Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

43130 Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach

Facility

$3,707.00

Service Code	HCPCS 43130
Hospital Charge Code	3153130
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,521.65
Rate for Payer: Aetna Commercial	$3,336.30
Rate for Payer: UnitedHealthcare Commercial	$3,521.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43180 Esophagoscopy, rigid, transoral with diverticulectomy

Facility

$2,025.00

Service Code	HCPCS 43180
Hospital Charge Code	3153180
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,923.75
Rate for Payer: Aetna Commercial	$1,822.50
Rate for Payer: UnitedHealthcare Commercial	$1,923.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43180 Esophagoscopy, rigid, transoral with diverticulectomy

Facility

$2,025.00

Service Code	HCPCS 43180
Hospital Charge Code	3153180
Hospital Revenue Code	360
Min. Negotiated Rate	$850.50
Max. Negotiated Rate	$1,923.75
Rate for Payer: Aetna Commercial	$1,822.50
Rate for Payer: Humana Medicare Advantage	$850.50
Rate for Payer: UnitedHealthcare Commercial	$1,923.75
Rate for Payer: UnitedHealthcare Medicaid	$1,315.11
Rate for Payer: WPPA Medicare Advantage	$1,215.00

43200 ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY ProFee

Facility

$2,216.00

Service Code	HCPCS 43200
Hospital Charge Code	3150317
Hospital Revenue Code	360
Min. Negotiated Rate	$293.65
Max. Negotiated Rate	$2,105.20
Rate for Payer: Aetna Commercial	$1,994.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,376.63
Rate for Payer: Humana Medicare Advantage	$930.72
Rate for Payer: UnitedHealthcare Commercial	$2,105.20
Rate for Payer: UnitedHealthcare Medicaid	$293.65
Rate for Payer: WPPA Medicare Advantage	$1,329.60

43200 ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY ProFee

Facility

$2,216.00

Service Code	HCPCS 43200
Hospital Charge Code	3150317
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,105.20
Rate for Payer: Aetna Commercial	$1,994.40
Rate for Payer: UnitedHealthcare Commercial	$2,105.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43202 Esophagoscopy, flexible, transoral; with biopsy, single or multiple

Facility

$1,731.00

Service Code	HCPCS 43202
Hospital Charge Code	3150321
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,644.45
Rate for Payer: Aetna Commercial	$1,557.90
Rate for Payer: UnitedHealthcare Commercial	$1,644.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43202 Esophagoscopy, flexible, transoral; with biopsy, single or multiple

Facility

$1,731.00

Service Code	HCPCS 43202
Hospital Charge Code	3150321
Hospital Revenue Code	360
Min. Negotiated Rate	$616.42
Max. Negotiated Rate	$1,644.45
Rate for Payer: Aetna Commercial	$1,557.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$914.05
Rate for Payer: Humana Medicare Advantage	$727.02
Rate for Payer: UnitedHealthcare Commercial	$1,644.45
Rate for Payer: UnitedHealthcare Medicaid	$616.42
Rate for Payer: WPPA Medicare Advantage	$1,038.60

43220 Esophagoscopy, flexible, transoral; w/ transendoscopic balloon dilation, < 30 mm diameter

Facility

$1,717.00

Service Code	HCPCS 43220
Hospital Charge Code	3150412
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,631.15
Rate for Payer: Aetna Commercial	$1,545.30
Rate for Payer: UnitedHealthcare Commercial	$1,631.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43220 Esophagoscopy, flexible, transoral; w/ transendoscopic balloon dilation, < 30 mm diameter

Facility

$1,717.00

Service Code	HCPCS 43220
Hospital Charge Code	3150412
Hospital Revenue Code	360
Min. Negotiated Rate	$616.42
Max. Negotiated Rate	$1,631.15
Rate for Payer: Aetna Commercial	$1,545.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,058.48
Rate for Payer: Humana Medicare Advantage	$721.14
Rate for Payer: UnitedHealthcare Commercial	$1,631.15
Rate for Payer: UnitedHealthcare Medicaid	$616.42
Rate for Payer: WPPA Medicare Advantage	$1,030.20

43233 EGD BALLOON DILATION

Facility

$1,575.00

Service Code	HCPCS 43233
Hospital Charge Code	3153233
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,496.25
Rate for Payer: Aetna Commercial	$1,417.50
Rate for Payer: UnitedHealthcare Commercial	$1,496.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43233 EGD BALLOON DILATION

Facility

$1,575.00

Service Code	HCPCS 43233
Hospital Charge Code	3153233
Hospital Revenue Code	360
Min. Negotiated Rate	$661.50
Max. Negotiated Rate	$1,496.25
Rate for Payer: Aetna Commercial	$1,417.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,021.11
Rate for Payer: Humana Medicare Advantage	$661.50
Rate for Payer: UnitedHealthcare Commercial	$1,496.25
Rate for Payer: UnitedHealthcare Medicaid	$684.82
Rate for Payer: WPPA Medicare Advantage	$945.00

43235 UPPR GI ENDOSCOPY, DIAGNOSIS

Facility

$1,896.00

Service Code	HCPCS 43235
Hospital Charge Code	3150318
Hospital Revenue Code	360
Min. Negotiated Rate	$293.65
Max. Negotiated Rate	$1,801.20
Rate for Payer: Aetna Commercial	$1,706.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,033.23
Rate for Payer: Humana Medicare Advantage	$796.32
Rate for Payer: UnitedHealthcare Commercial	$1,801.20
Rate for Payer: UnitedHealthcare Medicaid	$293.65
Rate for Payer: WPPA Medicare Advantage	$1,137.60

43235 UPPR GI ENDOSCOPY, DIAGNOSIS

Facility

$1,896.00

Service Code	HCPCS 43235
Hospital Charge Code	3150318
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,801.20
Rate for Payer: Aetna Commercial	$1,706.40
Rate for Payer: UnitedHealthcare Commercial	$1,801.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43236 EGD SUBMUCOSAL INJ Tech Charge

Facility

$1,318.00

Service Code	HCPCS 43236
Hospital Charge Code	3153236
Hospital Revenue Code	360
Min. Negotiated Rate	$343.20
Max. Negotiated Rate	$1,252.10
Rate for Payer: Aetna Commercial	$1,186.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$998.76
Rate for Payer: Humana Medicare Advantage	$553.56
Rate for Payer: UnitedHealthcare Commercial	$1,252.10
Rate for Payer: UnitedHealthcare Medicaid	$343.20
Rate for Payer: WPPA Medicare Advantage	$790.80

43236 EGD SUBMUCOSAL INJ Tech Charge

Facility

$1,318.00

Service Code	HCPCS 43236
Hospital Charge Code	3153236
Hospital Revenue Code	360
Min. Negotiated Rate	$1,186.20
Max. Negotiated Rate	$1,252.10
Rate for Payer: Aetna Commercial	$1,186.20
Rate for Payer: UnitedHealthcare Commercial	$1,252.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43239 UPPER GI ENDOSCOPY, BIOPSY

Facility

$2,117.00

Service Code	HCPCS 43239
Hospital Charge Code	3150316
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,011.15
Rate for Payer: Aetna Commercial	$1,905.30
Rate for Payer: UnitedHealthcare Commercial	$2,011.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43239 UPPER GI ENDOSCOPY, BIOPSY

Facility

$2,117.00

Service Code	HCPCS 43239
Hospital Charge Code	3150316
Hospital Revenue Code	360
Min. Negotiated Rate	$293.65
Max. Negotiated Rate	$2,011.15
Rate for Payer: Aetna Commercial	$1,905.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,153.42
Rate for Payer: Humana Medicare Advantage	$889.14
Rate for Payer: UnitedHealthcare Commercial	$2,011.15
Rate for Payer: UnitedHealthcare Medicaid	$293.65
Rate for Payer: WPPA Medicare Advantage	$1,270.20

43241 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF INTRALUMINAL TUBE O ProFee

Facility

$1,410.00

Service Code	HCPCS 43241
Hospital Charge Code	3153241
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,339.50
Rate for Payer: Aetna Commercial	$1,269.00
Rate for Payer: UnitedHealthcare Commercial	$1,339.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43241 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF INTRALUMINAL TUBE O ProFee

Facility

$1,410.00

Service Code	HCPCS 43241
Hospital Charge Code	3153241
Hospital Revenue Code	360
Min. Negotiated Rate	$592.20
Max. Negotiated Rate	$1,339.50
Rate for Payer: Aetna Commercial	$1,269.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$914.05
Rate for Payer: Humana Medicare Advantage	$592.20
Rate for Payer: UnitedHealthcare Commercial	$1,339.50
Rate for Payer: UnitedHealthcare Medicaid	$616.42
Rate for Payer: WPPA Medicare Advantage	$846.00

43245 EGD DILATION GASTRIC/DUODENAL STRICTURE Tech Charge

Facility

$2,558.00

Service Code	HCPCS 43245
Hospital Charge Code	3403245
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,430.10
Rate for Payer: Aetna Commercial	$2,302.20
Rate for Payer: UnitedHealthcare Commercial	$2,430.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43245 EGD DILATION GASTRIC/DUODENAL STRICTURE Tech Charge

Facility

$2,558.00

Service Code	HCPCS 43245
Hospital Charge Code	3403245
Hospital Revenue Code	360
Min. Negotiated Rate	$616.42
Max. Negotiated Rate	$2,430.10
Rate for Payer: Aetna Commercial	$2,302.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,580.65
Rate for Payer: Humana Medicare Advantage	$1,074.36
Rate for Payer: UnitedHealthcare Commercial	$2,430.10
Rate for Payer: UnitedHealthcare Medicaid	$616.42
Rate for Payer: WPPA Medicare Advantage	$1,534.80

43246 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(

Facility

$3,290.00

Service Code	HCPCS 43246
Hospital Charge Code	3150520
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,125.50
Rate for Payer: Aetna Commercial	$2,961.00
Rate for Payer: UnitedHealthcare Commercial	$3,125.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43246 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(

Facility

$3,290.00

Service Code	HCPCS 43246
Hospital Charge Code	3150520
Hospital Revenue Code	360
Min. Negotiated Rate	$616.42
Max. Negotiated Rate	$3,125.50
Rate for Payer: Aetna Commercial	$2,961.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,134.13
Rate for Payer: Humana Medicare Advantage	$1,381.80
Rate for Payer: UnitedHealthcare Commercial	$3,125.50
Rate for Payer: UnitedHealthcare Medicaid	$616.42
Rate for Payer: WPPA Medicare Advantage	$1,974.00

43248 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED TechFee

Facility

$1,512.00

Service Code	HCPCS 43248
Hospital Charge Code	3363248
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,436.40
Rate for Payer: Aetna Commercial	$1,360.80
Rate for Payer: UnitedHealthcare Commercial	$1,436.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43248 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED TechFee

Facility

$1,512.00

Service Code	HCPCS 43248
Hospital Charge Code	3363248
Hospital Revenue Code	360
Min. Negotiated Rate	$293.65
Max. Negotiated Rate	$1,436.40
Rate for Payer: Aetna Commercial	$1,360.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,090.80
Rate for Payer: Humana Medicare Advantage	$635.04
Rate for Payer: UnitedHealthcare Commercial	$1,436.40
Rate for Payer: UnitedHealthcare Medicaid	$293.65
Rate for Payer: WPPA Medicare Advantage	$907.20

Know your out-of-pocket cost for care.

All Charges