Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC

Facility

$4,701.96

Service Code	MSDRG 581
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 VASCULAR PROCEDURES WITH CC

Facility

$7,656.57

Service Code	MSDRG 253
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,656.57
Rate for Payer: UnitedHealthcare Medicaid	$7,656.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER VASCULAR PROCEDURES WITH MCC

Facility

$12,835.08

Service Code	MSDRG 252
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,835.08
Rate for Payer: UnitedHealthcare Medicaid	$12,835.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTHER VASCULAR PROCEDURES WITHOUT CC/MCC

Facility

$6,385.77

Service Code	MSDRG 254
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

OT High Complex Units

Facility

$338.00

Service Code	HCPCS 97167 GO
Hospital Charge Code	3977167
Hospital Revenue Code	434
Min. Negotiated Rate	$55.76
Max. Negotiated Rate	$321.10
Rate for Payer: Aetna Commercial	$304.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$117.24
Rate for Payer: Humana Medicare Advantage	$141.96
Rate for Payer: UnitedHealthcare Commercial	$321.10
Rate for Payer: UnitedHealthcare Medicaid	$55.76
Rate for Payer: WPPA Medicare Advantage	$202.80

OT High Complex Units

Facility

$338.00

Service Code	HCPCS 97167 GO
Hospital Charge Code	3977167
Hospital Revenue Code	434
Min. Negotiated Rate	$304.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$304.20
Rate for Payer: UnitedHealthcare Commercial	$321.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Iontophoresis Assistant Units

Facility

$89.00

Service Code	HCPCS 97033 GO
Hospital Charge Code	3970160
Hospital Revenue Code	430
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$84.55
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$38.38
Rate for Payer: Humana Medicare Advantage	$37.38
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: UnitedHealthcare Medicaid	$8.58
Rate for Payer: WPPA Medicare Advantage	$53.40

OT Iontophoresis Assistant Units

Facility

$89.00

Service Code	HCPCS 97033 GO
Hospital Charge Code	3970160
Hospital Revenue Code	430
Min. Negotiated Rate	$80.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OTITIS MEDIA AND URI WITH MCC

Facility

$3,431.16

Service Code	MSDRG 152
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

OTITIS MEDIA AND URI WITHOUT MCC

Facility

$2,160.36

Service Code	MSDRG 153
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,160.36
Rate for Payer: UnitedHealthcare Medicaid	$2,160.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Low Complex Units

Facility

$338.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	3970100
Hospital Revenue Code	434
Min. Negotiated Rate	$55.76
Max. Negotiated Rate	$321.10
Rate for Payer: Aetna Commercial	$304.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$117.24
Rate for Payer: Humana Medicare Advantage	$141.96
Rate for Payer: UnitedHealthcare Commercial	$321.10
Rate for Payer: UnitedHealthcare Medicaid	$55.76
Rate for Payer: WPPA Medicare Advantage	$202.80

OT Low Complex Units

Facility

$338.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	3970100
Hospital Revenue Code	434
Min. Negotiated Rate	$304.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$304.20
Rate for Payer: UnitedHealthcare Commercial	$321.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Manual Therapy Charge Units

Facility

$122.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	3977140
Hospital Revenue Code	431
Min. Negotiated Rate	$109.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Manual Therapy Charge Units

Facility

$122.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	3977140
Hospital Revenue Code	431
Min. Negotiated Rate	$22.37
Max. Negotiated Rate	$115.90
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$58.08
Rate for Payer: Humana Medicare Advantage	$51.24
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: UnitedHealthcare Medicaid	$22.37
Rate for Payer: WPPA Medicare Advantage	$73.20

OT Manual Traction Assistant Units

Facility

$122.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	3977140
Hospital Revenue Code	431
Min. Negotiated Rate	$109.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Manual Traction Assistant Units

Facility

$122.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	3977140
Hospital Revenue Code	431
Min. Negotiated Rate	$22.37
Max. Negotiated Rate	$115.90
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$58.08
Rate for Payer: Humana Medicare Advantage	$51.24
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: UnitedHealthcare Medicaid	$22.37
Rate for Payer: WPPA Medicare Advantage	$73.20

OT Moderate Complex Units

Facility

$338.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	3977166
Hospital Revenue Code	434
Min. Negotiated Rate	$55.76
Max. Negotiated Rate	$321.10
Rate for Payer: Aetna Commercial	$304.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$117.24
Rate for Payer: Humana Medicare Advantage	$141.96
Rate for Payer: UnitedHealthcare Commercial	$321.10
Rate for Payer: UnitedHealthcare Medicaid	$55.76
Rate for Payer: WPPA Medicare Advantage	$202.80

OT Moderate Complex Units

Facility

$338.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	3977166
Hospital Revenue Code	434
Min. Negotiated Rate	$304.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$304.20
Rate for Payer: UnitedHealthcare Commercial	$321.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Neuromuscular Reeducation Assist Unit

Facility

$132.00

Service Code	HCPCS 97112 GO
Hospital Charge Code	3970200
Hospital Revenue Code	430
Min. Negotiated Rate	$27.18
Max. Negotiated Rate	$125.40
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$50.50
Rate for Payer: Humana Medicare Advantage	$55.44
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: UnitedHealthcare Medicaid	$27.18
Rate for Payer: WPPA Medicare Advantage	$79.20

OT Neuromuscular Reeducation Assist Unit

Facility

$132.00

Service Code	HCPCS 97112 GO
Hospital Charge Code	3970200
Hospital Revenue Code	430
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

OT Neuromuscular Reeducation Charges

Facility

$132.00

Service Code	HCPCS 97112 GO
Hospital Charge Code	3970200
Hospital Revenue Code	430
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

OT Neuromuscular Reeducation Charges

Facility

$132.00

Service Code	HCPCS 97112 GO
Hospital Charge Code	3970200
Hospital Revenue Code	430
Min. Negotiated Rate	$27.18
Max. Negotiated Rate	$125.40
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$50.50
Rate for Payer: Humana Medicare Advantage	$55.44
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: UnitedHealthcare Medicaid	$27.18
Rate for Payer: WPPA Medicare Advantage	$79.20

OT Orthotic Mgmt, Train Assistant Units

Facility

$134.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	3970250
Hospital Revenue Code	430
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OT Orthotic Mgmt, Train Assistant Units

Facility

$134.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	3970250
Hospital Revenue Code	430
Min. Negotiated Rate	$39.64
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$39.64
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$53.60
Rate for Payer: WPPA Medicare Advantage	$80.40

OT OUTSOURCING ASSISTANT

Facility

$9.00

Hospital Charge Code	5576409
Hospital Revenue Code	432
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges