Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

US Breast Device Plcmnt w/US Guide Left

Facility

$645.00

Service Code	HCPCS 19285 LT
Hospital Charge Code	3739285
Hospital Revenue Code	402
Min. Negotiated Rate	$66.41
Max. Negotiated Rate	$612.75
Rate for Payer: Aetna Commercial	$580.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$398.95
Rate for Payer: Humana Medicare Advantage	$270.90
Rate for Payer: UnitedHealthcare Commercial	$612.75
Rate for Payer: UnitedHealthcare Medicaid	$66.41
Rate for Payer: WPPA Medicare Advantage	$387.00

US Breast Device Plcmnt w/US Guide Left

Facility

$645.00

Service Code	HCPCS 19285 LT
Hospital Charge Code	3739285
Hospital Revenue Code	402
Min. Negotiated Rate	$580.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$580.50
Rate for Payer: UnitedHealthcare Commercial	$612.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Breast Device Plcmnt w/US Guide Right

Facility

$645.00

Service Code	HCPCS 19285 RT
Hospital Charge Code	3739285
Hospital Revenue Code	402
Min. Negotiated Rate	$66.41
Max. Negotiated Rate	$612.75
Rate for Payer: Aetna Commercial	$580.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$398.95
Rate for Payer: Humana Medicare Advantage	$270.90
Rate for Payer: UnitedHealthcare Commercial	$612.75
Rate for Payer: UnitedHealthcare Medicaid	$66.41
Rate for Payer: WPPA Medicare Advantage	$387.00

US Breast Device Plcmnt w/US Guide Right

Facility

$645.00

Service Code	HCPCS 19285 RT
Hospital Charge Code	3739285
Hospital Revenue Code	402
Min. Negotiated Rate	$580.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$580.50
Rate for Payer: UnitedHealthcare Commercial	$612.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Breast Limited Bilat

Facility

$764.00

Service Code	HCPCS 76642 LT
Hospital Charge Code	3737664
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 Limited Bilat

Facility

$764.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	3737664
Hospital Revenue Code	402
Min. Negotiated Rate	$48.74
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	$48.74
Rate for Payer: WPPA Medicare Advantage	$458.40

US Breast Limited Bilat

Facility

$764.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	3737664
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 Limited Bilat

Facility

$764.00

Service Code	HCPCS 76642 LT
Hospital Charge Code	3737664
Hospital Revenue Code	402
Min. Negotiated Rate	$48.74
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	$48.74
Rate for Payer: WPPA Medicare Advantage	$458.40

US Breast Limited Left

Facility

$764.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	3737664
Hospital Revenue Code	402
Min. Negotiated Rate	$48.74
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	$48.74
Rate for Payer: WPPA Medicare Advantage	$458.40

US Breast Limited Left

Facility

$764.00

Service Code	HCPCS 76642 LT
Hospital Charge Code	3737664
Hospital Revenue Code	402
Min. Negotiated Rate	$48.74
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	$48.74
Rate for Payer: WPPA Medicare Advantage	$458.40

US Breast Limited Left

Facility

$764.00

Service Code	HCPCS 76642 LT
Hospital Charge Code	3737664
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 Limited Left

Facility

$764.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	3737664
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 Limited Right

Facility

$764.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	3737664
Hospital Revenue Code	402
Min. Negotiated Rate	$48.74
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	$48.74
Rate for Payer: WPPA Medicare Advantage	$458.40

US Breast Limited Right

Facility

$764.00

Service Code	HCPCS 76642 RT
Hospital Charge Code	3737664
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 Limited Right

Facility

$764.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	3737664
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 Limited Right

Facility

$764.00

Service Code	HCPCS 76642 RT
Hospital Charge Code	3737664
Hospital Revenue Code	402
Min. Negotiated Rate	$48.74
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	$48.74
Rate for Payer: WPPA Medicare Advantage	$458.40

US Carotid Duplex Bilateral

Facility

$1,063.00

Service Code	HCPCS 93880 TC
Hospital Charge Code	3610023
Hospital Revenue Code	921
Min. Negotiated Rate	$142.48
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	$142.48
Rate for Payer: WPPA Medicare Advantage	$637.80

US Carotid Duplex Bilateral

Facility

$1,063.00

Service Code	HCPCS 93880 TC
Hospital Charge Code	3610023
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 DOPPLER ARTERIAL/VENOUS COMPLETE Add-on

Facility

$1,063.00

Service Code	HCPCS 93975
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 DOPPLER ARTERIAL/VENOUS COMPLETE Add-on

Facility

$1,063.00

Service Code	HCPCS 93975
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	$137.39
Rate for Payer: WPPA Medicare Advantage	$637.80

US Doppler Middle Cerebral Artery

Facility

$298.00

Service Code	HCPCS 76821 TC
Hospital Charge Code	3616821
Hospital Revenue Code	921
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$178.80

US Doppler Middle Cerebral Artery

Facility

$298.00

Service Code	HCPCS 76821 TC
Hospital Charge Code	3616821
Hospital Revenue Code	921
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Doppler Umbilical Artery

Facility

$268.00

Service Code	HCPCS 76820 TC
Hospital Charge Code	3616820
Hospital Revenue Code	921
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$254.60
Rate for Payer: Aetna Commercial	$241.20
Rate for Payer: Humana Medicare Advantage	$112.56
Rate for Payer: UnitedHealthcare Commercial	$254.60
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$160.80

US Doppler Umbilical Artery

Facility

$268.00

Service Code	HCPCS 76820 TC
Hospital Charge Code	3616820
Hospital Revenue Code	921
Min. Negotiated Rate	$241.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$241.20
Rate for Payer: UnitedHealthcare Commercial	$254.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Echo 2D Complete

Facility

$3,387.00

Service Code	HCPCS 93306 TC
Hospital Charge Code	3620025
Hospital Revenue Code	480
Min. Negotiated Rate	$178.27
Max. Negotiated Rate	$3,217.65
Rate for Payer: Aetna Commercial	$3,048.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,532.17
Rate for Payer: Humana Medicare Advantage	$1,422.54
Rate for Payer: UnitedHealthcare Commercial	$3,217.65
Rate for Payer: UnitedHealthcare Medicaid	$291.61
Rate for Payer: WPPA Medicare Advantage	$2,032.20

Know your out-of-pocket cost for care.

All Charges