Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

OT Cog Ther Intervent, Addl 15 Min Units

Facility

$160.00

Service Code	HCPCS 97130 GO
Hospital Charge Code	97130
Hospital Revenue Code	430
Min. Negotiated Rate	$144.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$144.00
Rate for Payer: UnitedHealthcare Commercial	$152.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Cog Ther Intervent, First 15 Min Asst

Facility

$111.00

Service Code	HCPCS 97129 GO
Hospital Charge Code	97129
Hospital Revenue Code	430
Min. Negotiated Rate	$44.40
Max. Negotiated Rate	$105.45
Rate for Payer: Aetna Commercial	$99.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$50.50
Rate for Payer: Humana Medicare Advantage	$46.62
Rate for Payer: UnitedHealthcare Commercial	$105.45
Rate for Payer: UnitedHealthcare Medicaid	$44.40
Rate for Payer: WPPA Medicare Advantage	$66.60

OT Cog Ther Intervent, First 15 Min Asst

Facility

$111.00

Service Code	HCPCS 97129 GO
Hospital Charge Code	97129
Hospital Revenue Code	430
Min. Negotiated Rate	$99.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$99.90
Rate for Payer: UnitedHealthcare Commercial	$105.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Cog Ther Intervent,First 15 Min Units

Facility

$111.00

Service Code	HCPCS 97129 GO
Hospital Charge Code	97129
Hospital Revenue Code	430
Min. Negotiated Rate	$99.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$99.90
Rate for Payer: UnitedHealthcare Commercial	$105.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Cog Ther Intervent,First 15 Min Units

Facility

$111.00

Service Code	HCPCS 97129 GO
Hospital Charge Code	97129
Hospital Revenue Code	430
Min. Negotiated Rate	$44.40
Max. Negotiated Rate	$105.45
Rate for Payer: Aetna Commercial	$99.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$50.50
Rate for Payer: Humana Medicare Advantage	$46.62
Rate for Payer: UnitedHealthcare Commercial	$105.45
Rate for Payer: UnitedHealthcare Medicaid	$44.40
Rate for Payer: WPPA Medicare Advantage	$66.60

OTElectrical Stim (Unattended) - Non-Wound

Facility

$84.00

Service Code	HCPCS 97014 GO
Hospital Charge Code	3970115
Hospital Revenue Code	430
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$75.60
Rate for Payer: UnitedHealthcare Commercial	$79.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTElectrical Stim (Unattended) - Non-Wound

Facility

$84.00

Service Code	HCPCS 97014 GO
Hospital Charge Code	3970115
Hospital Revenue Code	430
Min. Negotiated Rate	$14.75
Max. Negotiated Rate	$79.80
Rate for Payer: Aetna Commercial	$75.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.31
Rate for Payer: Humana Medicare Advantage	$35.28
Rate for Payer: UnitedHealthcare Commercial	$79.80
Rate for Payer: UnitedHealthcare Medicaid	$14.75
Rate for Payer: WPPA Medicare Advantage	$50.40

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC

Facility

$4,701.96

Service Code	MSDRG 818
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,701.96
Rate for Payer: UnitedHealthcare Medicaid	$4,701.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC

Facility

$7,910.73

Service Code	MSDRG 817
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,910.73
Rate for Payer: UnitedHealthcare Medicaid	$7,910.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$2,700.45

Service Code	MSDRG 819
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,700.45
Rate for Payer: UnitedHealthcare Medicaid	$2,700.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC

Facility

$2,732.22

Service Code	MSDRG 832
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,732.22
Rate for Payer: UnitedHealthcare Medicaid	$2,732.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC

Facility

$3,526.47

Service Code	MSDRG 831
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,526.47
Rate for Payer: UnitedHealthcare Medicaid	$3,526.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC

Facility

$1,906.20

Service Code	MSDRG 833
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,906.20
Rate for Payer: UnitedHealthcare Medicaid	$1,906.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER CARDIOTHORACIC PROCEDURES WITH MCC

Facility

$17,727.66

Service Code	MSDRG 228
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$17,727.66
Rate for Payer: UnitedHealthcare Medicaid	$17,727.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC

Facility

$11,278.35

Service Code	MSDRG 229
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,278.35
Rate for Payer: UnitedHealthcare Medicaid	$11,278.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER CEREBROVASCULAR DISORDERS WITH CC

Facility

$4,638.42

Service Code	MSDRG 071
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,638.42
Rate for Payer: UnitedHealthcare Medicaid	$4,638.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER CEREBROVASCULAR DISORDERS WITH MCC

Facility

$8,832.06

Service Code	MSDRG 070
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,832.06
Rate for Payer: UnitedHealthcare Medicaid	$8,832.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC

Facility

$3,431.16

Service Code	MSDRG 072
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,431.16
Rate for Payer: UnitedHealthcare Medicaid	$3,431.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC

Facility

$4,225.41

Service Code	MSDRG 315
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,225.41
Rate for Payer: UnitedHealthcare Medicaid	$4,225.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC

Facility

$11,151.27

Service Code	MSDRG 314
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

OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC

Facility

$2,986.38

Service Code	MSDRG 316
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,986.38
Rate for Payer: UnitedHealthcare Medicaid	$2,986.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER CIRCULATORY SYSTEM O.R. PROCEDURES

Facility

$14,582.43

Service Code	MSDRG 264
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,582.43
Rate for Payer: UnitedHealthcare Medicaid	$14,582.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC

Facility

$3,717.09

Service Code	MSDRG 394
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,717.09
Rate for Payer: UnitedHealthcare Medicaid	$3,717.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC

Facility

$7,370.64

Service Code	MSDRG 393
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,370.64
Rate for Payer: UnitedHealthcare Medicaid	$7,370.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC

Facility

$2,350.98

Service Code	MSDRG 395
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,350.98
Rate for Payer: UnitedHealthcare Medicaid	$2,350.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges