Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Giardia Ag, EIA, Stool QST

Facility

$112.00

Service Code	HCPCS 87329
Hospital Charge Code	3550461
Hospital Revenue Code	300
Min. Negotiated Rate	$10.18
Max. Negotiated Rate	$106.40
Rate for Payer: Aetna Commercial	$100.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$60.35
Rate for Payer: Humana Medicare Advantage	$47.04
Rate for Payer: UnitedHealthcare Commercial	$106.40
Rate for Payer: UnitedHealthcare Medicaid	$10.18
Rate for Payer: WPPA Medicare Advantage	$67.20

GI Pathogen Panel, PCR, F QST

Facility

$1,301.00

Service Code	HCPCS 0097U
Hospital Charge Code	3550097
Hospital Revenue Code	300
Min. Negotiated Rate	$520.40
Max. Negotiated Rate	$1,235.95
Rate for Payer: Aetna Commercial	$1,170.90
Rate for Payer: Humana Medicare Advantage	$546.42
Rate for Payer: UnitedHealthcare Commercial	$1,235.95
Rate for Payer: UnitedHealthcare Medicaid	$520.40
Rate for Payer: WPPA Medicare Advantage	$780.60

GI Pathogen Panel, PCR, F QST

Facility

$1,301.00

Service Code	HCPCS 0097U
Hospital Charge Code	3550097
Hospital Revenue Code	300
Min. Negotiated Rate	$1,170.90
Max. Negotiated Rate	$1,235.95
Rate for Payer: Aetna Commercial	$1,170.90
Rate for Payer: UnitedHealthcare Commercial	$1,235.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GlideScope BFlex 2 Regular Bronchoscope 5.0 Single-Use

Facility

$678.50

Hospital Charge Code	3254110
Hospital Revenue Code	270
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$644.58
Rate for Payer: Aetna Commercial	$610.65
Rate for Payer: Humana Medicare Advantage	$284.97
Rate for Payer: UnitedHealthcare Commercial	$644.58
Rate for Payer: UnitedHealthcare Medicaid	$271.40
Rate for Payer: WPPA Medicare Advantage	$407.10

GlideScope BFlex 2 Regular Bronchoscope 5.0 Single-Use

Facility

$678.50

Hospital Charge Code	3254110
Hospital Revenue Code	270
Min. Negotiated Rate	$610.65
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$610.65
Rate for Payer: UnitedHealthcare Commercial	$644.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GlideScope BFlex 2 Slim Bronchoscope 3.8 Single-Use

Facility

$678.50

Hospital Charge Code	3254111
Hospital Revenue Code	270
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$644.58
Rate for Payer: Aetna Commercial	$610.65
Rate for Payer: Humana Medicare Advantage	$284.97
Rate for Payer: UnitedHealthcare Commercial	$644.58
Rate for Payer: UnitedHealthcare Medicaid	$271.40
Rate for Payer: WPPA Medicare Advantage	$407.10

GlideScope BFlex 2 Slim Bronchoscope 3.8 Single-Use

Facility

$678.50

Hospital Charge Code	3254111
Hospital Revenue Code	270
Min. Negotiated Rate	$610.65
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$610.65
Rate for Payer: UnitedHealthcare Commercial	$644.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Glidescope GVL Blade Size 0 for AVL System

Facility

$96.00

Hospital Charge Code	3250000
Hospital Revenue Code	270
Min. Negotiated Rate	$86.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$86.40
Rate for Payer: UnitedHealthcare Commercial	$91.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Glidescope GVL Blade Size 0 for AVL System

Facility

$96.00

Hospital Charge Code	3250000
Hospital Revenue Code	270
Min. Negotiated Rate	$38.40
Max. Negotiated Rate	$91.20
Rate for Payer: Aetna Commercial	$86.40
Rate for Payer: Humana Medicare Advantage	$40.32
Rate for Payer: UnitedHealthcare Commercial	$91.20
Rate for Payer: UnitedHealthcare Medicaid	$38.40
Rate for Payer: WPPA Medicare Advantage	$57.60

Glidescope GVL Blade Size 1 for AVL System

Facility

$88.00

Hospital Charge Code	3251000
Hospital Revenue Code	270
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$79.20
Rate for Payer: UnitedHealthcare Commercial	$83.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Glidescope GVL Blade Size 1 for AVL System

Facility

$88.00

Hospital Charge Code	3251000
Hospital Revenue Code	270
Min. Negotiated Rate	$35.20
Max. Negotiated Rate	$83.60
Rate for Payer: Aetna Commercial	$79.20
Rate for Payer: Humana Medicare Advantage	$36.96
Rate for Payer: UnitedHealthcare Commercial	$83.60
Rate for Payer: UnitedHealthcare Medicaid	$35.20
Rate for Payer: WPPA Medicare Advantage	$52.80

Glidescope GVL Blade Size 2.5 for AVL System

Facility

$96.00

Hospital Charge Code	3252500
Hospital Revenue Code	270
Min. Negotiated Rate	$86.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$86.40
Rate for Payer: UnitedHealthcare Commercial	$91.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Glidescope GVL Blade Size 2.5 for AVL System

Facility

$96.00

Hospital Charge Code	3252500
Hospital Revenue Code	270
Min. Negotiated Rate	$38.40
Max. Negotiated Rate	$91.20
Rate for Payer: Aetna Commercial	$86.40
Rate for Payer: Humana Medicare Advantage	$40.32
Rate for Payer: UnitedHealthcare Commercial	$91.20
Rate for Payer: UnitedHealthcare Medicaid	$38.40
Rate for Payer: WPPA Medicare Advantage	$57.60

Glidescope GVL Blade Size 2 for AVL System

Facility

$88.00

Hospital Charge Code	3252200
Hospital Revenue Code	270
Min. Negotiated Rate	$35.20
Max. Negotiated Rate	$83.60
Rate for Payer: Aetna Commercial	$79.20
Rate for Payer: Humana Medicare Advantage	$36.96
Rate for Payer: UnitedHealthcare Commercial	$83.60
Rate for Payer: UnitedHealthcare Medicaid	$35.20
Rate for Payer: WPPA Medicare Advantage	$52.80

Glidescope GVL Blade Size 2 for AVL System

Facility

$88.00

Hospital Charge Code	3252200
Hospital Revenue Code	270
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$79.20
Rate for Payer: UnitedHealthcare Commercial	$83.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Glidescope GVL Blade Size 3 for AVL System

Facility

$78.00

Hospital Charge Code	3253000
Hospital Revenue Code	270
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: UnitedHealthcare Commercial	$74.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Glidescope GVL Blade Size 3 for AVL System

Facility

$78.00

Hospital Charge Code	3253000
Hospital Revenue Code	270
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$74.10
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: Humana Medicare Advantage	$32.76
Rate for Payer: UnitedHealthcare Commercial	$74.10
Rate for Payer: UnitedHealthcare Medicaid	$31.20
Rate for Payer: WPPA Medicare Advantage	$46.80

Glidescope GVL Blade Size 4 for AVL System

Facility

$78.00

Hospital Charge Code	3254000
Hospital Revenue Code	270
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$74.10
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: Humana Medicare Advantage	$32.76
Rate for Payer: UnitedHealthcare Commercial	$74.10
Rate for Payer: UnitedHealthcare Medicaid	$31.20
Rate for Payer: WPPA Medicare Advantage	$46.80

Glidescope GVL Blade Size 4 for AVL System

Facility

$78.00

Hospital Charge Code	3254000
Hospital Revenue Code	270
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: UnitedHealthcare Commercial	$74.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GlideScope Spectrum QC Hyperangle S1 Blade

Facility

$177.94

Hospital Charge Code	3254112
Hospital Revenue Code	270
Min. Negotiated Rate	$160.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$160.15
Rate for Payer: UnitedHealthcare Commercial	$169.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GlideScope Spectrum QC Hyperangle S1 Blade

Facility

$177.94

Hospital Charge Code	3254112
Hospital Revenue Code	270
Min. Negotiated Rate	$71.18
Max. Negotiated Rate	$169.04
Rate for Payer: Aetna Commercial	$160.15
Rate for Payer: Humana Medicare Advantage	$74.73
Rate for Payer: UnitedHealthcare Commercial	$169.04
Rate for Payer: UnitedHealthcare Medicaid	$71.18
Rate for Payer: WPPA Medicare Advantage	$106.76

GlideScope Spectrum QC Hyperangle S2 Blade

Facility

$177.94

Hospital Charge Code	3254113
Hospital Revenue Code	270
Min. Negotiated Rate	$160.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$160.15
Rate for Payer: UnitedHealthcare Commercial	$169.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GlideScope Spectrum QC Hyperangle S2 Blade

Facility

$177.94

Hospital Charge Code	3254113
Hospital Revenue Code	270
Min. Negotiated Rate	$71.18
Max. Negotiated Rate	$169.04
Rate for Payer: Aetna Commercial	$160.15
Rate for Payer: Humana Medicare Advantage	$74.73
Rate for Payer: UnitedHealthcare Commercial	$169.04
Rate for Payer: UnitedHealthcare Medicaid	$71.18
Rate for Payer: WPPA Medicare Advantage	$106.76

GlideScope Spectrum QC MAC S3

Facility

$142.80

Hospital Charge Code	3254114
Hospital Revenue Code	270
Min. Negotiated Rate	$128.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$128.52
Rate for Payer: UnitedHealthcare Commercial	$135.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

GlideScope Spectrum QC MAC S3

Facility

$142.80

Hospital Charge Code	3254114
Hospital Revenue Code	270
Min. Negotiated Rate	$57.12
Max. Negotiated Rate	$135.66
Rate for Payer: Aetna Commercial	$128.52
Rate for Payer: Humana Medicare Advantage	$59.98
Rate for Payer: UnitedHealthcare Commercial	$135.66
Rate for Payer: UnitedHealthcare Medicaid	$57.12
Rate for Payer: WPPA Medicare Advantage	$85.68

Know your out-of-pocket cost for care.

All Charges