Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

tezepelumab 210 mg/1.91 mL Inj Sol [HMC]

Facility

$7,291.50

Service Code	HCPCS J2356
Hospital Charge Code	3806330
Hospital Revenue Code	259
Min. Negotiated Rate	$17.82
Max. Negotiated Rate	$6,926.93
Rate for Payer: Aetna Commercial	$6,562.35
Rate for Payer: Aetna Commercial	$7,021.02
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$22.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$22.90
Rate for Payer: Humana Medicare Advantage	$3,276.47
Rate for Payer: Humana Medicare Advantage	$3,062.43
Rate for Payer: UnitedHealthcare Commercial	$7,411.07
Rate for Payer: UnitedHealthcare Commercial	$6,926.93
Rate for Payer: UnitedHealthcare Medicaid	$17.82
Rate for Payer: UnitedHealthcare Medicaid	$17.82
Rate for Payer: WPPA Medicare Advantage	$4,680.68
Rate for Payer: WPPA Medicare Advantage	$4,374.90

tezepelumab 210 mg/1.91 mL Inj Sol [HMC]

Facility

$7,291.50

Service Code	HCPCS J2356
Hospital Charge Code	3806330
Hospital Revenue Code	259
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,926.93
Rate for Payer: Aetna Commercial	$6,562.35
Rate for Payer: Aetna Commercial	$7,021.02
Rate for Payer: UnitedHealthcare Commercial	$7,411.07
Rate for Payer: UnitedHealthcare Commercial	$6,926.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Thalassemia And Hemoglobinopathy Comp QST

Facility

$728.00

Service Code	HCPCS 81257
Hospital Charge Code	3552728
Hospital Revenue Code	300
Min. Negotiated Rate	$291.20
Max. Negotiated Rate	$691.60
Rate for Payer: Aetna Commercial	$655.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$371.14
Rate for Payer: Humana Medicare Advantage	$305.76
Rate for Payer: UnitedHealthcare Commercial	$691.60
Rate for Payer: UnitedHealthcare Medicaid	$291.20
Rate for Payer: WPPA Medicare Advantage	$436.80

Thalassemia And Hemoglobinopathy Comp QST

Facility

$728.00

Service Code	HCPCS 81257
Hospital Charge Code	3552728
Hospital Revenue Code	300
Min. Negotiated Rate	$655.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$655.20
Rate for Payer: UnitedHealthcare Commercial	$691.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Theophylline QST

Facility

$102.00

Service Code	HCPCS 80198
Hospital Charge Code	3550809
Hospital Revenue Code	300
Min. Negotiated Rate	$14.14
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$60.54
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$14.14
Rate for Payer: WPPA Medicare Advantage	$61.20

Theophylline QST

Facility

$102.00

Service Code	HCPCS 80198
Hospital Charge Code	3550809
Hospital Revenue Code	300
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Therapeutic Activities Charge

Facility

$134.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	3950564
Hospital Revenue Code	420
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Therapeutic Activities Charge

Facility

$134.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	3950564
Hospital Revenue Code	420
Min. Negotiated Rate	$28.44
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$56.91
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$28.44
Rate for Payer: WPPA Medicare Advantage	$80.40

Therapeutic Exercise Charges

Facility

$134.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	3950093
Hospital Revenue Code	420
Min. Negotiated Rate	$28.04
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$56.91
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$28.04
Rate for Payer: WPPA Medicare Advantage	$80.40

Therapeutic Exercise Charges

Facility

$134.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	3950093
Hospital Revenue Code	420
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Therapeutic Injection

Facility

$267.00

Service Code	HCPCS 20526
Hospital Charge Code	3152526
Hospital Revenue Code	360
Min. Negotiated Rate	$240.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$240.30
Rate for Payer: UnitedHealthcare Commercial	$253.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Therapeutic Injection

Facility

$267.00

Service Code	HCPCS 20526
Hospital Charge Code	3152526
Hospital Revenue Code	360
Min. Negotiated Rate	$112.14
Max. Negotiated Rate	$253.65
Rate for Payer: Aetna Commercial	$240.30
Rate for Payer: Humana Medicare Advantage	$112.14
Rate for Payer: UnitedHealthcare Commercial	$253.65
Rate for Payer: UnitedHealthcare Medicaid	$192.19
Rate for Payer: WPPA Medicare Advantage	$160.20

thiamine 100 mg/mL Inj Sol [HMC]

Facility

$43.88

Service Code	HCPCS J3411
Hospital Charge Code	3804223
Hospital Revenue Code	250
Min. Negotiated Rate	$39.49
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.49
Rate for Payer: Aetna Commercial	$38.09
Rate for Payer: UnitedHealthcare Commercial	$40.20
Rate for Payer: UnitedHealthcare Commercial	$41.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

thiamine 100 mg/mL Inj Sol [HMC]

Facility

$42.32

Service Code	HCPCS J3411
Hospital Charge Code	3804223
Hospital Revenue Code	250
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$40.20
Rate for Payer: Aetna Commercial	$38.09
Rate for Payer: Aetna Commercial	$39.49
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.90
Rate for Payer: Humana Medicare Advantage	$18.43
Rate for Payer: Humana Medicare Advantage	$17.77
Rate for Payer: UnitedHealthcare Commercial	$41.69
Rate for Payer: UnitedHealthcare Commercial	$40.20
Rate for Payer: UnitedHealthcare Medicaid	$16.93
Rate for Payer: UnitedHealthcare Medicaid	$17.55
Rate for Payer: WPPA Medicare Advantage	$26.33
Rate for Payer: WPPA Medicare Advantage	$25.39

Thoracentesis

Facility

$3,515.00

Service Code	HCPCS 32554
Hospital Charge Code	3150390
Hospital Revenue Code	360
Min. Negotiated Rate	$278.77
Max. Negotiated Rate	$3,339.25
Rate for Payer: Aetna Commercial	$3,163.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$742.35
Rate for Payer: Humana Medicare Advantage	$1,476.30
Rate for Payer: UnitedHealthcare Commercial	$3,339.25
Rate for Payer: UnitedHealthcare Medicaid	$278.77
Rate for Payer: WPPA Medicare Advantage	$2,109.00

Thoracentesis

Facility

$3,515.00

Service Code	HCPCS 32554
Hospital Charge Code	3150390
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,339.25
Rate for Payer: Aetna Commercial	$3,163.50
Rate for Payer: UnitedHealthcare Commercial	$3,339.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Thoracentesis Multi-Purpose Drainage Kit 10fr Pigtail

Facility

$488.00

Hospital Charge Code	3252151
Hospital Revenue Code	270
Min. Negotiated Rate	$195.20
Max. Negotiated Rate	$463.60
Rate for Payer: Aetna Commercial	$439.20
Rate for Payer: Humana Medicare Advantage	$204.96
Rate for Payer: UnitedHealthcare Commercial	$463.60
Rate for Payer: UnitedHealthcare Medicaid	$195.20
Rate for Payer: WPPA Medicare Advantage	$292.80

Thoracentesis Multi-Purpose Drainage Kit 10fr Pigtail

Facility

$488.00

Hospital Charge Code	3252151
Hospital Revenue Code	270
Min. Negotiated Rate	$439.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$439.20
Rate for Payer: UnitedHealthcare Commercial	$463.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Thoracentesis Multi-Purpose Drainage Kit 14fr Pigtail

Facility

$637.47

Hospital Charge Code	3252150
Hospital Revenue Code	270
Min. Negotiated Rate	$254.99
Max. Negotiated Rate	$605.60
Rate for Payer: Aetna Commercial	$573.72
Rate for Payer: Humana Medicare Advantage	$267.74
Rate for Payer: UnitedHealthcare Commercial	$605.60
Rate for Payer: UnitedHealthcare Medicaid	$254.99
Rate for Payer: WPPA Medicare Advantage	$382.48

Thoracentesis Multi-Purpose Drainage Kit 14fr Pigtail

Facility

$637.47

Hospital Charge Code	3252150
Hospital Revenue Code	270
Min. Negotiated Rate	$573.72
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$573.72
Rate for Payer: UnitedHealthcare Commercial	$605.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Thoracentesis Tray Arrow Pleura-Seal

Facility

$162.00

Hospital Charge Code	3252157
Hospital Revenue Code	270
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna Commercial	$145.80
Rate for Payer: Humana Medicare Advantage	$68.04
Rate for Payer: UnitedHealthcare Commercial	$153.90
Rate for Payer: UnitedHealthcare Medicaid	$64.80
Rate for Payer: WPPA Medicare Advantage	$97.20

Thoracentesis Tray Arrow Pleura-Seal

Facility

$162.00

Hospital Charge Code	3252157
Hospital Revenue Code	270
Min. Negotiated Rate	$145.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$145.80
Rate for Payer: UnitedHealthcare Commercial	$153.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Thoracentesis Tray Safe-T-Centesis 8fr Carefusion

Facility

$250.92

Hospital Charge Code	3252155
Hospital Revenue Code	270
Min. Negotiated Rate	$225.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$225.83
Rate for Payer: UnitedHealthcare Commercial	$238.37
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Thoracentesis Tray Safe-T-Centesis 8fr Carefusion

Facility

$250.92

Hospital Charge Code	3252155
Hospital Revenue Code	270
Min. Negotiated Rate	$100.37
Max. Negotiated Rate	$238.37
Rate for Payer: Aetna Commercial	$225.83
Rate for Payer: Humana Medicare Advantage	$105.39
Rate for Payer: UnitedHealthcare Commercial	$238.37
Rate for Payer: UnitedHealthcare Medicaid	$100.37
Rate for Payer: WPPA Medicare Advantage	$150.55

Thoracentesis Tubing 30inch

Facility

$16.00

Hospital Charge Code	3257156
Hospital Revenue Code	270
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$14.40
Rate for Payer: UnitedHealthcare Commercial	$15.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges