Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Total Contact Cast Regular Boot

Facility

$270.00

Hospital Charge Code	3254101
Hospital Revenue Code	270
Min. Negotiated Rate	$243.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$243.00
Rate for Payer: UnitedHealthcare Commercial	$256.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Total Contact Cast System 3

Facility

$504.00

Hospital Charge Code	3254100
Hospital Revenue Code	270
Min. Negotiated Rate	$453.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$453.60
Rate for Payer: UnitedHealthcare Commercial	$478.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Total Contact Cast System 3

Facility

$504.00

Hospital Charge Code	3254100
Hospital Revenue Code	270
Min. Negotiated Rate	$201.60
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna Commercial	$453.60
Rate for Payer: Humana Medicare Advantage	$211.68
Rate for Payer: UnitedHealthcare Commercial	$478.80
Rate for Payer: UnitedHealthcare Medicaid	$201.60
Rate for Payer: WPPA Medicare Advantage	$302.40

Total Iron Binding Capacity

Facility

$139.00

Service Code	HCPCS 83550
Hospital Charge Code	3550502
Hospital Revenue Code	300
Min. Negotiated Rate	$125.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$125.10
Rate for Payer: UnitedHealthcare Commercial	$132.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Total Iron Binding Capacity

Facility

$139.00

Service Code	HCPCS 83550
Hospital Charge Code	3550502
Hospital Revenue Code	300
Min. Negotiated Rate	$8.74
Max. Negotiated Rate	$132.05
Rate for Payer: Aetna Commercial	$125.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$41.23
Rate for Payer: Humana Medicare Advantage	$58.38
Rate for Payer: UnitedHealthcare Commercial	$132.05
Rate for Payer: UnitedHealthcare Medicaid	$8.74
Rate for Payer: WPPA Medicare Advantage	$83.40

Total T4 Level

Facility

$11.00

Service Code	HCPCS 84436
Hospital Charge Code	3551047
Hospital Revenue Code	300
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.90
Rate for Payer: UnitedHealthcare Commercial	$10.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Total T4 Level

Facility

$11.00

Service Code	HCPCS 84436
Hospital Charge Code	3551047
Hospital Revenue Code	300
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$17.96
Rate for Payer: Aetna Commercial	$9.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$17.96
Rate for Payer: Humana Medicare Advantage	$4.62
Rate for Payer: UnitedHealthcare Commercial	$10.45
Rate for Payer: UnitedHealthcare Medicaid	$6.87
Rate for Payer: WPPA Medicare Advantage	$6.60

Total vital capacity - RT CHARGE PFT

Facility

$243.00

Service Code	HCPCS 94150
Hospital Charge Code	3900269
Hospital Revenue Code	460
Min. Negotiated Rate	$218.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$218.70
Rate for Payer: UnitedHealthcare Commercial	$230.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Total vital capacity - RT CHARGE PFT

Facility

$243.00

Service Code	HCPCS 94150
Hospital Charge Code	3900269
Hospital Revenue Code	460
Min. Negotiated Rate	$34.35
Max. Negotiated Rate	$230.85
Rate for Payer: Aetna Commercial	$218.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$34.35
Rate for Payer: Humana Medicare Advantage	$102.06
Rate for Payer: UnitedHealthcare Commercial	$230.85
Rate for Payer: UnitedHealthcare Medicaid	$50.60
Rate for Payer: WPPA Medicare Advantage	$145.80

Toxoplasma Ab (IgG) QST

Facility

$171.00

Service Code	HCPCS 86778
Hospital Charge Code	3552490
Hospital Revenue Code	300
Min. Negotiated Rate	$153.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$153.90
Rate for Payer: UnitedHealthcare Commercial	$162.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Toxoplasma Ab (IgG) QST

Facility

$171.00

Service Code	HCPCS 86778
Hospital Charge Code	3552490
Hospital Revenue Code	300
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$162.45
Rate for Payer: Aetna Commercial	$153.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.29
Rate for Payer: Humana Medicare Advantage	$71.82
Rate for Payer: UnitedHealthcare Commercial	$162.45
Rate for Payer: UnitedHealthcare Medicaid	$12.25
Rate for Payer: WPPA Medicare Advantage	$102.60

TRAb (TSH Receptor Binding Antibody) QST

Facility

$252.00

Service Code	HCPCS 84442
Hospital Charge Code	3554442
Hospital Revenue Code	300
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TRAb (TSH Receptor Binding Antibody) QST

Facility

$252.00

Service Code	HCPCS 84442
Hospital Charge Code	3554442
Hospital Revenue Code	300
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$239.40
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$55.33
Rate for Payer: Humana Medicare Advantage	$105.84
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: UnitedHealthcare Medicaid	$14.78
Rate for Payer: WPPA Medicare Advantage	$151.20

Trach Care Tray Standard w/o Trach Dressing

Facility

$10.00

Hospital Charge Code	3251640
Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.00
Rate for Payer: UnitedHealthcare Commercial	$9.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Trach Care Tray Standard w/o Trach Dressing

Facility

$10.00

Hospital Charge Code	3251640
Hospital Revenue Code	270
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$9.50
Rate for Payer: Aetna Commercial	$9.00
Rate for Payer: Humana Medicare Advantage	$4.20
Rate for Payer: UnitedHealthcare Commercial	$9.50
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: WPPA Medicare Advantage	$6.00

Trach Care Tray Standard w/Trach Dressing

Facility

$7.00

Hospital Charge Code	3252223
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: UnitedHealthcare Commercial	$6.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Trach Care Tray Standard w/Trach Dressing

Facility

$7.00

Hospital Charge Code	3252223
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$6.65
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: Humana Medicare Advantage	$2.94
Rate for Payer: UnitedHealthcare Commercial	$6.65
Rate for Payer: UnitedHealthcare Medicaid	$2.80
Rate for Payer: WPPA Medicare Advantage	$4.20

TRACHEOSTOMY DECANNULATION PLUG DISP USE W/ANY SIZE DFEN DCFS DCFN TUBE

Facility

$18.00

Hospital Charge Code	3251643
Hospital Revenue Code	270
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.20
Rate for Payer: UnitedHealthcare Commercial	$17.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TRACHEOSTOMY DECANNULATION PLUG DISP USE W/ANY SIZE DFEN DCFS DCFN TUBE

Facility

$18.00

Hospital Charge Code	3251643
Hospital Revenue Code	270
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna Commercial	$16.20
Rate for Payer: Humana Medicare Advantage	$7.56
Rate for Payer: UnitedHealthcare Commercial	$17.10
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: WPPA Medicare Advantage	$10.80

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC

Facility

$11,151.27

Service Code	MSDRG 012
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,151.27
Rate for Payer: UnitedHealthcare Medicaid	$11,151.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC

Facility

$14,423.58

Service Code	MSDRG 011
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,423.58
Rate for Payer: UnitedHealthcare Medicaid	$14,423.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC

Facility

$7,624.80

Service Code	MSDRG 013
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,624.80
Rate for Payer: UnitedHealthcare Medicaid	$7,624.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TRACHEOSTOMY INNER CANNULA SIZE 6 FENESTRATED USE WITH SHILEY 6DFEN 6DCFN

Facility

$17.00

Hospital Charge Code	3251644
Hospital Revenue Code	270
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$16.15
Rate for Payer: Aetna Commercial	$15.30
Rate for Payer: Humana Medicare Advantage	$7.14
Rate for Payer: UnitedHealthcare Commercial	$16.15
Rate for Payer: UnitedHealthcare Medicaid	$6.80
Rate for Payer: WPPA Medicare Advantage	$10.20

TRACHEOSTOMY INNER CANNULA SIZE 6 FENESTRATED USE WITH SHILEY 6DFEN 6DCFN

Facility

$17.00

Hospital Charge Code	3251644
Hospital Revenue Code	270
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.30
Rate for Payer: UnitedHealthcare Commercial	$16.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TRACHEOSTOMY INNER CANNULA SIZE 6 NON-FENESTRATED USE WITH SHILEY 6DFEN 6DCT

Facility

$21.00

Hospital Charge Code	3251645
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$8.40
Rate for Payer: WPPA Medicare Advantage	$12.60

Know your out-of-pocket cost for care.

All Charges