Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

17284 Destruct malign lesion, face; 3.1-4.0cm

Facility

$710.00

Service Code	HCPCS 17284
Hospital Charge Code	3157284
Hospital Revenue Code	360
Min. Negotiated Rate	$298.20
Max. Negotiated Rate	$674.50
Rate for Payer: Aetna Commercial	$639.00
Rate for Payer: Humana Medicare Advantage	$298.20
Rate for Payer: UnitedHealthcare Commercial	$674.50
Rate for Payer: UnitedHealthcare Medicaid	$343.20
Rate for Payer: WPPA Medicare Advantage	$426.00

17284 Destruct malign lesion, face; 3.1-4.0cm

Facility

$710.00

Service Code	HCPCS 17284
Hospital Charge Code	3157284
Hospital Revenue Code	360
Min. Negotiated Rate	$639.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$639.00
Rate for Payer: UnitedHealthcare Commercial	$674.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

17999 PF UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBQ TISSUE

Facility

$248.00

Service Code	HCPCS 17999
Hospital Charge Code	3157999
Hospital Revenue Code	360
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

17999 PF UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBQ TISSUE

Facility

$248.00

Service Code	HCPCS 17999
Hospital Charge Code	3157999
Hospital Revenue Code	360
Min. Negotiated Rate	$73.24
Max. Negotiated Rate	$235.60
Rate for Payer: Aetna Commercial	$223.20
Rate for Payer: Humana Medicare Advantage	$104.16
Rate for Payer: UnitedHealthcare Commercial	$235.60
Rate for Payer: UnitedHealthcare Medicaid	$73.24
Rate for Payer: WPPA Medicare Advantage	$148.80

17 Hydroxyprogesterone, LC/MS/MS QST

Facility

$130.00

Service Code	HCPCS 83498
Hospital Charge Code	3553498
Hospital Revenue Code	300
Min. Negotiated Rate	$27.17
Max. Negotiated Rate	$123.50
Rate for Payer: Aetna Commercial	$117.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$87.62
Rate for Payer: Humana Medicare Advantage	$54.60
Rate for Payer: UnitedHealthcare Commercial	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$27.17
Rate for Payer: WPPA Medicare Advantage	$78.00

17 Hydroxyprogesterone, LC/MS/MS QST

Facility

$130.00

Service Code	HCPCS 83498
Hospital Charge Code	3553498
Hospital Revenue Code	300
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$117.00
Rate for Payer: UnitedHealthcare Commercial	$123.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19020 INCISION OF BREAST LESION

Facility

$2,859.00

Service Code	HCPCS 19020
Hospital Charge Code	3159020
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,716.05
Rate for Payer: Aetna Commercial	$2,573.10
Rate for Payer: UnitedHealthcare Commercial	$2,716.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19020 INCISION OF BREAST LESION

Facility

$2,859.00

Service Code	HCPCS 19020
Hospital Charge Code	3159020
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$2,716.05
Rate for Payer: Aetna Commercial	$2,573.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,766.49
Rate for Payer: Humana Medicare Advantage	$1,200.78
Rate for Payer: UnitedHealthcare Commercial	$2,716.05
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,715.40

19020-Mastotomy Exploration/Drain Abscess Deep

Facility

$286.00

Service Code	HCPCS 19020
Hospital Charge Code	3401845
Hospital Revenue Code	450
Min. Negotiated Rate	$257.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$257.40
Rate for Payer: UnitedHealthcare Commercial	$271.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19020-Mastotomy Exploration/Drain Abscess Deep

Facility

$286.00

Service Code	HCPCS 19020
Hospital Charge Code	3401845
Hospital Revenue Code	450
Min. Negotiated Rate	$120.12
Max. Negotiated Rate	$1,766.49
Rate for Payer: Aetna Commercial	$257.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,766.49
Rate for Payer: Humana Medicare Advantage	$120.12
Rate for Payer: UnitedHealthcare Commercial	$271.70
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$171.60

19083 Biopsy, breast, w/placement of breast localization device(s), imag biopsy; 1st lesi TechFee

Facility

$2,529.00

Service Code	HCPCS 19083
Hospital Charge Code	3150839
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,402.55
Rate for Payer: Aetna Commercial	$2,276.10
Rate for Payer: UnitedHealthcare Commercial	$2,402.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19083 Biopsy, breast, w/placement of breast localization device(s), imag biopsy; 1st lesi TechFee

Facility

$2,529.00

Service Code	HCPCS 19083
Hospital Charge Code	3150839
Hospital Revenue Code	360
Min. Negotiated Rate	$474.60
Max. Negotiated Rate	$2,402.55
Rate for Payer: Aetna Commercial	$2,276.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,640.24
Rate for Payer: Humana Medicare Advantage	$1,062.18
Rate for Payer: UnitedHealthcare Commercial	$2,402.55
Rate for Payer: UnitedHealthcare Medicaid	$474.60
Rate for Payer: WPPA Medicare Advantage	$1,517.40

19083 BREAST BX W/LOCALIZATION CLIP CHARGE

Facility

$2,529.00

Service Code	HCPCS 19083
Hospital Charge Code	3359083
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,402.55
Rate for Payer: Aetna Commercial	$2,276.10
Rate for Payer: UnitedHealthcare Commercial	$2,402.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19083 BREAST BX W/LOCALIZATION CLIP CHARGE

Facility

$2,529.00

Service Code	HCPCS 19083
Hospital Charge Code	3359083
Hospital Revenue Code	761
Min. Negotiated Rate	$474.60
Max. Negotiated Rate	$2,402.55
Rate for Payer: Aetna Commercial	$2,276.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,640.24
Rate for Payer: Humana Medicare Advantage	$1,062.18
Rate for Payer: UnitedHealthcare Commercial	$2,402.55
Rate for Payer: UnitedHealthcare Medicaid	$474.60
Rate for Payer: WPPA Medicare Advantage	$1,517.40

19084 BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PE

Facility

$2,909.00

Service Code	HCPCS 19084
Hospital Charge Code	3159084
Hospital Revenue Code	360
Min. Negotiated Rate	$1,163.60
Max. Negotiated Rate	$2,763.55
Rate for Payer: Aetna Commercial	$2,618.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,886.68
Rate for Payer: Humana Medicare Advantage	$1,221.78
Rate for Payer: UnitedHealthcare Commercial	$2,763.55
Rate for Payer: UnitedHealthcare Medicaid	$1,163.60
Rate for Payer: WPPA Medicare Advantage	$1,745.40

19084 BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PE

Facility

$2,909.00

Service Code	HCPCS 19084
Hospital Charge Code	3159084
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,763.55
Rate for Payer: Aetna Commercial	$2,618.10
Rate for Payer: UnitedHealthcare Commercial	$2,763.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19084 BREAST BX EA ADDTL LESION CHARGE

Facility

$2,909.00

Service Code	HCPCS 19084
Hospital Charge Code	3359084
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,763.55
Rate for Payer: Aetna Commercial	$2,618.10
Rate for Payer: UnitedHealthcare Commercial	$2,763.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19084 BREAST BX EA ADDTL LESION CHARGE

Facility

$2,909.00

Service Code	HCPCS 19084
Hospital Charge Code	3359084
Hospital Revenue Code	761
Min. Negotiated Rate	$1,163.60
Max. Negotiated Rate	$2,763.55
Rate for Payer: Aetna Commercial	$2,618.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,886.68
Rate for Payer: Humana Medicare Advantage	$1,221.78
Rate for Payer: UnitedHealthcare Commercial	$2,763.55
Rate for Payer: UnitedHealthcare Medicaid	$1,163.60
Rate for Payer: WPPA Medicare Advantage	$1,745.40

19100 BIOPSY BREAST PERCUT W/O IMAGE

Facility

$630.00

Service Code	HCPCS 19100
Hospital Charge Code	3359100
Hospital Revenue Code	761
Min. Negotiated Rate	$264.60
Max. Negotiated Rate	$598.50
Rate for Payer: Aetna Commercial	$567.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.47
Rate for Payer: Humana Medicare Advantage	$264.60
Rate for Payer: UnitedHealthcare Commercial	$598.50
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$378.00

19100 BIOPSY BREAST PERCUT W/O IMAGE

Facility

$630.00

Service Code	HCPCS 19100
Hospital Charge Code	3359100
Hospital Revenue Code	761
Min. Negotiated Rate	$567.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$567.00
Rate for Payer: UnitedHealthcare Commercial	$598.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19100-Biopsy of breast, percutaneous, needle core, not using imaging guidance

Facility

$630.00

Service Code	HCPCS 19100
Hospital Charge Code	3359100
Hospital Revenue Code	761
Min. Negotiated Rate	$264.60
Max. Negotiated Rate	$598.50
Rate for Payer: Aetna Commercial	$567.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.47
Rate for Payer: Humana Medicare Advantage	$264.60
Rate for Payer: UnitedHealthcare Commercial	$598.50
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$378.00

19100-Biopsy of breast, percutaneous, needle core, not using imaging guidance

Facility

$630.00

Service Code	HCPCS 19100
Hospital Charge Code	3359100
Hospital Revenue Code	761
Min. Negotiated Rate	$567.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$567.00
Rate for Payer: UnitedHealthcare Commercial	$598.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19101 Biopsy of breast; open, incisional

Facility

$2,328.00

Service Code	HCPCS 19101
Hospital Charge Code	3159101
Hospital Revenue Code	360
Min. Negotiated Rate	$977.76
Max. Negotiated Rate	$2,211.60
Rate for Payer: Aetna Commercial	$2,095.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,509.95
Rate for Payer: Humana Medicare Advantage	$977.76
Rate for Payer: UnitedHealthcare Commercial	$2,211.60
Rate for Payer: UnitedHealthcare Medicaid	$1,234.81
Rate for Payer: WPPA Medicare Advantage	$1,396.80

19101 Biopsy of breast; open, incisional

Facility

$2,328.00

Service Code	HCPCS 19101
Hospital Charge Code	3159101
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,211.60
Rate for Payer: Aetna Commercial	$2,095.20
Rate for Payer: UnitedHealthcare Commercial	$2,211.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19120 Excision of cyst, fibroadenoma, other benign or malignant tumor, aberrant breast tissue

Facility

$5,742.00

Service Code	HCPCS 19120
Hospital Charge Code	3159120
Hospital Revenue Code	360
Min. Negotiated Rate	$1,234.81
Max. Negotiated Rate	$5,454.90
Rate for Payer: Aetna Commercial	$5,167.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,142.99
Rate for Payer: Humana Medicare Advantage	$2,411.64
Rate for Payer: UnitedHealthcare Commercial	$5,454.90
Rate for Payer: UnitedHealthcare Medicaid	$1,234.81
Rate for Payer: WPPA Medicare Advantage	$3,445.20

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All Charges