Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

12020 TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE ProFee

Facility

$406.00

Service Code	HCPCS 12020
Hospital Charge Code	3305801
Hospital Revenue Code	450
Min. Negotiated Rate	$365.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$365.40
Rate for Payer: UnitedHealthcare Commercial	$385.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12021 CLOSURE OF SPLIT WOUND CHARGE

Facility

$426.00

Service Code	HCPCS 12021
Hospital Charge Code	3352021
Hospital Revenue Code	761
Min. Negotiated Rate	$178.92
Max. Negotiated Rate	$404.70
Rate for Payer: Aetna Commercial	$383.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$216.14
Rate for Payer: Humana Medicare Advantage	$178.92
Rate for Payer: UnitedHealthcare Commercial	$404.70
Rate for Payer: UnitedHealthcare Medicaid	$232.69
Rate for Payer: WPPA Medicare Advantage	$255.60

12021 CLOSURE OF SPLIT WOUND CHARGE

Facility

$426.00

Service Code	HCPCS 12021
Hospital Charge Code	3352021
Hospital Revenue Code	761
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$383.40
Rate for Payer: UnitedHealthcare Commercial	$404.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12021-Superficial Dehiscence w/packing

Facility

$2,323.00

Service Code	HCPCS 12021
Hospital Charge Code	3305802
Hospital Revenue Code	450
Min. Negotiated Rate	$216.14
Max. Negotiated Rate	$2,206.85
Rate for Payer: Aetna Commercial	$2,090.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$216.14
Rate for Payer: Humana Medicare Advantage	$975.66
Rate for Payer: UnitedHealthcare Commercial	$2,206.85
Rate for Payer: UnitedHealthcare Medicaid	$232.69
Rate for Payer: WPPA Medicare Advantage	$1,393.80

12021-Superficial Dehiscence w/packing

Facility

$2,323.00

Service Code	HCPCS 12021
Hospital Charge Code	3305802
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,206.85
Rate for Payer: Aetna Commercial	$2,090.70
Rate for Payer: UnitedHealthcare Commercial	$2,206.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12021 Treatment of superficial wound dehiscence with packing

Facility

$426.00

Service Code	HCPCS 12021
Hospital Charge Code	3352021
Hospital Revenue Code	761
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$383.40
Rate for Payer: UnitedHealthcare Commercial	$404.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12021 Treatment of superficial wound dehiscence with packing

Facility

$426.00

Service Code	HCPCS 12021
Hospital Charge Code	3352021
Hospital Revenue Code	761
Min. Negotiated Rate	$178.92
Max. Negotiated Rate	$404.70
Rate for Payer: Aetna Commercial	$383.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$216.14
Rate for Payer: Humana Medicare Advantage	$178.92
Rate for Payer: UnitedHealthcare Commercial	$404.70
Rate for Payer: UnitedHealthcare Medicaid	$232.69
Rate for Payer: WPPA Medicare Advantage	$255.60

12031 Layered closure, scalp, axillae, trunk and/or extremities </= 2.5 CM

Facility

$2,598.00

Service Code	HCPCS 12031
Hospital Charge Code	3152031
Hospital Revenue Code	360
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$2,468.10
Rate for Payer: Aetna Commercial	$2,338.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.17
Rate for Payer: Humana Medicare Advantage	$1,091.16
Rate for Payer: UnitedHealthcare Commercial	$2,468.10
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$1,558.80

12031 Layered closure, scalp, axillae, trunk and/or extremities </= 2.5 CM

Facility

$2,598.00

Service Code	HCPCS 12031
Hospital Charge Code	3152031
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,468.10
Rate for Payer: Aetna Commercial	$2,338.20
Rate for Payer: UnitedHealthcare Commercial	$2,468.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12031 REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< TechFee

Facility

$2,598.00

Service Code	HCPCS 12031
Hospital Charge Code	3300203
Hospital Revenue Code	450
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$2,468.10
Rate for Payer: Aetna Commercial	$2,338.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.17
Rate for Payer: Humana Medicare Advantage	$1,091.16
Rate for Payer: UnitedHealthcare Commercial	$2,468.10
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$1,558.80

12031 REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< TechFee

Facility

$2,598.00

Service Code	HCPCS 12031
Hospital Charge Code	3300203
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,468.10
Rate for Payer: Aetna Commercial	$2,338.20
Rate for Payer: UnitedHealthcare Commercial	$2,468.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12031-Scalp/Trunk/Extremity Less Than/Equal to 2.5 cm

Facility

$1,599.00

Service Code	HCPCS 12031
Hospital Charge Code	3300203
Hospital Revenue Code	450
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.17
Rate for Payer: Humana Medicare Advantage	$671.58
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$959.40

12031-Scalp/Trunk/Extremity Less Than/Equal to 2.5 cm

Facility

$1,599.00

Service Code	HCPCS 12031
Hospital Charge Code	3300203
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12032-Scalp/Trunk/Extremity 2.6-7.5cm

Facility

$7,259.00

Service Code	HCPCS 12032
Hospital Charge Code	3300805
Hospital Revenue Code	450
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$6,896.05
Rate for Payer: Aetna Commercial	$6,533.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.17
Rate for Payer: Humana Medicare Advantage	$3,048.78
Rate for Payer: UnitedHealthcare Commercial	$6,896.05
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$4,355.40

12032-Scalp/Trunk/Extremity 2.6-7.5cm

Facility

$7,259.00

Service Code	HCPCS 12032
Hospital Charge Code	3300805
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,896.05
Rate for Payer: Aetna Commercial	$6,533.10
Rate for Payer: UnitedHealthcare Commercial	$6,896.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12034-Scalp/Trunk/Extremity 7.6-12.5 cm

Facility

$541.00

Service Code	HCPCS 12034
Hospital Charge Code	3300117
Hospital Revenue Code	450
Min. Negotiated Rate	$227.22
Max. Negotiated Rate	$1,548.33
Rate for Payer: Aetna Commercial	$486.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,548.33
Rate for Payer: Humana Medicare Advantage	$227.22
Rate for Payer: UnitedHealthcare Commercial	$513.95
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$324.60

12034-Scalp/Trunk/Extremity 7.6-12.5 cm

Facility

$541.00

Service Code	HCPCS 12034
Hospital Charge Code	3300117
Hospital Revenue Code	450
Min. Negotiated Rate	$486.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$486.90
Rate for Payer: UnitedHealthcare Commercial	$513.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12035-Scalp/Trunk/Extremity 12.6-20.0 cm

Facility

$2,989.00

Service Code	HCPCS 12035
Hospital Charge Code	3302035
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,839.55
Rate for Payer: Aetna Commercial	$2,690.10
Rate for Payer: UnitedHealthcare Commercial	$2,839.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12035-Scalp/Trunk/Extremity 12.6-20.0 cm

Facility

$2,989.00

Service Code	HCPCS 12035
Hospital Charge Code	3302035
Hospital Revenue Code	450
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$2,839.55
Rate for Payer: Aetna Commercial	$2,690.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,824.06
Rate for Payer: Humana Medicare Advantage	$1,255.38
Rate for Payer: UnitedHealthcare Commercial	$2,839.55
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$1,793.40

12041-Neck/Hand/Feet/Genital Less Than/Equal to 2.5 cm

Facility

$1,599.00

Service Code	HCPCS 12041
Hospital Charge Code	3300806
Hospital Revenue Code	450
Min. Negotiated Rate	$257.40
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$532.27
Rate for Payer: Humana Medicare Advantage	$671.58
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: UnitedHealthcare Medicaid	$257.40
Rate for Payer: WPPA Medicare Advantage	$959.40

12041-Neck/Hand/Feet/Genital Less Than/Equal to 2.5 cm

Facility

$1,599.00

Service Code	HCPCS 12041
Hospital Charge Code	3300806
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,519.05
Rate for Payer: Aetna Commercial	$1,439.10
Rate for Payer: UnitedHealthcare Commercial	$1,519.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12042-Neck/Hand/Feet/Genital 2.6-7.5 cm

Facility

$4,290.00

Service Code	HCPCS 12042
Hospital Charge Code	3300802
Hospital Revenue Code	450
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$4,075.50
Rate for Payer: Aetna Commercial	$3,861.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$707.00
Rate for Payer: Humana Medicare Advantage	$1,801.80
Rate for Payer: UnitedHealthcare Commercial	$4,075.50
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$2,574.00

12042-Neck/Hand/Feet/Genital 2.6-7.5 cm

Facility

$4,290.00

Service Code	HCPCS 12042
Hospital Charge Code	3300802
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,075.50
Rate for Payer: Aetna Commercial	$3,861.00
Rate for Payer: UnitedHealthcare Commercial	$4,075.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

12044-Neck/Hand/Feet/Genital 7.6-12.5 cm

Facility

$1,560.00

Service Code	HCPCS 12044
Hospital Charge Code	3300121
Hospital Revenue Code	450
Min. Negotiated Rate	$343.20
Max. Negotiated Rate	$1,482.00
Rate for Payer: Aetna Commercial	$1,404.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$655.20
Rate for Payer: UnitedHealthcare Commercial	$1,482.00
Rate for Payer: UnitedHealthcare Medicaid	$343.20
Rate for Payer: WPPA Medicare Advantage	$936.00

12044-Neck/Hand/Feet/Genital 7.6-12.5 cm

Facility

$1,560.00

Service Code	HCPCS 12044
Hospital Charge Code	3300121
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,482.00
Rate for Payer: Aetna Commercial	$1,404.00
Rate for Payer: UnitedHealthcare Commercial	$1,482.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges