Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

PT Physical PerFormance Assistant Test

Facility

$95.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	3957750
Hospital Revenue Code	420
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: UnitedHealthcare Commercial	$90.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Physical Performance Test Charges

Facility

$95.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	3957750
Hospital Revenue Code	420
Min. Negotiated Rate	$17.56
Max. Negotiated Rate	$90.25
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$53.53
Rate for Payer: Humana Medicare Advantage	$39.90
Rate for Payer: UnitedHealthcare Commercial	$90.25
Rate for Payer: UnitedHealthcare Medicaid	$17.56
Rate for Payer: WPPA Medicare Advantage	$57.00

PT Physical Performance Test Charges

Facility

$95.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	3957750
Hospital Revenue Code	420
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: UnitedHealthcare Commercial	$90.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT ReEval Units

Facility

$181.00

Service Code	HCPCS 97164 GP
Hospital Charge Code	3950226
Hospital Revenue Code	424
Min. Negotiated Rate	$53.19
Max. Negotiated Rate	$171.95
Rate for Payer: Aetna Commercial	$162.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$81.34
Rate for Payer: Humana Medicare Advantage	$76.02
Rate for Payer: UnitedHealthcare Commercial	$171.95
Rate for Payer: UnitedHealthcare Medicaid	$53.19
Rate for Payer: WPPA Medicare Advantage	$108.60

PT ReEval Units

Facility

$181.00

Service Code	HCPCS 97164 GP
Hospital Charge Code	3950226
Hospital Revenue Code	424
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$162.90
Rate for Payer: UnitedHealthcare Commercial	$171.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT ROM Measurements and Report Charges

Facility

$60.00

Service Code	HCPCS 95851 GP
Hospital Charge Code	3950606
Hospital Revenue Code	420
Min. Negotiated Rate	$8.46
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.83
Rate for Payer: Humana Medicare Advantage	$25.20
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: UnitedHealthcare Medicaid	$8.46
Rate for Payer: WPPA Medicare Advantage	$36.00

PT ROM Measurements and Report Charges

Facility

$60.00

Service Code	HCPCS 95851 GP
Hospital Charge Code	3950606
Hospital Revenue Code	420
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT ROM Measurements/Reports Assist

Facility

$60.00

Service Code	HCPCS 95851 GP
Hospital Charge Code	3950606
Hospital Revenue Code	420
Min. Negotiated Rate	$8.46
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.83
Rate for Payer: Humana Medicare Advantage	$25.20
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: UnitedHealthcare Medicaid	$8.46
Rate for Payer: WPPA Medicare Advantage	$36.00

PT ROM Measurements/Reports Assist

Facility

$60.00

Service Code	HCPCS 95851 GP
Hospital Charge Code	3950606
Hospital Revenue Code	420
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Self Care, Home Management Charges

Facility

$128.00

Service Code	HCPCS 97535 GP
Hospital Charge Code	3950523
Hospital Revenue Code	420
Min. Negotiated Rate	$19.46
Max. Negotiated Rate	$121.60
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$34.17
Rate for Payer: Humana Medicare Advantage	$53.76
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: UnitedHealthcare Medicaid	$19.46
Rate for Payer: WPPA Medicare Advantage	$76.80

PT Self Care, Home Management Charges

Facility

$128.00

Service Code	HCPCS 97535 GP
Hospital Charge Code	3950523
Hospital Revenue Code	420
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Self Care, Home Mgmt Assistant units

Facility

$128.00

Service Code	HCPCS 97535 GP
Hospital Charge Code	3950523
Hospital Revenue Code	420
Min. Negotiated Rate	$19.46
Max. Negotiated Rate	$121.60
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$34.17
Rate for Payer: Humana Medicare Advantage	$53.76
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: UnitedHealthcare Medicaid	$19.46
Rate for Payer: WPPA Medicare Advantage	$76.80

PT Self Care, Home Mgmt Assistant units

Facility

$128.00

Service Code	HCPCS 97535 GP
Hospital Charge Code	3950523
Hospital Revenue Code	420
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$115.20
Rate for Payer: UnitedHealthcare Commercial	$121.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Therapeutic Activity Assistant Units

Facility

$134.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	3950564
Hospital Revenue Code	420
Min. Negotiated Rate	$28.44
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$56.91
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$28.44
Rate for Payer: WPPA Medicare Advantage	$80.40

PT Therapeutic Activity Assistant Units

Facility

$134.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	3950564
Hospital Revenue Code	420
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

PT Therapeutic Exercise Assit Units

Facility

$134.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	3950093
Hospital Revenue Code	420
Min. Negotiated Rate	$28.04
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$56.91
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$28.04
Rate for Payer: WPPA Medicare Advantage	$80.40

PT Therapeutic Exercise Assit Units

Facility

$134.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	3950093
Hospital Revenue Code	420
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

PT Ultrasound Assistant Units

Facility

$67.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	3950143
Hospital Revenue Code	420
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

PT Ultrasound Assistant Units

Facility

$67.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	3950143
Hospital Revenue Code	420
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$63.65
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$29.29
Rate for Payer: Humana Medicare Advantage	$28.14
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: UnitedHealthcare Medicaid	$12.33
Rate for Payer: WPPA Medicare Advantage	$40.20

PT Unattended E-Stim Assistant Units

Facility

$75.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	3950840
Hospital Revenue Code	420
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Unattended E-Stim Assistant Units

Facility

$75.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	3950840
Hospital Revenue Code	420
Min. Negotiated Rate	$14.75
Max. Negotiated Rate	$71.25
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.31
Rate for Payer: Humana Medicare Advantage	$31.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: UnitedHealthcare Medicaid	$14.75
Rate for Payer: WPPA Medicare Advantage	$45.00

PT Unattended E-Stim Units

Facility

$75.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	3950840
Hospital Revenue Code	420
Min. Negotiated Rate	$14.75
Max. Negotiated Rate	$71.25
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.31
Rate for Payer: Humana Medicare Advantage	$31.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: UnitedHealthcare Medicaid	$14.75
Rate for Payer: WPPA Medicare Advantage	$45.00

PT Unattended E-Stim Units

Facility

$75.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	3950840
Hospital Revenue Code	420
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: UnitedHealthcare Commercial	$71.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Vasopneumatic Devices Assistant Units

Facility

$197.00

Service Code	HCPCS 97016 GP
Hospital Charge Code	3957016
Hospital Revenue Code	420
Min. Negotiated Rate	$177.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$177.30
Rate for Payer: UnitedHealthcare Commercial	$187.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

PT Vasopneumatic Devices Assistant Units

Facility

$197.00

Service Code	HCPCS 97016 GP
Hospital Charge Code	3957016
Hospital Revenue Code	420
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$187.15
Rate for Payer: Aetna Commercial	$177.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.33
Rate for Payer: Humana Medicare Advantage	$82.74
Rate for Payer: UnitedHealthcare Commercial	$187.15
Rate for Payer: UnitedHealthcare Medicaid	$16.50
Rate for Payer: WPPA Medicare Advantage	$118.20

Know your out-of-pocket cost for care.

All Charges