Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

42330 Removal of Salivary Stone

Facility

$4,988.00

Service Code	HCPCS 42330
Hospital Charge Code	3152330
Hospital Revenue Code	360
Min. Negotiated Rate	$1,042.99
Max. Negotiated Rate	$4,738.60
Rate for Payer: Aetna Commercial	$4,489.20
Rate for Payer: Humana Medicare Advantage	$2,094.96
Rate for Payer: UnitedHealthcare Commercial	$4,738.60
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$2,992.80

42330 REMOVAL OF SALIVARY STONE CHARGE

Facility

$4,988.00

Service Code	HCPCS 42330
Hospital Charge Code	3352230
Hospital Revenue Code	761
Min. Negotiated Rate	$1,042.99
Max. Negotiated Rate	$4,738.60
Rate for Payer: Aetna Commercial	$4,489.20
Rate for Payer: Humana Medicare Advantage	$2,094.96
Rate for Payer: UnitedHealthcare Commercial	$4,738.60
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$2,992.80

42330 REMOVAL OF SALIVARY STONE CHARGE

Facility

$4,988.00

Service Code	HCPCS 42330
Hospital Charge Code	3352230
Hospital Revenue Code	761
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

42335 Sialolithotomy; submandibular (submaxillary), complicated, intraoral

Facility

$1,840.00

Service Code	HCPCS 42335
Hospital Charge Code	3152335
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,748.00
Rate for Payer: Aetna Commercial	$1,656.00
Rate for Payer: UnitedHealthcare Commercial	$1,748.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42335 Sialolithotomy; submandibular (submaxillary), complicated, intraoral

Facility

$1,840.00

Service Code	HCPCS 42335
Hospital Charge Code	3152335
Hospital Revenue Code	360
Min. Negotiated Rate	$772.80
Max. Negotiated Rate	$1,748.00
Rate for Payer: Aetna Commercial	$1,656.00
Rate for Payer: Humana Medicare Advantage	$772.80
Rate for Payer: UnitedHealthcare Commercial	$1,748.00
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$1,104.00

42405 Biopsy of salivary gland; incisional

Facility

$1,823.00

Service Code	HCPCS 42405
Hospital Charge Code	3292405
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,731.85
Rate for Payer: Aetna Commercial	$1,640.70
Rate for Payer: UnitedHealthcare Commercial	$1,731.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42405 Biopsy of salivary gland; incisional

Facility

$1,823.00

Service Code	HCPCS 42405
Hospital Charge Code	3292405
Hospital Revenue Code	761
Min. Negotiated Rate	$494.04
Max. Negotiated Rate	$1,731.85
Rate for Payer: Aetna Commercial	$1,640.70
Rate for Payer: Humana Medicare Advantage	$765.66
Rate for Payer: UnitedHealthcare Commercial	$1,731.85
Rate for Payer: UnitedHealthcare Medicaid	$494.04
Rate for Payer: WPPA Medicare Advantage	$1,093.80

42415 Excision of parotid tumor/gland; lateral lobe, w/ dissection and preservation of facial nerve

Facility

$8,934.00

Service Code	HCPCS 42415
Hospital Charge Code	3152415
Hospital Revenue Code	360
Min. Negotiated Rate	$1,897.10
Max. Negotiated Rate	$8,487.30
Rate for Payer: Aetna Commercial	$8,040.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$6,446.09
Rate for Payer: Humana Medicare Advantage	$3,752.28
Rate for Payer: UnitedHealthcare Commercial	$8,487.30
Rate for Payer: UnitedHealthcare Medicaid	$1,897.10
Rate for Payer: WPPA Medicare Advantage	$5,360.40

42415 Excision of parotid tumor/gland; lateral lobe, w/ dissection and preservation of facial nerve

Facility

$8,934.00

Service Code	HCPCS 42415
Hospital Charge Code	3152415
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,487.30
Rate for Payer: Aetna Commercial	$8,040.60
Rate for Payer: UnitedHealthcare Commercial	$8,487.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42440 Excision of submandibular (submaxillary) gland

Facility

$4,925.00

Service Code	HCPCS 42440
Hospital Charge Code	3152440
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,678.75
Rate for Payer: Aetna Commercial	$4,432.50
Rate for Payer: UnitedHealthcare Commercial	$4,678.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42440 Excision of submandibular (submaxillary) gland

Facility

$4,925.00

Service Code	HCPCS 42440
Hospital Charge Code	3152440
Hospital Revenue Code	360
Min. Negotiated Rate	$1,897.10
Max. Negotiated Rate	$4,678.75
Rate for Payer: Aetna Commercial	$4,432.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,518.42
Rate for Payer: Humana Medicare Advantage	$2,068.50
Rate for Payer: UnitedHealthcare Commercial	$4,678.75
Rate for Payer: UnitedHealthcare Medicaid	$1,897.10
Rate for Payer: WPPA Medicare Advantage	$2,955.00

42505 Plastic repair of salivary duct, sialodochoplasty; secondary or complicated

Facility

$7,199.00

Service Code	HCPCS 42505
Hospital Charge Code	3152505
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,839.05
Rate for Payer: Aetna Commercial	$6,479.10
Rate for Payer: UnitedHealthcare Commercial	$6,839.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42505 Plastic repair of salivary duct, sialodochoplasty; secondary or complicated

Facility

$7,199.00

Service Code	HCPCS 42505
Hospital Charge Code	3152505
Hospital Revenue Code	360
Min. Negotiated Rate	$2,720.12
Max. Negotiated Rate	$6,839.05
Rate for Payer: Aetna Commercial	$6,479.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,720.12
Rate for Payer: Humana Medicare Advantage	$3,023.58
Rate for Payer: UnitedHealthcare Commercial	$6,839.05
Rate for Payer: UnitedHealthcare Medicaid	$2,879.60
Rate for Payer: WPPA Medicare Advantage	$4,319.40

42650 Dilation salivary duct

Facility

$395.00

Service Code	HCPCS 42650
Hospital Charge Code	3352650
Hospital Revenue Code	761
Min. Negotiated Rate	$355.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$355.50
Rate for Payer: UnitedHealthcare Commercial	$375.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42650 Dilation salivary duct

Facility

$395.00

Service Code	HCPCS 42650
Hospital Charge Code	3352650
Hospital Revenue Code	761
Min. Negotiated Rate	$165.90
Max. Negotiated Rate	$494.04
Rate for Payer: Aetna Commercial	$355.50
Rate for Payer: Humana Medicare Advantage	$165.90
Rate for Payer: UnitedHealthcare Commercial	$375.25
Rate for Payer: UnitedHealthcare Medicaid	$494.04
Rate for Payer: WPPA Medicare Advantage	$237.00

42700 I & D ABSCESS, PERITONSILLAR-ER SERV PRO

Facility

$727.00

Service Code	HCPCS 42700
Hospital Charge Code	3352700
Hospital Revenue Code	761
Min. Negotiated Rate	$654.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$654.30
Rate for Payer: UnitedHealthcare Commercial	$690.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42700 I & D ABSCESS, PERITONSILLAR-ER SERV PRO

Facility

$727.00

Service Code	HCPCS 42700
Hospital Charge Code	3352700
Hospital Revenue Code	761
Min. Negotiated Rate	$305.34
Max. Negotiated Rate	$690.65
Rate for Payer: Aetna Commercial	$654.30
Rate for Payer: Humana Medicare Advantage	$305.34
Rate for Payer: UnitedHealthcare Commercial	$690.65
Rate for Payer: UnitedHealthcare Medicaid	$400.40
Rate for Payer: WPPA Medicare Advantage	$436.20

42700 Incision and drainage abscess; peritonsillar

Facility

$706.00

Service Code	HCPCS 42700
Hospital Charge Code	3352700
Hospital Revenue Code	761
Min. Negotiated Rate	$635.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$635.40
Rate for Payer: UnitedHealthcare Commercial	$670.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42700 Incision and drainage abscess; peritonsillar

Facility

$706.00

Service Code	HCPCS 42700
Hospital Charge Code	3352700
Hospital Revenue Code	761
Min. Negotiated Rate	$296.52
Max. Negotiated Rate	$670.70
Rate for Payer: Aetna Commercial	$635.40
Rate for Payer: Humana Medicare Advantage	$296.52
Rate for Payer: UnitedHealthcare Commercial	$670.70
Rate for Payer: UnitedHealthcare Medicaid	$400.40
Rate for Payer: WPPA Medicare Advantage	$423.60

42800 Biopsy; oropharynx

Facility

$3,703.00

Service Code	HCPCS 42800
Hospital Charge Code	3292800
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,517.85
Rate for Payer: Aetna Commercial	$3,332.70
Rate for Payer: UnitedHealthcare Commercial	$3,517.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42800 Biopsy; oropharynx

Facility

$3,703.00

Service Code	HCPCS 42800
Hospital Charge Code	3292800
Hospital Revenue Code	761
Min. Negotiated Rate	$494.04
Max. Negotiated Rate	$3,517.85
Rate for Payer: Aetna Commercial	$3,332.70
Rate for Payer: Humana Medicare Advantage	$1,555.26
Rate for Payer: UnitedHealthcare Commercial	$3,517.85
Rate for Payer: UnitedHealthcare Medicaid	$494.04
Rate for Payer: WPPA Medicare Advantage	$2,221.80

42800 BIOPSY OROPHARYNX CHARGE

Facility

$3,703.00

Service Code	HCPCS 42800
Hospital Charge Code	3152800
Hospital Revenue Code	360
Min. Negotiated Rate	$494.04
Max. Negotiated Rate	$3,517.85
Rate for Payer: Aetna Commercial	$3,332.70
Rate for Payer: Humana Medicare Advantage	$1,555.26
Rate for Payer: UnitedHealthcare Commercial	$3,517.85
Rate for Payer: UnitedHealthcare Medicaid	$494.04
Rate for Payer: WPPA Medicare Advantage	$2,221.80

42800 BIOPSY OROPHARYNX CHARGE

Facility

$3,703.00

Service Code	HCPCS 42800
Hospital Charge Code	3152800
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,517.85
Rate for Payer: Aetna Commercial	$3,332.70
Rate for Payer: UnitedHealthcare Commercial	$3,517.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42808 EXCISE PHARYNX LESION

Facility

$667.00

Service Code	HCPCS 42808
Hospital Charge Code	3152808
Hospital Revenue Code	360
Min. Negotiated Rate	$280.14
Max. Negotiated Rate	$1,142.59
Rate for Payer: Aetna Commercial	$600.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,142.59
Rate for Payer: Humana Medicare Advantage	$280.14
Rate for Payer: UnitedHealthcare Commercial	$633.65
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$400.20

42808 EXCISE PHARYNX LESION

Facility

$667.00

Service Code	HCPCS 42808
Hospital Charge Code	3152808
Hospital Revenue Code	360
Min. Negotiated Rate	$600.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$600.30
Rate for Payer: UnitedHealthcare Commercial	$633.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges