Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

SLP Cog Ther Intervent, Addl 15 Units

Facility

$110.00

Service Code	HCPCS 97130 GN
Hospital Charge Code	4057130
Hospital Revenue Code	444
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$99.00
Rate for Payer: UnitedHealthcare Commercial	$104.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SLP Fiberoptic Swallow Eval Units

Facility

$384.00

Service Code	HCPCS 92612 GN
Hospital Charge Code	4052612
Hospital Revenue Code	444
Min. Negotiated Rate	$345.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$345.60
Rate for Payer: UnitedHealthcare Commercial	$364.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SLP Fiberoptic Swallow Eval Units

Facility

$384.00

Service Code	HCPCS 92612 GN
Hospital Charge Code	4052612
Hospital Revenue Code	444
Min. Negotiated Rate	$97.28
Max. Negotiated Rate	$364.80
Rate for Payer: Aetna Commercial	$345.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$177.76
Rate for Payer: Humana Medicare Advantage	$161.28
Rate for Payer: UnitedHealthcare Commercial	$364.80
Rate for Payer: UnitedHealthcare Medicaid	$97.28
Rate for Payer: WPPA Medicare Advantage	$230.40

SLP Flex fib endo, lar. Sens Eval Units

Facility

$223.00

Service Code	HCPCS 92614 GN
Hospital Charge Code	4052614
Hospital Revenue Code	444
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

SLP Flex fib endo, lar. Sens Eval Units

Facility

$223.00

Service Code	HCPCS 92614 GN
Hospital Charge Code	4052614
Hospital Revenue Code	444
Min. Negotiated Rate	$93.66
Max. Negotiated Rate	$211.85
Rate for Payer: Aetna Commercial	$200.70
Rate for Payer: Humana Medicare Advantage	$93.66
Rate for Payer: UnitedHealthcare Commercial	$211.85
Rate for Payer: UnitedHealthcare Medicaid	$97.28
Rate for Payer: WPPA Medicare Advantage	$133.80

SLP Flex fiber endo, lary. Sw Eval Units

Facility

$318.00

Service Code	HCPCS 92616 GN
Hospital Charge Code	4052616
Hospital Revenue Code	444
Min. Negotiated Rate	$97.28
Max. Negotiated Rate	$302.10
Rate for Payer: Aetna Commercial	$286.20
Rate for Payer: Humana Medicare Advantage	$133.56
Rate for Payer: UnitedHealthcare Commercial	$302.10
Rate for Payer: UnitedHealthcare Medicaid	$97.28
Rate for Payer: WPPA Medicare Advantage	$190.80

SLP Flex fiber endo, lary. Sw Eval Units

Facility

$318.00

Service Code	HCPCS 92616 GN
Hospital Charge Code	4052616
Hospital Revenue Code	444
Min. Negotiated Rate	$286.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$286.20
Rate for Payer: UnitedHealthcare Commercial	$302.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SLP Tx Generating Device Units

Facility

$168.00

Service Code	HCPCS 92609 GN
Hospital Charge Code	4052609
Hospital Revenue Code	444
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$159.60
Rate for Payer: Aetna Commercial	$151.20
Rate for Payer: Humana Medicare Advantage	$70.56
Rate for Payer: UnitedHealthcare Commercial	$159.60
Rate for Payer: UnitedHealthcare Medicaid	$67.20
Rate for Payer: WPPA Medicare Advantage	$100.80

SLP Tx Generating Device Units

Facility

$168.00

Service Code	HCPCS 92609 GN
Hospital Charge Code	4052609
Hospital Revenue Code	444
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$151.20
Rate for Payer: UnitedHealthcare Commercial	$159.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sm Antibody QST

Facility

$64.00

Service Code	HCPCS 86235
Hospital Charge Code	3556403
Hospital Revenue Code	300
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$60.80
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$52.26
Rate for Payer: Humana Medicare Advantage	$26.88
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: UnitedHealthcare Medicaid	$17.93
Rate for Payer: WPPA Medicare Advantage	$38.40

Sm Antibody QST

Facility

$64.00

Service Code	HCPCS 86235
Hospital Charge Code	3556403
Hospital Revenue Code	300
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Smoking Cessation Instruction

Facility

$44.00

Service Code	HCPCS 99406
Hospital Charge Code	3359406
Hospital Revenue Code	410
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.60
Rate for Payer: UnitedHealthcare Commercial	$41.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Smoking Cessation Instruction

Facility

$44.00

Service Code	HCPCS 99406
Hospital Charge Code	3359406
Hospital Revenue Code	410
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$41.80
Rate for Payer: Aetna Commercial	$39.60
Rate for Payer: Humana Medicare Advantage	$18.48
Rate for Payer: UnitedHealthcare Commercial	$41.80
Rate for Payer: UnitedHealthcare Medicaid	$17.60
Rate for Payer: WPPA Medicare Advantage	$26.40

Smooth Muscle Ab w/Refl Titer QST

Facility

$415.00

Service Code	HCPCS 86015
Hospital Charge Code	3552540
Hospital Revenue Code	300
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$373.50
Rate for Payer: UnitedHealthcare Commercial	$394.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Smooth Muscle Ab w/Refl Titer QST

Facility

$415.00

Service Code	HCPCS 86015
Hospital Charge Code	3552540
Hospital Revenue Code	300
Min. Negotiated Rate	$7.49
Max. Negotiated Rate	$394.25
Rate for Payer: Aetna Commercial	$373.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$21.62
Rate for Payer: Humana Medicare Advantage	$174.30
Rate for Payer: UnitedHealthcare Commercial	$394.25
Rate for Payer: UnitedHealthcare Medicaid	$7.49
Rate for Payer: WPPA Medicare Advantage	$249.00

Snap Off Screw 2.0mm X 11mm

Facility

$1,103.00

Hospital Charge Code	3258588
Hospital Revenue Code	270
Min. Negotiated Rate	$992.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$992.70
Rate for Payer: UnitedHealthcare Commercial	$1,047.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Snap Off Screw 2.0mm X 11mm

Facility

$1,103.00

Hospital Charge Code	3258588
Hospital Revenue Code	270
Min. Negotiated Rate	$441.20
Max. Negotiated Rate	$1,047.85
Rate for Payer: Aetna Commercial	$992.70
Rate for Payer: Humana Medicare Advantage	$463.26
Rate for Payer: UnitedHealthcare Commercial	$1,047.85
Rate for Payer: UnitedHealthcare Medicaid	$441.20
Rate for Payer: WPPA Medicare Advantage	$661.80

sodium bicarbonate 4.2% IV Sol 10 mL [HMC]

Facility

$46.64

Service Code	NDC 51754501204
Hospital Charge Code	3808794
Hospital Revenue Code	250
Min. Negotiated Rate	$18.66
Max. Negotiated Rate	$44.31
Rate for Payer: Aetna Commercial	$41.98
Rate for Payer: Humana Medicare Advantage	$19.59
Rate for Payer: UnitedHealthcare Commercial	$44.31
Rate for Payer: UnitedHealthcare Medicaid	$18.66
Rate for Payer: WPPA Medicare Advantage	$27.98

sodium bicarbonate 4.2% IV Sol 10 mL [HMC]

Facility

$46.64

Service Code	NDC 51754501204
Hospital Charge Code	3808794
Hospital Revenue Code	250
Min. Negotiated Rate	$41.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.98
Rate for Payer: UnitedHealthcare Commercial	$44.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 4.2% IV Sol 10 mL [HMC]

Facility

$45.94

Service Code	NDC 00409553434
Hospital Charge Code	3808794
Hospital Revenue Code	250
Min. Negotiated Rate	$18.38
Max. Negotiated Rate	$43.64
Rate for Payer: Aetna Commercial	$41.35
Rate for Payer: Humana Medicare Advantage	$19.29
Rate for Payer: UnitedHealthcare Commercial	$43.64
Rate for Payer: UnitedHealthcare Medicaid	$18.38
Rate for Payer: WPPA Medicare Advantage	$27.56

sodium bicarbonate 4.2% IV Sol 10 mL [HMC]

Facility

$45.94

Service Code	NDC 00409553434
Hospital Charge Code	3808794
Hospital Revenue Code	250
Min. Negotiated Rate	$41.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.35
Rate for Payer: UnitedHealthcare Commercial	$43.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 650 mg Tab [HMC]

Facility

$5.10

Service Code	NDC 00536454410
Hospital Charge Code	3800087
Hospital Revenue Code	250
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.59
Rate for Payer: UnitedHealthcare Commercial	$4.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 650 mg Tab [HMC]

Facility

$5.61

Service Code	NDC 77333082710
Hospital Charge Code	3800087
Hospital Revenue Code	250
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$5.33
Rate for Payer: Aetna Commercial	$5.05
Rate for Payer: Humana Medicare Advantage	$2.36
Rate for Payer: UnitedHealthcare Commercial	$5.33
Rate for Payer: UnitedHealthcare Medicaid	$2.24
Rate for Payer: WPPA Medicare Advantage	$3.37

sodium bicarbonate 650 mg Tab [HMC]

Facility

$5.10

Service Code	NDC 00536454410
Hospital Charge Code	3800087
Hospital Revenue Code	250
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$4.84
Rate for Payer: Aetna Commercial	$4.59
Rate for Payer: Humana Medicare Advantage	$2.14
Rate for Payer: UnitedHealthcare Commercial	$4.84
Rate for Payer: UnitedHealthcare Medicaid	$2.04
Rate for Payer: WPPA Medicare Advantage	$3.06

sodium bicarbonate 650 mg Tab [HMC]

Facility

$5.16

Service Code	NDC 00223172101
Hospital Charge Code	3800087
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

Know your out-of-pocket cost for care.

All Charges