Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC

Facility

$4,320.72

Service Code	MSDRG 482
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,320.72
Rate for Payer: UnitedHealthcare Medicaid	$4,320.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC

Facility

$10,865.34

Service Code	MSDRG 521
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,865.34
Rate for Payer: UnitedHealthcare Medicaid	$10,865.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC

Facility

$8,006.04

Service Code	MSDRG 522
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,006.04
Rate for Payer: UnitedHealthcare Medicaid	$8,006.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Histamine, P QST

Facility

$212.00

Service Code	HCPCS 83088
Hospital Charge Code	3553088
Hospital Revenue Code	300
Min. Negotiated Rate	$190.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$190.80
Rate for Payer: UnitedHealthcare Commercial	$201.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Histamine, P QST

Facility

$212.00

Service Code	HCPCS 83088
Hospital Charge Code	3553088
Hospital Revenue Code	300
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$201.40
Rate for Payer: Aetna Commercial	$190.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$99.74
Rate for Payer: Humana Medicare Advantage	$89.04
Rate for Payer: UnitedHealthcare Commercial	$201.40
Rate for Payer: UnitedHealthcare Medicaid	$25.00
Rate for Payer: WPPA Medicare Advantage	$127.20

Histone Abs QST

Facility

$315.00

Service Code	HCPCS 83516
Hospital Charge Code	3558351
Hospital Revenue Code	300
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$299.25
Rate for Payer: Aetna Commercial	$283.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.34
Rate for Payer: Humana Medicare Advantage	$132.30
Rate for Payer: UnitedHealthcare Commercial	$299.25
Rate for Payer: UnitedHealthcare Medicaid	$10.00
Rate for Payer: WPPA Medicare Advantage	$189.00

Histone Abs QST

Facility

$315.00

Service Code	HCPCS 83516
Hospital Charge Code	3558351
Hospital Revenue Code	300
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$283.50
Rate for Payer: UnitedHealthcare Commercial	$299.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Histoplasma Antigen Urine UPHS

Facility

$178.00

Service Code	HCPCS 87385
Hospital Charge Code	3557385
Hospital Revenue Code	300
Min. Negotiated Rate	$11.26
Max. Negotiated Rate	$169.10
Rate for Payer: Aetna Commercial	$160.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.84
Rate for Payer: Humana Medicare Advantage	$74.76
Rate for Payer: UnitedHealthcare Commercial	$169.10
Rate for Payer: UnitedHealthcare Medicaid	$11.26
Rate for Payer: WPPA Medicare Advantage	$106.80

Histoplasma Antigen Urine UPHS

Facility

$178.00

Service Code	HCPCS 87385
Hospital Charge Code	3557385
Hospital Revenue Code	300
Min. Negotiated Rate	$160.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$160.20
Rate for Payer: UnitedHealthcare Commercial	$169.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Histoplasma Galactomannan Ag, U QST

Facility

$117.00

Service Code	HCPCS 87385
Hospital Charge Code	3557385
Hospital Revenue Code	300
Min. Negotiated Rate	$11.26
Max. Negotiated Rate	$111.15
Rate for Payer: Aetna Commercial	$105.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.84
Rate for Payer: Humana Medicare Advantage	$49.14
Rate for Payer: UnitedHealthcare Commercial	$111.15
Rate for Payer: UnitedHealthcare Medicaid	$11.26
Rate for Payer: WPPA Medicare Advantage	$70.20

Histoplasma Galactomannan Ag, U QST

Facility

$117.00

Service Code	HCPCS 87385
Hospital Charge Code	3557385
Hospital Revenue Code	300
Min. Negotiated Rate	$105.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$105.30
Rate for Payer: UnitedHealthcare Commercial	$111.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HIV 1/2 Antibody Screen

Facility

$208.00

Service Code	HCPCS 87389
Hospital Charge Code	3550910
Hospital Revenue Code	300
Min. Negotiated Rate	$24.08
Max. Negotiated Rate	$197.60
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$60.02
Rate for Payer: Humana Medicare Advantage	$87.36
Rate for Payer: UnitedHealthcare Commercial	$197.60
Rate for Payer: UnitedHealthcare Medicaid	$24.08
Rate for Payer: WPPA Medicare Advantage	$124.80

HIV 1/2 Antibody Screen

Facility

$208.00

Service Code	HCPCS 87389
Hospital Charge Code	3550910
Hospital Revenue Code	300
Min. Negotiated Rate	$187.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: UnitedHealthcare Commercial	$197.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HIV 1 RNA, Quant Real Time PCR QST

Facility

$521.00

Service Code	HCPCS 87536
Hospital Charge Code	3550085
Hospital Revenue Code	300
Min. Negotiated Rate	$85.10
Max. Negotiated Rate	$494.95
Rate for Payer: Aetna Commercial	$468.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$182.59
Rate for Payer: Humana Medicare Advantage	$218.82
Rate for Payer: UnitedHealthcare Commercial	$494.95
Rate for Payer: UnitedHealthcare Medicaid	$85.10
Rate for Payer: WPPA Medicare Advantage	$312.60

HIV 1 RNA, Quant Real Time PCR QST

Facility

$521.00

Service Code	HCPCS 87536
Hospital Charge Code	3550085
Hospital Revenue Code	300
Min. Negotiated Rate	$468.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$468.90
Rate for Payer: UnitedHealthcare Commercial	$494.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HIV Ag/Ab Combo 1/2 Screen

Facility

$218.00

Service Code	HCPCS 87389
Hospital Charge Code	3550910
Hospital Revenue Code	300
Min. Negotiated Rate	$24.08
Max. Negotiated Rate	$207.10
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$60.02
Rate for Payer: Humana Medicare Advantage	$91.56
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: UnitedHealthcare Medicaid	$24.08
Rate for Payer: WPPA Medicare Advantage	$130.80

HIV Ag/Ab Combo 1/2 Screen

Facility

$218.00

Service Code	HCPCS 87389
Hospital Charge Code	3550910
Hospital Revenue Code	300
Min. Negotiated Rate	$196.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC

Facility

$21,444.75

Service Code	MSDRG 969
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$21,444.75
Rate for Payer: UnitedHealthcare Medicaid	$21,444.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC

Facility

$9,245.07

Service Code	MSDRG 970
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,245.07
Rate for Payer: UnitedHealthcare Medicaid	$9,245.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HIV WITH MAJOR RELATED CONDITION WITH CC

Facility

$4,130.10

Service Code	MSDRG 975
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,130.10
Rate for Payer: UnitedHealthcare Medicaid	$4,130.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HIV WITH MAJOR RELATED CONDITION WITH MCC

Facility

$9,245.07

Service Code	MSDRG 974
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,245.07
Rate for Payer: UnitedHealthcare Medicaid	$9,245.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC

Facility

$2,891.07

Service Code	MSDRG 976
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,891.07
Rate for Payer: UnitedHealthcare Medicaid	$2,891.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HIV WITH OR WITHOUT OTHER RELATED CONDITION

Facility

$4,161.87

Service Code	MSDRG 977
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,161.87
Rate for Payer: UnitedHealthcare Medicaid	$4,161.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HLA B27 Ab QST Bill Only

Facility

$87.00

Service Code	HCPCS 86812
Hospital Charge Code	3552300
Hospital Revenue Code	300
Min. Negotiated Rate	$25.81
Max. Negotiated Rate	$82.65
Rate for Payer: Aetna Commercial	$78.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$55.39
Rate for Payer: Humana Medicare Advantage	$36.54
Rate for Payer: UnitedHealthcare Commercial	$82.65
Rate for Payer: UnitedHealthcare Medicaid	$25.81
Rate for Payer: WPPA Medicare Advantage	$52.20

HLA B27 Ab QST Bill Only

Facility

$87.00

Service Code	HCPCS 86812
Hospital Charge Code	3552300
Hospital Revenue Code	300
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

Know your out-of-pocket cost for care.

All Charges