Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Protein Urine

Facility

$66.00

Service Code	HCPCS 84156
Hospital Charge Code	3552546
Hospital Revenue Code	300
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$62.70
Rate for Payer: Aetna Commercial	$59.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$18.82
Rate for Payer: Humana Medicare Advantage	$27.72
Rate for Payer: UnitedHealthcare Commercial	$62.70
Rate for Payer: UnitedHealthcare Medicaid	$3.67
Rate for Payer: WPPA Medicare Advantage	$39.60

Prothrombin (Factor II) 20210G>A Mut QST

Facility

$349.00

Service Code	HCPCS 81240
Hospital Charge Code	3552822
Hospital Revenue Code	300
Min. Negotiated Rate	$139.60
Max. Negotiated Rate	$331.55
Rate for Payer: Aetna Commercial	$314.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$190.18
Rate for Payer: Humana Medicare Advantage	$146.58
Rate for Payer: UnitedHealthcare Commercial	$331.55
Rate for Payer: UnitedHealthcare Medicaid	$139.60
Rate for Payer: WPPA Medicare Advantage	$209.40

Prothrombin (Factor II) 20210G>A Mut QST

Facility

$349.00

Service Code	HCPCS 81240
Hospital Charge Code	3552822
Hospital Revenue Code	300
Min. Negotiated Rate	$314.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$314.10
Rate for Payer: UnitedHealthcare Commercial	$331.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Prothrombin Time

Facility

$57.00

Service Code	HCPCS 85610
Hospital Charge Code	3550585
Hospital Revenue Code	301
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$54.15
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$16.08
Rate for Payer: Humana Medicare Advantage	$23.94
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: UnitedHealthcare Medicaid	$4.29
Rate for Payer: WPPA Medicare Advantage	$34.20

Prothrombin Time

Facility

$57.00

Service Code	HCPCS 85610
Hospital Charge Code	3550585
Hospital Revenue Code	301
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PSA Diagnostic

Facility

$223.00

Service Code	HCPCS 84153
Hospital Charge Code	3556550
Hospital Revenue Code	300
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$211.85
Rate for Payer: Aetna Commercial	$200.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.95
Rate for Payer: Humana Medicare Advantage	$93.66
Rate for Payer: UnitedHealthcare Commercial	$211.85
Rate for Payer: UnitedHealthcare Medicaid	$18.39
Rate for Payer: WPPA Medicare Advantage	$133.80

PSA Diagnostic

Facility

$223.00

Service Code	HCPCS 84153
Hospital Charge Code	3556550
Hospital Revenue Code	300
Min. Negotiated Rate	$200.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$200.70
Rate for Payer: UnitedHealthcare Commercial	$211.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PSA (Free and Total) QST

Facility

$223.00

Service Code	HCPCS 84153
Hospital Charge Code	3557080
Hospital Revenue Code	300
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$211.85
Rate for Payer: Aetna Commercial	$200.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.95
Rate for Payer: Humana Medicare Advantage	$93.66
Rate for Payer: UnitedHealthcare Commercial	$211.85
Rate for Payer: UnitedHealthcare Medicaid	$18.39
Rate for Payer: WPPA Medicare Advantage	$133.80

PSA (Free and Total) QST

Facility

$223.00

Service Code	HCPCS 84153
Hospital Charge Code	3557080
Hospital Revenue Code	300
Min. Negotiated Rate	$200.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$200.70
Rate for Payer: UnitedHealthcare Commercial	$211.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PSA Screen

Facility

$223.00

Service Code	HCPCS G0103
Hospital Charge Code	3552904
Hospital Revenue Code	300
Min. Negotiated Rate	$200.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$200.70
Rate for Payer: UnitedHealthcare Commercial	$211.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PSA Screen

Facility

$223.00

Service Code	HCPCS G0103
Hospital Charge Code	3552904
Hospital Revenue Code	300
Min. Negotiated Rate	$69.98
Max. Negotiated Rate	$211.85
Rate for Payer: Aetna Commercial	$200.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$69.98
Rate for Payer: Humana Medicare Advantage	$93.66
Rate for Payer: UnitedHealthcare Commercial	$211.85
Rate for Payer: UnitedHealthcare Medicaid	$89.20
Rate for Payer: WPPA Medicare Advantage	$133.80

pseudoephedrine 30 mg Tab [HMC]

Facility

$5.13

Service Code	NDC 00904699061
Hospital Charge Code	3806938
Hospital Revenue Code	250
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.62
Rate for Payer: UnitedHealthcare Commercial	$4.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pseudoephedrine 30 mg Tab [HMC]

Facility

$5.13

Service Code	NDC 00904699061
Hospital Charge Code	3806938
Hospital Revenue Code	250
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$4.87
Rate for Payer: Aetna Commercial	$4.62
Rate for Payer: Humana Medicare Advantage	$2.15
Rate for Payer: UnitedHealthcare Commercial	$4.87
Rate for Payer: UnitedHealthcare Medicaid	$2.05
Rate for Payer: WPPA Medicare Advantage	$3.08

pseudoephedrine 30 mg Tab [HMC]

Facility

$5.16

Service Code	NDC 00904505324
Hospital Charge Code	3806938
Hospital Revenue Code	250
Min. Negotiated Rate	$4.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.64
Rate for Payer: UnitedHealthcare Commercial	$4.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

pseudoephedrine 30 mg Tab [HMC]

Facility

$5.16

Service Code	NDC 00904505324
Hospital Charge Code	3806938
Hospital Revenue Code	250
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$4.90
Rate for Payer: Aetna Commercial	$4.64
Rate for Payer: Humana Medicare Advantage	$2.17
Rate for Payer: UnitedHealthcare Commercial	$4.90
Rate for Payer: UnitedHealthcare Medicaid	$2.06
Rate for Payer: WPPA Medicare Advantage	$3.10

PSYCHOSES

Facility

$2,763.99

Service Code	MSDRG 885
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,763.99
Rate for Payer: UnitedHealthcare Medicaid	$2,763.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

psyllium 3.4 g/3.7 g Pow [HMC]

Facility

$1.25

Service Code	NDC 37000074108
Hospital Charge Code	3802532
Hospital Revenue Code	250
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1.12
Rate for Payer: UnitedHealthcare Commercial	$1.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

psyllium 3.4 g/3.7 g Pow [HMC]

Facility

$1.25

Service Code	NDC 37000074108
Hospital Charge Code	3802532
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.19
Rate for Payer: Aetna Commercial	$1.12
Rate for Payer: Humana Medicare Advantage	$0.53
Rate for Payer: UnitedHealthcare Commercial	$1.19
Rate for Payer: UnitedHealthcare Medicaid	$0.50
Rate for Payer: WPPA Medicare Advantage	$0.75

psyllium 3.4 g/5.8 g Oral Pwdr [HMC]

Facility

$10.89

Service Code	NDC 37000002404
Hospital Charge Code	3802532
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.80
Rate for Payer: UnitedHealthcare Commercial	$10.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

psyllium 3.4 g/5.8 g Oral Pwdr [HMC]

Facility

$10.89

Service Code	NDC 37000002404
Hospital Charge Code	3802532
Hospital Revenue Code	250
Min. Negotiated Rate	$4.36
Max. Negotiated Rate	$10.35
Rate for Payer: Aetna Commercial	$9.80
Rate for Payer: Humana Medicare Advantage	$4.57
Rate for Payer: UnitedHealthcare Commercial	$10.35
Rate for Payer: UnitedHealthcare Medicaid	$4.36
Rate for Payer: WPPA Medicare Advantage	$6.53

PT Attended E-Stim Assistant Units

Facility

$97.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	3950200
Hospital Revenue Code	420
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$92.15
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$34.34
Rate for Payer: Humana Medicare Advantage	$40.74
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: UnitedHealthcare Medicaid	$8.58
Rate for Payer: WPPA Medicare Advantage	$58.20

PT Attended E-Stim Assistant Units

Facility

$97.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	3950200
Hospital Revenue Code	420
Min. Negotiated Rate	$87.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Dry Needling, 1-2 Muscles Assist Unit

Facility

$32.00

Service Code	HCPCS 20560 GP
Hospital Charge Code	3957799
Hospital Revenue Code	420
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.80
Rate for Payer: UnitedHealthcare Commercial	$30.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Dry Needling, 1-2 Muscles Assist Unit

Facility

$32.00

Service Code	HCPCS 20560 GP
Hospital Charge Code	3957799
Hospital Revenue Code	420
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna Commercial	$28.80
Rate for Payer: Humana Medicare Advantage	$13.44
Rate for Payer: UnitedHealthcare Commercial	$30.40
Rate for Payer: UnitedHealthcare Medicaid	$12.80
Rate for Payer: WPPA Medicare Advantage	$19.20

PT Dry Needling, 1-2 Muscles Charges

Facility

$32.00

Service Code	HCPCS 20560 GP
Hospital Charge Code	3957799
Hospital Revenue Code	420
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna Commercial	$28.80
Rate for Payer: Humana Medicare Advantage	$13.44
Rate for Payer: UnitedHealthcare Commercial	$30.40
Rate for Payer: UnitedHealthcare Medicaid	$12.80
Rate for Payer: WPPA Medicare Advantage	$19.20

Know your out-of-pocket cost for care.

All Charges