Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

MRI UE Non Joint w/ + w/o Contrast Rt

Facility

$2,062.00

Service Code	HCPCS 73220 TC
Hospital Charge Code	3750261
Hospital Revenue Code	610
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$1,958.90
Rate for Payer: Aetna Commercial	$1,855.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$552.52
Rate for Payer: Humana Medicare Advantage	$866.04
Rate for Payer: UnitedHealthcare Commercial	$1,958.90
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,237.20

MRI UE Non Joint w/ + w/o Contrast Rt

Facility

$2,062.00

Service Code	HCPCS 73220 TC
Hospital Charge Code	3750261
Hospital Revenue Code	610
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,958.90
Rate for Payer: Aetna Commercial	$1,855.80
Rate for Payer: UnitedHealthcare Commercial	$1,958.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRSA Screen (GeneXpert)

Facility

$264.00

Service Code	HCPCS 87641
Hospital Charge Code	3550827
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$250.80
Rate for Payer: Aetna Commercial	$237.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$75.31
Rate for Payer: Humana Medicare Advantage	$110.88
Rate for Payer: UnitedHealthcare Commercial	$250.80
Rate for Payer: UnitedHealthcare Medicaid	$35.09
Rate for Payer: WPPA Medicare Advantage	$158.40

MRSA Screen (GeneXpert)

Facility

$264.00

Service Code	HCPCS 87641
Hospital Charge Code	3550827
Hospital Revenue Code	300
Min. Negotiated Rate	$237.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$237.60
Rate for Payer: UnitedHealthcare Commercial	$250.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRV Brain 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

MRV Brain 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

MRV Brain 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

MRV Brain 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

MRV Brain 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

MRV Brain 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

MSLT CHARGE

Facility

$2,212.00

Service Code	HCPCS 95805
Hospital Charge Code	3920020
Hospital Revenue Code	920
Min. Negotiated Rate	$434.08
Max. Negotiated Rate	$2,101.40
Rate for Payer: Aetna Commercial	$1,990.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,056.46
Rate for Payer: Humana Medicare Advantage	$929.04
Rate for Payer: UnitedHealthcare Commercial	$2,101.40
Rate for Payer: UnitedHealthcare Medicaid	$434.08
Rate for Payer: WPPA Medicare Advantage	$1,327.20

MSLT CHARGE

Facility

$2,212.00

Service Code	HCPCS 95805
Hospital Charge Code	3920020
Hospital Revenue Code	920
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,101.40
Rate for Payer: Aetna Commercial	$1,990.80
Rate for Payer: UnitedHealthcare Commercial	$2,101.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MTHFR, DNA QST

Facility

$536.00

Service Code	HCPCS 81291
Hospital Charge Code	3555107
Hospital Revenue Code	300
Min. Negotiated Rate	$159.65
Max. Negotiated Rate	$509.20
Rate for Payer: Aetna Commercial	$482.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$159.65
Rate for Payer: Humana Medicare Advantage	$225.12
Rate for Payer: UnitedHealthcare Commercial	$509.20
Rate for Payer: UnitedHealthcare Medicaid	$214.40
Rate for Payer: WPPA Medicare Advantage	$321.60

MTHFR, DNA QST

Facility

$536.00

Service Code	HCPCS 81291
Hospital Charge Code	3555107
Hospital Revenue Code	300
Min. Negotiated Rate	$482.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$482.40
Rate for Payer: UnitedHealthcare Commercial	$509.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mucor racemosus (M4) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	35527014
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

Mucor racemosus (M4) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	35527014
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

Mucous Trap

Facility

$4.59

Hospital Charge Code	3251431
Hospital Revenue Code	270
Min. Negotiated Rate	$4.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.13
Rate for Payer: UnitedHealthcare Commercial	$4.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Mucous Trap

Facility

$4.59

Hospital Charge Code	3251431
Hospital Revenue Code	270
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$4.36
Rate for Payer: Aetna Commercial	$4.13
Rate for Payer: Humana Medicare Advantage	$1.93
Rate for Payer: UnitedHealthcare Commercial	$4.36
Rate for Payer: UnitedHealthcare Medicaid	$1.84
Rate for Payer: WPPA Medicare Advantage	$2.75

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC

Facility

$27,322.20

Service Code	MSDRG 427
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$27,322.20
Rate for Payer: UnitedHealthcare Medicaid	$27,322.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$41,714.01

Service Code	MSDRG 426
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$41,714.01
Rate for Payer: UnitedHealthcare Medicaid	$41,714.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC

Facility

$21,285.90

Service Code	MSDRG 428
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$21,285.90
Rate for Payer: UnitedHealthcare Medicaid	$21,285.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$25,288.92

Service Code	MSDRG 447
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$25,288.92
Rate for Payer: UnitedHealthcare Medicaid	$25,288.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$15,757.92

Service Code	MSDRG 448
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$15,757.92
Rate for Payer: UnitedHealthcare Medicaid	$15,757.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC

Facility

$5,623.29

Service Code	MSDRG 059
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,623.29
Rate for Payer: UnitedHealthcare Medicaid	$5,623.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC

Facility

$7,720.11

Service Code	MSDRG 058
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,720.11
Rate for Payer: UnitedHealthcare Medicaid	$7,720.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges