Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

10120-Subcutaneous Tissue Simple

Facility

$2,006.00

Service Code	HCPCS 10120
Hospital Charge Code	3304775
Hospital Revenue Code	450
Min. Negotiated Rate	$223.08
Max. Negotiated Rate	$1,905.70
Rate for Payer: Aetna Commercial	$1,805.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,075.65
Rate for Payer: Humana Medicare Advantage	$842.52
Rate for Payer: UnitedHealthcare Commercial	$1,905.70
Rate for Payer: UnitedHealthcare Medicaid	$223.08
Rate for Payer: WPPA Medicare Advantage	$1,203.60

10120-Subcutaneous Tissue Simple

Facility

$2,006.00

Service Code	HCPCS 10120
Hospital Charge Code	3304775
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,905.70
Rate for Payer: Aetna Commercial	$1,805.40
Rate for Payer: UnitedHealthcare Commercial	$1,905.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10121 Incision and removal of foreign body, subcutaneous tissues, complicated

Facility

$2,786.00

Service Code	HCPCS 10121
Hospital Charge Code	3150121
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,646.70
Rate for Payer: Aetna Commercial	$2,507.40
Rate for Payer: UnitedHealthcare Commercial	$2,646.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10121 Incision and removal of foreign body, subcutaneous tissues, complicated

Facility

$2,786.00

Service Code	HCPCS 10121
Hospital Charge Code	3150121
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$2,646.70
Rate for Payer: Aetna Commercial	$2,507.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,517.02
Rate for Payer: Humana Medicare Advantage	$1,170.12
Rate for Payer: UnitedHealthcare Commercial	$2,646.70
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,671.60

10121 INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL TechFee

Facility

$2,786.00

Service Code	HCPCS 10121
Hospital Charge Code	3301012
Hospital Revenue Code	450
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$2,646.70
Rate for Payer: Aetna Commercial	$2,507.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,517.02
Rate for Payer: Humana Medicare Advantage	$1,170.12
Rate for Payer: UnitedHealthcare Commercial	$2,646.70
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,671.60

10121 INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL TechFee

Facility

$2,786.00

Service Code	HCPCS 10121
Hospital Charge Code	3301012
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,646.70
Rate for Payer: Aetna Commercial	$2,507.40
Rate for Payer: UnitedHealthcare Commercial	$2,646.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10121-Subcutaneous Tissue Complex

Facility

$1,759.00

Service Code	HCPCS 10121
Hospital Charge Code	3301012
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,671.05
Rate for Payer: Aetna Commercial	$1,583.10
Rate for Payer: UnitedHealthcare Commercial	$1,671.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10121-Subcutaneous Tissue Complex

Facility

$1,759.00

Service Code	HCPCS 10121
Hospital Charge Code	3301012
Hospital Revenue Code	450
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$1,671.05
Rate for Payer: Aetna Commercial	$1,583.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,517.02
Rate for Payer: Humana Medicare Advantage	$738.78
Rate for Payer: UnitedHealthcare Commercial	$1,671.05
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,055.40

10140 DRAINAGE OF HEMATOMA/FLUID

Facility

$1,830.00

Service Code	HCPCS 10140
Hospital Charge Code	3150140
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,738.50
Rate for Payer: Aetna Commercial	$1,647.00
Rate for Payer: UnitedHealthcare Commercial	$1,738.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10140 DRAINAGE OF HEMATOMA/FLUID

Facility

$1,830.00

Service Code	HCPCS 10140
Hospital Charge Code	3150140
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$1,738.50
Rate for Payer: Aetna Commercial	$1,647.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,186.75
Rate for Payer: Humana Medicare Advantage	$768.60
Rate for Payer: UnitedHealthcare Commercial	$1,738.50
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,098.00

10140-I&D Hematoma/Seroma/Fluid

Facility

$5,374.00

Service Code	HCPCS 10140
Hospital Charge Code	3300140
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,105.30
Rate for Payer: Aetna Commercial	$4,836.60
Rate for Payer: UnitedHealthcare Commercial	$5,105.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10140-I&D Hematoma/Seroma/Fluid

Facility

$5,374.00

Service Code	HCPCS 10140
Hospital Charge Code	3300140
Hospital Revenue Code	450
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$5,105.30
Rate for Payer: Aetna Commercial	$4,836.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,186.75
Rate for Payer: Humana Medicare Advantage	$2,257.08
Rate for Payer: UnitedHealthcare Commercial	$5,105.30
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$3,224.40

10140 I&D HEMATOMA SEROMA/FLUID COLLECTION TechFee

Facility

$1,910.00

Service Code	HCPCS 10140
Hospital Charge Code	3300140
Hospital Revenue Code	450
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$1,814.50
Rate for Payer: Aetna Commercial	$1,719.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,186.75
Rate for Payer: Humana Medicare Advantage	$802.20
Rate for Payer: UnitedHealthcare Commercial	$1,814.50
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,146.00

10140 I&D HEMATOMA SEROMA/FLUID COLLECTION TechFee

Facility

$1,910.00

Service Code	HCPCS 10140
Hospital Charge Code	3300140
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,814.50
Rate for Payer: Aetna Commercial	$1,719.00
Rate for Payer: UnitedHealthcare Commercial	$1,814.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10140 I & D OF HEMATOMA, SEROMMA OR FLUID CHARGE

Facility

$1,910.00

Service Code	HCPCS 10140
Hospital Charge Code	3350140
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,814.50
Rate for Payer: Aetna Commercial	$1,719.00
Rate for Payer: UnitedHealthcare Commercial	$1,814.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10140 I & D OF HEMATOMA, SEROMMA OR FLUID CHARGE

Facility

$1,910.00

Service Code	HCPCS 10140
Hospital Charge Code	3350140
Hospital Revenue Code	761
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$1,814.50
Rate for Payer: Aetna Commercial	$1,719.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,186.75
Rate for Payer: Humana Medicare Advantage	$802.20
Rate for Payer: UnitedHealthcare Commercial	$1,814.50
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,146.00

10160-Aspiration Abscess/Cyst/Hematoma

Facility

$610.00

Service Code	HCPCS 10160
Hospital Charge Code	3301160
Hospital Revenue Code	450
Min. Negotiated Rate	$549.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$549.00
Rate for Payer: UnitedHealthcare Commercial	$579.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10160-Aspiration Abscess/Cyst/Hematoma

Facility

$610.00

Service Code	HCPCS 10160
Hospital Charge Code	3301160
Hospital Revenue Code	450
Min. Negotiated Rate	$223.08
Max. Negotiated Rate	$947.38
Rate for Payer: Aetna Commercial	$549.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$947.38
Rate for Payer: Humana Medicare Advantage	$256.20
Rate for Payer: UnitedHealthcare Commercial	$579.50
Rate for Payer: UnitedHealthcare Medicaid	$223.08
Rate for Payer: WPPA Medicare Advantage	$366.00

10160 PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST TechFee

Facility

$1,675.00

Service Code	HCPCS 10160
Hospital Charge Code	3301160
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,591.25
Rate for Payer: Aetna Commercial	$1,507.50
Rate for Payer: UnitedHealthcare Commercial	$1,591.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10160 PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST TechFee

Facility

$1,675.00

Service Code	HCPCS 10160
Hospital Charge Code	3301160
Hospital Revenue Code	450
Min. Negotiated Rate	$223.08
Max. Negotiated Rate	$1,591.25
Rate for Payer: Aetna Commercial	$1,507.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$947.38
Rate for Payer: Humana Medicare Advantage	$703.50
Rate for Payer: UnitedHealthcare Commercial	$1,591.25
Rate for Payer: UnitedHealthcare Medicaid	$223.08
Rate for Payer: WPPA Medicare Advantage	$1,005.00

10160 Puncture aspiration of abscess, hematoma, bulla, cyst

Facility

$1,675.00

Service Code	HCPCS 10160
Hospital Charge Code	3151016
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,591.25
Rate for Payer: Aetna Commercial	$1,507.50
Rate for Payer: UnitedHealthcare Commercial	$1,591.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10160 Puncture aspiration of abscess, hematoma, bulla, cyst

Facility

$1,675.00

Service Code	HCPCS 10160
Hospital Charge Code	3151016
Hospital Revenue Code	360
Min. Negotiated Rate	$223.08
Max. Negotiated Rate	$1,591.25
Rate for Payer: Aetna Commercial	$1,507.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$947.38
Rate for Payer: Humana Medicare Advantage	$703.50
Rate for Payer: UnitedHealthcare Commercial	$1,591.25
Rate for Payer: UnitedHealthcare Medicaid	$223.08
Rate for Payer: WPPA Medicare Advantage	$1,005.00

10180 I&D CPLX POSTOP WND INF CHARGE

Facility

$5,246.00

Service Code	HCPCS 10180
Hospital Charge Code	3150727
Hospital Revenue Code	360
Min. Negotiated Rate	$920.50
Max. Negotiated Rate	$4,983.70
Rate for Payer: Aetna Commercial	$4,721.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,784.47
Rate for Payer: Humana Medicare Advantage	$2,203.32
Rate for Payer: UnitedHealthcare Commercial	$4,983.70
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$3,147.60

10180 I&D CPLX POSTOP WND INF CHARGE

Facility

$5,246.00

Service Code	HCPCS 10180
Hospital Charge Code	3150727
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,983.70
Rate for Payer: Aetna Commercial	$4,721.40
Rate for Payer: UnitedHealthcare Commercial	$4,983.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10180-I&D Postop Wound Infection Complex

Facility

$1,035.00

Service Code	HCPCS 10180
Hospital Charge Code	3301018
Hospital Revenue Code	450
Min. Negotiated Rate	$434.70
Max. Negotiated Rate	$3,784.47
Rate for Payer: Aetna Commercial	$931.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,784.47
Rate for Payer: Humana Medicare Advantage	$434.70
Rate for Payer: UnitedHealthcare Commercial	$983.25
Rate for Payer: UnitedHealthcare Medicaid	$920.50
Rate for Payer: WPPA Medicare Advantage	$621.00

Know your out-of-pocket cost for care.

All Charges