Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Block Brachial Plexus

Facility

$929.00

Service Code	HCPCS 64415
Hospital Charge Code	3154415
Hospital Revenue Code	360
Min. Negotiated Rate	$836.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$836.10
Rate for Payer: UnitedHealthcare Commercial	$882.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Block Brachial Plexus

Facility

$929.00

Service Code	HCPCS 64415
Hospital Charge Code	3154415
Hospital Revenue Code	360
Min. Negotiated Rate	$310.07
Max. Negotiated Rate	$882.55
Rate for Payer: Aetna Commercial	$836.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$390.18
Rate for Payer: UnitedHealthcare Commercial	$882.55
Rate for Payer: UnitedHealthcare Medicaid	$371.60
Rate for Payer: WPPA Medicare Advantage	$557.40

Block Erector Spinae

Facility

$551.00

Service Code	HCPCS 64999
Hospital Charge Code	3156999
Hospital Revenue Code	360
Min. Negotiated Rate	$157.06
Max. Negotiated Rate	$523.45
Rate for Payer: Aetna Commercial	$495.90
Rate for Payer: Humana Medicare Advantage	$231.42
Rate for Payer: UnitedHealthcare Commercial	$523.45
Rate for Payer: UnitedHealthcare Medicaid	$157.06
Rate for Payer: WPPA Medicare Advantage	$330.60

Block Erector Spinae

Facility

$551.00

Service Code	HCPCS 64999
Hospital Charge Code	3156999
Hospital Revenue Code	360
Min. Negotiated Rate	$495.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$495.90
Rate for Payer: UnitedHealthcare Commercial	$523.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Block Femoral Nerve

Facility

$627.00

Service Code	HCPCS 64447
Hospital Charge Code	3154447
Hospital Revenue Code	360
Min. Negotiated Rate	$224.03
Max. Negotiated Rate	$595.65
Rate for Payer: Aetna Commercial	$564.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$368.20
Rate for Payer: Humana Medicare Advantage	$263.34
Rate for Payer: UnitedHealthcare Commercial	$595.65
Rate for Payer: UnitedHealthcare Medicaid	$224.03
Rate for Payer: WPPA Medicare Advantage	$376.20

Block Femoral Nerve

Facility

$627.00

Service Code	HCPCS 64447
Hospital Charge Code	3154447
Hospital Revenue Code	360
Min. Negotiated Rate	$564.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$564.30
Rate for Payer: UnitedHealthcare Commercial	$595.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Block Ilioinguinal Nerve

Facility

$620.00

Service Code	HCPCS 64425
Hospital Charge Code	3154425
Hospital Revenue Code	360
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

Block Ilioinguinal Nerve

Facility

$620.00

Service Code	HCPCS 64425
Hospital Charge Code	3154425
Hospital Revenue Code	360
Min. Negotiated Rate	$224.03
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$224.03
Rate for Payer: WPPA Medicare Advantage	$372.00

Block Intercostal Nerve

Facility

$620.00

Service Code	HCPCS 64420
Hospital Charge Code	3150504
Hospital Revenue Code	360
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

Block Intercostal Nerve

Facility

$620.00

Service Code	HCPCS 64420
Hospital Charge Code	3150504
Hospital Revenue Code	360
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$463.69
Rate for Payer: WPPA Medicare Advantage	$372.00

Block Lumbar Paravertebral Nerve

Facility

$924.00

Service Code	HCPCS 64520
Hospital Charge Code	3154520
Hospital Revenue Code	360
Min. Negotiated Rate	$295.27
Max. Negotiated Rate	$877.80
Rate for Payer: Aetna Commercial	$831.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$473.69
Rate for Payer: Humana Medicare Advantage	$388.08
Rate for Payer: UnitedHealthcare Commercial	$877.80
Rate for Payer: UnitedHealthcare Medicaid	$295.27
Rate for Payer: WPPA Medicare Advantage	$554.40

Block Lumbar Paravertebral Nerve

Facility

$924.00

Service Code	HCPCS 64520
Hospital Charge Code	3154520
Hospital Revenue Code	360
Min. Negotiated Rate	$831.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$831.60
Rate for Payer: UnitedHealthcare Commercial	$877.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Block Medial Branch Nerve

Facility

$1,621.00

Service Code	HCPCS 64493
Hospital Charge Code	3150852
Hospital Revenue Code	360
Min. Negotiated Rate	$260.80
Max. Negotiated Rate	$1,539.95
Rate for Payer: Aetna Commercial	$1,458.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$692.03
Rate for Payer: Humana Medicare Advantage	$680.82
Rate for Payer: UnitedHealthcare Commercial	$1,539.95
Rate for Payer: UnitedHealthcare Medicaid	$260.80
Rate for Payer: WPPA Medicare Advantage	$972.60

Block Medial Branch Nerve

Facility

$1,621.00

Service Code	HCPCS 64493
Hospital Charge Code	3150852
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,539.95
Rate for Payer: Aetna Commercial	$1,458.90
Rate for Payer: UnitedHealthcare Commercial	$1,539.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Block Paravertebral Nerve

Facility

$894.00

Service Code	HCPCS 64461
Hospital Charge Code	3150854
Hospital Revenue Code	360
Min. Negotiated Rate	$804.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$804.60
Rate for Payer: UnitedHealthcare Commercial	$849.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Block Paravertebral Nerve

Facility

$894.00

Service Code	HCPCS 64461
Hospital Charge Code	3150854
Hospital Revenue Code	360
Min. Negotiated Rate	$375.48
Max. Negotiated Rate	$849.30
Rate for Payer: Aetna Commercial	$804.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.47
Rate for Payer: Humana Medicare Advantage	$375.48
Rate for Payer: UnitedHealthcare Commercial	$849.30
Rate for Payer: UnitedHealthcare Medicaid	$395.57
Rate for Payer: WPPA Medicare Advantage	$536.40

Block Peripheral Nerve

Facility

$1,519.00

Service Code	HCPCS 64450
Hospital Charge Code	3150190
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,443.05
Rate for Payer: Aetna Commercial	$1,367.10
Rate for Payer: UnitedHealthcare Commercial	$1,443.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Block Peripheral Nerve

Facility

$1,519.00

Service Code	HCPCS 64450
Hospital Charge Code	3150190
Hospital Revenue Code	360
Min. Negotiated Rate	$224.03
Max. Negotiated Rate	$1,443.05
Rate for Payer: Aetna Commercial	$1,367.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$859.51
Rate for Payer: Humana Medicare Advantage	$637.98
Rate for Payer: UnitedHealthcare Commercial	$1,443.05
Rate for Payer: UnitedHealthcare Medicaid	$224.03
Rate for Payer: WPPA Medicare Advantage	$911.40

Block Sciatic Nerve

Facility

$627.00

Service Code	HCPCS 64445
Hospital Charge Code	3154445
Hospital Revenue Code	360
Min. Negotiated Rate	$564.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$564.30
Rate for Payer: UnitedHealthcare Commercial	$595.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Block Sciatic Nerve

Facility

$627.00

Service Code	HCPCS 64445
Hospital Charge Code	3154445
Hospital Revenue Code	360
Min. Negotiated Rate	$224.03
Max. Negotiated Rate	$595.65
Rate for Payer: Aetna Commercial	$564.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$368.20
Rate for Payer: Humana Medicare Advantage	$263.34
Rate for Payer: UnitedHealthcare Commercial	$595.65
Rate for Payer: UnitedHealthcare Medicaid	$224.03
Rate for Payer: WPPA Medicare Advantage	$376.20

Block Sphenopalatine Ganglion

Facility

$246.00

Service Code	HCPCS 64505
Hospital Charge Code	3154505
Hospital Revenue Code	360
Min. Negotiated Rate	$221.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$221.40
Rate for Payer: UnitedHealthcare Commercial	$233.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Block Sphenopalatine Ganglion

Facility

$246.00

Service Code	HCPCS 64505
Hospital Charge Code	3154505
Hospital Revenue Code	360
Min. Negotiated Rate	$103.32
Max. Negotiated Rate	$983.74
Rate for Payer: Aetna Commercial	$221.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$983.74
Rate for Payer: Humana Medicare Advantage	$103.32
Rate for Payer: UnitedHealthcare Commercial	$233.70
Rate for Payer: UnitedHealthcare Medicaid	$143.00
Rate for Payer: WPPA Medicare Advantage	$147.60

Block Stellate Ganglion

Facility

$1,394.00

Service Code	HCPCS 64510
Hospital Charge Code	3154510
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,324.30
Rate for Payer: Aetna Commercial	$1,254.60
Rate for Payer: UnitedHealthcare Commercial	$1,324.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Block Stellate Ganglion

Facility

$1,394.00

Service Code	HCPCS 64510
Hospital Charge Code	3154510
Hospital Revenue Code	360
Min. Negotiated Rate	$295.27
Max. Negotiated Rate	$1,324.30
Rate for Payer: Aetna Commercial	$1,254.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$715.08
Rate for Payer: Humana Medicare Advantage	$585.48
Rate for Payer: UnitedHealthcare Commercial	$1,324.30
Rate for Payer: UnitedHealthcare Medicaid	$295.27
Rate for Payer: WPPA Medicare Advantage	$836.40

Blood Gas Arterial

Facility

$265.00

Service Code	HCPCS 82803
Hospital Charge Code	3550189
Hospital Revenue Code	300
Min. Negotiated Rate	$22.16
Max. Negotiated Rate	$251.75
Rate for Payer: Aetna Commercial	$238.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$68.05
Rate for Payer: Humana Medicare Advantage	$111.30
Rate for Payer: UnitedHealthcare Commercial	$251.75
Rate for Payer: UnitedHealthcare Medicaid	$22.16
Rate for Payer: WPPA Medicare Advantage	$159.00

Know your out-of-pocket cost for care.

All Charges