Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

15274 Application of skin substiture graft, trunk, arms, legs, total wound surface area, ea add'l 10

Facility

$4,743.00

Service Code	HCPCS 15274
Hospital Charge Code	3355274
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

15274 Application of skin substiture graft, trunk, arms, legs, total wound surface area, ea add'l 10

Facility

$4,743.00

Service Code	HCPCS 15274
Hospital Charge Code	3355274
Hospital Revenue Code	761
Min. Negotiated Rate	$153.99
Max. Negotiated Rate	$4,505.85
Rate for Payer: Aetna Commercial	$4,268.70
Rate for Payer: Humana Medicare Advantage	$1,992.06
Rate for Payer: UnitedHealthcare Commercial	$4,505.85
Rate for Payer: UnitedHealthcare Medicaid	$153.99
Rate for Payer: WPPA Medicare Advantage	$2,845.80

15275 APP SKN SUB GRFT F/S/N/H/F/G/M/D <100SQ CHARGE

Facility

$2,411.00

Service Code	HCPCS 15275
Hospital Charge Code	3355275
Hospital Revenue Code	761
Min. Negotiated Rate	$153.99
Max. Negotiated Rate	$4,483.39
Rate for Payer: Aetna Commercial	$2,169.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,483.39
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

15275 APP SKN SUB GRFT F/S/N/H/F/G/M/D <100SQ CHARGE

Facility

$2,411.00

Service Code	HCPCS 15275
Hospital Charge Code	3355275
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

15276 Application of skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genital

Facility

$2,411.00

Service Code	HCPCS 15276
Hospital Charge Code	3355276
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

15276 Application of skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genital

Facility

$2,411.00

Service Code	HCPCS 15276
Hospital Charge Code	3355276
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

15277 Application of skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genital

Facility

$2,411.00

Service Code	HCPCS 15277
Hospital Charge Code	3355277
Hospital Revenue Code	761
Min. Negotiated Rate	$235.00
Max. Negotiated Rate	$2,290.45
Rate for Payer: Aetna Commercial	$2,169.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$1,012.62
Rate for Payer: UnitedHealthcare Commercial	$2,290.45
Rate for Payer: UnitedHealthcare Medicaid	$235.00
Rate for Payer: WPPA Medicare Advantage	$1,446.60

15277 Application of skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genital

Facility

$2,411.00

Service Code	HCPCS 15277
Hospital Charge Code	3355277
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

15278 Application of skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genital

Facility

$2,411.00

Service Code	HCPCS 15278
Hospital Charge Code	3355278
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

15278 Application of skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genital

Facility

$2,411.00

Service Code	HCPCS 15278
Hospital Charge Code	3355278
Hospital Revenue Code	761
Min. Negotiated Rate	$153.99
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	$153.99
Rate for Payer: WPPA Medicare Advantage	$1,446.60

15570 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; TRUNK ProFee

Facility

$3,875.00

Service Code	HCPCS 15570
Hospital Charge Code	3155570
Hospital Revenue Code	360
Min. Negotiated Rate	$590.76
Max. Negotiated Rate	$3,681.25
Rate for Payer: Aetna Commercial	$3,487.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,182.46
Rate for Payer: Humana Medicare Advantage	$1,627.50
Rate for Payer: UnitedHealthcare Commercial	$3,681.25
Rate for Payer: UnitedHealthcare Medicaid	$590.76
Rate for Payer: WPPA Medicare Advantage	$2,325.00

15570 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; TRUNK ProFee

Facility

$3,875.00

Service Code	HCPCS 15570
Hospital Charge Code	3155570
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,681.25
Rate for Payer: Aetna Commercial	$3,487.50
Rate for Payer: UnitedHealthcare Commercial	$3,681.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15574 PEDCLE FH/CH/CH/M/N/AX/G/H/F

Facility

$2,778.00

Service Code	HCPCS 15574
Hospital Charge Code	3155574
Hospital Revenue Code	360
Min. Negotiated Rate	$590.76
Max. Negotiated Rate	$2,639.10
Rate for Payer: Aetna Commercial	$2,500.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,182.46
Rate for Payer: Humana Medicare Advantage	$1,166.76
Rate for Payer: UnitedHealthcare Commercial	$2,639.10
Rate for Payer: UnitedHealthcare Medicaid	$590.76
Rate for Payer: WPPA Medicare Advantage	$1,666.80

15574 PEDCLE FH/CH/CH/M/N/AX/G/H/F

Facility

$2,778.00

Service Code	HCPCS 15574
Hospital Charge Code	3155574
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,639.10
Rate for Payer: Aetna Commercial	$2,500.20
Rate for Payer: UnitedHealthcare Commercial	$2,639.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen

Facility

$466.00

Service Code	HCPCS 15847
Hospital Charge Code	3155847
Hospital Revenue Code	360
Min. Negotiated Rate	$186.40
Max. Negotiated Rate	$442.70
Rate for Payer: Aetna Commercial	$419.40
Rate for Payer: Humana Medicare Advantage	$195.72
Rate for Payer: UnitedHealthcare Commercial	$442.70
Rate for Payer: UnitedHealthcare Medicaid	$186.40
Rate for Payer: WPPA Medicare Advantage	$279.60

15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen

Facility

$466.00

Service Code	HCPCS 15847
Hospital Charge Code	3155847
Hospital Revenue Code	360
Min. Negotiated Rate	$419.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$419.40
Rate for Payer: UnitedHealthcare Commercial	$442.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15852 Dressing change (for other than burns) under anesthesia (other than local)

Facility

$599.00

Service Code	HCPCS 15852
Hospital Charge Code	3155852
Hospital Revenue Code	360
Min. Negotiated Rate	$539.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$539.10
Rate for Payer: UnitedHealthcare Commercial	$569.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

15852 Dressing change (for other than burns) under anesthesia (other than local)

Facility

$599.00

Service Code	HCPCS 15852
Hospital Charge Code	3155852
Hospital Revenue Code	360
Min. Negotiated Rate	$251.58
Max. Negotiated Rate	$569.05
Rate for Payer: Aetna Commercial	$539.10
Rate for Payer: Humana Medicare Advantage	$251.58
Rate for Payer: UnitedHealthcare Commercial	$569.05
Rate for Payer: UnitedHealthcare Medicaid	$314.60
Rate for Payer: WPPA Medicare Advantage	$359.40

15854 Removal of sutures and staples not requiring anesthesia

Facility

$34.00

Service Code	HCPCS 15854
Hospital Charge Code	3355854
Hospital Revenue Code	761
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$32.30
Rate for Payer: Aetna Commercial	$30.60
Rate for Payer: Humana Medicare Advantage	$14.28
Rate for Payer: UnitedHealthcare Commercial	$32.30
Rate for Payer: UnitedHealthcare Medicaid	$13.60
Rate for Payer: WPPA Medicare Advantage	$20.40

15854 Removal of sutures and staples not requiring anesthesia

Facility

$34.00

Service Code	HCPCS 15854
Hospital Charge Code	3355854
Hospital Revenue Code	761
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.60
Rate for Payer: UnitedHealthcare Commercial	$32.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

1.5mm Drill Bit Jacobs Chuck

Facility

$112.64

Hospital Charge Code	3258582
Hospital Revenue Code	270
Min. Negotiated Rate	$45.06
Max. Negotiated Rate	$107.01
Rate for Payer: Aetna Commercial	$101.38
Rate for Payer: Humana Medicare Advantage	$47.31
Rate for Payer: UnitedHealthcare Commercial	$107.01
Rate for Payer: UnitedHealthcare Medicaid	$45.06
Rate for Payer: WPPA Medicare Advantage	$67.58

1.5mm Drill Bit Jacobs Chuck

Facility

$112.64

Hospital Charge Code	3258582
Hospital Revenue Code	270
Min. Negotiated Rate	$101.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.38
Rate for Payer: UnitedHealthcare Commercial	$107.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

16000-Initial Treatment First Degree Burn

Facility

$734.00

Service Code	HCPCS 16000
Hospital Charge Code	3304710
Hospital Revenue Code	450
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$697.30
Rate for Payer: Aetna Commercial	$660.60
Rate for Payer: Humana Medicare Advantage	$308.28
Rate for Payer: UnitedHealthcare Commercial	$697.30
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$440.40

16000-Initial Treatment First Degree Burn

Facility

$734.00

Service Code	HCPCS 16000
Hospital Charge Code	3304710
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

Know your out-of-pocket cost for care.

All Charges