Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

A0426 AMBULANCE ALS NON-EMERGENT TRANSPORT TechFee

Facility

$228.00

Service Code	HCPCS A0426 QN
Hospital Charge Code	4550130
Hospital Revenue Code	540
Min. Negotiated Rate	$205.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$205.20
Rate for Payer: UnitedHealthcare Commercial	$216.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

A0427 Als1-emergency TechFee

Facility

$746.00

Service Code	HCPCS A0427 QN
Hospital Charge Code	4550148
Hospital Revenue Code	540
Min. Negotiated Rate	$298.40
Max. Negotiated Rate	$708.70
Rate for Payer: Aetna Commercial	$671.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$585.68
Rate for Payer: Humana Medicare Advantage	$313.32
Rate for Payer: UnitedHealthcare Commercial	$708.70
Rate for Payer: UnitedHealthcare Medicaid	$298.40
Rate for Payer: WPPA Medicare Advantage	$447.60

A0427 Als1-emergency TechFee

Facility

$746.00

Service Code	HCPCS A0427 QN
Hospital Charge Code	4550148
Hospital Revenue Code	540
Min. Negotiated Rate	$671.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$671.40
Rate for Payer: UnitedHealthcare Commercial	$708.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

A0427 AMBULANCE ALS LEVEL 1 EMERGENT TRANSPORT

Facility

$359.00

Service Code	HCPCS A0427
Hospital Charge Code	4550155
Hospital Revenue Code	540
Min. Negotiated Rate	$323.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$323.10
Rate for Payer: UnitedHealthcare Commercial	$341.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

A0427 AMBULANCE ALS LEVEL 1 EMERGENT TRANSPORT

Facility

$359.00

Service Code	HCPCS A0427
Hospital Charge Code	4550155
Hospital Revenue Code	540
Min. Negotiated Rate	$143.60
Max. Negotiated Rate	$585.68
Rate for Payer: Aetna Commercial	$323.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$585.68
Rate for Payer: Humana Medicare Advantage	$150.78
Rate for Payer: UnitedHealthcare Commercial	$341.05
Rate for Payer: UnitedHealthcare Medicaid	$143.60
Rate for Payer: WPPA Medicare Advantage	$215.40

A0428 AMBULANCE BLS NON-EMERGENT TRANSPORT TechFee

Facility

$352.00

Service Code	HCPCS A0428
Hospital Charge Code	4550098
Hospital Revenue Code	540
Min. Negotiated Rate	$316.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$316.80
Rate for Payer: UnitedHealthcare Commercial	$334.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

A0428 AMBULANCE BLS NON-EMERGENT TRANSPORT TechFee

Facility

$352.00

Service Code	HCPCS A0428
Hospital Charge Code	4550098
Hospital Revenue Code	540
Min. Negotiated Rate	$140.80
Max. Negotiated Rate	$367.67
Rate for Payer: Aetna Commercial	$316.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$367.67
Rate for Payer: Humana Medicare Advantage	$147.84
Rate for Payer: UnitedHealthcare Commercial	$334.40
Rate for Payer: UnitedHealthcare Medicaid	$140.80
Rate for Payer: WPPA Medicare Advantage	$211.20

A0428 Bls TechFee

Facility

$377.00

Service Code	HCPCS A0428 QN
Hospital Charge Code	4550080
Hospital Revenue Code	540
Min. Negotiated Rate	$339.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$339.30
Rate for Payer: UnitedHealthcare Commercial	$358.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

A0428 Bls TechFee

Facility

$377.00

Service Code	HCPCS A0428 QN
Hospital Charge Code	4550080
Hospital Revenue Code	540
Min. Negotiated Rate	$150.80
Max. Negotiated Rate	$367.67
Rate for Payer: Aetna Commercial	$339.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$367.67
Rate for Payer: Humana Medicare Advantage	$158.34
Rate for Payer: UnitedHealthcare Commercial	$358.15
Rate for Payer: UnitedHealthcare Medicaid	$150.80
Rate for Payer: WPPA Medicare Advantage	$226.20

A0429 AMBULANCE BLS EMERGENT TRANSPORT TechFee

Facility

$825.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	4550106
Hospital Revenue Code	540
Min. Negotiated Rate	$742.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

A0429 AMBULANCE BLS EMERGENT TRANSPORT TechFee

Facility

$825.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	4550106
Hospital Revenue Code	540
Min. Negotiated Rate	$330.00
Max. Negotiated Rate	$783.75
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$450.09
Rate for Payer: Humana Medicare Advantage	$346.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: UnitedHealthcare Medicaid	$330.00
Rate for Payer: WPPA Medicare Advantage	$495.00

A0429 Bls-emergency TechFee

Facility

$700.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	4550114
Hospital Revenue Code	540
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$665.00
Rate for Payer: Aetna Commercial	$630.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$450.09
Rate for Payer: Humana Medicare Advantage	$294.00
Rate for Payer: UnitedHealthcare Commercial	$665.00
Rate for Payer: UnitedHealthcare Medicaid	$280.00
Rate for Payer: WPPA Medicare Advantage	$420.00

A0429 Bls-emergency TechFee

Facility

$700.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	4550114
Hospital Revenue Code	540
Min. Negotiated Rate	$630.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$630.00
Rate for Payer: UnitedHealthcare Commercial	$665.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

A0434 Specialty care transport TechFee

Facility

$1,832.00

Service Code	HCPCS A0434 QN
Hospital Charge Code	4550163
Hospital Revenue Code	540
Min. Negotiated Rate	$732.80
Max. Negotiated Rate	$1,740.40
Rate for Payer: Aetna Commercial	$1,648.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$942.91
Rate for Payer: Humana Medicare Advantage	$769.44
Rate for Payer: UnitedHealthcare Commercial	$1,740.40
Rate for Payer: UnitedHealthcare Medicaid	$732.80
Rate for Payer: WPPA Medicare Advantage	$1,099.20

A0434 Specialty care transport TechFee

Facility

$1,832.00

Service Code	HCPCS A0434 QN
Hospital Charge Code	4550163
Hospital Revenue Code	540
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,740.40
Rate for Payer: Aetna Commercial	$1,648.80
Rate for Payer: UnitedHealthcare Commercial	$1,740.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

abatacept 250 mg IV Inj [HMC]

Facility

$2,642.47

Service Code	HCPCS J0129
Hospital Charge Code	3852115
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,510.35
Rate for Payer: Aetna Commercial	$2,378.22
Rate for Payer: UnitedHealthcare Commercial	$2,510.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

abatacept 250 mg IV Inj [HMC]

Facility

$2,642.47

Service Code	HCPCS J0129
Hospital Charge Code	3852115
Hospital Revenue Code	250
Min. Negotiated Rate	$44.77
Max. Negotiated Rate	$2,510.35
Rate for Payer: Aetna Commercial	$2,378.22
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$53.11
Rate for Payer: Humana Medicare Advantage	$1,109.84
Rate for Payer: UnitedHealthcare Commercial	$2,510.35
Rate for Payer: UnitedHealthcare Medicaid	$44.77
Rate for Payer: WPPA Medicare Advantage	$1,585.48

Abdominal Binder 9 Small/Medium 30-45

Facility

$32.76

Hospital Charge Code	3259798
Hospital Revenue Code	270
Min. Negotiated Rate	$13.10
Max. Negotiated Rate	$31.12
Rate for Payer: Aetna Commercial	$29.48
Rate for Payer: Humana Medicare Advantage	$13.76
Rate for Payer: UnitedHealthcare Commercial	$31.12
Rate for Payer: UnitedHealthcare Medicaid	$13.10
Rate for Payer: WPPA Medicare Advantage	$19.66

Abdominal Binder 9 Small/Medium 30-45

Facility

$32.76

Hospital Charge Code	3259798
Hospital Revenue Code	270
Min. Negotiated Rate	$29.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.48
Rate for Payer: UnitedHealthcare Commercial	$31.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Abdominal Binder LG 36-40

Facility

$51.00

Hospital Charge Code	3259806
Hospital Revenue Code	270
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$48.45
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: Humana Medicare Advantage	$21.42
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: WPPA Medicare Advantage	$30.60

Abdominal Binder LG 36-40

Facility

$51.00

Hospital Charge Code	3259806
Hospital Revenue Code	270
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Abdominal Binder SM 26-30

Facility

$57.00

Hospital Charge Code	3259780
Hospital Revenue Code	270
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Abdominal Binder SM 26-30

Facility

$57.00

Hospital Charge Code	3259780
Hospital Revenue Code	270
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$54.15
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Humana Medicare Advantage	$23.94
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: UnitedHealthcare Medicaid	$22.80
Rate for Payer: WPPA Medicare Advantage	$34.20

Abdominal Binder XL 42-48

Facility

$52.00

Hospital Charge Code	3255051
Hospital Revenue Code	270
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$49.40
Rate for Payer: Aetna Commercial	$46.80
Rate for Payer: Humana Medicare Advantage	$21.84
Rate for Payer: UnitedHealthcare Commercial	$49.40
Rate for Payer: UnitedHealthcare Medicaid	$20.80
Rate for Payer: WPPA Medicare Advantage	$31.20

Abdominal Binder XL 42-48

Facility

$52.00

Hospital Charge Code	3255051
Hospital Revenue Code	270
Min. Negotiated Rate	$46.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$46.80
Rate for Payer: UnitedHealthcare Commercial	$49.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges