Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

43249 ESOPH ENDOSCOPY, DILATION

Facility

$2,535.00

Service Code	HCPCS 43249
Hospital Charge Code	3150635
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,408.25
Rate for Payer: Aetna Commercial	$2,281.50
Rate for Payer: UnitedHealthcare Commercial	$2,408.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43249 ESOPH ENDOSCOPY, DILATION

Facility

$2,535.00

Service Code	HCPCS 43249
Hospital Charge Code	3150635
Hospital Revenue Code	360
Min. Negotiated Rate	$616.42
Max. Negotiated Rate	$2,408.25
Rate for Payer: Aetna Commercial	$2,281.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,566.51
Rate for Payer: Humana Medicare Advantage	$1,064.70
Rate for Payer: UnitedHealthcare Commercial	$2,408.25
Rate for Payer: UnitedHealthcare Medicaid	$616.42
Rate for Payer: WPPA Medicare Advantage	$1,521.00

43250 EGD W/ HOT BIOPSY

Facility

$1,625.00

Service Code	HCPCS 43250
Hospital Charge Code	3153250
Hospital Revenue Code	360
Min. Negotiated Rate	$616.42
Max. Negotiated Rate	$1,543.75
Rate for Payer: Aetna Commercial	$1,462.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,172.61
Rate for Payer: Humana Medicare Advantage	$682.50
Rate for Payer: UnitedHealthcare Commercial	$1,543.75
Rate for Payer: UnitedHealthcare Medicaid	$616.42
Rate for Payer: WPPA Medicare Advantage	$975.00

43250 EGD W/ HOT BIOPSY

Facility

$1,625.00

Service Code	HCPCS 43250
Hospital Charge Code	3153250
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,543.75
Rate for Payer: Aetna Commercial	$1,462.50
Rate for Payer: UnitedHealthcare Commercial	$1,543.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43251 GASTROSCOPY POLYP/REMOVAL W/ SNARE/ANESTHESIA

Facility

$2,484.00

Service Code	HCPCS 43251
Hospital Charge Code	3153251
Hospital Revenue Code	360
Min. Negotiated Rate	$616.42
Max. Negotiated Rate	$2,359.80
Rate for Payer: Aetna Commercial	$2,235.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,353.40
Rate for Payer: Humana Medicare Advantage	$1,043.28
Rate for Payer: UnitedHealthcare Commercial	$2,359.80
Rate for Payer: UnitedHealthcare Medicaid	$616.42
Rate for Payer: WPPA Medicare Advantage	$1,490.40

43251 GASTROSCOPY POLYP/REMOVAL W/ SNARE/ANESTHESIA

Facility

$2,484.00

Service Code	HCPCS 43251
Hospital Charge Code	3153251
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,359.80
Rate for Payer: Aetna Commercial	$2,235.60
Rate for Payer: UnitedHealthcare Commercial	$2,359.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43255 GASTROSCOPY W/HEMOSTASIS/ANESTHESIA

Facility

$2,911.00

Service Code	HCPCS 43255
Hospital Charge Code	3153255
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,765.45
Rate for Payer: Aetna Commercial	$2,619.90
Rate for Payer: UnitedHealthcare Commercial	$2,765.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43255 GASTROSCOPY W/HEMOSTASIS/ANESTHESIA

Facility

$2,911.00

Service Code	HCPCS 43255
Hospital Charge Code	3153255
Hospital Revenue Code	360
Min. Negotiated Rate	$616.42
Max. Negotiated Rate	$2,765.45
Rate for Payer: Aetna Commercial	$2,619.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,100.12
Rate for Payer: Humana Medicare Advantage	$1,222.62
Rate for Payer: UnitedHealthcare Commercial	$2,765.45
Rate for Payer: UnitedHealthcare Medicaid	$616.42
Rate for Payer: WPPA Medicare Advantage	$1,746.60

43270 ERCP; with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy)

Facility

$1,539.00

Service Code	HCPCS 43270
Hospital Charge Code	3153270
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,462.05
Rate for Payer: Aetna Commercial	$1,385.10
Rate for Payer: UnitedHealthcare Commercial	$1,462.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43270 ERCP; with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy)

Facility

$1,539.00

Service Code	HCPCS 43270
Hospital Charge Code	3153270
Hospital Revenue Code	360
Min. Negotiated Rate	$646.38
Max. Negotiated Rate	$1,462.05
Rate for Payer: Aetna Commercial	$1,385.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$914.05
Rate for Payer: Humana Medicare Advantage	$646.38
Rate for Payer: UnitedHealthcare Commercial	$1,462.05
Rate for Payer: UnitedHealthcare Medicaid	$684.82
Rate for Payer: WPPA Medicare Advantage	$923.40

43280 LAPAROSCOPY, FUNDOPLASTY

Facility

$14,927.00

Service Code	HCPCS 43280
Hospital Charge Code	3153280
Hospital Revenue Code	360
Min. Negotiated Rate	$3,334.64
Max. Negotiated Rate	$14,180.65
Rate for Payer: Aetna Commercial	$13,434.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11,308.67
Rate for Payer: Humana Medicare Advantage	$6,269.34
Rate for Payer: UnitedHealthcare Commercial	$14,180.65
Rate for Payer: UnitedHealthcare Medicaid	$3,334.64
Rate for Payer: WPPA Medicare Advantage	$8,956.20

43280 LAPAROSCOPY, FUNDOPLASTY

Facility

$14,927.00

Service Code	HCPCS 43280
Hospital Charge Code	3153280
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,180.65
Rate for Payer: Aetna Commercial	$13,434.30
Rate for Payer: UnitedHealthcare Commercial	$14,180.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43281 Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed

Facility

$15,673.00

Service Code	HCPCS 43281
Hospital Charge Code	3153281
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,889.35
Rate for Payer: Aetna Commercial	$14,105.70
Rate for Payer: UnitedHealthcare Commercial	$14,889.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43281 Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed

Facility

$15,673.00

Service Code	HCPCS 43281
Hospital Charge Code	3153281
Hospital Revenue Code	360
Min. Negotiated Rate	$6,269.20
Max. Negotiated Rate	$14,889.35
Rate for Payer: Aetna Commercial	$14,105.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$11,308.67
Rate for Payer: Humana Medicare Advantage	$6,582.66
Rate for Payer: UnitedHealthcare Commercial	$14,889.35
Rate for Payer: UnitedHealthcare Medicaid	$6,269.20
Rate for Payer: WPPA Medicare Advantage	$9,403.80

43332 REPAIR, PARAESOPHAGEAL HIATAL HERNIA (INCLUDING FUNDOPLICATION), VIA LAPAROTOMY, EXCEP ProFee

Facility

$6,512.00

Service Code	HCPCS 43332
Hospital Charge Code	3153332
Hospital Revenue Code	360
Min. Negotiated Rate	$2,604.80
Max. Negotiated Rate	$6,186.40
Rate for Payer: Aetna Commercial	$5,860.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,223.82
Rate for Payer: Humana Medicare Advantage	$2,735.04
Rate for Payer: UnitedHealthcare Commercial	$6,186.40
Rate for Payer: UnitedHealthcare Medicaid	$2,604.80
Rate for Payer: WPPA Medicare Advantage	$3,907.20

43332 REPAIR, PARAESOPHAGEAL HIATAL HERNIA (INCLUDING FUNDOPLICATION), VIA LAPAROTOMY, EXCEP ProFee

Facility

$6,512.00

Service Code	HCPCS 43332
Hospital Charge Code	3153332
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,186.40
Rate for Payer: Aetna Commercial	$5,860.80
Rate for Payer: UnitedHealthcare Commercial	$6,186.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43450 DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES TechFee

Facility

$1,382.00

Service Code	HCPCS 43450
Hospital Charge Code	3153450
Hospital Revenue Code	360
Min. Negotiated Rate	$293.65
Max. Negotiated Rate	$1,312.90
Rate for Payer: Aetna Commercial	$1,243.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$820.12
Rate for Payer: Humana Medicare Advantage	$580.44
Rate for Payer: UnitedHealthcare Commercial	$1,312.90
Rate for Payer: UnitedHealthcare Medicaid	$293.65
Rate for Payer: WPPA Medicare Advantage	$829.20

43450 DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES TechFee

Facility

$1,382.00

Service Code	HCPCS 43450
Hospital Charge Code	3153450
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,312.90
Rate for Payer: Aetna Commercial	$1,243.80
Rate for Payer: UnitedHealthcare Commercial	$1,312.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43752-Insertion NG tube

Facility

$620.00

Service Code	HCPCS 43752
Hospital Charge Code	3303752
Hospital Revenue Code	450
Min. Negotiated Rate	$558.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43752-Insertion NG tube

Facility

$620.00

Service Code	HCPCS 43752
Hospital Charge Code	3303752
Hospital Revenue Code	450
Min. Negotiated Rate	$248.00
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$248.00
Rate for Payer: WPPA Medicare Advantage	$372.00

43753-Gastric Intubation w/ Lavage

Facility

$759.00

Service Code	HCPCS 43753
Hospital Charge Code	3304685
Hospital Revenue Code	450
Min. Negotiated Rate	$683.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$683.10
Rate for Payer: UnitedHealthcare Commercial	$721.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43753-Gastric Intubation w/ Lavage

Facility

$759.00

Service Code	HCPCS 43753
Hospital Charge Code	3304685
Hospital Revenue Code	450
Min. Negotiated Rate	$24.85
Max. Negotiated Rate	$721.05
Rate for Payer: UnitedHealthcare Medicaid	$24.85
Rate for Payer: WPPA Medicare Advantage	$455.40
Rate for Payer: Aetna Commercial	$683.10
Rate for Payer: Humana Medicare Advantage	$318.78
Rate for Payer: UnitedHealthcare Commercial	$721.05

43753 GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE CHARGE-ED

Facility

$759.00

Service Code	HCPCS 43753
Hospital Charge Code	3304685
Hospital Revenue Code	450
Min. Negotiated Rate	$24.85
Max. Negotiated Rate	$721.05
Rate for Payer: Aetna Commercial	$683.10
Rate for Payer: Humana Medicare Advantage	$318.78
Rate for Payer: UnitedHealthcare Commercial	$721.05
Rate for Payer: UnitedHealthcare Medicaid	$24.85
Rate for Payer: WPPA Medicare Advantage	$455.40

43753 GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE CHARGE-ED

Facility

$759.00

Service Code	HCPCS 43753
Hospital Charge Code	3304685
Hospital Revenue Code	450
Min. Negotiated Rate	$683.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$683.10
Rate for Payer: UnitedHealthcare Commercial	$721.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43753 NURSE INSERTED NG TUBE CHARGE

Facility

$188.00

Service Code	HCPCS 43753
Hospital Charge Code	3003792
Hospital Revenue Code	761
Min. Negotiated Rate	$24.85
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$24.85
Rate for Payer: WPPA Medicare Advantage	$112.80

Know your out-of-pocket cost for care.

All Charges