Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

US Aorta IVC Iliac Duplex Limited

Facility

$764.00

Service Code	HCPCS 93979 TC
Hospital Charge Code	3733979
Hospital Revenue Code	402
Min. Negotiated Rate	$35.62
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.76
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$35.62
Rate for Payer: WPPA Medicare Advantage	$458.40

US Art/Vein Abd/Pelvis/Scrotal Complete

Facility

$1,063.00

Service Code	HCPCS 93975 TC
Hospital Charge Code	3610175
Hospital Revenue Code	921
Min. Negotiated Rate	$956.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Art/Vein Abd/Pelvis/Scrotal Complete

Facility

$1,063.00

Service Code	HCPCS 93975 TC
Hospital Charge Code	3610175
Hospital Revenue Code	921
Min. Negotiated Rate	$79.38
Max. Negotiated Rate	$1,009.85
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.76
Rate for Payer: Humana Medicare Advantage	$446.46
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: UnitedHealthcare Medicaid	$79.38
Rate for Payer: WPPA Medicare Advantage	$637.80

US Art/Vein Abd/Pelvis/Scrotal Limited

Facility

$1,063.00

Service Code	HCPCS 93976 TC
Hospital Charge Code	3610185
Hospital Revenue Code	921
Min. Negotiated Rate	$956.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Art/Vein Abd/Pelvis/Scrotal Limited

Facility

$1,063.00

Service Code	HCPCS 93976 TC
Hospital Charge Code	3610185
Hospital Revenue Code	921
Min. Negotiated Rate	$35.62
Max. Negotiated Rate	$1,009.85
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.76
Rate for Payer: Humana Medicare Advantage	$446.46
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: UnitedHealthcare Medicaid	$35.62
Rate for Payer: WPPA Medicare Advantage	$637.80

US Axilla Left

Facility

$764.00

Service Code	HCPCS 76882 LT
Hospital Charge Code	3730438
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Axilla Left

Facility

$764.00

Service Code	HCPCS 76882 LT
Hospital Charge Code	3730438
Hospital Revenue Code	402
Min. Negotiated Rate	$117.16
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$117.16
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$305.60
Rate for Payer: WPPA Medicare Advantage	$458.40

US Axilla Right

Facility

$764.00

Service Code	HCPCS 76882 RT
Hospital Charge Code	3730438
Hospital Revenue Code	402
Min. Negotiated Rate	$117.16
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$117.16
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$305.60
Rate for Payer: WPPA Medicare Advantage	$458.40

US Axilla Right

Facility

$764.00

Service Code	HCPCS 76882 RT
Hospital Charge Code	3730438
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Biopsy Liver

Facility

$764.00

Service Code	HCPCS 76942
Hospital Charge Code	3730253
Hospital Revenue Code	402
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$120.19
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$44.03
Rate for Payer: WPPA Medicare Advantage	$458.40

US Biopsy Liver

Facility

$764.00

Service Code	HCPCS 76942
Hospital Charge Code	3730253
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Biopsy Lymph Node

Facility

$764.00

Service Code	HCPCS 76942 TC
Hospital Charge Code	3730253
Hospital Revenue Code	402
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$120.19
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$31.20
Rate for Payer: WPPA Medicare Advantage	$458.40

US Biopsy Lymph Node

Facility

$764.00

Service Code	HCPCS 76942 TC
Hospital Charge Code	3730253
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Breast Complete Bilat

Facility

$764.00

Service Code	HCPCS 76641 LT
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Breast Complete Bilat

Facility

$764.00

Service Code	HCPCS 76641 TC
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Breast Complete Bilat

Facility

$764.00

Service Code	HCPCS 76641 TC
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$94.94
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$458.40

US Breast Complete Bilat

Facility

$764.00

Service Code	HCPCS 76641 LT
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$94.94
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$458.40

US Breast Complete Left

Facility

$764.00

Service Code	HCPCS 76641 LT
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$94.94
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$458.40

US Breast Complete Left

Facility

$764.00

Service Code	HCPCS 76641 LT
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Breast Complete Right

Facility

$764.00

Service Code	HCPCS 76641 RT
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$94.94
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$458.40

US Breast Complete Right

Facility

$764.00

Service Code	HCPCS 76641 RT
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Breast Complete Right Add-On

Facility

$764.00

Service Code	HCPCS 76641 RT
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$94.94
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$458.40

US Breast Complete Right Add-On

Facility

$764.00

Service Code	HCPCS 76641 TC
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Breast Complete Right Add-On

Facility

$764.00

Service Code	HCPCS 76641 RT
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Breast Complete Right Add-On

Facility

$764.00

Service Code	HCPCS 76641 TC
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$94.94
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$458.40

Know your out-of-pocket cost for care.

All Charges