Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

RSV RNA QST

Facility

$462.00

Service Code	HCPCS 87634
Hospital Charge Code	3556047
Hospital Revenue Code	300
Min. Negotiated Rate	$415.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$415.80
Rate for Payer: UnitedHealthcare Commercial	$438.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RSV vaccine, preF A-preF B, recombinant preservative-free 60 mcg-60 mcg Pow [HMC]

Facility

$572.24

Service Code	HCPCS 90678
Hospital Charge Code	3846510
Hospital Revenue Code	250
Min. Negotiated Rate	$515.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$515.02
Rate for Payer: UnitedHealthcare Commercial	$543.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RSV vaccine, preF A-preF B, recombinant preservative-free 60 mcg-60 mcg Pow [HMC]

Facility

$572.24

Service Code	HCPCS 90678
Hospital Charge Code	3846510
Hospital Revenue Code	250
Min. Negotiated Rate	$240.34
Max. Negotiated Rate	$543.63
Rate for Payer: Aetna Commercial	$515.02
Rate for Payer: Humana Medicare Advantage	$240.34
Rate for Payer: UnitedHealthcare Commercial	$543.63
Rate for Payer: UnitedHealthcare Medicaid	$295.00
Rate for Payer: WPPA Medicare Advantage	$343.34

RT Aerosol Initial CHARGE

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3900236
Hospital Revenue Code	410
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Aerosol Initial CHARGE

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3900236
Hospital Revenue Code	410
Min. Negotiated Rate	$55.44
Max. Negotiated Rate	$254.03
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$254.03
Rate for Payer: Humana Medicare Advantage	$55.44
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: UnitedHealthcare Medicaid	$69.09
Rate for Payer: WPPA Medicare Advantage	$79.20

RT Aerosol Subsequent CHARGE

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3900236
Hospital Revenue Code	410
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Aerosol Subsequent CHARGE

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3900236
Hospital Revenue Code	410
Min. Negotiated Rate	$55.44
Max. Negotiated Rate	$254.03
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$254.03
Rate for Payer: Humana Medicare Advantage	$55.44
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: UnitedHealthcare Medicaid	$69.09
Rate for Payer: WPPA Medicare Advantage	$79.20

RT Airway Suction CHARGE

Facility

$1,178.00

Service Code	HCPCS 31720
Hospital Charge Code	3901720
Hospital Revenue Code	410
Min. Negotiated Rate	$1,060.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,060.20
Rate for Payer: UnitedHealthcare Commercial	$1,119.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Airway Suction CHARGE

Facility

$1,178.00

Service Code	HCPCS 31720
Hospital Charge Code	3901720
Hospital Revenue Code	410
Min. Negotiated Rate	$69.09
Max. Negotiated Rate	$1,119.10
Rate for Payer: Aetna Commercial	$1,060.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$692.86
Rate for Payer: Humana Medicare Advantage	$494.76
Rate for Payer: UnitedHealthcare Commercial	$1,119.10
Rate for Payer: UnitedHealthcare Medicaid	$69.09
Rate for Payer: WPPA Medicare Advantage	$706.80

RT Arterial Puncture CHARGE

Facility

$188.00

Service Code	HCPCS 36600
Hospital Charge Code	3900630
Hospital Revenue Code	300
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Arterial Puncture CHARGE

Facility

$188.00

Service Code	HCPCS 36600
Hospital Charge Code	3900630
Hospital Revenue Code	300
Min. Negotiated Rate	$41.38
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.67
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$41.38
Rate for Payer: WPPA Medicare Advantage	$112.80

RT BiPAP Initial CHARGE

Facility

$478.00

Service Code	HCPCS 94660
Hospital Charge Code	3900575
Hospital Revenue Code	410
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT BiPAP Initial CHARGE

Facility

$478.00

Service Code	HCPCS 94660
Hospital Charge Code	3900575
Hospital Revenue Code	410
Min. Negotiated Rate	$191.20
Max. Negotiated Rate	$454.10
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$270.54
Rate for Payer: Humana Medicare Advantage	$200.76
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: UnitedHealthcare Medicaid	$191.20
Rate for Payer: WPPA Medicare Advantage	$286.80

RT BiPAP Subsequent CHARGE

Facility

$478.00

Service Code	HCPCS 94660
Hospital Charge Code	3900575
Hospital Revenue Code	410
Min. Negotiated Rate	$191.20
Max. Negotiated Rate	$454.10
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$270.54
Rate for Payer: Humana Medicare Advantage	$200.76
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: UnitedHealthcare Medicaid	$191.20
Rate for Payer: WPPA Medicare Advantage	$286.80

RT BiPAP Subsequent CHARGE

Facility

$478.00

Service Code	HCPCS 94660
Hospital Charge Code	3900575
Hospital Revenue Code	410
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Charge 6 Minute Walk

Facility

$257.00

Service Code	HCPCS 94761
Hospital Charge Code	3910045
Hospital Revenue Code	460
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$244.15
Rate for Payer: Aetna Commercial	$231.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$17.14
Rate for Payer: Humana Medicare Advantage	$107.94
Rate for Payer: UnitedHealthcare Commercial	$244.15
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: WPPA Medicare Advantage	$154.20

RT Charge 6 Minute Walk

Facility

$257.00

Service Code	HCPCS 94761
Hospital Charge Code	3910045
Hospital Revenue Code	460
Min. Negotiated Rate	$231.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$231.30
Rate for Payer: UnitedHealthcare Commercial	$244.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Continuous Neb Initial CHARGE

Facility

$311.00

Service Code	HCPCS 94644
Hospital Charge Code	3900565
Hospital Revenue Code	410
Min. Negotiated Rate	$46.56
Max. Negotiated Rate	$295.45
Rate for Payer: Aetna Commercial	$279.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$140.95
Rate for Payer: Humana Medicare Advantage	$130.62
Rate for Payer: UnitedHealthcare Commercial	$295.45
Rate for Payer: UnitedHealthcare Medicaid	$46.56
Rate for Payer: WPPA Medicare Advantage	$186.60

RT Continuous Neb Initial CHARGE

Facility

$311.00

Service Code	HCPCS 94644
Hospital Charge Code	3900565
Hospital Revenue Code	410
Min. Negotiated Rate	$279.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$279.90
Rate for Payer: UnitedHealthcare Commercial	$295.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Continuous Neb Subsequent CHARGE

Facility

$208.00

Service Code	HCPCS 94645
Hospital Charge Code	3900570
Hospital Revenue Code	410
Min. Negotiated Rate	$187.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: UnitedHealthcare Commercial	$197.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Continuous Neb Subsequent CHARGE

Facility

$208.00

Service Code	HCPCS 94645
Hospital Charge Code	3900570
Hospital Revenue Code	410
Min. Negotiated Rate	$46.56
Max. Negotiated Rate	$197.60
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: Humana Medicare Advantage	$87.36
Rate for Payer: UnitedHealthcare Commercial	$197.60
Rate for Payer: UnitedHealthcare Medicaid	$46.56
Rate for Payer: WPPA Medicare Advantage	$124.80

RT CPAP Initial CHARGE

Facility

$478.00

Service Code	HCPCS 94660
Hospital Charge Code	3900575
Hospital Revenue Code	410
Min. Negotiated Rate	$191.20
Max. Negotiated Rate	$454.10
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$270.54
Rate for Payer: Humana Medicare Advantage	$200.76
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: UnitedHealthcare Medicaid	$191.20
Rate for Payer: WPPA Medicare Advantage	$286.80

RT CPAP Initial CHARGE

Facility

$478.00

Service Code	HCPCS 94660
Hospital Charge Code	3900575
Hospital Revenue Code	410
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT CPAP Subsequent CHARGE

Facility

$478.00

Service Code	HCPCS 94660
Hospital Charge Code	3900575
Hospital Revenue Code	410
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT CPAP Subsequent CHARGE

Facility

$478.00

Service Code	HCPCS 94660
Hospital Charge Code	3900575
Hospital Revenue Code	410
Min. Negotiated Rate	$191.20
Max. Negotiated Rate	$454.10
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$270.54
Rate for Payer: Humana Medicare Advantage	$200.76
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: UnitedHealthcare Medicaid	$191.20
Rate for Payer: WPPA Medicare Advantage	$286.80

Know your out-of-pocket cost for care.

All Charges