Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

RF Abalation 2-Probe w/ 4-Introducers 1-Dual Tube 17G X 50mm 4mm-Active Tip

Facility

$2,713.20

Service Code	HCPCS A4649
Hospital Charge Code	3256670
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,577.54
Rate for Payer: Aetna Commercial	$2,441.88
Rate for Payer: UnitedHealthcare Commercial	$2,577.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RF Ablation 2-Probe w/ 4-Introducers 1-Dual Tube 17G X 100mm 4mm-Active Tip

Facility

$2,713.20

Service Code	HCPCS A4649
Hospital Charge Code	3256671
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,577.54
Rate for Payer: Aetna Commercial	$2,441.88
Rate for Payer: UnitedHealthcare Commercial	$2,577.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RF Ablation 2-Probe w/ 4-Introducers 1-Dual Tube 17G X 100mm 4mm-Active Tip

Facility

$2,713.20

Service Code	HCPCS A4649
Hospital Charge Code	3256671
Hospital Revenue Code	270
Min. Negotiated Rate	$1,085.28
Max. Negotiated Rate	$2,577.54
Rate for Payer: Aetna Commercial	$2,441.88
Rate for Payer: Humana Medicare Advantage	$1,139.54
Rate for Payer: UnitedHealthcare Commercial	$2,577.54
Rate for Payer: UnitedHealthcare Medicaid	$1,085.28
Rate for Payer: WPPA Medicare Advantage	$1,627.92

RF Ablation Probe 17G X 100mm

Facility

$1,129.65

Service Code	HCPCS A4649
Hospital Charge Code	3256673
Hospital Revenue Code	270
Min. Negotiated Rate	$451.86
Max. Negotiated Rate	$1,073.17
Rate for Payer: Aetna Commercial	$1,016.68
Rate for Payer: Humana Medicare Advantage	$474.45
Rate for Payer: UnitedHealthcare Commercial	$1,073.17
Rate for Payer: UnitedHealthcare Medicaid	$451.86
Rate for Payer: WPPA Medicare Advantage	$677.79

RF Ablation Probe 17G X 100mm

Facility

$1,129.65

Service Code	HCPCS A4649
Hospital Charge Code	3256673
Hospital Revenue Code	270
Min. Negotiated Rate	$1,016.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,016.68
Rate for Payer: UnitedHealthcare Commercial	$1,073.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RF Trident Cannula 18G X 100mm 5mm-Active Tip

Facility

$489.60

Service Code	HCPCS A4649
Hospital Charge Code	3256677
Hospital Revenue Code	270
Min. Negotiated Rate	$440.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$440.64
Rate for Payer: UnitedHealthcare Commercial	$465.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RF Trident Cannula 18G X 100mm 5mm-Active Tip

Facility

$489.60

Service Code	HCPCS A4649
Hospital Charge Code	3256677
Hospital Revenue Code	270
Min. Negotiated Rate	$195.84
Max. Negotiated Rate	$465.12
Rate for Payer: Aetna Commercial	$440.64
Rate for Payer: Humana Medicare Advantage	$205.63
Rate for Payer: UnitedHealthcare Commercial	$465.12
Rate for Payer: UnitedHealthcare Medicaid	$195.84
Rate for Payer: WPPA Medicare Advantage	$293.76

RF Trident Cannula 18G X 150mm 5mm-Active Tip

Facility

$489.60

Service Code	HCPCS A4649
Hospital Charge Code	3256678
Hospital Revenue Code	270
Min. Negotiated Rate	$195.84
Max. Negotiated Rate	$465.12
Rate for Payer: Aetna Commercial	$440.64
Rate for Payer: Humana Medicare Advantage	$205.63
Rate for Payer: UnitedHealthcare Commercial	$465.12
Rate for Payer: UnitedHealthcare Medicaid	$195.84
Rate for Payer: WPPA Medicare Advantage	$293.76

RF Trident Cannula 18G X 150mm 5mm-Active Tip

Facility

$489.60

Service Code	HCPCS A4649
Hospital Charge Code	3256678
Hospital Revenue Code	270
Min. Negotiated Rate	$440.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$440.64
Rate for Payer: UnitedHealthcare Commercial	$465.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RF Trident Cannula 18G X 54mm 5mm-Active Tip

Facility

$489.60

Service Code	HCPCS A4649
Hospital Charge Code	3256676
Hospital Revenue Code	270
Min. Negotiated Rate	$440.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$440.64
Rate for Payer: UnitedHealthcare Commercial	$465.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RF Trident Cannula 18G X 54mm 5mm-Active Tip

Facility

$489.60

Service Code	HCPCS A4649
Hospital Charge Code	3256676
Hospital Revenue Code	270
Min. Negotiated Rate	$195.84
Max. Negotiated Rate	$465.12
Rate for Payer: Aetna Commercial	$440.64
Rate for Payer: Humana Medicare Advantage	$205.63
Rate for Payer: UnitedHealthcare Commercial	$465.12
Rate for Payer: UnitedHealthcare Medicaid	$195.84
Rate for Payer: WPPA Medicare Advantage	$293.76

Rheumatoid Factor Titer

Facility

$83.00

Service Code	HCPCS 86901
Hospital Charge Code	3550700
Hospital Revenue Code	300
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$78.85
Rate for Payer: Aetna Commercial	$74.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$61.64
Rate for Payer: Humana Medicare Advantage	$34.86
Rate for Payer: UnitedHealthcare Commercial	$78.85
Rate for Payer: UnitedHealthcare Medicaid	$2.99
Rate for Payer: WPPA Medicare Advantage	$49.80

Rheumatoid Factor Titer

Facility

$83.00

Service Code	HCPCS 86901
Hospital Charge Code	3550700
Hospital Revenue Code	300
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$74.70
Rate for Payer: UnitedHealthcare Commercial	$78.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RhIG

Facility

$164.00

Service Code	HCPCS 90384
Hospital Charge Code	3560384
Hospital Revenue Code	300
Min. Negotiated Rate	$68.88
Max. Negotiated Rate	$155.80
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$115.24
Rate for Payer: Humana Medicare Advantage	$68.88
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: UnitedHealthcare Medicaid	$82.83
Rate for Payer: WPPA Medicare Advantage	$98.40

RhIG

Facility

$164.00

Service Code	HCPCS 90384
Hospital Charge Code	3560384
Hospital Revenue Code	300
Min. Negotiated Rate	$147.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RHo (D) immune globulin 300 mcg/mL IM Sol [HMC]

Facility

$210.80

Service Code	HCPCS J2790
Hospital Charge Code	3801648
Hospital Revenue Code	250
Min. Negotiated Rate	$80.53
Max. Negotiated Rate	$320.11
Rate for Payer: Aetna Commercial	$189.72
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$320.11
Rate for Payer: Humana Medicare Advantage	$88.54
Rate for Payer: UnitedHealthcare Commercial	$200.26
Rate for Payer: UnitedHealthcare Medicaid	$80.53
Rate for Payer: WPPA Medicare Advantage	$126.48

RHo (D) immune globulin 300 mcg/mL IM Sol [HMC]

Facility

$210.80

Service Code	HCPCS J2790
Hospital Charge Code	3801648
Hospital Revenue Code	250
Min. Negotiated Rate	$189.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$189.72
Rate for Payer: UnitedHealthcare Commercial	$200.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Rh Typing

Facility

$50.00

Service Code	HCPCS 86901
Hospital Charge Code	3560198
Hospital Revenue Code	300
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$61.64
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$61.64
Rate for Payer: Humana Medicare Advantage	$21.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: UnitedHealthcare Medicaid	$2.99
Rate for Payer: WPPA Medicare Advantage	$30.00

Rh Typing

Facility

$50.00

Service Code	HCPCS 86901
Hospital Charge Code	3560198
Hospital Revenue Code	300
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Rh Typing.

Facility

$50.00

Service Code	HCPCS 86901
Hospital Charge Code	3560073
Hospital Revenue Code	300
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$61.64
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$61.64
Rate for Payer: Humana Medicare Advantage	$21.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: UnitedHealthcare Medicaid	$2.99
Rate for Payer: WPPA Medicare Advantage	$30.00

Rh Typing.

Facility

$50.00

Service Code	HCPCS 86901
Hospital Charge Code	3560073
Hospital Revenue Code	300
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Rib Belt Male 6 Universal Elastic Latex-Free

Facility

$27.00

Hospital Charge Code	3259815
Hospital Revenue Code	270
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: WPPA Medicare Advantage	$16.20

Rib Belt Male 6 Universal Elastic Latex-Free

Facility

$27.00

Hospital Charge Code	3259815
Hospital Revenue Code	270
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

Rice (f9) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552815
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$12.60

Rice (f9) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552815
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges