Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

95076 Ingestion challenge test; initial 120 minutes (sequential&incremental ingestion of test items)

Facility

$365.00

Service Code	HCPCS 95076
Hospital Charge Code	3355076
Hospital Revenue Code	761
Min. Negotiated Rate	$328.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$328.50
Rate for Payer: UnitedHealthcare Commercial	$346.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95079 Ingestion challenge test;each additional 60 min (sequential/incremental ingest of test items)

Facility

$248.00

Service Code	HCPCS 95079
Hospital Charge Code	3355079
Hospital Revenue Code	761
Min. Negotiated Rate	$223.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$223.20
Rate for Payer: UnitedHealthcare Commercial	$235.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95079 Ingestion challenge test;each additional 60 min (sequential/incremental ingest of test items)

Facility

$248.00

Service Code	HCPCS 95079
Hospital Charge Code	3355079
Hospital Revenue Code	761
Min. Negotiated Rate	$99.20
Max. Negotiated Rate	$235.60
Rate for Payer: Aetna Commercial	$223.20
Rate for Payer: Humana Medicare Advantage	$104.16
Rate for Payer: UnitedHealthcare Commercial	$235.60
Rate for Payer: UnitedHealthcare Medicaid	$99.20
Rate for Payer: WPPA Medicare Advantage	$148.80

95165 Preparation and provision of antigens for allergen immunotherapy; single or multiple antigens

Facility

$27.00

Service Code	HCPCS 95165
Hospital Charge Code	3297999
Hospital Revenue Code	761
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: WPPA Medicare Advantage	$16.20

95165 Preparation and provision of antigens for allergen immunotherapy; single or multiple antigens

Facility

$27.00

Service Code	HCPCS 95165
Hospital Charge Code	3297999
Hospital Revenue Code	761
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95782 PED POLYSOMNOGRAPHY CHARGE

Facility

$2,212.00

Service Code	HCPCS 95782
Hospital Charge Code	3920035
Hospital Revenue Code	929
Min. Negotiated Rate	$846.75
Max. Negotiated Rate	$2,101.40
Rate for Payer: Aetna Commercial	$1,990.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,056.46
Rate for Payer: Humana Medicare Advantage	$929.04
Rate for Payer: UnitedHealthcare Commercial	$2,101.40
Rate for Payer: UnitedHealthcare Medicaid	$846.75
Rate for Payer: WPPA Medicare Advantage	$1,327.20

95782 PED POLYSOMNOGRAPHY CHARGE

Facility

$2,212.00

Service Code	HCPCS 95782
Hospital Charge Code	3920035
Hospital Revenue Code	929
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,101.40
Rate for Payer: Aetna Commercial	$1,990.80
Rate for Payer: UnitedHealthcare Commercial	$2,101.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95783 PED POLYSOMNO/CPAP CHARGE

Facility

$2,212.00

Service Code	HCPCS 95783
Hospital Charge Code	3920040
Hospital Revenue Code	929
Min. Negotiated Rate	$846.75
Max. Negotiated Rate	$2,101.40
Rate for Payer: Aetna Commercial	$1,990.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,056.46
Rate for Payer: Humana Medicare Advantage	$929.04
Rate for Payer: UnitedHealthcare Commercial	$2,101.40
Rate for Payer: UnitedHealthcare Medicaid	$846.75
Rate for Payer: WPPA Medicare Advantage	$1,327.20

95783 PED POLYSOMNO/CPAP CHARGE

Facility

$2,212.00

Service Code	HCPCS 95783
Hospital Charge Code	3920040
Hospital Revenue Code	929
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,101.40
Rate for Payer: Aetna Commercial	$1,990.80
Rate for Payer: UnitedHealthcare Commercial	$2,101.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95800 HOME SLEEP STUDY CHARGE.

Facility

$296.00

Service Code	HCPCS 95800
Hospital Charge Code	3925800
Hospital Revenue Code	929
Min. Negotiated Rate	$124.32
Max. Negotiated Rate	$281.20
Rate for Payer: Aetna Commercial	$266.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$206.04
Rate for Payer: Humana Medicare Advantage	$124.32
Rate for Payer: UnitedHealthcare Commercial	$281.20
Rate for Payer: UnitedHealthcare Medicaid	$126.51
Rate for Payer: WPPA Medicare Advantage	$177.60

95800 HOME SLEEP STUDY CHARGE.

Facility

$296.00

Service Code	HCPCS 95800
Hospital Charge Code	3925800
Hospital Revenue Code	929
Min. Negotiated Rate	$266.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$266.40
Rate for Payer: UnitedHealthcare Commercial	$281.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95810 POLYSOMNOGRAPHY CHARGE

Facility

$2,212.00

Service Code	HCPCS 95810
Hospital Charge Code	3920010
Hospital Revenue Code	920
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,101.40
Rate for Payer: Aetna Commercial	$1,990.80
Rate for Payer: UnitedHealthcare Commercial	$2,101.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95810 POLYSOMNOGRAPHY CHARGE

Facility

$2,212.00

Service Code	HCPCS 95810
Hospital Charge Code	3920010
Hospital Revenue Code	920
Min. Negotiated Rate	$846.75
Max. Negotiated Rate	$2,101.40
Rate for Payer: Aetna Commercial	$1,990.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,056.46
Rate for Payer: Humana Medicare Advantage	$929.04
Rate for Payer: UnitedHealthcare Commercial	$2,101.40
Rate for Payer: UnitedHealthcare Medicaid	$846.75
Rate for Payer: WPPA Medicare Advantage	$1,327.20

95811 POLYSOMNOGRAPHY W/ BIPAP/CPAP CHARGE

Facility

$2,212.00

Service Code	HCPCS 95811
Hospital Charge Code	3920015
Hospital Revenue Code	920
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,101.40
Rate for Payer: Aetna Commercial	$1,990.80
Rate for Payer: UnitedHealthcare Commercial	$2,101.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95811 POLYSOMNOGRAPHY W/ BIPAP/CPAP CHARGE

Facility

$2,212.00

Service Code	HCPCS 95811
Hospital Charge Code	3920015
Hospital Revenue Code	920
Min. Negotiated Rate	$846.75
Max. Negotiated Rate	$2,101.40
Rate for Payer: Aetna Commercial	$1,990.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,056.46
Rate for Payer: Humana Medicare Advantage	$929.04
Rate for Payer: UnitedHealthcare Commercial	$2,101.40
Rate for Payer: UnitedHealthcare Medicaid	$846.75
Rate for Payer: WPPA Medicare Advantage	$1,327.20

95812 EEG MONITORING 41-60 MIN CHARGE

Facility

$732.00

Service Code	HCPCS 95812
Hospital Charge Code	3905812
Hospital Revenue Code	740
Min. Negotiated Rate	$658.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$658.80
Rate for Payer: UnitedHealthcare Commercial	$695.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95812 EEG MONITORING 41-60 MIN CHARGE

Facility

$732.00

Service Code	HCPCS 95812
Hospital Charge Code	3905812
Hospital Revenue Code	740
Min. Negotiated Rate	$101.68
Max. Negotiated Rate	$695.40
Rate for Payer: Aetna Commercial	$658.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$331.32
Rate for Payer: Humana Medicare Advantage	$307.44
Rate for Payer: UnitedHealthcare Commercial	$695.40
Rate for Payer: UnitedHealthcare Medicaid	$101.68
Rate for Payer: WPPA Medicare Advantage	$439.20

95816 EEG AWAKE/DROWSY CHARGE

Facility

$688.00

Service Code	HCPCS 95816
Hospital Charge Code	3905816
Hospital Revenue Code	740
Min. Negotiated Rate	$101.68
Max. Negotiated Rate	$653.60
Rate for Payer: Aetna Commercial	$619.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$311.41
Rate for Payer: Humana Medicare Advantage	$288.96
Rate for Payer: UnitedHealthcare Commercial	$653.60
Rate for Payer: UnitedHealthcare Medicaid	$101.68
Rate for Payer: WPPA Medicare Advantage	$412.80

95816 EEG AWAKE/DROWSY CHARGE

Facility

$688.00

Service Code	HCPCS 95816
Hospital Charge Code	3905816
Hospital Revenue Code	740
Min. Negotiated Rate	$619.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$619.20
Rate for Payer: UnitedHealthcare Commercial	$653.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95819 EEG AWAKE AND ASLEEP CHARGE

Facility

$620.00

Service Code	HCPCS 95819
Hospital Charge Code	3905819
Hospital Revenue Code	740
Min. Negotiated Rate	$558.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95819 EEG AWAKE AND ASLEEP CHARGE

Facility

$620.00

Service Code	HCPCS 95819
Hospital Charge Code	3905819
Hospital Revenue Code	740
Min. Negotiated Rate	$109.25
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$349.91
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$109.25
Rate for Payer: WPPA Medicare Advantage	$372.00

95860 Needle electromyography; 1 extremity with or without related paraspinal areas

Facility

$312.00

Service Code	HCPCS 95860
Hospital Charge Code	3955860
Hospital Revenue Code	922
Min. Negotiated Rate	$280.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$280.80
Rate for Payer: UnitedHealthcare Commercial	$296.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95860 Needle electromyography; 1 extremity with or without related paraspinal areas

Facility

$312.00

Service Code	HCPCS 95860
Hospital Charge Code	3955860
Hospital Revenue Code	922
Min. Negotiated Rate	$52.32
Max. Negotiated Rate	$296.40
Rate for Payer: Aetna Commercial	$280.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$214.12
Rate for Payer: Humana Medicare Advantage	$131.04
Rate for Payer: UnitedHealthcare Commercial	$296.40
Rate for Payer: UnitedHealthcare Medicaid	$52.32
Rate for Payer: WPPA Medicare Advantage	$187.20

95860 NEEDLE ELECTROMYOGRAPHY;1 EXTREMITY WITH OR WITHOUT RELATED PARASPINAL AREAS

Facility

$312.00

Service Code	HCPCS 95860
Hospital Charge Code	3955860
Hospital Revenue Code	922
Min. Negotiated Rate	$52.32
Max. Negotiated Rate	$296.40
Rate for Payer: Aetna Commercial	$280.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$214.12
Rate for Payer: Humana Medicare Advantage	$131.04
Rate for Payer: UnitedHealthcare Commercial	$296.40
Rate for Payer: UnitedHealthcare Medicaid	$52.32
Rate for Payer: WPPA Medicare Advantage	$187.20

95860 NEEDLE ELECTROMYOGRAPHY;1 EXTREMITY WITH OR WITHOUT RELATED PARASPINAL AREAS

Facility

$312.00

Service Code	HCPCS 95860
Hospital Charge Code	3955860
Hospital Revenue Code	922
Min. Negotiated Rate	$280.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$280.80
Rate for Payer: UnitedHealthcare Commercial	$296.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges