Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

Angled Staple Assembly 10mm X 10mm

Facility

$4,610.00

Hospital Charge Code	3258314
Hospital Revenue Code	270
Min. Negotiated Rate	$1,844.00
Max. Negotiated Rate	$4,379.50
Rate for Payer: Aetna Commercial	$4,149.00
Rate for Payer: Humana Medicare Advantage	$1,936.20
Rate for Payer: UnitedHealthcare Commercial	$4,379.50
Rate for Payer: UnitedHealthcare Medicaid	$1,844.00
Rate for Payer: WPPA Medicare Advantage	$2,766.00

Angled Staple Assembly 10mm X 10mm

Facility

$4,610.00

Hospital Charge Code	3258314
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,379.50
Rate for Payer: Aetna Commercial	$4,149.00
Rate for Payer: UnitedHealthcare Commercial	$4,379.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

anidulafungin 100 mg IV Inj [HMC]

Facility

$468.14

Service Code	HCPCS J0348
Hospital Charge Code	3850033
Hospital Revenue Code	250
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$444.73
Rate for Payer: Aetna Commercial	$421.33
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.60
Rate for Payer: Humana Medicare Advantage	$196.62
Rate for Payer: UnitedHealthcare Commercial	$444.73
Rate for Payer: UnitedHealthcare Medicaid	$0.51
Rate for Payer: WPPA Medicare Advantage	$280.88

anidulafungin 100 mg IV Inj [HMC]

Facility

$468.14

Service Code	HCPCS J0348
Hospital Charge Code	3850033
Hospital Revenue Code	250
Min. Negotiated Rate	$421.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$421.33
Rate for Payer: UnitedHealthcare Commercial	$444.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ankle Air Brace Left

Facility

$89.55

Service Code	HCPCS L4350
Hospital Charge Code	3255853
Hospital Revenue Code	274
Min. Negotiated Rate	$80.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$80.59
Rate for Payer: UnitedHealthcare Commercial	$85.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ankle Air Brace Left

Facility

$89.55

Service Code	HCPCS L4350
Hospital Charge Code	3255853
Hospital Revenue Code	274
Min. Negotiated Rate	$37.61
Max. Negotiated Rate	$85.07
Rate for Payer: Aetna Commercial	$80.59
Rate for Payer: Humana Medicare Advantage	$37.61
Rate for Payer: UnitedHealthcare Commercial	$85.07
Rate for Payer: UnitedHealthcare Medicaid	$78.67
Rate for Payer: WPPA Medicare Advantage	$53.73

Ankle Air Brace Right - Size L

Facility

$83.97

Service Code	HCPCS L4350
Hospital Charge Code	3251158
Hospital Revenue Code	274
Min. Negotiated Rate	$75.57
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$75.57
Rate for Payer: UnitedHealthcare Commercial	$79.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ankle Air Brace Right - Size L

Facility

$83.97

Service Code	HCPCS L4350
Hospital Charge Code	3251158
Hospital Revenue Code	274
Min. Negotiated Rate	$35.27
Max. Negotiated Rate	$79.77
Rate for Payer: Aetna Commercial	$75.57
Rate for Payer: Humana Medicare Advantage	$35.27
Rate for Payer: UnitedHealthcare Commercial	$79.77
Rate for Payer: UnitedHealthcare Medicaid	$78.67
Rate for Payer: WPPA Medicare Advantage	$50.38

Anoscope Sani-Scope Large Disposable Rectal Speculum without Light

Facility

$2.79

Hospital Charge Code	3257342
Hospital Revenue Code	270
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$2.65
Rate for Payer: Aetna Commercial	$2.51
Rate for Payer: Humana Medicare Advantage	$1.17
Rate for Payer: UnitedHealthcare Commercial	$2.65
Rate for Payer: UnitedHealthcare Medicaid	$1.12
Rate for Payer: WPPA Medicare Advantage	$1.67

Anoscope Sani-Scope Large Disposable Rectal Speculum without Light

Facility

$2.79

Hospital Charge Code	3257342
Hospital Revenue Code	270
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.51
Rate for Payer: UnitedHealthcare Commercial	$2.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Antibody Screen Gel 2

Facility

$79.00

Service Code	HCPCS 86850
Hospital Charge Code	3560073
Hospital Revenue Code	300
Min. Negotiated Rate	$71.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$71.10
Rate for Payer: UnitedHealthcare Commercial	$75.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Antibody Screen Gel 2

Facility

$79.00

Service Code	HCPCS 86850
Hospital Charge Code	3560073
Hospital Revenue Code	300
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$91.28
Rate for Payer: Aetna Commercial	$71.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$91.28
Rate for Payer: Humana Medicare Advantage	$33.18
Rate for Payer: UnitedHealthcare Commercial	$75.05
Rate for Payer: UnitedHealthcare Medicaid	$8.30
Rate for Payer: WPPA Medicare Advantage	$47.40

Antibody Screen, RBC w/Rfx ID, Titer And Ag QST

Facility

$79.00

Service Code	HCPCS 86850
Hospital Charge Code	3560073
Hospital Revenue Code	300
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$91.28
Rate for Payer: Aetna Commercial	$71.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$91.28
Rate for Payer: Humana Medicare Advantage	$33.18
Rate for Payer: UnitedHealthcare Commercial	$75.05
Rate for Payer: UnitedHealthcare Medicaid	$8.30
Rate for Payer: WPPA Medicare Advantage	$47.40

Antibody Screen, RBC w/Rfx ID, Titer And Ag QST

Facility

$79.00

Service Code	HCPCS 86850
Hospital Charge Code	3560073
Hospital Revenue Code	300
Min. Negotiated Rate	$71.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$71.10
Rate for Payer: UnitedHealthcare Commercial	$75.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Anti-Mullerian Hormone (Amh), Female QST

Facility

$415.00

Service Code	HCPCS 83520
Hospital Charge Code	3558352
Hospital Revenue Code	300
Min. Negotiated Rate	$36.48
Max. Negotiated Rate	$394.25
Rate for Payer: Aetna Commercial	$373.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.48
Rate for Payer: Humana Medicare Advantage	$174.30
Rate for Payer: UnitedHealthcare Commercial	$394.25
Rate for Payer: UnitedHealthcare Medicaid	$166.00
Rate for Payer: WPPA Medicare Advantage	$249.00

Anti-Mullerian Hormone (Amh), Female QST

Facility

$415.00

Service Code	HCPCS 83520
Hospital Charge Code	3558352
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

Antioxidant Multiple Vitamins and Minerals Tab [HMC]

Facility

$5.22

Service Code	NDC 00536509008
Hospital Charge Code	3807564
Hospital Revenue Code	250
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$4.96
Rate for Payer: Aetna Commercial	$4.70
Rate for Payer: Humana Medicare Advantage	$2.19
Rate for Payer: UnitedHealthcare Commercial	$4.96
Rate for Payer: UnitedHealthcare Medicaid	$2.09
Rate for Payer: WPPA Medicare Advantage	$3.13

Antioxidant Multiple Vitamins and Minerals Tab [HMC]

Facility

$5.41

Service Code	NDC 24208038760
Hospital Charge Code	3807564
Hospital Revenue Code	250
Min. Negotiated Rate	$4.87
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.87
Rate for Payer: UnitedHealthcare Commercial	$5.14
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Antioxidant Multiple Vitamins and Minerals Tab [HMC]

Facility

$5.22

Service Code	NDC 00536509008
Hospital Charge Code	3807564
Hospital Revenue Code	250
Min. Negotiated Rate	$4.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.70
Rate for Payer: UnitedHealthcare Commercial	$4.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Antioxidant Multiple Vitamins and Minerals Tab [HMC]

Facility

$5.41

Service Code	NDC 24208038760
Hospital Charge Code	3807564
Hospital Revenue Code	250
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$5.14
Rate for Payer: Aetna Commercial	$4.87
Rate for Payer: Humana Medicare Advantage	$2.27
Rate for Payer: UnitedHealthcare Commercial	$5.14
Rate for Payer: UnitedHealthcare Medicaid	$2.16
Rate for Payer: WPPA Medicare Advantage	$3.25

Antiphospholipid Ab Pnl QST

Facility

$772.20

Service Code	HCPCS 83516
Hospital Charge Code	3553516
Hospital Revenue Code	300
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$733.59
Rate for Payer: Aetna Commercial	$694.98
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.34
Rate for Payer: Humana Medicare Advantage	$324.32
Rate for Payer: UnitedHealthcare Commercial	$733.59
Rate for Payer: UnitedHealthcare Medicaid	$10.00
Rate for Payer: WPPA Medicare Advantage	$463.32

Antiphospholipid Ab Pnl QST

Facility

$772.20

Service Code	HCPCS 83516
Hospital Charge Code	3553516
Hospital Revenue Code	300
Min. Negotiated Rate	$694.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$694.98
Rate for Payer: UnitedHealthcare Commercial	$733.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Anti-Streptolysin O QST

Facility

$113.00

Service Code	HCPCS 86060
Hospital Charge Code	3550072
Hospital Revenue Code	300
Min. Negotiated Rate	$7.30
Max. Negotiated Rate	$107.35
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.20
Rate for Payer: Humana Medicare Advantage	$47.46
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: UnitedHealthcare Medicaid	$7.30
Rate for Payer: WPPA Medicare Advantage	$67.80

Anti-Streptolysin O QST

Facility

$113.00

Service Code	HCPCS 86060
Hospital Charge Code	3550072
Hospital Revenue Code	300
Min. Negotiated Rate	$101.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges