Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Amphetamine Confirmation By GCMS, U QST

Facility

$91.00

Service Code	HCPCS 80324
Hospital Charge Code	3550324
Hospital Revenue Code	300
Min. Negotiated Rate	$10.48
Max. Negotiated Rate	$86.45
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$37.14
Rate for Payer: Humana Medicare Advantage	$38.22
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: UnitedHealthcare Medicaid	$10.48
Rate for Payer: WPPA Medicare Advantage	$54.60

Amphetamine Confirmation By GCMS, U QST

Facility

$91.00

Service Code	HCPCS 80324
Hospital Charge Code	3550324
Hospital Revenue Code	300
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amphotericin B liposomal 50 mg IV Inj [HMC]

Facility

$751.70

Service Code	HCPCS J0287
Hospital Charge Code	3800778
Hospital Revenue Code	250
Min. Negotiated Rate	$676.53
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$676.53
Rate for Payer: UnitedHealthcare Commercial	$714.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

amphotericin B liposomal 50 mg IV Inj [HMC]

Facility

$751.70

Service Code	HCPCS J0287
Hospital Charge Code	3800778
Hospital Revenue Code	250
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$714.12
Rate for Payer: Aetna Commercial	$676.53
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$13.24
Rate for Payer: Humana Medicare Advantage	$315.71
Rate for Payer: UnitedHealthcare Commercial	$714.12
Rate for Payer: UnitedHealthcare Medicaid	$10.30
Rate for Payer: WPPA Medicare Advantage	$451.02

ampicillin 1 g Inj [HMC]

Facility

$44.62

Service Code	HCPCS J0290
Hospital Charge Code	3804404
Hospital Revenue Code	250
Min. Negotiated Rate	$40.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.16
Rate for Payer: Aetna Commercial	$41.33
Rate for Payer: UnitedHealthcare Commercial	$43.62
Rate for Payer: UnitedHealthcare Commercial	$42.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ampicillin 1 g Inj [HMC]

Facility

$45.92

Service Code	HCPCS J0290
Hospital Charge Code	3804404
Hospital Revenue Code	250
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$43.62
Rate for Payer: Aetna Commercial	$41.33
Rate for Payer: Aetna Commercial	$40.16
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.04
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.04
Rate for Payer: Humana Medicare Advantage	$19.29
Rate for Payer: Humana Medicare Advantage	$18.74
Rate for Payer: UnitedHealthcare Commercial	$42.39
Rate for Payer: UnitedHealthcare Commercial	$43.62
Rate for Payer: UnitedHealthcare Medicaid	$0.59
Rate for Payer: UnitedHealthcare Medicaid	$0.59
Rate for Payer: WPPA Medicare Advantage	$27.55
Rate for Payer: WPPA Medicare Advantage	$26.77

ampicillin 500 mg Cap [HMC]

Facility

$6.94

Service Code	NDC 00781214501
Hospital Charge Code	3800213
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.25
Rate for Payer: UnitedHealthcare Commercial	$6.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ampicillin 500 mg Cap [HMC]

Facility

$6.94

Service Code	NDC 00781214501
Hospital Charge Code	3800213
Hospital Revenue Code	250
Min. Negotiated Rate	$2.78
Max. Negotiated Rate	$6.59
Rate for Payer: Aetna Commercial	$6.25
Rate for Payer: Humana Medicare Advantage	$2.91
Rate for Payer: UnitedHealthcare Commercial	$6.59
Rate for Payer: UnitedHealthcare Medicaid	$2.78
Rate for Payer: WPPA Medicare Advantage	$4.16

ampicillin-sulbactam 1 g-0.5 g Inj [HMC]

Facility

$47.76

Service Code	HCPCS J0295
Hospital Charge Code	3802069
Hospital Revenue Code	250
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$45.37
Rate for Payer: Aetna Commercial	$42.98
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.33
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.33
Rate for Payer: Humana Medicare Advantage	$18.14
Rate for Payer: Humana Medicare Advantage	$20.06
Rate for Payer: UnitedHealthcare Commercial	$45.37
Rate for Payer: UnitedHealthcare Commercial	$41.04
Rate for Payer: UnitedHealthcare Medicaid	$1.33
Rate for Payer: UnitedHealthcare Medicaid	$1.33
Rate for Payer: WPPA Medicare Advantage	$25.92
Rate for Payer: WPPA Medicare Advantage	$28.66

ampicillin-sulbactam 1 g-0.5 g Inj [HMC]

Facility

$43.20

Service Code	HCPCS J0295
Hospital Charge Code	3802069
Hospital Revenue Code	250
Min. Negotiated Rate	$38.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.88
Rate for Payer: Aetna Commercial	$42.98
Rate for Payer: UnitedHealthcare Commercial	$41.04
Rate for Payer: UnitedHealthcare Commercial	$45.37
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ampicillin-sulbactam 2 g-1 g Inj [HMC]

Facility

$50.74

Service Code	HCPCS J0295
Hospital Charge Code	3807589
Hospital Revenue Code	250
Min. Negotiated Rate	$45.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.67
Rate for Payer: Aetna Commercial	$44.28
Rate for Payer: Aetna Commercial	$49.45
Rate for Payer: UnitedHealthcare Commercial	$48.20
Rate for Payer: UnitedHealthcare Commercial	$46.74
Rate for Payer: UnitedHealthcare Commercial	$52.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ampicillin-sulbactam 2 g-1 g Inj [HMC]

Facility

$50.74

Service Code	HCPCS J0295
Hospital Charge Code	3807589
Hospital Revenue Code	250
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$48.20
Rate for Payer: Aetna Commercial	$45.67
Rate for Payer: Aetna Commercial	$44.28
Rate for Payer: Aetna Commercial	$49.45
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.33
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.33
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.33
Rate for Payer: Humana Medicare Advantage	$23.08
Rate for Payer: Humana Medicare Advantage	$20.66
Rate for Payer: Humana Medicare Advantage	$21.31
Rate for Payer: UnitedHealthcare Commercial	$52.20
Rate for Payer: UnitedHealthcare Commercial	$48.20
Rate for Payer: UnitedHealthcare Commercial	$46.74
Rate for Payer: UnitedHealthcare Medicaid	$1.33
Rate for Payer: UnitedHealthcare Medicaid	$1.33
Rate for Payer: UnitedHealthcare Medicaid	$1.33
Rate for Payer: WPPA Medicare Advantage	$30.44
Rate for Payer: WPPA Medicare Advantage	$29.52
Rate for Payer: WPPA Medicare Advantage	$32.97

Amputation

Facility

$1,946.00

Service Code	HCPCS 26910
Hospital Charge Code	3156910
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,848.70
Rate for Payer: Aetna Commercial	$1,751.40
Rate for Payer: UnitedHealthcare Commercial	$1,848.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Amputation

Facility

$1,946.00

Service Code	HCPCS 26910
Hospital Charge Code	3156910
Hospital Revenue Code	360
Min. Negotiated Rate	$817.32
Max. Negotiated Rate	$1,848.70
Rate for Payer: Aetna Commercial	$1,751.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,402.45
Rate for Payer: Humana Medicare Advantage	$817.32
Rate for Payer: UnitedHealthcare Commercial	$1,848.70
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$1,167.60

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC

Facility

$10,229.94

Service Code	MSDRG 240
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,229.94
Rate for Payer: UnitedHealthcare Medicaid	$10,229.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC

Facility

$17,632.35

Service Code	MSDRG 239
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$17,632.35
Rate for Payer: UnitedHealthcare Medicaid	$17,632.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC

Facility

$4,956.12

Service Code	MSDRG 241
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,956.12
Rate for Payer: UnitedHealthcare Medicaid	$4,956.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$7,370.64

Service Code	MSDRG 475
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,370.64
Rate for Payer: UnitedHealthcare Medicaid	$7,370.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$16,266.24

Service Code	MSDRG 474
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$16,266.24
Rate for Payer: UnitedHealthcare Medicaid	$16,266.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$4,479.57

Service Code	MSDRG 476
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,479.57
Rate for Payer: UnitedHealthcare Medicaid	$4,479.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$7,974.27

Service Code	MSDRG 617
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,974.27
Rate for Payer: UnitedHealthcare Medicaid	$7,974.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$12,453.84

Service Code	MSDRG 616
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,453.84
Rate for Payer: UnitedHealthcare Medicaid	$12,453.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$5,051.43

Service Code	MSDRG 618
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,051.43
Rate for Payer: UnitedHealthcare Medicaid	$5,051.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Amylase Level

Facility

$82.00

Service Code	HCPCS 82150
Hospital Charge Code	3550049
Hospital Revenue Code	300
Min. Negotiated Rate	$73.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$73.80
Rate for Payer: UnitedHealthcare Commercial	$77.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Amylase Level

Facility

$82.00

Service Code	HCPCS 82150
Hospital Charge Code	3550049
Hospital Revenue Code	300
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$77.90
Rate for Payer: Aetna Commercial	$73.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$25.05
Rate for Payer: Humana Medicare Advantage	$34.44
Rate for Payer: UnitedHealthcare Commercial	$77.90
Rate for Payer: UnitedHealthcare Medicaid	$6.48
Rate for Payer: WPPA Medicare Advantage	$49.20

Know your out-of-pocket cost for care.

All Charges