Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

64636 ABLATION RADIOFREQUENCY ADDL LEVEL

Facility

$759.00

Service Code	HCPCS 64636
Hospital Charge Code	3154636
Hospital Revenue Code	360
Min. Negotiated Rate	$318.78
Max. Negotiated Rate	$721.05
Rate for Payer: Aetna Commercial	$683.10
Rate for Payer: Humana Medicare Advantage	$318.78
Rate for Payer: UnitedHealthcare Commercial	$721.05
Rate for Payer: UnitedHealthcare Medicaid	$353.46
Rate for Payer: WPPA Medicare Advantage	$455.40

64636 ABLATION RADIOFREQUENCY ADDL LEVEL

Facility

$759.00

Service Code	HCPCS 64636
Hospital Charge Code	3154636
Hospital Revenue Code	360
Min. Negotiated Rate	$683.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$683.10
Rate for Payer: UnitedHealthcare Commercial	$721.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64636 DESTRUCTION BY NEURO AGENT PARAVERT LUMBAR OR SACRAL, EA ADD

Facility

$620.00

Service Code	HCPCS 64636
Hospital Charge Code	3184636
Hospital Revenue Code	360
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

64636 DESTRUCTION BY NEURO AGENT PARAVERT LUMBAR OR SACRAL, EA ADD

Facility

$620.00

Service Code	HCPCS 64636
Hospital Charge Code	3184636
Hospital Revenue Code	360
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$353.46
Rate for Payer: WPPA Medicare Advantage	$372.00

64640 Destruction by neurolytic agent other peripheral nerve or branch

Facility

$918.00

Service Code	HCPCS 64640
Hospital Charge Code	3296464
Hospital Revenue Code	761
Min. Negotiated Rate	$826.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$826.20
Rate for Payer: UnitedHealthcare Commercial	$872.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64640 Destruction by neurolytic agent other peripheral nerve or branch

Facility

$918.00

Service Code	HCPCS 64640
Hospital Charge Code	3296464
Hospital Revenue Code	761
Min. Negotiated Rate	$215.70
Max. Negotiated Rate	$872.10
Rate for Payer: Aetna Commercial	$826.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$215.70
Rate for Payer: Humana Medicare Advantage	$385.56
Rate for Payer: UnitedHealthcare Commercial	$872.10
Rate for Payer: UnitedHealthcare Medicaid	$295.27
Rate for Payer: WPPA Medicare Advantage	$550.80

64642 Chemodenervation of one extremity; 1-4 muscle(s)

Facility

$414.00

Service Code	HCPCS 64642
Hospital Charge Code	3354642
Hospital Revenue Code	761
Min. Negotiated Rate	$173.88
Max. Negotiated Rate	$393.30
Rate for Payer: Aetna Commercial	$372.60
Rate for Payer: Humana Medicare Advantage	$173.88
Rate for Payer: UnitedHealthcare Commercial	$393.30
Rate for Payer: UnitedHealthcare Medicaid	$240.23
Rate for Payer: WPPA Medicare Advantage	$248.40

64642 Chemodenervation of one extremity; 1-4 muscle(s)

Facility

$414.00

Service Code	HCPCS 64642
Hospital Charge Code	3354642
Hospital Revenue Code	761
Min. Negotiated Rate	$372.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$372.60
Rate for Payer: UnitedHealthcare Commercial	$393.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64643 Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s)

Facility

$206.00

Service Code	HCPCS 64643
Hospital Charge Code	3354643
Hospital Revenue Code	761
Min. Negotiated Rate	$185.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64643 Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s)

Facility

$206.00

Service Code	HCPCS 64643
Hospital Charge Code	3354643
Hospital Revenue Code	761
Min. Negotiated Rate	$82.40
Max. Negotiated Rate	$195.70
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: Humana Medicare Advantage	$86.52
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: UnitedHealthcare Medicaid	$82.40
Rate for Payer: WPPA Medicare Advantage	$123.60

64644 Chemodenervation of one extremity; 5 or more muscles

Facility

$722.00

Service Code	HCPCS 64644
Hospital Charge Code	3354644
Hospital Revenue Code	761
Min. Negotiated Rate	$649.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$649.80
Rate for Payer: UnitedHealthcare Commercial	$685.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64644 Chemodenervation of one extremity; 5 or more muscles

Facility

$722.00

Service Code	HCPCS 64644
Hospital Charge Code	3354644
Hospital Revenue Code	761
Min. Negotiated Rate	$240.23
Max. Negotiated Rate	$685.90
Rate for Payer: Aetna Commercial	$649.80
Rate for Payer: Humana Medicare Advantage	$303.24
Rate for Payer: UnitedHealthcare Commercial	$685.90
Rate for Payer: UnitedHealthcare Medicaid	$240.23
Rate for Payer: WPPA Medicare Advantage	$433.20

64645 Chemodenervation of one extremity; each additional extremity, 5 or more muscles

Facility

$372.00

Service Code	HCPCS 64645
Hospital Charge Code	3354645
Hospital Revenue Code	761
Min. Negotiated Rate	$334.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$334.80
Rate for Payer: UnitedHealthcare Commercial	$353.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64645 Chemodenervation of one extremity; each additional extremity, 5 or more muscles

Facility

$372.00

Service Code	HCPCS 64645
Hospital Charge Code	3354645
Hospital Revenue Code	761
Min. Negotiated Rate	$148.80
Max. Negotiated Rate	$353.40
Rate for Payer: Aetna Commercial	$334.80
Rate for Payer: Humana Medicare Advantage	$156.24
Rate for Payer: UnitedHealthcare Commercial	$353.40
Rate for Payer: UnitedHealthcare Medicaid	$148.80
Rate for Payer: WPPA Medicare Advantage	$223.20

64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s)

Facility

$516.00

Service Code	HCPCS 64646
Hospital Charge Code	3354646
Hospital Revenue Code	761
Min. Negotiated Rate	$464.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$464.40
Rate for Payer: UnitedHealthcare Commercial	$490.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s)

Facility

$516.00

Service Code	HCPCS 64646
Hospital Charge Code	3354646
Hospital Revenue Code	761
Min. Negotiated Rate	$216.72
Max. Negotiated Rate	$490.20
Rate for Payer: Aetna Commercial	$464.40
Rate for Payer: Humana Medicare Advantage	$216.72
Rate for Payer: UnitedHealthcare Commercial	$490.20
Rate for Payer: UnitedHealthcare Medicaid	$240.23
Rate for Payer: WPPA Medicare Advantage	$309.60

64647 Chemodenervation of trunk muscle(s); 6 or more muscles

Facility

$393.00

Service Code	HCPCS 64647
Hospital Charge Code	3354647
Hospital Revenue Code	761
Min. Negotiated Rate	$165.06
Max. Negotiated Rate	$373.35
Rate for Payer: Aetna Commercial	$353.70
Rate for Payer: Humana Medicare Advantage	$165.06
Rate for Payer: UnitedHealthcare Commercial	$373.35
Rate for Payer: UnitedHealthcare Medicaid	$240.23
Rate for Payer: WPPA Medicare Advantage	$235.80

64647 Chemodenervation of trunk muscle(s); 6 or more muscles

Facility

$393.00

Service Code	HCPCS 64647
Hospital Charge Code	3354647
Hospital Revenue Code	761
Min. Negotiated Rate	$353.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$353.70
Rate for Payer: UnitedHealthcare Commercial	$373.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64718 REVISE ULNAR NERVE AT ELBOW

Facility

$4,386.00

Service Code	HCPCS 64718
Hospital Charge Code	3154718
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,166.70
Rate for Payer: Aetna Commercial	$3,947.40
Rate for Payer: UnitedHealthcare Commercial	$4,166.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64718 REVISE ULNAR NERVE AT ELBOW

Facility

$4,386.00

Service Code	HCPCS 64718
Hospital Charge Code	3154718
Hospital Revenue Code	360
Min. Negotiated Rate	$625.47
Max. Negotiated Rate	$4,166.70
Rate for Payer: Aetna Commercial	$3,947.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,479.55
Rate for Payer: Humana Medicare Advantage	$1,842.12
Rate for Payer: UnitedHealthcare Commercial	$4,166.70
Rate for Payer: UnitedHealthcare Medicaid	$625.47
Rate for Payer: WPPA Medicare Advantage	$2,631.60

64721 Neuroplasty and/or transposition; median nerve at carpal tunnel

Facility

$3,333.00

Service Code	HCPCS 64721
Hospital Charge Code	3150280
Hospital Revenue Code	360
Min. Negotiated Rate	$625.47
Max. Negotiated Rate	$3,166.35
Rate for Payer: Aetna Commercial	$2,999.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,624.08
Rate for Payer: Humana Medicare Advantage	$1,399.86
Rate for Payer: UnitedHealthcare Commercial	$3,166.35
Rate for Payer: UnitedHealthcare Medicaid	$625.47
Rate for Payer: WPPA Medicare Advantage	$1,999.80

64721 Neuroplasty and/or transposition; median nerve at carpal tunnel

Facility

$3,333.00

Service Code	HCPCS 64721
Hospital Charge Code	3150280
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,166.35
Rate for Payer: Aetna Commercial	$2,999.70
Rate for Payer: UnitedHealthcare Commercial	$3,166.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64772 Transection or avulsion of other spinal nerve, extradural

Facility

$3,016.00

Service Code	HCPCS 64772
Hospital Charge Code	3154772
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,865.20
Rate for Payer: Aetna Commercial	$2,714.40
Rate for Payer: UnitedHealthcare Commercial	$2,865.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64772 Transection or avulsion of other spinal nerve, extradural

Facility

$3,016.00

Service Code	HCPCS 64772
Hospital Charge Code	3154772
Hospital Revenue Code	360
Min. Negotiated Rate	$625.47
Max. Negotiated Rate	$2,865.20
Rate for Payer: Aetna Commercial	$2,714.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,624.08
Rate for Payer: Humana Medicare Advantage	$1,266.72
Rate for Payer: UnitedHealthcare Commercial	$2,865.20
Rate for Payer: UnitedHealthcare Medicaid	$625.47
Rate for Payer: WPPA Medicare Advantage	$1,809.60

64774 Excision of neuroma; cutaneous nerve, surgically identifiable

Facility

$2,734.00

Service Code	HCPCS 64774
Hospital Charge Code	3154774
Hospital Revenue Code	360
Min. Negotiated Rate	$1,093.60
Max. Negotiated Rate	$2,597.30
Rate for Payer: Aetna Commercial	$2,460.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,624.08
Rate for Payer: Humana Medicare Advantage	$1,148.28
Rate for Payer: UnitedHealthcare Commercial	$2,597.30
Rate for Payer: UnitedHealthcare Medicaid	$1,093.60
Rate for Payer: WPPA Medicare Advantage	$1,640.40

Know your out-of-pocket cost for care.

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