Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

20610 Arthrocentesis aspiration and/or injection major joint or bursa without ultrasound guidance

Facility

$1,130.00

Service Code	HCPCS 20610
Hospital Charge Code	3290046
Hospital Revenue Code	761
Min. Negotiated Rate	$1,017.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,017.00
Rate for Payer: UnitedHealthcare Commercial	$1,073.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20610 INJECTION LARGE JOINT

Facility

$754.00

Service Code	HCPCS 20610
Hospital Charge Code	3150745
Hospital Revenue Code	360
Min. Negotiated Rate	$257.40
Max. Negotiated Rate	$716.30
Rate for Payer: Aetna Commercial	$678.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$330.53
Rate for Payer: Humana Medicare Advantage	$316.68
Rate for Payer: UnitedHealthcare Commercial	$716.30
Rate for Payer: UnitedHealthcare Medicaid	$257.40
Rate for Payer: WPPA Medicare Advantage	$452.40

20610 INJECTION LARGE JOINT

Facility

$754.00

Service Code	HCPCS 20610
Hospital Charge Code	3150745
Hospital Revenue Code	360
Min. Negotiated Rate	$678.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$678.60
Rate for Payer: UnitedHealthcare Commercial	$716.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20610-Major Joint Aspirate/Inject w/o US

Facility

$2,826.00

Service Code	HCPCS 20610
Hospital Charge Code	3303210
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,684.70
Rate for Payer: Aetna Commercial	$2,543.40
Rate for Payer: UnitedHealthcare Commercial	$2,684.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20610-Major Joint Aspirate/Inject w/o US

Facility

$2,826.00

Service Code	HCPCS 20610
Hospital Charge Code	3303210
Hospital Revenue Code	450
Min. Negotiated Rate	$257.40
Max. Negotiated Rate	$2,684.70
Rate for Payer: Aetna Commercial	$2,543.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$330.53
Rate for Payer: Humana Medicare Advantage	$1,186.92
Rate for Payer: UnitedHealthcare Commercial	$2,684.70
Rate for Payer: UnitedHealthcare Medicaid	$257.40
Rate for Payer: WPPA Medicare Advantage	$1,695.60

20611 Arthrocentesis, aspiration and/or injection, major joint or bursa; w/ ultrasound

Facility

$436.00

Service Code	HCPCS 20611
Hospital Charge Code	3182061
Hospital Revenue Code	964
Min. Negotiated Rate	$392.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$392.40
Rate for Payer: UnitedHealthcare Commercial	$414.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20611 Arthrocentesis, aspiration and/or injection, major joint or bursa; w/ ultrasound

Facility

$436.00

Service Code	HCPCS 20611
Hospital Charge Code	3182061
Hospital Revenue Code	964
Min. Negotiated Rate	$142.73
Max. Negotiated Rate	$414.20
Rate for Payer: Aetna Commercial	$392.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$330.53
Rate for Payer: Humana Medicare Advantage	$183.12
Rate for Payer: UnitedHealthcare Commercial	$414.20
Rate for Payer: UnitedHealthcare Medicaid	$142.73
Rate for Payer: WPPA Medicare Advantage	$261.60

20611 INJECTION LARGE JOINT US GUIDED

Facility

$754.00

Service Code	HCPCS 20611
Hospital Charge Code	3152061
Hospital Revenue Code	360
Min. Negotiated Rate	$142.73
Max. Negotiated Rate	$716.30
Rate for Payer: Aetna Commercial	$678.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$330.53
Rate for Payer: Humana Medicare Advantage	$316.68
Rate for Payer: UnitedHealthcare Commercial	$716.30
Rate for Payer: UnitedHealthcare Medicaid	$142.73
Rate for Payer: WPPA Medicare Advantage	$452.40

20611 INJECTION LARGE JOINT US GUIDED

Facility

$754.00

Service Code	HCPCS 20611
Hospital Charge Code	3152061
Hospital Revenue Code	360
Min. Negotiated Rate	$678.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$678.60
Rate for Payer: UnitedHealthcare Commercial	$716.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20612 Aspiration and/or injection of ganglion cyst(s) any location

Facility

$219.00

Service Code	HCPCS 20612
Hospital Charge Code	3350612
Hospital Revenue Code	761
Min. Negotiated Rate	$197.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$197.10
Rate for Payer: UnitedHealthcare Commercial	$208.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20612 Aspiration and/or injection of ganglion cyst(s) any location

Facility

$219.00

Service Code	HCPCS 20612
Hospital Charge Code	3350612
Hospital Revenue Code	761
Min. Negotiated Rate	$91.98
Max. Negotiated Rate	$208.05
Rate for Payer: Aetna Commercial	$197.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$142.41
Rate for Payer: Humana Medicare Advantage	$91.98
Rate for Payer: UnitedHealthcare Commercial	$208.05
Rate for Payer: UnitedHealthcare Medicaid	$192.19
Rate for Payer: WPPA Medicare Advantage	$131.40

20615-Aspiration/Injection Bone Cyst

Facility

$1,558.00

Service Code	HCPCS 20615
Hospital Charge Code	3300615
Hospital Revenue Code	450
Min. Negotiated Rate	$142.41
Max. Negotiated Rate	$1,480.10
Rate for Payer: Aetna Commercial	$1,402.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$142.41
Rate for Payer: Humana Medicare Advantage	$654.36
Rate for Payer: UnitedHealthcare Commercial	$1,480.10
Rate for Payer: UnitedHealthcare Medicaid	$623.20
Rate for Payer: WPPA Medicare Advantage	$934.80

20615-Aspiration/Injection Bone Cyst

Facility

$1,558.00

Service Code	HCPCS 20615
Hospital Charge Code	3300615
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,480.10
Rate for Payer: Aetna Commercial	$1,402.20
Rate for Payer: UnitedHealthcare Commercial	$1,480.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20680 REMOVAL OF DEEP DEVICE

Facility

$4,558.00

Service Code	HCPCS 20680
Hospital Charge Code	3150721
Hospital Revenue Code	360
Min. Negotiated Rate	$920.50
Max. Negotiated Rate	$4,330.10
Rate for Payer: Aetna Commercial	$4,102.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,815.88
Rate for Payer: Humana Medicare Advantage	$1,914.36
Rate for Payer: UnitedHealthcare Commercial	$4,330.10
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$2,734.80

20680 REMOVAL OF DEEP DEVICE

Facility

$4,558.00

Service Code	HCPCS 20680
Hospital Charge Code	3150721
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,330.10
Rate for Payer: Aetna Commercial	$4,102.20
Rate for Payer: UnitedHealthcare Commercial	$4,330.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20680 Removal of Implant deep ( buried wire, pin, screw, metal band, nail, rod or plate)

Facility

$4,558.00

Service Code	HCPCS 20680
Hospital Charge Code	3150721
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,330.10
Rate for Payer: Aetna Commercial	$4,102.20
Rate for Payer: UnitedHealthcare Commercial	$4,330.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20680 Removal of Implant deep ( buried wire, pin, screw, metal band, nail, rod or plate)

Facility

$4,558.00

Service Code	HCPCS 20680
Hospital Charge Code	3150721
Hospital Revenue Code	761
Min. Negotiated Rate	$920.50
Max. Negotiated Rate	$4,330.10
Rate for Payer: Aetna Commercial	$4,102.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,815.88
Rate for Payer: Humana Medicare Advantage	$1,914.36
Rate for Payer: UnitedHealthcare Commercial	$4,330.10
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$2,734.80

20% Mannitol Inj 50g/250 mL [HMC]

Facility

$17.00

Service Code	NDC 00990771512
Hospital Charge Code	3808760
Hospital Revenue Code	259
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.30
Rate for Payer: UnitedHealthcare Commercial	$16.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20% Mannitol Inj 50g/250 mL [HMC]

Facility

$17.00

Service Code	NDC 00990771512
Hospital Charge Code	3808760
Hospital Revenue Code	259
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$16.15
Rate for Payer: Aetna Commercial	$15.30
Rate for Payer: Humana Medicare Advantage	$7.14
Rate for Payer: UnitedHealthcare Commercial	$16.15
Rate for Payer: UnitedHealthcare Medicaid	$6.80
Rate for Payer: WPPA Medicare Advantage	$10.20

2.0mm Cann Drill Bit QC/145mm

Facility

$1,245.00

Hospital Charge Code	3258324
Hospital Revenue Code	270
Min. Negotiated Rate	$498.00
Max. Negotiated Rate	$1,182.75
Rate for Payer: Aetna Commercial	$1,120.50
Rate for Payer: Humana Medicare Advantage	$522.90
Rate for Payer: UnitedHealthcare Commercial	$1,182.75
Rate for Payer: UnitedHealthcare Medicaid	$498.00
Rate for Payer: WPPA Medicare Advantage	$747.00

2.0mm Cann Drill Bit QC/145mm

Facility

$1,245.00

Hospital Charge Code	3258324
Hospital Revenue Code	270
Min. Negotiated Rate	$1,120.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,120.50
Rate for Payer: UnitedHealthcare Commercial	$1,182.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

2.0mm Cannulated SQC Drill Bit

Facility

$835.00

Hospital Charge Code	3258589
Hospital Revenue Code	270
Min. Negotiated Rate	$334.00
Max. Negotiated Rate	$793.25
Rate for Payer: Aetna Commercial	$751.50
Rate for Payer: Humana Medicare Advantage	$350.70
Rate for Payer: UnitedHealthcare Commercial	$793.25
Rate for Payer: UnitedHealthcare Medicaid	$334.00
Rate for Payer: WPPA Medicare Advantage	$501.00

2.0mm Cannulated SQC Drill Bit

Facility

$835.00

Hospital Charge Code	3258589
Hospital Revenue Code	270
Min. Negotiated Rate	$751.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$751.50
Rate for Payer: UnitedHealthcare Commercial	$793.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

2.0mm X 30mm Cannulated Screw

Facility

$621.00

Hospital Charge Code	3258590
Hospital Revenue Code	270
Min. Negotiated Rate	$248.40
Max. Negotiated Rate	$589.95
Rate for Payer: Aetna Commercial	$558.90
Rate for Payer: Humana Medicare Advantage	$260.82
Rate for Payer: UnitedHealthcare Commercial	$589.95
Rate for Payer: UnitedHealthcare Medicaid	$248.40
Rate for Payer: WPPA Medicare Advantage	$372.60

2.0mm X 30mm Cannulated Screw

Facility

$621.00

Hospital Charge Code	3258590
Hospital Revenue Code	270
Min. Negotiated Rate	$558.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$558.90
Rate for Payer: UnitedHealthcare Commercial	$589.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges