Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Lumbar Puncture Tray 22G x 3.5

Facility

$70.65

Hospital Charge Code	3251944
Hospital Revenue Code	270
Min. Negotiated Rate	$28.26
Max. Negotiated Rate	$67.12
Rate for Payer: Aetna Commercial	$63.59
Rate for Payer: Humana Medicare Advantage	$29.67
Rate for Payer: UnitedHealthcare Commercial	$67.12
Rate for Payer: UnitedHealthcare Medicaid	$28.26
Rate for Payer: WPPA Medicare Advantage	$42.39

Lumbar Puncture Tray 22G x 3.5

Facility

$70.65

Hospital Charge Code	3251944
Hospital Revenue Code	270
Min. Negotiated Rate	$63.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.59
Rate for Payer: UnitedHealthcare Commercial	$67.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LUNG TRANSPLANT

Facility

$34,216.29

Service Code	MSDRG 007
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$34,216.29
Rate for Payer: UnitedHealthcare Medicaid	$34,216.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lupus Anticoagulant Evaluation w/Rfx QST

Facility

$118.00

Service Code	HCPCS 85613
Hospital Charge Code	3555598
Hospital Revenue Code	300
Min. Negotiated Rate	$106.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lupus Anticoagulant Evaluation w/Rfx QST

Facility

$118.00

Service Code	HCPCS 85613
Hospital Charge Code	3555598
Hospital Revenue Code	300
Min. Negotiated Rate	$8.14
Max. Negotiated Rate	$112.10
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$27.03
Rate for Payer: Humana Medicare Advantage	$49.56
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: UnitedHealthcare Medicaid	$8.14
Rate for Payer: WPPA Medicare Advantage	$70.80

lurasidone 40 mg Tab [HMC]

Facility

$61.75

Service Code	NDC 63402030430
Hospital Charge Code	3800307
Hospital Revenue Code	250
Min. Negotiated Rate	$55.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$55.58
Rate for Payer: UnitedHealthcare Commercial	$58.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lurasidone 40 mg Tab [HMC]

Facility

$61.75

Service Code	NDC 63402030430
Hospital Charge Code	3800307
Hospital Revenue Code	250
Min. Negotiated Rate	$24.70
Max. Negotiated Rate	$58.66
Rate for Payer: Aetna Commercial	$55.58
Rate for Payer: Humana Medicare Advantage	$25.93
Rate for Payer: UnitedHealthcare Commercial	$58.66
Rate for Payer: UnitedHealthcare Medicaid	$24.70
Rate for Payer: WPPA Medicare Advantage	$37.05

LVP solution Dextrose 5% in Water Sol

Facility

$39.68

Service Code	HCPCS J7070
Hospital Charge Code	3250128
Hospital Revenue Code	250
Min. Negotiated Rate	$35.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.71
Rate for Payer: UnitedHealthcare Commercial	$37.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LVP solution Dextrose 5% in Water Sol

Facility

$39.68

Service Code	HCPCS J7070
Hospital Charge Code	3250128
Hospital Revenue Code	250
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$37.70
Rate for Payer: Aetna Commercial	$35.71
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4.63
Rate for Payer: Humana Medicare Advantage	$16.67
Rate for Payer: UnitedHealthcare Commercial	$37.70
Rate for Payer: UnitedHealthcare Medicaid	$2.94
Rate for Payer: WPPA Medicare Advantage	$23.81

Lyme Disease Abs (IgG,IgM), Blot QST

Facility

$166.00

Service Code	HCPCS 86617
Hospital Charge Code	3556617
Hospital Revenue Code	300
Min. Negotiated Rate	$149.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$149.40
Rate for Payer: UnitedHealthcare Commercial	$157.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lyme Disease Abs (IgG,IgM), Blot QST

Facility

$166.00

Service Code	HCPCS 86617
Hospital Charge Code	3556617
Hospital Revenue Code	300
Min. Negotiated Rate	$13.17
Max. Negotiated Rate	$157.70
Rate for Payer: Aetna Commercial	$149.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.71
Rate for Payer: Humana Medicare Advantage	$69.72
Rate for Payer: UnitedHealthcare Commercial	$157.70
Rate for Payer: UnitedHealthcare Medicaid	$13.17
Rate for Payer: WPPA Medicare Advantage	$99.60

Lyme Disease Ab w/Rfx Blot (IgG,IgM) QST

Facility

$166.00

Service Code	HCPCS 86617
Hospital Charge Code	3556617
Hospital Revenue Code	300
Min. Negotiated Rate	$149.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$149.40
Rate for Payer: UnitedHealthcare Commercial	$157.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lyme Disease Ab w/Rfx Blot (IgG,IgM) QST

Facility

$166.00

Service Code	HCPCS 86617
Hospital Charge Code	3556617
Hospital Revenue Code	300
Min. Negotiated Rate	$13.17
Max. Negotiated Rate	$157.70
Rate for Payer: Aetna Commercial	$149.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.71
Rate for Payer: Humana Medicare Advantage	$69.72
Rate for Payer: UnitedHealthcare Commercial	$157.70
Rate for Payer: UnitedHealthcare Medicaid	$13.17
Rate for Payer: WPPA Medicare Advantage	$99.60

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$7,847.19

Service Code	MSDRG 821
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,847.19
Rate for Payer: UnitedHealthcare Medicaid	$7,847.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$20,555.19

Service Code	MSDRG 820
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$20,555.19
Rate for Payer: UnitedHealthcare Medicaid	$20,555.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$4,225.41

Service Code	MSDRG 822
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,225.41
Rate for Payer: UnitedHealthcare Medicaid	$4,225.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC

Facility

$4,892.58

Service Code	MSDRG 841
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,892.58
Rate for Payer: UnitedHealthcare Medicaid	$4,892.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC

Facility

$9,721.62

Service Code	MSDRG 840
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,721.62
Rate for Payer: UnitedHealthcare Medicaid	$9,721.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC

Facility

$7,942.50

Service Code	MSDRG 824
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,942.50
Rate for Payer: UnitedHealthcare Medicaid	$7,942.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC

Facility

$16,075.62

Service Code	MSDRG 823
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$16,075.62
Rate for Payer: UnitedHealthcare Medicaid	$16,075.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$4,733.73

Service Code	MSDRG 825
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,733.73
Rate for Payer: UnitedHealthcare Medicaid	$4,733.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$3,049.92

Service Code	MSDRG 842
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,049.92
Rate for Payer: UnitedHealthcare Medicaid	$3,049.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lysine 500 mg Tab [HMC]

Facility

$5.00

Service Code	NDC 79854060055
Hospital Charge Code	3800541
Hospital Revenue Code	250
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

lysine 500 mg Tab [HMC]

Facility

$5.08

Service Code	NDC 00536673101
Hospital Charge Code	3800541
Hospital Revenue Code	250
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$4.83
Rate for Payer: Aetna Commercial	$4.57
Rate for Payer: Humana Medicare Advantage	$2.13
Rate for Payer: UnitedHealthcare Commercial	$4.83
Rate for Payer: UnitedHealthcare Medicaid	$2.03
Rate for Payer: WPPA Medicare Advantage	$3.05

lysine 500 mg Tab [HMC]

Facility

$5.14

Service Code	NDC 00904268760
Hospital Charge Code	3800541
Hospital Revenue Code	250
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.63
Rate for Payer: UnitedHealthcare Commercial	$4.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges