Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

76942 US GUIDED NEEDLE PLACEMENT

Facility

$764.00

Service Code	HCPCS 76942
Hospital Charge Code	3156942
Hospital Revenue Code	761
Min. Negotiated Rate	$44.03
Max. Negotiated Rate	$725.80
Rate for Payer: Aetna Commercial	$687.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$120.19
Rate for Payer: Humana Medicare Advantage	$320.88
Rate for Payer: UnitedHealthcare Commercial	$725.80
Rate for Payer: UnitedHealthcare Medicaid	$44.03
Rate for Payer: WPPA Medicare Advantage	$458.40

76942 US GUIDED NEEDLE PLACEMENT

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

77067 MG Mammo Digital Screening Bilateral

Facility

$303.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$161.00
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$72.25
Rate for Payer: WPPA Medicare Advantage	$181.80

77067 MG Mammo Digital Screening Bilateral

Facility

$303.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

77263 RADTH PLANNING COMPLEX ProFee

Facility

$690.00

Service Code	HCPCS 77263
Hospital Charge Code	3157263
Hospital Revenue Code	360
Min. Negotiated Rate	$621.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$621.00
Rate for Payer: UnitedHealthcare Commercial	$655.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

77263 RADTH PLANNING COMPLEX ProFee

Facility

$690.00

Service Code	HCPCS 77263
Hospital Charge Code	3157263
Hospital Revenue Code	360
Min. Negotiated Rate	$171.77
Max. Negotiated Rate	$655.50
Rate for Payer: Aetna Commercial	$621.00
Rate for Payer: Humana Medicare Advantage	$289.80
Rate for Payer: UnitedHealthcare Commercial	$655.50
Rate for Payer: UnitedHealthcare Medicaid	$171.77
Rate for Payer: WPPA Medicare Advantage	$414.00

77290 THER RAD SIMULAJ-AIDED FLD SETTING CPLX ProFee

Facility

$2,042.00

Service Code	HCPCS 77290
Hospital Charge Code	3157290
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,939.90
Rate for Payer: Aetna Commercial	$1,837.80
Rate for Payer: UnitedHealthcare Commercial	$1,939.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

77290 THER RAD SIMULAJ-AIDED FLD SETTING CPLX ProFee

Facility

$2,042.00

Service Code	HCPCS 77290
Hospital Charge Code	3157290
Hospital Revenue Code	360
Min. Negotiated Rate	$304.91
Max. Negotiated Rate	$1,939.90
Rate for Payer: Aetna Commercial	$1,837.80
Rate for Payer: Humana Medicare Advantage	$857.64
Rate for Payer: UnitedHealthcare Commercial	$1,939.90
Rate for Payer: UnitedHealthcare Medicaid	$304.91
Rate for Payer: WPPA Medicare Advantage	$1,225.20

77301 NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS ProFee

Facility

$2,498.00

Service Code	HCPCS 77301
Hospital Charge Code	3157301
Hospital Revenue Code	360
Min. Negotiated Rate	$1,049.16
Max. Negotiated Rate	$2,373.10
Rate for Payer: Aetna Commercial	$2,248.20
Rate for Payer: Humana Medicare Advantage	$1,049.16
Rate for Payer: UnitedHealthcare Commercial	$2,373.10
Rate for Payer: UnitedHealthcare Medicaid	$1,139.57
Rate for Payer: WPPA Medicare Advantage	$1,498.80

77301 NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS ProFee

Facility

$2,498.00

Service Code	HCPCS 77301
Hospital Charge Code	3157301
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,373.10
Rate for Payer: Aetna Commercial	$2,248.20
Rate for Payer: UnitedHealthcare Commercial	$2,373.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

77334 RADTH TX AID(S) COMPLX ProFee

Facility

$615.00

Service Code	HCPCS 77334
Hospital Charge Code	3157334
Hospital Revenue Code	360
Min. Negotiated Rate	$553.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$553.50
Rate for Payer: UnitedHealthcare Commercial	$584.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

77334 RADTH TX AID(S) COMPLX ProFee

Facility

$615.00

Service Code	HCPCS 77334
Hospital Charge Code	3157334
Hospital Revenue Code	360
Min. Negotiated Rate	$258.30
Max. Negotiated Rate	$584.25
Rate for Payer: Aetna Commercial	$553.50
Rate for Payer: Humana Medicare Advantage	$258.30
Rate for Payer: UnitedHealthcare Commercial	$584.25
Rate for Payer: UnitedHealthcare Medicaid	$304.91
Rate for Payer: WPPA Medicare Advantage	$369.00

80359 Methamphetamine QST

Facility

$91.00

Service Code	HCPCS 80359
Hospital Charge Code	3550359
Hospital Revenue Code	300
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

80359 Methamphetamine QST

Facility

$91.00

Service Code	HCPCS 80359
Hospital Charge Code	3550359
Hospital Revenue Code	300
Min. Negotiated Rate	$19.97
Max. Negotiated Rate	$86.45
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.88
Rate for Payer: Humana Medicare Advantage	$38.22
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: UnitedHealthcare Medicaid	$19.97
Rate for Payer: WPPA Medicare Advantage	$54.60

83520 Vedolizumab Quantitation with Antibodies, Serum QST

Facility

$105.00

Service Code	HCPCS 83520
Hospital Charge Code	3556517
Hospital Revenue Code	300
Min. Negotiated Rate	$36.48
Max. Negotiated Rate	$99.75
Rate for Payer: Aetna Commercial	$94.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.48
Rate for Payer: Humana Medicare Advantage	$44.10
Rate for Payer: UnitedHealthcare Commercial	$99.75
Rate for Payer: UnitedHealthcare Medicaid	$42.00
Rate for Payer: WPPA Medicare Advantage	$63.00

83520 Vedolizumab Quantitation with Antibodies, Serum QST

Facility

$105.00

Service Code	HCPCS 83520
Hospital Charge Code	3556517
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$94.50
Rate for Payer: UnitedHealthcare Commercial	$99.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

84112-Eval Cervicovaginal fluid

Facility

$1,142.00

Service Code	HCPCS 84112
Hospital Charge Code	3304112
Hospital Revenue Code	450
Min. Negotiated Rate	$83.39
Max. Negotiated Rate	$1,084.90
Rate for Payer: Aetna Commercial	$1,027.80
Rate for Payer: Aetna Commercial	$181.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$124.11
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$124.11
Rate for Payer: Humana Medicare Advantage	$84.84
Rate for Payer: Humana Medicare Advantage	$479.64
Rate for Payer: UnitedHealthcare Commercial	$1,084.90
Rate for Payer: UnitedHealthcare Commercial	$191.90
Rate for Payer: UnitedHealthcare Medicaid	$83.39
Rate for Payer: UnitedHealthcare Medicaid	$83.39
Rate for Payer: WPPA Medicare Advantage	$121.20
Rate for Payer: WPPA Medicare Advantage	$685.20

84112-Eval Cervicovaginal fluid

Facility

$1,142.00

Service Code	HCPCS 84112
Hospital Charge Code	3304112
Hospital Revenue Code	450
Min. Negotiated Rate	$1,027.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,027.80
Rate for Payer: Aetna Commercial	$181.80
Rate for Payer: UnitedHealthcare Commercial	$191.90
Rate for Payer: UnitedHealthcare Commercial	$1,084.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

86003 - Allergy-Shellfish Panel QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552810
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$12.60

86003 - Allergy-Shellfish Panel QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552810
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

86003 HMC

Facility

$22.00

Service Code	HCPCS 86003
Hospital Charge Code	3556267
Hospital Revenue Code	300
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.80
Rate for Payer: UnitedHealthcare Commercial	$20.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

86003 HMC

Facility

$22.00

Service Code	HCPCS 86003
Hospital Charge Code	3556267
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$20.90
Rate for Payer: Aetna Commercial	$19.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$9.24
Rate for Payer: UnitedHealthcare Commercial	$20.90
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$13.20

86480 TB SKIN TEST IMMUN M CHARGE

Facility

$423.00

Service Code	HCPCS 86480
Hospital Charge Code	3550076
Hospital Revenue Code	300
Min. Negotiated Rate	$380.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$380.70
Rate for Payer: UnitedHealthcare Commercial	$401.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

86480 TB SKIN TEST IMMUN M CHARGE

Facility

$423.00

Service Code	HCPCS 86480
Hospital Charge Code	3550076
Hospital Revenue Code	300
Min. Negotiated Rate	$61.98
Max. Negotiated Rate	$401.85
Rate for Payer: Aetna Commercial	$380.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.00
Rate for Payer: Humana Medicare Advantage	$177.66
Rate for Payer: UnitedHealthcare Commercial	$401.85
Rate for Payer: UnitedHealthcare Medicaid	$61.98
Rate for Payer: WPPA Medicare Advantage	$253.80

Know your out-of-pocket cost for care.

All Charges