Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

HMC MG Mammo Digital Screening Right

Facility

$303.00

Service Code	HCPCS 77067 RT
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$161.00
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$72.25
Rate for Payer: WPPA Medicare Advantage	$181.80

HMC NM CCK Kinovac 5 Micrograms

Facility

$186.00

Service Code	HCPCS J2805
Hospital Charge Code	3720325
Hospital Revenue Code	343
Min. Negotiated Rate	$167.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$167.40
Rate for Payer: UnitedHealthcare Commercial	$176.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM CCK Kinovac 5 Micrograms

Facility

$186.00

Service Code	HCPCS J2805
Hospital Charge Code	3720325
Hospital Revenue Code	343
Min. Negotiated Rate	$74.40
Max. Negotiated Rate	$176.70
Rate for Payer: Aetna Commercial	$167.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$171.22
Rate for Payer: Humana Medicare Advantage	$78.12
Rate for Payer: UnitedHealthcare Commercial	$176.70
Rate for Payer: UnitedHealthcare Medicaid	$74.40
Rate for Payer: WPPA Medicare Advantage	$111.60

HMC NM Choletec

Facility

$520.00

Service Code	HCPCS A9537
Hospital Charge Code	3720315
Hospital Revenue Code	343
Min. Negotiated Rate	$468.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$468.00
Rate for Payer: UnitedHealthcare Commercial	$494.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM Choletec

Facility

$520.00

Service Code	HCPCS A9537
Hospital Charge Code	3720315
Hospital Revenue Code	343
Min. Negotiated Rate	$141.98
Max. Negotiated Rate	$494.00
Rate for Payer: Aetna Commercial	$468.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$141.98
Rate for Payer: Humana Medicare Advantage	$218.40
Rate for Payer: UnitedHealthcare Commercial	$494.00
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$312.00

HMC NM Iodine I-123 SOD

Facility

$394.00

Service Code	HCPCS A9516
Hospital Charge Code	3720500
Hospital Revenue Code	343
Min. Negotiated Rate	$122.03
Max. Negotiated Rate	$374.30
Rate for Payer: Aetna Commercial	$354.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$122.03
Rate for Payer: Humana Medicare Advantage	$165.48
Rate for Payer: UnitedHealthcare Commercial	$374.30
Rate for Payer: UnitedHealthcare Medicaid	$157.60
Rate for Payer: WPPA Medicare Advantage	$236.40

HMC NM Iodine I-123 SOD

Facility

$394.00

Service Code	HCPCS A9516
Hospital Charge Code	3720500
Hospital Revenue Code	343
Min. Negotiated Rate	$354.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$354.60
Rate for Payer: UnitedHealthcare Commercial	$374.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM Lexiscan

Facility

$169.00

Service Code	HCPCS J2785
Hospital Charge Code	3720470
Hospital Revenue Code	636
Min. Negotiated Rate	$152.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$152.10
Rate for Payer: UnitedHealthcare Commercial	$160.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM Lexiscan

Facility

$169.00

Service Code	HCPCS J2785
Hospital Charge Code	3720470
Hospital Revenue Code	636
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$160.55
Rate for Payer: Aetna Commercial	$152.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$19.79
Rate for Payer: Humana Medicare Advantage	$70.98
Rate for Payer: UnitedHealthcare Commercial	$160.55
Rate for Payer: UnitedHealthcare Medicaid	$2.68
Rate for Payer: WPPA Medicare Advantage	$101.40

HMC NM MAA

Facility

$502.00

Service Code	HCPCS A9540
Hospital Charge Code	3720515
Hospital Revenue Code	343
Min. Negotiated Rate	$200.80
Max. Negotiated Rate	$476.90
Rate for Payer: Aetna Commercial	$451.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$219.72
Rate for Payer: Humana Medicare Advantage	$210.84
Rate for Payer: UnitedHealthcare Commercial	$476.90
Rate for Payer: UnitedHealthcare Medicaid	$200.80
Rate for Payer: WPPA Medicare Advantage	$301.20

HMC NM MAA

Facility

$502.00

Service Code	HCPCS A9540
Hospital Charge Code	3720515
Hospital Revenue Code	343
Min. Negotiated Rate	$451.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$451.80
Rate for Payer: UnitedHealthcare Commercial	$476.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM Medronate

Facility

$512.00

Service Code	HCPCS A9503
Hospital Charge Code	3720525
Hospital Revenue Code	343
Min. Negotiated Rate	$460.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$460.80
Rate for Payer: UnitedHealthcare Commercial	$486.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM Medronate

Facility

$512.00

Service Code	HCPCS A9503
Hospital Charge Code	3720525
Hospital Revenue Code	343
Min. Negotiated Rate	$204.80
Max. Negotiated Rate	$486.40
Rate for Payer: Aetna Commercial	$460.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$215.13
Rate for Payer: Humana Medicare Advantage	$215.04
Rate for Payer: UnitedHealthcare Commercial	$486.40
Rate for Payer: UnitedHealthcare Medicaid	$204.80
Rate for Payer: WPPA Medicare Advantage	$307.20

HMC NM Mertiatide

Facility

$1,029.00

Service Code	HCPCS A9562
Hospital Charge Code	3720520
Hospital Revenue Code	343
Min. Negotiated Rate	$926.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$926.10
Rate for Payer: UnitedHealthcare Commercial	$977.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM Mertiatide

Facility

$1,029.00

Service Code	HCPCS A9562
Hospital Charge Code	3720520
Hospital Revenue Code	343
Min. Negotiated Rate	$215.13
Max. Negotiated Rate	$977.55
Rate for Payer: Aetna Commercial	$926.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$215.13
Rate for Payer: Humana Medicare Advantage	$432.18
Rate for Payer: UnitedHealthcare Commercial	$977.55
Rate for Payer: UnitedHealthcare Medicaid	$411.60
Rate for Payer: WPPA Medicare Advantage	$617.40

HMC NM Pertech/mCi

Facility

$56.00

Service Code	HCPCS A9512
Hospital Charge Code	3720335
Hospital Revenue Code	343
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM Pertech/mCi

Facility

$56.00

Service Code	HCPCS A9512
Hospital Charge Code	3720335
Hospital Revenue Code	343
Min. Negotiated Rate	$20.38
Max. Negotiated Rate	$53.20
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$20.38
Rate for Payer: Humana Medicare Advantage	$23.52
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: UnitedHealthcare Medicaid	$22.40
Rate for Payer: WPPA Medicare Advantage	$33.60

HMC NM Pertech/mCi/10 per millicure

Facility

$56.00

Service Code	HCPCS A9512
Hospital Charge Code	3720335
Hospital Revenue Code	343
Min. Negotiated Rate	$20.38
Max. Negotiated Rate	$53.20
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$20.38
Rate for Payer: Humana Medicare Advantage	$23.52
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: UnitedHealthcare Medicaid	$22.40
Rate for Payer: WPPA Medicare Advantage	$33.60

HMC NM Pertech/mCi/10 per millicure

Facility

$56.00

Service Code	HCPCS A9512
Hospital Charge Code	3720335
Hospital Revenue Code	343
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM PYP

Facility

$520.00

Service Code	HCPCS A9560
Hospital Charge Code	3720510
Hospital Revenue Code	343
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$494.00
Rate for Payer: Aetna Commercial	$468.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$215.13
Rate for Payer: Humana Medicare Advantage	$218.40
Rate for Payer: UnitedHealthcare Commercial	$494.00
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$312.00

HMC NM PYP

Facility

$520.00

Service Code	HCPCS A9560
Hospital Charge Code	3720510
Hospital Revenue Code	343
Min. Negotiated Rate	$468.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$468.00
Rate for Payer: UnitedHealthcare Commercial	$494.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM Sestamibi

Facility

$502.00

Service Code	HCPCS A9500
Hospital Charge Code	3720305
Hospital Revenue Code	343
Min. Negotiated Rate	$200.80
Max. Negotiated Rate	$476.90
Rate for Payer: Aetna Commercial	$451.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$215.13
Rate for Payer: Humana Medicare Advantage	$210.84
Rate for Payer: UnitedHealthcare Commercial	$476.90
Rate for Payer: UnitedHealthcare Medicaid	$200.80
Rate for Payer: WPPA Medicare Advantage	$301.20

HMC NM Sestamibi

Facility

$502.00

Service Code	HCPCS A9500
Hospital Charge Code	3720305
Hospital Revenue Code	343
Min. Negotiated Rate	$451.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$451.80
Rate for Payer: UnitedHealthcare Commercial	$476.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM Sulf Coll/mCi5

Facility

$537.00

Service Code	HCPCS A9541
Hospital Charge Code	3720310
Hospital Revenue Code	343
Min. Negotiated Rate	$173.14
Max. Negotiated Rate	$510.15
Rate for Payer: Aetna Commercial	$483.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$173.14
Rate for Payer: Humana Medicare Advantage	$225.54
Rate for Payer: UnitedHealthcare Commercial	$510.15
Rate for Payer: UnitedHealthcare Medicaid	$214.80
Rate for Payer: WPPA Medicare Advantage	$322.20

HMC NM Sulf Coll/mCi5

Facility

$537.00

Service Code	HCPCS A9541
Hospital Charge Code	3720310
Hospital Revenue Code	343
Min. Negotiated Rate	$483.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$483.30
Rate for Payer: UnitedHealthcare Commercial	$510.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges