Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

H. Pylori, Urea Breath Test QST

Facility

$467.00

Service Code	HCPCS 83013
Hospital Charge Code	3553013
Hospital Revenue Code	300
Min. Negotiated Rate	$420.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$420.30
Rate for Payer: UnitedHealthcare Commercial	$443.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

H. Pylori, Urea Breath Test QST

Facility

$467.00

Service Code	HCPCS 83013
Hospital Charge Code	3553013
Hospital Revenue Code	300
Min. Negotiated Rate	$57.26
Max. Negotiated Rate	$443.65
Rate for Payer: Aetna Commercial	$420.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$274.88
Rate for Payer: Humana Medicare Advantage	$196.14
Rate for Payer: UnitedHealthcare Commercial	$443.65
Rate for Payer: UnitedHealthcare Medicaid	$57.26
Rate for Payer: WPPA Medicare Advantage	$280.20

HSV Culture w/Rfl To Typing QST

Facility

$159.00

Service Code	HCPCS 87255
Hospital Charge Code	3557255
Hospital Revenue Code	300
Min. Negotiated Rate	$28.78
Max. Negotiated Rate	$151.05
Rate for Payer: Aetna Commercial	$143.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$80.54
Rate for Payer: Humana Medicare Advantage	$66.78
Rate for Payer: UnitedHealthcare Commercial	$151.05
Rate for Payer: UnitedHealthcare Medicaid	$28.78
Rate for Payer: WPPA Medicare Advantage	$95.40

HSV Culture w/Rfl To Typing QST

Facility

$159.00

Service Code	HCPCS 87255
Hospital Charge Code	3557255
Hospital Revenue Code	300
Min. Negotiated Rate	$143.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$143.10
Rate for Payer: UnitedHealthcare Commercial	$151.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HSV,Type 1 and 2 DNA, Ql RT PCR QST

Facility

$439.00

Service Code	HCPCS 87529
Hospital Charge Code	3557529
Hospital Revenue Code	300
Min. Negotiated Rate	$395.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$395.10
Rate for Payer: UnitedHealthcare Commercial	$417.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HSV,Type 1 and 2 DNA, Ql RT PCR QST

Facility

$439.00

Service Code	HCPCS 87529
Hospital Charge Code	3557529
Hospital Revenue Code	300
Min. Negotiated Rate	$29.83
Max. Negotiated Rate	$417.05
Rate for Payer: Aetna Commercial	$395.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$75.32
Rate for Payer: Humana Medicare Advantage	$184.38
Rate for Payer: UnitedHealthcare Commercial	$417.05
Rate for Payer: UnitedHealthcare Medicaid	$29.83
Rate for Payer: WPPA Medicare Advantage	$263.40

HTLV-I/II Antibody, with Reflex to Confirmatory Assay QST

Facility

$137.00

Service Code	HCPCS 86790
Hospital Charge Code	3556791
Hospital Revenue Code	300
Min. Negotiated Rate	$10.95
Max. Negotiated Rate	$130.15
Rate for Payer: Aetna Commercial	$123.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.65
Rate for Payer: Humana Medicare Advantage	$57.54
Rate for Payer: UnitedHealthcare Commercial	$130.15
Rate for Payer: UnitedHealthcare Medicaid	$10.95
Rate for Payer: WPPA Medicare Advantage	$82.20

HTLV-I/II Antibody, with Reflex to Confirmatory Assay QST

Facility

$137.00

Service Code	HCPCS 86790
Hospital Charge Code	3556791
Hospital Revenue Code	300
Min. Negotiated Rate	$123.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$123.30
Rate for Payer: UnitedHealthcare Commercial	$130.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Humidifier AquaPak 1070ML O2 Bubbler

Facility

$14.72

Hospital Charge Code	3256968
Hospital Revenue Code	270
Min. Negotiated Rate	$5.89
Max. Negotiated Rate	$13.98
Rate for Payer: Aetna Commercial	$13.25
Rate for Payer: Humana Medicare Advantage	$6.18
Rate for Payer: UnitedHealthcare Commercial	$13.98
Rate for Payer: UnitedHealthcare Medicaid	$5.89
Rate for Payer: WPPA Medicare Advantage	$8.83

Humidifier AquaPak 1070ML O2 Bubbler

Facility

$14.72

Hospital Charge Code	3256968
Hospital Revenue Code	270
Min. Negotiated Rate	$13.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.25
Rate for Payer: UnitedHealthcare Commercial	$13.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Humidifier AquaPak 340ML O2 Bubbler

Facility

$5.00

Hospital Charge Code	3256375
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Humidifier AquaPak 340ML O2 Bubbler

Facility

$5.00

Hospital Charge Code	3256375
Hospital Revenue Code	270
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: Humana Medicare Advantage	$2.10
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: UnitedHealthcare Medicaid	$2.00
Rate for Payer: WPPA Medicare Advantage	$3.00

Humidifier Cool Mist (Room Air)

Facility

$127.26

Hospital Charge Code	3256377
Hospital Revenue Code	270
Min. Negotiated Rate	$50.90
Max. Negotiated Rate	$120.90
Rate for Payer: Aetna Commercial	$114.53
Rate for Payer: Humana Medicare Advantage	$53.45
Rate for Payer: UnitedHealthcare Commercial	$120.90
Rate for Payer: UnitedHealthcare Medicaid	$50.90
Rate for Payer: WPPA Medicare Advantage	$76.36

Humidifier Cool Mist (Room Air)

Facility

$127.26

Hospital Charge Code	3256377
Hospital Revenue Code	270
Min. Negotiated Rate	$114.53
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$114.53
Rate for Payer: UnitedHealthcare Commercial	$120.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Huntington Disease Mutation Analysis REF

Facility

$618.00

Service Code	HCPCS 81271
Hospital Charge Code	3552947
Hospital Revenue Code	300
Min. Negotiated Rate	$116.45
Max. Negotiated Rate	$587.10
Rate for Payer: Aetna Commercial	$556.20
Rate for Payer: Humana Medicare Advantage	$259.56
Rate for Payer: UnitedHealthcare Commercial	$587.10
Rate for Payer: UnitedHealthcare Medicaid	$116.45
Rate for Payer: WPPA Medicare Advantage	$370.80

Huntington Disease Mutation Analysis REF

Facility

$618.00

Service Code	HCPCS 81271
Hospital Charge Code	3552947
Hospital Revenue Code	300
Min. Negotiated Rate	$556.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$556.20
Rate for Payer: UnitedHealthcare Commercial	$587.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydrALAZINE 10 mg Tab [HMC]

Facility

$6.24

Service Code	NDC 51079007420
Hospital Charge Code	3805641
Hospital Revenue Code	250
Min. Negotiated Rate	$5.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.62
Rate for Payer: UnitedHealthcare Commercial	$5.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydrALAZINE 10 mg Tab [HMC]

Facility

$5.37

Service Code	NDC 00904644061
Hospital Charge Code	3805641
Hospital Revenue Code	250
Min. Negotiated Rate	$4.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.83
Rate for Payer: UnitedHealthcare Commercial	$5.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydrALAZINE 10 mg Tab [HMC]

Facility

$6.60

Service Code	NDC 68084044701
Hospital Charge Code	3805641
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

hydrALAZINE 10 mg Tab [HMC]

Facility

$6.24

Service Code	NDC 51079007420
Hospital Charge Code	3805641
Hospital Revenue Code	250
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$5.93
Rate for Payer: Aetna Commercial	$5.62
Rate for Payer: Humana Medicare Advantage	$2.62
Rate for Payer: UnitedHealthcare Commercial	$5.93
Rate for Payer: UnitedHealthcare Medicaid	$2.50
Rate for Payer: WPPA Medicare Advantage	$3.74

hydrALAZINE 10 mg Tab [HMC]

Facility

$6.60

Service Code	NDC 68084044701
Hospital Charge Code	3805641
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

hydrALAZINE 10 mg Tab [HMC]

Facility

$5.37

Service Code	NDC 00904644061
Hospital Charge Code	3805641
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$5.10
Rate for Payer: Aetna Commercial	$4.83
Rate for Payer: Humana Medicare Advantage	$2.26
Rate for Payer: UnitedHealthcare Commercial	$5.10
Rate for Payer: UnitedHealthcare Medicaid	$2.15
Rate for Payer: WPPA Medicare Advantage	$3.22

hydrALAZINE 20 mg/mL Inj Sol [HMC]

Facility

$48.80

Service Code	HCPCS J0360
Hospital Charge Code	3805658
Hospital Revenue Code	250
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$43.92
Rate for Payer: Aetna Commercial	$48.93
Rate for Payer: UnitedHealthcare Commercial	$51.65
Rate for Payer: UnitedHealthcare Commercial	$46.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydrALAZINE 20 mg/mL Inj Sol [HMC]

Facility

$54.37

Service Code	HCPCS J0360
Hospital Charge Code	3805658
Hospital Revenue Code	250
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$51.65
Rate for Payer: Aetna Commercial	$48.93
Rate for Payer: Aetna Commercial	$43.92
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7.19
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7.19
Rate for Payer: Humana Medicare Advantage	$22.84
Rate for Payer: Humana Medicare Advantage	$20.50
Rate for Payer: UnitedHealthcare Commercial	$46.36
Rate for Payer: UnitedHealthcare Commercial	$51.65
Rate for Payer: UnitedHealthcare Medicaid	$4.39
Rate for Payer: UnitedHealthcare Medicaid	$4.39
Rate for Payer: WPPA Medicare Advantage	$32.62
Rate for Payer: WPPA Medicare Advantage	$29.28

hydrALAZINE 25 mg Tab [HMC]

Facility

$5.76

Service Code	NDC 60687082201
Hospital Charge Code	3805666
Hospital Revenue Code	250
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$5.47
Rate for Payer: Aetna Commercial	$5.18
Rate for Payer: Humana Medicare Advantage	$2.42
Rate for Payer: UnitedHealthcare Commercial	$5.47
Rate for Payer: UnitedHealthcare Medicaid	$2.30
Rate for Payer: WPPA Medicare Advantage	$3.46

Know your out-of-pocket cost for care.

All Charges