Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC

Facility

$5,496.21

Service Code	MSDRG 563
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,496.21
Rate for Payer: UnitedHealthcare Medicaid	$5,496.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Free T4 Level

Facility

$100.00

Service Code	HCPCS 84439
Hospital Charge Code	3552748
Hospital Revenue Code	300
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$30.77
Rate for Payer: Humana Medicare Advantage	$42.00
Rate for Payer: UnitedHealthcare Commercial	$95.00
Rate for Payer: UnitedHealthcare Medicaid	$9.02
Rate for Payer: WPPA Medicare Advantage	$60.00

Free T4 Level

Facility

$100.00

Service Code	HCPCS 84439
Hospital Charge Code	3552748
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

Free Triiodothyronine

Facility

$276.00

Service Code	HCPCS 84481
Hospital Charge Code	3552391
Hospital Revenue Code	300
Min. Negotiated Rate	$16.94
Max. Negotiated Rate	$262.20
Rate for Payer: Aetna Commercial	$248.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$84.25
Rate for Payer: Humana Medicare Advantage	$115.92
Rate for Payer: UnitedHealthcare Commercial	$262.20
Rate for Payer: UnitedHealthcare Medicaid	$16.94
Rate for Payer: WPPA Medicare Advantage	$165.60

Free Triiodothyronine

Facility

$276.00

Service Code	HCPCS 84481
Hospital Charge Code	3552391
Hospital Revenue Code	300
Min. Negotiated Rate	$248.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$248.40
Rate for Payer: UnitedHealthcare Commercial	$262.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Frenectomy

Facility

$753.00

Service Code	HCPCS 41010
Hospital Charge Code	3151010
Hospital Revenue Code	360
Min. Negotiated Rate	$316.26
Max. Negotiated Rate	$715.35
Rate for Payer: Aetna Commercial	$677.70
Rate for Payer: Humana Medicare Advantage	$316.26
Rate for Payer: UnitedHealthcare Commercial	$715.35
Rate for Payer: UnitedHealthcare Medicaid	$494.04
Rate for Payer: WPPA Medicare Advantage	$451.80

Frenectomy

Facility

$753.00

Service Code	HCPCS 41010
Hospital Charge Code	3151010
Hospital Revenue Code	360
Min. Negotiated Rate	$677.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$677.70
Rate for Payer: UnitedHealthcare Commercial	$715.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fresh Frozen Plasma

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

Fresh Frozen Plasma

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

Fructosamine QST

Facility

$64.00

Service Code	HCPCS 82985
Hospital Charge Code	3552955
Hospital Revenue Code	300
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$60.80
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$41.53
Rate for Payer: Humana Medicare Advantage	$26.88
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: UnitedHealthcare Medicaid	$14.40
Rate for Payer: WPPA Medicare Advantage	$38.40

Fructosamine QST

Facility

$64.00

Service Code	HCPCS 82985
Hospital Charge Code	3552955
Hospital Revenue Code	300
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FTA-Abs QST

Facility

$95.00

Service Code	HCPCS 86762
Hospital Charge Code	3556780
Hospital Revenue Code	300
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: UnitedHealthcare Commercial	$90.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FTA-Abs QST

Facility

$95.00

Service Code	HCPCS 86762
Hospital Charge Code	3556780
Hospital Revenue Code	300
Min. Negotiated Rate	$12.23
Max. Negotiated Rate	$90.25
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$30.90
Rate for Payer: Humana Medicare Advantage	$39.90
Rate for Payer: UnitedHealthcare Commercial	$90.25
Rate for Payer: UnitedHealthcare Medicaid	$12.23
Rate for Payer: WPPA Medicare Advantage	$57.00

Fukuda ETCO2 Tubing Adult Oral/Nasal O2 Sampling Filter Line with O2 Cannula 6.5 ft with Orange Shor

Facility

$83.88

Hospital Charge Code	3253674
Hospital Revenue Code	270
Min. Negotiated Rate	$75.49
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$75.49
Rate for Payer: UnitedHealthcare Commercial	$79.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Fukuda ETCO2 Tubing Adult Oral/Nasal O2 Sampling Filter Line with O2 Cannula 6.5 ft with Orange Shor

Facility

$83.88

Hospital Charge Code	3253674
Hospital Revenue Code	270
Min. Negotiated Rate	$33.55
Max. Negotiated Rate	$79.69
Rate for Payer: Aetna Commercial	$75.49
Rate for Payer: Humana Medicare Advantage	$35.23
Rate for Payer: UnitedHealthcare Commercial	$79.69
Rate for Payer: UnitedHealthcare Medicaid	$33.55
Rate for Payer: WPPA Medicare Advantage	$50.33

Fukuda ETCO2 Tubing Adult or Pediatric - Orange Luer connector with silver circle on tip required by

Facility

$44.42

Hospital Charge Code	3257328
Hospital Revenue Code	270
Min. Negotiated Rate	$17.77
Max. Negotiated Rate	$42.20
Rate for Payer: Aetna Commercial	$39.98
Rate for Payer: Humana Medicare Advantage	$18.66
Rate for Payer: UnitedHealthcare Commercial	$42.20
Rate for Payer: UnitedHealthcare Medicaid	$17.77
Rate for Payer: WPPA Medicare Advantage	$26.65

Fukuda ETCO2 Tubing Adult or Pediatric - Orange Luer connector with silver circle on tip required by

Facility

$44.42

Hospital Charge Code	3257328
Hospital Revenue Code	270
Min. Negotiated Rate	$39.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.98
Rate for Payer: UnitedHealthcare Commercial	$42.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FULL TERM NEONATE WITH MAJOR PROBLEMS

Facility

$3,208.77

Service Code	MSDRG 793
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,208.77
Rate for Payer: UnitedHealthcare Medicaid	$3,208.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY

Facility

$7,084.71

Service Code	MSDRG 934
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,084.71
Rate for Payer: UnitedHealthcare Medicaid	$7,084.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC

Facility

$25,130.07

Service Code	MSDRG 928
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$25,130.07
Rate for Payer: UnitedHealthcare Medicaid	$25,130.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC

Facility

$11,278.35

Service Code	MSDRG 929
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,278.35
Rate for Payer: UnitedHealthcare Medicaid	$11,278.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

fulvestrant 50 mg/mL IM Inj [HMC]

Facility

$1,765.14

Service Code	HCPCS J9395
Hospital Charge Code	3852145
Hospital Revenue Code	250
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$1,676.88
Rate for Payer: Aetna Commercial	$1,588.63
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$10.51
Rate for Payer: Humana Medicare Advantage	$741.36
Rate for Payer: UnitedHealthcare Commercial	$1,676.88
Rate for Payer: UnitedHealthcare Medicaid	$5.72
Rate for Payer: WPPA Medicare Advantage	$1,059.08

fulvestrant 50 mg/mL IM Inj [HMC]

Facility

$1,765.14

Service Code	HCPCS J9395
Hospital Charge Code	3852145
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,676.88
Rate for Payer: Aetna Commercial	$1,588.63
Rate for Payer: UnitedHealthcare Commercial	$1,676.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

furosemide 10 mg/mL Inj Sol [HMC]

Facility

$29.60

Service Code	HCPCS J1938
Hospital Charge Code	3805401
Hospital Revenue Code	250
Min. Negotiated Rate	$11.84
Max. Negotiated Rate	$28.12
Rate for Payer: Aetna Commercial	$26.64
Rate for Payer: Aetna Commercial	$25.29
Rate for Payer: Aetna Commercial	$30.61
Rate for Payer: Aetna Commercial	$33.84
Rate for Payer: Aetna Commercial	$34.97
Rate for Payer: Humana Medicare Advantage	$11.80
Rate for Payer: Humana Medicare Advantage	$15.79
Rate for Payer: Humana Medicare Advantage	$12.43
Rate for Payer: Humana Medicare Advantage	$14.28
Rate for Payer: Humana Medicare Advantage	$16.32
Rate for Payer: UnitedHealthcare Commercial	$36.91
Rate for Payer: UnitedHealthcare Commercial	$28.12
Rate for Payer: UnitedHealthcare Commercial	$35.72
Rate for Payer: UnitedHealthcare Commercial	$32.31
Rate for Payer: UnitedHealthcare Commercial	$26.70
Rate for Payer: UnitedHealthcare Medicaid	$15.54
Rate for Payer: UnitedHealthcare Medicaid	$11.84
Rate for Payer: UnitedHealthcare Medicaid	$13.60
Rate for Payer: UnitedHealthcare Medicaid	$15.04
Rate for Payer: UnitedHealthcare Medicaid	$11.24
Rate for Payer: WPPA Medicare Advantage	$23.31
Rate for Payer: WPPA Medicare Advantage	$20.41
Rate for Payer: WPPA Medicare Advantage	$17.76
Rate for Payer: WPPA Medicare Advantage	$16.86
Rate for Payer: WPPA Medicare Advantage	$22.56

furosemide 10 mg/mL Inj Sol [HMC]

Facility

$37.60

Service Code	HCPCS J1938
Hospital Charge Code	3805401
Hospital Revenue Code	250
Min. Negotiated Rate	$33.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.84
Rate for Payer: Aetna Commercial	$30.61
Rate for Payer: Aetna Commercial	$34.97
Rate for Payer: Aetna Commercial	$26.64
Rate for Payer: Aetna Commercial	$25.29
Rate for Payer: UnitedHealthcare Commercial	$26.70
Rate for Payer: UnitedHealthcare Commercial	$28.12
Rate for Payer: UnitedHealthcare Commercial	$32.31
Rate for Payer: UnitedHealthcare Commercial	$35.72
Rate for Payer: UnitedHealthcare Commercial	$36.91
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges