Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$210.00
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna Commercial	$450.00
Rate for Payer: Humana Medicare Advantage	$210.00
Rate for Payer: UnitedHealthcare Commercial	$475.00
Rate for Payer: UnitedHealthcare Medicaid	$228.80
Rate for Payer: WPPA Medicare Advantage	$300.00

64615 Chemodenervation of muscle(s); muscle(s) innervated nerves, bilateral

Facility

$500.00

Service Code	HCPCS 64615
Hospital Charge Code	3354615
Hospital Revenue Code	761
Min. Negotiated Rate	$123.45
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna Commercial	$450.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$293.63
Rate for Payer: Humana Medicare Advantage	$210.00
Rate for Payer: UnitedHealthcare Commercial	$475.00
Rate for Payer: UnitedHealthcare Medicaid	$123.45
Rate for Payer: WPPA Medicare Advantage	$300.00

64615 Chemodenervation of muscle(s); muscle(s) innervated nerves, bilateral

Facility

$500.00

Service Code	HCPCS 64615
Hospital Charge Code	3354615
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

64615 Profee Chemodenervation of Muscle(s) innervated by facial trigeminal, cervical spinal and aces

Facility

$286.00

Service Code	HCPCS 64615
Hospital Charge Code	SCC64615SP
Hospital Revenue Code	521
Min. Negotiated Rate	$257.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$257.40
Rate for Payer: UnitedHealthcare Commercial	$271.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64615 Profee Chemodenervation of Muscle(s) innervated by facial trigeminal, cervical spinal and aces

Facility

$286.00

Service Code	HCPCS 64615
Hospital Charge Code	SCC64615SP
Hospital Revenue Code	521
Min. Negotiated Rate	$120.12
Max. Negotiated Rate	$293.63
Rate for Payer: Aetna Commercial	$257.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$293.63
Rate for Payer: Humana Medicare Advantage	$120.12
Rate for Payer: UnitedHealthcare Commercial	$271.70
Rate for Payer: UnitedHealthcare Medicaid	$123.45
Rate for Payer: WPPA Medicare Advantage	$171.60

64616 Chemodenervation of muscle(s); neck muscle(s), unilateral

Facility

$500.00

Service Code	HCPCS 64616
Hospital Charge Code	3354616
Hospital Revenue Code	761
Min. Negotiated Rate	$136.70
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna Commercial	$450.00
Rate for Payer: Humana Medicare Advantage	$210.00
Rate for Payer: UnitedHealthcare Commercial	$475.00
Rate for Payer: UnitedHealthcare Medicaid	$136.70
Rate for Payer: WPPA Medicare Advantage	$300.00

64616 Chemodenervation of muscle(s); neck muscle(s), unilateral

Facility

$500.00

Service Code	HCPCS 64616
Hospital Charge Code	3354616
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

64620 Intercostal neurolysis

Facility

$1,102.00

Service Code	HCPCS 64620
Hospital Charge Code	3294620
Hospital Revenue Code	761
Min. Negotiated Rate	$295.27
Max. Negotiated Rate	$1,046.90
Rate for Payer: Aetna Commercial	$991.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$551.00
Rate for Payer: Humana Medicare Advantage	$462.84
Rate for Payer: UnitedHealthcare Commercial	$1,046.90
Rate for Payer: UnitedHealthcare Medicaid	$295.27
Rate for Payer: WPPA Medicare Advantage	$661.20

64620 Intercostal neurolysis

Facility

$1,102.00

Service Code	HCPCS 64620
Hospital Charge Code	3294620
Hospital Revenue Code	761
Min. Negotiated Rate	$991.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$991.80
Rate for Payer: UnitedHealthcare Commercial	$1,046.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when per

Facility

$1,132.00

Service Code	HCPCS 64624
Hospital Charge Code	3154624
Hospital Revenue Code	360
Min. Negotiated Rate	$475.44
Max. Negotiated Rate	$1,117.58
Rate for Payer: Aetna Commercial	$1,018.80
Rate for Payer: Humana Medicare Advantage	$475.44
Rate for Payer: UnitedHealthcare Commercial	$1,075.40
Rate for Payer: UnitedHealthcare Medicaid	$1,117.58
Rate for Payer: WPPA Medicare Advantage	$679.20

64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when per

Facility

$1,132.00

Service Code	HCPCS 64624
Hospital Charge Code	3154624
Hospital Revenue Code	360
Min. Negotiated Rate	$1,018.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,018.80
Rate for Payer: UnitedHealthcare Commercial	$1,075.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64624 Genicular knee ablation

Facility

$1,132.00

Service Code	HCPCS 64624
Hospital Charge Code	3154624
Hospital Revenue Code	360
Min. Negotiated Rate	$475.44
Max. Negotiated Rate	$1,117.58
Rate for Payer: Aetna Commercial	$1,018.80
Rate for Payer: Humana Medicare Advantage	$475.44
Rate for Payer: UnitedHealthcare Commercial	$1,075.40
Rate for Payer: UnitedHealthcare Medicaid	$1,117.58
Rate for Payer: WPPA Medicare Advantage	$679.20

64624 Genicular knee ablation

Facility

$1,132.00

Service Code	HCPCS 64624
Hospital Charge Code	3154624
Hospital Revenue Code	360
Min. Negotiated Rate	$1,018.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,018.80
Rate for Payer: UnitedHealthcare Commercial	$1,075.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64625 DESTRUCTION BY NEURO AGENT SACRAL JT W/IMAGE GUID

Facility

$633.00

Service Code	HCPCS 64625
Hospital Charge Code	3154625
Hospital Revenue Code	360
Min. Negotiated Rate	$569.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$569.70
Rate for Payer: UnitedHealthcare Commercial	$601.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64625 DESTRUCTION BY NEURO AGENT SACRAL JT W/IMAGE GUID

Facility

$633.00

Service Code	HCPCS 64625
Hospital Charge Code	3154625
Hospital Revenue Code	360
Min. Negotiated Rate	$265.86
Max. Negotiated Rate	$1,117.58
Rate for Payer: Aetna Commercial	$569.70
Rate for Payer: Humana Medicare Advantage	$265.86
Rate for Payer: UnitedHealthcare Commercial	$601.35
Rate for Payer: UnitedHealthcare Medicaid	$1,117.58
Rate for Payer: WPPA Medicare Advantage	$379.80

64632 CLTX DISTAL FEMORAL EPIPHYSL SEPARATION W/O MANJ

Facility

$420.00

Service Code	HCPCS 64632
Hospital Charge Code	3294632
Hospital Revenue Code	761
Min. Negotiated Rate	$111.07
Max. Negotiated Rate	$399.00
Rate for Payer: Aetna Commercial	$378.00
Rate for Payer: Humana Medicare Advantage	$176.40
Rate for Payer: UnitedHealthcare Commercial	$399.00
Rate for Payer: UnitedHealthcare Medicaid	$111.07
Rate for Payer: WPPA Medicare Advantage	$252.00

64632 CLTX DISTAL FEMORAL EPIPHYSL SEPARATION W/O MANJ

Facility

$420.00

Service Code	HCPCS 64632
Hospital Charge Code	3294632
Hospital Revenue Code	761
Min. Negotiated Rate	$378.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$378.00
Rate for Payer: UnitedHealthcare Commercial	$399.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64633 DESTR PV NERVE C/T BI CHARGE

Facility

$1,842.00

Service Code	HCPCS 64633
Hospital Charge Code	3154633
Hospital Revenue Code	360
Min. Negotiated Rate	$353.46
Max. Negotiated Rate	$1,749.90
Rate for Payer: Aetna Commercial	$1,657.80
Rate for Payer: Humana Medicare Advantage	$773.64
Rate for Payer: UnitedHealthcare Commercial	$1,749.90
Rate for Payer: UnitedHealthcare Medicaid	$353.46
Rate for Payer: WPPA Medicare Advantage	$1,105.20

64633 DESTR PV NERVE C/T BI CHARGE

Facility

$1,842.00

Service Code	HCPCS 64633
Hospital Charge Code	3154633
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,749.90
Rate for Payer: Aetna Commercial	$1,657.80
Rate for Payer: UnitedHealthcare Commercial	$1,749.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64634 DESTRUCTION BY NEURO AGENT PARAVERT CERVICAL OR THORACIC, EA ADD

Facility

$844.00

Service Code	HCPCS 64634
Hospital Charge Code	3184634
Hospital Revenue Code	360
Min. Negotiated Rate	$123.52
Max. Negotiated Rate	$801.80
Rate for Payer: Aetna Commercial	$759.60
Rate for Payer: Humana Medicare Advantage	$354.48
Rate for Payer: UnitedHealthcare Commercial	$801.80
Rate for Payer: UnitedHealthcare Medicaid	$123.52
Rate for Payer: WPPA Medicare Advantage	$506.40

64634 DESTRUCTION BY NEURO AGENT PARAVERT CERVICAL OR THORACIC, EA ADD

Facility

$844.00

Service Code	HCPCS 64634
Hospital Charge Code	3184634
Hospital Revenue Code	360
Min. Negotiated Rate	$759.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$759.60
Rate for Payer: UnitedHealthcare Commercial	$801.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64634 Radiofrequency ablation (RFA) _x0096_ cervical or thoracic (each additional joint)

Facility

$844.00

Service Code	HCPCS 64634
Hospital Charge Code	3154634
Hospital Revenue Code	360
Min. Negotiated Rate	$759.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$759.60
Rate for Payer: UnitedHealthcare Commercial	$801.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64634 Radiofrequency ablation (RFA) _x0096_ cervical or thoracic (each additional joint)

Facility

$844.00

Service Code	HCPCS 64634
Hospital Charge Code	3154634
Hospital Revenue Code	360
Min. Negotiated Rate	$123.52
Max. Negotiated Rate	$801.80
Rate for Payer: Aetna Commercial	$759.60
Rate for Payer: Humana Medicare Advantage	$354.48
Rate for Payer: UnitedHealthcare Commercial	$801.80
Rate for Payer: UnitedHealthcare Medicaid	$123.52
Rate for Payer: WPPA Medicare Advantage	$506.40

64635 DESTR PV NERVE L/S BI CHARGE

Facility

$1,810.00

Service Code	HCPCS 64635
Hospital Charge Code	3154635
Hospital Revenue Code	360
Min. Negotiated Rate	$609.97
Max. Negotiated Rate	$1,719.50
Rate for Payer: Aetna Commercial	$1,629.00
Rate for Payer: Humana Medicare Advantage	$760.20
Rate for Payer: UnitedHealthcare Commercial	$1,719.50
Rate for Payer: UnitedHealthcare Medicaid	$609.97
Rate for Payer: WPPA Medicare Advantage	$1,086.00

64635 DESTR PV NERVE L/S BI CHARGE

Facility

$1,810.00

Service Code	HCPCS 64635
Hospital Charge Code	3154635
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,719.50
Rate for Payer: Aetna Commercial	$1,629.00
Rate for Payer: UnitedHealthcare Commercial	$1,719.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges