Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

69801 LABYRINTHOTOMY TRANSCANAL CHARGE

Facility

$2,248.00

Service Code	HCPCS 69801
Hospital Charge Code	3359801
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,135.60
Rate for Payer: Aetna Commercial	$2,023.20
Rate for Payer: UnitedHealthcare Commercial	$2,135.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69801 LABYRINTHOTOMY TRANSCANAL CHARGE

Facility

$2,248.00

Service Code	HCPCS 69801
Hospital Charge Code	3359801
Hospital Revenue Code	360
Min. Negotiated Rate	$899.20
Max. Negotiated Rate	$2,135.60
Rate for Payer: Aetna Commercial	$2,023.20
Rate for Payer: Humana Medicare Advantage	$944.16
Rate for Payer: UnitedHealthcare Commercial	$2,135.60
Rate for Payer: UnitedHealthcare Medicaid	$899.20
Rate for Payer: WPPA Medicare Advantage	$1,348.80

69990 Operating Microscope Procedures

Facility

$7,226.00

Service Code	HCPCS 69990
Hospital Charge Code	3159990
Hospital Revenue Code	360
Min. Negotiated Rate	$2,890.40
Max. Negotiated Rate	$6,864.70
Rate for Payer: Aetna Commercial	$6,503.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,250.08
Rate for Payer: Humana Medicare Advantage	$3,034.92
Rate for Payer: UnitedHealthcare Commercial	$6,864.70
Rate for Payer: UnitedHealthcare Medicaid	$2,890.40
Rate for Payer: WPPA Medicare Advantage	$4,335.60

69990 Operating Microscope Procedures

Facility

$7,226.00

Service Code	HCPCS 69990
Hospital Charge Code	3159990
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,864.70
Rate for Payer: Aetna Commercial	$6,503.40
Rate for Payer: UnitedHealthcare Commercial	$6,864.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

70450 CT Brain/Head w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 70450
Hospital Charge Code	3740204
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

70450 CT Brain/Head w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 70450
Hospital Charge Code	3740204
Hospital Revenue Code	350
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$610.26
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: UnitedHealthcare Medicaid	$106.88
Rate for Payer: WPPA Medicare Advantage	$871.80

71046 XR Chest 2 Views

Facility

$321.00

Service Code	HCPCS 71046 TC
Hospital Charge Code	3771046
Hospital Revenue Code	320
Min. Negotiated Rate	$288.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$288.90
Rate for Payer: UnitedHealthcare Commercial	$304.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

71046 XR Chest 2 Views

Facility

$321.00

Service Code	HCPCS 71046 TC
Hospital Charge Code	3771046
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$304.95
Rate for Payer: Aetna Commercial	$288.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$150.77
Rate for Payer: Humana Medicare Advantage	$134.82
Rate for Payer: UnitedHealthcare Commercial	$304.95
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$192.60

72125 CT Spine Cervical w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 72125
Hospital Charge Code	3740345
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

72125 CT Spine Cervical w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 72125
Hospital Charge Code	3740345
Hospital Revenue Code	350
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$610.26
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: UnitedHealthcare Medicaid	$106.88
Rate for Payer: WPPA Medicare Advantage	$871.80

72220 RADEX SACRUM&COCCYX MINIMUM 2 VIEWS ProFee

Facility

$249.00

Service Code	HCPCS 72220 TC
Hospital Charge Code	3700433
Hospital Revenue Code	320
Min. Negotiated Rate	$224.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$224.10
Rate for Payer: UnitedHealthcare Commercial	$236.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

72220 RADEX SACRUM&COCCYX MINIMUM 2 VIEWS ProFee

Facility

$249.00

Service Code	HCPCS 72220 TC
Hospital Charge Code	3700433
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$236.55
Rate for Payer: Aetna Commercial	$224.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$143.10
Rate for Payer: Humana Medicare Advantage	$104.58
Rate for Payer: UnitedHealthcare Commercial	$236.55
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$149.40

76641 ULTRASOUND BREAST COMPLETE

Facility

$764.00

Service Code	HCPCS 76641
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

76641 ULTRASOUND BREAST COMPLETE

Facility

$764.00

Service Code	HCPCS 76641
Hospital Charge Code	3736641
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$94.94
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$90.85
Rate for Payer: WPPA Medicare Advantage	$458.40

76705 US Abdomen/Lower Back Limited

Facility

$764.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	3730089
Hospital Revenue Code	402
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

76705 US Abdomen/Lower Back Limited

Facility

$764.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	3730089
Hospital Revenue Code	402
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$130.94
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$458.40

76815 LIMITED US OB CHARGE

Facility

$742.00

Service Code	HCPCS 76815
Hospital Charge Code	1169856
Hospital Revenue Code	402
Min. Negotiated Rate	$90.85
Max. Negotiated Rate	$704.90
Rate for Payer: Aetna Commercial	$667.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$141.50
Rate for Payer: Humana Medicare Advantage	$311.64
Rate for Payer: UnitedHealthcare Commercial	$704.90
Rate for Payer: UnitedHealthcare Medicaid	$90.85
Rate for Payer: WPPA Medicare Advantage	$445.20

76815 LIMITED US OB CHARGE

Facility

$742.00

Service Code	HCPCS 76815
Hospital Charge Code	1169856
Hospital Revenue Code	402
Min. Negotiated Rate	$667.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$667.80
Rate for Payer: UnitedHealthcare Commercial	$704.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

76818 OP FETAL BIOPHYSICAL PROFILE NONSTRESS CHARGE

Facility

$812.00

Service Code	HCPCS 76818
Hospital Charge Code	3296818
Hospital Revenue Code	761
Min. Negotiated Rate	$730.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$730.80
Rate for Payer: UnitedHealthcare Commercial	$771.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

76818 OP FETAL BIOPHYSICAL PROFILE NONSTRESS CHARGE

Facility

$812.00

Service Code	HCPCS 76818
Hospital Charge Code	3296818
Hospital Revenue Code	761
Min. Negotiated Rate	$90.85
Max. Negotiated Rate	$771.40
Rate for Payer: Aetna Commercial	$730.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$141.50
Rate for Payer: Humana Medicare Advantage	$341.04
Rate for Payer: UnitedHealthcare Commercial	$771.40
Rate for Payer: UnitedHealthcare Medicaid	$90.85
Rate for Payer: WPPA Medicare Advantage	$487.20

76937 POCUS Vascular Access TechFee

Facility

$112.00

Service Code	HCPCS 76937
Hospital Charge Code	3156937
Hospital Revenue Code	402
Min. Negotiated Rate	$23.32
Max. Negotiated Rate	$106.40
Rate for Payer: Aetna Commercial	$100.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$41.41
Rate for Payer: Humana Medicare Advantage	$47.04
Rate for Payer: UnitedHealthcare Commercial	$106.40
Rate for Payer: UnitedHealthcare Medicaid	$23.32
Rate for Payer: WPPA Medicare Advantage	$67.20

76937 POCUS Vascular Access TechFee

Facility

$112.00

Service Code	HCPCS 76937
Hospital Charge Code	3156937
Hospital Revenue Code	402
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$100.80
Rate for Payer: UnitedHealthcare Commercial	$106.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

76937 USG for Vascular Access

Facility

$53.00

Service Code	HCPCS 76937
Hospital Charge Code	3186937
Hospital Revenue Code	360
Min. Negotiated Rate	$22.26
Max. Negotiated Rate	$50.35
Rate for Payer: Aetna Commercial	$47.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$41.41
Rate for Payer: Humana Medicare Advantage	$22.26
Rate for Payer: UnitedHealthcare Commercial	$50.35
Rate for Payer: UnitedHealthcare Medicaid	$23.32
Rate for Payer: WPPA Medicare Advantage	$31.80

76937 USG for Vascular Access

Facility

$53.00

Service Code	HCPCS 76937
Hospital Charge Code	3186937
Hospital Revenue Code	360
Min. Negotiated Rate	$47.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$47.70
Rate for Payer: UnitedHealthcare Commercial	$50.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

76942 U/S GUIDANCE FOR NEEDLE PLACEMENT, IMAGING SUPERVISION & INTERPRETATION

Facility

$764.00

Service Code	HCPCS 76942
Hospital Charge Code	3156942
Hospital Revenue Code	761
Min. Negotiated Rate	$687.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges