Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Tx of Speech/Lang/Voice/Comm/Auditory Chg

Facility

$206.00

Service Code	HCPCS 92507 GN
Hospital Charge Code	4050024
Hospital Revenue Code	441
Min. Negotiated Rate	$185.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Tx of Speech/Lang/Voice/Comm/Auditory Chg

Facility

$206.00

Service Code	HCPCS 92507 GN
Hospital Charge Code	4050024
Hospital Revenue Code	441
Min. Negotiated Rate	$76.68
Max. Negotiated Rate	$195.70
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$77.77
Rate for Payer: Humana Medicare Advantage	$86.52
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: UnitedHealthcare Medicaid	$76.68
Rate for Payer: WPPA Medicare Advantage	$123.60

UA Drainage Bag 2000ML

Facility

$11.84

Hospital Charge Code	3252322
Hospital Revenue Code	270
Min. Negotiated Rate	$4.74
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna Commercial	$10.66
Rate for Payer: Humana Medicare Advantage	$4.97
Rate for Payer: UnitedHealthcare Commercial	$11.25
Rate for Payer: UnitedHealthcare Medicaid	$4.74
Rate for Payer: WPPA Medicare Advantage	$7.10

UA Drainage Bag 2000ML

Facility

$11.84

Hospital Charge Code	3252322
Hospital Revenue Code	270
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.66
Rate for Payer: UnitedHealthcare Commercial	$11.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UA DRUG SCREEN-NON-DOT CHARGE

Facility

$40.00

Service Code	HCPCS 99000
Hospital Charge Code	3559000
Hospital Revenue Code	300
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$10.85
Rate for Payer: Humana Medicare Advantage	$16.80
Rate for Payer: UnitedHealthcare Commercial	$38.00
Rate for Payer: UnitedHealthcare Medicaid	$16.00
Rate for Payer: WPPA Medicare Advantage	$24.00

UA DRUG SCREEN-NON-DOT CHARGE

Facility

$40.00

Service Code	HCPCS 99000
Hospital Charge Code	3559000
Hospital Revenue Code	300
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.00
Rate for Payer: UnitedHealthcare Commercial	$38.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UA Meter

Facility

$30.11

Hospital Charge Code	3252330
Hospital Revenue Code	270
Min. Negotiated Rate	$27.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.10
Rate for Payer: UnitedHealthcare Commercial	$28.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UA Meter

Facility

$30.11

Hospital Charge Code	3252330
Hospital Revenue Code	270
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$28.60
Rate for Payer: Aetna Commercial	$27.10
Rate for Payer: Humana Medicare Advantage	$12.65
Rate for Payer: UnitedHealthcare Commercial	$28.60
Rate for Payer: UnitedHealthcare Medicaid	$12.04
Rate for Payer: WPPA Medicare Advantage	$18.07

UA Microscopic

Facility

$57.00

Service Code	HCPCS 81001
Hospital Charge Code	3550841
Hospital Revenue Code	300
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UA Microscopic

Facility

$57.00

Service Code	HCPCS 81001
Hospital Charge Code	3550841
Hospital Revenue Code	300
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$54.15
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$9.72
Rate for Payer: Humana Medicare Advantage	$23.94
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: UnitedHealthcare Medicaid	$3.17
Rate for Payer: WPPA Medicare Advantage	$34.20

UA Midstream

Facility

$4.55

Hospital Charge Code	3252017
Hospital Revenue Code	270
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.09
Rate for Payer: UnitedHealthcare Commercial	$4.32
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UA Midstream

Facility

$4.55

Hospital Charge Code	3252017
Hospital Revenue Code	270
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$4.32
Rate for Payer: Aetna Commercial	$4.09
Rate for Payer: Humana Medicare Advantage	$1.91
Rate for Payer: UnitedHealthcare Commercial	$4.32
Rate for Payer: UnitedHealthcare Medicaid	$1.82
Rate for Payer: WPPA Medicare Advantage	$2.73

ubiquinone 200 mg Cap [HMC]

Facility

$7.22

Service Code	NDC 54022800201
Hospital Charge Code	3801033
Hospital Revenue Code	250
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$6.86
Rate for Payer: Aetna Commercial	$6.50
Rate for Payer: Humana Medicare Advantage	$3.03
Rate for Payer: UnitedHealthcare Commercial	$6.86
Rate for Payer: UnitedHealthcare Medicaid	$2.89
Rate for Payer: WPPA Medicare Advantage	$4.33

ubiquinone 200 mg Cap [HMC]

Facility

$5.00

Service Code	NDC 40985027435
Hospital Charge Code	3801033
Hospital Revenue Code	250
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: Humana Medicare Advantage	$2.10
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: UnitedHealthcare Medicaid	$2.00
Rate for Payer: WPPA Medicare Advantage	$3.00

ubiquinone 200 mg Cap [HMC]

Facility

$7.22

Service Code	NDC 54022800201
Hospital Charge Code	3801033
Hospital Revenue Code	250
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.50
Rate for Payer: UnitedHealthcare Commercial	$6.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ubiquinone 200 mg Cap [HMC]

Facility

$5.00

Service Code	NDC 40985027435
Hospital Charge Code	3801033
Hospital Revenue Code	250
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: UnitedHealthcare Commercial	$4.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ublituximab xiiy 150 mg/6 mL Sol [HMC]

Facility

$23,331.00

Service Code	HCPCS J2329
Hospital Charge Code	3850324
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$22,164.45
Rate for Payer: Aetna Commercial	$20,997.90
Rate for Payer: UnitedHealthcare Commercial	$22,164.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ublituximab xiiy 150 mg/6 mL Sol [HMC]

Facility

$23,331.00

Service Code	HCPCS J2329
Hospital Charge Code	3850324
Hospital Revenue Code	250
Min. Negotiated Rate	$70.18
Max. Negotiated Rate	$22,164.45
Rate for Payer: Aetna Commercial	$20,997.90
Rate for Payer: Humana Medicare Advantage	$9,799.02
Rate for Payer: UnitedHealthcare Commercial	$22,164.45
Rate for Payer: UnitedHealthcare Medicaid	$70.18
Rate for Payer: WPPA Medicare Advantage	$13,998.60

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC

Facility

$19,951.56

Service Code	MSDRG 278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$19,951.56
Rate for Payer: UnitedHealthcare Medicaid	$19,951.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC

Facility

$12,930.39

Service Code	MSDRG 279
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,930.39
Rate for Payer: UnitedHealthcare Medicaid	$12,930.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM

Facility

$10,420.56

Service Code	MSDRG 173
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,420.56
Rate for Payer: UnitedHealthcare Medicaid	$10,420.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ultrasound Charges

Facility

$78.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	3970125
Hospital Revenue Code	430
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$74.10
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$29.29
Rate for Payer: Humana Medicare Advantage	$32.76
Rate for Payer: UnitedHealthcare Commercial	$74.10
Rate for Payer: UnitedHealthcare Medicaid	$12.33
Rate for Payer: WPPA Medicare Advantage	$46.80

Ultrasound Charges

Facility

$67.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	3950143
Hospital Revenue Code	420
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ultrasound Charges

Facility

$78.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	3970125
Hospital Revenue Code	430
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: UnitedHealthcare Commercial	$74.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ultrasound Charges

Facility

$67.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	3950143
Hospital Revenue Code	420
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$63.65
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$29.29
Rate for Payer: Humana Medicare Advantage	$28.14
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: UnitedHealthcare Medicaid	$12.33
Rate for Payer: WPPA Medicare Advantage	$40.20

Know your out-of-pocket cost for care.

All Charges