Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

14.3.3 ETA Protein QST

Facility

$169.00

Service Code	HCPCS 83520
Hospital Charge Code	3551455
Hospital Revenue Code	300
Min. Negotiated Rate	$36.48
Max. Negotiated Rate	$160.55
Rate for Payer: Aetna Commercial	$152.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.48
Rate for Payer: Humana Medicare Advantage	$70.98
Rate for Payer: UnitedHealthcare Commercial	$160.55
Rate for Payer: UnitedHealthcare Medicaid	$67.60
Rate for Payer: WPPA Medicare Advantage	$101.40

14.3.3 ETA Protein QST

Facility

$169.00

Service Code	HCPCS 83520
Hospital Charge Code	3551455
Hospital Revenue Code	300
Min. Negotiated Rate	$152.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$152.10
Rate for Payer: UnitedHealthcare Commercial	$160.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

1.4 Guide Wire/ 150 Length Trocar Tip

Facility

$333.00

Hospital Charge Code	3258325
Hospital Revenue Code	270
Min. Negotiated Rate	$133.20
Max. Negotiated Rate	$316.35
Rate for Payer: Aetna Commercial	$299.70
Rate for Payer: Humana Medicare Advantage	$139.86
Rate for Payer: UnitedHealthcare Commercial	$316.35
Rate for Payer: UnitedHealthcare Medicaid	$133.20
Rate for Payer: WPPA Medicare Advantage	$199.80

1.4 Guide Wire/ 150 Length Trocar Tip

Facility

$333.00

Hospital Charge Code	3258325
Hospital Revenue Code	270
Min. Negotiated Rate	$299.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$299.70
Rate for Payer: UnitedHealthcare Commercial	$316.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

1-4 Hours - Blood Administration Charges

Facility

$1,253.00

Service Code	HCPCS 36430
Hospital Charge Code	3290167
Hospital Revenue Code	391
Min. Negotiated Rate	$1,127.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,127.70
Rate for Payer: UnitedHealthcare Commercial	$1,190.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

1-4 Hours - Blood Administration Charges

Facility

$1,253.00

Service Code	HCPCS 36430
Hospital Charge Code	3290167
Hospital Revenue Code	391
Min. Negotiated Rate	$257.40
Max. Negotiated Rate	$1,190.35
Rate for Payer: Aetna Commercial	$1,127.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$515.69
Rate for Payer: Humana Medicare Advantage	$526.26
Rate for Payer: UnitedHealthcare Commercial	$1,190.35
Rate for Payer: UnitedHealthcare Medicaid	$257.40
Rate for Payer: WPPA Medicare Advantage	$751.80

15002 Surg Prep/Create Recipient Site, Trunk/Arm/Leg; first 100 sq cm

Facility

$1,247.00

Service Code	HCPCS 15002
Hospital Charge Code	3155002
Hospital Revenue Code	360
Min. Negotiated Rate	$1,122.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,122.30
Rate for Payer: UnitedHealthcare Commercial	$1,184.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15002 Surg Prep/Create Recipient Site, Trunk/Arm/Leg; first 100 sq cm

Facility

$1,247.00

Service Code	HCPCS 15002
Hospital Charge Code	3155002
Hospital Revenue Code	360
Min. Negotiated Rate	$218.54
Max. Negotiated Rate	$1,184.65
Rate for Payer: Aetna Commercial	$1,122.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$523.74
Rate for Payer: UnitedHealthcare Commercial	$1,184.65
Rate for Payer: UnitedHealthcare Medicaid	$218.54
Rate for Payer: WPPA Medicare Advantage	$748.20

15004 WOUND PREP F/N/HF/G [HGHO]

Facility

$1,353.00

Service Code	HCPCS 15004
Hospital Charge Code	3155004
Hospital Revenue Code	360
Min. Negotiated Rate	$218.54
Max. Negotiated Rate	$1,285.35
Rate for Payer: Aetna Commercial	$1,217.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,025.15
Rate for Payer: Humana Medicare Advantage	$568.26
Rate for Payer: UnitedHealthcare Commercial	$1,285.35
Rate for Payer: UnitedHealthcare Medicaid	$218.54
Rate for Payer: WPPA Medicare Advantage	$811.80

15004 WOUND PREP F/N/HF/G [HGHO]

Facility

$1,353.00

Service Code	HCPCS 15004
Hospital Charge Code	3155004
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,285.35
Rate for Payer: Aetna Commercial	$1,217.70
Rate for Payer: UnitedHealthcare Commercial	$1,285.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15100 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of i

Facility

$6,065.00

Service Code	HCPCS 15100
Hospital Charge Code	3150670
Hospital Revenue Code	360
Min. Negotiated Rate	$590.76
Max. Negotiated Rate	$5,761.75
Rate for Payer: Aetna Commercial	$5,458.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,746.09
Rate for Payer: Humana Medicare Advantage	$2,547.30
Rate for Payer: UnitedHealthcare Commercial	$5,761.75
Rate for Payer: UnitedHealthcare Medicaid	$590.76
Rate for Payer: WPPA Medicare Advantage	$3,639.00

15100 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of i

Facility

$6,065.00

Service Code	HCPCS 15100
Hospital Charge Code	3150670
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,761.75
Rate for Payer: Aetna Commercial	$5,458.50
Rate for Payer: UnitedHealthcare Commercial	$5,761.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15110 EPIDRM AUTOGRFT TRNK/ARM/LEG

Facility

$2,359.00

Service Code	HCPCS 15110
Hospital Charge Code	3155110
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,241.05
Rate for Payer: Aetna Commercial	$2,123.10
Rate for Payer: UnitedHealthcare Commercial	$2,241.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15110 EPIDRM AUTOGRFT TRNK/ARM/LEG

Facility

$2,359.00

Service Code	HCPCS 15110
Hospital Charge Code	3155110
Hospital Revenue Code	360
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$2,241.05
Rate for Payer: Aetna Commercial	$2,123.10
Rate for Payer: Humana Medicare Advantage	$990.78
Rate for Payer: UnitedHealthcare Commercial	$2,241.05
Rate for Payer: UnitedHealthcare Medicaid	$281.50
Rate for Payer: WPPA Medicare Advantage	$1,415.40

15120 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands,

Facility

$5,069.00

Service Code	HCPCS 15120
Hospital Charge Code	3155120
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,815.55
Rate for Payer: Aetna Commercial	$4,562.10
Rate for Payer: UnitedHealthcare Commercial	$4,815.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15120 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands,

Facility

$5,069.00

Service Code	HCPCS 15120
Hospital Charge Code	3155120
Hospital Revenue Code	360
Min. Negotiated Rate	$1,162.21
Max. Negotiated Rate	$4,815.55
Rate for Payer: Aetna Commercial	$4,562.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,840.02
Rate for Payer: Humana Medicare Advantage	$2,128.98
Rate for Payer: UnitedHealthcare Commercial	$4,815.55
Rate for Payer: UnitedHealthcare Medicaid	$1,162.21
Rate for Payer: WPPA Medicare Advantage	$3,041.40

15221 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/O ProFee

Facility

$483.00

Service Code	HCPCS 15220
Hospital Charge Code	3155221
Hospital Revenue Code	360
Min. Negotiated Rate	$434.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$434.70
Rate for Payer: UnitedHealthcare Commercial	$458.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15221 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/O ProFee

Facility

$483.00

Service Code	HCPCS 15220
Hospital Charge Code	3155221
Hospital Revenue Code	360
Min. Negotiated Rate	$202.86
Max. Negotiated Rate	$590.76
Rate for Payer: Aetna Commercial	$434.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$348.45
Rate for Payer: Humana Medicare Advantage	$202.86
Rate for Payer: UnitedHealthcare Commercial	$458.85
Rate for Payer: UnitedHealthcare Medicaid	$590.76
Rate for Payer: WPPA Medicare Advantage	$289.80

15240-Full thickness graft 20 sq cm/less

Facility

$734.00

Service Code	HCPCS 15240
Hospital Charge Code	3305240
Hospital Revenue Code	450
Min. Negotiated Rate	$308.28
Max. Negotiated Rate	$3,312.80
Rate for Payer: Aetna Commercial	$660.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,312.80
Rate for Payer: Humana Medicare Advantage	$308.28
Rate for Payer: UnitedHealthcare Commercial	$697.30
Rate for Payer: UnitedHealthcare Medicaid	$590.76
Rate for Payer: WPPA Medicare Advantage	$440.40

15240-Full thickness graft 20 sq cm/less

Facility

$734.00

Service Code	HCPCS 15240
Hospital Charge Code	3305240
Hospital Revenue Code	450
Min. Negotiated Rate	$660.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$660.60
Rate for Payer: UnitedHealthcare Commercial	$697.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15271 App of skin substitute graft trunk, arms, leg, total wound surface area up to 100sq cm or less

Facility

$2,411.00

Service Code	HCPCS 15271
Hospital Charge Code	3355271
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,290.45
Rate for Payer: Aetna Commercial	$2,169.90
Rate for Payer: UnitedHealthcare Commercial	$2,290.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15271 App of skin substitute graft trunk, arms, leg, total wound surface area up to 100sq cm or less

Facility

$2,411.00

Service Code	HCPCS 15271
Hospital Charge Code	3355271
Hospital Revenue Code	761
Min. Negotiated Rate	$153.99
Max. Negotiated Rate	$3,014.85
Rate for Payer: Aetna Commercial	$2,169.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,014.85
Rate for Payer: Humana Medicare Advantage	$1,012.62
Rate for Payer: UnitedHealthcare Commercial	$2,290.45
Rate for Payer: UnitedHealthcare Medicaid	$153.99
Rate for Payer: WPPA Medicare Advantage	$1,446.60

15272 Application of skin graft to trunk,arms,legs, up to 100 sq cm; ea add 25 sq cm

Facility

$2,411.00

Service Code	HCPCS 15272
Hospital Charge Code	3355272
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,290.45
Rate for Payer: Aetna Commercial	$2,169.90
Rate for Payer: UnitedHealthcare Commercial	$2,290.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15272 Application of skin graft to trunk,arms,legs, up to 100 sq cm; ea add 25 sq cm

Facility

$2,411.00

Service Code	HCPCS 15272
Hospital Charge Code	3355272
Hospital Revenue Code	761
Min. Negotiated Rate	$56.48
Max. Negotiated Rate	$2,290.45
Rate for Payer: Aetna Commercial	$2,169.90
Rate for Payer: Humana Medicare Advantage	$1,012.62
Rate for Payer: UnitedHealthcare Commercial	$2,290.45
Rate for Payer: UnitedHealthcare Medicaid	$56.48
Rate for Payer: WPPA Medicare Advantage	$1,446.60

15273 APP SKN SUBGRFT T/A/L AREA/100SQ CM 1ST CHARGE

Facility

$4,743.00

Service Code	HCPCS 15273
Hospital Charge Code	3355273
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,505.85
Rate for Payer: Aetna Commercial	$4,268.70
Rate for Payer: UnitedHealthcare Commercial	$4,505.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges