Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

92504 Binocular microscopy (separate diagnostic procedure)

Facility

$85.00

Service Code	HCPCS 92504
Hospital Charge Code	3352504
Hospital Revenue Code	761
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: UnitedHealthcare Commercial	$80.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

92504 Binocular microscopy (separate diagnostic procedure)

Facility

$85.00

Service Code	HCPCS 92504
Hospital Charge Code	3352504
Hospital Revenue Code	761
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$80.75
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: Humana Medicare Advantage	$35.70
Rate for Payer: UnitedHealthcare Commercial	$80.75
Rate for Payer: UnitedHealthcare Medicaid	$19.55
Rate for Payer: WPPA Medicare Advantage	$51.00

92507 SPEECH TREATMENT Charge

Facility

$206.00

Service Code	HCPCS 92507 GN
Hospital Charge Code	4050024
Hospital Revenue Code	441
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

92507 SPEECH TREATMENT Charge

Facility

$206.00

Service Code	HCPCS 92507 GN
Hospital Charge Code	4050024
Hospital Revenue Code	441
Min. Negotiated Rate	$76.68
Max. Negotiated Rate	$195.70
Rate for Payer: Aetna Commercial	$185.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$77.77
Rate for Payer: Humana Medicare Advantage	$86.52
Rate for Payer: UnitedHealthcare Commercial	$195.70
Rate for Payer: UnitedHealthcare Medicaid	$76.68
Rate for Payer: WPPA Medicare Advantage	$123.60

92508 TREATMENT SPEECH - GROUP, 2 OR MORE

Facility

$102.00

Service Code	HCPCS 92508
Hospital Charge Code	4052508
Hospital Revenue Code	444
Min. Negotiated Rate	$10.77
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$51.51
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$10.77
Rate for Payer: WPPA Medicare Advantage	$61.20

92508 TREATMENT SPEECH - GROUP, 2 OR MORE

Facility

$102.00

Service Code	HCPCS 92508
Hospital Charge Code	4052508
Hospital Revenue Code	444
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

92511 Nasopharyngoscopy with endoscope (separate procedure)

Facility

$2,419.00

Service Code	HCPCS 92511
Hospital Charge Code	3352511
Hospital Revenue Code	761
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$2,298.05
Rate for Payer: Aetna Commercial	$2,177.10
Rate for Payer: Humana Medicare Advantage	$1,015.98
Rate for Payer: UnitedHealthcare Commercial	$2,298.05
Rate for Payer: UnitedHealthcare Medicaid	$234.00
Rate for Payer: WPPA Medicare Advantage	$1,451.40

92511 Nasopharyngoscopy with endoscope (separate procedure)

Facility

$2,419.00

Service Code	HCPCS 92511
Hospital Charge Code	3352511
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,298.05
Rate for Payer: Aetna Commercial	$2,177.10
Rate for Payer: UnitedHealthcare Commercial	$2,298.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

92523 EVAL LANGUANGE ONLY CHARGE

Facility

$433.00

Service Code	HCPCS 92523 GN
Hospital Charge Code	4051105
Hospital Revenue Code	444
Min. Negotiated Rate	$389.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$389.70
Rate for Payer: UnitedHealthcare Commercial	$411.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

92523 EVAL LANGUANGE ONLY CHARGE

Facility

$433.00

Service Code	HCPCS 92523 GN
Hospital Charge Code	4051105
Hospital Revenue Code	444
Min. Negotiated Rate	$116.15
Max. Negotiated Rate	$411.35
Rate for Payer: Aetna Commercial	$389.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$116.15
Rate for Payer: Humana Medicare Advantage	$181.86
Rate for Payer: UnitedHealthcare Commercial	$411.35
Rate for Payer: UnitedHealthcare Medicaid	$182.72
Rate for Payer: WPPA Medicare Advantage	$259.80

92524 EVAL VOICE/ RESONANCE

Facility

$226.00

Service Code	HCPCS 92524 GN
Hospital Charge Code	4052524
Hospital Revenue Code	444
Min. Negotiated Rate	$203.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$203.40
Rate for Payer: UnitedHealthcare Commercial	$214.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

92524 EVAL VOICE/ RESONANCE

Facility

$226.00

Service Code	HCPCS 92524 GN
Hospital Charge Code	4052524
Hospital Revenue Code	444
Min. Negotiated Rate	$66.74
Max. Negotiated Rate	$214.70
Rate for Payer: Aetna Commercial	$203.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$116.15
Rate for Payer: Humana Medicare Advantage	$94.92
Rate for Payer: UnitedHealthcare Commercial	$214.70
Rate for Payer: UnitedHealthcare Medicaid	$66.74
Rate for Payer: WPPA Medicare Advantage	$135.60

92526 OP TREATMNT SWALL/ORAL FUNCTION CHARGE

Facility

$248.00

Service Code	HCPCS 92526 GN
Hospital Charge Code	4050214
Hospital Revenue Code	441
Min. Negotiated Rate	$223.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$223.20
Rate for Payer: UnitedHealthcare Commercial	$235.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

92526 OP TREATMNT SWALL/ORAL FUNCTION CHARGE

Facility

$248.00

Service Code	HCPCS 92526 GN
Hospital Charge Code	4050214
Hospital Revenue Code	441
Min. Negotiated Rate	$65.44
Max. Negotiated Rate	$235.60
Rate for Payer: Aetna Commercial	$223.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$65.44
Rate for Payer: Humana Medicare Advantage	$104.16
Rate for Payer: UnitedHealthcare Commercial	$235.60
Rate for Payer: UnitedHealthcare Medicaid	$70.82
Rate for Payer: WPPA Medicare Advantage	$148.80

92557 Comprehensive audiometry threshold evaluation and speech recognition

Facility

$147.00

Service Code	HCPCS 92557
Hospital Charge Code	3352557
Hospital Revenue Code	761
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$132.30
Rate for Payer: UnitedHealthcare Commercial	$139.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

92557 Comprehensive audiometry threshold evaluation and speech recognition

Facility

$147.00

Service Code	HCPCS 92557
Hospital Charge Code	3352557
Hospital Revenue Code	761
Min. Negotiated Rate	$50.60
Max. Negotiated Rate	$139.65
Rate for Payer: Aetna Commercial	$132.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$82.30
Rate for Payer: Humana Medicare Advantage	$61.74
Rate for Payer: UnitedHealthcare Commercial	$139.65
Rate for Payer: UnitedHealthcare Medicaid	$50.60
Rate for Payer: WPPA Medicare Advantage	$88.20

92567 Tympanometry (impedance testing)

Facility

$57.00

Service Code	HCPCS 92567
Hospital Charge Code	3352567
Hospital Revenue Code	471
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$54.15
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$32.64
Rate for Payer: Humana Medicare Advantage	$23.94
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: UnitedHealthcare Medicaid	$20.28
Rate for Payer: WPPA Medicare Advantage	$34.20

92567 Tympanometry (impedance testing)

Facility

$57.00

Service Code	HCPCS 92567
Hospital Charge Code	3352567
Hospital Revenue Code	471
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

92582 Conditioning play audiometry

Facility

$398.00

Service Code	HCPCS 92582
Hospital Charge Code	3352582
Hospital Revenue Code	761
Min. Negotiated Rate	$358.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$358.20
Rate for Payer: UnitedHealthcare Commercial	$378.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

92582 Conditioning play audiometry

Facility

$398.00

Service Code	HCPCS 92582
Hospital Charge Code	3352582
Hospital Revenue Code	761
Min. Negotiated Rate	$50.60
Max. Negotiated Rate	$378.10
Rate for Payer: Aetna Commercial	$358.20
Rate for Payer: Humana Medicare Advantage	$167.16
Rate for Payer: UnitedHealthcare Commercial	$378.10
Rate for Payer: UnitedHealthcare Medicaid	$50.60
Rate for Payer: WPPA Medicare Advantage	$238.80

92587 Evoked otoacoustic emissions; limited evaluation, with interpretation and report

Facility

$274.00

Service Code	HCPCS 92587 TC
Hospital Charge Code	3352587
Hospital Revenue Code	471
Min. Negotiated Rate	$246.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$246.60
Rate for Payer: UnitedHealthcare Commercial	$260.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

92587 Evoked otoacoustic emissions; limited evaluation, with interpretation and report

Facility

$274.00

Service Code	HCPCS 92587 TC
Hospital Charge Code	3352587
Hospital Revenue Code	471
Min. Negotiated Rate	$56.33
Max. Negotiated Rate	$260.30
Rate for Payer: Aetna Commercial	$246.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$56.33
Rate for Payer: Humana Medicare Advantage	$115.08
Rate for Payer: UnitedHealthcare Commercial	$260.30
Rate for Payer: UnitedHealthcare Medicaid	$101.68
Rate for Payer: WPPA Medicare Advantage	$164.40

92610 ST SWALLOW EVAL CHARGE

Facility

$384.00

Service Code	HCPCS 92610 GN
Hospital Charge Code	4050206
Hospital Revenue Code	444
Min. Negotiated Rate	$88.44
Max. Negotiated Rate	$364.80
Rate for Payer: Aetna Commercial	$345.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$128.71
Rate for Payer: Humana Medicare Advantage	$161.28
Rate for Payer: UnitedHealthcare Commercial	$364.80
Rate for Payer: UnitedHealthcare Medicaid	$88.44
Rate for Payer: WPPA Medicare Advantage	$230.40

92610 ST SWALLOW EVAL CHARGE

Facility

$384.00

Service Code	HCPCS 92610 GN
Hospital Charge Code	4050206
Hospital Revenue Code	444
Min. Negotiated Rate	$345.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$345.60
Rate for Payer: UnitedHealthcare Commercial	$364.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

92612 Flexible endoscopic evaluation of swallowing by cine or video recording.

Facility

$384.00

Service Code	HCPCS 92612
Hospital Charge Code	4052612
Hospital Revenue Code	444
Min. Negotiated Rate	$345.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$345.60
Rate for Payer: UnitedHealthcare Commercial	$364.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges