Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

40804 Removal of embedded foreign body, vestibule of mouth; simple

Facility

$738.00

Service Code	HCPCS 40804
Hospital Charge Code	3150804
Hospital Revenue Code	360
Min. Negotiated Rate	$293.65
Max. Negotiated Rate	$701.10
Rate for Payer: Aetna Commercial	$664.20
Rate for Payer: Humana Medicare Advantage	$309.96
Rate for Payer: UnitedHealthcare Commercial	$701.10
Rate for Payer: UnitedHealthcare Medicaid	$293.65
Rate for Payer: WPPA Medicare Advantage	$442.80

40804 Removal of embedded foreign body, vestibule of mouth; simple

Facility

$738.00

Service Code	HCPCS 40804
Hospital Charge Code	3150804
Hospital Revenue Code	360
Min. Negotiated Rate	$664.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$664.20
Rate for Payer: UnitedHealthcare Commercial	$701.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

40819 EXCISE LIP OR CHEEK FOLD

Facility

$2,601.00

Service Code	HCPCS 40819
Hospital Charge Code	3150819
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,470.95
Rate for Payer: Aetna Commercial	$2,340.90
Rate for Payer: UnitedHealthcare Commercial	$2,470.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

40819 EXCISE LIP OR CHEEK FOLD

Facility

$2,601.00

Service Code	HCPCS 40819
Hospital Charge Code	3150819
Hospital Revenue Code	360
Min. Negotiated Rate	$494.04
Max. Negotiated Rate	$2,470.95
Rate for Payer: Aetna Commercial	$2,340.90
Rate for Payer: Humana Medicare Advantage	$1,092.42
Rate for Payer: UnitedHealthcare Commercial	$2,470.95
Rate for Payer: UnitedHealthcare Medicaid	$494.04
Rate for Payer: WPPA Medicare Advantage	$1,560.60

41100 Biopsy of tongue anterior two thirds

Facility

$624.00

Service Code	HCPCS 41100
Hospital Charge Code	3151100
Hospital Revenue Code	761
Min. Negotiated Rate	$561.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$561.60
Rate for Payer: UnitedHealthcare Commercial	$592.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

41100 Biopsy of tongue anterior two thirds

Facility

$624.00

Service Code	HCPCS 41100
Hospital Charge Code	3151100
Hospital Revenue Code	761
Min. Negotiated Rate	$249.60
Max. Negotiated Rate	$592.80
Rate for Payer: Aetna Commercial	$561.60
Rate for Payer: Humana Medicare Advantage	$262.08
Rate for Payer: UnitedHealthcare Commercial	$592.80
Rate for Payer: UnitedHealthcare Medicaid	$249.60
Rate for Payer: WPPA Medicare Advantage	$374.40

41105 Biopsy of tongue; posterior one-third

Facility

$633.00

Service Code	HCPCS 41105
Hospital Charge Code	3151105
Hospital Revenue Code	360
Min. Negotiated Rate	$265.86
Max. Negotiated Rate	$1,042.99
Rate for Payer: Aetna Commercial	$569.70
Rate for Payer: Humana Medicare Advantage	$265.86
Rate for Payer: UnitedHealthcare Commercial	$601.35
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$379.80

41105 Biopsy of tongue; posterior one-third

Facility

$633.00

Service Code	HCPCS 41105
Hospital Charge Code	3151105
Hospital Revenue Code	360
Min. Negotiated Rate	$569.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$569.70
Rate for Payer: UnitedHealthcare Commercial	$601.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

41120 Glossectomy; less than one-half tongue

Facility

$4,452.00

Service Code	HCPCS 41120
Hospital Charge Code	3151900
Hospital Revenue Code	360
Min. Negotiated Rate	$1,869.84
Max. Negotiated Rate	$4,229.40
Rate for Payer: Aetna Commercial	$4,006.80
Rate for Payer: Humana Medicare Advantage	$1,869.84
Rate for Payer: UnitedHealthcare Commercial	$4,229.40
Rate for Payer: UnitedHealthcare Medicaid	$1,897.10
Rate for Payer: WPPA Medicare Advantage	$2,671.20

41120 Glossectomy; less than one-half tongue

Facility

$4,452.00

Service Code	HCPCS 41120
Hospital Charge Code	3151900
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,229.40
Rate for Payer: Aetna Commercial	$4,006.80
Rate for Payer: UnitedHealthcare Commercial	$4,229.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

41250-Mouth Floor/Tongue Ant 2/3 Less Than/Equal to 2.5cm

Facility

$2,869.00

Service Code	HCPCS 41250
Hospital Charge Code	3301250
Hospital Revenue Code	450
Min. Negotiated Rate	$171.60
Max. Negotiated Rate	$2,725.55
Rate for Payer: Aetna Commercial	$2,582.10
Rate for Payer: Humana Medicare Advantage	$1,204.98
Rate for Payer: UnitedHealthcare Commercial	$2,725.55
Rate for Payer: UnitedHealthcare Medicaid	$171.60
Rate for Payer: WPPA Medicare Advantage	$1,721.40

41250-Mouth Floor/Tongue Ant 2/3 Less Than/Equal to 2.5cm

Facility

$2,869.00

Service Code	HCPCS 41250
Hospital Charge Code	3301250
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,725.55
Rate for Payer: Aetna Commercial	$2,582.10
Rate for Payer: UnitedHealthcare Commercial	$2,725.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

41800-Drainage Abscess/Cyst Dentoalveolar

Facility

$450.00

Service Code	HCPCS 41800
Hospital Charge Code	3301800
Hospital Revenue Code	450
Min. Negotiated Rate	$405.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$405.00
Rate for Payer: UnitedHealthcare Commercial	$427.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

41800-Drainage Abscess/Cyst Dentoalveolar

Facility

$450.00

Service Code	HCPCS 41800
Hospital Charge Code	3301800
Hospital Revenue Code	450
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$427.50
Rate for Payer: Aetna Commercial	$405.00
Rate for Payer: Humana Medicare Advantage	$189.00
Rate for Payer: UnitedHealthcare Commercial	$427.50
Rate for Payer: UnitedHealthcare Medicaid	$260.00
Rate for Payer: WPPA Medicare Advantage	$270.00

41899 - Dentoalveolar structures

Facility

$461.00

Service Code	HCPCS 41899
Hospital Charge Code	3304899
Hospital Revenue Code	450
Min. Negotiated Rate	$414.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$414.90
Rate for Payer: UnitedHealthcare Commercial	$437.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

41899 - Dentoalveolar structures

Facility

$461.00

Service Code	HCPCS 41899
Hospital Charge Code	3304899
Hospital Revenue Code	450
Min. Negotiated Rate	$193.62
Max. Negotiated Rate	$2,859.31
Rate for Payer: Aetna Commercial	$414.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,859.31
Rate for Payer: Humana Medicare Advantage	$193.62
Rate for Payer: UnitedHealthcare Commercial	$437.95
Rate for Payer: UnitedHealthcare Medicaid	$228.61
Rate for Payer: WPPA Medicare Advantage	$276.60

42100 Biopsy of palate, uvula

Facility

$575.00

Service Code	HCPCS 42100
Hospital Charge Code	3152100
Hospital Revenue Code	360
Min. Negotiated Rate	$517.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$517.50
Rate for Payer: UnitedHealthcare Commercial	$546.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42100 Biopsy of palate, uvula

Facility

$575.00

Service Code	HCPCS 42100
Hospital Charge Code	3152100
Hospital Revenue Code	360
Min. Negotiated Rate	$241.50
Max. Negotiated Rate	$546.25
Rate for Payer: Aetna Commercial	$517.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$241.50
Rate for Payer: UnitedHealthcare Commercial	$546.25
Rate for Payer: UnitedHealthcare Medicaid	$494.04
Rate for Payer: WPPA Medicare Advantage	$345.00

42106 Excision, lesion of palate, uvula; with simple primary closure

Facility

$969.00

Service Code	HCPCS 42106
Hospital Charge Code	3152106
Hospital Revenue Code	360
Min. Negotiated Rate	$406.98
Max. Negotiated Rate	$1,042.99
Rate for Payer: Aetna Commercial	$872.10
Rate for Payer: Humana Medicare Advantage	$406.98
Rate for Payer: UnitedHealthcare Commercial	$920.55
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$581.40

42106 Excision, lesion of palate, uvula; with simple primary closure

Facility

$969.00

Service Code	HCPCS 42106
Hospital Charge Code	3152106
Hospital Revenue Code	360
Min. Negotiated Rate	$872.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$872.10
Rate for Payer: UnitedHealthcare Commercial	$920.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42140 EXCISION OF UVULA

Facility

$1,883.00

Service Code	HCPCS 42140
Hospital Charge Code	3152140
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,788.85
Rate for Payer: Aetna Commercial	$1,694.70
Rate for Payer: UnitedHealthcare Commercial	$1,788.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42140 EXCISION OF UVULA

Facility

$1,883.00

Service Code	HCPCS 42140
Hospital Charge Code	3152140
Hospital Revenue Code	360
Min. Negotiated Rate	$790.86
Max. Negotiated Rate	$1,788.85
Rate for Payer: Aetna Commercial	$1,694.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,358.45
Rate for Payer: Humana Medicare Advantage	$790.86
Rate for Payer: UnitedHealthcare Commercial	$1,788.85
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$1,129.80

42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Facility

$2,903.00

Service Code	HCPCS 42145
Hospital Charge Code	3152145
Hospital Revenue Code	360
Min. Negotiated Rate	$1,219.26
Max. Negotiated Rate	$2,757.85
Rate for Payer: Aetna Commercial	$2,612.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,094.74
Rate for Payer: Humana Medicare Advantage	$1,219.26
Rate for Payer: UnitedHealthcare Commercial	$2,757.85
Rate for Payer: UnitedHealthcare Medicaid	$1,897.10
Rate for Payer: WPPA Medicare Advantage	$1,741.80

42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Facility

$2,903.00

Service Code	HCPCS 42145
Hospital Charge Code	3152145
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,757.85
Rate for Payer: Aetna Commercial	$2,612.70
Rate for Payer: UnitedHealthcare Commercial	$2,757.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42330 Removal of Salivary Stone

Facility

$4,988.00

Service Code	HCPCS 42330
Hospital Charge Code	3152330
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,738.60
Rate for Payer: Aetna Commercial	$4,489.20
Rate for Payer: UnitedHealthcare Commercial	$4,738.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

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All Charges