Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Complement, Total (CH50) QST

Facility

$155.00

Service Code	HCPCS 86162
Hospital Charge Code	3556162
Hospital Revenue Code	300
Min. Negotiated Rate	$20.32
Max. Negotiated Rate	$147.25
Rate for Payer: Aetna Commercial	$139.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$79.39
Rate for Payer: Humana Medicare Advantage	$65.10
Rate for Payer: UnitedHealthcare Commercial	$147.25
Rate for Payer: UnitedHealthcare Medicaid	$20.32
Rate for Payer: WPPA Medicare Advantage	$93.00

Complement, Total (CH50) QST

Facility

$155.00

Service Code	HCPCS 86162
Hospital Charge Code	3556162
Hospital Revenue Code	300
Min. Negotiated Rate	$139.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$139.50
Rate for Payer: UnitedHealthcare Commercial	$147.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

COMPLEX AORTIC ARCH PROCEDURES

Facility

$40,570.29

Service Code	MSDRG 209
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$40,570.29
Rate for Payer: UnitedHealthcare Medicaid	$40,570.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

COMPLICATED PEPTIC ULCER WITH CC

Facility

$4,987.89

Service Code	MSDRG 381
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,987.89
Rate for Payer: UnitedHealthcare Medicaid	$4,987.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

COMPLICATED PEPTIC ULCER WITH MCC

Facility

$9,054.45

Service Code	MSDRG 380
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,054.45
Rate for Payer: UnitedHealthcare Medicaid	$9,054.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

COMPLICATED PEPTIC ULCER WITHOUT CC/MCC

Facility

$3,685.32

Service Code	MSDRG 382
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,685.32
Rate for Payer: UnitedHealthcare Medicaid	$3,685.32
Rate for Payer: WPPA Medicare Advantage	$1,200.00

COMPLICATIONS OF TREATMENT WITH CC

Facility

$3,049.92

Service Code	MSDRG 920
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,049.92
Rate for Payer: UnitedHealthcare Medicaid	$3,049.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

COMPLICATIONS OF TREATMENT WITH MCC

Facility

$5,559.75

Service Code	MSDRG 919
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,559.75
Rate for Payer: UnitedHealthcare Medicaid	$5,559.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

COMPLICATIONS OF TREATMENT WITHOUT CC/MCC

Facility

$2,096.82

Service Code	MSDRG 921
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,096.82
Rate for Payer: UnitedHealthcare Medicaid	$2,096.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Comprehensive Metabolic Panel

Facility

$82.00

Service Code	HCPCS 80053
Hospital Charge Code	3551302
Hospital Revenue Code	300
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$77.90
Rate for Payer: Aetna Commercial	$73.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$22.68
Rate for Payer: Humana Medicare Advantage	$34.44
Rate for Payer: UnitedHealthcare Commercial	$77.90
Rate for Payer: UnitedHealthcare Medicaid	$10.56
Rate for Payer: WPPA Medicare Advantage	$49.20

Comprehensive Metabolic Panel

Facility

$82.00

Service Code	HCPCS 80053
Hospital Charge Code	3551302
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

Compression Arm Sleeve Medium 12-14

Facility

$90.00

Hospital Charge Code	3258370
Hospital Revenue Code	270
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna Commercial	$81.00
Rate for Payer: Humana Medicare Advantage	$37.80
Rate for Payer: UnitedHealthcare Commercial	$85.50
Rate for Payer: UnitedHealthcare Medicaid	$36.00
Rate for Payer: WPPA Medicare Advantage	$54.00

Compression Arm Sleeve Medium 12-14

Facility

$90.00

Hospital Charge Code	3258370
Hospital Revenue Code	270
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$81.00
Rate for Payer: UnitedHealthcare Commercial	$85.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Compression Bandage Kit 2-Layer CoFlex TLC Lite - Light Compression 25-30 mmHg

Facility

$44.00

Hospital Charge Code	3251262
Hospital Revenue Code	270
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.60
Rate for Payer: UnitedHealthcare Commercial	$41.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Compression Bandage Kit 2-Layer CoFlex TLC Lite - Light Compression 25-30 mmHg

Facility

$44.00

Hospital Charge Code	3251262
Hospital Revenue Code	270
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$41.80
Rate for Payer: Aetna Commercial	$39.60
Rate for Payer: Humana Medicare Advantage	$18.48
Rate for Payer: UnitedHealthcare Commercial	$41.80
Rate for Payer: UnitedHealthcare Medicaid	$17.60
Rate for Payer: WPPA Medicare Advantage	$26.40

Compression Bandage Kit 2-Layer CoFlex TLC Standard Compression 35-40 mmHg

Facility

$43.00

Hospital Charge Code	3251261
Hospital Revenue Code	270
Min. Negotiated Rate	$17.20
Max. Negotiated Rate	$40.85
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$18.06
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: UnitedHealthcare Medicaid	$17.20
Rate for Payer: WPPA Medicare Advantage	$25.80

Compression Bandage Kit 2-Layer CoFlex TLC Standard Compression 35-40 mmHg

Facility

$43.00

Hospital Charge Code	3251261
Hospital Revenue Code	270
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Compression Bandage Kit 4-Layer 4 Dry Non-Latex

Facility

$61.00

Hospital Charge Code	3251260
Hospital Revenue Code	270
Min. Negotiated Rate	$54.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.90
Rate for Payer: UnitedHealthcare Commercial	$57.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Compression Bandage Kit 4-Layer 4 Dry Non-Latex

Facility

$61.00

Hospital Charge Code	3251260
Hospital Revenue Code	270
Min. Negotiated Rate	$24.40
Max. Negotiated Rate	$57.95
Rate for Payer: Aetna Commercial	$54.90
Rate for Payer: Humana Medicare Advantage	$25.62
Rate for Payer: UnitedHealthcare Commercial	$57.95
Rate for Payer: UnitedHealthcare Medicaid	$24.40
Rate for Payer: WPPA Medicare Advantage	$36.60

COMPR FT SCRW, 2.5 MICRO, 30MM LGTH

Facility

$1,168.00

Hospital Charge Code	3258538
Hospital Revenue Code	270
Min. Negotiated Rate	$1,051.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,051.20
Rate for Payer: UnitedHealthcare Commercial	$1,109.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

COMPR FT SCRW, 2.5 MICRO, 30MM LGTH

Facility

$1,168.00

Hospital Charge Code	3258538
Hospital Revenue Code	270
Min. Negotiated Rate	$467.20
Max. Negotiated Rate	$1,109.60
Rate for Payer: Aetna Commercial	$1,051.20
Rate for Payer: Humana Medicare Advantage	$490.56
Rate for Payer: UnitedHealthcare Commercial	$1,109.60
Rate for Payer: UnitedHealthcare Medicaid	$467.20
Rate for Payer: WPPA Medicare Advantage	$700.80

COMPR FT SCRW, 2.5 MICRO, 38MM LGTH

Facility

$1,168.00

Hospital Charge Code	3258550
Hospital Revenue Code	270
Min. Negotiated Rate	$467.20
Max. Negotiated Rate	$1,109.60
Rate for Payer: Aetna Commercial	$1,051.20
Rate for Payer: Humana Medicare Advantage	$490.56
Rate for Payer: UnitedHealthcare Commercial	$1,109.60
Rate for Payer: UnitedHealthcare Medicaid	$467.20
Rate for Payer: WPPA Medicare Advantage	$700.80

COMPR FT SCRW, 2.5 MICRO, 38MM LGTH

Facility

$1,168.00

Hospital Charge Code	3258550
Hospital Revenue Code	270
Min. Negotiated Rate	$1,051.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,051.20
Rate for Payer: UnitedHealthcare Commercial	$1,109.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Computer XM OK - Computer Crossmatch Interp

Facility

$113.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
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

Computer XM OK - Computer Crossmatch Interp

Facility

$113.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$42.03
Max. Negotiated Rate	$107.35
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$42.03
Rate for Payer: Humana Medicare Advantage	$47.46
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: UnitedHealthcare Medicaid	$45.20
Rate for Payer: WPPA Medicare Advantage	$67.80

Know your out-of-pocket cost for care.

All Charges