Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

US Renal Artery Duplex Bilateral

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 Renal Artery Duplex Bilateral

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 Renal Artery Duplex Left

Facility

$1,063.00

Service Code	HCPCS 93976 LT
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 Renal Artery Duplex Left

Facility

$1,063.00

Service Code	HCPCS 93976 LT
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 Renal Artery Duplex Right

Facility

$1,063.00

Service Code	HCPCS 93976 RT
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 Renal Artery Duplex Right

Facility

$1,063.00

Service Code	HCPCS 93976 RT
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 Renal Bilateral

Facility

$764.00

Service Code	HCPCS 76770 TC
Hospital Charge Code	3730105
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	$151.50
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 Renal Bilateral

Facility

$764.00

Service Code	HCPCS 76770
Hospital Charge Code	3730105
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 Renal Bilateral

Facility

$764.00

Service Code	HCPCS 76770
Hospital Charge Code	3730105
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	$151.50
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$90.85
Rate for Payer: WPPA Medicare Advantage	$458.40

US Renal Bilateral

Facility

$764.00

Service Code	HCPCS 76770 TC
Hospital Charge Code	3730105
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 Renal Left

Facility

$764.00

Service Code	HCPCS 76775 LT
Hospital Charge Code	3730449
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 Renal Left

Facility

$764.00

Service Code	HCPCS 76775 LT
Hospital Charge Code	3730449
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	$117.16
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 Renal Right

Facility

$764.00

Service Code	HCPCS 76775 RT
Hospital Charge Code	3730449
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	$117.16
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 Renal Right

Facility

$764.00

Service Code	HCPCS 76775 RT
Hospital Charge Code	3730449
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 Scrotum (Contents)

Facility

$764.00

Service Code	HCPCS 76870
Hospital Charge Code	3730246
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	$123.22
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$90.85
Rate for Payer: WPPA Medicare Advantage	$458.40

US Scrotum (Contents)

Facility

$764.00

Service Code	HCPCS 76870
Hospital Charge Code	3730246
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 Scrotum Contents

Facility

$764.00

Service Code	HCPCS 76870 TC
Hospital Charge Code	3730246
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	$123.22
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 Scrotum Contents

Facility

$764.00

Service Code	HCPCS 76870 TC
Hospital Charge Code	3730246
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 Soft Tissue

Facility

$764.00

Service Code	HCPCS 76882 TC
Hospital Charge Code	3730089
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 Soft Tissue

Facility

$764.00

Service Code	HCPCS 76882 TC
Hospital Charge Code	3730089
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 Soft Tissue Abd/Pel

Facility

$764.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	3730089
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	$130.94
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 Soft Tissue Abd/Pel

Facility

$764.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	3730089
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 Soft Tissue Buttocks or Pelvic Wall

Facility

$206.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	3730430
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$195.70
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$103.02
Rate for Payer: Humana Medicare Advantage	$86.52
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$123.60

US Soft Tissue Buttocks or Pelvic Wall

Facility

$206.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	3730430
Hospital Revenue Code	402
Min. Negotiated Rate	$185.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

US Soft Tissue Chest or Upper Back

Facility

$764.00

Service Code	HCPCS 76604 TC
Hospital Charge Code	3730439
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	$111.10
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