Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

28110 Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure)

Facility

$5,035.00

Service Code	HCPCS 28110
Hospital Charge Code	3158110
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,783.25
Rate for Payer: Aetna Commercial	$4,531.50
Rate for Payer: UnitedHealthcare Commercial	$4,783.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28113 Ostectomy, complete excision

Facility

$5,957.00

Service Code	HCPCS 28113
Hospital Charge Code	3158113
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.57
Max. Negotiated Rate	$5,659.15
Rate for Payer: Aetna Commercial	$5,361.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,297.55
Rate for Payer: Humana Medicare Advantage	$2,501.94
Rate for Payer: UnitedHealthcare Commercial	$5,659.15
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$3,574.20

28113 Ostectomy, complete excision

Facility

$5,957.00

Service Code	HCPCS 28113
Hospital Charge Code	3158113
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,659.15
Rate for Payer: Aetna Commercial	$5,361.30
Rate for Payer: UnitedHealthcare Commercial	$5,659.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28122 PARTIAL REMOVAL OF FOOT BONE

Facility

$6,630.00

Service Code	HCPCS 28122
Hospital Charge Code	3158122
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.57
Max. Negotiated Rate	$6,298.50
Rate for Payer: Aetna Commercial	$5,967.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,935.97
Rate for Payer: Humana Medicare Advantage	$2,784.60
Rate for Payer: UnitedHealthcare Commercial	$6,298.50
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$3,978.00

28122 PARTIAL REMOVAL OF FOOT BONE

Facility

$6,630.00

Service Code	HCPCS 28122
Hospital Charge Code	3158122
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,298.50
Rate for Payer: Aetna Commercial	$5,967.00
Rate for Payer: UnitedHealthcare Commercial	$6,298.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28124 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, os

Facility

$3,493.00

Service Code	HCPCS 28124
Hospital Charge Code	3158124
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,318.35
Rate for Payer: Aetna Commercial	$3,143.70
Rate for Payer: UnitedHealthcare Commercial	$3,318.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28124 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, os

Facility

$3,493.00

Service Code	HCPCS 28124
Hospital Charge Code	3158124
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.57
Max. Negotiated Rate	$3,318.35
Rate for Payer: Aetna Commercial	$3,143.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,157.36
Rate for Payer: Humana Medicare Advantage	$1,467.06
Rate for Payer: UnitedHealthcare Commercial	$3,318.35
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$2,095.80

28160 PARTIAL REMOVAL OF TOE

Facility

$3,168.00

Service Code	HCPCS 28160
Hospital Charge Code	3158160
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,009.60
Rate for Payer: Aetna Commercial	$2,851.20
Rate for Payer: UnitedHealthcare Commercial	$3,009.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28160 PARTIAL REMOVAL OF TOE

Facility

$3,168.00

Service Code	HCPCS 28160
Hospital Charge Code	3158160
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.57
Max. Negotiated Rate	$3,009.60
Rate for Payer: Aetna Commercial	$2,851.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,157.36
Rate for Payer: Humana Medicare Advantage	$1,330.56
Rate for Payer: UnitedHealthcare Commercial	$3,009.60
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$1,900.80

28190-Foot Subcutaneous

Facility

$4,613.00

Service Code	HCPCS 28190
Hospital Charge Code	3308190
Hospital Revenue Code	450
Min. Negotiated Rate	$457.60
Max. Negotiated Rate	$4,382.35
Rate for Payer: Aetna Commercial	$4,151.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,991.72
Rate for Payer: Humana Medicare Advantage	$1,937.46
Rate for Payer: UnitedHealthcare Commercial	$4,382.35
Rate for Payer: UnitedHealthcare Medicaid	$457.60
Rate for Payer: WPPA Medicare Advantage	$2,767.80

28190-Foot Subcutaneous

Facility

$4,613.00

Service Code	HCPCS 28190
Hospital Charge Code	3308190
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,382.35
Rate for Payer: Aetna Commercial	$4,151.70
Rate for Payer: UnitedHealthcare Commercial	$4,382.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28190 REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS TechFee

Facility

$2,760.00

Service Code	HCPCS 28190
Hospital Charge Code	3308190
Hospital Revenue Code	450
Min. Negotiated Rate	$457.60
Max. Negotiated Rate	$2,622.00
Rate for Payer: Aetna Commercial	$2,484.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,991.72
Rate for Payer: Humana Medicare Advantage	$1,159.20
Rate for Payer: UnitedHealthcare Commercial	$2,622.00
Rate for Payer: UnitedHealthcare Medicaid	$457.60
Rate for Payer: WPPA Medicare Advantage	$1,656.00

28190 REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS TechFee

Facility

$2,760.00

Service Code	HCPCS 28190
Hospital Charge Code	3308190
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,622.00
Rate for Payer: Aetna Commercial	$2,484.00
Rate for Payer: UnitedHealthcare Commercial	$2,622.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28192 REMOVE FB, FOOT DEEP [HGHO]

Facility

$1,727.00

Service Code	HCPCS 28192
Hospital Charge Code	3158192
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$1,640.65
Rate for Payer: Aetna Commercial	$1,554.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,246.34
Rate for Payer: Humana Medicare Advantage	$725.34
Rate for Payer: UnitedHealthcare Commercial	$1,640.65
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,036.20

28192 REMOVE FB, FOOT DEEP [HGHO]

Facility

$1,727.00

Service Code	HCPCS 28192
Hospital Charge Code	3158192
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,640.65
Rate for Payer: Aetna Commercial	$1,554.30
Rate for Payer: UnitedHealthcare Commercial	$1,640.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28200 REP TENDON FLEXOR FT PRIM OR 2ND WO FREE CHARGE

Facility

$6,773.00

Service Code	HCPCS 28200
Hospital Charge Code	3158200
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.57
Max. Negotiated Rate	$6,434.35
Rate for Payer: Aetna Commercial	$6,095.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,021.82
Rate for Payer: Humana Medicare Advantage	$2,844.66
Rate for Payer: UnitedHealthcare Commercial	$6,434.35
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$4,063.80

28200 REP TENDON FLEXOR FT PRIM OR 2ND WO FREE CHARGE

Facility

$6,773.00

Service Code	HCPCS 28200
Hospital Charge Code	3158200
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,434.35
Rate for Payer: Aetna Commercial	$6,095.70
Rate for Payer: UnitedHealthcare Commercial	$6,434.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28285 HAMMERTOES CORR/UNI

Facility

$8,619.00

Service Code	HCPCS 28285
Hospital Charge Code	3150580
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.57
Max. Negotiated Rate	$8,188.05
Rate for Payer: Aetna Commercial	$7,757.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,595.00
Rate for Payer: Humana Medicare Advantage	$3,619.98
Rate for Payer: UnitedHealthcare Commercial	$8,188.05
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$5,171.40

28285 HAMMERTOES CORR/UNI

Facility

$8,619.00

Service Code	HCPCS 28285
Hospital Charge Code	3150580
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,188.05
Rate for Payer: Aetna Commercial	$7,757.10
Rate for Payer: UnitedHealthcare Commercial	$8,188.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28288 PARTIAL REMOVAL OF FOOT BONE

Facility

$4,748.00

Service Code	HCPCS 28288
Hospital Charge Code	3158288
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,510.60
Rate for Payer: Aetna Commercial	$4,273.20
Rate for Payer: UnitedHealthcare Commercial	$4,510.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28288 PARTIAL REMOVAL OF FOOT BONE

Facility

$4,748.00

Service Code	HCPCS 28288
Hospital Charge Code	3158288
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.57
Max. Negotiated Rate	$4,510.60
Rate for Payer: Aetna Commercial	$4,273.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,818.91
Rate for Payer: Humana Medicare Advantage	$1,994.16
Rate for Payer: UnitedHealthcare Commercial	$4,510.60
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$2,848.80

28289 HALLUX CORRECT/CHEILECTOM

Facility

$5,379.00

Service Code	HCPCS 28289
Hospital Charge Code	3158289
Hospital Revenue Code	360
Min. Negotiated Rate	$2,151.60
Max. Negotiated Rate	$5,110.05
Rate for Payer: Aetna Commercial	$4,841.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,322.90
Rate for Payer: Humana Medicare Advantage	$2,259.18
Rate for Payer: UnitedHealthcare Commercial	$5,110.05
Rate for Payer: UnitedHealthcare Medicaid	$2,151.60
Rate for Payer: WPPA Medicare Advantage	$3,227.40

28289 HALLUX CORRECT/CHEILECTOM

Facility

$5,379.00

Service Code	HCPCS 28289
Hospital Charge Code	3158289
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,110.05
Rate for Payer: Aetna Commercial	$4,841.10
Rate for Payer: UnitedHealthcare Commercial	$5,110.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28295 CORRECTIONHALLUXVALG [HGHO]

Facility

$4,788.00

Service Code	HCPCS 28295
Hospital Charge Code	3358295
Hospital Revenue Code	360
Min. Negotiated Rate	$1,813.15
Max. Negotiated Rate	$4,548.60
Rate for Payer: Aetna Commercial	$4,309.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,454.20
Rate for Payer: Humana Medicare Advantage	$2,010.96
Rate for Payer: UnitedHealthcare Commercial	$4,548.60
Rate for Payer: UnitedHealthcare Medicaid	$1,813.15
Rate for Payer: WPPA Medicare Advantage	$2,872.80

28295 CORRECTIONHALLUXVALG [HGHO]

Facility

$4,788.00

Service Code	HCPCS 28295
Hospital Charge Code	3358295
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,548.60
Rate for Payer: Aetna Commercial	$4,309.20
Rate for Payer: UnitedHealthcare Commercial	$4,548.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges