Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

ANAchoice Pnl 1 w/ Rfxs QST

Facility

$74.00

Service Code	HCPCS 86039
Hospital Charge Code	3556039
Hospital Revenue Code	300
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

ANAchoice Pnl 1 w/ Rfxs QST

Facility

$74.00

Service Code	HCPCS 86039
Hospital Charge Code	3556039
Hospital Revenue Code	300
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$70.30
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$41.77
Rate for Payer: Humana Medicare Advantage	$31.08
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: UnitedHealthcare Medicaid	$11.16
Rate for Payer: WPPA Medicare Advantage	$44.40

ANAL AND STOMAL PROCEDURES WITH CC

Facility

$4,956.12

Service Code	MSDRG 348
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

ANAL AND STOMAL PROCEDURES WITH MCC

Facility

$8,673.21

Service Code	MSDRG 347
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,673.21
Rate for Payer: UnitedHealthcare Medicaid	$8,673.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC

Facility

$3,304.08

Service Code	MSDRG 349
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,304.08
Rate for Payer: UnitedHealthcare Medicaid	$3,304.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ANA Multiplex w/Reflex 11 Ab Cascade QST

Facility

$158.00

Service Code	HCPCS 83516
Hospital Charge Code	3553516
Hospital Revenue Code	300
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$150.10
Rate for Payer: Aetna Commercial	$142.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.34
Rate for Payer: Humana Medicare Advantage	$66.36
Rate for Payer: UnitedHealthcare Commercial	$150.10
Rate for Payer: UnitedHealthcare Medicaid	$10.00
Rate for Payer: WPPA Medicare Advantage	$94.80

ANA Multiplex w/Reflex 11 Ab Cascade QST

Facility

$158.00

Service Code	HCPCS 83516
Hospital Charge Code	3553516
Hospital Revenue Code	300
Min. Negotiated Rate	$142.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$142.20
Rate for Payer: UnitedHealthcare Commercial	$150.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ANA Screen, IFA, w/Refl Tit &Pattern QST

Facility

$74.00

Service Code	HCPCS 86038
Hospital Charge Code	3550056
Hospital Revenue Code	300
Min. Negotiated Rate	$12.09
Max. Negotiated Rate	$70.30
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$44.30
Rate for Payer: Humana Medicare Advantage	$31.08
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: UnitedHealthcare Medicaid	$12.09
Rate for Payer: WPPA Medicare Advantage	$44.40

ANA Screen, IFA, w/Refl Tit &Pattern QST

Facility

$74.00

Service Code	HCPCS 86038
Hospital Charge Code	3550056
Hospital Revenue Code	300
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

ANA Scr, IFA w/Rfx Titer/Pattern & Rfx MPL x 11 Ab Cascade QST

Facility

$74.00

Service Code	HCPCS 86038
Hospital Charge Code	3550056
Hospital Revenue Code	300
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

ANA Scr, IFA w/Rfx Titer/Pattern & Rfx MPL x 11 Ab Cascade QST

Facility

$74.00

Service Code	HCPCS 86038
Hospital Charge Code	3550056
Hospital Revenue Code	300
Min. Negotiated Rate	$12.09
Max. Negotiated Rate	$70.30
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$44.30
Rate for Payer: Humana Medicare Advantage	$31.08
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: UnitedHealthcare Medicaid	$12.09
Rate for Payer: WPPA Medicare Advantage	$44.40

anastrozole 1 mg Tab [HMC]

Facility

$31.96

Service Code	NDC 68382020906
Hospital Charge Code	3805596
Hospital Revenue Code	250
Min. Negotiated Rate	$12.78
Max. Negotiated Rate	$30.36
Rate for Payer: Aetna Commercial	$28.76
Rate for Payer: Humana Medicare Advantage	$13.42
Rate for Payer: UnitedHealthcare Commercial	$30.36
Rate for Payer: UnitedHealthcare Medicaid	$12.78
Rate for Payer: WPPA Medicare Advantage	$19.18

anastrozole 1 mg Tab [HMC]

Facility

$31.96

Service Code	NDC 68382020906
Hospital Charge Code	3805596
Hospital Revenue Code	250
Min. Negotiated Rate	$28.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.76
Rate for Payer: UnitedHealthcare Commercial	$30.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

anastrozole 1 mg Tab [HMC]

Facility

$11.22

Service Code	NDC 60687011221
Hospital Charge Code	3805596
Hospital Revenue Code	250
Min. Negotiated Rate	$4.49
Max. Negotiated Rate	$10.66
Rate for Payer: Aetna Commercial	$10.10
Rate for Payer: Humana Medicare Advantage	$4.71
Rate for Payer: UnitedHealthcare Commercial	$10.66
Rate for Payer: UnitedHealthcare Medicaid	$4.49
Rate for Payer: WPPA Medicare Advantage	$6.73

anastrozole 1 mg Tab [HMC]

