Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Sleep Endoscopy

Facility

$2,954.00

Service Code	HCPCS 42975 TC
Hospital Charge Code	3152975
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,806.30
Rate for Payer: Aetna Commercial	$2,658.60
Rate for Payer: UnitedHealthcare Commercial	$2,806.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sleep Endoscopy

Facility

$2,954.00

Service Code	HCPCS 42975 TC
Hospital Charge Code	3152975
Hospital Revenue Code	360
Min. Negotiated Rate	$109.28
Max. Negotiated Rate	$2,806.30
Rate for Payer: Aetna Commercial	$2,658.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$190.25
Rate for Payer: Humana Medicare Advantage	$1,240.68
Rate for Payer: UnitedHealthcare Commercial	$2,806.30
Rate for Payer: UnitedHealthcare Medicaid	$109.28
Rate for Payer: WPPA Medicare Advantage	$1,772.40

Sling Arm Child

Facility

$18.27

Hospital Charge Code	3251067
Hospital Revenue Code	270
Min. Negotiated Rate	$16.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.44
Rate for Payer: UnitedHealthcare Commercial	$17.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sling Arm Child

Facility

$18.27

Hospital Charge Code	3251067
Hospital Revenue Code	270
Min. Negotiated Rate	$7.31
Max. Negotiated Rate	$17.36
Rate for Payer: Aetna Commercial	$16.44
Rate for Payer: Humana Medicare Advantage	$7.67
Rate for Payer: UnitedHealthcare Commercial	$17.36
Rate for Payer: UnitedHealthcare Medicaid	$7.31
Rate for Payer: WPPA Medicare Advantage	$10.96

Sling Arm Large

Facility

$18.27

Hospital Charge Code	3251075
Hospital Revenue Code	270
Min. Negotiated Rate	$7.31
Max. Negotiated Rate	$17.36
Rate for Payer: Aetna Commercial	$16.44
Rate for Payer: Humana Medicare Advantage	$7.67
Rate for Payer: UnitedHealthcare Commercial	$17.36
Rate for Payer: UnitedHealthcare Medicaid	$7.31
Rate for Payer: WPPA Medicare Advantage	$10.96

Sling Arm Large

Facility

$18.27

Hospital Charge Code	3251075
Hospital Revenue Code	270
Min. Negotiated Rate	$16.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.44
Rate for Payer: UnitedHealthcare Commercial	$17.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sling Arm Medium

Facility

$18.27

Hospital Charge Code	3252081
Hospital Revenue Code	270
Min. Negotiated Rate	$7.31
Max. Negotiated Rate	$17.36
Rate for Payer: Aetna Commercial	$16.44
Rate for Payer: Humana Medicare Advantage	$7.67
Rate for Payer: UnitedHealthcare Commercial	$17.36
Rate for Payer: UnitedHealthcare Medicaid	$7.31
Rate for Payer: WPPA Medicare Advantage	$10.96

Sling Arm Medium

Facility

$18.27

Hospital Charge Code	3252081
Hospital Revenue Code	270
Min. Negotiated Rate	$16.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.44
Rate for Payer: UnitedHealthcare Commercial	$17.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sling Arm Small

Facility

$18.27

Hospital Charge Code	3251828
Hospital Revenue Code	270
Min. Negotiated Rate	$7.31
Max. Negotiated Rate	$17.36
Rate for Payer: Aetna Commercial	$16.44
Rate for Payer: Humana Medicare Advantage	$7.67
Rate for Payer: UnitedHealthcare Commercial	$17.36
Rate for Payer: UnitedHealthcare Medicaid	$7.31
Rate for Payer: WPPA Medicare Advantage	$10.96

Sling Arm Small

Facility

$18.27

Hospital Charge Code	3251828
Hospital Revenue Code	270
Min. Negotiated Rate	$16.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.44
Rate for Payer: UnitedHealthcare Commercial	$17.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sling Arm X-Large

Facility

$18.27

Hospital Charge Code	3251894
Hospital Revenue Code	270
Min. Negotiated Rate	$7.31
Max. Negotiated Rate	$17.36
Rate for Payer: Aetna Commercial	$16.44
Rate for Payer: Humana Medicare Advantage	$7.67
Rate for Payer: UnitedHealthcare Commercial	$17.36
Rate for Payer: UnitedHealthcare Medicaid	$7.31
Rate for Payer: WPPA Medicare Advantage	$10.96

Sling Arm X-Large

Facility

$18.27

Hospital Charge Code	3251894
Hospital Revenue Code	270
Min. Negotiated Rate	$16.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.44
Rate for Payer: UnitedHealthcare Commercial	$17.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sling & Swathe Large

Facility

$44.69

Hospital Charge Code	3251059
Hospital Revenue Code	270
Min. Negotiated Rate	$17.88
Max. Negotiated Rate	$42.46
Rate for Payer: Aetna Commercial	$40.22
Rate for Payer: Humana Medicare Advantage	$18.77
Rate for Payer: UnitedHealthcare Commercial	$42.46
Rate for Payer: UnitedHealthcare Medicaid	$17.88
Rate for Payer: WPPA Medicare Advantage	$26.81

Sling & Swathe Large

Facility

$44.69

Hospital Charge Code	3251059
Hospital Revenue Code	270
Min. Negotiated Rate	$40.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.22
Rate for Payer: UnitedHealthcare Commercial	$42.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sling & Swathe Medium

Facility

$44.69

Hospital Charge Code	3251042
Hospital Revenue Code	270
Min. Negotiated Rate	$40.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.22
Rate for Payer: UnitedHealthcare Commercial	$42.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sling & Swathe Medium

Facility

$44.69

Hospital Charge Code	3251042
Hospital Revenue Code	270
Min. Negotiated Rate	$17.88
Max. Negotiated Rate	$42.46
Rate for Payer: Aetna Commercial	$40.22
Rate for Payer: Humana Medicare Advantage	$18.77
Rate for Payer: UnitedHealthcare Commercial	$42.46
Rate for Payer: UnitedHealthcare Medicaid	$17.88
Rate for Payer: WPPA Medicare Advantage	$26.81

Sling & Swathe Small

Facility

$43.00

Hospital Charge Code	3251034
Hospital Revenue Code	270
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sling & Swathe Small

Facility

$43.00

Hospital Charge Code	3251034
Hospital Revenue Code	270
Min. Negotiated Rate	$17.20
Max. Negotiated Rate	$40.85
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$18.06
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: UnitedHealthcare Medicaid	$17.20
Rate for Payer: WPPA Medicare Advantage	$25.80

Sling & Swathe X-Large

Facility

$35.87

Hospital Charge Code	3252354
Hospital Revenue Code	270
Min. Negotiated Rate	$14.35
Max. Negotiated Rate	$34.08
Rate for Payer: Aetna Commercial	$32.28
Rate for Payer: Humana Medicare Advantage	$15.07
Rate for Payer: UnitedHealthcare Commercial	$34.08
Rate for Payer: UnitedHealthcare Medicaid	$14.35
Rate for Payer: WPPA Medicare Advantage	$21.52

Sling & Swathe X-Large

Facility

$35.87

Hospital Charge Code	3252354
Hospital Revenue Code	270
Min. Negotiated Rate	$32.28
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$32.28
Rate for Payer: UnitedHealthcare Commercial	$34.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sling & Swathe X-Small

Facility

$48.00

Hospital Charge Code	3259875
Hospital Revenue Code	270
Min. Negotiated Rate	$43.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$43.20
Rate for Payer: UnitedHealthcare Commercial	$45.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sling & Swathe X-Small

Facility

$48.00

Hospital Charge Code	3259875
Hospital Revenue Code	270
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$45.60
Rate for Payer: Aetna Commercial	$43.20
Rate for Payer: Humana Medicare Advantage	$20.16
Rate for Payer: UnitedHealthcare Commercial	$45.60
Rate for Payer: UnitedHealthcare Medicaid	$19.20
Rate for Payer: WPPA Medicare Advantage	$28.80

SLP Cog Ther Intervent1st 15min Unit

Facility

$110.00

Service Code	HCPCS 97129 GN
Hospital Charge Code	4057532
Hospital Revenue Code	444
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$99.00
Rate for Payer: UnitedHealthcare Commercial	$104.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SLP Cog Ther Intervent1st 15min Unit

Facility

$110.00

Service Code	HCPCS 97129 GN
Hospital Charge Code	4057532
Hospital Revenue Code	444
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$104.50
Rate for Payer: Aetna Commercial	$99.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$50.50
Rate for Payer: Humana Medicare Advantage	$46.20
Rate for Payer: UnitedHealthcare Commercial	$104.50
Rate for Payer: UnitedHealthcare Medicaid	$44.00
Rate for Payer: WPPA Medicare Advantage	$66.00

SLP Cog Ther Intervent, Addl 15 Units

Facility

$110.00

Service Code	HCPCS 97130 GN
Hospital Charge Code	4057130
Hospital Revenue Code	444
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$104.50
Rate for Payer: Aetna Commercial	$99.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$50.50
Rate for Payer: Humana Medicare Advantage	$46.20
Rate for Payer: UnitedHealthcare Commercial	$104.50
Rate for Payer: UnitedHealthcare Medicaid	$44.00
Rate for Payer: WPPA Medicare Advantage	$66.00

Know your out-of-pocket cost for care.

All Charges