Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

US Fetal Biophysical Profile w/o N Str

Facility

$229.00

Service Code	HCPCS 76819 TC
Hospital Charge Code	3730415
Hospital Revenue Code	402
Min. Negotiated Rate	$206.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$206.10
Rate for Payer: UnitedHealthcare Commercial	$217.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Fetal Biophysical Profile w/o N Str

Facility

$229.00

Service Code	HCPCS 76819 TC
Hospital Charge Code	3730415
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$217.55
Rate for Payer: Aetna Commercial	$206.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$141.50
Rate for Payer: Humana Medicare Advantage	$96.18
Rate for Payer: UnitedHealthcare Commercial	$217.55
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$137.40

US Fetal Echo 2D

Facility

$613.00

Service Code	HCPCS 76825 TC
Hospital Charge Code	3626825
Hospital Revenue Code	402
Min. Negotiated Rate	$94.94
Max. Negotiated Rate	$582.35
Rate for Payer: Aetna Commercial	$551.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$94.94
Rate for Payer: Humana Medicare Advantage	$257.46
Rate for Payer: UnitedHealthcare Commercial	$582.35
Rate for Payer: UnitedHealthcare Medicaid	$282.26
Rate for Payer: WPPA Medicare Advantage	$367.80

US Fetal Echo 2D

Facility

$613.00

Service Code	HCPCS 76825 TC
Hospital Charge Code	3626825
Hospital Revenue Code	402
Min. Negotiated Rate	$551.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$551.70
Rate for Payer: UnitedHealthcare Commercial	$582.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Gallbladder

Facility

$764.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	3730089
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Gallbladder

Facility

$764.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	3730089
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$130.94
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$458.40

US Guided Vascular Access

Facility

$91.00

Service Code	HCPCS 76937 TC
Hospital Charge Code	3730056
Hospital Revenue Code	402
Min. Negotiated Rate	$12.30
Max. Negotiated Rate	$86.45
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$41.41
Rate for Payer: Humana Medicare Advantage	$38.22
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: UnitedHealthcare Medicaid	$12.30
Rate for Payer: WPPA Medicare Advantage	$54.60

US Guided Vascular Access

Facility

$91.00

Service Code	HCPCS 76937 TC
Hospital Charge Code	3730056
Hospital Revenue Code	402
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Intraoperative

Facility

$370.00

Service Code	HCPCS 76998 TC
Hospital Charge Code	3730110
Hospital Revenue Code	402
Min. Negotiated Rate	$61.54
Max. Negotiated Rate	$351.50
Rate for Payer: Aetna Commercial	$333.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$166.65
Rate for Payer: Humana Medicare Advantage	$155.40
Rate for Payer: UnitedHealthcare Commercial	$351.50
Rate for Payer: UnitedHealthcare Medicaid	$61.54
Rate for Payer: WPPA Medicare Advantage	$222.00

US Intraoperative

Facility

$370.00

Service Code	HCPCS 76998 TC
Hospital Charge Code	3730110
Hospital Revenue Code	402
Min. Negotiated Rate	$333.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$333.00
Rate for Payer: UnitedHealthcare Commercial	$351.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Liver (Hepatic)

Facility

$764.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	3730089
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Liver (Hepatic)

Facility

$764.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	3730089
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$130.94
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$458.40

US Lower Ext Arterial Duplex Bilateral

Facility

$1,063.00

Service Code	HCPCS 93925 TC
Hospital Charge Code	3610049
Hospital Revenue Code	921
Min. Negotiated Rate	$79.38
Max. Negotiated Rate	$1,009.85
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.76
Rate for Payer: Humana Medicare Advantage	$446.46
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: UnitedHealthcare Medicaid	$79.38
Rate for Payer: WPPA Medicare Advantage	$637.80

US Lower Ext Arterial Duplex Bilateral

Facility

$1,063.00

Service Code	HCPCS 93925 TC
Hospital Charge Code	3610049
Hospital Revenue Code	921
Min. Negotiated Rate	$956.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Lower Ext Arterial Duplex Left

Facility

$1,063.00

Service Code	HCPCS 93926 LT
Hospital Charge Code	3610056
Hospital Revenue Code	921
Min. Negotiated Rate	$35.62
Max. Negotiated Rate	$1,009.85
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.76
Rate for Payer: Humana Medicare Advantage	$446.46
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: UnitedHealthcare Medicaid	$35.62
Rate for Payer: WPPA Medicare Advantage	$637.80

US Lower Ext Arterial Duplex Left

Facility

$1,063.00

Service Code	HCPCS 93926 LT
Hospital Charge Code	3610056
Hospital Revenue Code	921
Min. Negotiated Rate	$956.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Lower Ext Arterial Duplex Right

Facility

$1,063.00

Service Code	HCPCS 93926 RT
Hospital Charge Code	3610056
Hospital Revenue Code	921
Min. Negotiated Rate	$35.62
Max. Negotiated Rate	$1,009.85
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.76
Rate for Payer: Humana Medicare Advantage	$446.46
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: UnitedHealthcare Medicaid	$35.62
Rate for Payer: WPPA Medicare Advantage	$637.80

US Lower Ext Arterial Duplex Right

Facility

$1,063.00

Service Code	HCPCS 93926 RT
Hospital Charge Code	3610056
Hospital Revenue Code	921
Min. Negotiated Rate	$956.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Lower Ext Venous Duplex Bilateral

Facility

$1,063.00

Service Code	HCPCS 93970 TC
Hospital Charge Code	3610064
Hospital Revenue Code	921
Min. Negotiated Rate	$956.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Lower Ext Venous Duplex Bilateral

Facility

$1,063.00

Service Code	HCPCS 93970 TC
Hospital Charge Code	3610064
Hospital Revenue Code	921
Min. Negotiated Rate	$79.38
Max. Negotiated Rate	$1,009.85
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.76
Rate for Payer: Humana Medicare Advantage	$446.46
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: UnitedHealthcare Medicaid	$79.38
Rate for Payer: WPPA Medicare Advantage	$637.80

US Lower Ext Venous Duplex Left

Facility

$1,058.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	3610072
Hospital Revenue Code	921
Min. Negotiated Rate	$952.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$952.20
Rate for Payer: UnitedHealthcare Commercial	$1,005.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Lower Ext Venous Duplex Left

Facility

$1,058.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	3610072
Hospital Revenue Code	921
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$1,005.10
Rate for Payer: Aetna Commercial	$952.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.76
Rate for Payer: Humana Medicare Advantage	$444.36
Rate for Payer: UnitedHealthcare Commercial	$1,005.10
Rate for Payer: UnitedHealthcare Medicaid	$104.75
Rate for Payer: WPPA Medicare Advantage	$634.80

US Lower Ext Venous Duplex Right

Facility

$1,058.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	3610072
Hospital Revenue Code	921
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$1,005.10
Rate for Payer: Aetna Commercial	$952.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.76
Rate for Payer: Humana Medicare Advantage	$444.36
Rate for Payer: UnitedHealthcare Commercial	$1,005.10
Rate for Payer: UnitedHealthcare Medicaid	$104.75
Rate for Payer: WPPA Medicare Advantage	$634.80

US Lower Ext Venous Duplex Right

Facility

$1,058.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	3610072
Hospital Revenue Code	921
Min. Negotiated Rate	$952.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$952.20
Rate for Payer: UnitedHealthcare Commercial	$1,005.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Lower Ext Venous Insufficiency Bil

Facility

$1,063.00

Service Code	HCPCS 93970 TC
Hospital Charge Code	3610064
Hospital Revenue Code	921
Min. Negotiated Rate	$79.38
Max. Negotiated Rate	$1,009.85
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.76
Rate for Payer: Humana Medicare Advantage	$446.46
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: UnitedHealthcare Medicaid	$79.38
Rate for Payer: WPPA Medicare Advantage	$637.80

Know your out-of-pocket cost for care.

All Charges