Facility

$11.22

Service Code	NDC 60687011221
Hospital Charge Code	3805596
Hospital Revenue Code	250
Min. Negotiated Rate	$10.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.10
Rate for Payer: UnitedHealthcare Commercial	$10.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

anastrozole 1 mg Tab [HMC]

Facility

$28.99

Service Code	NDC 00904619546
Hospital Charge Code	3805596
Hospital Revenue Code	250
Min. Negotiated Rate	$11.60
Max. Negotiated Rate	$27.54
Rate for Payer: Aetna Commercial	$26.09
Rate for Payer: Humana Medicare Advantage	$12.18
Rate for Payer: UnitedHealthcare Commercial	$27.54
Rate for Payer: UnitedHealthcare Medicaid	$11.60
Rate for Payer: WPPA Medicare Advantage	$17.39

anastrozole 1 mg Tab [HMC]

Facility

$28.99

Service Code	NDC 00904619546
Hospital Charge Code	3805596
Hospital Revenue Code	250
Min. Negotiated Rate	$26.09
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.09
Rate for Payer: UnitedHealthcare Commercial	$27.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ANCA Screen With Reflex To Titer QST

Facility

$104.00

Service Code	HCPCS 86036
Hospital Charge Code	3556036
Hospital Revenue Code	300
Min. Negotiated Rate	$93.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$93.60
Rate for Payer: UnitedHealthcare Commercial	$98.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ANCA Screen With Reflex To Titer QST

Facility

$104.00

Service Code	HCPCS 86036
Hospital Charge Code	3556036
Hospital Revenue Code	300
Min. Negotiated Rate	$7.83
Max. Negotiated Rate	$98.80
Rate for Payer: Aetna Commercial	$93.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$22.59
Rate for Payer: Humana Medicare Advantage	$43.68
Rate for Payer: UnitedHealthcare Commercial	$98.80
Rate for Payer: UnitedHealthcare Medicaid	$7.83
Rate for Payer: WPPA Medicare Advantage	$62.40

ANCA Vasculitides QST

Facility

$251.00

Service Code	HCPCS 86021
Hospital Charge Code	3556036
Hospital Revenue Code	300
Min. Negotiated Rate	$225.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$225.90
Rate for Payer: UnitedHealthcare Commercial	$238.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ANCA Vasculitides QST

Facility

$251.00

Service Code	HCPCS 86021
Hospital Charge Code	3556036
Hospital Revenue Code	300
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$238.45
Rate for Payer: Aetna Commercial	$225.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$27.03
Rate for Payer: Humana Medicare Advantage	$105.42
Rate for Payer: UnitedHealthcare Commercial	$238.45
Rate for Payer: UnitedHealthcare Medicaid	$12.79
Rate for Payer: WPPA Medicare Advantage	$150.60

Anesthesia Combined Spinal and Epidural

Facility

$146.00

Hospital Charge Code	3256260
Hospital Revenue Code	270
Min. Negotiated Rate	$131.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$131.40
Rate for Payer: UnitedHealthcare Commercial	$138.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Anesthesia Combined Spinal and Epidural

Facility

$146.00

Hospital Charge Code	3256260
Hospital Revenue Code	270
Min. Negotiated Rate	$58.40
Max. Negotiated Rate	$138.70
Rate for Payer: Aetna Commercial	$131.40
Rate for Payer: Humana Medicare Advantage	$61.32
Rate for Payer: UnitedHealthcare Commercial	$138.70
Rate for Payer: UnitedHealthcare Medicaid	$58.40
Rate for Payer: WPPA Medicare Advantage	$87.60

ANGINA PECTORIS

Facility

$3,081.69

Service Code	MSDRG 311
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,081.69
Rate for Payer: UnitedHealthcare Medicaid	$3,081.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Angiotensin-1-Converting Enzyme QST

Facility

$138.00

Service Code	HCPCS 82164
Hospital Charge Code	3556415
Hospital Revenue Code	300
Min. Negotiated Rate	$14.60
Max. Negotiated Rate	$131.10
Rate for Payer: Aetna Commercial	$124.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$49.38
Rate for Payer: Humana Medicare Advantage	$57.96
Rate for Payer: UnitedHealthcare Commercial	$131.10
Rate for Payer: UnitedHealthcare Medicaid	$14.60
Rate for Payer: WPPA Medicare Advantage	$82.80

Know your out-of-pocket cost for care.

All Charges