Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

64450 Injection, anesthetic agent; other peripheral nerve or branch

Facility

$1,519.00

Service Code	HCPCS 64450
Hospital Charge Code	3294450
Hospital Revenue Code	761
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 Injection, anesthetic agent; other peripheral nerve or branch

Facility

$1,519.00

Service Code	HCPCS 64450
Hospital Charge Code	3294450
Hospital Revenue Code	761
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

64450-Injection Nerve Block Peripheral

Facility

$1,066.00

Service Code	HCPCS 64450
Hospital Charge Code	3300189
Hospital Revenue Code	450
Min. Negotiated Rate	$959.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$959.40
Rate for Payer: UnitedHealthcare Commercial	$1,012.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64450-Injection Nerve Block Peripheral

Facility

$1,066.00

Service Code	HCPCS 64450
Hospital Charge Code	3300189
Hospital Revenue Code	450
Min. Negotiated Rate	$224.03
Max. Negotiated Rate	$1,012.70
Rate for Payer: Aetna Commercial	$959.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$859.51
Rate for Payer: Humana Medicare Advantage	$447.72
Rate for Payer: UnitedHealthcare Commercial	$1,012.70
Rate for Payer: UnitedHealthcare Medicaid	$224.03
Rate for Payer: WPPA Medicare Advantage	$639.60

64454 Genicular Nerve Block

Facility

$1,141.00

Service Code	HCPCS 64454
Hospital Charge Code	3154454
Hospital Revenue Code	360
Min. Negotiated Rate	$406.28
Max. Negotiated Rate	$1,083.95
Rate for Payer: Aetna Commercial	$1,026.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$823.63
Rate for Payer: Humana Medicare Advantage	$479.22
Rate for Payer: UnitedHealthcare Commercial	$1,083.95
Rate for Payer: UnitedHealthcare Medicaid	$406.28
Rate for Payer: WPPA Medicare Advantage	$684.60

64454 Genicular Nerve Block

Facility

$1,141.00

Service Code	HCPCS 64454
Hospital Charge Code	3154454
Hospital Revenue Code	360
Min. Negotiated Rate	$1,026.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,026.90
Rate for Payer: UnitedHealthcare Commercial	$1,083.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64454 Genicular Nerve Block HMC

Facility

$756.00

Service Code	HCPCS 64454
Hospital Charge Code	3154454
Hospital Revenue Code	360
Min. Negotiated Rate	$680.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$680.40
Rate for Payer: UnitedHealthcare Commercial	$718.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64454 Genicular Nerve Block HMC

Facility

$756.00

Service Code	HCPCS 64454
Hospital Charge Code	3154454
Hospital Revenue Code	360
Min. Negotiated Rate	$317.52
Max. Negotiated Rate	$823.63
Rate for Payer: Aetna Commercial	$680.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$823.63
Rate for Payer: Humana Medicare Advantage	$317.52
Rate for Payer: UnitedHealthcare Commercial	$718.20
Rate for Payer: UnitedHealthcare Medicaid	$406.28
Rate for Payer: WPPA Medicare Advantage	$453.60

64455 Injection,anesthetic agent and/or steroid, plantar common digital nerve(s)

Facility

$678.00

Service Code	HCPCS 64455
Hospital Charge Code	3350235
Hospital Revenue Code	761
Min. Negotiated Rate	$111.07
Max. Negotiated Rate	$644.10
Rate for Payer: Aetna Commercial	$610.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$368.20
Rate for Payer: Humana Medicare Advantage	$284.76
Rate for Payer: UnitedHealthcare Commercial	$644.10
Rate for Payer: UnitedHealthcare Medicaid	$111.07
Rate for Payer: WPPA Medicare Advantage	$406.80

64455 Injection,anesthetic agent and/or steroid, plantar common digital nerve(s)

Facility

$678.00

Service Code	HCPCS 64455
Hospital Charge Code	3350235
Hospital Revenue Code	761
Min. Negotiated Rate	$610.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$610.20
Rate for Payer: UnitedHealthcare Commercial	$644.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64480 EPIDURAL STEROID INJECTION CERVICAL

Facility

$881.00

Service Code	HCPCS 64480
Hospital Charge Code	3154480
Hospital Revenue Code	360
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$836.95
Rate for Payer: Aetna Commercial	$792.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.47
Rate for Payer: Humana Medicare Advantage	$370.02
Rate for Payer: UnitedHealthcare Commercial	$836.95
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$528.60

64480 EPIDURAL STEROID INJECTION CERVICAL

Facility

$881.00

Service Code	HCPCS 64480
Hospital Charge Code	3154480
Hospital Revenue Code	360
Min. Negotiated Rate	$792.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$792.90
Rate for Payer: UnitedHealthcare Commercial	$836.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64493 FACET JOINT INJECTION

Facility

$966.00

Service Code	HCPCS 64493
Hospital Charge Code	3154493
Hospital Revenue Code	360
Min. Negotiated Rate	$260.80
Max. Negotiated Rate	$917.70
Rate for Payer: Aetna Commercial	$869.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$692.03
Rate for Payer: Humana Medicare Advantage	$405.72
Rate for Payer: UnitedHealthcare Commercial	$917.70
Rate for Payer: UnitedHealthcare Medicaid	$260.80
Rate for Payer: WPPA Medicare Advantage	$579.60

64493 FACET JOINT INJECTION

Facility

$966.00

Service Code	HCPCS 64493
Hospital Charge Code	3154493
Hospital Revenue Code	360
Min. Negotiated Rate	$869.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$869.40
Rate for Payer: UnitedHealthcare Commercial	$917.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64505 BLOCK SPHENOPALATINE GANGLION

Facility

$1,364.00

Service Code	HCPCS 64505
Hospital Charge Code	3154505
Hospital Revenue Code	360
Min. Negotiated Rate	$143.00
Max. Negotiated Rate	$1,295.80
Rate for Payer: Aetna Commercial	$1,227.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$983.74
Rate for Payer: Humana Medicare Advantage	$572.88
Rate for Payer: UnitedHealthcare Commercial	$1,295.80
Rate for Payer: UnitedHealthcare Medicaid	$143.00
Rate for Payer: WPPA Medicare Advantage	$818.40

64505 BLOCK SPHENOPALATINE GANGLION

Facility

$1,364.00

Service Code	HCPCS 64505
Hospital Charge Code	3154505
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,295.80
Rate for Payer: Aetna Commercial	$1,227.60
Rate for Payer: UnitedHealthcare Commercial	$1,295.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64510 BLOCK STELLATE GANGLION

Facility

$992.00

Service Code	HCPCS 64510
Hospital Charge Code	3154510
Hospital Revenue Code	360
Min. Negotiated Rate	$892.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$892.80
Rate for Payer: UnitedHealthcare Commercial	$942.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64510 BLOCK STELLATE GANGLION

Facility

$992.00

Service Code	HCPCS 64510
Hospital Charge Code	3154510
Hospital Revenue Code	360
Min. Negotiated Rate	$295.27
Max. Negotiated Rate	$942.40
Rate for Payer: Aetna Commercial	$892.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$715.08
Rate for Payer: Humana Medicare Advantage	$416.64
Rate for Payer: UnitedHealthcare Commercial	$942.40
Rate for Payer: UnitedHealthcare Medicaid	$295.27
Rate for Payer: WPPA Medicare Advantage	$595.20

64568 Incision for implantation of cranial nerve neuro electrode array and pulse generator

Facility

$73,196.00

Service Code	HCPCS 64568
Hospital Charge Code	3154568
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$69,536.20
Rate for Payer: Aetna Commercial	$65,876.40
Rate for Payer: UnitedHealthcare Commercial	$69,536.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64568 Incision for implantation of cranial nerve neuro electrode array and pulse generator

Facility

$73,196.00

Service Code	HCPCS 64568
Hospital Charge Code	3154568
Hospital Revenue Code	360
Min. Negotiated Rate	$21,840.00
Max. Negotiated Rate	$69,536.20
Rate for Payer: Aetna Commercial	$65,876.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31,428.86
Rate for Payer: Humana Medicare Advantage	$30,742.32
Rate for Payer: UnitedHealthcare Commercial	$69,536.20
Rate for Payer: UnitedHealthcare Medicaid	$21,840.00
Rate for Payer: WPPA Medicare Advantage	$43,917.60

64611 Chemodenervation of parotid and submandibular salivary glands, bilateral

Facility

$270.00

Service Code	HCPCS 64611
Hospital Charge Code	3364611
Hospital Revenue Code	761
Min. Negotiated Rate	$243.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$243.00
Rate for Payer: UnitedHealthcare Commercial	$256.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64611 Chemodenervation of parotid and submandibular salivary glands, bilateral

Facility

$270.00

Service Code	HCPCS 64611
Hospital Charge Code	3364611
Hospital Revenue Code	761
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$256.50
Rate for Payer: Aetna Commercial	$243.00
Rate for Payer: Humana Medicare Advantage	$113.40
Rate for Payer: UnitedHealthcare Commercial	$256.50
Rate for Payer: UnitedHealthcare Medicaid	$108.00
Rate for Payer: WPPA Medicare Advantage	$162.00

64611 CHEMODENERVATION OF PAROTID AND SUBMANDIBULAR SALIVARY GLANDS, BILATERAL ProFee

Facility

$270.00

Service Code	HCPCS 64611
Hospital Charge Code	3364611
Hospital Revenue Code	761
Min. Negotiated Rate	$243.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$243.00
Rate for Payer: UnitedHealthcare Commercial	$256.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64611 CHEMODENERVATION OF PAROTID AND SUBMANDIBULAR SALIVARY GLANDS, BILATERAL ProFee

Facility

$270.00

Service Code	HCPCS 64611
Hospital Charge Code	3364611
Hospital Revenue Code	761
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$256.50
Rate for Payer: Aetna Commercial	$243.00
Rate for Payer: Humana Medicare Advantage	$113.40
Rate for Payer: UnitedHealthcare Commercial	$256.50
Rate for Payer: UnitedHealthcare Medicaid	$108.00
Rate for Payer: WPPA Medicare Advantage	$162.00

64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral

Facility

$500.00

Service Code	HCPCS 64612
Hospital Charge Code	3354612
Hospital Revenue Code	761
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$450.00
Rate for Payer: UnitedHealthcare Commercial	$475.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

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