Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

69420 MYRINGOTOMY CHARGE

Facility

$835.00

Service Code	HCPCS 69420
Hospital Charge Code	3359420
Hospital Revenue Code	761
Min. Negotiated Rate	$277.68
Max. Negotiated Rate	$793.25
Rate for Payer: Aetna Commercial	$751.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$541.36
Rate for Payer: Humana Medicare Advantage	$350.70
Rate for Payer: UnitedHealthcare Commercial	$793.25
Rate for Payer: UnitedHealthcare Medicaid	$277.68
Rate for Payer: WPPA Medicare Advantage	$501.00

69420 MYRINGOTOMY CHARGE

Facility

$835.00

Service Code	HCPCS 69420
Hospital Charge Code	3359420
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

69420 Myringotomy including aspiration and/or eustachian tube inflation

Facility

$835.00

Service Code	HCPCS 69420
Hospital Charge Code	3359420
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

69420 Myringotomy including aspiration and/or eustachian tube inflation

Facility

$835.00

Service Code	HCPCS 69420
Hospital Charge Code	3359420
Hospital Revenue Code	761
Min. Negotiated Rate	$277.68
Max. Negotiated Rate	$793.25
Rate for Payer: Aetna Commercial	$751.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$541.36
Rate for Payer: Humana Medicare Advantage	$350.70
Rate for Payer: UnitedHealthcare Commercial	$793.25
Rate for Payer: UnitedHealthcare Medicaid	$277.68
Rate for Payer: WPPA Medicare Advantage	$501.00

69424 Ventilating tube removal requiring general anesthesia

Facility

$4,029.00

Service Code	HCPCS 69424
Hospital Charge Code	3159424
Hospital Revenue Code	360
Min. Negotiated Rate	$1,042.99
Max. Negotiated Rate	$3,827.55
Rate for Payer: Aetna Commercial	$3,626.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,957.38
Rate for Payer: Humana Medicare Advantage	$1,692.18
Rate for Payer: UnitedHealthcare Commercial	$3,827.55
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$2,417.40

69424 Ventilating tube removal requiring general anesthesia

Facility

$4,029.00

Service Code	HCPCS 69424
Hospital Charge Code	3159424
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,827.55
Rate for Payer: Aetna Commercial	$3,626.10
Rate for Payer: UnitedHealthcare Commercial	$3,827.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69433 TYMPANOSTOMY CREATE EARDRUM OPENING CHARGE

Facility

$1,084.00

Service Code	HCPCS 69433
Hospital Charge Code	3159433
Hospital Revenue Code	360
Min. Negotiated Rate	$975.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$975.60
Rate for Payer: UnitedHealthcare Commercial	$1,029.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69433 TYMPANOSTOMY CREATE EARDRUM OPENING CHARGE

Facility

$1,084.00

Service Code	HCPCS 69433
Hospital Charge Code	3159433
Hospital Revenue Code	360
Min. Negotiated Rate	$305.45
Max. Negotiated Rate	$1,029.80
Rate for Payer: Aetna Commercial	$975.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$659.65
Rate for Payer: Humana Medicare Advantage	$455.28
Rate for Payer: UnitedHealthcare Commercial	$1,029.80
Rate for Payer: UnitedHealthcare Medicaid	$305.45
Rate for Payer: WPPA Medicare Advantage	$650.40

69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia

Facility

$1,084.00

Service Code	HCPCS 69433
Hospital Charge Code	3359433
Hospital Revenue Code	761
Min. Negotiated Rate	$975.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$975.60
Rate for Payer: UnitedHealthcare Commercial	$1,029.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia

Facility

$1,084.00

Service Code	HCPCS 69433
Hospital Charge Code	3359433
Hospital Revenue Code	761
Min. Negotiated Rate	$305.45
Max. Negotiated Rate	$1,029.80
Rate for Payer: Aetna Commercial	$975.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$659.65
Rate for Payer: Humana Medicare Advantage	$455.28
Rate for Payer: UnitedHealthcare Commercial	$1,029.80
Rate for Payer: UnitedHealthcare Medicaid	$305.45
Rate for Payer: WPPA Medicare Advantage	$650.40

69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia

Facility

$3,247.00

Service Code	HCPCS 69436
Hospital Charge Code	3159436
Hospital Revenue Code	360
Min. Negotiated Rate	$494.04
Max. Negotiated Rate	$3,084.65
Rate for Payer: Aetna Commercial	$2,922.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,284.72
Rate for Payer: Humana Medicare Advantage	$1,363.74
Rate for Payer: UnitedHealthcare Commercial	$3,084.65
Rate for Payer: UnitedHealthcare Medicaid	$494.04
Rate for Payer: WPPA Medicare Advantage	$1,948.20

69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia

Facility

$3,247.00

Service Code	HCPCS 69436
Hospital Charge Code	3159436
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,084.65
Rate for Payer: Aetna Commercial	$2,922.30
Rate for Payer: UnitedHealthcare Commercial	$3,084.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69440 Middle ear exploration through postauricular or ear canal incision

Facility

$2,125.00

Service Code	HCPCS 69440
Hospital Charge Code	3159440
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,018.75
Rate for Payer: Aetna Commercial	$1,912.50
Rate for Payer: UnitedHealthcare Commercial	$2,018.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69440 Middle ear exploration through postauricular or ear canal incision

Facility

$2,125.00

Service Code	HCPCS 69440
Hospital Charge Code	3159440
Hospital Revenue Code	360
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,018.75
Rate for Payer: Aetna Commercial	$1,912.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,202.00
Rate for Payer: Humana Medicare Advantage	$892.50
Rate for Payer: UnitedHealthcare Commercial	$2,018.75
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$1,275.00

69610 TYMPANIC MEMB RPR W/WO PREPJ PERFOR PATC CHARGE

Facility

$7,026.00

Service Code	HCPCS 69610
Hospital Charge Code	3159610
Hospital Revenue Code	360
Min. Negotiated Rate	$494.04
Max. Negotiated Rate	$6,674.70
Rate for Payer: Aetna Commercial	$6,323.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,747.10
Rate for Payer: Humana Medicare Advantage	$2,950.92
Rate for Payer: UnitedHealthcare Commercial	$6,674.70
Rate for Payer: UnitedHealthcare Medicaid	$494.04
Rate for Payer: WPPA Medicare Advantage	$4,215.60

69610 TYMPANIC MEMB RPR W/WO PREPJ PERFOR PATC CHARGE

Facility

$7,026.00

Service Code	HCPCS 69610
Hospital Charge Code	3159610
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,674.70
Rate for Payer: Aetna Commercial	$6,323.40
Rate for Payer: UnitedHealthcare Commercial	$6,674.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69620 Myringoplasty (surgery confined to drumhead and donor area)

Facility

$6,113.00

Service Code	HCPCS 69620
Hospital Charge Code	3159620
Hospital Revenue Code	360
Min. Negotiated Rate	$1,042.99
Max. Negotiated Rate	$5,807.35
Rate for Payer: Aetna Commercial	$5,501.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,747.10
Rate for Payer: Humana Medicare Advantage	$2,567.46
Rate for Payer: UnitedHealthcare Commercial	$5,807.35
Rate for Payer: UnitedHealthcare Medicaid	$1,042.99
Rate for Payer: WPPA Medicare Advantage	$3,667.80

69620 Myringoplasty (surgery confined to drumhead and donor area)

Facility

$6,113.00

Service Code	HCPCS 69620
Hospital Charge Code	3159620
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,807.35
Rate for Payer: Aetna Commercial	$5,501.70
Rate for Payer: UnitedHealthcare Commercial	$5,807.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69631 Tympanoplasty w/o mastoidectomy, initial or revision; without ossicular chain reconstruction

Facility

$9,625.00

Service Code	HCPCS 69631
Hospital Charge Code	3159631
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,143.75
Rate for Payer: Aetna Commercial	$8,662.50
Rate for Payer: UnitedHealthcare Commercial	$9,143.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69631 Tympanoplasty w/o mastoidectomy, initial or revision; without ossicular chain reconstruction

Facility

$9,625.00

Service Code	HCPCS 69631
Hospital Charge Code	3159631
Hospital Revenue Code	360
Min. Negotiated Rate	$1,897.10
Max. Negotiated Rate	$9,143.75
Rate for Payer: Aetna Commercial	$8,662.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5,949.91
Rate for Payer: Humana Medicare Advantage	$4,042.50
Rate for Payer: UnitedHealthcare Commercial	$9,143.75
Rate for Payer: UnitedHealthcare Medicaid	$1,897.10
Rate for Payer: WPPA Medicare Advantage	$5,775.00

69642 Tympanoplasty, w/ mastoidectomy; w/ ossicular chain reconstruction

Facility

$5,193.00

Service Code	HCPCS 69642
Hospital Charge Code	3159642
Hospital Revenue Code	360
Min. Negotiated Rate	$1,897.10
Max. Negotiated Rate	$4,933.35
Rate for Payer: Aetna Commercial	$4,673.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,747.10
Rate for Payer: Humana Medicare Advantage	$2,181.06
Rate for Payer: UnitedHealthcare Commercial	$4,933.35
Rate for Payer: UnitedHealthcare Medicaid	$1,897.10
Rate for Payer: WPPA Medicare Advantage	$3,115.80

69642 Tympanoplasty, w/ mastoidectomy; w/ ossicular chain reconstruction

Facility

$5,193.00

Service Code	HCPCS 69642
Hospital Charge Code	3159642
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,933.35
Rate for Payer: Aetna Commercial	$4,673.70
Rate for Payer: UnitedHealthcare Commercial	$4,933.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

69705 Nasopharyngoscopy, surgical, w/dilation of Eustachian tube (ie, balloon dilation); unilateral

Facility

$751.00

Service Code	HCPCS 69705
Hospital Charge Code	3159705
Hospital Revenue Code	360
Min. Negotiated Rate	$315.42
Max. Negotiated Rate	$3,305.93
Rate for Payer: Aetna Commercial	$675.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$541.36
Rate for Payer: Humana Medicare Advantage	$315.42
Rate for Payer: UnitedHealthcare Commercial	$713.45
Rate for Payer: UnitedHealthcare Medicaid	$3,305.93
Rate for Payer: WPPA Medicare Advantage	$450.60

69705 Nasopharyngoscopy, surgical, w/dilation of Eustachian tube (ie, balloon dilation); unilateral

Facility

$751.00

Service Code	HCPCS 69705
Hospital Charge Code	3159705
Hospital Revenue Code	360
Min. Negotiated Rate	$675.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$675.90
Rate for Payer: UnitedHealthcare Commercial	$713.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges