Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

23076 Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular)

Facility

$2,479.00

Service Code	HCPCS 23076
Hospital Charge Code	3157036
Hospital Revenue Code	360
Min. Negotiated Rate	$809.01
Max. Negotiated Rate	$2,355.05
Rate for Payer: Aetna Commercial	$2,231.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$1,041.18
Rate for Payer: UnitedHealthcare Commercial	$2,355.05
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$1,487.40

23076 Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular)

Facility

$2,479.00

Service Code	HCPCS 23076
Hospital Charge Code	3157036
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,355.05
Rate for Payer: Aetna Commercial	$2,231.10
Rate for Payer: UnitedHealthcare Commercial	$2,355.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

23076 Excision, tumor, soft tissue of shoulder area, subfascial; less than 5 cm

Facility

$2,479.00

Service Code	HCPCS 23076
Hospital Charge Code	3353076
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,355.05
Rate for Payer: Aetna Commercial	$2,231.10
Rate for Payer: UnitedHealthcare Commercial	$2,355.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

23076 Excision, tumor, soft tissue of shoulder area, subfascial; less than 5 cm

Facility

$2,479.00

Service Code	HCPCS 23076
Hospital Charge Code	3353076
Hospital Revenue Code	761
Min. Negotiated Rate	$809.01
Max. Negotiated Rate	$2,355.05
Rate for Payer: Aetna Commercial	$2,231.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$1,041.18
Rate for Payer: UnitedHealthcare Commercial	$2,355.05
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$1,487.40

23650-Shoulder w/o Anesthesia

Facility

$2,355.00

Service Code	HCPCS 23650
Hospital Charge Code	3304695
Hospital Revenue Code	450
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$2,237.25
Rate for Payer: Aetna Commercial	$2,119.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$897.89
Rate for Payer: Humana Medicare Advantage	$989.10
Rate for Payer: UnitedHealthcare Commercial	$2,237.25
Rate for Payer: UnitedHealthcare Medicaid	$260.00
Rate for Payer: WPPA Medicare Advantage	$1,413.00

23650-Shoulder w/o Anesthesia

Facility

$2,355.00

Service Code	HCPCS 23650
Hospital Charge Code	3304695
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,237.25
Rate for Payer: Aetna Commercial	$2,119.50
Rate for Payer: UnitedHealthcare Commercial	$2,237.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

23655 Closed treatment of shoulder dislocation.

Facility

$1,599.00

Service Code	HCPCS 23655
Hospital Charge Code	3363655
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

23655 Closed treatment of shoulder dislocation.

Facility

$1,599.00

Service Code	HCPCS 23655
Hospital Charge Code	3363655
Hospital Revenue Code	450
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$671.58
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: UnitedHealthcare Medicaid	$520.65
Rate for Payer: WPPA Medicare Advantage	$959.40

23655 CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES TechFee

Facility

$1,599.00

Service Code	HCPCS 23655
Hospital Charge Code	3360265
Hospital Revenue Code	450
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$671.58
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: UnitedHealthcare Medicaid	$520.65
Rate for Payer: WPPA Medicare Advantage	$959.40

23655 CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES TechFee

Facility

$1,599.00

Service Code	HCPCS 23655
Hospital Charge Code	3360265
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

23655-Shoulder w/ Anesthesia

Facility

$1,599.00

Service Code	HCPCS 23655
Hospital Charge Code	3304610
Hospital Revenue Code	450
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$671.58
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: UnitedHealthcare Medicaid	$520.65
Rate for Payer: WPPA Medicare Advantage	$959.40

23655-Shoulder w/ Anesthesia

Facility

$1,599.00

Service Code	HCPCS 23655
Hospital Charge Code	3304610
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

2,3-Dinor-11 Beta-Prostaglandin F2 Alpha, 24 Hour Urine QST

Facility

$380.00

Service Code	HCPCS 84150
Hospital Charge Code	3554150
Hospital Revenue Code	300
Min. Negotiated Rate	$342.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: UnitedHealthcare Commercial	$361.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

2,3-Dinor-11 Beta-Prostaglandin F2 Alpha, 24 Hour Urine QST

Facility

$380.00

Service Code	HCPCS 84150
Hospital Charge Code	3554150
Hospital Revenue Code	300
Min. Negotiated Rate	$35.50
Max. Negotiated Rate	$361.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$113.14
Rate for Payer: Humana Medicare Advantage	$159.60
Rate for Payer: UnitedHealthcare Commercial	$361.00
Rate for Payer: UnitedHealthcare Medicaid	$35.50
Rate for Payer: WPPA Medicare Advantage	$228.00

24071 EXC ARM/ELBOW LES SC 3 CM/>

Facility

$2,536.00

Service Code	HCPCS 24071
Hospital Charge Code	3154071
Hospital Revenue Code	360
Min. Negotiated Rate	$847.14
Max. Negotiated Rate	$2,409.20
Rate for Payer: Aetna Commercial	$2,282.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,727.10
Rate for Payer: Humana Medicare Advantage	$1,065.12
Rate for Payer: UnitedHealthcare Commercial	$2,409.20
Rate for Payer: UnitedHealthcare Medicaid	$847.14
Rate for Payer: WPPA Medicare Advantage	$1,521.60

24071 EXC ARM/ELBOW LES SC 3 CM/>

Facility

$2,536.00

Service Code	HCPCS 24071
Hospital Charge Code	3154071
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,409.20
Rate for Payer: Aetna Commercial	$2,282.40
Rate for Payer: UnitedHealthcare Commercial	$2,409.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

24073 Excision, tumor, soft tissue of upper arm or elbow area, subfascial; 5 cm or greater

Facility

$4,255.00

Service Code	HCPCS 24073
Hospital Charge Code	3154073
Hospital Revenue Code	360
Min. Negotiated Rate	$847.14
Max. Negotiated Rate	$4,042.25
Rate for Payer: Aetna Commercial	$3,829.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,069.39
Rate for Payer: Humana Medicare Advantage	$1,787.10
Rate for Payer: UnitedHealthcare Commercial	$4,042.25
Rate for Payer: UnitedHealthcare Medicaid	$847.14
Rate for Payer: WPPA Medicare Advantage	$2,553.00

24073 Excision, tumor, soft tissue of upper arm or elbow area, subfascial; 5 cm or greater

Facility

$4,255.00

Service Code	HCPCS 24073
Hospital Charge Code	3154073
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,042.25
Rate for Payer: Aetna Commercial	$3,829.50
Rate for Payer: UnitedHealthcare Commercial	$4,042.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

24075 Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cm

Facility

$4,489.00

Service Code	HCPCS 24075
Hospital Charge Code	3404075
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,264.55
Rate for Payer: Aetna Commercial	$4,040.10
Rate for Payer: UnitedHealthcare Commercial	$4,264.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

24075 Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cm

Facility

$4,489.00

Service Code	HCPCS 24075
Hospital Charge Code	3404075
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$4,264.55
Rate for Payer: Aetna Commercial	$4,040.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,284.72
Rate for Payer: Humana Medicare Advantage	$1,885.38
Rate for Payer: UnitedHealthcare Commercial	$4,264.55
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$2,693.40

24075 Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cm.

Facility

$2,569.00

Service Code	HCPCS 24075
Hospital Charge Code	3294075
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,440.55
Rate for Payer: Aetna Commercial	$2,312.10
Rate for Payer: UnitedHealthcare Commercial	$2,440.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

24075 Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cm.

Facility

$2,569.00

Service Code	HCPCS 24075
Hospital Charge Code	3294075
Hospital Revenue Code	761
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$2,440.55
Rate for Payer: Aetna Commercial	$2,312.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,284.72
Rate for Payer: Humana Medicare Advantage	$1,078.98
Rate for Payer: UnitedHealthcare Commercial	$2,440.55
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,541.40

24076-Excision, tumor, soft tissue of upper arm or elbow area, subfascial; less than 5 cm

Facility

$2,394.00

Service Code	HCPCS 24076
Hospital Charge Code	3154076
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,274.30
Rate for Payer: Aetna Commercial	$2,154.60
Rate for Payer: UnitedHealthcare Commercial	$2,274.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

24076-Excision, tumor, soft tissue of upper arm or elbow area, subfascial; less than 5 cm

Facility

$2,394.00

Service Code	HCPCS 24076
Hospital Charge Code	3154076
Hospital Revenue Code	360
Min. Negotiated Rate	$920.50
Max. Negotiated Rate	$2,274.30
Rate for Payer: Aetna Commercial	$2,154.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,727.10
Rate for Payer: Humana Medicare Advantage	$1,005.48
Rate for Payer: UnitedHealthcare Commercial	$2,274.30
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$1,436.40

24605-Elbow w/ Anesthesia

Facility

$2,472.00

Service Code	HCPCS 24605
Hospital Charge Code	3304605
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,348.40
Rate for Payer: Aetna Commercial	$2,224.80
Rate for Payer: UnitedHealthcare Commercial	$2,348.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges