Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Urinalysis with Micro if Indicated and Culture if Indicated

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

Urinalysis with Micro if Indicated and Culture if Indicated

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

URINARY STONES WITH MCC

Facility

$5,718.60

Service Code	MSDRG 693
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,718.60
Rate for Payer: UnitedHealthcare Medicaid	$5,718.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

URINARY STONES WITHOUT MCC

Facility

$3,335.85

Service Code	MSDRG 694
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,335.85
Rate for Payer: UnitedHealthcare Medicaid	$3,335.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Urine Creatinine

Facility

$74.00

Service Code	HCPCS 82570
Hospital Charge Code	3551774
Hospital Revenue Code	300
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Urine Creatinine

Facility

$74.00

Service Code	HCPCS 82570
Hospital Charge Code	3551774
Hospital Revenue Code	300
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$70.30
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$21.53
Rate for Payer: Humana Medicare Advantage	$31.08
Rate for Payer: UnitedHealthcare Commercial	$70.30
Rate for Payer: UnitedHealthcare Medicaid	$5.18
Rate for Payer: WPPA Medicare Advantage	$44.40

Urine Microalbumin

Facility

$78.00

Service Code	HCPCS 82043
Hospital Charge Code	3557105
Hospital Revenue Code	300
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

Urine Microalbumin

Facility

$78.00

Service Code	HCPCS 82043
Hospital Charge Code	3557105
Hospital Revenue Code	300
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$74.10
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$24.82
Rate for Payer: Humana Medicare Advantage	$32.76
Rate for Payer: UnitedHealthcare Commercial	$74.10
Rate for Payer: UnitedHealthcare Medicaid	$5.25
Rate for Payer: WPPA Medicare Advantage	$46.80

Urine Phosphate W/O Creatinine QST

Facility

$67.00

Service Code	HCPCS 84105
Hospital Charge Code	3554105
Hospital Revenue Code	300
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$63.65
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$17.72
Rate for Payer: Humana Medicare Advantage	$28.14
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: UnitedHealthcare Medicaid	$5.78
Rate for Payer: WPPA Medicare Advantage	$40.20

Urine Phosphate W/O Creatinine QST

Facility

$67.00

Service Code	HCPCS 84105
Hospital Charge Code	3554105
Hospital Revenue Code	300
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

Urine Protein Level

Facility

$66.00

Service Code	HCPCS 84156
Hospital Charge Code	3552545
Hospital Revenue Code	300
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$59.40
Rate for Payer: UnitedHealthcare Commercial	$62.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Urine Protein Level

Facility

$66.00

Service Code	HCPCS 84156
Hospital Charge Code	3552545
Hospital Revenue Code	300
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$62.70
Rate for Payer: Aetna Commercial	$59.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$18.82
Rate for Payer: Humana Medicare Advantage	$27.72
Rate for Payer: UnitedHealthcare Commercial	$62.70
Rate for Payer: UnitedHealthcare Medicaid	$3.67
Rate for Payer: WPPA Medicare Advantage	$39.60

ursodiol 250 mg Tab [HMC]

Facility

$13.05

Service Code	NDC 64380091806
Hospital Charge Code	3802398
Hospital Revenue Code	250
Min. Negotiated Rate	$11.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.74
Rate for Payer: UnitedHealthcare Commercial	$12.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ursodiol 250 mg Tab [HMC]

Facility

$13.05

Service Code	NDC 64380091806
Hospital Charge Code	3802398
Hospital Revenue Code	250
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$12.40
Rate for Payer: Aetna Commercial	$11.74
Rate for Payer: Humana Medicare Advantage	$5.48
Rate for Payer: UnitedHealthcare Commercial	$12.40
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$7.83

ursodiol 250 mg Tab [HMC]

Facility

$13.05

Service Code	NDC 68462047301
Hospital Charge Code	3802398
Hospital Revenue Code	250
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$12.40
Rate for Payer: Aetna Commercial	$11.74
Rate for Payer: Humana Medicare Advantage	$5.48
Rate for Payer: UnitedHealthcare Commercial	$12.40
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$7.83

ursodiol 250 mg Tab [HMC]

Facility

$13.05

Service Code	NDC 68462047301
Hospital Charge Code	3802398
Hospital Revenue Code	250
Min. Negotiated Rate	$11.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.74
Rate for Payer: UnitedHealthcare Commercial	$12.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US AAA Screening

Facility

$337.00

Service Code	HCPCS 76706 TC
Hospital Charge Code	3736706
Hospital Revenue Code	402
Min. Negotiated Rate	$303.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$303.30
Rate for Payer: UnitedHealthcare Commercial	$320.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US AAA Screening

Facility

$337.00

Service Code	HCPCS 76706 TC
Hospital Charge Code	3736706
Hospital Revenue Code	402
Min. Negotiated Rate	$90.85
Max. Negotiated Rate	$320.15
Rate for Payer: Aetna Commercial	$303.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$151.50
Rate for Payer: Humana Medicare Advantage	$141.54
Rate for Payer: UnitedHealthcare Commercial	$320.15
Rate for Payer: UnitedHealthcare Medicaid	$90.85
Rate for Payer: WPPA Medicare Advantage	$202.20

US Abdomen Complete

Facility

$764.00

Service Code	HCPCS 76700 TC
Hospital Charge Code	3730055
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$151.50
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$458.40

US Abdomen Complete

Facility

$764.00

Service Code	HCPCS 76700 TC
Hospital Charge Code	3730055
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Aorta

Facility

$764.00

Service Code	HCPCS 76775 TC
Hospital Charge Code	3730449
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Aorta

Facility

$764.00

Service Code	HCPCS 76775 TC
Hospital Charge Code	3730449
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$117.16
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$458.40

US Aorta IVC Iliac Duplex Complete

Facility

$764.00

Service Code	HCPCS 93978 TC
Hospital Charge Code	3733978
Hospital Revenue Code	402
Min. Negotiated Rate	$79.38
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.76
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$79.38
Rate for Payer: WPPA Medicare Advantage	$458.40

US Aorta IVC Iliac Duplex Complete

Facility

$764.00

Service Code	HCPCS 93978 TC
Hospital Charge Code	3733978
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Aorta IVC Iliac Duplex Limited

Facility

$764.00

Service Code	HCPCS 93979 TC
Hospital Charge Code	3733979
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges