Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

51798 MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON- TechFee

Facility

$180.00

Service Code	HCPCS 51798
Hospital Charge Code	3451998
Hospital Revenue Code	450
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$162.00
Rate for Payer: UnitedHealthcare Commercial	$171.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

51798 - Post-Voiding Residual Urine w/US

Facility

$164.00

Service Code	HCPCS 51798
Hospital Charge Code	3300415
Hospital Revenue Code	450
Min. Negotiated Rate	$147.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

51798 - Post-Voiding Residual Urine w/US

Facility

$164.00

Service Code	HCPCS 51798
Hospital Charge Code	3300415
Hospital Revenue Code	450
Min. Negotiated Rate	$67.67
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$147.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.67
Rate for Payer: Humana Medicare Advantage	$68.88
Rate for Payer: UnitedHealthcare Commercial	$155.80
Rate for Payer: UnitedHealthcare Medicaid	$156.00
Rate for Payer: WPPA Medicare Advantage	$98.40

51860 Cystorrhaphy, suture of bladder wound, injury or rupture; simple

Facility

$2,410.00

Service Code	HCPCS 51860
Hospital Charge Code	3151860
Hospital Revenue Code	360
Min. Negotiated Rate	$964.00
Max. Negotiated Rate	$2,289.50
Rate for Payer: Aetna Commercial	$2,169.00
Rate for Payer: Humana Medicare Advantage	$1,012.20
Rate for Payer: UnitedHealthcare Commercial	$2,289.50
Rate for Payer: UnitedHealthcare Medicaid	$964.00
Rate for Payer: WPPA Medicare Advantage	$1,446.00

51860 Cystorrhaphy, suture of bladder wound, injury or rupture; simple

Facility

$2,410.00

Service Code	HCPCS 51860
Hospital Charge Code	3151860
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,289.50
Rate for Payer: Aetna Commercial	$2,169.00
Rate for Payer: UnitedHealthcare Commercial	$2,289.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

52000 Cystourethroscopy (separate procedure)

Facility

$2,205.00

Service Code	HCPCS 52000
Hospital Charge Code	3350210
Hospital Revenue Code	761
Min. Negotiated Rate	$343.20
Max. Negotiated Rate	$2,094.75
Rate for Payer: Aetna Commercial	$1,984.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$757.36
Rate for Payer: Humana Medicare Advantage	$926.10
Rate for Payer: UnitedHealthcare Commercial	$2,094.75
Rate for Payer: UnitedHealthcare Medicaid	$343.20
Rate for Payer: WPPA Medicare Advantage	$1,323.00

52000 Cystourethroscopy (separate procedure)

Facility

$2,205.00

Service Code	HCPCS 52000
Hospital Charge Code	3350210
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,094.75
Rate for Payer: Aetna Commercial	$1,984.50
Rate for Payer: UnitedHealthcare Commercial	$2,094.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

52310 Cystourethroscopy, w/ removal of foreign body, calculus, or ureteral stent; simple

Facility

$3,110.00

Service Code	HCPCS 52310
Hospital Charge Code	3352310
Hospital Revenue Code	761
Min. Negotiated Rate	$659.82
Max. Negotiated Rate	$2,954.50
Rate for Payer: Aetna Commercial	$2,799.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,244.28
Rate for Payer: Humana Medicare Advantage	$1,306.20
Rate for Payer: UnitedHealthcare Commercial	$2,954.50
Rate for Payer: UnitedHealthcare Medicaid	$659.82
Rate for Payer: WPPA Medicare Advantage	$1,866.00

52310 Cystourethroscopy, w/ removal of foreign body, calculus, or ureteral stent; simple

Facility

$3,110.00

Service Code	HCPCS 52310
Hospital Charge Code	3352310
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,954.50
Rate for Payer: Aetna Commercial	$2,799.00
Rate for Payer: UnitedHealthcare Commercial	$2,954.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

52334 Cystourethroscopy with insertion of ureteral guide wire through kidney to establish a percutan

Facility

$3,996.00

Service Code	HCPCS 52334
Hospital Charge Code	3152334
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,796.20
Rate for Payer: Aetna Commercial	$3,596.40
Rate for Payer: UnitedHealthcare Commercial	$3,796.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

52334 Cystourethroscopy with insertion of ureteral guide wire through kidney to establish a percutan

Facility

$3,996.00

Service Code	HCPCS 52334
Hospital Charge Code	3152334
Hospital Revenue Code	360
Min. Negotiated Rate	$1,129.34
Max. Negotiated Rate	$3,796.20
Rate for Payer: Aetna Commercial	$3,596.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,721.95
Rate for Payer: Humana Medicare Advantage	$1,678.32
Rate for Payer: UnitedHealthcare Commercial	$3,796.20
Rate for Payer: UnitedHealthcare Medicaid	$1,129.34
Rate for Payer: WPPA Medicare Advantage	$2,397.60

53600 DILATION OF URETHRAL STRICTURE-ER SERV P

Facility

$2,854.00

Service Code	HCPCS 53600
Hospital Charge Code	3350245
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,711.30
Rate for Payer: Aetna Commercial	$2,568.60
Rate for Payer: UnitedHealthcare Commercial	$2,711.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

53600 DILATION OF URETHRAL STRICTURE-ER SERV P

Facility

$2,854.00

Service Code	HCPCS 53600
Hospital Charge Code	3350245
Hospital Revenue Code	761
Min. Negotiated Rate	$228.80
Max. Negotiated Rate	$2,711.30
Rate for Payer: Aetna Commercial	$2,568.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,980.61
Rate for Payer: Humana Medicare Advantage	$1,198.68
Rate for Payer: UnitedHealthcare Commercial	$2,711.30
Rate for Payer: UnitedHealthcare Medicaid	$228.80
Rate for Payer: WPPA Medicare Advantage	$1,712.40

54160 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of

Facility

$3,814.00

Service Code	HCPCS 54160
Hospital Charge Code	3150083
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,623.30
Rate for Payer: Aetna Commercial	$3,432.60
Rate for Payer: UnitedHealthcare Commercial	$3,623.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

54160 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of

Facility

$3,814.00

Service Code	HCPCS 54160
Hospital Charge Code	3150083
Hospital Revenue Code	360
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$3,623.30
Rate for Payer: Aetna Commercial	$3,432.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$1,601.88
Rate for Payer: UnitedHealthcare Commercial	$3,623.30
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$2,288.40

54161 Circumcision, surgical excision other than clamp, device, or dorsal slit, older than 28 days

Facility

$4,040.00

Service Code	HCPCS 54161
Hospital Charge Code	3150084
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,838.00
Rate for Payer: Aetna Commercial	$3,636.00
Rate for Payer: UnitedHealthcare Commercial	$3,838.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

54161 Circumcision, surgical excision other than clamp, device, or dorsal slit, older than 28 days

Facility

$4,040.00

Service Code	HCPCS 54161
Hospital Charge Code	3150084
Hospital Revenue Code	360
Min. Negotiated Rate	$659.82
Max. Negotiated Rate	$3,838.00
Rate for Payer: Aetna Commercial	$3,636.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,751.24
Rate for Payer: Humana Medicare Advantage	$1,696.80
Rate for Payer: UnitedHealthcare Commercial	$3,838.00
Rate for Payer: UnitedHealthcare Medicaid	$659.82
Rate for Payer: WPPA Medicare Advantage	$2,424.00

54520 Orchiectomy, simple, with or w/o testicular prosthesis, scrotal or inguinal approach

Facility

$1,231.00

Service Code	HCPCS 54520
Hospital Charge Code	3155205
Hospital Revenue Code	360
Min. Negotiated Rate	$1,107.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,107.90
Rate for Payer: UnitedHealthcare Commercial	$1,169.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

54520 Orchiectomy, simple, with or w/o testicular prosthesis, scrotal or inguinal approach

Facility

$1,231.00

Service Code	HCPCS 54520
Hospital Charge Code	3155205
Hospital Revenue Code	360
Min. Negotiated Rate	$517.02
Max. Negotiated Rate	$1,945.31
Rate for Payer: Aetna Commercial	$1,107.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,945.31
Rate for Payer: Humana Medicare Advantage	$517.02
Rate for Payer: UnitedHealthcare Commercial	$1,169.45
Rate for Payer: UnitedHealthcare Medicaid	$1,129.34
Rate for Payer: WPPA Medicare Advantage	$738.60

55250 Vasectomy, unilateral or bilateral, including postoperative semen examination(s)

Facility

$2,359.00

Service Code	HCPCS 55250
Hospital Charge Code	3350195
Hospital Revenue Code	761
Min. Negotiated Rate	$659.82
Max. Negotiated Rate	$2,244.28
Rate for Payer: Aetna Commercial	$2,123.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,244.28
Rate for Payer: Humana Medicare Advantage	$990.78
Rate for Payer: UnitedHealthcare Commercial	$2,241.05
Rate for Payer: UnitedHealthcare Medicaid	$659.82
Rate for Payer: WPPA Medicare Advantage	$1,415.40

55250 Vasectomy, unilateral or bilateral, including postoperative semen examination(s)

Facility

$2,359.00

Service Code	HCPCS 55250
Hospital Charge Code	3350195
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,241.05
Rate for Payer: Aetna Commercial	$2,123.10
Rate for Payer: UnitedHealthcare Commercial	$2,241.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

55250 VASECTOMY UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINAT

Facility

$3,110.00

Service Code	HCPCS 55250
Hospital Charge Code	3155250
Hospital Revenue Code	360
Min. Negotiated Rate	$659.82
Max. Negotiated Rate	$2,954.50
Rate for Payer: Aetna Commercial	$2,799.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,244.28
Rate for Payer: Humana Medicare Advantage	$1,306.20
Rate for Payer: UnitedHealthcare Commercial	$2,954.50
Rate for Payer: UnitedHealthcare Medicaid	$659.82
Rate for Payer: WPPA Medicare Advantage	$1,866.00

55250 VASECTOMY UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINAT

Facility

$3,110.00

Service Code	HCPCS 55250
Hospital Charge Code	3155250
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,954.50
Rate for Payer: Aetna Commercial	$2,799.00
Rate for Payer: UnitedHealthcare Commercial	$2,954.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

55250 VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN ProFee.

Facility

$3,110.00

Service Code	HCPCS 55250
Hospital Charge Code	3350195
Hospital Revenue Code	761
Min. Negotiated Rate	$659.82
Max. Negotiated Rate	$2,954.50
Rate for Payer: Aetna Commercial	$2,799.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,244.28
Rate for Payer: Humana Medicare Advantage	$1,306.20
Rate for Payer: UnitedHealthcare Commercial	$2,954.50
Rate for Payer: UnitedHealthcare Medicaid	$659.82
Rate for Payer: WPPA Medicare Advantage	$1,866.00

55250 VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN ProFee.

Facility

$3,110.00

Service Code	HCPCS 55250
Hospital Charge Code	3350195
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,954.50
Rate for Payer: Aetna Commercial	$2,799.00
Rate for Payer: UnitedHealthcare Commercial	$2,954.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges