Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

94626 PULMONARY REHAB W/ CONT ECG MONITOR CHARGE

Facility

$693.00

Service Code	HCPCS 94626
Hospital Charge Code	3860424
Hospital Revenue Code	948
Min. Negotiated Rate	$623.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$623.70
Rate for Payer: UnitedHealthcare Commercial	$658.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

94626 PULMONARY REHAB W/ CONT ECG MONITOR CHARGE

Facility

$693.00

Service Code	HCPCS 94626
Hospital Charge Code	3860424
Hospital Revenue Code	948
Min. Negotiated Rate	$47.20
Max. Negotiated Rate	$658.35
Rate for Payer: Aetna Commercial	$623.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$533.97
Rate for Payer: Humana Medicare Advantage	$291.06
Rate for Payer: UnitedHealthcare Commercial	$658.35
Rate for Payer: UnitedHealthcare Medicaid	$47.20
Rate for Payer: WPPA Medicare Advantage	$415.80

94640 PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3304680
Hospital Revenue Code	410
Min. Negotiated Rate	$55.44
Max. Negotiated Rate	$254.03
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$254.03
Rate for Payer: Humana Medicare Advantage	$55.44
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: UnitedHealthcare Medicaid	$69.09
Rate for Payer: WPPA Medicare Advantage	$79.20

94640 PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3304680
Hospital Revenue Code	410
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3294640
Hospital Revenue Code	410
Min. Negotiated Rate	$55.44
Max. Negotiated Rate	$254.03
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$254.03
Rate for Payer: Humana Medicare Advantage	$55.44
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: UnitedHealthcare Medicaid	$69.09
Rate for Payer: WPPA Medicare Advantage	$79.20

94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3294640
Hospital Revenue Code	410
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

94642 PENTAMIDINE AEROSOL TREATMENT CHARGE

Facility

$332.00

Service Code	HCPCS 94642
Hospital Charge Code	3900625
Hospital Revenue Code	410
Min. Negotiated Rate	$69.09
Max. Negotiated Rate	$315.40
Rate for Payer: Aetna Commercial	$298.80
Rate for Payer: Humana Medicare Advantage	$139.44
Rate for Payer: UnitedHealthcare Commercial	$315.40
Rate for Payer: UnitedHealthcare Medicaid	$69.09
Rate for Payer: WPPA Medicare Advantage	$199.20

94642 PENTAMIDINE AEROSOL TREATMENT CHARGE

Facility

$332.00

Service Code	HCPCS 94642
Hospital Charge Code	3900625
Hospital Revenue Code	410
Min. Negotiated Rate	$298.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$298.80
Rate for Payer: UnitedHealthcare Commercial	$315.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

94664 Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer

Facility

$132.00

Service Code	HCPCS 94664
Hospital Charge Code	3364664
Hospital Revenue Code	761
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

94664 Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer

Facility

$132.00

Service Code	HCPCS 94664
Hospital Charge Code	3364664
Hospital Revenue Code	761
Min. Negotiated Rate	$55.44
Max. Negotiated Rate	$211.17
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$211.17
Rate for Payer: Humana Medicare Advantage	$55.44
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: UnitedHealthcare Medicaid	$69.09
Rate for Payer: WPPA Medicare Advantage	$79.20

94760 OXIMETRY PULSE 1X CHARGE

Facility

$118.00

Service Code	HCPCS 94760
Hospital Charge Code	3900037
Hospital Revenue Code	460
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$112.10
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$9.13
Rate for Payer: Humana Medicare Advantage	$49.56
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: UnitedHealthcare Medicaid	$9.03
Rate for Payer: WPPA Medicare Advantage	$70.80

94760 OXIMETRY PULSE 1X CHARGE

Facility

$118.00

Service Code	HCPCS 94760
Hospital Charge Code	3900037
Hospital Revenue Code	460
Min. Negotiated Rate	$106.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

94761 Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations

Facility

$257.00

Service Code	HCPCS 94761
Hospital Charge Code	3354761
Hospital Revenue Code	460
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$244.15
Rate for Payer: Aetna Commercial	$231.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$17.14
Rate for Payer: Humana Medicare Advantage	$107.94
Rate for Payer: UnitedHealthcare Commercial	$244.15
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: WPPA Medicare Advantage	$154.20

94761 Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations

Facility

$257.00

Service Code	HCPCS 94761
Hospital Charge Code	3354761
Hospital Revenue Code	460
Min. Negotiated Rate	$231.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$231.30
Rate for Payer: UnitedHealthcare Commercial	$244.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95004 Percutaneous tests w/ allergenic extracts, includes interp/report, specify number of tests

Facility

$18.00

Service Code	HCPCS 95004
Hospital Charge Code	3355004
Hospital Revenue Code	924
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

95004 Percutaneous tests w/ allergenic extracts, includes interp/report, specify number of tests

Facility

$18.00

Service Code	HCPCS 95004
Hospital Charge Code	3355004
Hospital Revenue Code	924
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$338.70
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	$338.70
Rate for Payer: WPPA Medicare Advantage	$10.80

95012 Nitric oxide expired gas determination

Facility

$63.00

Service Code	HCPCS 95012
Hospital Charge Code	3355012
Hospital Revenue Code	761
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95012 Nitric oxide expired gas determination

Facility

$63.00

Service Code	HCPCS 95012
Hospital Charge Code	3355012
Hospital Revenue Code	761
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$59.85
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: Humana Medicare Advantage	$26.46
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: UnitedHealthcare Medicaid	$25.20
Rate for Payer: WPPA Medicare Advantage	$37.80

95017 Allergy testing, percutaneous & intracutaneous/intradermal w/ venoms,(sr/pun/prick specify #)

Facility

$19.00

Service Code	HCPCS 95017
Hospital Charge Code	3355017
Hospital Revenue Code	761
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$18.44
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Humana Medicare Advantage	$7.98
Rate for Payer: UnitedHealthcare Commercial	$18.05
Rate for Payer: UnitedHealthcare Medicaid	$18.44
Rate for Payer: WPPA Medicare Advantage	$11.40

95017 Allergy testing, percutaneous & intracutaneous/intradermal w/ venoms,(sr/pun/prick specify #)

Facility

$19.00

Service Code	HCPCS 95017
Hospital Charge Code	3355017
Hospital Revenue Code	761
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: UnitedHealthcare Commercial	$18.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95018 Allergy testing, percutaneous (scr/punct/prick) & intracutaneous w/ drugs or biologicals

Facility

$45.00

Service Code	HCPCS 95018
Hospital Charge Code	3355018
Hospital Revenue Code	761
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95018 Allergy testing, percutaneous (scr/punct/prick) & intracutaneous w/ drugs or biologicals

Facility

$45.00

Service Code	HCPCS 95018
Hospital Charge Code	3355018
Hospital Revenue Code	761
Min. Negotiated Rate	$18.44
Max. Negotiated Rate	$42.75
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: Humana Medicare Advantage	$18.90
Rate for Payer: UnitedHealthcare Commercial	$42.75
Rate for Payer: UnitedHealthcare Medicaid	$18.44
Rate for Payer: WPPA Medicare Advantage	$27.00

95024 Intracutaneous tests w/allergenic extracts, immediate reac, specify number of tests

Facility

$20.00

Service Code	HCPCS 95024
Hospital Charge Code	3355024
Hospital Revenue Code	761
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$19.82
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: Humana Medicare Advantage	$8.40
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: UnitedHealthcare Medicaid	$19.82
Rate for Payer: WPPA Medicare Advantage	$12.00

95024 Intracutaneous tests w/allergenic extracts, immediate reac, specify number of tests

Facility

$20.00

Service Code	HCPCS 95024
Hospital Charge Code	3355024
Hospital Revenue Code	761
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: UnitedHealthcare Commercial	$19.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95076 Ingestion challenge test; initial 120 minutes (sequential&incremental ingestion of test items)

Facility

$365.00

Service Code	HCPCS 95076
Hospital Charge Code	3355076
Hospital Revenue Code	761
Min. Negotiated Rate	$328.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$328.50
Rate for Payer: UnitedHealthcare Commercial	$346.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

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All Charges