Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC

Facility

$4,765.50

Service Code	MSDRG 436
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,765.50
Rate for Payer: UnitedHealthcare Medicaid	$4,765.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC

Facility

$7,084.71

Service Code	MSDRG 435
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,084.71
Rate for Payer: UnitedHealthcare Medicaid	$7,084.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC

Facility

$3,590.01

Service Code	MSDRG 437
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,590.01
Rate for Payer: UnitedHealthcare Medicaid	$3,590.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MALIGNANT BREAST DISORDERS WITH CC

Facility

$5,305.59

Service Code	MSDRG 598
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,305.59
Rate for Payer: UnitedHealthcare Medicaid	$5,305.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MALIGNANT BREAST DISORDERS WITH MCC

Facility

$7,815.42

Service Code	MSDRG 597
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,815.42
Rate for Payer: UnitedHealthcare Medicaid	$7,815.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MALIGNANT BREAST DISORDERS WITHOUT CC/MCC

Facility

$3,590.01

Service Code	MSDRG 599
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,590.01
Rate for Payer: UnitedHealthcare Medicaid	$3,590.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Manganese, Blood QST

Facility

$301.00

Service Code	HCPCS 83785
Hospital Charge Code	3553785
Hospital Revenue Code	300
Min. Negotiated Rate	$22.65
Max. Negotiated Rate	$285.95
Rate for Payer: Aetna Commercial	$270.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.14
Rate for Payer: Humana Medicare Advantage	$126.42
Rate for Payer: UnitedHealthcare Commercial	$285.95
Rate for Payer: UnitedHealthcare Medicaid	$22.65
Rate for Payer: WPPA Medicare Advantage	$180.60

Manganese, Blood QST

Facility

$301.00

Service Code	HCPCS 83785
Hospital Charge Code	3553785
Hospital Revenue Code	300
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$270.90
Rate for Payer: UnitedHealthcare Commercial	$285.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

mannitol 20% Sol 250 mL [HMC]

Facility

$112.47

Service Code	NDC 00990771502
Hospital Charge Code	3808760
Hospital Revenue Code	259
Min. Negotiated Rate	$44.99
Max. Negotiated Rate	$106.85
Rate for Payer: Aetna Commercial	$101.22
Rate for Payer: Humana Medicare Advantage	$47.24
Rate for Payer: UnitedHealthcare Commercial	$106.85
Rate for Payer: UnitedHealthcare Medicaid	$44.99
Rate for Payer: WPPA Medicare Advantage	$67.48

mannitol 20% Sol 250 mL [HMC]

Facility

$112.47

Service Code	NDC 00990771502
Hospital Charge Code	3808760
Hospital Revenue Code	259
Min. Negotiated Rate	$101.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.22
Rate for Payer: UnitedHealthcare Commercial	$106.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.Manual Differential (HMCSH)

Facility

$38.00

Service Code	HCPCS 85007
Hospital Charge Code	3552488
Hospital Revenue Code	300
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.Manual Differential (HMCSH)

Facility

$38.00

Service Code	HCPCS 85007
Hospital Charge Code	3552488
Hospital Revenue Code	300
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$36.10
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7.53
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: UnitedHealthcare Medicaid	$3.23
Rate for Payer: WPPA Medicare Advantage	$22.80

Manual Therapy Charge Units

Facility

$122.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	3950572
Hospital Revenue Code	420
Min. Negotiated Rate	$109.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Manual Therapy Charge Units

Facility

$122.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	3950572
Hospital Revenue Code	420
Min. Negotiated Rate	$22.37
Max. Negotiated Rate	$115.90
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$58.08
Rate for Payer: Humana Medicare Advantage	$51.24
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: UnitedHealthcare Medicaid	$22.37
Rate for Payer: WPPA Medicare Advantage	$73.20

Maple (Box Elder) (T1) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1015
Hospital Revenue Code	300
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Maple (Box Elder) (T1) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1015
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$16.20

Marijuana Metabolites By GC/MS QST

Facility

$38.00

Service Code	HCPCS 80349
Hospital Charge Code	3555722
Hospital Revenue Code	300
Min. Negotiated Rate	$15.96
Max. Negotiated Rate	$36.10
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.88
Rate for Payer: Humana Medicare Advantage	$15.96
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: UnitedHealthcare Medicaid	$17.88
Rate for Payer: WPPA Medicare Advantage	$22.80

Marijuana Metabolites By GC/MS QST

Facility

$38.00

Service Code	HCPCS 80349
Hospital Charge Code	3555722
Hospital Revenue Code	300
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: UnitedHealthcare Commercial	$36.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Marijuana Metabolite, with Ratio, Urine QST

Facility

$36.00

Service Code	HCPCS 80349
Hospital Charge Code	3555722
Hospital Revenue Code	300
Min. Negotiated Rate	$32.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$32.40
Rate for Payer: UnitedHealthcare Commercial	$34.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Marijuana Metabolite, with Ratio, Urine QST

Facility

$36.00

Service Code	HCPCS 80349
Hospital Charge Code	3555722
Hospital Revenue Code	300
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$34.20
Rate for Payer: Aetna Commercial	$32.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.88
Rate for Payer: Humana Medicare Advantage	$15.12
Rate for Payer: UnitedHealthcare Commercial	$34.20
Rate for Payer: UnitedHealthcare Medicaid	$17.88
Rate for Payer: WPPA Medicare Advantage	$21.60

Mask Aeroeclipse Large

Facility

$2.70

Hospital Charge Code	3250203
Hospital Revenue Code	270
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.43
Rate for Payer: UnitedHealthcare Commercial	$2.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Aeroeclipse Large

Facility

$2.70

Hospital Charge Code	3250203
Hospital Revenue Code	270
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$2.56
Rate for Payer: Aetna Commercial	$2.43
Rate for Payer: Humana Medicare Advantage	$1.13
Rate for Payer: UnitedHealthcare Commercial	$2.56
Rate for Payer: UnitedHealthcare Medicaid	$1.08
Rate for Payer: WPPA Medicare Advantage	$1.62

Mask Aeroeclipse Small

Facility

$2.50

Hospital Charge Code	3250205
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mask Aeroeclipse Small

Facility

$2.50

Hospital Charge Code	3250205
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

Mask Aerosol Adult

Facility

$2.50

Hospital Charge Code	3256794
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges