Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Umbilical Cord Clamp Clipper Remover Single Patient Use

Facility

$6.00

Hospital Charge Code	3250764
Hospital Revenue Code	270
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$5.70
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: Humana Medicare Advantage	$2.52
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: WPPA Medicare Advantage	$3.60

Umbilical Cord Clamp Clipper Remover Single Patient Use

Facility

$6.00

Hospital Charge Code	3250764
Hospital Revenue Code	270
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

umeclidinium 62.5 mcg (0.0625 mg)/inh Pow [HMC]

Facility

$576.94

Service Code	NDC 00173087310
Hospital Charge Code	3800546
Hospital Revenue Code	250
Min. Negotiated Rate	$230.78
Max. Negotiated Rate	$548.09
Rate for Payer: Aetna Commercial	$519.25
Rate for Payer: Humana Medicare Advantage	$242.31
Rate for Payer: UnitedHealthcare Commercial	$548.09
Rate for Payer: UnitedHealthcare Medicaid	$230.78
Rate for Payer: WPPA Medicare Advantage	$346.16

umeclidinium 62.5 mcg (0.0625 mg)/inh Pow [HMC]

Facility

$576.94

Service Code	NDC 00173087310
Hospital Charge Code	3800546
Hospital Revenue Code	250
Min. Negotiated Rate	$519.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$519.25
Rate for Payer: UnitedHealthcare Commercial	$548.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

umeclidinium-vilanterol 62.5 mcg-25 mcg/inh Pow [HMC]

Facility

$204.87

Service Code	NDC 00173086906
Hospital Charge Code	3800869
Hospital Revenue Code	250
Min. Negotiated Rate	$81.95
Max. Negotiated Rate	$194.63
Rate for Payer: Aetna Commercial	$184.38
Rate for Payer: Humana Medicare Advantage	$86.05
Rate for Payer: UnitedHealthcare Commercial	$194.63
Rate for Payer: UnitedHealthcare Medicaid	$81.95
Rate for Payer: WPPA Medicare Advantage	$122.92

umeclidinium-vilanterol 62.5 mcg-25 mcg/inh Pow [HMC]

Facility

$199.49

Service Code	NDC 00173086910
Hospital Charge Code	3800869
Hospital Revenue Code	250
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$189.52
Rate for Payer: Aetna Commercial	$179.54
Rate for Payer: Humana Medicare Advantage	$83.79
Rate for Payer: UnitedHealthcare Commercial	$189.52
Rate for Payer: UnitedHealthcare Medicaid	$79.80
Rate for Payer: WPPA Medicare Advantage	$119.69

umeclidinium-vilanterol 62.5 mcg-25 mcg/inh Pow [HMC]

Facility

$199.49

Service Code	NDC 00173086910
Hospital Charge Code	3800869
Hospital Revenue Code	250
Min. Negotiated Rate	$179.54
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$179.54
Rate for Payer: UnitedHealthcare Commercial	$189.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

umeclidinium-vilanterol 62.5 mcg-25 mcg/inh Pow [HMC]

Facility

$204.87

Service Code	NDC 00173086906
Hospital Charge Code	3800869
Hospital Revenue Code	250
Min. Negotiated Rate	$184.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$184.38
Rate for Payer: UnitedHealthcare Commercial	$194.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UNCOMPLICATED PEPTIC ULCER WITH MCC

Facility

$6,385.77

Service Code	MSDRG 383
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,385.77
Rate for Payer: UnitedHealthcare Medicaid	$6,385.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UNCOMPLICATED PEPTIC ULCER WITHOUT MCC

Facility

$3,939.48

Service Code	MSDRG 384
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,939.48
Rate for Payer: UnitedHealthcare Medicaid	$3,939.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UNGROUPABLE

Facility

$1,200.00

Service Code	MSDRG 999
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC

Facility

$6,099.84

Service Code	MSDRG 256
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,099.84
Rate for Payer: UnitedHealthcare Medicaid	$6,099.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC

Facility

$9,658.08

Service Code	MSDRG 255
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,658.08
Rate for Payer: UnitedHealthcare Medicaid	$9,658.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$3,907.71

Service Code	MSDRG 257
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,907.71
Rate for Payer: UnitedHealthcare Medicaid	$3,907.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

URETHRAL PROCEDURES WITH CC/MCC

Facility

$6,036.30

Service Code	MSDRG 671
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,036.30
Rate for Payer: UnitedHealthcare Medicaid	$6,036.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

URETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$3,653.55

Service Code	MSDRG 672
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,653.55
Rate for Payer: UnitedHealthcare Medicaid	$3,653.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

URETHRAL STRICTURE

Facility

$4,574.88

Service Code	MSDRG 697
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,574.88
Rate for Payer: UnitedHealthcare Medicaid	$4,574.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

URGENT CARE-90715 TDAP - ADULT

Facility

$120.00

Service Code	HCPCS 90715
Hospital Charge Code	3804631
Hospital Revenue Code	636
Min. Negotiated Rate	$39.69
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.14
Rate for Payer: Humana Medicare Advantage	$50.40
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicaid	$39.69
Rate for Payer: WPPA Medicare Advantage	$72.00

URGENT CARE-90715 TDAP - ADULT

Facility

$120.00

Service Code	HCPCS 90715
Hospital Charge Code	3804631
Hospital Revenue Code	636
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$108.00
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Uric Acid

Facility

$54.00

Service Code	HCPCS 84560
Hospital Charge Code	3552375
Hospital Revenue Code	300
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$20.39
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$5.08
Rate for Payer: WPPA Medicare Advantage	$32.40

Uric Acid

Facility

$54.00

Service Code	HCPCS 84560
Hospital Charge Code	3552375
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

Urinalysis Complete with Culture if Indicated

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

Urinalysis Complete with Culture if Indicated

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

Urinalysis Dipstick Only

Facility

$40.00

Service Code	HCPCS 81003
Hospital Charge Code	3550866
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

Urinalysis Dipstick Only

Facility

$40.00

Service Code	HCPCS 81003
Hospital Charge Code	3550866
Hospital Revenue Code	300
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$9.20
Rate for Payer: Humana Medicare Advantage	$16.80
Rate for Payer: UnitedHealthcare Commercial	$38.00
Rate for Payer: UnitedHealthcare Medicaid	$1.91
Rate for Payer: WPPA Medicare Advantage	$24.00

Know your out-of-pocket cost for care.

All Charges