Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

Corn, Grass (g202) IgE QST

Facility

$32.00

Service Code	HCPCS 86003
Hospital Charge Code	3553490
Hospital Revenue Code	300
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.80
Rate for Payer: UnitedHealthcare Commercial	$30.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Corn, Grass (g202) IgE QST

Facility

$32.00

Service Code	HCPCS 86003
Hospital Charge Code	3553490
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna Commercial	$28.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$13.44
Rate for Payer: UnitedHealthcare Commercial	$30.40
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$19.20

CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC

Facility

$24,272.28

Service Code	MSDRG 233
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$24,272.28
Rate for Payer: UnitedHealthcare Medicaid	$24,272.28
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC

Facility

$20,269.26

Service Code	MSDRG 234
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$20,269.26
Rate for Payer: UnitedHealthcare Medicaid	$20,269.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC

Facility

$14,868.36

Service Code	MSDRG 235
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,868.36
Rate for Payer: UnitedHealthcare Medicaid	$14,868.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC

Facility

$14,169.42

Service Code	MSDRG 236
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,169.42
Rate for Payer: UnitedHealthcare Medicaid	$14,169.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CORONARY BYPASS WITH PTCA WITH MCC

Facility

$30,213.27

Service Code	MSDRG 231
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$30,213.27
Rate for Payer: UnitedHealthcare Medicaid	$30,213.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CORONARY BYPASS WITH PTCA WITHOUT MCC

Facility

$21,730.68

Service Code	MSDRG 232
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$21,730.68
Rate for Payer: UnitedHealthcare Medicaid	$21,730.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC

Facility

$12,263.22

Service Code	MSDRG 323
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,263.22
Rate for Payer: UnitedHealthcare Medicaid	$12,263.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$11,691.36

Service Code	MSDRG 324
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,691.36
Rate for Payer: UnitedHealthcare Medicaid	$11,691.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE

Facility

$11,119.50

Service Code	MSDRG 325
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,119.50
Rate for Payer: UnitedHealthcare Medicaid	$11,119.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Corrected - Serological Immediate Spin

Facility

$91.00

Service Code	HCPCS 86920
Hospital Charge Code	3560149
Hospital Revenue Code	300
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$86.45
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$46.33
Rate for Payer: Humana Medicare Advantage	$38.22
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: UnitedHealthcare Medicaid	$36.40
Rate for Payer: WPPA Medicare Advantage	$54.60

Corrected - Serological Immediate Spin

Facility

$91.00

Service Code	HCPCS 86920
Hospital Charge Code	3560149
Hospital Revenue Code	300
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Corrected - XM AHG Tube 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

Corrected - XM AHG Tube 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

Cortisol, A.M. QST

Facility

$102.00

Service Code	HCPCS 82533
Hospital Charge Code	3559035
Hospital Revenue Code	300
Min. Negotiated Rate	$16.30
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$60.54
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$16.30
Rate for Payer: WPPA Medicare Advantage	$61.20

Cortisol, A.M. QST

Facility

$102.00

Service Code	HCPCS 82533
Hospital Charge Code	3559035
Hospital Revenue Code	300
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cortisol, Free QST

Facility

$236.00

Service Code	HCPCS 82530
Hospital Charge Code	3558253
Hospital Revenue Code	300
Min. Negotiated Rate	$212.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$212.40
Rate for Payer: UnitedHealthcare Commercial	$224.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cortisol, Free QST

Facility

$236.00

Service Code	HCPCS 82530
Hospital Charge Code	3558253
Hospital Revenue Code	300
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$224.20
Rate for Payer: Aetna Commercial	$212.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$66.51
Rate for Payer: Humana Medicare Advantage	$99.12
Rate for Payer: UnitedHealthcare Commercial	$224.20
Rate for Payer: UnitedHealthcare Medicaid	$15.00
Rate for Payer: WPPA Medicare Advantage	$141.60

Cortisol, Free, U24 QST

Facility

$599.00

Hospital Charge Code	3557355
Hospital Revenue Code	300
Min. Negotiated Rate	$239.60
Max. Negotiated Rate	$569.05
Rate for Payer: Aetna Commercial	$539.10
Rate for Payer: Humana Medicare Advantage	$251.58
Rate for Payer: UnitedHealthcare Commercial	$569.05
Rate for Payer: UnitedHealthcare Medicaid	$239.60
Rate for Payer: WPPA Medicare Advantage	$359.40

Cortisol, Free, U24 QST

Facility

$599.00

Hospital Charge Code	3557355
Hospital Revenue Code	300
Min. Negotiated Rate	$539.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$539.10
Rate for Payer: UnitedHealthcare Commercial	$569.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cortisol, P.M. QST

Facility

$102.00

Service Code	HCPCS 82533
Hospital Charge Code	3559035
Hospital Revenue Code	300
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cortisol, P.M. QST

Facility

$102.00

Service Code	HCPCS 82533
Hospital Charge Code	3559035
Hospital Revenue Code	300
Min. Negotiated Rate	$16.30
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$60.54
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$16.30
Rate for Payer: WPPA Medicare Advantage	$61.20

Cortisol, Total QST

Facility

$102.00

Service Code	HCPCS 82533
Hospital Charge Code	3551914
Hospital Revenue Code	300
Min. Negotiated Rate	$16.30
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$60.54
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$16.30
Rate for Payer: WPPA Medicare Advantage	$61.20

Know your out-of-pocket cost for care.

All Charges