Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Pistachio (F203) IgE QST

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3558600
Hospital Revenue Code	300
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Pistachio (F203) IgE QST

Facility

$26.00

Service Code	HCPCS 86003
Hospital Charge Code	3558600
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$24.70
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$10.92
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$15.60

Place of Pickup: Physician's Office (A0426)

Facility

$469.00

Service Code	HCPCS A0428 QN
Hospital Charge Code	4550122
Hospital Revenue Code	540
Min. Negotiated Rate	$422.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$422.10
Rate for Payer: UnitedHealthcare Commercial	$445.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Place of Pickup: Physician's Office (A0426)

Facility

$469.00

Service Code	HCPCS A0428 QN
Hospital Charge Code	4550122
Hospital Revenue Code	540
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$445.55
Rate for Payer: Aetna Commercial	$422.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$367.67
Rate for Payer: Humana Medicare Advantage	$196.98
Rate for Payer: UnitedHealthcare Commercial	$445.55
Rate for Payer: UnitedHealthcare Medicaid	$187.60
Rate for Payer: WPPA Medicare Advantage	$281.40

Place of Pickup: Physician's Office (A0427)

Facility

$746.00

Service Code	HCPCS A0427
Hospital Charge Code	4550148
Hospital Revenue Code	540
Min. Negotiated Rate	$298.40
Max. Negotiated Rate	$708.70
Rate for Payer: Aetna Commercial	$671.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$585.68
Rate for Payer: Humana Medicare Advantage	$313.32
Rate for Payer: UnitedHealthcare Commercial	$708.70
Rate for Payer: UnitedHealthcare Medicaid	$298.40
Rate for Payer: WPPA Medicare Advantage	$447.60

Place of Pickup: Physician's Office (A0427)

Facility

$746.00

Service Code	HCPCS A0427
Hospital Charge Code	4550148
Hospital Revenue Code	540
Min. Negotiated Rate	$671.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$671.40
Rate for Payer: UnitedHealthcare Commercial	$708.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Place of Pickup: Physician's Office (A0428)

Facility

$377.00

Service Code	HCPCS A0428 QN
Hospital Charge Code	4550080
Hospital Revenue Code	540
Min. Negotiated Rate	$339.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$339.30
Rate for Payer: UnitedHealthcare Commercial	$358.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Place of Pickup: Physician's Office (A0428)

Facility

$377.00

Service Code	HCPCS A0428 QN
Hospital Charge Code	4550080
Hospital Revenue Code	540
Min. Negotiated Rate	$150.80
Max. Negotiated Rate	$367.67
Rate for Payer: Aetna Commercial	$339.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$367.67
Rate for Payer: Humana Medicare Advantage	$158.34
Rate for Payer: UnitedHealthcare Commercial	$358.15
Rate for Payer: UnitedHealthcare Medicaid	$150.80
Rate for Payer: WPPA Medicare Advantage	$226.20

Place of Pickup: Physician's Office (A0429)

Facility

$825.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	4550106
Hospital Revenue Code	540
Min. Negotiated Rate	$742.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Place of Pickup: Physician's Office (A0429)

Facility

$825.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	4550106
Hospital Revenue Code	540
Min. Negotiated Rate	$330.00
Max. Negotiated Rate	$783.75
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$450.09
Rate for Payer: Humana Medicare Advantage	$346.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: UnitedHealthcare Medicaid	$330.00
Rate for Payer: WPPA Medicare Advantage	$495.00

Place of Pickup: Physician's Office (A0434)

Facility

$1,832.00

Service Code	HCPCS A0434
Hospital Charge Code	4550163
Hospital Revenue Code	540
Min. Negotiated Rate	$732.80
Max. Negotiated Rate	$1,740.40
Rate for Payer: Aetna Commercial	$1,648.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$942.91
Rate for Payer: Humana Medicare Advantage	$769.44
Rate for Payer: UnitedHealthcare Commercial	$1,740.40
Rate for Payer: UnitedHealthcare Medicaid	$732.80
Rate for Payer: WPPA Medicare Advantage	$1,099.20

Place of Pickup: Physician's Office (A0434)

Facility

$1,832.00

Service Code	HCPCS A0434
Hospital Charge Code	4550163
Hospital Revenue Code	540
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,740.40
Rate for Payer: Aetna Commercial	$1,648.80
Rate for Payer: UnitedHealthcare Commercial	$1,740.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Place of Pickup: Residence (A0426)

Facility

$469.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	4550122
Hospital Revenue Code	540
Min. Negotiated Rate	$422.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$422.10
Rate for Payer: UnitedHealthcare Commercial	$445.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Place of Pickup: Residence (A0426)

Facility

$469.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	4550122
Hospital Revenue Code	540
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$450.09
Rate for Payer: Aetna Commercial	$422.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$450.09
Rate for Payer: Humana Medicare Advantage	$196.98
Rate for Payer: UnitedHealthcare Commercial	$445.55
Rate for Payer: UnitedHealthcare Medicaid	$187.60
Rate for Payer: WPPA Medicare Advantage	$281.40

Place of Pickup: Residence (A0427)

Facility

$746.00

Service Code	HCPCS A0427
Hospital Charge Code	4550148
Hospital Revenue Code	540
Min. Negotiated Rate	$298.40
Max. Negotiated Rate	$708.70
Rate for Payer: Aetna Commercial	$671.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$585.68
Rate for Payer: Humana Medicare Advantage	$313.32
Rate for Payer: UnitedHealthcare Commercial	$708.70
Rate for Payer: UnitedHealthcare Medicaid	$298.40
Rate for Payer: WPPA Medicare Advantage	$447.60

Place of Pickup: Residence (A0427)

Facility

$746.00

Service Code	HCPCS A0427
Hospital Charge Code	4550148
Hospital Revenue Code	540
Min. Negotiated Rate	$671.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$671.40
Rate for Payer: UnitedHealthcare Commercial	$708.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Place of Pickup: Residence (A0428)

Facility

$377.00

Service Code	HCPCS A0428 QN
Hospital Charge Code	4550080
Hospital Revenue Code	540
Min. Negotiated Rate	$339.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$339.30
Rate for Payer: UnitedHealthcare Commercial	$358.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Place of Pickup: Residence (A0428)

Facility

$377.00

Service Code	HCPCS A0428 QN
Hospital Charge Code	4550080
Hospital Revenue Code	540
Min. Negotiated Rate	$150.80
Max. Negotiated Rate	$367.67
Rate for Payer: Aetna Commercial	$339.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$367.67
Rate for Payer: Humana Medicare Advantage	$158.34
Rate for Payer: UnitedHealthcare Commercial	$358.15
Rate for Payer: UnitedHealthcare Medicaid	$150.80
Rate for Payer: WPPA Medicare Advantage	$226.20

Place of Pickup: Residence (A0429)

Facility

$825.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	4550106
Hospital Revenue Code	540
Min. Negotiated Rate	$742.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Place of Pickup: Residence (A0429)

Facility

$825.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	4550106
Hospital Revenue Code	540
Min. Negotiated Rate	$330.00
Max. Negotiated Rate	$783.75
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$450.09
Rate for Payer: Humana Medicare Advantage	$346.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: UnitedHealthcare Medicaid	$330.00
Rate for Payer: WPPA Medicare Advantage	$495.00

Place of Pickup: Residence (A0434)

Facility

$1,832.00

Service Code	HCPCS A0434
Hospital Charge Code	4550163
Hospital Revenue Code	540
Min. Negotiated Rate	$732.80
Max. Negotiated Rate	$1,740.40
Rate for Payer: Aetna Commercial	$1,648.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$942.91
Rate for Payer: Humana Medicare Advantage	$769.44
Rate for Payer: UnitedHealthcare Commercial	$1,740.40
Rate for Payer: UnitedHealthcare Medicaid	$732.80
Rate for Payer: WPPA Medicare Advantage	$1,099.20

Place of Pickup: Residence (A0434)

Facility

$1,832.00

Service Code	HCPCS A0434
Hospital Charge Code	4550163
Hospital Revenue Code	540
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,740.40
Rate for Payer: Aetna Commercial	$1,648.80
Rate for Payer: UnitedHealthcare Commercial	$1,740.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Place of Pickup: Scene (A0426)

Facility

$469.00

Service Code	HCPCS A0430 QN
Hospital Charge Code	4550122
Hospital Revenue Code	540
Min. Negotiated Rate	$422.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$422.10
Rate for Payer: UnitedHealthcare Commercial	$445.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Place of Pickup: Scene (A0426)

Facility

$469.00

Service Code	HCPCS A0430 QN
Hospital Charge Code	4550122
Hospital Revenue Code	540
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$6,837.15
Rate for Payer: Aetna Commercial	$422.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$6,837.15
Rate for Payer: Humana Medicare Advantage	$196.98
Rate for Payer: UnitedHealthcare Commercial	$445.55
Rate for Payer: UnitedHealthcare Medicaid	$187.60
Rate for Payer: WPPA Medicare Advantage	$281.40

Place of Pickup: Scene (A0427)

Facility

$746.00

Service Code	HCPCS A0427
Hospital Charge Code	4550148
Hospital Revenue Code	540
Min. Negotiated Rate	$298.40
Max. Negotiated Rate	$708.70
Rate for Payer: Aetna Commercial	$671.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$585.68
Rate for Payer: Humana Medicare Advantage	$313.32
Rate for Payer: UnitedHealthcare Commercial	$708.70
Rate for Payer: UnitedHealthcare Medicaid	$298.40
Rate for Payer: WPPA Medicare Advantage	$447.60

Know your out-of-pocket cost for care.

All Charges