Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

13132-Face/Neck/Hand/Feet/Genital 2.6-7.5 cm

Facility

$2,129.00

Service Code	HCPCS 13132
Hospital Charge Code	3304830
Hospital Revenue Code	450
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$2,022.55
Rate for Payer: Aetna Commercial	$1,916.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,008.99
Rate for Payer: Humana Medicare Advantage	$894.18
Rate for Payer: UnitedHealthcare Commercial	$2,022.55
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$1,277.40

13132-Face/Neck/Hand/Feet/Genital 2.6-7.5 cm

Facility

$2,129.00

Service Code	HCPCS 13132
Hospital Charge Code	3304830
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,022.55
Rate for Payer: Aetna Commercial	$1,916.10
Rate for Payer: UnitedHealthcare Commercial	$2,022.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13132 Repair, Comp, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or fe

Facility

$2,129.00

Service Code	HCPCS 13132
Hospital Charge Code	3304830
Hospital Revenue Code	450
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$2,022.55
Rate for Payer: Aetna Commercial	$1,916.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,008.99
Rate for Payer: Humana Medicare Advantage	$894.18
Rate for Payer: UnitedHealthcare Commercial	$2,022.55
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$1,277.40

13132 Repair, Comp, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or fe

Facility

$2,129.00

Service Code	HCPCS 13132
Hospital Charge Code	3304830
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,022.55
Rate for Payer: Aetna Commercial	$1,916.10
Rate for Payer: UnitedHealthcare Commercial	$2,022.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13133-Face/Neck/Hand/Feet/Genital Each Addl 5 cm

Facility

$840.00

Service Code	HCPCS 13133
Hospital Charge Code	3304831
Hospital Revenue Code	450
Min. Negotiated Rate	$117.51
Max. Negotiated Rate	$798.00
Rate for Payer: Aetna Commercial	$756.00
Rate for Payer: Humana Medicare Advantage	$352.80
Rate for Payer: UnitedHealthcare Commercial	$798.00
Rate for Payer: UnitedHealthcare Medicaid	$117.51
Rate for Payer: WPPA Medicare Advantage	$504.00

13133-Face/Neck/Hand/Feet/Genital Each Addl 5 cm

Facility

$840.00

Service Code	HCPCS 13133
Hospital Charge Code	3304831
Hospital Revenue Code	450
Min. Negotiated Rate	$756.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$756.00
Rate for Payer: UnitedHealthcare Commercial	$798.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13133 Repair Complex - each addl 5cm Tech Fees

Facility

$840.00

Service Code	HCPCS 13133
Hospital Charge Code	3304831
Hospital Revenue Code	450
Min. Negotiated Rate	$756.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$756.00
Rate for Payer: UnitedHealthcare Commercial	$798.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13133 Repair Complex - each addl 5cm Tech Fees

Facility

$840.00

Service Code	HCPCS 13133
Hospital Charge Code	3304831
Hospital Revenue Code	450
Min. Negotiated Rate	$117.51
Max. Negotiated Rate	$798.00
Rate for Payer: Aetna Commercial	$756.00
Rate for Payer: Humana Medicare Advantage	$352.80
Rate for Payer: UnitedHealthcare Commercial	$798.00
Rate for Payer: UnitedHealthcare Medicaid	$117.51
Rate for Payer: WPPA Medicare Advantage	$504.00

13151-Eyes/Ears/Nose/Lip 1.1-2.5 cm

Facility

$688.00

Service Code	HCPCS 13151
Hospital Charge Code	3303151
Hospital Revenue Code	450
Min. Negotiated Rate	$275.20
Max. Negotiated Rate	$1,315.02
Rate for Payer: Aetna Commercial	$619.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,315.02
Rate for Payer: Humana Medicare Advantage	$288.96
Rate for Payer: UnitedHealthcare Commercial	$653.60
Rate for Payer: UnitedHealthcare Medicaid	$275.20
Rate for Payer: WPPA Medicare Advantage	$412.80

13151-Eyes/Ears/Nose/Lip 1.1-2.5 cm

Facility

$688.00

Service Code	HCPCS 13151
Hospital Charge Code	3303151
Hospital Revenue Code	450
Min. Negotiated Rate	$619.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$619.20
Rate for Payer: UnitedHealthcare Commercial	$653.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13151 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM TechFee

Facility

$2,028.00

Service Code	HCPCS 13151
Hospital Charge Code	3303151
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,926.60
Rate for Payer: Aetna Commercial	$1,825.20
Rate for Payer: UnitedHealthcare Commercial	$1,926.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13151 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM TechFee

Facility

$2,028.00

Service Code	HCPCS 13151
Hospital Charge Code	3303151
Hospital Revenue Code	450
Min. Negotiated Rate	$811.20
Max. Negotiated Rate	$1,926.60
Rate for Payer: Aetna Commercial	$1,825.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,315.02
Rate for Payer: Humana Medicare Advantage	$851.76
Rate for Payer: UnitedHealthcare Commercial	$1,926.60
Rate for Payer: UnitedHealthcare Medicaid	$811.20
Rate for Payer: WPPA Medicare Advantage	$1,216.80

13152 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM TechFee

Facility

$2,243.00

Service Code	HCPCS 13152
Hospital Charge Code	3153152
Hospital Revenue Code	981
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,130.85
Rate for Payer: Aetna Commercial	$2,018.70
Rate for Payer: UnitedHealthcare Commercial	$2,130.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

13152 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM TechFee

Facility

$2,243.00

Service Code	HCPCS 13152
Hospital Charge Code	3153152
Hospital Revenue Code	981
Min. Negotiated Rate	$897.20
Max. Negotiated Rate	$2,130.85
Rate for Payer: Aetna Commercial	$2,018.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,618.02
Rate for Payer: Humana Medicare Advantage	$942.06
Rate for Payer: UnitedHealthcare Commercial	$2,130.85
Rate for Payer: UnitedHealthcare Medicaid	$897.20
Rate for Payer: WPPA Medicare Advantage	$1,345.80

13153-Eye/Ear/Nose/Lip Each Addl 5 cm

Facility

$274.00

Service Code	HCPCS 13153
Hospital Charge Code	3300809
Hospital Revenue Code	450
Min. Negotiated Rate	$109.60
Max. Negotiated Rate	$260.30
Rate for Payer: Aetna Commercial	$246.60
Rate for Payer: Humana Medicare Advantage	$115.08
Rate for Payer: UnitedHealthcare Commercial	$260.30
Rate for Payer: UnitedHealthcare Medicaid	$109.60
Rate for Payer: WPPA Medicare Advantage	$164.40

13153-Eye/Ear/Nose/Lip Each Addl 5 cm

Facility

$274.00

Service Code	HCPCS 13153
Hospital Charge Code	3300809
Hospital Revenue Code	450
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

14020 TIS TRNFR S/A/L 10 SQ CM/<

Facility

$3,212.00

Service Code	HCPCS 14020
Hospital Charge Code	3350330
Hospital Revenue Code	360
Min. Negotiated Rate	$590.76
Max. Negotiated Rate	$3,051.40
Rate for Payer: Aetna Commercial	$2,890.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,187.66
Rate for Payer: Humana Medicare Advantage	$1,349.04
Rate for Payer: UnitedHealthcare Commercial	$3,051.40
Rate for Payer: UnitedHealthcare Medicaid	$590.76
Rate for Payer: WPPA Medicare Advantage	$1,927.20

14020 TIS TRNFR S/A/L 10 SQ CM/<

Facility

$3,212.00

Service Code	HCPCS 14020
Hospital Charge Code	3350330
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,051.40
Rate for Payer: Aetna Commercial	$2,890.80
Rate for Payer: UnitedHealthcare Commercial	$3,051.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

14040 Adjacent tissue transfer; forehead, cheeks, chin, mouth, neck, axillae, hands; < 10 sq cm

Facility

$3,266.00

Service Code	HCPCS 14040
Hospital Charge Code	3150803
Hospital Revenue Code	360
Min. Negotiated Rate	$590.76
Max. Negotiated Rate	$3,102.70
Rate for Payer: Aetna Commercial	$2,939.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,778.61
Rate for Payer: Humana Medicare Advantage	$1,371.72
Rate for Payer: UnitedHealthcare Commercial	$3,102.70
Rate for Payer: UnitedHealthcare Medicaid	$590.76
Rate for Payer: WPPA Medicare Advantage	$1,959.60

14040 Adjacent tissue transfer; forehead, cheeks, chin, mouth, neck, axillae, hands; < 10 sq cm

Facility

$3,266.00

Service Code	HCPCS 14040
Hospital Charge Code	3150803
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,102.70
Rate for Payer: Aetna Commercial	$2,939.40
Rate for Payer: UnitedHealthcare Commercial	$3,102.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

14301 ADJ TISSUE TRANSFER REARRANGE ANY AREA DEFECT 301 SQ CM TO 600 SQ CM TechFee

Facility

$3,620.00

Service Code	HCPCS 14301
Hospital Charge Code	3304301
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,439.00
Rate for Payer: Aetna Commercial	$3,258.00
Rate for Payer: UnitedHealthcare Commercial	$3,439.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

14301 ADJ TISSUE TRANSFER REARRANGE ANY AREA DEFECT 301 SQ CM TO 600 SQ CM TechFee

Facility

$3,620.00

Service Code	HCPCS 14301
Hospital Charge Code	3304301
Hospital Revenue Code	450
Min. Negotiated Rate	$866.84
Max. Negotiated Rate	$3,439.00
Rate for Payer: Aetna Commercial	$3,258.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,611.79
Rate for Payer: Humana Medicare Advantage	$1,520.40
Rate for Payer: UnitedHealthcare Commercial	$3,439.00
Rate for Payer: UnitedHealthcare Medicaid	$866.84
Rate for Payer: WPPA Medicare Advantage	$2,172.00

14302 Adjacent tissue transfer or rearrangement, any area; each addtnl 30.0 sq cm, or part thereof

Facility

$1,067.00

Service Code	HCPCS 14302
Hospital Charge Code	3304302
Hospital Revenue Code	450
Min. Negotiated Rate	$448.14
Max. Negotiated Rate	$1,013.65
Rate for Payer: Aetna Commercial	$960.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$769.62
Rate for Payer: Humana Medicare Advantage	$448.14
Rate for Payer: UnitedHealthcare Commercial	$1,013.65
Rate for Payer: UnitedHealthcare Medicaid	$866.84
Rate for Payer: WPPA Medicare Advantage	$640.20

14302 Adjacent tissue transfer or rearrangement, any area; each addtnl 30.0 sq cm, or part thereof

Facility

$1,067.00

Service Code	HCPCS 14302
Hospital Charge Code	3304302
Hospital Revenue Code	450
Min. Negotiated Rate	$960.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$960.30
Rate for Payer: UnitedHealthcare Commercial	$1,013.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges