Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

RECTAL RESECTION WITHOUT CC/MCC

Facility

$6,195.15

Service Code	MSDRG 334
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,195.15
Rate for Payer: UnitedHealthcare Medicaid	$6,195.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RECTAL TUBE 24FR W/LUBE

Facility

$12.06

Hospital Charge Code	3255036
Hospital Revenue Code	270
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.85
Rate for Payer: UnitedHealthcare Commercial	$11.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RECTAL TUBE 24FR W/LUBE

Facility

$12.06

Hospital Charge Code	3255036
Hospital Revenue Code	270
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$11.46
Rate for Payer: Aetna Commercial	$10.85
Rate for Payer: Humana Medicare Advantage	$5.07
Rate for Payer: UnitedHealthcare Commercial	$11.46
Rate for Payer: UnitedHealthcare Medicaid	$4.82
Rate for Payer: WPPA Medicare Advantage	$7.24

RED BLOOD CELL DISORDERS WITH MCC

Facility

$5,972.76

Service Code	MSDRG 811
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,972.76
Rate for Payer: UnitedHealthcare Medicaid	$5,972.76
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RED BLOOD CELL DISORDERS WITHOUT MCC

Facility

$4,161.87

Service Code	MSDRG 812
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,161.87
Rate for Payer: UnitedHealthcare Medicaid	$4,161.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

REF Fetal Screen

Facility

$331.00

Service Code	HCPCS 85460
Hospital Charge Code	3555460
Hospital Revenue Code	300
Min. Negotiated Rate	$297.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$297.90
Rate for Payer: UnitedHealthcare Commercial	$314.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

REF Fetal Screen

Facility

$331.00

Service Code	HCPCS 85460
Hospital Charge Code	3555460
Hospital Revenue Code	300
Min. Negotiated Rate	$7.73
Max. Negotiated Rate	$314.45
Rate for Payer: Aetna Commercial	$297.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$30.44
Rate for Payer: Humana Medicare Advantage	$139.02
Rate for Payer: UnitedHealthcare Commercial	$314.45
Rate for Payer: UnitedHealthcare Medicaid	$7.73
Rate for Payer: WPPA Medicare Advantage	$198.60

Refill Pain Pump

Facility

$625.00

Service Code	HCPCS 95991
Hospital Charge Code	3195991
Hospital Revenue Code	360
Min. Negotiated Rate	$562.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$562.50
Rate for Payer: UnitedHealthcare Commercial	$593.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Refill Pain Pump

Facility

$625.00

Service Code	HCPCS 95991
Hospital Charge Code	3195991
Hospital Revenue Code	360
Min. Negotiated Rate	$250.00
Max. Negotiated Rate	$593.75
Rate for Payer: Aetna Commercial	$562.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$371.68
Rate for Payer: Humana Medicare Advantage	$262.50
Rate for Payer: UnitedHealthcare Commercial	$593.75
Rate for Payer: UnitedHealthcare Medicaid	$250.00
Rate for Payer: WPPA Medicare Advantage	$375.00

REHABILITATION WITH CC/MCC

Facility

$7,148.25

Service Code	MSDRG 945
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,148.25
Rate for Payer: UnitedHealthcare Medicaid	$7,148.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

REHABILITATION WITHOUT CC/MCC

Facility

$6,830.55

Service Code	MSDRG 946
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,830.55
Rate for Payer: UnitedHealthcare Medicaid	$6,830.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Removal of fecal impaction or foreign body (separate procedure) under anesthesia

Facility

$1,278.00

Service Code	HCPCS 45915
Hospital Charge Code	3155915
Hospital Revenue Code	360
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$1,214.10
Rate for Payer: Aetna Commercial	$1,150.20
Rate for Payer: Humana Medicare Advantage	$536.76
Rate for Payer: UnitedHealthcare Commercial	$1,214.10
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: WPPA Medicare Advantage	$766.80

Removal of fecal impaction or foreign body (separate procedure) under anesthesia

Facility

$1,278.00

Service Code	HCPCS 45915
Hospital Charge Code	3155915
Hospital Revenue Code	360
Min. Negotiated Rate	$1,150.20
Max. Negotiated Rate	$1,214.10
Rate for Payer: Aetna Commercial	$1,150.20
Rate for Payer: UnitedHealthcare Commercial	$1,214.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Removal of Finger Nail

Facility

$4,558.00

Service Code	HCPCS 20680
Hospital Charge Code	3350680
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,330.10
Rate for Payer: Aetna Commercial	$4,102.20
Rate for Payer: UnitedHealthcare Commercial	$4,330.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Removal of Finger Nail

Facility

$4,558.00

Service Code	HCPCS 20680
Hospital Charge Code	3350680
Hospital Revenue Code	360
Min. Negotiated Rate	$920.50
Max. Negotiated Rate	$4,330.10
Rate for Payer: Aetna Commercial	$4,102.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,815.88
Rate for Payer: Humana Medicare Advantage	$1,914.36
Rate for Payer: UnitedHealthcare Commercial	$4,330.10
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$2,734.80

RENAL FAILURE WITH CC

Facility

$4,098.33

Service Code	MSDRG 683
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,098.33
Rate for Payer: UnitedHealthcare Medicaid	$4,098.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RENAL FAILURE WITH MCC

Facility

$4,956.12

Service Code	MSDRG 682
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,956.12
Rate for Payer: UnitedHealthcare Medicaid	$4,956.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RENAL FAILURE WITHOUT CC/MCC

Facility

$2,541.60

Service Code	MSDRG 684
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,541.60
Rate for Payer: UnitedHealthcare Medicaid	$2,541.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Renal Function Panel

Facility

$179.00

Service Code	HCPCS 80069
Hospital Charge Code	3550069
Hospital Revenue Code	300
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$170.05
Rate for Payer: Aetna Commercial	$161.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$20.32
Rate for Payer: Humana Medicare Advantage	$75.18
Rate for Payer: UnitedHealthcare Commercial	$170.05
Rate for Payer: UnitedHealthcare Medicaid	$8.68
Rate for Payer: WPPA Medicare Advantage	$107.40

Renal Function Panel

Facility

$179.00

Service Code	HCPCS 80069
Hospital Charge Code	3550069
Hospital Revenue Code	300
Min. Negotiated Rate	$161.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$161.10
Rate for Payer: UnitedHealthcare Commercial	$170.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Repair Hallux Valgus

Facility

$4,159.00

Service Code	HCPCS 28292
Hospital Charge Code	3158292
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.57
Max. Negotiated Rate	$3,951.05
Rate for Payer: Aetna Commercial	$3,743.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,000.71
Rate for Payer: Humana Medicare Advantage	$1,746.78
Rate for Payer: UnitedHealthcare Commercial	$3,951.05
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$2,495.40

Repair Hallux Valgus

Facility

$4,159.00

Service Code	HCPCS 28292
Hospital Charge Code	3158292
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,951.05
Rate for Payer: Aetna Commercial	$3,743.10
Rate for Payer: UnitedHealthcare Commercial	$3,951.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Replacement Jejunostomy Tube

Facility

$2,063.00

Service Code	HCPCS 49451
Hospital Charge Code	3159451
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,959.85
Rate for Payer: Aetna Commercial	$1,856.70
Rate for Payer: UnitedHealthcare Commercial	$1,959.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Replacement Jejunostomy Tube

Facility

$2,063.00

Service Code	HCPCS 49451
Hospital Charge Code	3159451
Hospital Revenue Code	360
Min. Negotiated Rate	$139.43
Max. Negotiated Rate	$1,959.85
Rate for Payer: Aetna Commercial	$1,856.70
Rate for Payer: Humana Medicare Advantage	$866.46
Rate for Payer: UnitedHealthcare Commercial	$1,959.85
Rate for Payer: UnitedHealthcare Medicaid	$139.43
Rate for Payer: WPPA Medicare Advantage	$1,237.80

Respiratory Allergy Profile Region IX QST

Facility

$265.00

Service Code	HCPCS 86003
Hospital Charge Code	3552785
Hospital Revenue Code	300
Min. Negotiated Rate	$238.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$238.50
Rate for Payer: UnitedHealthcare Commercial	$251.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges