Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

CT Wrist w/o Contrast Left

Facility

$1,453.00

Service Code	HCPCS 73200 LT
Hospital Charge Code	3740402
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 Wrist w/o Contrast Left

Facility

$1,453.00

Service Code	HCPCS 73200 LT
Hospital Charge Code	3740402
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 Wrist w/o Contrast Right

Facility

$1,453.00

Service Code	HCPCS 73200 RT
Hospital Charge Code	3740402
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 Wrist w/o Contrast Right

Facility

$1,453.00

Service Code	HCPCS 73200 RT
Hospital Charge Code	3740402
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 Wrist w/ + w/o Contrast Left

Facility

$1,607.00

Service Code	HCPCS 73202 LT
Hospital Charge Code	3740428
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 Wrist w/ + w/o Contrast Left

Facility

$1,607.00

Service Code	HCPCS 73202 LT
Hospital Charge Code	3740428
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 Wrist w/ + w/o Contrast Right

Facility

$1,607.00

Service Code	HCPCS 73202 RT
Hospital Charge Code	3740428
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 Wrist w/ + w/o Contrast Right

Facility

$1,607.00

Service Code	HCPCS 73202 RT
Hospital Charge Code	3740428
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

Culture, Aerobic Bacteria QST

Facility

$51.00

Service Code	HCPCS 87070
Hospital Charge Code	3550320
Hospital Revenue Code	300
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$48.45
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.88
Rate for Payer: Humana Medicare Advantage	$21.42
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: UnitedHealthcare Medicaid	$7.35
Rate for Payer: WPPA Medicare Advantage	$30.60

Culture, Aerobic Bacteria QST

Facility

$51.00

Service Code	HCPCS 87070
Hospital Charge Code	3550320
Hospital Revenue Code	300
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Culture, Anaerobic Bacteria w/ Gram Stain QST

Facility

$49.00

Service Code	HCPCS 87075
Hospital Charge Code	3550460
Hospital Revenue Code	300
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$44.10
Rate for Payer: UnitedHealthcare Commercial	$46.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Culture, Anaerobic Bacteria w/ Gram Stain QST

Facility

$49.00

Service Code	HCPCS 87075
Hospital Charge Code	3550460
Hospital Revenue Code	300
Min. Negotiated Rate	$9.47
Max. Negotiated Rate	$46.55
Rate for Payer: Aetna Commercial	$44.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.21
Rate for Payer: Humana Medicare Advantage	$20.58
Rate for Payer: UnitedHealthcare Commercial	$46.55
Rate for Payer: UnitedHealthcare Medicaid	$9.47
Rate for Payer: WPPA Medicare Advantage	$29.40

Culture, Blood QST

Facility

$122.00

Service Code	HCPCS 87040
Hospital Charge Code	3550106
Hospital Revenue Code	300
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$115.90
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$38.41
Rate for Payer: Humana Medicare Advantage	$51.24
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: UnitedHealthcare Medicaid	$9.45
Rate for Payer: WPPA Medicare Advantage	$73.20

Culture, Blood QST

Facility

$122.00

Service Code	HCPCS 87040
Hospital Charge Code	3550106
Hospital Revenue Code	300
Min. Negotiated Rate	$109.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Culture, CSF QST

Facility

$71.00

Service Code	HCPCS 87070
Hospital Charge Code	3551179
Hospital Revenue Code	300
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$67.45
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.88
Rate for Payer: Humana Medicare Advantage	$29.82
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: UnitedHealthcare Medicaid	$7.35
Rate for Payer: WPPA Medicare Advantage	$42.60

Culture, CSF QST

Facility

$71.00

Service Code	HCPCS 87070
Hospital Charge Code	3551179
Hospital Revenue Code	300
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Culture, Ear External ST

Facility

$71.00

Service Code	HCPCS 87070
Hospital Charge Code	3550312
Hospital Revenue Code	300
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$67.45
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.88
Rate for Payer: Humana Medicare Advantage	$29.82
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: UnitedHealthcare Medicaid	$7.35
Rate for Payer: WPPA Medicare Advantage	$42.60

Culture, Ear External ST

Facility

$71.00

Service Code	HCPCS 87070
Hospital Charge Code	3550312
Hospital Revenue Code	300
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Culture, Fungus (H,S,N) w/Direct Fluor./KOH QST

Facility

$145.00

Service Code	HCPCS 87101
Hospital Charge Code	3551187
Hospital Revenue Code	300
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$130.50
Rate for Payer: UnitedHealthcare Commercial	$137.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Culture, Fungus (H,S,N) w/Direct Fluor./KOH QST

Facility

$145.00

Service Code	HCPCS 87101
Hospital Charge Code	3551187
Hospital Revenue Code	300
Min. Negotiated Rate	$7.71
Max. Negotiated Rate	$137.75
Rate for Payer: Aetna Commercial	$130.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$24.15
Rate for Payer: Humana Medicare Advantage	$60.90
Rate for Payer: UnitedHealthcare Commercial	$137.75
Rate for Payer: UnitedHealthcare Medicaid	$7.71
Rate for Payer: WPPA Medicare Advantage	$87.00

Culture, Fungus, Other QST

Facility

$70.00

Service Code	HCPCS 87102
Hospital Charge Code	3551708
Hospital Revenue Code	300
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: UnitedHealthcare Commercial	$66.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Culture, Fungus, Other QST

Facility

$70.00

Service Code	HCPCS 87102
Hospital Charge Code	3551708
Hospital Revenue Code	300
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$66.50
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$35.59
Rate for Payer: Humana Medicare Advantage	$29.40
Rate for Payer: UnitedHealthcare Commercial	$66.50
Rate for Payer: UnitedHealthcare Medicaid	$8.40
Rate for Payer: WPPA Medicare Advantage	$42.00

Culture, Genital QST

Facility

$71.00

Service Code	HCPCS 87070
Hospital Charge Code	3550312
Hospital Revenue Code	300
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$67.45
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.88
Rate for Payer: Humana Medicare Advantage	$29.82
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: UnitedHealthcare Medicaid	$7.35
Rate for Payer: WPPA Medicare Advantage	$42.60

Culture, Genital QST

Facility

$71.00

Service Code	HCPCS 87070
Hospital Charge Code	3550312
Hospital Revenue Code	300
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Culture, Mycobacteria w/ Fluorochrome Smear QST

Facility

$80.00

Service Code	HCPCS 87116
Hospital Charge Code	3551229
Hospital Revenue Code	300
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$72.00
Rate for Payer: UnitedHealthcare Commercial	$76.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges