthcare Commercial	$10.92
Rate for Payer: UnitedHealthcare Medicaid	$4.60
Rate for Payer: WPPA Medicare Advantage	$6.89

zinc gluconate 50 mg Tab [HMC]

Facility

$5.11

Service Code	NDC 40093010153
Hospital Charge Code	3809586
Hospital Revenue Code	257
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.60
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

zinc gluconate 50 mg Tab [HMC]

Facility

$5.11

Service Code	NDC 40093010153
Hospital Charge Code	3809586
Hospital Revenue Code	257
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$4.85
Rate for Payer: Aetna Commercial	$4.60
Rate for Payer: Humana Medicare Advantage	$2.15
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: UnitedHealthcare Medicaid	$2.04
Rate for Payer: WPPA Medicare Advantage	$3.07

zinc gluconate 50 mg Tab [HMC]

Facility

$5.08

Service Code	NDC 80681000200
Hospital Charge Code	3809586
Hospital Revenue Code	257
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.57
Rate for Payer: UnitedHealthcare Commercial	$4.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

zinc gluconate 50 mg Tab [HMC]

Facility

$5.08

Service Code	NDC 80681000200
Hospital Charge Code	3809586
Hospital Revenue Code	257
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$4.83
Rate for Payer: Aetna Commercial	$4.57
Rate for Payer: Humana Medicare Advantage	$2.13
Rate for Payer: UnitedHealthcare Commercial	$4.83
Rate for Payer: UnitedHealthcare Medicaid	$2.03
Rate for Payer: WPPA Medicare Advantage	$3.05

Know your out-of-pocket cost for care.

All Charges