Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

30901 Control anterior nasal hemorrhage.

Facility

$825.00

Service Code	HCPCS 30901
Hospital Charge Code	3350901
Hospital Revenue Code	761
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$783.75
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$488.84
Rate for Payer: Humana Medicare Advantage	$346.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: UnitedHealthcare Medicaid	$234.00
Rate for Payer: WPPA Medicare Advantage	$495.00

30901 CONTROL ANT. NASAL HEMORRHAGE- ER SERV P

Facility

$825.00

Service Code	HCPCS 30901
Hospital Charge Code	3300901
Hospital Revenue Code	450
Min. Negotiated Rate	$742.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

30901 CONTROL ANT. NASAL HEMORRHAGE- ER SERV P

Facility

$825.00

Service Code	HCPCS 30901
Hospital Charge Code	3300901
Hospital Revenue Code	450
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$783.75
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$488.84
Rate for Payer: Humana Medicare Advantage	$346.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: UnitedHealthcare Medicaid	$234.00
Rate for Payer: WPPA Medicare Advantage	$495.00

30901 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method

Facility

$825.00

Service Code	HCPCS 30901
Hospital Charge Code	3350901
Hospital Revenue Code	761
Min. Negotiated Rate	$742.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

30901 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method

Facility

$825.00

Service Code	HCPCS 30901
Hospital Charge Code	3350901
Hospital Revenue Code	761
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$783.75
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$488.84
Rate for Payer: Humana Medicare Advantage	$346.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: UnitedHealthcare Medicaid	$234.00
Rate for Payer: WPPA Medicare Advantage	$495.00

30901 CONTROL NASAL HEMORRHAGE SIMPLE CHARGE

Facility

$825.00

Service Code	HCPCS 30901
Hospital Charge Code	3150901
Hospital Revenue Code	360
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$783.75
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$488.84
Rate for Payer: Humana Medicare Advantage	$346.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: UnitedHealthcare Medicaid	$234.00
Rate for Payer: WPPA Medicare Advantage	$495.00

30901 CONTROL NASAL HEMORRHAGE SIMPLE CHARGE

Facility

$825.00

Service Code	HCPCS 30901
Hospital Charge Code	3150901
Hospital Revenue Code	360
Min. Negotiated Rate	$742.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$742.50
Rate for Payer: UnitedHealthcare Commercial	$783.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

30903-Anterior Complex

Facility

$1,012.00

Service Code	HCPCS 30903
Hospital Charge Code	3300903
Hospital Revenue Code	450
Min. Negotiated Rate	$312.00
Max. Negotiated Rate	$961.40
Rate for Payer: Aetna Commercial	$910.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$593.88
Rate for Payer: Humana Medicare Advantage	$425.04
Rate for Payer: UnitedHealthcare Commercial	$961.40
Rate for Payer: UnitedHealthcare Medicaid	$312.00
Rate for Payer: WPPA Medicare Advantage	$607.20

30903-Anterior Complex

Facility

$1,012.00

Service Code	HCPCS 30903
Hospital Charge Code	3300903
Hospital Revenue Code	450
Min. Negotiated Rate	$910.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$910.80
Rate for Payer: UnitedHealthcare Commercial	$961.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

30903 CONTROL ANT. NASAL HEMOR,COMP- ER SERV P

Facility

$1,049.00

Service Code	HCPCS 30903
Hospital Charge Code	3300903
Hospital Revenue Code	450
Min. Negotiated Rate	$312.00
Max. Negotiated Rate	$996.55
Rate for Payer: Aetna Commercial	$944.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$593.88
Rate for Payer: Humana Medicare Advantage	$440.58
Rate for Payer: UnitedHealthcare Commercial	$996.55
Rate for Payer: UnitedHealthcare Medicaid	$312.00
Rate for Payer: WPPA Medicare Advantage	$629.40

30903 CONTROL ANT. NASAL HEMOR,COMP- ER SERV P

Facility

$1,049.00

Service Code	HCPCS 30903
Hospital Charge Code	3300903
Hospital Revenue Code	450
Min. Negotiated Rate	$944.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$944.10
Rate for Payer: UnitedHealthcare Commercial	$996.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

30903 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method

Facility

$1,049.00

Service Code	HCPCS 30903
Hospital Charge Code	SCC30903
Hospital Revenue Code	761
Min. Negotiated Rate	$312.00
Max. Negotiated Rate	$996.55
Rate for Payer: Aetna Commercial	$944.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$593.88
Rate for Payer: Humana Medicare Advantage	$440.58
Rate for Payer: UnitedHealthcare Commercial	$996.55
Rate for Payer: UnitedHealthcare Medicaid	$312.00
Rate for Payer: WPPA Medicare Advantage	$629.40

30903 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method

Facility

$1,049.00

Service Code	HCPCS 30903
Hospital Charge Code	SCC30903
Hospital Revenue Code	761
Min. Negotiated Rate	$944.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$944.10
Rate for Payer: UnitedHealthcare Commercial	$996.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

30903 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing), any method

Facility

$1,049.00

Service Code	HCPCS 30903
Hospital Charge Code	3150903
Hospital Revenue Code	360
Min. Negotiated Rate	$944.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$944.10
Rate for Payer: UnitedHealthcare Commercial	$996.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

30903 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing), any method

Facility

$1,049.00

Service Code	HCPCS 30903
Hospital Charge Code	3150903
Hospital Revenue Code	360
Min. Negotiated Rate	$312.00
Max. Negotiated Rate	$996.55
Rate for Payer: Aetna Commercial	$944.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$593.88
Rate for Payer: Humana Medicare Advantage	$440.58
Rate for Payer: UnitedHealthcare Commercial	$996.55
Rate for Payer: UnitedHealthcare Medicaid	$312.00
Rate for Payer: WPPA Medicare Advantage	$629.40

30905 CONTROL NASAL HEMOR,POSTERIOR- ER SERV P

Facility

$620.00

Service Code	HCPCS 30905
Hospital Charge Code	3350905
Hospital Revenue Code	761
Min. Negotiated Rate	$558.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

30905 CONTROL NASAL HEMOR,POSTERIOR- ER SERV P

Facility

$620.00

Service Code	HCPCS 30905
Hospital Charge Code	3350905
Hospital Revenue Code	761
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$354.51
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$372.00

30905-Posterior Initial

Facility

$1,126.00

Service Code	HCPCS 30905
Hospital Charge Code	3300223
Hospital Revenue Code	450
Min. Negotiated Rate	$1,013.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,013.40
Rate for Payer: UnitedHealthcare Commercial	$1,069.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

30905-Posterior Initial

Facility

$1,126.00

Service Code	HCPCS 30905
Hospital Charge Code	3300223
Hospital Revenue Code	450
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$1,069.70
Rate for Payer: Aetna Commercial	$1,013.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$354.51
Rate for Payer: Humana Medicare Advantage	$472.92
Rate for Payer: UnitedHealthcare Commercial	$1,069.70
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$675.60

30930 Fracture nasal inferior turbinate(s), therapeutic

Facility

$857.00

Service Code	HCPCS 30930
Hospital Charge Code	3150930
Hospital Revenue Code	360
Min. Negotiated Rate	$771.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$771.30
Rate for Payer: UnitedHealthcare Commercial	$814.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

30930 Fracture nasal inferior turbinate(s), therapeutic

Facility

$857.00

Service Code	HCPCS 30930
Hospital Charge Code	3150930
Hospital Revenue Code	360
Min. Negotiated Rate	$359.94
Max. Negotiated Rate	$1,042.99
Rate for Payer: Aetna Commercial	$771.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$618.12
Rate for Payer: Humana Medicare Advantage	$359.94
Rate for Payer: UnitedHealthcare Commercial	$814.15
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$514.20

3.0 TI CANN COMP HDLESS SCR-ST- 24

Facility

$1,165.00

Hospital Charge Code	3258322
Hospital Revenue Code	270
Min. Negotiated Rate	$1,048.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,048.50
Rate for Payer: UnitedHealthcare Commercial	$1,106.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

3.0 TI CANN COMP HDLESS SCR-ST- 24

Facility

$1,165.00

Hospital Charge Code	3258322
Hospital Revenue Code	270
Min. Negotiated Rate	$466.00
Max. Negotiated Rate	$1,106.75
Rate for Payer: Aetna Commercial	$1,048.50
Rate for Payer: Humana Medicare Advantage	$489.30
Rate for Payer: UnitedHealthcare Commercial	$1,106.75
Rate for Payer: UnitedHealthcare Medicaid	$466.00
Rate for Payer: WPPA Medicare Advantage	$699.00

3.0 X 16mm Cannulated Screw

Facility

$699.00

Hospital Charge Code	3258591
Hospital Revenue Code	270
Min. Negotiated Rate	$629.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$629.10
Rate for Payer: UnitedHealthcare Commercial	$664.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

3.0 X 16mm Cannulated Screw

Facility

$699.00

Hospital Charge Code	3258591
Hospital Revenue Code	270
Min. Negotiated Rate	$279.60
Max. Negotiated Rate	$664.05
Rate for Payer: Aetna Commercial	$629.10
Rate for Payer: Humana Medicare Advantage	$293.58
Rate for Payer: UnitedHealthcare Commercial	$664.05
Rate for Payer: UnitedHealthcare Medicaid	$279.60
Rate for Payer: WPPA Medicare Advantage	$419.40

Know your out-of-pocket cost for care.

All Charges