Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

US Upper Ext Arterial Duplex Right

Facility

$1,063.00

Service Code	HCPCS 93931 RT
Hospital Charge Code	3610171
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 Upper Ext Arterial Duplex Right

Facility

$1,063.00

Service Code	HCPCS 93931 RT
Hospital Charge Code	3610171
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 Upper 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 Upper 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 Upper 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 Upper 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 Upper 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 Upper 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

UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC

Facility

$6,163.38

Service Code	MSDRG 742
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,163.38
Rate for Payer: UnitedHealthcare Medicaid	$6,163.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC

Facility

$4,161.87

Service Code	MSDRG 743
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,161.87
Rate for Payer: UnitedHealthcare Medicaid	$4,161.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC

Facility

$6,068.07

Service Code	MSDRG 740
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,068.07
Rate for Payer: UnitedHealthcare Medicaid	$6,068.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC

Facility

$12,009.06

Service Code	MSDRG 739
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,009.06
Rate for Payer: UnitedHealthcare Medicaid	$12,009.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC

Facility

$4,765.50

Service Code	MSDRG 741
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,765.50
Rate for Payer: UnitedHealthcare Medicaid	$4,765.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC

Facility

$6,894.09

Service Code	MSDRG 737
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,894.09
Rate for Payer: UnitedHealthcare Medicaid	$6,894.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC

Facility

$11,977.29

Service Code	MSDRG 736
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,977.29
Rate for Payer: UnitedHealthcare Medicaid	$11,977.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC

Facility

$4,924.35

Service Code	MSDRG 738
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,924.35
Rate for Payer: UnitedHealthcare Medicaid	$4,924.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UTERINE MANIPULATOR INJEC

Facility

$180.18

Hospital Charge Code	3258931
Hospital Revenue Code	270
Min. Negotiated Rate	$162.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$162.16
Rate for Payer: UnitedHealthcare Commercial	$171.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

UTERINE MANIPULATOR INJEC

Facility

$180.18

Hospital Charge Code	3258931
Hospital Revenue Code	270
Min. Negotiated Rate	$72.07
Max. Negotiated Rate	$171.17
Rate for Payer: Aetna Commercial	$162.16
Rate for Payer: Humana Medicare Advantage	$75.68
Rate for Payer: UnitedHealthcare Commercial	$171.17
Rate for Payer: UnitedHealthcare Medicaid	$72.07
Rate for Payer: WPPA Medicare Advantage	$108.11

Vacuum Delivery Device Medium - Kiwi

Facility

$114.84

Hospital Charge Code	3250678
Hospital Revenue Code	270
Min. Negotiated Rate	$103.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$103.36
Rate for Payer: UnitedHealthcare Commercial	$109.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Vacuum Delivery Device Medium - Kiwi

Facility

$114.84

Hospital Charge Code	3250678
Hospital Revenue Code	270
Min. Negotiated Rate	$45.94
Max. Negotiated Rate	$109.10
Rate for Payer: Aetna Commercial	$103.36
Rate for Payer: Humana Medicare Advantage	$48.23
Rate for Payer: UnitedHealthcare Commercial	$109.10
Rate for Payer: UnitedHealthcare Medicaid	$45.94
Rate for Payer: WPPA Medicare Advantage	$68.90

VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC

Facility

$5,813.91

Service Code	MSDRG 746
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,813.91
Rate for Payer: UnitedHealthcare Medicaid	$5,813.91
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC

Facility

$2,891.07

Service Code	MSDRG 747
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,891.07
Rate for Payer: UnitedHealthcare Medicaid	$2,891.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VAGINAL DELIVERY CHARGE

Facility

$2,069.00

Hospital Charge Code	3200025
Hospital Revenue Code	720
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,965.55
Rate for Payer: Aetna Commercial	$1,862.10
Rate for Payer: UnitedHealthcare Commercial	$1,965.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VAGINAL DELIVERY CHARGE

Facility

$2,069.00

Hospital Charge Code	3200025
Hospital Revenue Code	720
Min. Negotiated Rate	$827.60
Max. Negotiated Rate	$1,965.55
Rate for Payer: Aetna Commercial	$1,862.10
Rate for Payer: Humana Medicare Advantage	$868.98
Rate for Payer: UnitedHealthcare Commercial	$1,965.55
Rate for Payer: UnitedHealthcare Medicaid	$827.60
Rate for Payer: WPPA Medicare Advantage	$1,241.40

VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C

Facility

$3,399.39

Service Code	MSDRG 768
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,399.39
Rate for Payer: UnitedHealthcare Medicaid	$3,399.39
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges