Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

19125 EXCISION BREAST LESION

Facility

$5,742.00

Service Code	HCPCS 19125
Hospital Charge Code	3159125
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,454.90
Rate for Payer: Aetna Commercial	$5,167.80
Rate for Payer: UnitedHealthcare Commercial	$5,454.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19125 EXCISION BREAST LESION

Facility

$5,742.00

Service Code	HCPCS 19125
Hospital Charge Code	3159125
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

19301 PARTIAL MASTECTOMY

Facility

$8,632.00

Service Code	HCPCS 19301
Hospital Charge Code	3159301
Hospital Revenue Code	360
Min. Negotiated Rate	$801.08
Max. Negotiated Rate	$8,200.40
Rate for Payer: Aetna Commercial	$7,768.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5,598.43
Rate for Payer: Humana Medicare Advantage	$3,625.44
Rate for Payer: UnitedHealthcare Commercial	$8,200.40
Rate for Payer: UnitedHealthcare Medicaid	$801.08
Rate for Payer: WPPA Medicare Advantage	$5,179.20

19301 PARTIAL MASTECTOMY

Facility

$8,632.00

Service Code	HCPCS 19301
Hospital Charge Code	3159301
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,200.40
Rate for Payer: Aetna Commercial	$7,768.80
Rate for Payer: UnitedHealthcare Commercial	$8,200.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19302 P-MASTECTOMY W/LN REMOVAL

Facility

$11,081.00

Service Code	HCPCS 19302
Hospital Charge Code	3159302
Hospital Revenue Code	360
Min. Negotiated Rate	$1,537.39
Max. Negotiated Rate	$10,526.95
Rate for Payer: Aetna Commercial	$9,972.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7,187.16
Rate for Payer: Humana Medicare Advantage	$4,654.02
Rate for Payer: UnitedHealthcare Commercial	$10,526.95
Rate for Payer: UnitedHealthcare Medicaid	$1,537.39
Rate for Payer: WPPA Medicare Advantage	$6,648.60

19302 P-MASTECTOMY W/LN REMOVAL

Facility

$11,081.00

Service Code	HCPCS 19302
Hospital Charge Code	3159302
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,526.95
Rate for Payer: Aetna Commercial	$9,972.90
Rate for Payer: UnitedHealthcare Commercial	$10,526.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19303 MAST SIMPLE COMPLETE

Facility

$11,167.00

Service Code	HCPCS 19303
Hospital Charge Code	3159303
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$10,608.65
Rate for Payer: Aetna Commercial	$10,050.30
Rate for Payer: UnitedHealthcare Commercial	$10,608.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19303 MAST SIMPLE COMPLETE

Facility

$11,167.00

Service Code	HCPCS 19303
Hospital Charge Code	3159303
Hospital Revenue Code	360
Min. Negotiated Rate	$1,164.16
Max. Negotiated Rate	$10,608.65
Rate for Payer: Aetna Commercial	$10,050.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7,242.71
Rate for Payer: Humana Medicare Advantage	$4,690.14
Rate for Payer: UnitedHealthcare Commercial	$10,608.65
Rate for Payer: UnitedHealthcare Medicaid	$1,164.16
Rate for Payer: WPPA Medicare Advantage	$6,700.20

19305 Mastectomy; radical; including pectoral muscles; axillary lymph nodes

Facility

$12,293.00

Service Code	HCPCS 19305
Hospital Charge Code	3159305
Hospital Revenue Code	360
Min. Negotiated Rate	$4,917.20
Max. Negotiated Rate	$11,678.35
Rate for Payer: Aetna Commercial	$11,063.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7,973.95
Rate for Payer: Humana Medicare Advantage	$5,163.06
Rate for Payer: UnitedHealthcare Commercial	$11,678.35
Rate for Payer: UnitedHealthcare Medicaid	$4,917.20
Rate for Payer: WPPA Medicare Advantage	$7,375.80

19305 Mastectomy; radical; including pectoral muscles; axillary lymph nodes

Facility

$12,293.00

Service Code	HCPCS 19305
Hospital Charge Code	3159305
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,678.35
Rate for Payer: Aetna Commercial	$11,063.70
Rate for Payer: UnitedHealthcare Commercial	$11,678.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19307 Mastectomyectomy, modified radical, including axillary lymph nodes, with or without pectoralis

Facility

$12,826.00

Service Code	HCPCS 19307
Hospital Charge Code	3159307
Hospital Revenue Code	360
Min. Negotiated Rate	$1,573.55
Max. Negotiated Rate	$12,184.70
Rate for Payer: Aetna Commercial	$11,543.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8,318.36
Rate for Payer: Humana Medicare Advantage	$5,386.92
Rate for Payer: UnitedHealthcare Commercial	$12,184.70
Rate for Payer: UnitedHealthcare Medicaid	$1,573.55
Rate for Payer: WPPA Medicare Advantage	$7,695.60

19307 Mastectomyectomy, modified radical, including axillary lymph nodes, with or without pectoralis

Facility

$12,826.00

Service Code	HCPCS 19307
Hospital Charge Code	3159307
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,184.70
Rate for Payer: Aetna Commercial	$11,543.40
Rate for Payer: UnitedHealthcare Commercial	$12,184.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19328 Removal of intact mammary implant

Facility

$2,834.00

Service Code	HCPCS 19328
Hospital Charge Code	3159328
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,692.30
Rate for Payer: Aetna Commercial	$2,550.60
Rate for Payer: UnitedHealthcare Commercial	$2,692.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19328 Removal of intact mammary implant

Facility

$2,834.00

Service Code	HCPCS 19328
Hospital Charge Code	3159328
Hospital Revenue Code	360
Min. Negotiated Rate	$1,133.60
Max. Negotiated Rate	$2,692.30
Rate for Payer: Aetna Commercial	$2,550.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,241.87
Rate for Payer: Humana Medicare Advantage	$1,190.28
Rate for Payer: UnitedHealthcare Commercial	$2,692.30
Rate for Payer: UnitedHealthcare Medicaid	$1,133.60
Rate for Payer: WPPA Medicare Advantage	$1,700.40

19330 Removal of mammary implant material

Facility

$3,674.00

Service Code	HCPCS 19330
Hospital Charge Code	3159330
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,490.30
Rate for Payer: Aetna Commercial	$3,306.60
Rate for Payer: UnitedHealthcare Commercial	$3,490.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

19330 Removal of mammary implant material

Facility

$3,674.00

Service Code	HCPCS 19330
Hospital Charge Code	3159330
Hospital Revenue Code	360
Min. Negotiated Rate	$1,469.60
Max. Negotiated Rate	$3,490.30
Rate for Payer: Aetna Commercial	$3,306.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,836.82
Rate for Payer: Humana Medicare Advantage	$1,543.08
Rate for Payer: UnitedHealthcare Commercial	$3,490.30
Rate for Payer: UnitedHealthcare Medicaid	$1,469.60
Rate for Payer: WPPA Medicare Advantage	$2,204.40

20245 Biopsy, bone, open; deep (eg, humerus, ischium, femur)

Facility

$2,222.00

Service Code	HCPCS 20245
Hospital Charge Code	3290245
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,110.90
Rate for Payer: Aetna Commercial	$1,999.80
Rate for Payer: UnitedHealthcare Commercial	$2,110.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20245 Biopsy, bone, open; deep (eg, humerus, ischium, femur)

Facility

$2,222.00

Service Code	HCPCS 20245
Hospital Charge Code	3290245
Hospital Revenue Code	761
Min. Negotiated Rate	$920.50
Max. Negotiated Rate	$2,110.90
Rate for Payer: Aetna Commercial	$1,999.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,111.00
Rate for Payer: Humana Medicare Advantage	$933.24
Rate for Payer: UnitedHealthcare Commercial	$2,110.90
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$1,333.20

20520-Removal Body Muscle Sheath; Simple

Facility

$578.00

Service Code	HCPCS 20520
Hospital Charge Code	3300520
Hospital Revenue Code	450
Min. Negotiated Rate	$520.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$520.20
Rate for Payer: UnitedHealthcare Commercial	$549.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20520-Removal Body Muscle Sheath; Simple

Facility

$578.00

Service Code	HCPCS 20520
Hospital Charge Code	3300520
Hospital Revenue Code	450
Min. Negotiated Rate	$242.76
Max. Negotiated Rate	$606.00
Rate for Payer: Aetna Commercial	$520.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$606.00
Rate for Payer: Humana Medicare Advantage	$242.76
Rate for Payer: UnitedHealthcare Commercial	$549.10
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$346.80

20526 INJECT CARPAL TUNNEL CHARGE

Facility

$267.00

Service Code	HCPCS 20526
Hospital Charge Code	3350325
Hospital Revenue Code	761
Min. Negotiated Rate	$112.14
Max. Negotiated Rate	$253.65
Rate for Payer: Aetna Commercial	$240.30
Rate for Payer: Humana Medicare Advantage	$112.14
Rate for Payer: UnitedHealthcare Commercial	$253.65
Rate for Payer: UnitedHealthcare Medicaid	$192.19
Rate for Payer: WPPA Medicare Advantage	$160.20

20526 INJECT CARPAL TUNNEL CHARGE

Facility

$267.00

Service Code	HCPCS 20526
Hospital Charge Code	3350325
Hospital Revenue Code	761
Min. Negotiated Rate	$240.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$240.30
Rate for Payer: UnitedHealthcare Commercial	$253.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20526 Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel

Facility

$267.00

Service Code	HCPCS 20526
Hospital Charge Code	3350325
Hospital Revenue Code	761
Min. Negotiated Rate	$240.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$240.30
Rate for Payer: UnitedHealthcare Commercial	$253.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

20526 Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel

Facility

$267.00

Service Code	HCPCS 20526
Hospital Charge Code	3350325
Hospital Revenue Code	761
Min. Negotiated Rate	$112.14
Max. Negotiated Rate	$253.65
Rate for Payer: Aetna Commercial	$240.30
Rate for Payer: Humana Medicare Advantage	$112.14
Rate for Payer: UnitedHealthcare Commercial	$253.65
Rate for Payer: UnitedHealthcare Medicaid	$192.19
Rate for Payer: WPPA Medicare Advantage	$160.20

Know your out-of-pocket cost for care.

All Charges