Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

62326 EPIDURAL INFUSION LUMBAR/SACRAL CHARGE

Facility

$1,368.00

Service Code	HCPCS 62326
Hospital Charge Code	3152326
Hospital Revenue Code	360
Min. Negotiated Rate	$475.10
Max. Negotiated Rate	$1,299.60
Rate for Payer: Aetna Commercial	$1,231.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$588.83
Rate for Payer: Humana Medicare Advantage	$574.56
Rate for Payer: UnitedHealthcare Commercial	$1,299.60
Rate for Payer: UnitedHealthcare Medicaid	$475.10
Rate for Payer: WPPA Medicare Advantage	$820.80

62368 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG I ProFee

Facility

$82.00

Service Code	HCPCS 62368
Hospital Charge Code	3182368
Hospital Revenue Code	360
Min. Negotiated Rate	$73.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$73.80
Rate for Payer: UnitedHealthcare Commercial	$77.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

62368 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG I ProFee

Facility

$82.00

Service Code	HCPCS 62368
Hospital Charge Code	3182368
Hospital Revenue Code	360
Min. Negotiated Rate	$34.44
Max. Negotiated Rate	$140.13
Rate for Payer: Aetna Commercial	$73.80
Rate for Payer: Humana Medicare Advantage	$34.44
Rate for Payer: UnitedHealthcare Commercial	$77.90
Rate for Payer: UnitedHealthcare Medicaid	$140.13
Rate for Payer: WPPA Medicare Advantage	$49.20

62370 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG I ProFee

Facility

$750.00

Service Code	HCPCS 62370
Hospital Charge Code	3182370
Hospital Revenue Code	360
Min. Negotiated Rate	$113.14
Max. Negotiated Rate	$712.50
Rate for Payer: Aetna Commercial	$675.00
Rate for Payer: Humana Medicare Advantage	$315.00
Rate for Payer: UnitedHealthcare Commercial	$712.50
Rate for Payer: UnitedHealthcare Medicaid	$113.14
Rate for Payer: WPPA Medicare Advantage	$450.00

62370 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG I ProFee

Facility

$750.00

Service Code	HCPCS 62370
Hospital Charge Code	3182370
Hospital Revenue Code	360
Min. Negotiated Rate	$675.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$675.00
Rate for Payer: UnitedHealthcare Commercial	$712.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

62370 PAIN PF/TECH ANAL SP INF PUMP REPROG/REFILL

Facility

$750.00

Service Code	HCPCS 62370
Hospital Charge Code	3192370
Hospital Revenue Code	360
Min. Negotiated Rate	$113.14
Max. Negotiated Rate	$712.50
Rate for Payer: Aetna Commercial	$675.00
Rate for Payer: Humana Medicare Advantage	$315.00
Rate for Payer: UnitedHealthcare Commercial	$712.50
Rate for Payer: UnitedHealthcare Medicaid	$113.14
Rate for Payer: WPPA Medicare Advantage	$450.00

62370 PAIN PF/TECH ANAL SP INF PUMP REPROG/REFILL

Facility

$750.00

Service Code	HCPCS 62370
Hospital Charge Code	3192370
Hospital Revenue Code	360
Min. Negotiated Rate	$675.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$675.00
Rate for Payer: UnitedHealthcare Commercial	$712.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

63688 IPG explant/revision

Facility

$3,385.00

Service Code	HCPCS 63688
Hospital Charge Code	3153688
Hospital Revenue Code	360
Min. Negotiated Rate	$1,354.00
Max. Negotiated Rate	$3,215.75
Rate for Payer: Aetna Commercial	$3,046.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,563.38
Rate for Payer: Humana Medicare Advantage	$1,421.70
Rate for Payer: UnitedHealthcare Commercial	$3,215.75
Rate for Payer: UnitedHealthcare Medicaid	$1,354.00
Rate for Payer: WPPA Medicare Advantage	$2,031.00

63688 IPG explant/revision

Facility

$3,385.00

Service Code	HCPCS 63688
Hospital Charge Code	3153688
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,215.75
Rate for Payer: Aetna Commercial	$3,046.50
Rate for Payer: UnitedHealthcare Commercial	$3,215.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64400 Inject, anes agent and/or steroid; Trigeminal Nerve, each branch

Facility

$707.00

Service Code	HCPCS 64400
Hospital Charge Code	3354400
Hospital Revenue Code	761
Min. Negotiated Rate	$636.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$636.30
Rate for Payer: UnitedHealthcare Commercial	$671.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64400 Inject, anes agent and/or steroid; Trigeminal Nerve, each branch

Facility

$707.00

Service Code	HCPCS 64400
Hospital Charge Code	3354400
Hospital Revenue Code	761
Min. Negotiated Rate	$282.80
Max. Negotiated Rate	$671.65
Rate for Payer: Aetna Commercial	$636.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$361.58
Rate for Payer: Humana Medicare Advantage	$296.94
Rate for Payer: UnitedHealthcare Commercial	$671.65
Rate for Payer: UnitedHealthcare Medicaid	$282.80
Rate for Payer: WPPA Medicare Advantage	$424.20

64400-Injection Nerve Block Trigeminal

Facility

$620.00

Service Code	HCPCS 64400
Hospital Charge Code	3304400
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

64400-Injection Nerve Block Trigeminal

Facility

$620.00

Service Code	HCPCS 64400
Hospital Charge Code	3304400
Hospital Revenue Code	450
Min. Negotiated Rate	$248.00
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$361.58
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

64405 BLOCK OCCIPITAL NERVE

Facility

$583.00

Service Code	HCPCS 64405
Hospital Charge Code	3150760
Hospital Revenue Code	360
Min. Negotiated Rate	$192.19
Max. Negotiated Rate	$553.85
Rate for Payer: Aetna Commercial	$524.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$319.16
Rate for Payer: Humana Medicare Advantage	$244.86
Rate for Payer: UnitedHealthcare Commercial	$553.85
Rate for Payer: UnitedHealthcare Medicaid	$192.19
Rate for Payer: WPPA Medicare Advantage	$349.80

64405 BLOCK OCCIPITAL NERVE

Facility

$583.00

Service Code	HCPCS 64405
Hospital Charge Code	3150760
Hospital Revenue Code	360
Min. Negotiated Rate	$524.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$524.70
Rate for Payer: UnitedHealthcare Commercial	$553.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64405 Injection, anesthetic agent; greater occipital nerve

Facility

$583.00

Service Code	HCPCS 64405
Hospital Charge Code	3354405
Hospital Revenue Code	761
Min. Negotiated Rate	$524.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$524.70
Rate for Payer: UnitedHealthcare Commercial	$553.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64405 Injection, anesthetic agent; greater occipital nerve

Facility

$583.00

Service Code	HCPCS 64405
Hospital Charge Code	3354405
Hospital Revenue Code	761
Min. Negotiated Rate	$192.19
Max. Negotiated Rate	$553.85
Rate for Payer: Aetna Commercial	$524.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$319.16
Rate for Payer: Humana Medicare Advantage	$244.86
Rate for Payer: UnitedHealthcare Commercial	$553.85
Rate for Payer: UnitedHealthcare Medicaid	$192.19
Rate for Payer: WPPA Medicare Advantage	$349.80

64405 Profee Greater Occipital Nerve

Facility

$208.00

Service Code	HCPCS 64405
Hospital Charge Code	SCC64405SP
Hospital Revenue Code	521
Min. Negotiated Rate	$187.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: UnitedHealthcare Commercial	$197.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64405 Profee Greater Occipital Nerve

Facility

$208.00

Service Code	HCPCS 64405
Hospital Charge Code	SCC64405SP
Hospital Revenue Code	521
Min. Negotiated Rate	$87.36
Max. Negotiated Rate	$319.16
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$319.16
Rate for Payer: Humana Medicare Advantage	$87.36
Rate for Payer: UnitedHealthcare Commercial	$197.60
Rate for Payer: UnitedHealthcare Medicaid	$192.19
Rate for Payer: WPPA Medicare Advantage	$124.80

64417 Axillary nerve inj

Facility

$455.00

Service Code	HCPCS 64417
Hospital Charge Code	3154417
Hospital Revenue Code	360
Min. Negotiated Rate	$409.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$409.50
Rate for Payer: UnitedHealthcare Commercial	$432.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64417 Axillary nerve inj

Facility

$455.00

Service Code	HCPCS 64417
Hospital Charge Code	3154417
Hospital Revenue Code	360
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$432.25
Rate for Payer: Aetna Commercial	$409.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$191.10
Rate for Payer: UnitedHealthcare Commercial	$432.25
Rate for Payer: UnitedHealthcare Medicaid	$295.27
Rate for Payer: WPPA Medicare Advantage	$273.00

64425 INJECTION ANESTHETIC AGENT ILIOINGU-ER P

Facility

$620.00

Service Code	HCPCS 64425
Hospital Charge Code	3294425
Hospital Revenue Code	761
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

64425 INJECTION ANESTHETIC AGENT ILIOINGU-ER P

Facility

$620.00

Service Code	HCPCS 64425
Hospital Charge Code	3294425
Hospital Revenue Code	761
Min. Negotiated Rate	$224.03
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$224.03
Rate for Payer: WPPA Medicare Advantage	$372.00

64450 ED Tech Inject Anesthetic Agent, Other Peripheral Nerve or Branch

Facility

$1,519.00

Service Code	HCPCS 64450
Hospital Charge Code	3304450
Hospital Revenue Code	450
Min. Negotiated Rate	$224.03
Max. Negotiated Rate	$1,443.05
Rate for Payer: Aetna Commercial	$1,367.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$859.51
Rate for Payer: Humana Medicare Advantage	$637.98
Rate for Payer: UnitedHealthcare Commercial	$1,443.05
Rate for Payer: UnitedHealthcare Medicaid	$224.03
Rate for Payer: WPPA Medicare Advantage	$911.40

64450 ED Tech Inject Anesthetic Agent, Other Peripheral Nerve or Branch

Facility

$1,519.00

Service Code	HCPCS 64450
Hospital Charge Code	3304450
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,443.05
Rate for Payer: Aetna Commercial	$1,367.10
Rate for Payer: UnitedHealthcare Commercial	$1,443.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges