Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$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 Groin

Facility

$764.00

Service Code	HCPCS 76882 TC
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 Soft Tissue Groin

Facility

$764.00

Service Code	HCPCS 76882 TC
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 Soft Tissue Head/Neck

Facility

$1,063.00

Service Code	HCPCS 76536 TC
Hospital Charge Code	3730154
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
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	$59.96
Rate for Payer: WPPA Medicare Advantage	$637.80

US Soft Tissue Head/Neck

Facility

$1,063.00

Service Code	HCPCS 76536 TC
Hospital Charge Code	3730154
Hospital Revenue Code	402
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 Soft Tissue Lower Back

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 Lower Back

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 Lower Ext 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 Soft Tissue Lower Ext 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 Soft Tissue Lower Ext 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 Soft Tissue Lower Ext 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 Soft Tissue Upper Ext 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 Soft Tissue Upper Ext 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 Soft Tissue Upper Ext 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 Soft Tissue Upper Ext 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

ustekinumab 5 mg/mL [HMC]

Facility

$4,858.82

Service Code	HCPCS J3358
Hospital Charge Code	3800705
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,615.88
Rate for Payer: Aetna Commercial	$4,372.94
Rate for Payer: UnitedHealthcare Commercial	$4,615.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ustekinumab 5 mg/mL [HMC]

Facility

$4,858.82

Service Code	HCPCS J3358
Hospital Charge Code	3800705
Hospital Revenue Code	250
Min. Negotiated Rate	$12.49
Max. Negotiated Rate	$4,615.88
Rate for Payer: Aetna Commercial	$4,372.94
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.59
Rate for Payer: Humana Medicare Advantage	$2,040.70
Rate for Payer: UnitedHealthcare Commercial	$4,615.88
Rate for Payer: UnitedHealthcare Medicaid	$12.49
Rate for Payer: WPPA Medicare Advantage	$2,915.29

US Thyroid

Facility

$1,063.00

Service Code	HCPCS 76536 TC
Hospital Charge Code	3730154
Hospital Revenue Code	402
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 Thyroid

Facility

$1,063.00

Service Code	HCPCS 76536 TC
Hospital Charge Code	3730154
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
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	$59.96
Rate for Payer: WPPA Medicare Advantage	$637.80

US Transvaginal Non-OB

Facility

$764.00

Service Code	HCPCS 76830 TC
Hospital Charge Code	3730337
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 Transvaginal Non-OB

Facility

$764.00

Service Code	HCPCS 76830 TC
Hospital Charge Code	3730337
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 Upper Ext Arterial Duplex Bilateral

Facility

$1,063.00

Service Code	HCPCS 93930 TC
Hospital Charge Code	3610172
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 Upper Ext Arterial Duplex Bilateral

Facility

$1,063.00

Service Code	HCPCS 93930 TC
Hospital Charge Code	3610172
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 Upper Ext Arterial Duplex Left

Facility

$1,063.00

Service Code	HCPCS 93931 LT
Hospital Charge Code	3610171
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 Upper Ext Arterial Duplex Left

Facility

$1,063.00

Service Code	HCPCS 93931 LT
Hospital Charge Code	3610171
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

Know your out-of-pocket cost for care.

All Charges