Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

Ear Tube Goode

Facility

$50.00

Hospital Charge Code	3256976
Hospital Revenue Code	270
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

Ear Tube Goode

Facility

$50.00

Hospital Charge Code	3256976
Hospital Revenue Code	270
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$47.50
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: Humana Medicare Advantage	$21.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: UnitedHealthcare Medicaid	$20.00
Rate for Payer: WPPA Medicare Advantage	$30.00

Ear Tube Pope

Facility

$63.14

Hospital Charge Code	3256978
Hospital Revenue Code	270
Min. Negotiated Rate	$25.26
Max. Negotiated Rate	$59.98
Rate for Payer: Aetna Commercial	$56.83
Rate for Payer: Humana Medicare Advantage	$26.52
Rate for Payer: UnitedHealthcare Commercial	$59.98
Rate for Payer: UnitedHealthcare Medicaid	$25.26
Rate for Payer: WPPA Medicare Advantage	$37.88

Ear Tube Pope

Facility

$63.14

Hospital Charge Code	3256978
Hospital Revenue Code	270
Min. Negotiated Rate	$56.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.83
Rate for Payer: UnitedHealthcare Commercial	$59.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ear Tube Richards

Facility

$87.00

Hospital Charge Code	3256974
Hospital Revenue Code	270
Min. Negotiated Rate	$34.80
Max. Negotiated Rate	$82.65
Rate for Payer: Aetna Commercial	$78.30
Rate for Payer: Humana Medicare Advantage	$36.54
Rate for Payer: UnitedHealthcare Commercial	$82.65
Rate for Payer: UnitedHealthcare Medicaid	$34.80
Rate for Payer: WPPA Medicare Advantage	$52.20

Ear Tube Richards

Facility

$87.00

Hospital Charge Code	3256974
Hospital Revenue Code	270
Min. Negotiated Rate	$78.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$78.30
Rate for Payer: UnitedHealthcare Commercial	$82.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EBV DNA, Ql Real Time PCR QST

Facility

$418.00

Service Code	HCPCS 87798
Hospital Charge Code	3552235
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$397.10
Rate for Payer: Aetna Commercial	$376.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$185.64
Rate for Payer: Humana Medicare Advantage	$175.56
Rate for Payer: UnitedHealthcare Commercial	$397.10
Rate for Payer: UnitedHealthcare Medicaid	$35.09
Rate for Payer: WPPA Medicare Advantage	$250.80

EBV DNA, Ql Real Time PCR QST

Facility

$418.00

Service Code	HCPCS 87798
Hospital Charge Code	3552235
Hospital Revenue Code	300
Min. Negotiated Rate	$376.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$376.20
Rate for Payer: UnitedHealthcare Commercial	$397.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

EBV Early Ag D Ab (IgG) QST

Facility

$180.00

Service Code	HCPCS 86663
Hospital Charge Code	3556663
Hospital Revenue Code	300
Min. Negotiated Rate	$11.15
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna Commercial	$162.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$59.89
Rate for Payer: Humana Medicare Advantage	$75.60
Rate for Payer: UnitedHealthcare Commercial	$171.00
Rate for Payer: UnitedHealthcare Medicaid	$11.15
Rate for Payer: WPPA Medicare Advantage	$108.00

EBV Early Ag D Ab (IgG) QST

Facility

$180.00

Service Code	HCPCS 86663
Hospital Charge Code	3556663
Hospital Revenue Code	300
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$162.00
Rate for Payer: UnitedHealthcare Commercial	$171.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Echocardiogram Complete

Facility

$3,387.00

Service Code	HCPCS 93306
Hospital Charge Code	3620025
Hospital Revenue Code	480
Min. Negotiated Rate	$178.27
Max. Negotiated Rate	$3,217.65
Rate for Payer: Aetna Commercial	$3,048.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,532.17
Rate for Payer: Humana Medicare Advantage	$1,422.54
Rate for Payer: UnitedHealthcare Commercial	$3,217.65
Rate for Payer: UnitedHealthcare Medicaid	$178.27
Rate for Payer: WPPA Medicare Advantage	$2,032.20

Echocardiogram Complete

Facility

$3,387.00

Service Code	HCPCS 93306
Hospital Charge Code	3620025
Hospital Revenue Code	480
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,217.65
Rate for Payer: Aetna Commercial	$3,048.30
Rate for Payer: UnitedHealthcare Commercial	$3,217.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES

Facility

$52,801.74

Service Code	MSDRG 003
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$52,801.74
Rate for Payer: UnitedHealthcare Medicaid	$52,801.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ED Procedure Charges

Facility

$303.00

Service Code	HCPCS 93005
Hospital Charge Code	3600023
Hospital Revenue Code	730
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ED Procedure Charges

Facility

$303.00

Service Code	HCPCS 93005
Hospital Charge Code	3600023
Hospital Revenue Code	730
Min. Negotiated Rate	$20.86
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$164.48
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$20.86
Rate for Payer: WPPA Medicare Advantage	$181.80

Egg White (F1) IgE QST

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3550282
Hospital Revenue Code	300
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Egg White (F1) IgE QST

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3550282
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$24.70
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$10.92
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$15.60

EKG 12 Lead Nursing

Facility

$240.00

Service Code	HCPCS 93005
Hospital Charge Code	3600023
Hospital Revenue Code	730
Min. Negotiated Rate	$20.86
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$164.48
Rate for Payer: Humana Medicare Advantage	$100.80
Rate for Payer: UnitedHealthcare Commercial	$228.00
Rate for Payer: UnitedHealthcare Medicaid	$20.86
Rate for Payer: WPPA Medicare Advantage	$144.00

EKG 12 Lead Nursing

Facility

$240.00

Service Code	HCPCS 93005
Hospital Charge Code	3600023
Hospital Revenue Code	730
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: UnitedHealthcare Commercial	$228.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Electrocardiogram 12 Lead

Facility

$240.00

Service Code	HCPCS 93005
Hospital Charge Code	3600023
Hospital Revenue Code	730
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: UnitedHealthcare Commercial	$228.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Electrocardiogram 12 Lead

Facility

$240.00

Service Code	HCPCS 93005
Hospital Charge Code	3600023
Hospital Revenue Code	730
Min. Negotiated Rate	$20.86
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$164.48
Rate for Payer: Humana Medicare Advantage	$100.80
Rate for Payer: UnitedHealthcare Commercial	$228.00
Rate for Payer: UnitedHealthcare Medicaid	$20.86
Rate for Payer: WPPA Medicare Advantage	$144.00

Electrode AED EMS Lifepak 15 (1 pack = 1 pair = 1each)

Facility

$117.50

Hospital Charge Code	3250187
Hospital Revenue Code	270
Min. Negotiated Rate	$47.00
Max. Negotiated Rate	$111.62
Rate for Payer: Aetna Commercial	$105.75
Rate for Payer: Humana Medicare Advantage	$49.35
Rate for Payer: UnitedHealthcare Commercial	$111.62
Rate for Payer: UnitedHealthcare Medicaid	$47.00
Rate for Payer: WPPA Medicare Advantage	$70.50

Electrode AED EMS Lifepak 15 (1 pack = 1 pair = 1each)

Facility

$117.50

Hospital Charge Code	3250187
Hospital Revenue Code	270
Min. Negotiated Rate	$105.75
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$105.75
Rate for Payer: UnitedHealthcare Commercial	$111.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Electrode Natus Gold Cup EEG 1.5 meter (59) lead (12 per Pack) w/ 1.5mm Female Connector

Facility

$318.00

Hospital Charge Code	3253875
Hospital Revenue Code	270
Min. Negotiated Rate	$286.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$286.20
Rate for Payer: UnitedHealthcare Commercial	$302.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges