Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

31259 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including

Facility

$10,335.00

Service Code	HCPCS 31259
Hospital Charge Code	3151259
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,818.25
Rate for Payer: Aetna Commercial	$9,301.50
Rate for Payer: UnitedHealthcare Commercial	$9,818.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

31267 ENDOSCOPY MAXILLARY SINUS

Facility

$10,281.00

Service Code	HCPCS 31267
Hospital Charge Code	3151267
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,766.95
Rate for Payer: Aetna Commercial	$9,252.90
Rate for Payer: UnitedHealthcare Commercial	$9,766.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

31267 ENDOSCOPY MAXILLARY SINUS

Facility

$10,281.00

Service Code	HCPCS 31267
Hospital Charge Code	3151267
Hospital Revenue Code	360
Min. Negotiated Rate	$2,217.20
Max. Negotiated Rate	$9,766.95
Rate for Payer: Aetna Commercial	$9,252.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5,536.82
Rate for Payer: Humana Medicare Advantage	$4,318.02
Rate for Payer: UnitedHealthcare Commercial	$9,766.95
Rate for Payer: UnitedHealthcare Medicaid	$2,217.20
Rate for Payer: WPPA Medicare Advantage	$6,168.60

31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration

Facility

$10,229.00

Service Code	HCPCS 31276
Hospital Charge Code	3151276
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,717.55
Rate for Payer: Aetna Commercial	$9,206.10
Rate for Payer: UnitedHealthcare Commercial	$9,717.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration

Facility

$10,229.00

Service Code	HCPCS 31276
Hospital Charge Code	3151276
Hospital Revenue Code	360
Min. Negotiated Rate	$2,217.20
Max. Negotiated Rate	$9,717.55
Rate for Payer: Aetna Commercial	$9,206.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$7,380.07
Rate for Payer: Humana Medicare Advantage	$4,296.18
Rate for Payer: UnitedHealthcare Commercial	$9,717.55
Rate for Payer: UnitedHealthcare Medicaid	$2,217.20
Rate for Payer: WPPA Medicare Advantage	$6,137.40

31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy

Facility

$11,969.00

Service Code	HCPCS 31287
Hospital Charge Code	3151287
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,370.55
Rate for Payer: Aetna Commercial	$10,772.10
Rate for Payer: UnitedHealthcare Commercial	$11,370.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy

Facility

$11,969.00

Service Code	HCPCS 31287
Hospital Charge Code	3151287
Hospital Revenue Code	360
Min. Negotiated Rate	$2,217.20
Max. Negotiated Rate	$11,370.55
Rate for Payer: Aetna Commercial	$10,772.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$8,635.50
Rate for Payer: Humana Medicare Advantage	$5,026.98
Rate for Payer: UnitedHealthcare Commercial	$11,370.55
Rate for Payer: UnitedHealthcare Medicaid	$2,217.20
Rate for Payer: WPPA Medicare Advantage	$7,181.40

31288 Nasal/sinus endoscopy, surgical, w/ sphenoidotomy; w/ removal tissue from the sphenoid sinus

Facility

$6,627.00

Service Code	HCPCS 31288
Hospital Charge Code	3151288
Hospital Revenue Code	360
Min. Negotiated Rate	$2,217.20
Max. Negotiated Rate	$6,295.65
Rate for Payer: Aetna Commercial	$5,964.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,781.34
Rate for Payer: Humana Medicare Advantage	$2,783.34
Rate for Payer: UnitedHealthcare Commercial	$6,295.65
Rate for Payer: UnitedHealthcare Medicaid	$2,217.20
Rate for Payer: WPPA Medicare Advantage	$3,976.20

31288 Nasal/sinus endoscopy, surgical, w/ sphenoidotomy; w/ removal tissue from the sphenoid sinus

Facility

$6,627.00

Service Code	HCPCS 31288
Hospital Charge Code	3151288
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,295.65
Rate for Payer: Aetna Commercial	$5,964.30
Rate for Payer: UnitedHealthcare Commercial	$6,295.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation)

Facility

$10,433.00

Service Code	HCPCS 31296
Hospital Charge Code	3151296
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,911.35
Rate for Payer: Aetna Commercial	$9,389.70
Rate for Payer: UnitedHealthcare Commercial	$9,911.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation)

Facility

$10,433.00

Service Code	HCPCS 31296
Hospital Charge Code	3151296
Hospital Revenue Code	360
Min. Negotiated Rate	$2,217.20
Max. Negotiated Rate	$9,911.35
Rate for Payer: Aetna Commercial	$9,389.70
Rate for Payer: Humana Medicare Advantage	$4,381.86
Rate for Payer: UnitedHealthcare Commercial	$9,911.35
Rate for Payer: UnitedHealthcare Medicaid	$2,217.20
Rate for Payer: WPPA Medicare Advantage	$6,259.80

31500-Endotracheal Intubation

Facility

$1,012.00

Service Code	HCPCS 31500
Hospital Charge Code	3304640
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

31500-Endotracheal Intubation

Facility

$1,012.00

Service Code	HCPCS 31500
Hospital Charge Code	3304640
Hospital Revenue Code	450
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$961.40
Rate for Payer: Aetna Commercial	$910.80
Rate for Payer: Humana Medicare Advantage	$425.04
Rate for Payer: UnitedHealthcare Commercial	$961.40
Rate for Payer: UnitedHealthcare Medicaid	$234.00
Rate for Payer: WPPA Medicare Advantage	$607.20

31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE TechFee

Facility

$1,012.00

Service Code	HCPCS 31500
Hospital Charge Code	3304640
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

31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE TechFee

Facility

$1,012.00

Service Code	HCPCS 31500
Hospital Charge Code	3304640
Hospital Revenue Code	450
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$961.40
Rate for Payer: Aetna Commercial	$910.80
Rate for Payer: Humana Medicare Advantage	$425.04
Rate for Payer: UnitedHealthcare Commercial	$961.40
Rate for Payer: UnitedHealthcare Medicaid	$234.00
Rate for Payer: WPPA Medicare Advantage	$607.20

31502 TRACHEOTOMY TUBE CHANGE - ER SERV PROCED

Facility

$134.00

Service Code	HCPCS 31502
Hospital Charge Code	3351502
Hospital Revenue Code	761
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

31502 TRACHEOTOMY TUBE CHANGE - ER SERV PROCED

Facility

$134.00

Service Code	HCPCS 31502
Hospital Charge Code	3351502
Hospital Revenue Code	761
Min. Negotiated Rate	$56.28
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$114.40
Rate for Payer: WPPA Medicare Advantage	$80.40

31502 Tracheotomy tube change prior to establishment of fistula tract

Facility

$134.00

Service Code	HCPCS 31502
Hospital Charge Code	3351502
Hospital Revenue Code	761
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

31502 Tracheotomy tube change prior to establishment of fistula tract

Facility

$134.00

Service Code	HCPCS 31502
Hospital Charge Code	3351502
Hospital Revenue Code	761
Min. Negotiated Rate	$56.28
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$114.40
Rate for Payer: WPPA Medicare Advantage	$80.40

31525 Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn

Facility

$6,559.00

Service Code	HCPCS 31525
Hospital Charge Code	3151525
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,231.05
Rate for Payer: Aetna Commercial	$5,903.10
Rate for Payer: UnitedHealthcare Commercial	$6,231.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

31525 Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn

Facility

$6,559.00

Service Code	HCPCS 31525
Hospital Charge Code	3151525
Hospital Revenue Code	360
Min. Negotiated Rate	$549.83
Max. Negotiated Rate	$6,231.05
Rate for Payer: Aetna Commercial	$5,903.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,467.23
Rate for Payer: Humana Medicare Advantage	$2,754.78
Rate for Payer: UnitedHealthcare Commercial	$6,231.05
Rate for Payer: UnitedHealthcare Medicaid	$549.83
Rate for Payer: WPPA Medicare Advantage	$3,935.40

31530 Laryngoscopy, direct, operative, with foreign body removal;

Facility

$5,761.00

Service Code	HCPCS 31530
Hospital Charge Code	3151530
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,472.95
Rate for Payer: Aetna Commercial	$5,184.90
Rate for Payer: UnitedHealthcare Commercial	$5,472.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

31530 Laryngoscopy, direct, operative, with foreign body removal;

Facility

$5,761.00

Service Code	HCPCS 31530
Hospital Charge Code	3151530
Hospital Revenue Code	360
Min. Negotiated Rate	$549.83
Max. Negotiated Rate	$5,472.95
Rate for Payer: Aetna Commercial	$5,184.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,157.16
Rate for Payer: Humana Medicare Advantage	$2,419.62
Rate for Payer: UnitedHealthcare Commercial	$5,472.95
Rate for Payer: UnitedHealthcare Medicaid	$549.83
Rate for Payer: WPPA Medicare Advantage	$3,456.60

31535 LARYNGOSCOPY W/BIOPSY

Facility

$6,409.00

Service Code	HCPCS 31535
Hospital Charge Code	3151535
Hospital Revenue Code	360
Min. Negotiated Rate	$1,213.14
Max. Negotiated Rate	$6,088.55
Rate for Payer: Aetna Commercial	$5,768.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,157.16
Rate for Payer: Humana Medicare Advantage	$2,691.78
Rate for Payer: UnitedHealthcare Commercial	$6,088.55
Rate for Payer: UnitedHealthcare Medicaid	$1,213.14
Rate for Payer: WPPA Medicare Advantage	$3,845.40

31535 LARYNGOSCOPY W/BIOPSY

Facility

$6,409.00

Service Code	HCPCS 31535
Hospital Charge Code	3151535
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,088.55
Rate for Payer: Aetna Commercial	$5,768.10
Rate for Payer: UnitedHealthcare Commercial	$6,088.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges