Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

E0336 RBC CPD AS1 500 LR

Facility

$571.00

Service Code	HCPCS P9016
Hospital Charge Code	3560180
Hospital Revenue Code	390
Min. Negotiated Rate	$513.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$513.90
Rate for Payer: UnitedHealthcare Commercial	$542.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E0678 Aph RBC CP2D AS3 LR

Facility

$571.00

Service Code	HCPCS P9016
Hospital Charge Code	3560180
Hospital Revenue Code	390
Min. Negotiated Rate	$87.00
Max. Negotiated Rate	$542.45
Rate for Payer: Aetna Commercial	$513.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$534.34
Rate for Payer: Humana Medicare Advantage	$239.82
Rate for Payer: UnitedHealthcare Commercial	$542.45
Rate for Payer: UnitedHealthcare Medicaid	$87.00
Rate for Payer: WPPA Medicare Advantage	$342.60

E0678 Aph RBC CP2D AS3 LR

Facility

$571.00

Service Code	HCPCS P9016
Hospital Charge Code	3560180
Hospital Revenue Code	390
Min. Negotiated Rate	$513.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$513.90
Rate for Payer: UnitedHealthcare Commercial	$542.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E0685 Aph RBC CP2D AS3 LR 1

Facility

$571.00

Service Code	HCPCS P9016
Hospital Charge Code	3560180
Hospital Revenue Code	390
Min. Negotiated Rate	$87.00
Max. Negotiated Rate	$542.45
Rate for Payer: Aetna Commercial	$513.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$534.34
Rate for Payer: Humana Medicare Advantage	$239.82
Rate for Payer: UnitedHealthcare Commercial	$542.45
Rate for Payer: UnitedHealthcare Medicaid	$87.00
Rate for Payer: WPPA Medicare Advantage	$342.60

E0685 Aph RBC CP2D AS3 LR 1

Facility

$571.00

Service Code	HCPCS P9016
Hospital Charge Code	3560180
Hospital Revenue Code	390
Min. Negotiated Rate	$513.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$513.90
Rate for Payer: UnitedHealthcare Commercial	$542.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E0686 Aph RBC CP2D AS3 LR 2

Facility

$571.00

Service Code	HCPCS P9016
Hospital Charge Code	3560180
Hospital Revenue Code	390
Min. Negotiated Rate	$87.00
Max. Negotiated Rate	$542.45
Rate for Payer: Aetna Commercial	$513.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$534.34
Rate for Payer: Humana Medicare Advantage	$239.82
Rate for Payer: UnitedHealthcare Commercial	$542.45
Rate for Payer: UnitedHealthcare Medicaid	$87.00
Rate for Payer: WPPA Medicare Advantage	$342.60

E0686 Aph RBC CP2D AS3 LR 2

Facility

$571.00

Service Code	HCPCS P9016
Hospital Charge Code	3560180
Hospital Revenue Code	390
Min. Negotiated Rate	$513.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$513.90
Rate for Payer: UnitedHealthcare Commercial	$542.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E0701 FFP CPD

Facility

$292.00

Service Code	HCPCS P9017
Hospital Charge Code	3560131
Hospital Revenue Code	390
Min. Negotiated Rate	$262.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$262.80
Rate for Payer: UnitedHealthcare Commercial	$277.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E0701 FFP CPD

Facility

$292.00

Service Code	HCPCS P9017
Hospital Charge Code	3560131
Hospital Revenue Code	390
Min. Negotiated Rate	$23.50
Max. Negotiated Rate	$277.40
Rate for Payer: Aetna Commercial	$262.80
Rate for Payer: Humana Medicare Advantage	$122.64
Rate for Payer: UnitedHealthcare Commercial	$277.40
Rate for Payer: UnitedHealthcare Medicaid	$23.50
Rate for Payer: WPPA Medicare Advantage	$175.20

E3057 Aph Plt ACDA LR Irr 2

Facility

$1,447.00

Service Code	HCPCS P9035
Hospital Charge Code	3560115
Hospital Revenue Code	390
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,374.65
Rate for Payer: Aetna Commercial	$1,302.30
Rate for Payer: UnitedHealthcare Commercial	$1,374.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E3057 Aph Plt ACDA LR Irr 2

Facility

$1,447.00

Service Code	HCPCS P9035
Hospital Charge Code	3560115
Hospital Revenue Code	390
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$1,374.65
Rate for Payer: Aetna Commercial	$1,302.30
Rate for Payer: Humana Medicare Advantage	$607.74
Rate for Payer: UnitedHealthcare Commercial	$1,374.65
Rate for Payer: UnitedHealthcare Medicaid	$25.50
Rate for Payer: WPPA Medicare Advantage	$868.20

E8341 Aph Plr ACDA>PASC LR Psoralen 1

Facility

$1,447.00

Service Code	HCPCS P9035
Hospital Charge Code	3560115
Hospital Revenue Code	392
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,374.65
Rate for Payer: Aetna Commercial	$1,302.30
Rate for Payer: UnitedHealthcare Commercial	$1,374.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E8341 Aph Plr ACDA>PASC LR Psoralen 1

Facility

$1,447.00

Service Code	HCPCS P9035
Hospital Charge Code	3560115
Hospital Revenue Code	392
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$1,374.65
Rate for Payer: Aetna Commercial	$1,302.30
Rate for Payer: Humana Medicare Advantage	$607.74
Rate for Payer: UnitedHealthcare Commercial	$1,374.65
Rate for Payer: UnitedHealthcare Medicaid	$25.50
Rate for Payer: WPPA Medicare Advantage	$868.20

E8342 Aph Plr ACDA>PASC LR Psoralen 2

Facility

$1,447.00

Service Code	HCPCS P9035
Hospital Charge Code	3550115
Hospital Revenue Code	390
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,374.65
Rate for Payer: Aetna Commercial	$1,302.30
Rate for Payer: UnitedHealthcare Commercial	$1,374.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E8342 Aph Plr ACDA>PASC LR Psoralen 2

Facility

$1,447.00

Service Code	HCPCS P9035
Hospital Charge Code	3550115
Hospital Revenue Code	390
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$1,374.65
Rate for Payer: Aetna Commercial	$1,302.30
Rate for Payer: Humana Medicare Advantage	$607.74
Rate for Payer: UnitedHealthcare Commercial	$1,374.65
Rate for Payer: UnitedHealthcare Medicaid	$25.50
Rate for Payer: WPPA Medicare Advantage	$868.20

E8343 Aph Plt ACDA>PASC LR Psoralen 3

Facility

$1,447.00

Service Code	HCPCS 3560115
Hospital Charge Code	3560115
Hospital Revenue Code	390
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,374.65
Rate for Payer: Aetna Commercial	$1,302.30
Rate for Payer: UnitedHealthcare Commercial	$1,374.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E8343 Aph Plt ACDA>PASC LR Psoralen 3

Facility

$1,447.00

Service Code	HCPCS 3560115
Hospital Charge Code	3560115
Hospital Revenue Code	390
Min. Negotiated Rate	$578.80
Max. Negotiated Rate	$1,374.65
Rate for Payer: Aetna Commercial	$1,302.30
Rate for Payer: Humana Medicare Advantage	$607.74
Rate for Payer: UnitedHealthcare Commercial	$1,374.65
Rate for Payer: UnitedHealthcare Medicaid	$578.80
Rate for Payer: WPPA Medicare Advantage	$868.20

E9139 Aph Plt ACDA>PASC LR <3E11 Pso 2

Facility

$1,447.00

Service Code	HCPCS P9035
Hospital Charge Code	3560115
Hospital Revenue Code	390
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,374.65
Rate for Payer: Aetna Commercial	$1,302.30
Rate for Payer: UnitedHealthcare Commercial	$1,374.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

E9139 Aph Plt ACDA>PASC LR <3E11 Pso 2

Facility

$1,447.00

Service Code	HCPCS P9035
Hospital Charge Code	3560115
Hospital Revenue Code	390
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$1,374.65
Rate for Payer: Aetna Commercial	$1,302.30
Rate for Payer: Humana Medicare Advantage	$607.74
Rate for Payer: UnitedHealthcare Commercial	$1,374.65
Rate for Payer: UnitedHealthcare Medicaid	$25.50
Rate for Payer: WPPA Medicare Advantage	$868.20

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$3,717.09

Service Code	MSDRG 147
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

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility

$6,163.38

Service Code	MSDRG 146
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,163.38
Rate for Payer: UnitedHealthcare Medicaid	$6,163.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC

Facility

$2,319.21

Service Code	MSDRG 148
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,319.21
Rate for Payer: UnitedHealthcare Medicaid	$2,319.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ear Tube Armstrong

Facility

$54.27

Hospital Charge Code	3256970
Hospital Revenue Code	270
Min. Negotiated Rate	$48.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.84
Rate for Payer: UnitedHealthcare Commercial	$51.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ear Tube Armstrong

Facility

$54.27

Hospital Charge Code	3256970
Hospital Revenue Code	270
Min. Negotiated Rate	$21.71
Max. Negotiated Rate	$51.56
Rate for Payer: Aetna Commercial	$48.84
Rate for Payer: Humana Medicare Advantage	$22.79
Rate for Payer: UnitedHealthcare Commercial	$51.56
Rate for Payer: UnitedHealthcare Medicaid	$21.71
Rate for Payer: WPPA Medicare Advantage	$32.56

Ear Tube Duravent

Facility

$77.81

Hospital Charge Code	3256972
Hospital Revenue Code	270
Min. Negotiated Rate	$70.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.03
Rate for Payer: UnitedHealthcare Commercial	$73.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges