Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

24605 TREAT ELBOW DISLOCATION CHARGE

Facility

$2,243.00

Service Code	HCPCS 24605
Hospital Charge Code	3154605
Hospital Revenue Code	360
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$2,130.85
Rate for Payer: Aetna Commercial	$2,018.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,117.06
Rate for Payer: Humana Medicare Advantage	$942.06
Rate for Payer: UnitedHealthcare Commercial	$2,130.85
Rate for Payer: UnitedHealthcare Medicaid	$520.65
Rate for Payer: WPPA Medicare Advantage	$1,345.80

24605 TREAT ELBOW DISLOCATION CHARGE

Facility

$2,243.00

Service Code	HCPCS 24605
Hospital Charge Code	3154605
Hospital Revenue Code	360
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

24605 TREATMENT CLOSED ELBOW DISLOCATION REQ ANES TechFee

Facility

$2,243.00

Service Code	HCPCS 24605
Hospital Charge Code	3304605
Hospital Revenue Code	450
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

24605 TREATMENT CLOSED ELBOW DISLOCATION REQ ANES TechFee

Facility

$2,243.00

Service Code	HCPCS 24605
Hospital Charge Code	3304605
Hospital Revenue Code	450
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$2,130.85
Rate for Payer: Aetna Commercial	$2,018.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,117.06
Rate for Payer: Humana Medicare Advantage	$942.06
Rate for Payer: UnitedHealthcare Commercial	$2,130.85
Rate for Payer: UnitedHealthcare Medicaid	$520.65
Rate for Payer: WPPA Medicare Advantage	$1,345.80

24640 CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ TechFee

Facility

$2,886.00

Service Code	HCPCS 24640
Hospital Charge Code	3302464
Hospital Revenue Code	450
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$2,741.70
Rate for Payer: Aetna Commercial	$2,597.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$1,212.12
Rate for Payer: UnitedHealthcare Commercial	$2,741.70
Rate for Payer: UnitedHealthcare Medicaid	$364.00
Rate for Payer: WPPA Medicare Advantage	$1,731.60

24640 CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ TechFee

Facility

$2,886.00

Service Code	HCPCS 24640
Hospital Charge Code	3302464
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,741.70
Rate for Payer: Aetna Commercial	$2,597.40
Rate for Payer: UnitedHealthcare Commercial	$2,741.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

24640-Nursemaid Elbow

Facility

$2,886.00

Service Code	HCPCS 24640
Hospital Charge Code	3302464
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,741.70
Rate for Payer: Aetna Commercial	$2,597.40
Rate for Payer: UnitedHealthcare Commercial	$2,741.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

24640-Nursemaid Elbow

Facility

$2,886.00

Service Code	HCPCS 24640
Hospital Charge Code	3302464
Hospital Revenue Code	450
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$2,741.70
Rate for Payer: Aetna Commercial	$2,597.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$1,212.12
Rate for Payer: UnitedHealthcare Commercial	$2,741.70
Rate for Payer: UnitedHealthcare Medicaid	$364.00
Rate for Payer: WPPA Medicare Advantage	$1,731.60

25000 Incision, extensor tendon sheath, wrist (eg, deQuervains disease)

Facility

$3,001.00

Service Code	HCPCS 25000
Hospital Charge Code	3355000
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,850.95
Rate for Payer: Aetna Commercial	$2,700.90
Rate for Payer: UnitedHealthcare Commercial	$2,850.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25000 Incision, extensor tendon sheath, wrist (eg, deQuervains disease)

Facility

$3,001.00

Service Code	HCPCS 25000
Hospital Charge Code	3355000
Hospital Revenue Code	360
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$2,850.95
Rate for Payer: Aetna Commercial	$2,700.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,165.44
Rate for Payer: Humana Medicare Advantage	$1,260.42
Rate for Payer: UnitedHealthcare Commercial	$2,850.95
Rate for Payer: UnitedHealthcare Medicaid	$520.65
Rate for Payer: WPPA Medicare Advantage	$1,800.60

25071-Excision, tumor, soft tissue and/or wrist area, subcutaneous; 3 cm or greater

Facility

$2,482.00

Service Code	HCPCS 25071
Hospital Charge Code	3355071
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,357.90
Rate for Payer: Aetna Commercial	$2,233.80
Rate for Payer: UnitedHealthcare Commercial	$2,357.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25071-Excision, tumor, soft tissue and/or wrist area, subcutaneous; 3 cm or greater

Facility

$2,482.00

Service Code	HCPCS 25071
Hospital Charge Code	3355071
Hospital Revenue Code	761
Min. Negotiated Rate	$847.14
Max. Negotiated Rate	$2,357.90
Rate for Payer: Aetna Commercial	$2,233.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,790.73
Rate for Payer: Humana Medicare Advantage	$1,042.44
Rate for Payer: UnitedHealthcare Commercial	$2,357.90
Rate for Payer: UnitedHealthcare Medicaid	$847.14
Rate for Payer: WPPA Medicare Advantage	$1,489.20

25071 Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm or greater-Hosp

Facility

$2,482.00

Service Code	HCPCS 25071
Hospital Charge Code	3155071
Hospital Revenue Code	360
Min. Negotiated Rate	$847.14
Max. Negotiated Rate	$2,357.90
Rate for Payer: Aetna Commercial	$2,233.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,790.73
Rate for Payer: Humana Medicare Advantage	$1,042.44
Rate for Payer: UnitedHealthcare Commercial	$2,357.90
Rate for Payer: UnitedHealthcare Medicaid	$847.14
Rate for Payer: WPPA Medicare Advantage	$1,489.20

25071 Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm or greater-Hosp

Facility

$2,482.00

Service Code	HCPCS 25071
Hospital Charge Code	3155071
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,357.90
Rate for Payer: Aetna Commercial	$2,233.80
Rate for Payer: UnitedHealthcare Commercial	$2,357.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25073-Excise Tumor, soft tissue of forearm and/or wrist area, subfascial; 3cm or greater

Facility

$2,132.00

Service Code	HCPCS 25073
Hospital Charge Code	3155073
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,025.40
Rate for Payer: Aetna Commercial	$1,918.80
Rate for Payer: UnitedHealthcare Commercial	$2,025.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25073-Excise Tumor, soft tissue of forearm and/or wrist area, subfascial; 3cm or greater

Facility

$2,132.00

Service Code	HCPCS 25073
Hospital Charge Code	3155073
Hospital Revenue Code	360
Min. Negotiated Rate	$847.14
Max. Negotiated Rate	$2,025.40
Rate for Payer: Aetna Commercial	$1,918.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,538.23
Rate for Payer: Humana Medicare Advantage	$895.44
Rate for Payer: UnitedHealthcare Commercial	$2,025.40
Rate for Payer: UnitedHealthcare Medicaid	$847.14
Rate for Payer: WPPA Medicare Advantage	$1,279.20

25075- Excision, tumor, soft tissue and/or wrist area, subcutaneous; less than 3 cm

Facility

$1,762.00

Service Code	HCPCS 25075
Hospital Charge Code	3155075
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,673.90
Rate for Payer: Aetna Commercial	$1,585.80
Rate for Payer: UnitedHealthcare Commercial	$1,673.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25075- Excision, tumor, soft tissue and/or wrist area, subcutaneous; less than 3 cm

Facility

$1,762.00

Service Code	HCPCS 25075
Hospital Charge Code	3155075
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$1,673.90
Rate for Payer: Aetna Commercial	$1,585.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,199.88
Rate for Payer: Humana Medicare Advantage	$740.04
Rate for Payer: UnitedHealthcare Commercial	$1,673.90
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,057.20

25075 Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; less than 3 cm

Facility

$1,762.00

Service Code	HCPCS 25075
Hospital Charge Code	3355075
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,673.90
Rate for Payer: Aetna Commercial	$1,585.80
Rate for Payer: UnitedHealthcare Commercial	$1,673.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25075 Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; less than 3 cm

Facility

$1,762.00

Service Code	HCPCS 25075
Hospital Charge Code	3355075
Hospital Revenue Code	761
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$1,673.90
Rate for Payer: Aetna Commercial	$1,585.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,199.88
Rate for Payer: Humana Medicare Advantage	$740.04
Rate for Payer: UnitedHealthcare Commercial	$1,673.90
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,057.20

25076 Excision, tumor, soft tissue of forearm and/or wrist area, subfascial; less than 3 cm

Facility

$2,133.00

Service Code	HCPCS 25076
Hospital Charge Code	3155076
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$2,026.35
Rate for Payer: Aetna Commercial	$1,919.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,538.23
Rate for Payer: Humana Medicare Advantage	$895.86
Rate for Payer: UnitedHealthcare Commercial	$2,026.35
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,279.80

25076 Excision, tumor, soft tissue of forearm and/or wrist area, subfascial; less than 3 cm

Facility

$2,133.00

Service Code	HCPCS 25076
Hospital Charge Code	3155076
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,026.35
Rate for Payer: Aetna Commercial	$1,919.70
Rate for Payer: UnitedHealthcare Commercial	$2,026.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25111 GANGLIONECTOMY

Facility

$3,906.00

Service Code	HCPCS 25111
Hospital Charge Code	3155111
Hospital Revenue Code	360
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$3,710.70
Rate for Payer: Aetna Commercial	$3,515.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,330.07
Rate for Payer: Humana Medicare Advantage	$1,640.52
Rate for Payer: UnitedHealthcare Commercial	$3,710.70
Rate for Payer: UnitedHealthcare Medicaid	$520.65
Rate for Payer: WPPA Medicare Advantage	$2,343.60

25111 GANGLIONECTOMY

Facility

$3,906.00

Service Code	HCPCS 25111
Hospital Charge Code	3155111
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,710.70
Rate for Payer: Aetna Commercial	$3,515.40
Rate for Payer: UnitedHealthcare Commercial	$3,710.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges