Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Bill Only Crossmatch

Facility

$185.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$42.03
Max. Negotiated Rate	$175.75
Rate for Payer: Aetna Commercial	$166.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$42.03
Rate for Payer: Humana Medicare Advantage	$77.70
Rate for Payer: UnitedHealthcare Commercial	$175.75
Rate for Payer: UnitedHealthcare Medicaid	$74.00
Rate for Payer: WPPA Medicare Advantage	$111.00

Bill Only Crossmatch

Facility

$185.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$166.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$166.50
Rate for Payer: UnitedHealthcare Commercial	$175.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only DAT

Facility

$47.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$44.65
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.24
Rate for Payer: Humana Medicare Advantage	$19.74
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: UnitedHealthcare Medicaid	$5.39
Rate for Payer: WPPA Medicare Advantage	$28.20

Bill Only DAT

Facility

$47.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only DAT C3

Facility

$47.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$44.65
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.24
Rate for Payer: Humana Medicare Advantage	$19.74
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: UnitedHealthcare Medicaid	$5.39
Rate for Payer: WPPA Medicare Advantage	$28.20

Bill Only DAT C3

Facility

$47.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only DAT IgG

Facility

$47.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$44.65
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.24
Rate for Payer: Humana Medicare Advantage	$19.74
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: UnitedHealthcare Medicaid	$5.39
Rate for Payer: WPPA Medicare Advantage	$28.20

Bill Only DAT IgG

Facility

$47.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only DAT Poly

Facility

$47.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only DAT Poly

Facility

$47.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$44.65
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.24
Rate for Payer: Humana Medicare Advantage	$19.74
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: UnitedHealthcare Medicaid	$5.39
Rate for Payer: WPPA Medicare Advantage	$28.20

Bill Only Elution

Facility

$138.00

Service Code	HCPCS 86860
Hospital Charge Code	3550289
Hospital Revenue Code	300
Min. Negotiated Rate	$19.23
Max. Negotiated Rate	$131.10
Rate for Payer: Aetna Commercial	$124.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$19.23
Rate for Payer: Humana Medicare Advantage	$57.96
Rate for Payer: UnitedHealthcare Commercial	$131.10
Rate for Payer: UnitedHealthcare Medicaid	$129.47
Rate for Payer: WPPA Medicare Advantage	$82.80

Bill Only Elution

Facility

$138.00

Service Code	HCPCS 86860
Hospital Charge Code	3550289
Hospital Revenue Code	300
Min. Negotiated Rate	$124.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$124.20
Rate for Payer: UnitedHealthcare Commercial	$131.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only Fetal Screen

Facility

$170.00

Service Code	HCPCS 83030
Hospital Charge Code	3552417
Hospital Revenue Code	300
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$161.50
Rate for Payer: Aetna Commercial	$153.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$56.65
Rate for Payer: Humana Medicare Advantage	$71.40
Rate for Payer: UnitedHealthcare Commercial	$161.50
Rate for Payer: UnitedHealthcare Medicaid	$10.74
Rate for Payer: WPPA Medicare Advantage	$102.00

Bill Only Fetal Screen

Facility

$170.00

Service Code	HCPCS 83030
Hospital Charge Code	3552417
Hospital Revenue Code	300
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$153.00
Rate for Payer: UnitedHealthcare Commercial	$161.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only Fungal Yeast ID AMS

Facility

$64.00

Service Code	HCPCS 87106
Hospital Charge Code	3551706
Hospital Revenue Code	300
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only Fungal Yeast ID AMS

Facility

$64.00

Service Code	HCPCS 87106
Hospital Charge Code	3551706
Hospital Revenue Code	300
Min. Negotiated Rate	$10.32
Max. Negotiated Rate	$60.80
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$38.54
Rate for Payer: Humana Medicare Advantage	$26.88
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: UnitedHealthcare Medicaid	$10.32
Rate for Payer: WPPA Medicare Advantage	$38.40

Bill Only Indirect Antiglobulin

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

Bill Only Indirect Antiglobulin

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

Bill Only Liver Fibrosis Panel

Facility

$21.00

Service Code	HCPCS 82947
Hospital Charge Code	3551979
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only Liver Fibrosis Panel

Facility

$21.00

Service Code	HCPCS 82947
Hospital Charge Code	3551979
Hospital Revenue Code	300
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8.64
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$3.93
Rate for Payer: WPPA Medicare Advantage	$12.60

Bill Only Micro or Agar Dilution (MIC)

Facility

$100.00

Service Code	HCPCS 87077
Hospital Charge Code	3550940
Hospital Revenue Code	300
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$30.65
Rate for Payer: Humana Medicare Advantage	$42.00
Rate for Payer: UnitedHealthcare Commercial	$95.00
Rate for Payer: UnitedHealthcare Medicaid	$8.08
Rate for Payer: WPPA Medicare Advantage	$60.00

Bill Only Micro or Agar Dilution (MIC)

Facility

$100.00

Service Code	HCPCS 87077
Hospital Charge Code	3550940
Hospital Revenue Code	300
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$90.00
Rate for Payer: UnitedHealthcare Commercial	$95.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only Miscellaneous Lab

Facility

$47.00

Service Code	HCPCS 36415
Hospital Charge Code	3550890
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$44.65
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$12.05
Rate for Payer: Humana Medicare Advantage	$19.74
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: UnitedHealthcare Medicaid	$18.80
Rate for Payer: WPPA Medicare Advantage	$28.20

Bill Only Miscellaneous Lab

Facility

$47.00

Service Code	HCPCS 36415
Hospital Charge Code	3550890
Hospital Revenue Code	300
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only RBC, Pre-treat

Facility

$210.00

Service Code	HCPCS 86972
Hospital Charge Code	3556972
Hospital Revenue Code	300
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$199.50
Rate for Payer: Aetna Commercial	$189.00
Rate for Payer: Humana Medicare Advantage	$88.20
Rate for Payer: UnitedHealthcare Commercial	$199.50
Rate for Payer: UnitedHealthcare Medicaid	$84.00
Rate for Payer: WPPA Medicare Advantage	$126.00

Know your out-of-pocket cost for care.

All Charges