Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

12051-Face/Ear/Eye/Nose/Lip Less Than/Equal to 2.5 cm

Facility

$620.00

Service Code	HCPCS 12051
Hospital Charge Code	3300803
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

12051-Face/Ear/Eye/Nose/Lip Less Than/Equal to 2.5 cm

Facility

$620.00

Service Code	HCPCS 12051
Hospital Charge Code	3300803
Hospital Revenue Code	450
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$715.08
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$715.08
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$343.20
Rate for Payer: WPPA Medicare Advantage	$372.00

12052-Face/Ear/Eye/Nose/Lip 2.6-5.0 cm

Facility

$1,134.00

Service Code	HCPCS 12052
Hospital Charge Code	3300804
Hospital Revenue Code	450
Min. Negotiated Rate	$1,020.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,020.60
Rate for Payer: UnitedHealthcare Commercial	$1,077.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12052-Face/Ear/Eye/Nose/Lip 2.6-5.0 cm

Facility

$1,134.00

Service Code	HCPCS 12052
Hospital Charge Code	3300804
Hospital Revenue Code	450
Min. Negotiated Rate	$343.20
Max. Negotiated Rate	$1,077.30
Rate for Payer: Aetna Commercial	$1,020.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.17
Rate for Payer: Humana Medicare Advantage	$476.28
Rate for Payer: UnitedHealthcare Commercial	$1,077.30
Rate for Payer: UnitedHealthcare Medicaid	$343.20
Rate for Payer: WPPA Medicare Advantage	$680.40

12053-Face/Ear/Eye/Nose/Lip 5.1-7.5 cm

Facility

$620.00

Service Code	HCPCS 12053
Hospital Charge Code	3300116
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

12053-Face/Ear/Eye/Nose/Lip 5.1-7.5 cm

Facility

$620.00

Service Code	HCPCS 12053
Hospital Charge Code	3300116
Hospital Revenue Code	450
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$973.64
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$973.64
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$343.20
Rate for Payer: WPPA Medicare Advantage	$372.00

12054-Face/Ear/Eye/Nose/Lip 7.6-12.5 cm

Facility

$1,066.00

Service Code	HCPCS 12054
Hospital Charge Code	3302054
Hospital Revenue Code	450
Min. Negotiated Rate	$959.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$959.40
Rate for Payer: UnitedHealthcare Commercial	$1,012.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12054-Face/Ear/Eye/Nose/Lip 7.6-12.5 cm

Facility

$1,066.00

Service Code	HCPCS 12054
Hospital Charge Code	3302054
Hospital Revenue Code	450
Min. Negotiated Rate	$343.20
Max. Negotiated Rate	$1,060.50
Rate for Payer: Aetna Commercial	$959.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,060.50
Rate for Payer: Humana Medicare Advantage	$447.72
Rate for Payer: UnitedHealthcare Commercial	$1,012.70
Rate for Payer: UnitedHealthcare Medicaid	$343.20
Rate for Payer: WPPA Medicare Advantage	$639.60

13101 Repair, complex, trunk; 2.6 cm to 7.5cm

Facility

$1,119.00

Service Code	HCPCS 13101
Hospital Charge Code	3150107
Hospital Revenue Code	360
Min. Negotiated Rate	$1,007.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,007.10
Rate for Payer: UnitedHealthcare Commercial	$1,063.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13101 Repair, complex, trunk; 2.6 cm to 7.5cm

Facility

$1,119.00

Service Code	HCPCS 13101
Hospital Charge Code	3150107
Hospital Revenue Code	360
Min. Negotiated Rate	$343.20
Max. Negotiated Rate	$1,063.05
Rate for Payer: Aetna Commercial	$1,007.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$539.34
Rate for Payer: Humana Medicare Advantage	$469.98
Rate for Payer: UnitedHealthcare Commercial	$1,063.05
Rate for Payer: UnitedHealthcare Medicaid	$343.20
Rate for Payer: WPPA Medicare Advantage	$671.40

13120-Scalp/Arms/Legs 1.1-2.5 cm

Facility

$435.00

Service Code	HCPCS 13120
Hospital Charge Code	3303120
Hospital Revenue Code	450
Min. Negotiated Rate	$391.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$391.50
Rate for Payer: UnitedHealthcare Commercial	$413.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13120-Scalp/Arms/Legs 1.1-2.5 cm

Facility

$435.00

Service Code	HCPCS 13120
Hospital Charge Code	3303120
Hospital Revenue Code	450
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$413.25
Rate for Payer: Aetna Commercial	$391.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$182.70
Rate for Payer: UnitedHealthcare Commercial	$413.25
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$261.00

13121 ED Tech Fee Repair, Complex, Scalp, Arms, and/or Legs; 2.6 cm to 7.5 cm

Facility

$1,066.00

Service Code	HCPCS 13121
Hospital Charge Code	3300807
Hospital Revenue Code	450
Min. Negotiated Rate	$400.40
Max. Negotiated Rate	$1,012.70
Rate for Payer: Aetna Commercial	$959.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$539.34
Rate for Payer: Humana Medicare Advantage	$447.72
Rate for Payer: UnitedHealthcare Commercial	$1,012.70
Rate for Payer: UnitedHealthcare Medicaid	$400.40
Rate for Payer: WPPA Medicare Advantage	$639.60

13121 ED Tech Fee Repair, Complex, Scalp, Arms, and/or Legs; 2.6 cm to 7.5 cm

Facility

$1,066.00

Service Code	HCPCS 13121
Hospital Charge Code	3300807
Hospital Revenue Code	450
Min. Negotiated Rate	$959.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$959.40
Rate for Payer: UnitedHealthcare Commercial	$1,012.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13121 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm SURG

Facility

$1,066.00

Service Code	HCPCS 13121
Hospital Charge Code	3153121
Hospital Revenue Code	360
Min. Negotiated Rate	$959.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$959.40
Rate for Payer: UnitedHealthcare Commercial	$1,012.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13121 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm SURG

Facility

$1,066.00

Service Code	HCPCS 13121
Hospital Charge Code	3153121
Hospital Revenue Code	360
Min. Negotiated Rate	$400.40
Max. Negotiated Rate	$1,012.70
Rate for Payer: Aetna Commercial	$959.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$539.34
Rate for Payer: Humana Medicare Advantage	$447.72
Rate for Payer: UnitedHealthcare Commercial	$1,012.70
Rate for Payer: UnitedHealthcare Medicaid	$400.40
Rate for Payer: WPPA Medicare Advantage	$639.60

13121-Scalp/Arms/Legs 2.6-7.5 cm

Facility

$620.00

Service Code	HCPCS 13121
Hospital Charge Code	3300807
Hospital Revenue Code	450
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$539.34
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$400.40
Rate for Payer: WPPA Medicare Advantage	$372.00

13121-Scalp/Arms/Legs 2.6-7.5 cm

Facility

$620.00

Service Code	HCPCS 13121
Hospital Charge Code	3300807
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

13122 ED Tech Fee Repair, Complex, Scalp, Arms, and/or Legs; each add 5 cm or less

Facility

$435.00

Service Code	HCPCS 13122
Hospital Charge Code	3300808
Hospital Revenue Code	450
Min. Negotiated Rate	$391.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$391.50
Rate for Payer: UnitedHealthcare Commercial	$413.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13122 ED Tech Fee Repair, Complex, Scalp, Arms, and/or Legs; each add 5 cm or less

Facility

$435.00

Service Code	HCPCS 13122
Hospital Charge Code	3300808
Hospital Revenue Code	450
Min. Negotiated Rate	$174.00
Max. Negotiated Rate	$413.25
Rate for Payer: Aetna Commercial	$391.50
Rate for Payer: Humana Medicare Advantage	$182.70
Rate for Payer: UnitedHealthcare Commercial	$413.25
Rate for Payer: UnitedHealthcare Medicaid	$174.00
Rate for Payer: WPPA Medicare Advantage	$261.00

13122 Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (list separately to pr

Facility

$435.00

Service Code	HCPCS 13122
Hospital Charge Code	3153122
Hospital Revenue Code	360
Min. Negotiated Rate	$174.00
Max. Negotiated Rate	$413.25
Rate for Payer: Aetna Commercial	$391.50
Rate for Payer: Humana Medicare Advantage	$182.70
Rate for Payer: UnitedHealthcare Commercial	$413.25
Rate for Payer: UnitedHealthcare Medicaid	$174.00
Rate for Payer: WPPA Medicare Advantage	$261.00

13122 Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (list separately to pr

Facility

$435.00

Service Code	HCPCS 13122
Hospital Charge Code	3153122
Hospital Revenue Code	360
Min. Negotiated Rate	$391.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$391.50
Rate for Payer: UnitedHealthcare Commercial	$413.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13122-Scalp/Arms/Legs Each Addl 5 cm

Facility

$1,063.00

Service Code	HCPCS 13122
Hospital Charge Code	3300808
Hospital Revenue Code	450
Min. Negotiated Rate	$425.20
Max. Negotiated Rate	$1,009.85
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: Humana Medicare Advantage	$446.46
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: UnitedHealthcare Medicaid	$425.20
Rate for Payer: WPPA Medicare Advantage	$637.80

13122-Scalp/Arms/Legs Each Addl 5 cm

Facility

$1,063.00

Service Code	HCPCS 13122
Hospital Charge Code	3300808
Hospital Revenue Code	450
Min. Negotiated Rate	$956.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$956.70
Rate for Payer: UnitedHealthcare Commercial	$1,009.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13131-Face/Neck/Hand/Feet/Genital 1.1-2.5 cm

Facility

$534.00

Service Code	HCPCS 13131
Hospital Charge Code	3303131
Hospital Revenue Code	450
Min. Negotiated Rate	$480.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$480.60
Rate for Payer: UnitedHealthcare Commercial	$507.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges