Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

64774 Excision of neuroma; cutaneous nerve, surgically identifiable

Facility

$2,734.00

Service Code	HCPCS 64774
Hospital Charge Code	3154774
Hospital Revenue Code	360
Min. Negotiated Rate	$1,093.60
Max. Negotiated Rate	$2,597.30
Rate for Payer: Aetna Commercial	$2,460.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,624.08
Rate for Payer: Humana Medicare Advantage	$1,148.28
Rate for Payer: UnitedHealthcare Commercial	$2,597.30
Rate for Payer: UnitedHealthcare Medicaid	$1,093.60
Rate for Payer: WPPA Medicare Advantage	$1,640.40

64782 Excision of neuroma; hand or foot, except digital nerve

Facility

$2,251.00

Service Code	HCPCS 64782
Hospital Charge Code	3304782
Hospital Revenue Code	975
Min. Negotiated Rate	$625.47
Max. Negotiated Rate	$2,138.45
Rate for Payer: Aetna Commercial	$2,025.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,624.08
Rate for Payer: Humana Medicare Advantage	$945.42
Rate for Payer: UnitedHealthcare Commercial	$2,138.45
Rate for Payer: UnitedHealthcare Medicaid	$625.47
Rate for Payer: WPPA Medicare Advantage	$1,350.60

64782 Excision of neuroma; hand or foot, except digital nerve

Facility

$2,251.00

Service Code	HCPCS 64782
Hospital Charge Code	3304782
Hospital Revenue Code	975
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,138.45
Rate for Payer: Aetna Commercial	$2,025.90
Rate for Payer: UnitedHealthcare Commercial	$2,138.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

64999 BLOCK ERECTOR SPINAE

Facility

$551.00

Service Code	HCPCS 64999
Hospital Charge Code	3154999
Hospital Revenue Code	360
Min. Negotiated Rate	$157.06
Max. Negotiated Rate	$523.45
Rate for Payer: Aetna Commercial	$495.90
Rate for Payer: Humana Medicare Advantage	$231.42
Rate for Payer: UnitedHealthcare Commercial	$523.45
Rate for Payer: UnitedHealthcare Medicaid	$157.06
Rate for Payer: WPPA Medicare Advantage	$330.60

64999 BLOCK ERECTOR SPINAE

Facility

$551.00

Service Code	HCPCS 64999
Hospital Charge Code	3154999
Hospital Revenue Code	360
Min. Negotiated Rate	$495.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$495.90
Rate for Payer: UnitedHealthcare Commercial	$523.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

65205-Conjuctival Superficial

Facility

$620.00

Service Code	HCPCS 65205
Hospital Charge Code	3304001
Hospital Revenue Code	450
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$558.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$260.40
Rate for Payer: UnitedHealthcare Commercial	$589.00
Rate for Payer: UnitedHealthcare Medicaid	$234.00
Rate for Payer: WPPA Medicare Advantage	$372.00

65205-Conjuctival Superficial

Facility

$620.00

Service Code	HCPCS 65205
Hospital Charge Code	3304001
Hospital Revenue Code	450
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

65205 REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL TechFee

Facility

$590.00

Service Code	HCPCS 65205
Hospital Charge Code	3304001
Hospital Revenue Code	450
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$560.50
Rate for Payer: Aetna Commercial	$531.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$310.07
Rate for Payer: Humana Medicare Advantage	$247.80
Rate for Payer: UnitedHealthcare Commercial	$560.50
Rate for Payer: UnitedHealthcare Medicaid	$234.00
Rate for Payer: WPPA Medicare Advantage	$354.00

65205 REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL TechFee

Facility

$590.00

Service Code	HCPCS 65205
Hospital Charge Code	3304001
Hospital Revenue Code	450
Min. Negotiated Rate	$531.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$531.00
Rate for Payer: UnitedHealthcare Commercial	$560.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

65220-Corneal w/o Slit Lamp

Facility

$1,431.00

Service Code	HCPCS 65220
Hospital Charge Code	3305220
Hospital Revenue Code	450
Min. Negotiated Rate	$416.00
Max. Negotiated Rate	$1,359.45
Rate for Payer: Aetna Commercial	$1,287.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$541.36
Rate for Payer: Humana Medicare Advantage	$601.02
Rate for Payer: UnitedHealthcare Commercial	$1,359.45
Rate for Payer: UnitedHealthcare Medicaid	$416.00
Rate for Payer: WPPA Medicare Advantage	$858.60

65220-Corneal w/o Slit Lamp

Facility

$1,431.00

Service Code	HCPCS 65220
Hospital Charge Code	3305220
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,359.45
Rate for Payer: Aetna Commercial	$1,287.90
Rate for Payer: UnitedHealthcare Commercial	$1,359.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

65235-Anterior Chamber of Eye/Lens

Facility

$373.00

Service Code	HCPCS 65235
Hospital Charge Code	3300301
Hospital Revenue Code	450
Min. Negotiated Rate	$156.66
Max. Negotiated Rate	$754.92
Rate for Payer: Aetna Commercial	$335.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$555.50
Rate for Payer: Humana Medicare Advantage	$156.66
Rate for Payer: UnitedHealthcare Commercial	$354.35
Rate for Payer: UnitedHealthcare Medicaid	$754.92
Rate for Payer: WPPA Medicare Advantage	$223.80

65235-Anterior Chamber of Eye/Lens

Facility

$373.00

Service Code	HCPCS 65235
Hospital Charge Code	3300301
Hospital Revenue Code	450
Min. Negotiated Rate	$335.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$335.70
Rate for Payer: UnitedHealthcare Commercial	$354.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

67800-Excision of Chalazion; Single

Facility

$963.00

Service Code	HCPCS 67800
Hospital Charge Code	3307800
Hospital Revenue Code	450
Min. Negotiated Rate	$180.18
Max. Negotiated Rate	$914.85
Rate for Payer: Aetna Commercial	$866.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$404.46
Rate for Payer: UnitedHealthcare Commercial	$914.85
Rate for Payer: UnitedHealthcare Medicaid	$180.18
Rate for Payer: WPPA Medicare Advantage	$577.80

67800-Excision of Chalazion; Single

Facility

$963.00

Service Code	HCPCS 67800
Hospital Charge Code	3307800
Hospital Revenue Code	450
Min. Negotiated Rate	$866.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$866.70
Rate for Payer: UnitedHealthcare Commercial	$914.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

67805 Excision of chalazion; multiple, different lids

Facility

$1,121.00

Service Code	HCPCS 67805
Hospital Charge Code	3157805
Hospital Revenue Code	360
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$1,064.95
Rate for Payer: Aetna Commercial	$1,008.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$470.82
Rate for Payer: UnitedHealthcare Commercial	$1,064.95
Rate for Payer: UnitedHealthcare Medicaid	$200.20
Rate for Payer: WPPA Medicare Advantage	$672.60

67805 Excision of chalazion; multiple, different lids

Facility

$1,121.00

Service Code	HCPCS 67805
Hospital Charge Code	3157805
Hospital Revenue Code	360
Min. Negotiated Rate	$1,008.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,008.90
Rate for Payer: UnitedHealthcare Commercial	$1,064.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69100 Biopsy external ear

Facility

$185.00

Service Code	HCPCS 69100
Hospital Charge Code	3359100
Hospital Revenue Code	761
Min. Negotiated Rate	$166.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$166.50
Rate for Payer: UnitedHealthcare Commercial	$175.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69100 Biopsy external ear

Facility

$185.00

Service Code	HCPCS 69100
Hospital Charge Code	3359100
Hospital Revenue Code	761
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$364.00
Rate for Payer: Aetna Commercial	$166.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$77.70
Rate for Payer: UnitedHealthcare Commercial	$175.75
Rate for Payer: UnitedHealthcare Medicaid	$364.00
Rate for Payer: WPPA Medicare Advantage	$111.00

69105 SC BIOPSY EXTERNAL AUDITORY CANAL-HOSP TECH

Facility

$195.00

Service Code	HCPCS 69105
Hospital Charge Code	3159105
Hospital Revenue Code	360
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$175.50
Rate for Payer: UnitedHealthcare Commercial	$185.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69105 SC BIOPSY EXTERNAL AUDITORY CANAL-HOSP TECH

Facility

$195.00

Service Code	HCPCS 69105
Hospital Charge Code	3159105
Hospital Revenue Code	360
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$494.04
Rate for Payer: Aetna Commercial	$175.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$81.90
Rate for Payer: UnitedHealthcare Commercial	$185.25
Rate for Payer: UnitedHealthcare Medicaid	$494.04
Rate for Payer: WPPA Medicare Advantage	$117.00

69200-External Auditory Canal

Facility

$706.00

Service Code	HCPCS 69200
Hospital Charge Code	3309200
Hospital Revenue Code	450
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

69200-External Auditory Canal

Facility

$706.00

Service Code	HCPCS 69200
Hospital Charge Code	3309200
Hospital Revenue Code	450
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$670.70
Rate for Payer: Aetna Commercial	$635.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$241.39
Rate for Payer: Humana Medicare Advantage	$296.52
Rate for Payer: UnitedHealthcare Commercial	$670.70
Rate for Payer: UnitedHealthcare Medicaid	$136.50
Rate for Payer: WPPA Medicare Advantage	$423.60

69200 Removal foreign body from external auditory canal without general anesthesia

Facility

$373.00

Service Code	HCPCS 69200
Hospital Charge Code	3359200
Hospital Revenue Code	761
Min. Negotiated Rate	$335.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$335.70
Rate for Payer: UnitedHealthcare Commercial	$354.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69200 Removal foreign body from external auditory canal without general anesthesia

Facility

$373.00

Service Code	HCPCS 69200
Hospital Charge Code	3359200
Hospital Revenue Code	761
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$354.35
Rate for Payer: Aetna Commercial	$335.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$241.39
Rate for Payer: Humana Medicare Advantage	$156.66
Rate for Payer: UnitedHealthcare Commercial	$354.35
Rate for Payer: UnitedHealthcare Medicaid	$136.50
Rate for Payer: WPPA Medicare Advantage	$223.80

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