Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES

Facility

$38,981.79

Service Code	MSDRG 212
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$38,981.79
Rate for Payer: UnitedHealthcare Medicaid	$38,981.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION

Facility

$23,954.58

Service Code	MSDRG 317
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$23,954.58
Rate for Payer: UnitedHealthcare Medicaid	$23,954.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CONCUSSION WITH CC

Facility

$4,956.12

Service Code	MSDRG 089
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

CONCUSSION WITH MCC

Facility

$6,099.84

Service Code	MSDRG 088
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,099.84
Rate for Payer: UnitedHealthcare Medicaid	$6,099.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CONCUSSION WITHOUT CC/MCC

Facility

$3,717.09

Service Code	MSDRG 090
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,717.09
Rate for Payer: UnitedHealthcare Medicaid	$3,717.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

conjugated estrogens 0.45 mg Tab [HMC]

Facility

$25.72

Service Code	NDC 00046110181
Hospital Charge Code	3804852
Hospital Revenue Code	250
Min. Negotiated Rate	$10.29
Max. Negotiated Rate	$24.43
Rate for Payer: Aetna Commercial	$23.15
Rate for Payer: Humana Medicare Advantage	$10.80
Rate for Payer: UnitedHealthcare Commercial	$24.43
Rate for Payer: UnitedHealthcare Medicaid	$10.29
Rate for Payer: WPPA Medicare Advantage	$15.43

conjugated estrogens 0.45 mg Tab [HMC]

Facility

$25.72

Service Code	NDC 00046110181
Hospital Charge Code	3804852
Hospital Revenue Code	250
Min. Negotiated Rate	$23.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.15
Rate for Payer: UnitedHealthcare Commercial	$24.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

conjugated estrogens 0.625 mg Tab [HMC]

Facility

$25.72

Service Code	NDC 00046110281
Hospital Charge Code	3803373
Hospital Revenue Code	250
Min. Negotiated Rate	$10.29
Max. Negotiated Rate	$24.43
Rate for Payer: Aetna Commercial	$23.15
Rate for Payer: Humana Medicare Advantage	$10.80
Rate for Payer: UnitedHealthcare Commercial	$24.43
Rate for Payer: UnitedHealthcare Medicaid	$10.29
Rate for Payer: WPPA Medicare Advantage	$15.43

conjugated estrogens 0.625 mg Tab [HMC]

Facility

$25.72

Service Code	NDC 00046110281
Hospital Charge Code	3803373
Hospital Revenue Code	250
Min. Negotiated Rate	$23.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.15
Rate for Payer: UnitedHealthcare Commercial	$24.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

conjugated estrogens 25 mg IV Inj [HMC]

Facility

$682.49

Service Code	HCPCS J1410
Hospital Charge Code	3801406
Hospital Revenue Code	250
Min. Negotiated Rate	$614.24
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$614.24
Rate for Payer: UnitedHealthcare Commercial	$648.37
Rate for Payer: WPPA Medicare Advantage	$1,200.00

conjugated estrogens 25 mg IV Inj [HMC]

Facility

$682.49

Service Code	HCPCS J1410
Hospital Charge Code	3801406
Hospital Revenue Code	250
Min. Negotiated Rate	$286.65
Max. Negotiated Rate	$648.37
Rate for Payer: Aetna Commercial	$614.24
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$478.73
Rate for Payer: Humana Medicare Advantage	$286.65
Rate for Payer: UnitedHealthcare Commercial	$648.37
Rate for Payer: UnitedHealthcare Medicaid	$391.76
Rate for Payer: WPPA Medicare Advantage	$409.49

CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$7,084.71

Service Code	MSDRG 546
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,084.71
Rate for Payer: UnitedHealthcare Medicaid	$7,084.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$15,217.83

Service Code	MSDRG 545
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$15,217.83
Rate for Payer: UnitedHealthcare Medicaid	$15,217.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$2,160.36

Service Code	MSDRG 547
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,160.36
Rate for Payer: UnitedHealthcare Medicaid	$2,160.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Co-Oximetry Arterial

Facility

$74.00

Service Code	HCPCS 82550
Hospital Charge Code	3553550
Hospital Revenue Code	300
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$70.30
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.11
Rate for Payer: Humana Medicare Advantage	$31.08
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: UnitedHealthcare Medicaid	$6.51
Rate for Payer: WPPA Medicare Advantage	$44.40

Co-Oximetry Arterial

Facility

$74.00

Service Code	HCPCS 82550
Hospital Charge Code	3553550
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

Co-Oximetry Venous

Facility

$208.00

Service Code	HCPCS 82805
Hospital Charge Code	3562805
Hospital Revenue Code	300
Min. Negotiated Rate	$66.95
Max. Negotiated Rate	$197.60
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$117.93
Rate for Payer: Humana Medicare Advantage	$87.36
Rate for Payer: UnitedHealthcare Commercial	$197.60
Rate for Payer: UnitedHealthcare Medicaid	$66.95
Rate for Payer: WPPA Medicare Advantage	$124.80

Co-Oximetry Venous

Facility

$208.00

Service Code	HCPCS 82805
Hospital Charge Code	3562805
Hospital Revenue Code	300
Min. Negotiated Rate	$187.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: UnitedHealthcare Commercial	$197.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Copper QST

Facility

$50.00

Service Code	HCPCS 82525
Hospital Charge Code	3552525
Hospital Revenue Code	300
Min. Negotiated Rate	$12.41
Max. Negotiated Rate	$47.50
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$26.90
Rate for Payer: Humana Medicare Advantage	$21.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: UnitedHealthcare Medicaid	$12.41
Rate for Payer: WPPA Medicare Advantage	$30.00

Copper QST

Facility

$50.00

Service Code	HCPCS 82525
Hospital Charge Code	3552525
Hospital Revenue Code	300
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cord ABO/Rh Gel

Facility

$63.00

Service Code	HCPCS 86900
Hospital Charge Code	3560081
Hospital Revenue Code	300
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$210.75
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$210.75
Rate for Payer: Humana Medicare Advantage	$26.46
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: UnitedHealthcare Medicaid	$2.99
Rate for Payer: WPPA Medicare Advantage	$37.80

Cord ABO/Rh Gel

Facility

$63.00

Service Code	HCPCS 86900
Hospital Charge Code	3560081
Hospital Revenue Code	300
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cord DAT Gel

Facility

$151.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$143.45
Rate for Payer: Aetna Commercial	$135.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.24
Rate for Payer: Humana Medicare Advantage	$63.42
Rate for Payer: UnitedHealthcare Commercial	$143.45
Rate for Payer: UnitedHealthcare Medicaid	$5.39
Rate for Payer: WPPA Medicare Advantage	$90.60

Cord DAT Gel

Facility

$151.00

Service Code	HCPCS 86880
Hospital Charge Code	3560016
Hospital Revenue Code	300
Min. Negotiated Rate	$135.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$135.90
Rate for Payer: UnitedHealthcare Commercial	$143.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CORN (F8) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552812
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$12.60

Know your out-of-pocket cost for care.

All Charges