Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

00338-0049-04 - Sodium Chloride 0.9% IV Sol 1000 mL [HMC]

Facility

$64.00

Hospital Charge Code	3253999
Hospital Revenue Code	250
Min. Negotiated Rate	$25.60
Max. Negotiated Rate	$60.80
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: Humana Medicare Advantage	$26.88
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: UnitedHealthcare Medicaid	$25.60
Rate for Payer: WPPA Medicare Advantage	$38.40

00338-0049-04 - Sodium Chloride 0.9% IV Sol 1000 mL [HMC]

Facility

$64.00

Hospital Charge Code	3253999
Hospital Revenue Code	250
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

00409-4902-34 - Dextrose 50% IV Sol 50 mL (D50 Syr) [HUMB]

Facility

$56.00

Hospital Charge Code	3801302
Hospital Revenue Code	250
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$53.20
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Humana Medicare Advantage	$23.52
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: UnitedHealthcare Medicaid	$22.40
Rate for Payer: WPPA Medicare Advantage	$33.60

00409-4902-34 - Dextrose 50% IV Sol 50 mL (D50 Syr) [HUMB]

Facility

$56.00

Hospital Charge Code	3801302
Hospital Revenue Code	250
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

0.9mm CSS Guidewire

Facility

$165.00

Hospital Charge Code	3258592
Hospital Revenue Code	270
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$148.50
Rate for Payer: UnitedHealthcare Commercial	$156.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

0.9mm CSS Guidewire

Facility

$165.00

Hospital Charge Code	3258592
Hospital Revenue Code	270
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$156.75
Rate for Payer: Aetna Commercial	$148.50
Rate for Payer: Humana Medicare Advantage	$69.30
Rate for Payer: UnitedHealthcare Commercial	$156.75
Rate for Payer: UnitedHealthcare Medicaid	$66.00
Rate for Payer: WPPA Medicare Advantage	$99.00

10005 FINE NDL ASPIRATION BX W/US GDN 1ST LSN CHARGE

Facility

$992.00

Service Code	HCPCS 10005
Hospital Charge Code	3150005
Hospital Revenue Code	360
Min. Negotiated Rate	$376.57
Max. Negotiated Rate	$942.40
Rate for Payer: Aetna Commercial	$892.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$643.64
Rate for Payer: Humana Medicare Advantage	$416.64
Rate for Payer: UnitedHealthcare Commercial	$942.40
Rate for Payer: UnitedHealthcare Medicaid	$376.57
Rate for Payer: WPPA Medicare Advantage	$595.20

10005 FINE NDL ASPIRATION BX W/US GDN 1ST LSN CHARGE

Facility

$992.00

Service Code	HCPCS 10005
Hospital Charge Code	3150005
Hospital Revenue Code	360
Min. Negotiated Rate	$892.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$892.80
Rate for Payer: UnitedHealthcare Commercial	$942.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10005 Fine needle aspiration biopsy, including ultrasound guidance

Facility

$992.00

Service Code	HCPCS 10005
Hospital Charge Code	3350005
Hospital Revenue Code	761
Min. Negotiated Rate	$376.57
Max. Negotiated Rate	$942.40
Rate for Payer: Aetna Commercial	$892.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$643.64
Rate for Payer: Humana Medicare Advantage	$416.64
Rate for Payer: UnitedHealthcare Commercial	$942.40
Rate for Payer: UnitedHealthcare Medicaid	$376.57
Rate for Payer: WPPA Medicare Advantage	$595.20

10005 Fine needle aspiration biopsy, including ultrasound guidance

Facility

$992.00

Service Code	HCPCS 10005
Hospital Charge Code	3350005
Hospital Revenue Code	761
Min. Negotiated Rate	$892.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$892.80
Rate for Payer: UnitedHealthcare Commercial	$942.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10006 FINE NDL ASPIRATION BX W/US GDN EA ADDL CHARGE

Facility

$992.00

Service Code	HCPCS 10006
Hospital Charge Code	3150006
Hospital Revenue Code	360
Min. Negotiated Rate	$396.80
Max. Negotiated Rate	$942.40
Rate for Payer: Aetna Commercial	$892.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$643.64
Rate for Payer: Humana Medicare Advantage	$416.64
Rate for Payer: UnitedHealthcare Commercial	$942.40
Rate for Payer: UnitedHealthcare Medicaid	$396.80
Rate for Payer: WPPA Medicare Advantage	$595.20

10006 FINE NDL ASPIRATION BX W/US GDN EA ADDL CHARGE

Facility

$992.00

Service Code	HCPCS 10006
Hospital Charge Code	3150006
Hospital Revenue Code	360
Min. Negotiated Rate	$892.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$892.80
Rate for Payer: UnitedHealthcare Commercial	$942.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10006 Fine needle aspiration biopsy, including ultrasound guidance; ea addl lesion

Facility

$992.00

Service Code	HCPCS 10006
Hospital Charge Code	3350006
Hospital Revenue Code	761
Min. Negotiated Rate	$892.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$892.80
Rate for Payer: UnitedHealthcare Commercial	$942.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10006 Fine needle aspiration biopsy, including ultrasound guidance; ea addl lesion

Facility

$992.00

Service Code	HCPCS 10006
Hospital Charge Code	3350006
Hospital Revenue Code	761
Min. Negotiated Rate	$396.80
Max. Negotiated Rate	$942.40
Rate for Payer: Aetna Commercial	$892.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$643.64
Rate for Payer: Humana Medicare Advantage	$416.64
Rate for Payer: UnitedHealthcare Commercial	$942.40
Rate for Payer: UnitedHealthcare Medicaid	$396.80
Rate for Payer: WPPA Medicare Advantage	$595.20

10021-Aspiration Fine Needle w/o Imaging

Facility

$2,511.00

Service Code	HCPCS 10021
Hospital Charge Code	3301002
Hospital Revenue Code	450
Min. Negotiated Rate	$129.17
Max. Negotiated Rate	$2,385.45
Rate for Payer: Aetna Commercial	$2,259.90
Rate for Payer: Humana Medicare Advantage	$1,054.62
Rate for Payer: UnitedHealthcare Commercial	$2,385.45
Rate for Payer: UnitedHealthcare Medicaid	$129.17
Rate for Payer: WPPA Medicare Advantage	$1,506.60

10021-Aspiration Fine Needle w/o Imaging

Facility

$2,511.00

Service Code	HCPCS 10021
Hospital Charge Code	3301002
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,385.45
Rate for Payer: Aetna Commercial	$2,259.90
Rate for Payer: UnitedHealthcare Commercial	$2,385.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10021 FINE NEEDLE ASPIRATION WITHOUT GUIDANCE CHARGE

Facility

$270.00

Service Code	HCPCS 10021
Hospital Charge Code	3291002
Hospital Revenue Code	761
Min. Negotiated Rate	$243.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$243.00
Rate for Payer: UnitedHealthcare Commercial	$256.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10021 FINE NEEDLE ASPIRATION WITHOUT GUIDANCE CHARGE

Facility

$270.00

Service Code	HCPCS 10021
Hospital Charge Code	3291002
Hospital Revenue Code	761
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$256.50
Rate for Payer: Aetna Commercial	$243.00
Rate for Payer: Humana Medicare Advantage	$113.40
Rate for Payer: UnitedHealthcare Commercial	$256.50
Rate for Payer: UnitedHealthcare Medicaid	$129.17
Rate for Payer: WPPA Medicare Advantage	$162.00

10021 Fine needle aspiration; without imaging guidance

Facility

$298.00

Service Code	HCPCS 10021
Hospital Charge Code	3350021
Hospital Revenue Code	761
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10021 Fine needle aspiration; without imaging guidance

Facility

$298.00

Service Code	HCPCS 10021
Hospital Charge Code	3350021
Hospital Revenue Code	761
Min. Negotiated Rate	$125.16
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$129.17
Rate for Payer: WPPA Medicare Advantage	$178.80

10060-I&D Abscess/Cyst/Hematoma Simple

Facility

$1,741.00

Service Code	HCPCS 10060
Hospital Charge Code	3304000
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,653.95
Rate for Payer: Aetna Commercial	$1,566.90
Rate for Payer: UnitedHealthcare Commercial	$1,653.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10060-I&D Abscess/Cyst/Hematoma Simple

Facility

$1,741.00

Service Code	HCPCS 10060
Hospital Charge Code	3304000
Hospital Revenue Code	450
Min. Negotiated Rate	$202.02
Max. Negotiated Rate	$1,653.95
Rate for Payer: Aetna Commercial	$1,566.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$217.72
Rate for Payer: Humana Medicare Advantage	$731.22
Rate for Payer: UnitedHealthcare Commercial	$1,653.95
Rate for Payer: UnitedHealthcare Medicaid	$202.02
Rate for Payer: WPPA Medicare Advantage	$1,044.60

10060 I&D, abscess, simple or single

Facility

$1,546.00

Service Code	HCPCS 10060
Hospital Charge Code	3150060
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,468.70
Rate for Payer: Aetna Commercial	$1,391.40
Rate for Payer: UnitedHealthcare Commercial	$1,468.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10060 I&D, abscess, simple or single

Facility

$1,546.00

Service Code	HCPCS 10060
Hospital Charge Code	3150060
Hospital Revenue Code	360
Min. Negotiated Rate	$202.02
Max. Negotiated Rate	$1,468.70
Rate for Payer: Aetna Commercial	$1,391.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$217.72
Rate for Payer: Humana Medicare Advantage	$649.32
Rate for Payer: UnitedHealthcare Commercial	$1,468.70
Rate for Payer: UnitedHealthcare Medicaid	$202.02
Rate for Payer: WPPA Medicare Advantage	$927.60

10060 I & D SIMPLE CHARGE

Facility

$1,741.00

Service Code	HCPCS 10060
Hospital Charge Code	3291060
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,653.95
Rate for Payer: Aetna Commercial	$1,566.90
Rate for Payer: UnitedHealthcare Commercial	$1,653.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges