Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$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 Insufficiency 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 Insufficiency 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 Insufficiency 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 Insufficiency 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 OB Detailed Complete Ea Addl Gest

Facility

$239.00

Service Code	HCPCS 76812 TC
Hospital Charge Code	3730212
Hospital Revenue Code	402
Min. Negotiated Rate	$36.22
Max. Negotiated Rate	$227.05
Rate for Payer: Aetna Commercial	$215.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$108.07
Rate for Payer: Humana Medicare Advantage	$100.38
Rate for Payer: UnitedHealthcare Commercial	$227.05
Rate for Payer: UnitedHealthcare Medicaid	$36.22
Rate for Payer: WPPA Medicare Advantage	$143.40

US OB Detailed Complete Ea Addl Gest

Facility

$239.00

Service Code	HCPCS 76812 TC
Hospital Charge Code	3730212
Hospital Revenue Code	402
Min. Negotiated Rate	$215.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$215.10
Rate for Payer: UnitedHealthcare Commercial	$227.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US OB Detailed Complete First Gest

Facility

$856.00

Service Code	HCPCS 76811 TC
Hospital Charge Code	3736811
Hospital Revenue Code	402
Min. Negotiated Rate	$770.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$770.40
Rate for Payer: UnitedHealthcare Commercial	$813.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US OB Detailed Complete First Gest

Facility

$856.00

Service Code	HCPCS 76811 TC
Hospital Charge Code	3736811
Hospital Revenue Code	402
Min. Negotiated Rate	$131.00
Max. Negotiated Rate	$813.20
Rate for Payer: Aetna Commercial	$770.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$235.33
Rate for Payer: Humana Medicare Advantage	$359.52
Rate for Payer: UnitedHealthcare Commercial	$813.20
Rate for Payer: UnitedHealthcare Medicaid	$131.00
Rate for Payer: WPPA Medicare Advantage	$513.60

US OB Follow Up

Facility

$764.00

Service Code	HCPCS 76816 TC
Hospital Charge Code	3730220
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	$141.50
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 OB Follow Up

Facility

$764.00

Service Code	HCPCS 76816 TC
Hospital Charge Code	3730220
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 OB Greater Than 14 Weeks

Facility

$764.00

Service Code	HCPCS 76805 TC
Hospital Charge Code	3730113
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	$132.31
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 OB Greater Than 14 Weeks

Facility

$764.00

Service Code	HCPCS 76805 TC
Hospital Charge Code	3730113
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 OB Less Than 14 Weeks Multi

Facility

$171.00

Service Code	HCPCS 76802 TC
Hospital Charge Code	3730425
Hospital Revenue Code	402
Min. Negotiated Rate	$153.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$153.90
Rate for Payer: UnitedHealthcare Commercial	$162.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US OB Less Than 14 Weeks Multi

Facility

$171.00

Service Code	HCPCS 76802 TC
Hospital Charge Code	3730425
Hospital Revenue Code	402
Min. Negotiated Rate	$36.22
Max. Negotiated Rate	$162.45
Rate for Payer: Aetna Commercial	$153.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$77.77
Rate for Payer: Humana Medicare Advantage	$71.82
Rate for Payer: UnitedHealthcare Commercial	$162.45
Rate for Payer: UnitedHealthcare Medicaid	$36.22
Rate for Payer: WPPA Medicare Advantage	$102.60

US OB Less Than 14 Weeks Single

Facility

$764.00

Service Code	HCPCS 76801 TC
Hospital Charge Code	3730410
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	$122.31
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 OB Less Than 14 Weeks Single

Facility

$764.00

Service Code	HCPCS 76801 TC
Hospital Charge Code	3730410
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 OB Limited

Facility

$742.00

Service Code	HCPCS 76815 TC
Hospital Charge Code	3730121
Hospital Revenue Code	402
Min. Negotiated Rate	$667.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$667.80
Rate for Payer: UnitedHealthcare Commercial	$704.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US OB Limited

Facility

$742.00

Service Code	HCPCS 76815 TC
Hospital Charge Code	3730121
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$704.90
Rate for Payer: Aetna Commercial	$667.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$141.50
Rate for Payer: Humana Medicare Advantage	$311.64
Rate for Payer: UnitedHealthcare Commercial	$704.90
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$445.20

US OB Transvaginal

Facility

$764.00

Service Code	HCPCS 76817 TC
Hospital Charge Code	3730435
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 OB Transvaginal

Facility

$764.00

Service Code	HCPCS 76817 TC
Hospital Charge Code	3730435
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	$141.50
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 Pelvic Non OB Comp

Facility

$764.00

Service Code	HCPCS 76856 TC
Hospital Charge Code	3730329
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 Pelvic Non OB Comp

Facility

$764.00

Service Code	HCPCS 76856 TC
Hospital Charge Code	3730329
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	$123.22
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 Pelvic Non OB Ltd

Facility

$206.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	3730430
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$195.70
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$103.02
Rate for Payer: Humana Medicare Advantage	$86.52
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$123.60

US Pelvic Non OB Ltd

Facility

$206.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	3730430
Hospital Revenue Code	402
Min. Negotiated Rate	$185.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges