Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Critical Care Ill/Injured Patient Addl 30 Min 99292

Facility

$541.00

Service Code	HCPCS 99292
Hospital Charge Code	3300200
Hospital Revenue Code	450
Min. Negotiated Rate	$58.86
Max. Negotiated Rate	$513.95
Rate for Payer: Aetna Commercial	$486.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$303.29
Rate for Payer: Humana Medicare Advantage	$227.22
Rate for Payer: UnitedHealthcare Commercial	$513.95
Rate for Payer: UnitedHealthcare Medicaid	$58.86
Rate for Payer: WPPA Medicare Advantage	$324.60

CRNA Meals

Facility

$38.00

Hospital Charge Code	5635500
Hospital Revenue Code	991
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

CRNA Meals

Facility

$38.00

Hospital Charge Code	5635500
Hospital Revenue Code	991
Min. Negotiated Rate	$15.20
Max. Negotiated Rate	$36.10
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: UnitedHealthcare Medicaid	$15.20
Rate for Payer: WPPA Medicare Advantage	$22.80

Cryoglobulin (%Cryocrit) QST

Facility

$123.00

Service Code	HCPCS 82595
Hospital Charge Code	3552595
Hospital Revenue Code	300
Min. Negotiated Rate	$110.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$110.70
Rate for Payer: UnitedHealthcare Commercial	$116.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Cryoglobulin (%Cryocrit) QST

Facility

$123.00

Service Code	HCPCS 82595
Hospital Charge Code	3552595
Hospital Revenue Code	300
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$116.85
Rate for Payer: Aetna Commercial	$110.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$18.75
Rate for Payer: Humana Medicare Advantage	$51.66
Rate for Payer: UnitedHealthcare Commercial	$116.85
Rate for Payer: UnitedHealthcare Medicaid	$6.47
Rate for Payer: WPPA Medicare Advantage	$73.80

Cryptococcus AB Serum REF

Facility

$100.00

Service Code	HCPCS 86403
Hospital Charge Code	3556641
Hospital Revenue Code	300
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$21.88
Rate for Payer: Humana Medicare Advantage	$42.00
Rate for Payer: UnitedHealthcare Commercial	$95.00
Rate for Payer: UnitedHealthcare Medicaid	$11.54
Rate for Payer: WPPA Medicare Advantage	$60.00

Cryptococcus AB Serum REF

Facility

$100.00

Service Code	HCPCS 86403
Hospital Charge Code	3556641
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

CRYPTOSPORIDIUM AG, EIA

Facility

$20.00

Service Code	HCPCS 87328
Hospital Charge Code	3557328
Hospital Revenue Code	300
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CRYPTOSPORIDIUM AG, EIA

Facility

$20.00

Service Code	HCPCS 87328
Hospital Charge Code	3557328
Hospital Revenue Code	300
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$60.35
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$60.35
Rate for Payer: Humana Medicare Advantage	$8.40
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: UnitedHealthcare Medicaid	$11.75
Rate for Payer: WPPA Medicare Advantage	$12.00

CSF Cell Count w/Diff

Facility

$128.00

Service Code	HCPCS 89051
Hospital Charge Code	3550767
Hospital Revenue Code	300
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$121.60
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$41.45
Rate for Payer: Humana Medicare Advantage	$53.76
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: UnitedHealthcare Medicaid	$4.76
Rate for Payer: WPPA Medicare Advantage	$76.80

CSF Cell Count w/Diff

Facility

$128.00

Service Code	HCPCS 89051
Hospital Charge Code	3550767
Hospital Revenue Code	300
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Abdomen and Pelvis w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 74177 TC
Hospital Charge Code	3740705
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,421.20
Rate for Payer: Aetna Commercial	$1,346.40
Rate for Payer: UnitedHealthcare Commercial	$1,421.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Abdomen and Pelvis w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 74177 TC
Hospital Charge Code	3740705
Hospital Revenue Code	350
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$1,421.20
Rate for Payer: Aetna Commercial	$1,346.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$628.32
Rate for Payer: UnitedHealthcare Commercial	$1,421.20
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$897.60

CT Abdomen and Pelvis w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 74176 TC
Hospital Charge Code	3740695
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Abdomen and Pelvis w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 74176 TC
Hospital Charge Code	3740695
Hospital Revenue Code	350
Min. Negotiated Rate	$131.00
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$610.26
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: UnitedHealthcare Medicaid	$131.00
Rate for Payer: WPPA Medicare Advantage	$871.80

CT Abdomen and Pelvis w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 74178 TC
Hospital Charge Code	3740710
Hospital Revenue Code	350
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$1,526.65
Rate for Payer: Aetna Commercial	$1,446.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$674.94
Rate for Payer: UnitedHealthcare Commercial	$1,526.65
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$964.20

CT Abdomen and Pelvis w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 74178 TC
Hospital Charge Code	3740710
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,526.65
Rate for Payer: Aetna Commercial	$1,446.30
Rate for Payer: UnitedHealthcare Commercial	$1,526.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Abdomen w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 74160 TC
Hospital Charge Code	3740311
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,421.20
Rate for Payer: Aetna Commercial	$1,346.40
Rate for Payer: UnitedHealthcare Commercial	$1,421.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Abdomen w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 74160 TC
Hospital Charge Code	3740311
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,421.20
Rate for Payer: Aetna Commercial	$1,346.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$628.32
Rate for Payer: UnitedHealthcare Commercial	$1,421.20
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$897.60

CT Abdomen w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 74150 TC
Hospital Charge Code	3740303
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Abdomen w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 74150 TC
Hospital Charge Code	3740303
Hospital Revenue Code	350
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$610.26
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$871.80

CT Abdomen w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 74170 TC
Hospital Charge Code	3740188
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,526.65
Rate for Payer: Aetna Commercial	$1,446.30
Rate for Payer: UnitedHealthcare Commercial	$1,526.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Abdomen w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 74170 TC
Hospital Charge Code	3740188
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,526.65
Rate for Payer: Aetna Commercial	$1,446.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$674.94
Rate for Payer: UnitedHealthcare Commercial	$1,526.65
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$964.20

CT Angio Abdomen

Facility

$2,528.00

Service Code	HCPCS 74175 TC
Hospital Charge Code	3740575
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Abdomen

Facility

$2,528.00

Service Code	HCPCS 74175 TC
Hospital Charge Code	3740575
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,186.59
Rate for Payer: Humana Medicare Advantage	$1,061.76
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$1,516.80

Know your out-of-pocket cost for care.

All Charges