Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

58661 Laparoscopy, Surgical Removal of Adnexal structures

Facility

$9,635.00

Service Code	HCPCS 58661
Hospital Charge Code	3158661
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,153.25
Rate for Payer: Aetna Commercial	$8,671.50
Rate for Payer: UnitedHealthcare Commercial	$9,153.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

58662 Laparoscopy, Surgical Excision of Lesions of the ovary

Facility

$8,989.00

Service Code	HCPCS 58662
Hospital Charge Code	3158662
Hospital Revenue Code	360
Min. Negotiated Rate	$1,869.18
Max. Negotiated Rate	$8,539.55
Rate for Payer: Aetna Commercial	$8,090.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5,061.11
Rate for Payer: Humana Medicare Advantage	$3,775.38
Rate for Payer: UnitedHealthcare Commercial	$8,539.55
Rate for Payer: UnitedHealthcare Medicaid	$1,869.18
Rate for Payer: WPPA Medicare Advantage	$5,393.40

58662 Laparoscopy, Surgical Excision of Lesions of the ovary

Facility

$8,989.00

Service Code	HCPCS 58662
Hospital Charge Code	3158662
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,539.55
Rate for Payer: Aetna Commercial	$8,090.10
Rate for Payer: UnitedHealthcare Commercial	$8,539.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59025 FETAL NONSTRESS TEST

Facility

$1,335.00

Service Code	HCPCS 59025
Hospital Charge Code	3309025
Hospital Revenue Code	450
Min. Negotiated Rate	$64.55
Max. Negotiated Rate	$1,268.25
Rate for Payer: Aetna Commercial	$1,201.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$359.77
Rate for Payer: Humana Medicare Advantage	$560.70
Rate for Payer: UnitedHealthcare Commercial	$1,268.25
Rate for Payer: UnitedHealthcare Medicaid	$64.55
Rate for Payer: WPPA Medicare Advantage	$801.00

59025 FETAL NONSTRESS TEST

Facility

$1,335.00

Service Code	HCPCS 59025
Hospital Charge Code	3309025
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,268.25
Rate for Payer: Aetna Commercial	$1,201.50
Rate for Payer: UnitedHealthcare Commercial	$1,268.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59051 FETAL MONITORING DURING LABOR BY CONSULTING PHYSICIAN (IE, NON-ATTENDING PHYSICIAN) WITH WRITT

Facility

$707.00

Service Code	HCPCS 59051
Hospital Charge Code	3309051
Hospital Revenue Code	450
Min. Negotiated Rate	$636.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$636.30
Rate for Payer: UnitedHealthcare Commercial	$671.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59051 FETAL MONITORING DURING LABOR BY CONSULTING PHYSICIAN (IE, NON-ATTENDING PHYSICIAN) WITH WRITT

Facility

$707.00

Service Code	HCPCS 59051
Hospital Charge Code	3309051
Hospital Revenue Code	450
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$671.65
Rate for Payer: Aetna Commercial	$636.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
Rate for Payer: Humana Medicare Advantage	$296.94
Rate for Payer: UnitedHealthcare Commercial	$671.65
Rate for Payer: UnitedHealthcare Medicaid	$282.80
Rate for Payer: WPPA Medicare Advantage	$424.20

59051 Fetal monitoring during labor by consulting physician w/ written report; interpretation only

Facility

$164.00

Service Code	HCPCS 59051
Hospital Charge Code	3209051
Hospital Revenue Code	761
Min. Negotiated Rate	$65.60
Max. Negotiated Rate	$155.80
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
Rate for Payer: Humana Medicare Advantage	$68.88
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: UnitedHealthcare Medicaid	$65.60
Rate for Payer: WPPA Medicare Advantage	$98.40

59051 Fetal monitoring during labor by consulting physician w/ written report; interpretation only

Facility

$164.00

Service Code	HCPCS 59051
Hospital Charge Code	3209051
Hospital Revenue Code	761
Min. Negotiated Rate	$147.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59051 FETAL MONITOR INTERP ONLY CHARGE

Facility

$164.00

Service Code	HCPCS 59051
Hospital Charge Code	3209051
Hospital Revenue Code	761
Min. Negotiated Rate	$147.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59051 FETAL MONITOR INTERP ONLY CHARGE

Facility

$164.00

Service Code	HCPCS 59051
Hospital Charge Code	3209051
Hospital Revenue Code	761
Min. Negotiated Rate	$65.60
Max. Negotiated Rate	$155.80
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
Rate for Payer: Humana Medicare Advantage	$68.88
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: UnitedHealthcare Medicaid	$65.60
Rate for Payer: WPPA Medicare Advantage	$98.40

59160 Curettage, postpartum SURG

Facility

$2,884.00

Service Code	HCPCS 59160
Hospital Charge Code	3159160
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,739.80
Rate for Payer: Aetna Commercial	$2,595.60
Rate for Payer: UnitedHealthcare Commercial	$2,739.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59160 Curettage, postpartum SURG

Facility

$2,884.00

Service Code	HCPCS 59160
Hospital Charge Code	3159160
Hospital Revenue Code	360
Min. Negotiated Rate	$1,012.78
Max. Negotiated Rate	$2,739.80
Rate for Payer: Aetna Commercial	$2,595.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,538.23
Rate for Payer: Humana Medicare Advantage	$1,211.28
Rate for Payer: UnitedHealthcare Commercial	$2,739.80
Rate for Payer: UnitedHealthcare Medicaid	$1,012.78
Rate for Payer: WPPA Medicare Advantage	$1,730.40

59200 INSERTION OF CERVICAL DILATOR CHARGE

Facility

$489.00

Service Code	HCPCS 59200
Hospital Charge Code	3299200
Hospital Revenue Code	761
Min. Negotiated Rate	$114.40
Max. Negotiated Rate	$464.55
Rate for Payer: Aetna Commercial	$440.10
Rate for Payer: Humana Medicare Advantage	$205.38
Rate for Payer: UnitedHealthcare Commercial	$464.55
Rate for Payer: UnitedHealthcare Medicaid	$114.40
Rate for Payer: WPPA Medicare Advantage	$293.40

59200 INSERTION OF CERVICAL DILATOR CHARGE

Facility

$489.00

Service Code	HCPCS 59200
Hospital Charge Code	3299200
Hospital Revenue Code	761
Min. Negotiated Rate	$440.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$440.10
Rate for Payer: UnitedHealthcare Commercial	$464.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59300 Episiotomy or vaginal repair, by other than attending

Facility

$7,949.00

Service Code	HCPCS 59300
Hospital Charge Code	3209300
Hospital Revenue Code	729
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,551.55
Rate for Payer: Aetna Commercial	$7,154.10
Rate for Payer: UnitedHealthcare Commercial	$7,551.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59300 Episiotomy or vaginal repair, by other than attending

Facility

$7,949.00

Service Code	HCPCS 59300
Hospital Charge Code	3209300
Hospital Revenue Code	729
Min. Negotiated Rate	$1,012.78
Max. Negotiated Rate	$7,551.55
Rate for Payer: Aetna Commercial	$7,154.10
Rate for Payer: Humana Medicare Advantage	$3,338.58
Rate for Payer: UnitedHealthcare Commercial	$7,551.55
Rate for Payer: UnitedHealthcare Medicaid	$1,012.78
Rate for Payer: WPPA Medicare Advantage	$4,769.40

59409 Vaginal delivery only, with or without episiotomy and/or forceps

Facility

$3,100.00

Service Code	HCPCS 59409
Hospital Charge Code	3209409
Hospital Revenue Code	724
Min. Negotiated Rate	$1,012.78
Max. Negotiated Rate	$2,945.00
Rate for Payer: Aetna Commercial	$2,790.00
Rate for Payer: Humana Medicare Advantage	$1,302.00
Rate for Payer: UnitedHealthcare Commercial	$2,945.00
Rate for Payer: UnitedHealthcare Medicaid	$1,012.78
Rate for Payer: WPPA Medicare Advantage	$1,860.00

59409 Vaginal delivery only, with or without episiotomy and/or forceps

Facility

$3,100.00

Service Code	HCPCS 59409
Hospital Charge Code	3209409
Hospital Revenue Code	724
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,945.00
Rate for Payer: Aetna Commercial	$2,790.00
Rate for Payer: UnitedHealthcare Commercial	$2,945.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59414 Deliver Placenta Charge

Facility

$288.00

Service Code	HCPCS 59414
Hospital Charge Code	3209414
Hospital Revenue Code	729
Min. Negotiated Rate	$259.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$259.20
Rate for Payer: UnitedHealthcare Commercial	$273.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59414 Deliver Placenta Charge

Facility

$288.00

Service Code	HCPCS 59414
Hospital Charge Code	3209414
Hospital Revenue Code	729
Min. Negotiated Rate	$120.96
Max. Negotiated Rate	$1,012.78
Rate for Payer: Aetna Commercial	$259.20
Rate for Payer: Humana Medicare Advantage	$120.96
Rate for Payer: UnitedHealthcare Commercial	$273.60
Rate for Payer: UnitedHealthcare Medicaid	$1,012.78
Rate for Payer: WPPA Medicare Advantage	$172.80

59620 CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN D ProFee

Facility

$6,344.00

Service Code	HCPCS 59620
Hospital Charge Code	3150295
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.95
Max. Negotiated Rate	$6,026.80
Rate for Payer: Aetna Commercial	$5,709.60
Rate for Payer: Humana Medicare Advantage	$2,664.48
Rate for Payer: UnitedHealthcare Commercial	$6,026.80
Rate for Payer: UnitedHealthcare Medicaid	$1,048.95
Rate for Payer: WPPA Medicare Advantage	$3,806.40

59620 CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN D ProFee

Facility

$6,344.00

Service Code	HCPCS 59620
Hospital Charge Code	3150295
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,026.80
Rate for Payer: Aetna Commercial	$5,709.60
Rate for Payer: UnitedHealthcare Commercial	$6,026.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59812 TX INCOMPLETE ABORTION ANY TRIMESTER SURGICAL TechFee

Facility

$3,506.00

Service Code	HCPCS 59812
Hospital Charge Code	3159812
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,330.70
Rate for Payer: Aetna Commercial	$3,155.40
Rate for Payer: UnitedHealthcare Commercial	$3,330.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

59812 TX INCOMPLETE ABORTION ANY TRIMESTER SURGICAL TechFee

Facility

$3,506.00

Service Code	HCPCS 59812
Hospital Charge Code	3159812
Hospital Revenue Code	360
Min. Negotiated Rate	$1,012.78
Max. Negotiated Rate	$3,330.70
Rate for Payer: Aetna Commercial	$3,155.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,165.44
Rate for Payer: Humana Medicare Advantage	$1,472.52
Rate for Payer: UnitedHealthcare Commercial	$3,330.70
Rate for Payer: UnitedHealthcare Medicaid	$1,012.78
Rate for Payer: WPPA Medicare Advantage	$2,103.60

Know your out-of-pocket cost for care.

All Charges