Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

11771 REMOVE PILONIDAL CYST EXTEN

Facility

$5,426.00

Service Code	HCPCS 11771
Hospital Charge Code	3151771
Hospital Revenue Code	360
Min. Negotiated Rate	$920.50
Max. Negotiated Rate	$5,154.70
Rate for Payer: Aetna Commercial	$4,883.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,068.38
Rate for Payer: Humana Medicare Advantage	$2,278.92
Rate for Payer: UnitedHealthcare Commercial	$5,154.70
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$3,255.60

11772 REMOVE PILONIDAL LESION CHARGE

Facility

$7,457.00

Service Code	HCPCS 11772
Hospital Charge Code	3151722
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,084.15
Rate for Payer: Aetna Commercial	$6,711.30
Rate for Payer: UnitedHealthcare Commercial	$7,084.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11772 REMOVE PILONIDAL LESION CHARGE

Facility

$7,457.00

Service Code	HCPCS 11772
Hospital Charge Code	3151722
Hospital Revenue Code	360
Min. Negotiated Rate	$920.50
Max. Negotiated Rate	$7,084.15
Rate for Payer: Aetna Commercial	$6,711.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,216.75
Rate for Payer: Humana Medicare Advantage	$3,131.94
Rate for Payer: UnitedHealthcare Commercial	$7,084.15
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$4,474.20

11982-Removal, non-biodegradable drug delivery implant

Facility

$384.00

Service Code	HCPCS 11982
Hospital Charge Code	3151982
Hospital Revenue Code	360
Min. Negotiated Rate	$129.07
Max. Negotiated Rate	$364.80
Rate for Payer: Aetna Commercial	$345.60
Rate for Payer: Humana Medicare Advantage	$161.28
Rate for Payer: UnitedHealthcare Commercial	$364.80
Rate for Payer: UnitedHealthcare Medicaid	$129.07
Rate for Payer: WPPA Medicare Advantage	$230.40

11982-Removal, non-biodegradable drug delivery implant

Facility

$384.00

Service Code	HCPCS 11982
Hospital Charge Code	3151982
Hospital Revenue Code	360
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

1.1 Guide Wire/ 150 Length Trocar Tip

Facility

$335.00

Hospital Charge Code	3258323
Hospital Revenue Code	270
Min. Negotiated Rate	$301.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$301.50
Rate for Payer: UnitedHealthcare Commercial	$318.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

1.1 Guide Wire/ 150 Length Trocar Tip

Facility

$335.00

Hospital Charge Code	3258323
Hospital Revenue Code	270
Min. Negotiated Rate	$134.00
Max. Negotiated Rate	$318.25
Rate for Payer: Aetna Commercial	$301.50
Rate for Payer: Humana Medicare Advantage	$140.70
Rate for Payer: UnitedHealthcare Commercial	$318.25
Rate for Payer: UnitedHealthcare Medicaid	$134.00
Rate for Payer: WPPA Medicare Advantage	$201.00

1.1mm CSS Guidewire

Facility

$165.00

Hospital Charge Code	3258593
Hospital Revenue Code	270
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$156.75
Rate for Payer: Aetna Commercial	$148.50
Rate for Payer: Humana Medicare Advantage	$69.30
Rate for Payer: UnitedHealthcare Commercial	$156.75
Rate for Payer: UnitedHealthcare Medicaid	$66.00
Rate for Payer: WPPA Medicare Advantage	$99.00

1.1mm CSS Guidewire

Facility

$165.00

Hospital Charge Code	3258593
Hospital Revenue Code	270
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$148.50
Rate for Payer: UnitedHealthcare Commercial	$156.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12001-Scalp/Neck/Trunk/Genital/Extremity <= 2.5 cm

Facility

$890.00

Service Code	HCPCS 12001
Hospital Charge Code	3304800
Hospital Revenue Code	450
Min. Negotiated Rate	$207.48
Max. Negotiated Rate	$845.50
Rate for Payer: Aetna Commercial	$801.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$382.79
Rate for Payer: Humana Medicare Advantage	$373.80
Rate for Payer: UnitedHealthcare Commercial	$845.50
Rate for Payer: UnitedHealthcare Medicaid	$207.48
Rate for Payer: WPPA Medicare Advantage	$534.00

12001-Scalp/Neck/Trunk/Genital/Extremity <= 2.5 cm

Facility

$890.00

Service Code	HCPCS 12001
Hospital Charge Code	3304800
Hospital Revenue Code	450
Min. Negotiated Rate	$801.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$801.00
Rate for Payer: UnitedHealthcare Commercial	$845.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12001 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< TechFee

Facility

$848.00

Service Code	HCPCS 12001
Hospital Charge Code	3304800
Hospital Revenue Code	450
Min. Negotiated Rate	$763.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$763.20
Rate for Payer: UnitedHealthcare Commercial	$805.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12001 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< TechFee

Facility

$848.00

Service Code	HCPCS 12001
Hospital Charge Code	3304800
Hospital Revenue Code	450
Min. Negotiated Rate	$207.48
Max. Negotiated Rate	$805.60
Rate for Payer: Aetna Commercial	$763.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$382.79
Rate for Payer: Humana Medicare Advantage	$356.16
Rate for Payer: UnitedHealthcare Commercial	$805.60
Rate for Payer: UnitedHealthcare Medicaid	$207.48
Rate for Payer: WPPA Medicare Advantage	$508.80

12002-Scalp/Neck/Trunk/Genital/Extremity 2.6-7.5 cm

Facility

$1,599.00

Service Code	HCPCS 12002
Hospital Charge Code	3304805
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12002-Scalp/Neck/Trunk/Genital/Extremity 2.6-7.5 cm

Facility

$1,599.00

Service Code	HCPCS 12002
Hospital Charge Code	3304805
Hospital Revenue Code	450
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$457.53
Rate for Payer: Humana Medicare Advantage	$671.58
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: UnitedHealthcare Medicaid	$260.00
Rate for Payer: WPPA Medicare Advantage	$959.40

12002 SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM TechFee

Facility

$1,523.00

Service Code	HCPCS 12002
Hospital Charge Code	3304805
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,446.85
Rate for Payer: Aetna Commercial	$1,370.70
Rate for Payer: UnitedHealthcare Commercial	$1,446.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12002 SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM TechFee

Facility

$1,523.00

Service Code	HCPCS 12002
Hospital Charge Code	3304805
Hospital Revenue Code	450
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,446.85
Rate for Payer: Aetna Commercial	$1,370.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$457.53
Rate for Payer: Humana Medicare Advantage	$639.66
Rate for Payer: UnitedHealthcare Commercial	$1,446.85
Rate for Payer: UnitedHealthcare Medicaid	$260.00
Rate for Payer: WPPA Medicare Advantage	$913.80

12004-Scalp/Neck/Trunk/Genital/Extremity 7.6-12.5 cm

Facility

$620.00

Service Code	HCPCS 12004
Hospital Charge Code	3300304
Hospital Revenue Code	450
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

12004-Scalp/Neck/Trunk/Genital/Extremity 7.6-12.5 cm

Facility

$620.00

Service Code	HCPCS 12004
Hospital Charge Code	3300304
Hospital Revenue Code	450
Min. Negotiated Rate	$207.48
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$577.72
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$207.48
Rate for Payer: WPPA Medicare Advantage	$372.00

12004 SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM TechFee

Facility

$848.00

Service Code	HCPCS 12004
Hospital Charge Code	3300304
Hospital Revenue Code	450
Min. Negotiated Rate	$763.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$763.20
Rate for Payer: UnitedHealthcare Commercial	$805.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12004 SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM TechFee

Facility

$848.00

Service Code	HCPCS 12004
Hospital Charge Code	3300304
Hospital Revenue Code	450
Min. Negotiated Rate	$207.48
Max. Negotiated Rate	$805.60
Rate for Payer: Aetna Commercial	$763.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$577.72
Rate for Payer: Humana Medicare Advantage	$356.16
Rate for Payer: UnitedHealthcare Commercial	$805.60
Rate for Payer: UnitedHealthcare Medicaid	$207.48
Rate for Payer: WPPA Medicare Advantage	$508.80

12005-Scalp/Neck/Trunk/Genital/Extremity 12.6-20.0 cm

Facility

$620.00

Service Code	HCPCS 12005
Hospital Charge Code	3303181
Hospital Revenue Code	450
Min. Negotiated Rate	$240.24
Max. Negotiated Rate	$809.01
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$240.24
Rate for Payer: WPPA Medicare Advantage	$372.00

12005-Scalp/Neck/Trunk/Genital/Extremity 12.6-20.0 cm

Facility

$620.00

Service Code	HCPCS 12005
Hospital Charge Code	3303181
Hospital Revenue Code	450
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

12005 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM TechFee

Facility

$620.00

Service Code	HCPCS 12005
Hospital Charge Code	3303181
Hospital Revenue Code	450
Min. Negotiated Rate	$240.24
Max. Negotiated Rate	$809.01
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$240.24
Rate for Payer: WPPA Medicare Advantage	$372.00

12005 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM TechFee

Facility

$620.00

Service Code	HCPCS 12005
Hospital Charge Code	3303181
Hospital Revenue Code	450
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

Know your out-of-pocket cost for care.

All Charges