Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

43762 Change of gastrostomy tube-PF

Facility

$858.00

Service Code	HCPCS 43762
Hospital Charge Code	3353762
Hospital Revenue Code	761
Min. Negotiated Rate	$772.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$772.20
Rate for Payer: UnitedHealthcare Commercial	$815.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43762 Change of gastrostomy tube-PF

Facility

$858.00

Service Code	HCPCS 43762
Hospital Charge Code	3353762
Hospital Revenue Code	761
Min. Negotiated Rate	$150.42
Max. Negotiated Rate	$815.10
Rate for Payer: Aetna Commercial	$772.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$462.58
Rate for Payer: Humana Medicare Advantage	$360.36
Rate for Payer: UnitedHealthcare Commercial	$815.10
Rate for Payer: UnitedHealthcare Medicaid	$150.42
Rate for Payer: WPPA Medicare Advantage	$514.80

43762 Change of gastrostomy tube-Tech Fee

Facility

$858.00

Service Code	HCPCS 43762
Hospital Charge Code	3153760
Hospital Revenue Code	360
Min. Negotiated Rate	$772.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$772.20
Rate for Payer: UnitedHealthcare Commercial	$815.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43762 Change of gastrostomy tube-Tech Fee

Facility

$858.00

Service Code	HCPCS 43762
Hospital Charge Code	3153760
Hospital Revenue Code	360
Min. Negotiated Rate	$150.42
Max. Negotiated Rate	$815.10
Rate for Payer: Aetna Commercial	$772.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$462.58
Rate for Payer: Humana Medicare Advantage	$360.36
Rate for Payer: UnitedHealthcare Commercial	$815.10
Rate for Payer: UnitedHealthcare Medicaid	$150.42
Rate for Payer: WPPA Medicare Advantage	$514.80

43762-Replacement of gastrostomy tube

Facility

$610.00

Service Code	HCPCS 43762
Hospital Charge Code	3300235
Hospital Revenue Code	450
Min. Negotiated Rate	$549.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$549.00
Rate for Payer: UnitedHealthcare Commercial	$579.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43762-Replacement of gastrostomy tube

Facility

$610.00

Service Code	HCPCS 43762
Hospital Charge Code	3300235
Hospital Revenue Code	450
Min. Negotiated Rate	$150.42
Max. Negotiated Rate	$579.50
Rate for Payer: Aetna Commercial	$549.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$462.58
Rate for Payer: Humana Medicare Advantage	$256.20
Rate for Payer: UnitedHealthcare Commercial	$579.50
Rate for Payer: UnitedHealthcare Medicaid	$150.42
Rate for Payer: WPPA Medicare Advantage	$366.00

43762 Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imagi

Facility

$858.00

Service Code	HCPCS 43762
Hospital Charge Code	3300235
Hospital Revenue Code	450
Min. Negotiated Rate	$150.42
Max. Negotiated Rate	$815.10
Rate for Payer: Aetna Commercial	$772.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$462.58
Rate for Payer: Humana Medicare Advantage	$360.36
Rate for Payer: UnitedHealthcare Commercial	$815.10
Rate for Payer: UnitedHealthcare Medicaid	$150.42
Rate for Payer: WPPA Medicare Advantage	$514.80

43762 Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imagi

Facility

$858.00

Service Code	HCPCS 43762
Hospital Charge Code	3300235
Hospital Revenue Code	450
Min. Negotiated Rate	$772.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$772.20
Rate for Payer: UnitedHealthcare Commercial	$815.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restricti

Facility

$5,931.00

Service Code	HCPCS 43772
Hospital Charge Code	3153772
Hospital Revenue Code	360
Min. Negotiated Rate	$646.18
Max. Negotiated Rate	$5,634.45
Rate for Payer: Aetna Commercial	$5,337.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,847.03
Rate for Payer: Humana Medicare Advantage	$2,491.02
Rate for Payer: UnitedHealthcare Commercial	$5,634.45
Rate for Payer: UnitedHealthcare Medicaid	$646.18
Rate for Payer: WPPA Medicare Advantage	$3,558.60

43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restricti

Facility

$5,931.00

Service Code	HCPCS 43772
Hospital Charge Code	3153772
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,634.45
Rate for Payer: Aetna Commercial	$5,337.90
Rate for Payer: UnitedHealthcare Commercial	$5,634.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43830 Gastrostomy, open

Facility

$3,850.00

Service Code	HCPCS 43830
Hospital Charge Code	3153830
Hospital Revenue Code	360
Min. Negotiated Rate	$616.42
Max. Negotiated Rate	$3,657.50
Rate for Payer: Aetna Commercial	$3,465.00
Rate for Payer: Humana Medicare Advantage	$1,617.00
Rate for Payer: UnitedHealthcare Commercial	$3,657.50
Rate for Payer: UnitedHealthcare Medicaid	$616.42
Rate for Payer: WPPA Medicare Advantage	$2,310.00

43830 Gastrostomy, open

Facility

$3,850.00

Service Code	HCPCS 43830
Hospital Charge Code	3153830
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,657.50
Rate for Payer: Aetna Commercial	$3,465.00
Rate for Payer: UnitedHealthcare Commercial	$3,657.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43840 Other Procedures on the Stomach

Facility

$4,855.00

Service Code	HCPCS 43840
Hospital Charge Code	3153840
Hospital Revenue Code	360
Min. Negotiated Rate	$1,942.00
Max. Negotiated Rate	$4,612.25
Rate for Payer: Aetna Commercial	$4,369.50
Rate for Payer: Humana Medicare Advantage	$2,039.10
Rate for Payer: UnitedHealthcare Commercial	$4,612.25
Rate for Payer: UnitedHealthcare Medicaid	$1,942.00
Rate for Payer: WPPA Medicare Advantage	$2,913.00

43840 Other Procedures on the Stomach

Facility

$4,855.00

Service Code	HCPCS 43840
Hospital Charge Code	3153840
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,612.25
Rate for Payer: Aetna Commercial	$4,369.50
Rate for Payer: UnitedHealthcare Commercial	$4,612.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43999 UNLISTED PROCEDURE, STOMACH ProFee

Facility

$7,830.00

Service Code	HCPCS 43999
Hospital Charge Code	3153999
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,438.50
Rate for Payer: Aetna Commercial	$7,047.00
Rate for Payer: UnitedHealthcare Commercial	$7,438.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43999 UNLISTED PROCEDURE, STOMACH ProFee

Facility

$7,830.00

Service Code	HCPCS 43999
Hospital Charge Code	3153999
Hospital Revenue Code	360
Min. Negotiated Rate	$554.43
Max. Negotiated Rate	$7,438.50
Rate for Payer: Aetna Commercial	$7,047.00
Rate for Payer: Humana Medicare Advantage	$3,288.60
Rate for Payer: UnitedHealthcare Commercial	$7,438.50
Rate for Payer: UnitedHealthcare Medicaid	$554.43
Rate for Payer: WPPA Medicare Advantage	$4,698.00

44005 FREEING OF BOWEL ADHESION

Facility

$8,047.00

Service Code	HCPCS 44005
Hospital Charge Code	3150900
Hospital Revenue Code	360
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$7,644.65
Rate for Payer: Aetna Commercial	$7,242.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,291.49
Rate for Payer: Humana Medicare Advantage	$3,379.74
Rate for Payer: UnitedHealthcare Commercial	$7,644.65
Rate for Payer: UnitedHealthcare Medicaid	$520.00
Rate for Payer: WPPA Medicare Advantage	$4,828.20

44005 FREEING OF BOWEL ADHESION

Facility

$8,047.00

Service Code	HCPCS 44005
Hospital Charge Code	3150900
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,644.65
Rate for Payer: Aetna Commercial	$7,242.30
Rate for Payer: UnitedHealthcare Commercial	$7,644.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

44120 Enterectomy, resection of small intestine

Facility

$7,298.00

Service Code	HCPCS 44120
Hospital Charge Code	3154120
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,933.10
Rate for Payer: Aetna Commercial	$6,568.20
Rate for Payer: UnitedHealthcare Commercial	$6,933.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

44120 Enterectomy, resection of small intestine

Facility

$7,298.00

Service Code	HCPCS 44120
Hospital Charge Code	3154120
Hospital Revenue Code	360
Min. Negotiated Rate	$2,919.20
Max. Negotiated Rate	$6,933.10
Rate for Payer: Aetna Commercial	$6,568.20
Rate for Payer: Humana Medicare Advantage	$3,065.16
Rate for Payer: UnitedHealthcare Commercial	$6,933.10
Rate for Payer: UnitedHealthcare Medicaid	$2,919.20
Rate for Payer: WPPA Medicare Advantage	$4,378.80

44139 MOBILIZATION COLON [HGHO]

Facility

$557.00

Service Code	HCPCS 44139
Hospital Charge Code	3154139
Hospital Revenue Code	360
Min. Negotiated Rate	$222.80
Max. Negotiated Rate	$529.15
Rate for Payer: Aetna Commercial	$501.30
Rate for Payer: Humana Medicare Advantage	$233.94
Rate for Payer: UnitedHealthcare Commercial	$529.15
Rate for Payer: UnitedHealthcare Medicaid	$222.80
Rate for Payer: WPPA Medicare Advantage	$334.20

44139 MOBILIZATION COLON [HGHO]

Facility

$557.00

Service Code	HCPCS 44139
Hospital Charge Code	3154139
Hospital Revenue Code	360
Min. Negotiated Rate	$501.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$501.30
Rate for Payer: UnitedHealthcare Commercial	$529.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

44140 PARTIAL REMOVAL OF COLON

Facility

$4,635.00

Service Code	HCPCS 44140
Hospital Charge Code	3154140
Hospital Revenue Code	360
Min. Negotiated Rate	$1,854.00
Max. Negotiated Rate	$4,403.25
Rate for Payer: Aetna Commercial	$4,171.50
Rate for Payer: Humana Medicare Advantage	$1,946.70
Rate for Payer: UnitedHealthcare Commercial	$4,403.25
Rate for Payer: UnitedHealthcare Medicaid	$1,854.00
Rate for Payer: WPPA Medicare Advantage	$2,781.00

44140 PARTIAL REMOVAL OF COLON

Facility

$4,635.00

Service Code	HCPCS 44140
Hospital Charge Code	3154140
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,403.25
Rate for Payer: Aetna Commercial	$4,171.50
Rate for Payer: UnitedHealthcare Commercial	$4,403.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges