Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

21011 EXCISION, TUMOR, SOFT TISS OF FACE/SCALP, SUBCUT; LESS THAN 2 CM

Facility

$1,256.00

Service Code	HCPCS 21011
Hospital Charge Code	3291011
Hospital Revenue Code	761
Min. Negotiated Rate	$1,130.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,130.40
Rate for Payer: UnitedHealthcare Commercial	$1,193.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21011 EXCISION, TUMOR, SOFT TISS OF FACE/SCALP, SUBCUT; LESS THAN 2 CM

Facility

$1,256.00

Service Code	HCPCS 21011
Hospital Charge Code	3291011
Hospital Revenue Code	761
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$1,193.20
Rate for Payer: Aetna Commercial	$1,130.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$905.97
Rate for Payer: Humana Medicare Advantage	$527.52
Rate for Payer: UnitedHealthcare Commercial	$1,193.20
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$753.60

21011 Excision, tumor, soft tissue of face or scalp, subcutaneous

Facility

$1,256.00

Service Code	HCPCS 21011
Hospital Charge Code	3151011
Hospital Revenue Code	360
Min. Negotiated Rate	$1,130.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,130.40
Rate for Payer: UnitedHealthcare Commercial	$1,193.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21011 Excision, tumor, soft tissue of face or scalp, subcutaneous

Facility

$1,256.00

Service Code	HCPCS 21011
Hospital Charge Code	3151011
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$1,193.20
Rate for Payer: Aetna Commercial	$1,130.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$905.97
Rate for Payer: Humana Medicare Advantage	$527.52
Rate for Payer: UnitedHealthcare Commercial	$1,193.20
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$753.60

21012 Excision, tumor, soft tissue of face or scalp, subcutaneous; 2cm or greater

Facility

$2,079.00

Service Code	HCPCS 21012
Hospital Charge Code	3151012
Hospital Revenue Code	360
Min. Negotiated Rate	$297.12
Max. Negotiated Rate	$1,975.05
Rate for Payer: Aetna Commercial	$1,871.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,348.35
Rate for Payer: Humana Medicare Advantage	$873.18
Rate for Payer: UnitedHealthcare Commercial	$1,975.05
Rate for Payer: UnitedHealthcare Medicaid	$297.12
Rate for Payer: WPPA Medicare Advantage	$1,247.40

21012 Excision, tumor, soft tissue of face or scalp, subcutaneous; 2cm or greater

Facility

$2,079.00

Service Code	HCPCS 21012
Hospital Charge Code	3151012
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,975.05
Rate for Payer: Aetna Commercial	$1,871.10
Rate for Payer: UnitedHealthcare Commercial	$1,975.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21013 EXCFACESCALLES>2CM [HGHO]

Facility

$2,276.00

Service Code	HCPCS 21013
Hospital Charge Code	3351013
Hospital Revenue Code	360
Min. Negotiated Rate	$297.12
Max. Negotiated Rate	$2,162.20
Rate for Payer: Aetna Commercial	$2,048.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,642.26
Rate for Payer: Humana Medicare Advantage	$955.92
Rate for Payer: UnitedHealthcare Commercial	$2,162.20
Rate for Payer: UnitedHealthcare Medicaid	$297.12
Rate for Payer: WPPA Medicare Advantage	$1,365.60

21013 EXCFACESCALLES>2CM [HGHO]

Facility

$2,276.00

Service Code	HCPCS 21013
Hospital Charge Code	3351013
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,162.20
Rate for Payer: Aetna Commercial	$2,048.40
Rate for Payer: UnitedHealthcare Commercial	$2,162.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21014 EXC FACE TUM DEEP = 2 CM

Facility

$2,995.00

Service Code	HCPCS 21014
Hospital Charge Code	3151014
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,845.25
Rate for Payer: Aetna Commercial	$2,695.50
Rate for Payer: UnitedHealthcare Commercial	$2,845.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21014 EXC FACE TUM DEEP = 2 CM

Facility

$2,995.00

Service Code	HCPCS 21014
Hospital Charge Code	3151014
Hospital Revenue Code	761
Min. Negotiated Rate	$297.12
Max. Negotiated Rate	$2,845.25
Rate for Payer: Aetna Commercial	$2,695.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,160.39
Rate for Payer: Humana Medicare Advantage	$1,257.90
Rate for Payer: UnitedHealthcare Commercial	$2,845.25
Rate for Payer: UnitedHealthcare Medicaid	$297.12
Rate for Payer: WPPA Medicare Advantage	$1,797.00

21320 Closed treatment of nasal bone fracture; with stabilization

Facility

$3,661.00

Service Code	HCPCS 21320
Hospital Charge Code	3151320
Hospital Revenue Code	360
Min. Negotiated Rate	$1,042.99
Max. Negotiated Rate	$3,477.95
Rate for Payer: Aetna Commercial	$3,294.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,971.52
Rate for Payer: Humana Medicare Advantage	$1,537.62
Rate for Payer: UnitedHealthcare Commercial	$3,477.95
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$2,196.60

21320 Closed treatment of nasal bone fracture; with stabilization

Facility

$3,661.00

Service Code	HCPCS 21320
Hospital Charge Code	3151320
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,477.95
Rate for Payer: Aetna Commercial	$3,294.90
Rate for Payer: UnitedHealthcare Commercial	$3,477.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21552 SUB TUMOR,NECK/THORAX, GREATER THAN 3CM

Facility

$5,185.00

Service Code	HCPCS 21552
Hospital Charge Code	3151552
Hospital Revenue Code	360
Min. Negotiated Rate	$847.14
Max. Negotiated Rate	$4,925.75
Rate for Payer: Aetna Commercial	$4,666.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,079.49
Rate for Payer: Humana Medicare Advantage	$2,177.70
Rate for Payer: UnitedHealthcare Commercial	$4,925.75
Rate for Payer: UnitedHealthcare Medicaid	$847.14
Rate for Payer: WPPA Medicare Advantage	$3,111.00

21552 SUB TUMOR,NECK/THORAX, GREATER THAN 3CM

Facility

$5,185.00

Service Code	HCPCS 21552
Hospital Charge Code	3151552
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,925.75
Rate for Payer: Aetna Commercial	$4,666.50
Rate for Payer: UnitedHealthcare Commercial	$4,925.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21554 EXC NECK TUM DEEP 5 CM/>

Facility

$8,841.00

Service Code	HCPCS 21554
Hospital Charge Code	3151554
Hospital Revenue Code	360
Min. Negotiated Rate	$847.56
Max. Negotiated Rate	$8,398.95
Rate for Payer: Aetna Commercial	$7,956.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5,461.07
Rate for Payer: Humana Medicare Advantage	$3,713.22
Rate for Payer: UnitedHealthcare Commercial	$8,398.95
Rate for Payer: UnitedHealthcare Medicaid	$847.56
Rate for Payer: WPPA Medicare Advantage	$5,304.60

21554 EXC NECK TUM DEEP 5 CM/>

Facility

$8,841.00

Service Code	HCPCS 21554
Hospital Charge Code	3151554
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,398.95
Rate for Payer: Aetna Commercial	$7,956.90
Rate for Payer: UnitedHealthcare Commercial	$8,398.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21555 SUB. TUMOR,NECK/THORAX, LESS THAN 3CM

Facility

$3,246.00

Service Code	HCPCS 21555
Hospital Charge Code	3351555
Hospital Revenue Code	761
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$3,083.70
Rate for Payer: Aetna Commercial	$2,921.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,104.84
Rate for Payer: Humana Medicare Advantage	$1,363.32
Rate for Payer: UnitedHealthcare Commercial	$3,083.70
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,947.60

21555 SUB. TUMOR,NECK/THORAX, LESS THAN 3CM

Facility

$3,246.00

Service Code	HCPCS 21555
Hospital Charge Code	3151555
Hospital Revenue Code	761
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$3,083.70
Rate for Payer: Aetna Commercial	$2,921.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,104.84
Rate for Payer: Humana Medicare Advantage	$1,363.32
Rate for Payer: UnitedHealthcare Commercial	$3,083.70
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,947.60

21555 SUB. TUMOR,NECK/THORAX, LESS THAN 3CM

Facility

$3,246.00

Service Code	HCPCS 21555
Hospital Charge Code	3151555
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,083.70
Rate for Payer: Aetna Commercial	$2,921.40
Rate for Payer: UnitedHealthcare Commercial	$3,083.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21555 SUB. TUMOR,NECK/THORAX, LESS THAN 3CM

Facility

$3,246.00

Service Code	HCPCS 21555
Hospital Charge Code	3351555
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,083.70
Rate for Payer: Aetna Commercial	$2,921.40
Rate for Payer: UnitedHealthcare Commercial	$3,083.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21556 EXC NECK TUM DEEP < 5 CM

Facility

$3,899.00

Service Code	HCPCS 21556
Hospital Charge Code	3151556
Hospital Revenue Code	360
Min. Negotiated Rate	$920.50
Max. Negotiated Rate	$3,704.05
Rate for Payer: Aetna Commercial	$3,509.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,812.85
Rate for Payer: Humana Medicare Advantage	$1,637.58
Rate for Payer: UnitedHealthcare Commercial	$3,704.05
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$2,339.40

21556 EXC NECK TUM DEEP < 5 CM

Facility

$3,899.00

Service Code	HCPCS 21556
Hospital Charge Code	3151556
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,704.05
Rate for Payer: Aetna Commercial	$3,509.10
Rate for Payer: UnitedHealthcare Commercial	$3,704.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21685 HYOID MYOTOMY AND SUSPENSION TechFee

Facility

$3,871.00

Service Code	HCPCS 21685
Hospital Charge Code	3151685
Hospital Revenue Code	360
Min. Negotiated Rate	$237.79
Max. Negotiated Rate	$3,677.45
Rate for Payer: Aetna Commercial	$3,483.90
Rate for Payer: Humana Medicare Advantage	$1,625.82
Rate for Payer: UnitedHealthcare Commercial	$3,677.45
Rate for Payer: UnitedHealthcare Medicaid	$237.79
Rate for Payer: WPPA Medicare Advantage	$2,322.60

21685 HYOID MYOTOMY AND SUSPENSION TechFee

Facility

$3,871.00

Service Code	HCPCS 21685
Hospital Charge Code	3151685
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,677.45
Rate for Payer: Aetna Commercial	$3,483.90
Rate for Payer: UnitedHealthcare Commercial	$3,677.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

21930 EXC BACK LES SC < 3 CM

Facility

$2,308.00

Service Code	HCPCS 21930
Hospital Charge Code	3151930
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,192.60
Rate for Payer: Aetna Commercial	$2,077.20
Rate for Payer: UnitedHealthcare Commercial	$2,192.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges