Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

42815 Excision branchial cleft cyst/vestige/fistula, beneath subq tissues and/or into pharynx

Facility

$14,789.00

Service Code	HCPCS 42815
Hospital Charge Code	3152815
Hospital Revenue Code	360
Min. Negotiated Rate	$1,897.10
Max. Negotiated Rate	$14,049.55
Rate for Payer: Aetna Commercial	$13,310.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,518.42
Rate for Payer: Humana Medicare Advantage	$6,211.38
Rate for Payer: UnitedHealthcare Commercial	$14,049.55
Rate for Payer: UnitedHealthcare Medicaid	$1,897.10
Rate for Payer: WPPA Medicare Advantage	$8,873.40

42815 Excision branchial cleft cyst/vestige/fistula, beneath subq tissues and/or into pharynx

Facility

$14,789.00

Service Code	HCPCS 42815
Hospital Charge Code	3152815
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,049.55
Rate for Payer: Aetna Commercial	$13,310.10
Rate for Payer: UnitedHealthcare Commercial	$14,049.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42820 Tonsillectomy and adenoidectomy; younger than age 12

Facility

$8,852.00

Service Code	HCPCS 42820
Hospital Charge Code	3150572
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,409.40
Rate for Payer: Aetna Commercial	$7,966.80
Rate for Payer: UnitedHealthcare Commercial	$8,409.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42820 Tonsillectomy and adenoidectomy; younger than age 12

Facility

$8,852.00

Service Code	HCPCS 42820
Hospital Charge Code	3150572
Hospital Revenue Code	360
Min. Negotiated Rate	$1,897.10
Max. Negotiated Rate	$8,409.40
Rate for Payer: Aetna Commercial	$7,966.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$6,386.01
Rate for Payer: Humana Medicare Advantage	$3,717.84
Rate for Payer: UnitedHealthcare Commercial	$8,409.40
Rate for Payer: UnitedHealthcare Medicaid	$1,897.10
Rate for Payer: WPPA Medicare Advantage	$5,311.20

42821 REMOVE TONSILS AND ADENOIDS

Facility

$7,297.00

Service Code	HCPCS 42821
Hospital Charge Code	3150576
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,932.15
Rate for Payer: Aetna Commercial	$6,567.30
Rate for Payer: UnitedHealthcare Commercial	$6,932.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42821 REMOVE TONSILS AND ADENOIDS

Facility

$7,297.00

Service Code	HCPCS 42821
Hospital Charge Code	3150576
Hospital Revenue Code	360
Min. Negotiated Rate	$1,042.99
Max. Negotiated Rate	$6,932.15
Rate for Payer: Aetna Commercial	$6,567.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,439.30
Rate for Payer: Humana Medicare Advantage	$3,064.74
Rate for Payer: UnitedHealthcare Commercial	$6,932.15
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$4,378.20

42825 Tonsillectomy, primary or secondary; younger than age 12

Facility

$8,852.00

Service Code	HCPCS 42825
Hospital Charge Code	3150571
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,409.40
Rate for Payer: Aetna Commercial	$7,966.80
Rate for Payer: UnitedHealthcare Commercial	$8,409.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42825 Tonsillectomy, primary or secondary; younger than age 12

Facility

$8,852.00

Service Code	HCPCS 42825
Hospital Charge Code	3150571
Hospital Revenue Code	360
Min. Negotiated Rate	$1,897.10
Max. Negotiated Rate	$8,409.40
Rate for Payer: Aetna Commercial	$7,966.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$6,386.01
Rate for Payer: Humana Medicare Advantage	$3,717.84
Rate for Payer: UnitedHealthcare Commercial	$8,409.40
Rate for Payer: UnitedHealthcare Medicaid	$1,897.10
Rate for Payer: WPPA Medicare Advantage	$5,311.20

42826 Tonsillectomy, primary or secondary; age 12 or over

Facility

$3,861.00

Service Code	HCPCS 42826
Hospital Charge Code	3150577
Hospital Revenue Code	360
Min. Negotiated Rate	$1,042.99
Max. Negotiated Rate	$3,667.95
Rate for Payer: Aetna Commercial	$3,474.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,785.47
Rate for Payer: Humana Medicare Advantage	$1,621.62
Rate for Payer: UnitedHealthcare Commercial	$3,667.95
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$2,316.60

42826 Tonsillectomy, primary or secondary; age 12 or over

Facility

$3,861.00

Service Code	HCPCS 42826
Hospital Charge Code	3150577
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,667.95
Rate for Payer: Aetna Commercial	$3,474.90
Rate for Payer: UnitedHealthcare Commercial	$3,667.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42830 Adenoidectomy, primary; younger than age 12

Facility

$4,767.00

Service Code	HCPCS 42830
Hospital Charge Code	3152830
Hospital Revenue Code	360
Min. Negotiated Rate	$1,042.99
Max. Negotiated Rate	$4,528.65
Rate for Payer: Aetna Commercial	$4,290.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,439.30
Rate for Payer: Humana Medicare Advantage	$2,002.14
Rate for Payer: UnitedHealthcare Commercial	$4,528.65
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$2,860.20

42830 Adenoidectomy, primary; younger than age 12

Facility

$4,767.00

Service Code	HCPCS 42830
Hospital Charge Code	3152830
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,528.65
Rate for Payer: Aetna Commercial	$4,290.30
Rate for Payer: UnitedHealthcare Commercial	$4,528.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42831 REMOVAL OF ADENOIDS

Facility

$7,297.00

Service Code	HCPCS 42831
Hospital Charge Code	3152831
Hospital Revenue Code	360
Min. Negotiated Rate	$1,042.99
Max. Negotiated Rate	$6,932.15
Rate for Payer: Aetna Commercial	$6,567.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,351.18
Rate for Payer: Humana Medicare Advantage	$3,064.74
Rate for Payer: UnitedHealthcare Commercial	$6,932.15
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$4,378.20

42831 REMOVAL OF ADENOIDS

Facility

$7,297.00

Service Code	HCPCS 42831
Hospital Charge Code	3152831
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,932.15
Rate for Payer: Aetna Commercial	$6,567.30
Rate for Payer: UnitedHealthcare Commercial	$6,932.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42835 Adenoidectomy, secondary; younger than age 12

Facility

$3,428.00

Service Code	HCPCS 42835
Hospital Charge Code	3152835
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,256.60
Rate for Payer: Aetna Commercial	$3,085.20
Rate for Payer: UnitedHealthcare Commercial	$3,256.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42835 Adenoidectomy, secondary; younger than age 12

Facility

$3,428.00

Service Code	HCPCS 42835
Hospital Charge Code	3152835
Hospital Revenue Code	360
Min. Negotiated Rate	$1,042.99
Max. Negotiated Rate	$3,256.60
Rate for Payer: Aetna Commercial	$3,085.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,117.97
Rate for Payer: Humana Medicare Advantage	$1,439.76
Rate for Payer: UnitedHealthcare Commercial	$3,256.60
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$2,056.80

42950 Pharyngoplasty

Facility

$3,134.00

Service Code	HCPCS 42950
Hospital Charge Code	3159504
Hospital Revenue Code	360
Min. Negotiated Rate	$1,316.28
Max. Negotiated Rate	$2,977.30
Rate for Payer: Aetna Commercial	$2,820.60
Rate for Payer: Humana Medicare Advantage	$1,316.28
Rate for Payer: UnitedHealthcare Commercial	$2,977.30
Rate for Payer: UnitedHealthcare Medicaid	$1,897.10
Rate for Payer: WPPA Medicare Advantage	$1,880.40

42950 Pharyngoplasty

Facility

$3,134.00

Service Code	HCPCS 42950
Hospital Charge Code	3159504
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,977.30
Rate for Payer: Aetna Commercial	$2,820.60
Rate for Payer: UnitedHealthcare Commercial	$2,977.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42961 Control oropharyngeal hemorrhage, primary or secondary; complicated, requiring hospitalization

Facility

$2,401.00

Service Code	HCPCS 42961
Hospital Charge Code	3152961
Hospital Revenue Code	360
Min. Negotiated Rate	$416.00
Max. Negotiated Rate	$2,280.95
Rate for Payer: Aetna Commercial	$2,160.90
Rate for Payer: Humana Medicare Advantage	$1,008.42
Rate for Payer: UnitedHealthcare Commercial	$2,280.95
Rate for Payer: UnitedHealthcare Medicaid	$416.00
Rate for Payer: WPPA Medicare Advantage	$1,440.60

42961 Control oropharyngeal hemorrhage, primary or secondary; complicated, requiring hospitalization

Facility

$2,401.00

Service Code	HCPCS 42961
Hospital Charge Code	3152961
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,280.95
Rate for Payer: Aetna Commercial	$2,160.90
Rate for Payer: UnitedHealthcare Commercial	$2,280.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

42975 Drug-induced sleep endoscopy, with dynamic evaluation of velum, pharynx ProFee

Facility

$2,813.00

Service Code	HCPCS 42975
Hospital Charge Code	3152975
Hospital Revenue Code	360
Min. Negotiated Rate	$109.28
Max. Negotiated Rate	$2,672.35
Rate for Payer: Aetna Commercial	$2,531.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$190.25
Rate for Payer: Humana Medicare Advantage	$1,181.46
Rate for Payer: UnitedHealthcare Commercial	$2,672.35
Rate for Payer: UnitedHealthcare Medicaid	$109.28
Rate for Payer: WPPA Medicare Advantage	$1,687.80

42975 Drug-induced sleep endoscopy, with dynamic evaluation of velum, pharynx ProFee

Facility

$2,813.00

Service Code	HCPCS 42975
Hospital Charge Code	3152975
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,672.35
Rate for Payer: Aetna Commercial	$2,531.70
Rate for Payer: UnitedHealthcare Commercial	$2,672.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43030 Cricopharyngeal myotomy

Facility

$2,443.00

Service Code	HCPCS 43030
Hospital Charge Code	3153030
Hospital Revenue Code	360
Min. Negotiated Rate	$1,026.06
Max. Negotiated Rate	$2,320.85
Rate for Payer: Aetna Commercial	$2,198.70
Rate for Payer: Humana Medicare Advantage	$1,026.06
Rate for Payer: UnitedHealthcare Commercial	$2,320.85
Rate for Payer: UnitedHealthcare Medicaid	$1,897.10
Rate for Payer: WPPA Medicare Advantage	$1,465.80

43030 Cricopharyngeal myotomy

Facility

$2,443.00

Service Code	HCPCS 43030
Hospital Charge Code	3153030
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,320.85
Rate for Payer: Aetna Commercial	$2,198.70
Rate for Payer: UnitedHealthcare Commercial	$2,320.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

43130 Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach

Facility

$3,707.00

Service Code	HCPCS 43130
Hospital Charge Code	3153130
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,521.65
Rate for Payer: Aetna Commercial	$3,336.30
Rate for Payer: UnitedHealthcare Commercial	$3,521.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges