Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

69200 RMVL FB XTRNL AUDITORY CANAL W/O ANES TechFee

Facility

$373.00

Service Code	HCPCS 69200
Hospital Charge Code	3359200
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

69200 RMVL FB XTRNL AUDITORY CANAL W/O ANES TechFee

Facility

$373.00

Service Code	HCPCS 69200
Hospital Charge Code	3359200
Hospital Revenue Code	450
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

69205 CLEAR OUTER EAR CANAL

Facility

$1,667.00

Service Code	HCPCS 69205
Hospital Charge Code	3159205
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,583.65
Rate for Payer: Aetna Commercial	$1,500.30
Rate for Payer: UnitedHealthcare Commercial	$1,583.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69205 CLEAR OUTER EAR CANAL

Facility

$1,667.00

Service Code	HCPCS 69205
Hospital Charge Code	3159205
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$1,583.65
Rate for Payer: Aetna Commercial	$1,500.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$897.89
Rate for Payer: Humana Medicare Advantage	$700.14
Rate for Payer: UnitedHealthcare Commercial	$1,583.65
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,000.20

69209-Cerumen Irrigation/Lavage

Facility

$212.00

Service Code	HCPCS 69209
Hospital Charge Code	3309209
Hospital Revenue Code	450
Min. Negotiated Rate	$37.81
Max. Negotiated Rate	$586.49
Rate for Payer: Aetna Commercial	$190.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$586.49
Rate for Payer: Humana Medicare Advantage	$89.04
Rate for Payer: UnitedHealthcare Commercial	$201.40
Rate for Payer: UnitedHealthcare Medicaid	$37.81
Rate for Payer: WPPA Medicare Advantage	$127.20

69209-Cerumen Irrigation/Lavage

Facility

$212.00

Service Code	HCPCS 69209
Hospital Charge Code	3309209
Hospital Revenue Code	450
Min. Negotiated Rate	$190.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$190.80
Rate for Payer: UnitedHealthcare Commercial	$201.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69209 - Removal impacted cerumen using irrigation/lavage, unilateral Tech Fee

Facility

$814.00

Service Code	HCPCS 69209
Hospital Charge Code	3359209
Hospital Revenue Code	450
Min. Negotiated Rate	$37.81
Max. Negotiated Rate	$773.30
Rate for Payer: Aetna Commercial	$732.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$586.49
Rate for Payer: Humana Medicare Advantage	$341.88
Rate for Payer: UnitedHealthcare Commercial	$773.30
Rate for Payer: UnitedHealthcare Medicaid	$37.81
Rate for Payer: WPPA Medicare Advantage	$488.40

69209 - Removal impacted cerumen using irrigation/lavage, unilateral Tech Fee

Facility

$814.00

Service Code	HCPCS 69209
Hospital Charge Code	3359209
Hospital Revenue Code	450
Min. Negotiated Rate	$732.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$732.60
Rate for Payer: UnitedHealthcare Commercial	$773.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69210-Cerumen w/ Instrumentation

Facility

$678.00

Service Code	HCPCS 69210
Hospital Charge Code	3309210
Hospital Revenue Code	450
Min. Negotiated Rate	$610.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$610.20
Rate for Payer: UnitedHealthcare Commercial	$644.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69210-Cerumen w/ Instrumentation

Facility

$678.00

Service Code	HCPCS 69210
Hospital Charge Code	3309210
Hospital Revenue Code	450
Min. Negotiated Rate	$140.40
Max. Negotiated Rate	$644.10
Rate for Payer: Aetna Commercial	$610.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$543.31
Rate for Payer: Humana Medicare Advantage	$284.76
Rate for Payer: UnitedHealthcare Commercial	$644.10
Rate for Payer: UnitedHealthcare Medicaid	$140.40
Rate for Payer: WPPA Medicare Advantage	$406.80

69210 REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT TechFee

Facility

$706.00

Service Code	HCPCS 69210
Hospital Charge Code	3309210
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

69210 REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT TechFee

Facility

$706.00

Service Code	HCPCS 69210
Hospital Charge Code	3309210
Hospital Revenue Code	450
Min. Negotiated Rate	$140.40
Max. Negotiated Rate	$670.70
Rate for Payer: Aetna Commercial	$635.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$543.31
Rate for Payer: Humana Medicare Advantage	$296.52
Rate for Payer: UnitedHealthcare Commercial	$670.70
Rate for Payer: UnitedHealthcare Medicaid	$140.40
Rate for Payer: WPPA Medicare Advantage	$423.60

69210 Removal impacted cerumen requiring instrumentation unilateral

Facility

$706.00

Service Code	HCPCS 69210
Hospital Charge Code	3359210
Hospital Revenue Code	761
Min. Negotiated Rate	$140.40
Max. Negotiated Rate	$670.70
Rate for Payer: Aetna Commercial	$635.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$543.31
Rate for Payer: Humana Medicare Advantage	$296.52
Rate for Payer: UnitedHealthcare Commercial	$670.70
Rate for Payer: UnitedHealthcare Medicaid	$140.40
Rate for Payer: WPPA Medicare Advantage	$423.60

69210 Removal impacted cerumen requiring instrumentation unilateral

Facility

$706.00

Service Code	HCPCS 69210
Hospital Charge Code	3359210
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

69210 Removal impacted cerumen requiring instrumentation, unilateral

Facility

$706.00

Service Code	HCPCS 69210
Hospital Charge Code	3359210
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

69210 Removal impacted cerumen requiring instrumentation, unilateral

Facility

$706.00

Service Code	HCPCS 69210
Hospital Charge Code	3359210
Hospital Revenue Code	761
Min. Negotiated Rate	$140.40
Max. Negotiated Rate	$670.70
Rate for Payer: Aetna Commercial	$635.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$543.31
Rate for Payer: Humana Medicare Advantage	$296.52
Rate for Payer: UnitedHealthcare Commercial	$670.70
Rate for Payer: UnitedHealthcare Medicaid	$140.40
Rate for Payer: WPPA Medicare Advantage	$423.60

69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL ProFee

Facility

$706.00

Service Code	HCPCS 69210
Hospital Charge Code	3359210
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

69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL ProFee

Facility

$706.00

Service Code	HCPCS 69210
Hospital Charge Code	3359210
Hospital Revenue Code	761
Min. Negotiated Rate	$140.40
Max. Negotiated Rate	$670.70
Rate for Payer: Aetna Commercial	$635.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$543.31
Rate for Payer: Humana Medicare Advantage	$296.52
Rate for Payer: UnitedHealthcare Commercial	$670.70
Rate for Payer: UnitedHealthcare Medicaid	$140.40
Rate for Payer: WPPA Medicare Advantage	$423.60

69210 REMOVAL OF CERUMEN CHARGE

Facility

$753.00

Service Code	HCPCS 69210
Hospital Charge Code	3159210
Hospital Revenue Code	360
Min. Negotiated Rate	$140.40
Max. Negotiated Rate	$715.35
Rate for Payer: Aetna Commercial	$677.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$543.31
Rate for Payer: Humana Medicare Advantage	$316.26
Rate for Payer: UnitedHealthcare Commercial	$715.35
Rate for Payer: UnitedHealthcare Medicaid	$140.40
Rate for Payer: WPPA Medicare Advantage	$451.80

69210 REMOVAL OF CERUMEN CHARGE

Facility

$753.00

Service Code	HCPCS 69210
Hospital Charge Code	3159210
Hospital Revenue Code	360
Min. Negotiated Rate	$677.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$677.70
Rate for Payer: UnitedHealthcare Commercial	$715.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69220 Debridement, mastoidectomy cavity, simple (eg, routine cleaning)

Facility

$648.00

Service Code	HCPCS 69220
Hospital Charge Code	3359220
Hospital Revenue Code	761
Min. Negotiated Rate	$259.20
Max. Negotiated Rate	$615.60
Rate for Payer: Aetna Commercial	$583.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$467.63
Rate for Payer: Humana Medicare Advantage	$272.16
Rate for Payer: UnitedHealthcare Commercial	$615.60
Rate for Payer: UnitedHealthcare Medicaid	$259.20
Rate for Payer: WPPA Medicare Advantage	$388.80

69220 Debridement, mastoidectomy cavity, simple (eg, routine cleaning)

Facility

$648.00

Service Code	HCPCS 69220
Hospital Charge Code	3359220
Hospital Revenue Code	761
Min. Negotiated Rate	$583.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$583.20
Rate for Payer: UnitedHealthcare Commercial	$615.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69222 Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning)

Facility

$817.00

Service Code	HCPCS 69222
Hospital Charge Code	3359222
Hospital Revenue Code	761
Min. Negotiated Rate	$735.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$735.30
Rate for Payer: UnitedHealthcare Commercial	$776.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69222 Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning)

Facility

$817.00

Service Code	HCPCS 69222
Hospital Charge Code	3359222
Hospital Revenue Code	761
Min. Negotiated Rate	$228.80
Max. Negotiated Rate	$776.15
Rate for Payer: Aetna Commercial	$735.30
Rate for Payer: Humana Medicare Advantage	$343.14
Rate for Payer: UnitedHealthcare Commercial	$776.15
Rate for Payer: UnitedHealthcare Medicaid	$228.80
Rate for Payer: WPPA Medicare Advantage	$490.20

69420 MYRINGOTOMY ASPIR&/EUSTACHIAN TUBE NFLTJ CHARGE

Facility

$835.00

Service Code	HCPCS 69420
Hospital Charge Code	3159420
Hospital Revenue Code	761
Min. Negotiated Rate	$751.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$751.50
Rate for Payer: UnitedHealthcare Commercial	$793.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges