Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

acetylcysteine 20% Inh Sol 4 mL [HMC]

Facility

$34.88

Service Code	HCPCS J7608
Hospital Charge Code	3805840
Hospital Revenue Code	250
Min. Negotiated Rate	$8.46
Max. Negotiated Rate	$33.14
Rate for Payer: Aetna Commercial	$31.39
Rate for Payer: Aetna Commercial	$34.88
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$12.04
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$12.04
Rate for Payer: Humana Medicare Advantage	$14.65
Rate for Payer: Humana Medicare Advantage	$16.27
Rate for Payer: UnitedHealthcare Commercial	$33.14
Rate for Payer: UnitedHealthcare Commercial	$36.81
Rate for Payer: UnitedHealthcare Medicaid	$8.46
Rate for Payer: UnitedHealthcare Medicaid	$8.46
Rate for Payer: WPPA Medicare Advantage	$20.93
Rate for Payer: WPPA Medicare Advantage	$23.25

acetylcysteine 20% Sol 6g/30 ml inj [HMC]

Facility

$545.00

Service Code	HCPCS J0132
Hospital Charge Code	3800103
Hospital Revenue Code	250
Min. Negotiated Rate	$490.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$490.50
Rate for Payer: UnitedHealthcare Commercial	$517.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acetylcysteine 20% Sol 6g/30 ml inj [HMC]

Facility

$545.00

Service Code	HCPCS J0132
Hospital Charge Code	3800103
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$517.75
Rate for Payer: Aetna Commercial	$490.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.99
Rate for Payer: Humana Medicare Advantage	$228.90
Rate for Payer: UnitedHealthcare Commercial	$517.75
Rate for Payer: UnitedHealthcare Medicaid	$0.37
Rate for Payer: WPPA Medicare Advantage	$327.00

Acetyl Fentanyl DS

Facility

$92.00

Service Code	HCPCS 80354
Hospital Charge Code	3551830
Hospital Revenue Code	300
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$87.40
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.88
Rate for Payer: Humana Medicare Advantage	$38.64
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: UnitedHealthcare Medicaid	$10.40
Rate for Payer: WPPA Medicare Advantage	$55.20

Acetyl Fentanyl DS

Facility

$92.00

Service Code	HCPCS 80354
Hospital Charge Code	3551830
Hospital Revenue Code	300
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: UnitedHealthcare Commercial	$87.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACTH, Plasma QST

Facility

$196.00

Service Code	HCPCS 82024
Hospital Charge Code	3551476
Hospital Revenue Code	300
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$176.40
Rate for Payer: UnitedHealthcare Commercial	$186.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACTH, Plasma QST

Facility

$196.00

Service Code	HCPCS 82024
Hospital Charge Code	3551476
Hospital Revenue Code	300
Min. Negotiated Rate	$32.83
Max. Negotiated Rate	$186.20
Rate for Payer: Aetna Commercial	$176.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$118.38
Rate for Payer: Humana Medicare Advantage	$82.32
Rate for Payer: UnitedHealthcare Commercial	$186.20
Rate for Payer: UnitedHealthcare Medicaid	$32.83
Rate for Payer: WPPA Medicare Advantage	$117.60

Actin (Smooth Muscle) Ab (IgG) QST

Facility

$415.00

Service Code	HCPCS 86015
Hospital Charge Code	3552540
Hospital Revenue Code	300
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$373.50
Rate for Payer: UnitedHealthcare Commercial	$394.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Actin (Smooth Muscle) Ab (IgG) QST

Facility

$415.00

Service Code	HCPCS 86015
Hospital Charge Code	3552540
Hospital Revenue Code	300
Min. Negotiated Rate	$7.49
Max. Negotiated Rate	$394.25
Rate for Payer: Aetna Commercial	$373.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$21.62
Rate for Payer: Humana Medicare Advantage	$174.30
Rate for Payer: UnitedHealthcare Commercial	$394.25
Rate for Payer: UnitedHealthcare Medicaid	$7.49
Rate for Payer: WPPA Medicare Advantage	$249.00

Activated Protein C Resistance QST

Facility

$442.00

Service Code	HCPCS 85307
Hospital Charge Code	3555307
Hospital Revenue Code	300
Min. Negotiated Rate	$15.32
Max. Negotiated Rate	$419.90
Rate for Payer: Aetna Commercial	$397.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$249.21
Rate for Payer: Humana Medicare Advantage	$185.64
Rate for Payer: UnitedHealthcare Commercial	$419.90
Rate for Payer: UnitedHealthcare Medicaid	$15.32
Rate for Payer: WPPA Medicare Advantage	$265.20

Activated Protein C Resistance QST

Facility

$442.00

Service Code	HCPCS 85307
Hospital Charge Code	3555307
Hospital Revenue Code	300
Min. Negotiated Rate	$397.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$397.80
Rate for Payer: UnitedHealthcare Commercial	$419.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION

Facility

$3,018.15

Service Code	MSDRG 880
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,018.15
Rate for Payer: UnitedHealthcare Medicaid	$3,018.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE AND SUBACUTE ENDOCARDITIS WITH CC

Facility

$7,497.72

Service Code	MSDRG 289
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,497.72
Rate for Payer: UnitedHealthcare Medicaid	$7,497.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC

Facility

$11,881.98

Service Code	MSDRG 288
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,881.98
Rate for Payer: UnitedHealthcare Medicaid	$11,881.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC

Facility

$4,066.56

Service Code	MSDRG 290
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,066.56
Rate for Payer: UnitedHealthcare Medicaid	$4,066.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE LEUKEMIA WITH CC

Facility

$6,258.69

Service Code	MSDRG 835
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,258.69
Rate for Payer: UnitedHealthcare Medicaid	$6,258.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE LEUKEMIA WITH MCC

Facility

$16,488.63

Service Code	MSDRG 834
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$16,488.63
Rate for Payer: UnitedHealthcare Medicaid	$16,488.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE LEUKEMIA WITH OTHER PROCEDURES

Facility

$30,340.35

Service Code	MSDRG 850
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$30,340.35
Rate for Payer: UnitedHealthcare Medicaid	$30,340.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$3,653.55

Service Code	MSDRG 836
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,653.55
Rate for Payer: UnitedHealthcare Medicaid	$3,653.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE MAJOR EYE INFECTIONS WITH CC/MCC

Facility

$3,717.09

Service Code	MSDRG 121
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,717.09
Rate for Payer: UnitedHealthcare Medicaid	$3,717.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC

Facility

$2,509.83

Service Code	MSDRG 122
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,509.83
Rate for Payer: UnitedHealthcare Medicaid	$2,509.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC

Facility

$5,432.67

Service Code	MSDRG 281
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,432.67
Rate for Payer: UnitedHealthcare Medicaid	$5,432.67
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC

Facility

$5,686.83

Service Code	MSDRG 280
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,686.83
Rate for Payer: UnitedHealthcare Medicaid	$5,686.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

Facility

$5,178.51

Service Code	MSDRG 282
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,178.51
Rate for Payer: UnitedHealthcare Medicaid	$5,178.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

Facility

$3,049.92

Service Code	MSDRG 284
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,049.92
Rate for Payer: UnitedHealthcare Medicaid	$3,049.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges