Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

morphine 2 mg/mL preservative-free Sol [HMC]

Facility

$30.57

Service Code	HCPCS J2270
Hospital Charge Code	3802656
Hospital Revenue Code	250
Min. Negotiated Rate	$27.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.51
Rate for Payer: UnitedHealthcare Commercial	$29.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

morphine compounding Pwdr [HMC]

Facility

$3,467.50

Service Code	NDC 38779067307
Hospital Charge Code	3800248
Hospital Revenue Code	250
Min. Negotiated Rate	$1,387.00
Max. Negotiated Rate	$3,294.12
Rate for Payer: Aetna Commercial	$3,120.75
Rate for Payer: Humana Medicare Advantage	$1,456.35
Rate for Payer: UnitedHealthcare Commercial	$3,294.12
Rate for Payer: UnitedHealthcare Medicaid	$1,387.00
Rate for Payer: WPPA Medicare Advantage	$2,080.50

morphine compounding Pwdr [HMC]

Facility

$3,467.50

Service Code	NDC 38779067307
Hospital Charge Code	3800248
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,294.12
Rate for Payer: Aetna Commercial	$3,120.75
Rate for Payer: UnitedHealthcare Commercial	$3,294.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

.Morphology (HMCSH)

Facility

$5.00

Service Code	HCPCS 85008
Hospital Charge Code	3550173
Hospital Revenue Code	300
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

.Morphology (HMCSH)

Facility

$5.00

Service Code	HCPCS 85008
Hospital Charge Code	3550173
Hospital Revenue Code	300
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$64.48
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$64.48
Rate for Payer: Humana Medicare Advantage	$2.10
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: UnitedHealthcare Medicaid	$2.92
Rate for Payer: WPPA Medicare Advantage	$3.00

Mountain Cedar (T6) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1016
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

Mountain Cedar (T6) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1016
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

Mouse Urine Proteins (E72) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1017
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

Mouse Urine Proteins (E72) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1017
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

Mouthpiece Vyaire Rubber Disposable Adult PFT Mouthpiece 32-35mm

Facility

$5.76

Hospital Charge Code	3251721
Hospital Revenue Code	270
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

Mouthpiece Vyaire Rubber Disposable Adult PFT Mouthpiece 32-35mm

Facility

$5.76

Hospital Charge Code	3251721
Hospital Revenue Code	270
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.18
Rate for Payer: UnitedHealthcare Commercial	$5.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MOUTH PROCEDURES WITH CC/MCC

Facility

$2,795.76

Service Code	MSDRG 137
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,795.76
Rate for Payer: UnitedHealthcare Medicaid	$2,795.76
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MOUTH PROCEDURES WITHOUT CC/MCC

Facility

$1,652.04

Service Code	MSDRG 138
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,652.04
Rate for Payer: UnitedHealthcare Medicaid	$1,652.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRA Abdomen w/ + w/o Contrast

Facility

$2,403.00

Service Code	HCPCS 74185 TC
Hospital Charge Code	3750080
Hospital Revenue Code	616
Min. Negotiated Rate	$221.19
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$664.93
Rate for Payer: Humana Medicare Advantage	$1,009.26
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: UnitedHealthcare Medicaid	$221.19
Rate for Payer: WPPA Medicare Advantage	$1,441.80

MRA Abdomen w/ + w/o Contrast

Facility

$2,403.00

Service Code	HCPCS 74185 TC
Hospital Charge Code	3750080
Hospital Revenue Code	616
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRA Brain/Head w/ Contrast

Facility

$2,294.00

Service Code	HCPCS 70545 TC
Hospital Charge Code	3750077
Hospital Revenue Code	615
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$2,179.30
Rate for Payer: Aetna Commercial	$2,064.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$664.93
Rate for Payer: Humana Medicare Advantage	$963.48
Rate for Payer: UnitedHealthcare Commercial	$2,179.30
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,376.40

MRA Brain/Head w/ Contrast

Facility

$2,294.00

Service Code	HCPCS 70545 TC
Hospital Charge Code	3750077
Hospital Revenue Code	615
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,179.30
Rate for Payer: Aetna Commercial	$2,064.60
Rate for Payer: UnitedHealthcare Commercial	$2,179.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRA Brain/Head w/o Contrast

Facility

$2,185.00

Service Code	HCPCS 70544 TC
Hospital Charge Code	3750069
Hospital Revenue Code	615
Min. Negotiated Rate	$131.00
Max. Negotiated Rate	$2,075.75
Rate for Payer: Aetna Commercial	$1,966.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$664.93
Rate for Payer: Humana Medicare Advantage	$917.70
Rate for Payer: UnitedHealthcare Commercial	$2,075.75
Rate for Payer: UnitedHealthcare Medicaid	$131.00
Rate for Payer: WPPA Medicare Advantage	$1,311.00

MRA Brain/Head w/o Contrast

Facility

$2,185.00

Service Code	HCPCS 70544 TC
Hospital Charge Code	3750069
Hospital Revenue Code	615
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,075.75
Rate for Payer: Aetna Commercial	$1,966.50
Rate for Payer: UnitedHealthcare Commercial	$2,075.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRA Brain/Head w/ + w/o Contrast

Facility

$2,403.00

Service Code	HCPCS 70546 TC
Hospital Charge Code	3750085
Hospital Revenue Code	615
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRA Brain/Head w/ + w/o Contrast

Facility

$2,403.00

Service Code	HCPCS 70546 TC
Hospital Charge Code	3750085
Hospital Revenue Code	615
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$664.93
Rate for Payer: Humana Medicare Advantage	$1,009.26
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,441.80

MRA Lower Extremity w/ + w/o Cnt Left

Facility

$2,403.00

Service Code	HCPCS 73725 LT
Hospital Charge Code	3750309
Hospital Revenue Code	616
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRA Lower Extremity w/ + w/o Cnt Left

Facility

$2,403.00

Service Code	HCPCS 73725 LT
Hospital Charge Code	3750309
Hospital Revenue Code	616
Min. Negotiated Rate	$206.34
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$664.93
Rate for Payer: Humana Medicare Advantage	$1,009.26
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: UnitedHealthcare Medicaid	$206.34
Rate for Payer: WPPA Medicare Advantage	$1,441.80

MRA Lower Extremity w/ + w/o Cnt Right

Facility

$2,403.00

Service Code	HCPCS 73725 RT
Hospital Charge Code	3750309
Hospital Revenue Code	616
Min. Negotiated Rate	$206.34
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$664.93
Rate for Payer: Humana Medicare Advantage	$1,009.26
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: UnitedHealthcare Medicaid	$206.34
Rate for Payer: WPPA Medicare Advantage	$1,441.80

MRA Lower Extremity w/ + w/o Cnt Right

Facility

$2,403.00

Service Code	HCPCS 73725 RT
Hospital Charge Code	3750309
Hospital Revenue Code	616
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges