Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

25215 Carpectomy; all bones of proximal row

Facility

$7,376.00

Service Code	HCPCS 25215
Hospital Charge Code	3155215
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,007.20
Rate for Payer: Aetna Commercial	$6,638.40
Rate for Payer: UnitedHealthcare Commercial	$7,007.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25215 Carpectomy; all bones of proximal row

Facility

$7,376.00

Service Code	HCPCS 25215
Hospital Charge Code	3155215
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.57
Max. Negotiated Rate	$7,007.20
Rate for Payer: Aetna Commercial	$6,638.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,402.45
Rate for Payer: Humana Medicare Advantage	$3,097.92
Rate for Payer: UnitedHealthcare Commercial	$7,007.20
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$4,425.60

25248 Exploration with removal of deep foreign body, forearm or wrist

Facility

$751.00

Service Code	HCPCS 25248
Hospital Charge Code	3355248
Hospital Revenue Code	761
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

25248 Exploration with removal of deep foreign body, forearm or wrist

Facility

$751.00

Service Code	HCPCS 25248
Hospital Charge Code	3355248
Hospital Revenue Code	761
Min. Negotiated Rate	$315.42
Max. Negotiated Rate	$713.45
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	$520.65
Rate for Payer: WPPA Medicare Advantage	$450.60

25565-Radial&Ulnar Shaft w/ Manipulation

Facility

$2,865.00

Service Code	HCPCS 25565
Hospital Charge Code	3305565
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,721.75
Rate for Payer: Aetna Commercial	$2,578.50
Rate for Payer: UnitedHealthcare Commercial	$2,721.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25565-Radial&Ulnar Shaft w/ Manipulation

Facility

$2,865.00

Service Code	HCPCS 25565
Hospital Charge Code	3305565
Hospital Revenue Code	450
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$2,721.75
Rate for Payer: Aetna Commercial	$2,578.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,454.40
Rate for Payer: Humana Medicare Advantage	$1,203.30
Rate for Payer: UnitedHealthcare Commercial	$2,721.75
Rate for Payer: UnitedHealthcare Medicaid	$520.65
Rate for Payer: WPPA Medicare Advantage	$1,719.00

25600 CL TX DISTAL RADIAL FX/EPIHY CHARGE

Facility

$495.00

Service Code	HCPCS 25600
Hospital Charge Code	3355600
Hospital Revenue Code	360
Min. Negotiated Rate	$445.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$445.50
Rate for Payer: UnitedHealthcare Commercial	$470.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25600 CL TX DISTAL RADIAL FX/EPIHY CHARGE

Facility

$495.00

Service Code	HCPCS 25600
Hospital Charge Code	3355600
Hospital Revenue Code	360
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$470.25
Rate for Payer: Aetna Commercial	$445.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$249.78
Rate for Payer: Humana Medicare Advantage	$207.90
Rate for Payer: UnitedHealthcare Commercial	$470.25
Rate for Payer: UnitedHealthcare Medicaid	$312.00
Rate for Payer: WPPA Medicare Advantage	$297.00

25600 CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ TechFee

Facility

$495.00

Service Code	HCPCS 25600
Hospital Charge Code	3305600
Hospital Revenue Code	450
Min. Negotiated Rate	$445.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$445.50
Rate for Payer: UnitedHealthcare Commercial	$470.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25600 CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ TechFee

Facility

$495.00

Service Code	HCPCS 25600
Hospital Charge Code	3305600
Hospital Revenue Code	450
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$470.25
Rate for Payer: Aetna Commercial	$445.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$249.78
Rate for Payer: Humana Medicare Advantage	$207.90
Rate for Payer: UnitedHealthcare Commercial	$470.25
Rate for Payer: UnitedHealthcare Medicaid	$312.00
Rate for Payer: WPPA Medicare Advantage	$297.00

25600-Distal Radial w/o Manipulation

Facility

$495.00

Service Code	HCPCS 25600
Hospital Charge Code	3300181
Hospital Revenue Code	450
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$470.25
Rate for Payer: Aetna Commercial	$445.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$249.78
Rate for Payer: Humana Medicare Advantage	$207.90
Rate for Payer: UnitedHealthcare Commercial	$470.25
Rate for Payer: UnitedHealthcare Medicaid	$312.00
Rate for Payer: WPPA Medicare Advantage	$297.00

25600-Distal Radial w/o Manipulation

Facility

$495.00

Service Code	HCPCS 25600
Hospital Charge Code	3300181
Hospital Revenue Code	450
Min. Negotiated Rate	$445.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$445.50
Rate for Payer: UnitedHealthcare Commercial	$470.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25605 TREAT FRACTURE RADIUS/ULNA CHARGE

Facility

$3,900.00

Service Code	HCPCS 25605
Hospital Charge Code	3300182
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,705.00
Rate for Payer: Aetna Commercial	$3,510.00
Rate for Payer: UnitedHealthcare Commercial	$3,705.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

25605 TREAT FRACTURE RADIUS/ULNA CHARGE

Facility

$3,900.00

Service Code	HCPCS 25605
Hospital Charge Code	3300182
Hospital Revenue Code	450
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$3,705.00
Rate for Payer: Aetna Commercial	$3,510.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,434.20
Rate for Payer: Humana Medicare Advantage	$1,638.00
Rate for Payer: UnitedHealthcare Commercial	$3,705.00
Rate for Payer: UnitedHealthcare Medicaid	$520.65
Rate for Payer: WPPA Medicare Advantage	$2,340.00

26010-I&D Finger Abscess Simple

Facility

$1,503.00

Service Code	HCPCS 26010
Hospital Charge Code	3303185
Hospital Revenue Code	450
Min. Negotiated Rate	$202.80
Max. Negotiated Rate	$1,427.85
Rate for Payer: Aetna Commercial	$1,352.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$320.17
Rate for Payer: Humana Medicare Advantage	$631.26
Rate for Payer: UnitedHealthcare Commercial	$1,427.85
Rate for Payer: UnitedHealthcare Medicaid	$202.80
Rate for Payer: WPPA Medicare Advantage	$901.80

26010-I&D Finger Abscess Simple

Facility

$1,503.00

Service Code	HCPCS 26010
Hospital Charge Code	3303185
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,427.85
Rate for Payer: Aetna Commercial	$1,352.70
Rate for Payer: UnitedHealthcare Commercial	$1,427.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

26040 Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous

Facility

$1,833.00

Service Code	HCPCS 26040
Hospital Charge Code	3156040
Hospital Revenue Code	360
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$1,741.35
Rate for Payer: Aetna Commercial	$1,649.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$764.26
Rate for Payer: Humana Medicare Advantage	$769.86
Rate for Payer: UnitedHealthcare Commercial	$1,741.35
Rate for Payer: UnitedHealthcare Medicaid	$520.65
Rate for Payer: WPPA Medicare Advantage	$1,099.80

26040 Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous

Facility

$1,833.00

Service Code	HCPCS 26040
Hospital Charge Code	3156040
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,741.35
Rate for Payer: Aetna Commercial	$1,649.70
Rate for Payer: UnitedHealthcare Commercial	$1,741.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

26055 Tendon sheath incision (eg, for trigger finger)

Facility

$2,367.00

Service Code	HCPCS 26055
Hospital Charge Code	3150385
Hospital Revenue Code	360
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$2,248.65
Rate for Payer: Aetna Commercial	$2,130.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,487.73
Rate for Payer: Humana Medicare Advantage	$994.14
Rate for Payer: UnitedHealthcare Commercial	$2,248.65
Rate for Payer: UnitedHealthcare Medicaid	$520.65
Rate for Payer: WPPA Medicare Advantage	$1,420.20

26055 Tendon sheath incision (eg, for trigger finger)

Facility

$2,367.00

Service Code	HCPCS 26055
Hospital Charge Code	3150385
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,248.65
Rate for Payer: Aetna Commercial	$2,130.30
Rate for Payer: UnitedHealthcare Commercial	$2,248.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

26113 Excision, tumor, soft tissue, or vascular malformation, of hand/finger, subfascial; 1.5 cm +

Facility

$3,330.00

Service Code	HCPCS 26113
Hospital Charge Code	3156113
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,163.50
Rate for Payer: Aetna Commercial	$2,997.00
Rate for Payer: UnitedHealthcare Commercial	$3,163.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

26113 Excision, tumor, soft tissue, or vascular malformation, of hand/finger, subfascial; 1.5 cm +

Facility

$3,330.00

Service Code	HCPCS 26113
Hospital Charge Code	3156113
Hospital Revenue Code	360
Min. Negotiated Rate	$847.14
Max. Negotiated Rate	$3,163.50
Rate for Payer: Aetna Commercial	$2,997.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,160.39
Rate for Payer: Humana Medicare Advantage	$1,398.60
Rate for Payer: UnitedHealthcare Commercial	$3,163.50
Rate for Payer: UnitedHealthcare Medicaid	$847.14
Rate for Payer: WPPA Medicare Advantage	$1,998.00

26115 - Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less

Facility

$1,762.00

Service Code	HCPCS 26115
Hospital Charge Code	3156115
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,673.90
Rate for Payer: Aetna Commercial	$1,585.80
Rate for Payer: UnitedHealthcare Commercial	$1,673.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

26115 - Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less

Facility

$1,762.00

Service Code	HCPCS 26115
Hospital Charge Code	3156115
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$1,673.90
Rate for Payer: Aetna Commercial	$1,585.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,199.88
Rate for Payer: Humana Medicare Advantage	$740.04
Rate for Payer: UnitedHealthcare Commercial	$1,673.90
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,057.20

26116 Exc, tumor/soft tissue/vascular malformation, of hand/finger, subfascial; less than 1.5 cm

Facility

$3,148.00

Service Code	HCPCS 26116
Hospital Charge Code	31156116
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,990.60
Rate for Payer: Aetna Commercial	$2,833.20
Rate for Payer: UnitedHealthcare Commercial	$2,990.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

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All Charges