Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

Bill Only Ref Antibody ID

Facility

$126.00

Service Code	HCPCS 86870
Hospital Charge Code	3560222
Hospital Revenue Code	300
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$113.40
Rate for Payer: UnitedHealthcare Commercial	$119.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only Ref Antibody ID

Facility

$126.00

Service Code	HCPCS 86870
Hospital Charge Code	3560222
Hospital Revenue Code	300
Min. Negotiated Rate	$52.92
Max. Negotiated Rate	$252.83
Rate for Payer: Aetna Commercial	$113.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$97.50
Rate for Payer: Humana Medicare Advantage	$52.92
Rate for Payer: UnitedHealthcare Commercial	$119.70
Rate for Payer: UnitedHealthcare Medicaid	$252.83
Rate for Payer: WPPA Medicare Advantage	$75.60

Bill Only Rh

Facility

$38.00

Service Code	HCPCS 86901
Hospital Charge Code	3560198
Hospital Revenue Code	300
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only Rh

Facility

$38.00

Service Code	HCPCS 86901
Hospital Charge Code	3560198
Hospital Revenue Code	300
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$61.64
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$61.64
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: UnitedHealthcare Medicaid	$2.99
Rate for Payer: WPPA Medicare Advantage	$22.80

Bill Only Rh Phenotype

Facility

$107.00

Service Code	HCPCS 86906
Hospital Charge Code	3556906
Hospital Revenue Code	300
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$101.65
Rate for Payer: Aetna Commercial	$96.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.05
Rate for Payer: Humana Medicare Advantage	$44.94
Rate for Payer: UnitedHealthcare Commercial	$101.65
Rate for Payer: UnitedHealthcare Medicaid	$7.75
Rate for Payer: WPPA Medicare Advantage	$64.20

Bill Only Rh Phenotype

Facility

$107.00

Service Code	HCPCS 86906
Hospital Charge Code	3556906
Hospital Revenue Code	300
Min. Negotiated Rate	$96.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$96.30
Rate for Payer: UnitedHealthcare Commercial	$101.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill Only Sensitivity Mic KSO FSI

Facility

$158.00

Service Code	HCPCS 87186
Hospital Charge Code	3550957
Hospital Revenue Code	300
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$150.10
Rate for Payer: Aetna Commercial	$142.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$32.94
Rate for Payer: Humana Medicare Advantage	$66.36
Rate for Payer: UnitedHealthcare Commercial	$150.10
Rate for Payer: UnitedHealthcare Medicaid	$8.65
Rate for Payer: WPPA Medicare Advantage	$94.80

Bill Only Sensitivity Mic KSO FSI

Facility

$158.00

Service Code	HCPCS 87186
Hospital Charge Code	3550957
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

Bill only T3 Auto Ab QST

Facility

$242.00

Service Code	HCPCS 83519
Hospital Charge Code	3555199
Hospital Revenue Code	300
Min. Negotiated Rate	$217.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$217.80
Rate for Payer: UnitedHealthcare Commercial	$229.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Bill only T3 Auto Ab QST

Facility

$242.00

Service Code	HCPCS 83519
Hospital Charge Code	3555199
Hospital Revenue Code	300
Min. Negotiated Rate	$15.64
Max. Negotiated Rate	$229.90
Rate for Payer: Aetna Commercial	$217.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.48
Rate for Payer: Humana Medicare Advantage	$101.64
Rate for Payer: UnitedHealthcare Commercial	$229.90
Rate for Payer: UnitedHealthcare Medicaid	$15.64
Rate for Payer: WPPA Medicare Advantage	$145.20

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC

Facility

$9,308.61

Service Code	MSDRG 478
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,308.61
Rate for Payer: UnitedHealthcare Medicaid	$9,308.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$13,089.24

Service Code	MSDRG 477
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$13,089.24
Rate for Payer: UnitedHealthcare Medicaid	$13,089.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC

Facility

$7,052.94

Service Code	MSDRG 479
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,052.94
Rate for Payer: UnitedHealthcare Medicaid	$7,052.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Biopsy Needle-Gun Max-Core Disposable 14g X 10cm Coaxile 7.8cm

Facility

$113.86

Hospital Charge Code	3255670
Hospital Revenue Code	270
Min. Negotiated Rate	$45.54
Max. Negotiated Rate	$108.17
Rate for Payer: Aetna Commercial	$102.47
Rate for Payer: Humana Medicare Advantage	$47.82
Rate for Payer: UnitedHealthcare Commercial	$108.17
Rate for Payer: UnitedHealthcare Medicaid	$45.54
Rate for Payer: WPPA Medicare Advantage	$68.32

Biopsy Needle-Gun Max-Core Disposable 14g X 10cm Coaxile 7.8cm

Facility

$113.86

Hospital Charge Code	3255670
Hospital Revenue Code	270
Min. Negotiated Rate	$102.47
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$102.47
Rate for Payer: UnitedHealthcare Commercial	$108.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Biopsy Needle-Gun Max-Core Disposable 14g x 16cm Coaxile 13.8cm

Facility

$152.00

Hospital Charge Code	3255669
Hospital Revenue Code	270
Min. Negotiated Rate	$60.80
Max. Negotiated Rate	$144.40
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Humana Medicare Advantage	$63.84
Rate for Payer: UnitedHealthcare Commercial	$144.40
Rate for Payer: UnitedHealthcare Medicaid	$60.80
Rate for Payer: WPPA Medicare Advantage	$91.20

Biopsy Needle-Gun Max-Core Disposable 14g x 16cm Coaxile 13.8cm

Facility

$152.00

Hospital Charge Code	3255669
Hospital Revenue Code	270
Min. Negotiated Rate	$136.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: UnitedHealthcare Commercial	$144.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

biotene dry mouth gel 42g [HMC]

Facility

$37.21

Service Code	NDC 48582051201
Hospital Charge Code	3802929
Hospital Revenue Code	257
Min. Negotiated Rate	$14.88
Max. Negotiated Rate	$35.35
Rate for Payer: Aetna Commercial	$33.49
Rate for Payer: Humana Medicare Advantage	$15.63
Rate for Payer: UnitedHealthcare Commercial	$35.35
Rate for Payer: UnitedHealthcare Medicaid	$14.88
Rate for Payer: WPPA Medicare Advantage	$22.33

biotene dry mouth gel 42g [HMC]

Facility

$37.21

Service Code	NDC 48582051201
Hospital Charge Code	3802929
Hospital Revenue Code	257
Min. Negotiated Rate	$33.49
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.49
Rate for Payer: UnitedHealthcare Commercial	$35.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bisacodyl 10 mg Supp [HMC]

Facility

$6.27

Service Code	NDC 00574705012
Hospital Charge Code	3804552
Hospital Revenue Code	250
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$5.96
Rate for Payer: Aetna Commercial	$5.64
Rate for Payer: Humana Medicare Advantage	$2.63
Rate for Payer: UnitedHealthcare Commercial	$5.96
Rate for Payer: UnitedHealthcare Medicaid	$2.51
Rate for Payer: WPPA Medicare Advantage	$3.76

bisacodyl 10 mg Supp [HMC]

Facility

$6.27

Service Code	NDC 00574705012
Hospital Charge Code	3804552
Hospital Revenue Code	250
Min. Negotiated Rate	$5.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.64
Rate for Payer: UnitedHealthcare Commercial	$5.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

bisacodyl 5 mg Oral EC Tab [HMC]

Facility

$5.22

Service Code	NDC 00904640761
Hospital Charge Code	3805592
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

bisacodyl 5 mg Oral EC Tab [HMC]

Facility

$5.22

Service Code	NDC 00904640761
Hospital Charge Code	3805592
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

bisoprolol 5 mg Tab [HMC]

Facility

$9.21

Service Code	NDC 29300012613
Hospital Charge Code	3809515
Hospital Revenue Code	250
Min. Negotiated Rate	$8.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.29
Rate for Payer: UnitedHealthcare Commercial	$8.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges