Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

RT CPT Initial CHARGE

Facility

$188.00

Service Code	HCPCS 94667
Hospital Charge Code	3900053
Hospital Revenue Code	410
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT CPT Initial CHARGE

Facility

$188.00

Service Code	HCPCS 94667
Hospital Charge Code	3900053
Hospital Revenue Code	410
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$75.20
Rate for Payer: WPPA Medicare Advantage	$112.80

RT CPT Subsequent CHARGE

Facility

$188.00

Service Code	HCPCS 94668
Hospital Charge Code	3900061
Hospital Revenue Code	410
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$75.20
Rate for Payer: WPPA Medicare Advantage	$112.80

RT CPT Subsequent CHARGE

Facility

$188.00

Service Code	HCPCS 94668
Hospital Charge Code	3900061
Hospital Revenue Code	410
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT CPT w/ Vest Initial CHARGE

Facility

$188.00

Service Code	HCPCS 94667
Hospital Charge Code	3900053-1
Hospital Revenue Code	410
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT CPT w/ Vest Initial CHARGE

Facility

$188.00

Service Code	HCPCS 94667
Hospital Charge Code	3900053-1
Hospital Revenue Code	410
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$75.20
Rate for Payer: WPPA Medicare Advantage	$112.80

RT CPT w/ Vest Subsequent CHARGE

Facility

$188.00

Service Code	HCPCS 94668
Hospital Charge Code	3900061-1
Hospital Revenue Code	410
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT CPT w/ Vest Subsequent CHARGE

Facility

$188.00

Service Code	HCPCS 94668
Hospital Charge Code	3900061-1
Hospital Revenue Code	410
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$75.20
Rate for Payer: WPPA Medicare Advantage	$112.80

RT Flutter Therapy Initial CHARGE

Facility

$188.00

Service Code	HCPCS 94667
Hospital Charge Code	3900053-2
Hospital Revenue Code	410
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Flutter Therapy Initial CHARGE

Facility

$188.00

Service Code	HCPCS 94667
Hospital Charge Code	3900053-2
Hospital Revenue Code	410
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$75.20
Rate for Payer: WPPA Medicare Advantage	$112.80

RT Flutter Therapy Subsequent CHARGE

Facility

$188.00

Service Code	HCPCS 94668
Hospital Charge Code	3900061-2
Hospital Revenue Code	410
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Flutter Therapy Subsequent CHARGE

Facility

$188.00

Service Code	HCPCS 94668
Hospital Charge Code	3900061-2
Hospital Revenue Code	410
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$75.20
Rate for Payer: WPPA Medicare Advantage	$112.80

RT Meter Dose Inhaler Initial CHARGE

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3900236
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

RT Meter Dose Inhaler Initial CHARGE

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3900236
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

RT Meter Dose Inhaler Subsequent CHARGE

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3900236
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

RT Meter Dose Inhaler Subsequent CHARGE

Facility

$132.00

Service Code	HCPCS 94640
Hospital Charge Code	3900236
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

RT Oxygen Therapy Initial CHARGE

Facility

$347.00

Hospital Charge Code	3900285
Hospital Revenue Code	270
Min. Negotiated Rate	$312.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$312.30
Rate for Payer: UnitedHealthcare Commercial	$329.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Oxygen Therapy Initial CHARGE

Facility

$347.00

Hospital Charge Code	3900285
Hospital Revenue Code	270
Min. Negotiated Rate	$138.80
Max. Negotiated Rate	$329.65
Rate for Payer: Aetna Commercial	$312.30
Rate for Payer: Humana Medicare Advantage	$145.74
Rate for Payer: UnitedHealthcare Commercial	$329.65
Rate for Payer: UnitedHealthcare Medicaid	$138.80
Rate for Payer: WPPA Medicare Advantage	$208.20

RT Pentamidine 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

RT Pentamidine 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

RT PEP Therapy Initial CHARGE

Facility

$188.00

Service Code	HCPCS 94667
Hospital Charge Code	3900053-3
Hospital Revenue Code	410
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$75.20
Rate for Payer: WPPA Medicare Advantage	$112.80

RT PEP Therapy Initial CHARGE

Facility

$188.00

Service Code	HCPCS 94667
Hospital Charge Code	3900053-3
Hospital Revenue Code	410
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT PEP Therapy Subsequent CHARGE

Facility

$188.00

Service Code	HCPCS 94668
Hospital Charge Code	3900061-3
Hospital Revenue Code	410
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$75.20
Rate for Payer: WPPA Medicare Advantage	$112.80

RT PEP Therapy Subsequent CHARGE

Facility

$188.00

Service Code	HCPCS 94668
Hospital Charge Code	3900061-3
Hospital Revenue Code	410
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

RT Postural Drainage Initial CHARGE

Facility

$188.00

Service Code	HCPCS 94667
Hospital Charge Code	3900053-4
Hospital Revenue Code	410
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$75.20
Rate for Payer: WPPA Medicare Advantage	$112.80

Know your out-of-pocket cost for care.

All Charges