Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

44373 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileu

Facility

$1,631.00

Service Code	HCPCS 44373
Hospital Charge Code	3154373
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,549.45
Rate for Payer: Aetna Commercial	$1,467.90
Rate for Payer: UnitedHealthcare Commercial	$1,549.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

44500 INTRODUCTION LONG GI TUBE SEPARATE PROCEDURE Tech Fee

Facility

$146.00

Service Code	HCPCS 44500
Hospital Charge Code	3304500
Hospital Revenue Code	450
Min. Negotiated Rate	$131.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$131.40
Rate for Payer: UnitedHealthcare Commercial	$138.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

44500 INTRODUCTION LONG GI TUBE SEPARATE PROCEDURE Tech Fee

Facility

$146.00

Service Code	HCPCS 44500
Hospital Charge Code	3304500
Hospital Revenue Code	450
Min. Negotiated Rate	$58.40
Max. Negotiated Rate	$138.70
Rate for Payer: Aetna Commercial	$131.40
Rate for Payer: Humana Medicare Advantage	$61.32
Rate for Payer: UnitedHealthcare Commercial	$138.70
Rate for Payer: UnitedHealthcare Medicaid	$58.40
Rate for Payer: WPPA Medicare Advantage	$87.60

44603 SUTOFSMALLINTESTPRO [HGHO]

Facility

$4,652.00

Service Code	HCPCS 44603
Hospital Charge Code	3154603
Hospital Revenue Code	360
Min. Negotiated Rate	$1,860.80
Max. Negotiated Rate	$4,419.40
Rate for Payer: Aetna Commercial	$4,186.80
Rate for Payer: Humana Medicare Advantage	$1,953.84
Rate for Payer: UnitedHealthcare Commercial	$4,419.40
Rate for Payer: UnitedHealthcare Medicaid	$1,860.80
Rate for Payer: WPPA Medicare Advantage	$2,791.20

44603 SUTOFSMALLINTESTPRO [HGHO]

Facility

$4,652.00

Service Code	HCPCS 44603
Hospital Charge Code	3154603
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,419.40
Rate for Payer: Aetna Commercial	$4,186.80
Rate for Payer: UnitedHealthcare Commercial	$4,419.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

44620 REPAIR BOWEL OPENING,CLOSURE

Facility

$5,972.00

Service Code	HCPCS 44620
Hospital Charge Code	3156204
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,673.40
Rate for Payer: Aetna Commercial	$5,374.80
Rate for Payer: UnitedHealthcare Commercial	$5,673.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

44620 REPAIR BOWEL OPENING,CLOSURE

Facility

$5,972.00

Service Code	HCPCS 44620
Hospital Charge Code	3156204
Hospital Revenue Code	360
Min. Negotiated Rate	$2,388.80
Max. Negotiated Rate	$5,673.40
Rate for Payer: Aetna Commercial	$5,374.80
Rate for Payer: Humana Medicare Advantage	$2,508.24
Rate for Payer: UnitedHealthcare Commercial	$5,673.40
Rate for Payer: UnitedHealthcare Medicaid	$2,388.80
Rate for Payer: WPPA Medicare Advantage	$3,583.20

44625 Closure of enterostomy, large or small intestine

Facility

$5,073.00

Service Code	HCPCS 44625
Hospital Charge Code	3154625
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,819.35
Rate for Payer: Aetna Commercial	$4,565.70
Rate for Payer: UnitedHealthcare Commercial	$4,819.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

44625 Closure of enterostomy, large or small intestine

Facility

$5,073.00

Service Code	HCPCS 44625
Hospital Charge Code	3154625
Hospital Revenue Code	360
Min. Negotiated Rate	$2,029.20
Max. Negotiated Rate	$4,819.35
Rate for Payer: Aetna Commercial	$4,565.70
Rate for Payer: Humana Medicare Advantage	$2,130.66
Rate for Payer: UnitedHealthcare Commercial	$4,819.35
Rate for Payer: UnitedHealthcare Medicaid	$2,029.20
Rate for Payer: WPPA Medicare Advantage	$3,043.80

44800 EXCISION OF BOWEL POUCH

Facility

$6,302.00

Service Code	HCPCS 44800
Hospital Charge Code	3154800
Hospital Revenue Code	360
Min. Negotiated Rate	$2,520.80
Max. Negotiated Rate	$5,986.90
Rate for Payer: Aetna Commercial	$5,671.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,291.49
Rate for Payer: Humana Medicare Advantage	$2,646.84
Rate for Payer: UnitedHealthcare Commercial	$5,986.90
Rate for Payer: UnitedHealthcare Medicaid	$2,520.80
Rate for Payer: WPPA Medicare Advantage	$3,781.20

44800 EXCISION OF BOWEL POUCH

Facility

$6,302.00

Service Code	HCPCS 44800
Hospital Charge Code	3154800
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,986.90
Rate for Payer: Aetna Commercial	$5,671.80
Rate for Payer: UnitedHealthcare Commercial	$5,986.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

44970 Laparoscopic Procedures on the Appendix

Facility

$9,215.00

Service Code	HCPCS 44970
Hospital Charge Code	3150241
Hospital Revenue Code	360
Min. Negotiated Rate	$1,869.18
Max. Negotiated Rate	$8,754.25
Rate for Payer: Aetna Commercial	$8,293.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5,451.98
Rate for Payer: Humana Medicare Advantage	$3,870.30
Rate for Payer: UnitedHealthcare Commercial	$8,754.25
Rate for Payer: UnitedHealthcare Medicaid	$1,869.18
Rate for Payer: WPPA Medicare Advantage	$5,529.00

44970 Laparoscopic Procedures on the Appendix

Facility

$9,215.00

Service Code	HCPCS 44970
Hospital Charge Code	3150241
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,754.25
Rate for Payer: Aetna Commercial	$8,293.50
Rate for Payer: UnitedHealthcare Commercial	$8,754.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

45171 Excision of rectal tumor, transanal approach; not including muscularis propria

Facility

$2,730.00

Service Code	HCPCS 45171
Hospital Charge Code	3155171
Hospital Revenue Code	360
Min. Negotiated Rate	$511.23
Max. Negotiated Rate	$2,593.50
Rate for Payer: Aetna Commercial	$2,457.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,211.29
Rate for Payer: Humana Medicare Advantage	$1,146.60
Rate for Payer: UnitedHealthcare Commercial	$2,593.50
Rate for Payer: UnitedHealthcare Medicaid	$511.23
Rate for Payer: WPPA Medicare Advantage	$1,638.00

45171 Excision of rectal tumor, transanal approach; not including muscularis propria

Facility

$2,730.00

Service Code	HCPCS 45171
Hospital Charge Code	3155171
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,593.50
Rate for Payer: Aetna Commercial	$2,457.00
Rate for Payer: UnitedHealthcare Commercial	$2,593.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

45172 EXC RCT TUM INCL MUSCULARIS PROPRIA Tech Charge

Facility

$4,001.00

Service Code	HCPCS 45172
Hospital Charge Code	3405172
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,800.95
Rate for Payer: Aetna Commercial	$3,600.90
Rate for Payer: UnitedHealthcare Commercial	$3,800.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

45172 EXC RCT TUM INCL MUSCULARIS PROPRIA Tech Charge

Facility

$4,001.00

Service Code	HCPCS 45172
Hospital Charge Code	3405172
Hospital Revenue Code	360
Min. Negotiated Rate	$868.23
Max. Negotiated Rate	$3,800.95
Rate for Payer: Aetna Commercial	$3,600.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,211.29
Rate for Payer: Humana Medicare Advantage	$1,680.42
Rate for Payer: UnitedHealthcare Commercial	$3,800.95
Rate for Payer: UnitedHealthcare Medicaid	$868.23
Rate for Payer: WPPA Medicare Advantage	$2,400.60

45300 Proctosigmoidoscopy, rigid

Facility

$1,246.00

Service Code	HCPCS 45300
Hospital Charge Code	3155300
Hospital Revenue Code	360
Min. Negotiated Rate	$296.08
Max. Negotiated Rate	$1,183.70
Rate for Payer: Aetna Commercial	$1,121.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$808.00
Rate for Payer: Humana Medicare Advantage	$523.32
Rate for Payer: UnitedHealthcare Commercial	$1,183.70
Rate for Payer: UnitedHealthcare Medicaid	$296.08
Rate for Payer: WPPA Medicare Advantage	$747.60

45300 Proctosigmoidoscopy, rigid

Facility

$1,246.00

Service Code	HCPCS 45300
Hospital Charge Code	3155300
Hospital Revenue Code	360
Min. Negotiated Rate	$1,121.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,121.40
Rate for Payer: UnitedHealthcare Commercial	$1,183.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

45330 FLEXIBLE SIGMOIDOSCOPY Charges

Facility

$2,589.00

Service Code	HCPCS 45330
Hospital Charge Code	3155330
Hospital Revenue Code	360
Min. Negotiated Rate	$296.08
Max. Negotiated Rate	$2,459.55
Rate for Payer: Aetna Commercial	$2,330.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$808.00
Rate for Payer: Humana Medicare Advantage	$1,087.38
Rate for Payer: UnitedHealthcare Commercial	$2,459.55
Rate for Payer: UnitedHealthcare Medicaid	$296.08
Rate for Payer: WPPA Medicare Advantage	$1,553.40

45330 FLEXIBLE SIGMOIDOSCOPY Charges

Facility

$2,589.00

Service Code	HCPCS 45330
Hospital Charge Code	3155330
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,459.55
Rate for Payer: Aetna Commercial	$2,330.10
Rate for Payer: UnitedHealthcare Commercial	$2,459.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

45331 FLEXIBLE SIGMOIDOSCOPY W/BIOPSY Charges

Facility

$1,599.00

Service Code	HCPCS 45331
Hospital Charge Code	3150438
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

45331 FLEXIBLE SIGMOIDOSCOPY W/BIOPSY Charges

Facility

$1,599.00

Service Code	HCPCS 45331
Hospital Charge Code	3150438
Hospital Revenue Code	360
Min. Negotiated Rate	$296.08
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$808.00
Rate for Payer: Humana Medicare Advantage	$671.58
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: UnitedHealthcare Medicaid	$296.08
Rate for Payer: WPPA Medicare Advantage	$959.40

45333 SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT ProFee

Facility

$1,599.00

Service Code	HCPCS 45333
Hospital Charge Code	3150921
Hospital Revenue Code	360
Min. Negotiated Rate	$296.08
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$808.00
Rate for Payer: Humana Medicare Advantage	$671.58
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: UnitedHealthcare Medicaid	$296.08
Rate for Payer: WPPA Medicare Advantage	$959.40

45333 SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT ProFee

Facility

$1,599.00

Service Code	HCPCS 45333
Hospital Charge Code	3150921
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges