Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

G0239 CR THER TX IMPROVE FUNCTION; 2+ PEOPLE CHARGE

Facility

$128.00

Service Code	HCPCS G0239
Hospital Charge Code	3860239
Hospital Revenue Code	943
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

G0268 Removal of impacted cerumen, same date of service as audiologic function testing

Facility

$120.00

Service Code	HCPCS G0268
Hospital Charge Code	3350268
Hospital Revenue Code	761
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$108.00
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

G0268 Removal of impacted cerumen, same date of service as audiologic function testing

Facility

$120.00

Service Code	HCPCS G0268
Hospital Charge Code	3350268
Hospital Revenue Code	761
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.67
Rate for Payer: Humana Medicare Advantage	$50.40
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicaid	$48.00
Rate for Payer: WPPA Medicare Advantage	$72.00

G0296 Counseling visit to discuss need for lung cancer screening using low dose CT scan

Facility

$176.00

Service Code	HCPCS G0296
Hospital Charge Code	SCCG029600
Hospital Revenue Code	521
Min. Negotiated Rate	$70.40
Max. Negotiated Rate	$167.20
Rate for Payer: Aetna Commercial	$158.40
Rate for Payer: Humana Medicare Advantage	$73.92
Rate for Payer: UnitedHealthcare Commercial	$167.20
Rate for Payer: UnitedHealthcare Medicaid	$70.40
Rate for Payer: WPPA Medicare Advantage	$105.60

G0296 Counseling visit to discuss need for lung cancer screening using low dose CT scan

Facility

$176.00

Service Code	HCPCS G0296
Hospital Charge Code	SCCG029600
Hospital Revenue Code	521
Min. Negotiated Rate	$158.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$158.40
Rate for Payer: UnitedHealthcare Commercial	$167.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

G0399 HOME SLEEP STUDY CHARGE

Facility

$634.00

Service Code	HCPCS G0399
Hospital Charge Code	3920030
Hospital Revenue Code	920
Min. Negotiated Rate	$206.04
Max. Negotiated Rate	$602.30
Rate for Payer: Aetna Commercial	$570.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$206.04
Rate for Payer: Humana Medicare Advantage	$266.28
Rate for Payer: UnitedHealthcare Commercial	$602.30
Rate for Payer: UnitedHealthcare Medicaid	$253.60
Rate for Payer: WPPA Medicare Advantage	$380.40

G0399 HOME SLEEP STUDY CHARGE

Facility

$634.00

Service Code	HCPCS G0399
Hospital Charge Code	3920030
Hospital Revenue Code	920
Min. Negotiated Rate	$570.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$570.60
Rate for Payer: UnitedHealthcare Commercial	$602.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

G0402 Initial preventive physical (Welcome to Medicare)

Facility

$214.00

Service Code	HCPCS G0402
Hospital Charge Code	SCCG040200
Hospital Revenue Code	521
Min. Negotiated Rate	$85.60
Max. Negotiated Rate	$203.30
Rate for Payer: Aetna Commercial	$192.60
Rate for Payer: Humana Medicare Advantage	$89.88
Rate for Payer: UnitedHealthcare Commercial	$203.30
Rate for Payer: UnitedHealthcare Medicaid	$85.60
Rate for Payer: WPPA Medicare Advantage	$128.40

G0402 Initial preventive physical (Welcome to Medicare)

Facility

$214.00

Service Code	HCPCS G0402
Hospital Charge Code	SCCG040200
Hospital Revenue Code	521
Min. Negotiated Rate	$192.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$192.60
Rate for Payer: UnitedHealthcare Commercial	$203.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

G0404 EKG MEDICARE INTIAL CHARGE

Facility

$240.00

Service Code	HCPCS G0404 TC
Hospital Charge Code	3360404
Hospital Revenue Code	730
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: Humana Medicare Advantage	$100.80
Rate for Payer: UnitedHealthcare Commercial	$228.00
Rate for Payer: UnitedHealthcare Medicaid	$96.00
Rate for Payer: WPPA Medicare Advantage	$144.00

G0404 EKG MEDICARE INTIAL CHARGE

Facility

$240.00

Service Code	HCPCS G0404 TC
Hospital Charge Code	3360404
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

G0404 EKG TRACING ONLY SCREEN CHARGE

Facility

$240.00

Service Code	HCPCS G0404 TC
Hospital Charge Code	3360404
Hospital Revenue Code	730
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: Humana Medicare Advantage	$100.80
Rate for Payer: UnitedHealthcare Commercial	$228.00
Rate for Payer: UnitedHealthcare Medicaid	$96.00
Rate for Payer: WPPA Medicare Advantage	$144.00

G0404 EKG TRACING ONLY SCREEN CHARGE

Facility

$240.00

Service Code	HCPCS G0404 TC
Hospital Charge Code	3360404
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

G0511 Chronic Care Management Charge

Facility

$54.00

Service Code	HCPCS G0511
Hospital Charge Code	SCCG051100
Hospital Revenue Code	521
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$21.60
Rate for Payer: WPPA Medicare Advantage	$32.40

G0511 Chronic Care Management Charge

Facility

$54.00

Service Code	HCPCS G0511
Hospital Charge Code	SCCG051100
Hospital Revenue Code	521
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 100 mg Cap [HMC]

Facility

$6.60

Service Code	NDC 69097081307
Hospital Charge Code	3800139
Hospital Revenue Code	250
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.94
Rate for Payer: UnitedHealthcare Commercial	$6.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 100 mg Cap [HMC]

Facility

$5.32

Service Code	NDC 63739090210
Hospital Charge Code	3800139
Hospital Revenue Code	250
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$5.05
Rate for Payer: Aetna Commercial	$4.79
Rate for Payer: Humana Medicare Advantage	$2.23
Rate for Payer: UnitedHealthcare Commercial	$5.05
Rate for Payer: UnitedHealthcare Medicaid	$2.13
Rate for Payer: WPPA Medicare Advantage	$3.19

gabapentin 100 mg Cap [HMC]

Facility

$5.42

Service Code	NDC 00904666561
Hospital Charge Code	3800139
Hospital Revenue Code	250
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$5.15
Rate for Payer: Aetna Commercial	$4.88
Rate for Payer: Humana Medicare Advantage	$2.28
Rate for Payer: UnitedHealthcare Commercial	$5.15
Rate for Payer: UnitedHealthcare Medicaid	$2.17
Rate for Payer: WPPA Medicare Advantage	$3.25

gabapentin 100 mg Cap [HMC]

Facility

$6.61

Service Code	NDC 67877022201
Hospital Charge Code	3800139
Hospital Revenue Code	250
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$6.28
Rate for Payer: Aetna Commercial	$5.95
Rate for Payer: Humana Medicare Advantage	$2.78
Rate for Payer: UnitedHealthcare Commercial	$6.28
Rate for Payer: UnitedHealthcare Medicaid	$2.64
Rate for Payer: WPPA Medicare Advantage	$3.97

gabapentin 100 mg Cap [HMC]

Facility

$5.42

Service Code	NDC 00904666561
Hospital Charge Code	3800139
Hospital Revenue Code	250
Min. Negotiated Rate	$4.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.88
Rate for Payer: UnitedHealthcare Commercial	$5.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 100 mg Cap [HMC]

Facility

$6.84

Service Code	NDC 68084059465
Hospital Charge Code	3800139
Hospital Revenue Code	250
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Humana Medicare Advantage	$2.87
Rate for Payer: UnitedHealthcare Commercial	$6.50
Rate for Payer: UnitedHealthcare Medicaid	$2.74
Rate for Payer: WPPA Medicare Advantage	$4.10

gabapentin 100 mg Cap [HMC]

Facility

$5.32

Service Code	NDC 63739090210
Hospital Charge Code	3800139
Hospital Revenue Code	250
Min. Negotiated Rate	$4.79
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.79
Rate for Payer: UnitedHealthcare Commercial	$5.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 100 mg Cap [HMC]

Facility

$6.60

Service Code	NDC 69097081307
Hospital Charge Code	3800139
Hospital Revenue Code	250
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$6.27
Rate for Payer: Aetna Commercial	$5.94
Rate for Payer: Humana Medicare Advantage	$2.77
Rate for Payer: UnitedHealthcare Commercial	$6.27
Rate for Payer: UnitedHealthcare Medicaid	$2.64
Rate for Payer: WPPA Medicare Advantage	$3.96

gabapentin 100 mg Cap [HMC]

Facility

$6.61

Service Code	NDC 67877022201
Hospital Charge Code	3800139
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.95
Rate for Payer: UnitedHealthcare Commercial	$6.28
Rate for Payer: WPPA Medicare Advantage	$1,200.00

gabapentin 100 mg Cap [HMC]

Facility

$6.84

Service Code	NDC 68084059465
Hospital Charge Code	3800139
Hospital Revenue Code	250
Min. Negotiated Rate	$6.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: UnitedHealthcare Commercial	$6.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges