Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

RT Postural Drainage Initial CHARGE

Facility

$188.00

Service Code	HCPCS 94667
Hospital Charge Code	3900053-4
Hospital Revenue Code	410
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 Postural Drainage Subsequent CHARGE

Facility

$188.00

Service Code	HCPCS 94668
Hospital Charge Code	3900061-4
Hospital Revenue Code	410
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 Postural Drainage Subsequent CHARGE

Facility

$188.00

Service Code	HCPCS 94668
Hospital Charge Code	3900061-4
Hospital Revenue Code	410
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$75.20
Rate for Payer: WPPA Medicare Advantage	$112.80

RT Ventilator Services Initial CHARGE

Facility

$2,547.00

Service Code	HCPCS 94002
Hospital Charge Code	3900079
Hospital Revenue Code	410
Min. Negotiated Rate	$108.51
Max. Negotiated Rate	$2,419.65
Rate for Payer: Aetna Commercial	$2,292.30
Rate for Payer: Humana Medicare Advantage	$1,069.74
Rate for Payer: UnitedHealthcare Commercial	$2,419.65
Rate for Payer: UnitedHealthcare Medicaid	$108.51
Rate for Payer: WPPA Medicare Advantage	$1,528.20

RT Ventilator Services Initial CHARGE

Facility

$2,547.00

Service Code	HCPCS 94002
Hospital Charge Code	3900079
Hospital Revenue Code	410
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,419.65
Rate for Payer: Aetna Commercial	$2,292.30
Rate for Payer: UnitedHealthcare Commercial	$2,419.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Ventilator Services Subsequent CHARGE

Facility

$1,899.00

Service Code	HCPCS 94003
Hospital Charge Code	3900087
Hospital Revenue Code	410
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,804.05
Rate for Payer: Aetna Commercial	$1,709.10
Rate for Payer: UnitedHealthcare Commercial	$1,804.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Ventilator Services Subsequent CHARGE

Facility

$1,899.00

Service Code	HCPCS 94003
Hospital Charge Code	3900087
Hospital Revenue Code	410
Min. Negotiated Rate	$108.51
Max. Negotiated Rate	$1,804.05
Rate for Payer: Aetna Commercial	$1,709.10
Rate for Payer: Humana Medicare Advantage	$797.58
Rate for Payer: UnitedHealthcare Commercial	$1,804.05
Rate for Payer: UnitedHealthcare Medicaid	$108.51
Rate for Payer: WPPA Medicare Advantage	$1,139.40

Rubella IgG

Facility

$54.00

Service Code	HCPCS 86762
Hospital Charge Code	3551633
Hospital Revenue Code	300
Min. Negotiated Rate	$12.23
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$30.90
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$12.23
Rate for Payer: WPPA Medicare Advantage	$32.40

Rubella IgG

Facility

$54.00

Service Code	HCPCS 86762
Hospital Charge Code	3551633
Hospital Revenue Code	300
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Rubella Immune Status QST

Facility

$54.00

Service Code	HCPCS 86762
Hospital Charge Code	3551633
Hospital Revenue Code	300
Min. Negotiated Rate	$12.23
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$30.90
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$12.23
Rate for Payer: WPPA Medicare Advantage	$32.40

Rubella Immune Status QST

Facility

$54.00

Service Code	HCPCS 86762
Hospital Charge Code	3551633
Hospital Revenue Code	300
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Russian Thistle (W11) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1022
Hospital Revenue Code	300
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

Russian Thistle (W11) IgE QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1022
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$16.20

Rye (f5) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552816
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

Rye (f5) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552816
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

S0390 Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive main

Facility

$77.00

Service Code	HCPCS S0390
Hospital Charge Code	3290390
Hospital Revenue Code	761
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$73.15
Rate for Payer: Aetna Commercial	$69.30
Rate for Payer: Humana Medicare Advantage	$32.34
Rate for Payer: UnitedHealthcare Commercial	$73.15
Rate for Payer: UnitedHealthcare Medicaid	$30.80
Rate for Payer: WPPA Medicare Advantage	$46.20

S0390 Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive main

Facility

$77.00

Service Code	HCPCS S0390
Hospital Charge Code	3290390
Hospital Revenue Code	761
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$69.30
Rate for Payer: UnitedHealthcare Commercial	$73.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sacubitril-valsartan 24 mg-26 mg Tab [HMC]

Facility

$20.87

Service Code	NDC 43598064360
Hospital Charge Code	3800884
Hospital Revenue Code	250
Min. Negotiated Rate	$18.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.78
Rate for Payer: UnitedHealthcare Commercial	$19.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sacubitril-valsartan 24 mg-26 mg Tab [HMC]

Facility

$32.52

Service Code	NDC 00078065920
Hospital Charge Code	3800884
Hospital Revenue Code	250
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$30.89
Rate for Payer: Aetna Commercial	$29.27
Rate for Payer: Humana Medicare Advantage	$13.66
Rate for Payer: UnitedHealthcare Commercial	$30.89
Rate for Payer: UnitedHealthcare Medicaid	$13.01
Rate for Payer: WPPA Medicare Advantage	$19.51

sacubitril-valsartan 24 mg-26 mg Tab [HMC]

Facility

$20.87

Service Code	NDC 43598064360
Hospital Charge Code	3800884
Hospital Revenue Code	250
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$19.83
Rate for Payer: Aetna Commercial	$18.78
Rate for Payer: Humana Medicare Advantage	$8.77
Rate for Payer: UnitedHealthcare Commercial	$19.83
Rate for Payer: UnitedHealthcare Medicaid	$8.35
Rate for Payer: WPPA Medicare Advantage	$12.52

sacubitril-valsartan 24 mg-26 mg Tab [HMC]

Facility

$32.52

Service Code	NDC 00078065920
Hospital Charge Code	3800884
Hospital Revenue Code	250
Min. Negotiated Rate	$29.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.27
Rate for Payer: UnitedHealthcare Commercial	$30.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Salicylate Level

Facility

$166.00

Service Code	HCPCS 80179
Hospital Charge Code	3551666
Hospital Revenue Code	300
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$157.70
Rate for Payer: Aetna Commercial	$149.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$29.09
Rate for Payer: Humana Medicare Advantage	$69.72
Rate for Payer: UnitedHealthcare Commercial	$157.70
Rate for Payer: UnitedHealthcare Medicaid	$15.84
Rate for Payer: WPPA Medicare Advantage	$99.60

Salicylate Level

Facility

$166.00

Service Code	HCPCS 80179
Hospital Charge Code	3551666
Hospital Revenue Code	300
Min. Negotiated Rate	$149.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$149.40
Rate for Payer: UnitedHealthcare Commercial	$157.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SALIVARY GLAND PROCEDURES

Facility

$2,319.21

Service Code	MSDRG 139
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,319.21
Rate for Payer: UnitedHealthcare Medicaid	$2,319.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Salmonella and Shigella, Culture QST

Facility

$89.00

Service Code	HCPCS 87427
Hospital Charge Code	3557427
Hospital Revenue Code	300
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$84.55
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.84
Rate for Payer: Humana Medicare Advantage	$37.38
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: UnitedHealthcare Medicaid	$11.98
Rate for Payer: WPPA Medicare Advantage	$53.40

Know your out-of-pocket cost for care.

All Charges