Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

NM Gastrointestinal Blood Loss Imaging

Facility

$1,043.00

Service Code	HCPCS 78278 TC
Hospital Charge Code	3720480
Hospital Revenue Code	341
Min. Negotiated Rate	$218.05
Max. Negotiated Rate	$990.85
Rate for Payer: Aetna Commercial	$938.70
Rate for Payer: Humana Medicare Advantage	$438.06
Rate for Payer: UnitedHealthcare Commercial	$990.85
Rate for Payer: UnitedHealthcare Medicaid	$218.05
Rate for Payer: WPPA Medicare Advantage	$625.80

NM Gastrointestinal Blood Loss Imaging

Facility

$1,043.00

Service Code	HCPCS 78278 TC
Hospital Charge Code	3720480
Hospital Revenue Code	341
Min. Negotiated Rate	$938.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$938.70
Rate for Payer: UnitedHealthcare Commercial	$990.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Hepatobiliary Imaging w/ Drug

Facility

$1,322.00

Service Code	HCPCS 78227 TC
Hospital Charge Code	3720535
Hospital Revenue Code	341
Min. Negotiated Rate	$1,189.80
Max. Negotiated Rate	$1,255.90
Rate for Payer: Aetna Commercial	$1,189.80
Rate for Payer: UnitedHealthcare Commercial	$1,255.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Hepatobiliary Imaging w/ Drug

Facility

$1,322.00

Service Code	HCPCS 78227 TC
Hospital Charge Code	3720535
Hospital Revenue Code	341
Min. Negotiated Rate	$283.02
Max. Negotiated Rate	$1,255.90
Rate for Payer: Aetna Commercial	$1,189.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$529.64
Rate for Payer: Humana Medicare Advantage	$555.24
Rate for Payer: UnitedHealthcare Commercial	$1,255.90
Rate for Payer: UnitedHealthcare Medicaid	$283.02
Rate for Payer: WPPA Medicare Advantage	$793.20

NM Intestine Imaging Meckels

Facility

$526.00

Service Code	HCPCS 78290 TC
Hospital Charge Code	3720090
Hospital Revenue Code	341
Min. Negotiated Rate	$473.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$473.40
Rate for Payer: UnitedHealthcare Commercial	$499.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Intestine Imaging Meckels

Facility

$526.00

Service Code	HCPCS 78290 TC
Hospital Charge Code	3720090
Hospital Revenue Code	341
Min. Negotiated Rate	$218.05
Max. Negotiated Rate	$499.70
Rate for Payer: Aetna Commercial	$473.40
Rate for Payer: Humana Medicare Advantage	$220.92
Rate for Payer: UnitedHealthcare Commercial	$499.70
Rate for Payer: UnitedHealthcare Medicaid	$218.05
Rate for Payer: WPPA Medicare Advantage	$315.60

NM Kidney Imaging Single w/o Pharm

Facility

$1,586.00

Service Code	HCPCS 78707 TC
Hospital Charge Code	3720223
Hospital Revenue Code	341
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,506.70
Rate for Payer: Aetna Commercial	$1,427.40
Rate for Payer: UnitedHealthcare Commercial	$1,506.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Kidney Imaging Single w/o Pharm

Facility

$1,586.00

Service Code	HCPCS 78707 TC
Hospital Charge Code	3720223
Hospital Revenue Code	341
Min. Negotiated Rate	$283.02
Max. Negotiated Rate	$1,506.70
Rate for Payer: Aetna Commercial	$1,427.40
Rate for Payer: Humana Medicare Advantage	$666.12
Rate for Payer: UnitedHealthcare Commercial	$1,506.70
Rate for Payer: UnitedHealthcare Medicaid	$283.02
Rate for Payer: WPPA Medicare Advantage	$951.60

NM Kidney Imaging Single w/ Pharm

Facility

$1,166.00

Service Code	HCPCS 78708 TC
Hospital Charge Code	3720215
Hospital Revenue Code	341
Min. Negotiated Rate	$283.02
Max. Negotiated Rate	$1,107.70
Rate for Payer: Aetna Commercial	$1,049.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$840.00
Rate for Payer: Humana Medicare Advantage	$489.72
Rate for Payer: UnitedHealthcare Commercial	$1,107.70
Rate for Payer: UnitedHealthcare Medicaid	$283.02
Rate for Payer: WPPA Medicare Advantage	$699.60

NM Kidney Imaging Single w/ Pharm

Facility

$1,166.00

Service Code	HCPCS 78708 TC
Hospital Charge Code	3720215
Hospital Revenue Code	341
Min. Negotiated Rate	$1,049.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,049.40
Rate for Payer: UnitedHealthcare Commercial	$1,107.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Localization Non-Image Probe IV

Facility

$1,005.00

Service Code	HCPCS 78808
Hospital Charge Code	3728808
Hospital Revenue Code	341
Min. Negotiated Rate	$904.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$904.50
Rate for Payer: UnitedHealthcare Commercial	$954.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Localization Non-Image Probe IV

Facility

$1,005.00

Service Code	HCPCS 78808
Hospital Charge Code	3728808
Hospital Revenue Code	341
Min. Negotiated Rate	$402.00
Max. Negotiated Rate	$954.75
Rate for Payer: Aetna Commercial	$904.50
Rate for Payer: Humana Medicare Advantage	$422.10
Rate for Payer: UnitedHealthcare Commercial	$954.75
Rate for Payer: UnitedHealthcare Medicaid	$402.00
Rate for Payer: WPPA Medicare Advantage	$603.00

NM Lymphoscintigraphy

Facility

$502.00

Service Code	HCPCS 78195 TC
Hospital Charge Code	3728195
Hospital Revenue Code	341
Min. Negotiated Rate	$210.84
Max. Negotiated Rate	$476.90
Rate for Payer: Aetna Commercial	$451.80
Rate for Payer: Humana Medicare Advantage	$210.84
Rate for Payer: UnitedHealthcare Commercial	$476.90
Rate for Payer: UnitedHealthcare Medicaid	$283.02
Rate for Payer: WPPA Medicare Advantage	$301.20

NM Lymphoscintigraphy

Facility

$502.00

Service Code	HCPCS 78195 TC
Hospital Charge Code	3728195
Hospital Revenue Code	341
Min. Negotiated Rate	$451.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$451.80
Rate for Payer: UnitedHealthcare Commercial	$476.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Myocardial SPECT Rest and Stress

Facility

$1,865.00

Service Code	HCPCS 78452 TC
Hospital Charge Code	3720530
Hospital Revenue Code	341
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,771.75
Rate for Payer: Aetna Commercial	$1,678.50
Rate for Payer: UnitedHealthcare Commercial	$1,771.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Myocardial SPECT Rest and Stress

Facility

$1,865.00

Service Code	HCPCS 78452 TC
Hospital Charge Code	3720530
Hospital Revenue Code	341
Min. Negotiated Rate	$744.60
Max. Negotiated Rate	$1,771.75
Rate for Payer: Aetna Commercial	$1,678.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,468.08
Rate for Payer: Humana Medicare Advantage	$783.30
Rate for Payer: UnitedHealthcare Commercial	$1,771.75
Rate for Payer: UnitedHealthcare Medicaid	$744.60
Rate for Payer: WPPA Medicare Advantage	$1,119.00

NM Parathyroid Imaging

Facility

$1,070.00

Service Code	HCPCS 78070 TC
Hospital Charge Code	3720066
Hospital Revenue Code	341
Min. Negotiated Rate	$963.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$963.00
Rate for Payer: UnitedHealthcare Commercial	$1,016.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Parathyroid Imaging

Facility

$1,070.00

Service Code	HCPCS 78070 TC
Hospital Charge Code	3720066
Hospital Revenue Code	341
Min. Negotiated Rate	$218.05
Max. Negotiated Rate	$1,016.50
Rate for Payer: Aetna Commercial	$963.00
Rate for Payer: Humana Medicare Advantage	$449.40
Rate for Payer: UnitedHealthcare Commercial	$1,016.50
Rate for Payer: UnitedHealthcare Medicaid	$218.05
Rate for Payer: WPPA Medicare Advantage	$642.00

NM Parathyroid Imaging w/ Spect

Facility

$1,070.00

Service Code	HCPCS 78071 TC
Hospital Charge Code	3720067
Hospital Revenue Code	341
Min. Negotiated Rate	$218.05
Max. Negotiated Rate	$1,016.50
Rate for Payer: Aetna Commercial	$963.00
Rate for Payer: Humana Medicare Advantage	$449.40
Rate for Payer: UnitedHealthcare Commercial	$1,016.50
Rate for Payer: UnitedHealthcare Medicaid	$218.05
Rate for Payer: WPPA Medicare Advantage	$642.00

NM Parathyroid Imaging w/ Spect

Facility

$1,070.00

Service Code	HCPCS 78071 TC
Hospital Charge Code	3720067
Hospital Revenue Code	341
Min. Negotiated Rate	$963.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$963.00
Rate for Payer: UnitedHealthcare Commercial	$1,016.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Thyroid Image w/ Uptake Sngl or Multi

Facility

$1,070.00

Service Code	HCPCS 78014 TC
Hospital Charge Code	3720060
Hospital Revenue Code	341
Min. Negotiated Rate	$963.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$963.00
Rate for Payer: UnitedHealthcare Commercial	$1,016.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Thyroid Image w/ Uptake Sngl or Multi

Facility

$1,070.00

Service Code	HCPCS 78014 TC
Hospital Charge Code	3720060
Hospital Revenue Code	341
Min. Negotiated Rate	$218.05
Max. Negotiated Rate	$1,016.50
Rate for Payer: Aetna Commercial	$963.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$424.64
Rate for Payer: Humana Medicare Advantage	$449.40
Rate for Payer: UnitedHealthcare Commercial	$1,016.50
Rate for Payer: UnitedHealthcare Medicaid	$218.05
Rate for Payer: WPPA Medicare Advantage	$642.00

NM Thyroid Imaging

Facility

$739.00

Service Code	HCPCS 78013 TC
Hospital Charge Code	3720058
Hospital Revenue Code	341
Min. Negotiated Rate	$218.05
Max. Negotiated Rate	$702.05
Rate for Payer: Aetna Commercial	$665.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$334.51
Rate for Payer: Humana Medicare Advantage	$310.38
Rate for Payer: UnitedHealthcare Commercial	$702.05
Rate for Payer: UnitedHealthcare Medicaid	$218.05
Rate for Payer: WPPA Medicare Advantage	$443.40

NM Thyroid Imaging

Facility

$739.00

Service Code	HCPCS 78013 TC
Hospital Charge Code	3720058
Hospital Revenue Code	341
Min. Negotiated Rate	$665.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$665.10
Rate for Payer: UnitedHealthcare Commercial	$702.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

NM Thyroid Uptake Single or Multi

Facility

$1,070.00

Service Code	HCPCS 78014 TC
Hospital Charge Code	3720060
Hospital Revenue Code	341
Min. Negotiated Rate	$963.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$963.00
Rate for Payer: UnitedHealthcare Commercial	$1,016.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

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All Charges