Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

28810 Amputation, metatarsal, with toe, single

Facility

$7,206.00

Service Code	HCPCS 28810
Hospital Charge Code	3158810
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,845.70
Rate for Payer: Aetna Commercial	$6,485.40
Rate for Payer: UnitedHealthcare Commercial	$6,845.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28820 Amputation, toe; metatarsophalangeal joint

Facility

$6,312.00

Service Code	HCPCS 28820
Hospital Charge Code	3158820
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,996.40
Rate for Payer: Aetna Commercial	$5,680.80
Rate for Payer: UnitedHealthcare Commercial	$5,996.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28820 Amputation, toe; metatarsophalangeal joint

Facility

$6,312.00

Service Code	HCPCS 28820
Hospital Charge Code	3158820
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.57
Max. Negotiated Rate	$5,996.40
Rate for Payer: Aetna Commercial	$5,680.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$4,298.56
Rate for Payer: Humana Medicare Advantage	$2,651.04
Rate for Payer: UnitedHealthcare Commercial	$5,996.40
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$3,787.20

28825 Amputation, toe; interphalangeal joint

Facility

$5,494.00

Service Code	HCPCS 28825
Hospital Charge Code	3158825
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,219.30
Rate for Payer: Aetna Commercial	$4,944.60
Rate for Payer: UnitedHealthcare Commercial	$5,219.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

28825 Amputation, toe; interphalangeal joint

Facility

$5,494.00

Service Code	HCPCS 28825
Hospital Charge Code	3158825
Hospital Revenue Code	360
Min. Negotiated Rate	$1,048.57
Max. Negotiated Rate	$5,219.30
Rate for Payer: Aetna Commercial	$4,944.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,963.24
Rate for Payer: Humana Medicare Advantage	$2,307.48
Rate for Payer: UnitedHealthcare Commercial	$5,219.30
Rate for Payer: UnitedHealthcare Medicaid	$1,048.57
Rate for Payer: WPPA Medicare Advantage	$3,296.40

28899 Tarsal Tunnel Injection

Facility

$567.00

Service Code	HCPCS 28899
Hospital Charge Code	3298899
Hospital Revenue Code	761
Min. Negotiated Rate	$125.74
Max. Negotiated Rate	$538.65
Rate for Payer: Aetna Commercial	$510.30
Rate for Payer: Humana Medicare Advantage	$238.14
Rate for Payer: UnitedHealthcare Commercial	$538.65
Rate for Payer: UnitedHealthcare Medicaid	$125.74
Rate for Payer: WPPA Medicare Advantage	$340.20

28899 Tarsal Tunnel Injection

Facility

$567.00

Service Code	HCPCS 28899
Hospital Charge Code	3298899
Hospital Revenue Code	761
Min. Negotiated Rate	$510.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$510.30
Rate for Payer: UnitedHealthcare Commercial	$538.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

29065 APPLICATION CAST SHOULDER HAND LONG ARM CHARGE-ED

Facility

$515.00

Service Code	HCPCS 29065
Hospital Charge Code	3299065
Hospital Revenue Code	761
Min. Negotiated Rate	$216.30
Max. Negotiated Rate	$489.25
Rate for Payer: Aetna Commercial	$463.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$432.28
Rate for Payer: Humana Medicare Advantage	$216.30
Rate for Payer: UnitedHealthcare Commercial	$489.25
Rate for Payer: UnitedHealthcare Medicaid	$228.80
Rate for Payer: WPPA Medicare Advantage	$309.00

29065 APPLICATION CAST SHOULDER HAND LONG ARM CHARGE-ED

Facility

$515.00

Service Code	HCPCS 29065
Hospital Charge Code	3299065
Hospital Revenue Code	761
Min. Negotiated Rate	$463.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$463.50
Rate for Payer: UnitedHealthcare Commercial	$489.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

29065 APPLICATION CAST SHOULDER HAND LONG ARM TechFee

Facility

$778.00

Service Code	HCPCS 29065
Hospital Charge Code	3301042
Hospital Revenue Code	450
Min. Negotiated Rate	$228.80
Max. Negotiated Rate	$739.10
Rate for Payer: Aetna Commercial	$700.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$432.28
Rate for Payer: Humana Medicare Advantage	$326.76
Rate for Payer: UnitedHealthcare Commercial	$739.10
Rate for Payer: UnitedHealthcare Medicaid	$228.80
Rate for Payer: WPPA Medicare Advantage	$466.80

29065 APPLICATION CAST SHOULDER HAND LONG ARM TechFee

Facility

$778.00

Service Code	HCPCS 29065
Hospital Charge Code	3301042
Hospital Revenue Code	450
Min. Negotiated Rate	$700.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$700.20
Rate for Payer: UnitedHealthcare Commercial	$739.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

29065-Application cast shoulder to hand (long arm)

Facility

$515.00

Service Code	HCPCS 29065
Hospital Charge Code	3309065
Hospital Revenue Code	450
Min. Negotiated Rate	$463.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$463.50
Rate for Payer: UnitedHealthcare Commercial	$489.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

29065-Application cast shoulder to hand (long arm)

Facility

$515.00

Service Code	HCPCS 29065
Hospital Charge Code	3309065
Hospital Revenue Code	450
Min. Negotiated Rate	$216.30
Max. Negotiated Rate	$489.25
Rate for Payer: Aetna Commercial	$463.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$432.28
Rate for Payer: Humana Medicare Advantage	$216.30
Rate for Payer: UnitedHealthcare Commercial	$489.25
Rate for Payer: UnitedHealthcare Medicaid	$228.80
Rate for Payer: WPPA Medicare Advantage	$309.00

29075 APPLICATION CAST ELBOW FINGER SHORT ARM CHARGE-ED

Facility

$406.00

Service Code	HCPCS 29075
Hospital Charge Code	3299075
Hospital Revenue Code	761
Min. Negotiated Rate	$365.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$365.40
Rate for Payer: UnitedHealthcare Commercial	$385.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

29075 APPLICATION CAST ELBOW FINGER SHORT ARM CHARGE-ED

Facility

$406.00

Service Code	HCPCS 29075
Hospital Charge Code	3299075
Hospital Revenue Code	761
Min. Negotiated Rate	$170.52
Max. Negotiated Rate	$432.28
Rate for Payer: Aetna Commercial	$365.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$432.28
Rate for Payer: Humana Medicare Advantage	$170.52
Rate for Payer: UnitedHealthcare Commercial	$385.70
Rate for Payer: UnitedHealthcare Medicaid	$228.80
Rate for Payer: WPPA Medicare Advantage	$243.60

29075-Cast Application Elbow to Finger (short arm)

Facility

$406.00

Service Code	HCPCS 29075
Hospital Charge Code	3303195
Hospital Revenue Code	450
Min. Negotiated Rate	$170.52
Max. Negotiated Rate	$432.28
Rate for Payer: Aetna Commercial	$365.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$432.28
Rate for Payer: Humana Medicare Advantage	$170.52
Rate for Payer: UnitedHealthcare Commercial	$385.70
Rate for Payer: UnitedHealthcare Medicaid	$228.80
Rate for Payer: WPPA Medicare Advantage	$243.60

29075-Cast Application Elbow to Finger (short arm)

Facility

$406.00

Service Code	HCPCS 29075
Hospital Charge Code	3303195
Hospital Revenue Code	450
Min. Negotiated Rate	$365.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$365.40
Rate for Payer: UnitedHealthcare Commercial	$385.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

29105 APPLICATION LONG ARM SPLINT (SHOULDER TO HAND)

Facility

$490.00

Service Code	HCPCS 29105
Hospital Charge Code	3304690
Hospital Revenue Code	450
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$441.00
Rate for Payer: UnitedHealthcare Commercial	$465.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

29105 APPLICATION LONG ARM SPLINT (SHOULDER TO HAND)

Facility

$490.00

Service Code	HCPCS 29105
Hospital Charge Code	3304690
Hospital Revenue Code	450
Min. Negotiated Rate	$205.80
Max. Negotiated Rate	$465.50
Rate for Payer: Aetna Commercial	$441.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$230.28
Rate for Payer: Humana Medicare Advantage	$205.80
Rate for Payer: UnitedHealthcare Commercial	$465.50
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$294.00

29105-Long Arm

Facility

$406.00

Service Code	HCPCS 29105
Hospital Charge Code	3304690
Hospital Revenue Code	450
Min. Negotiated Rate	$170.52
Max. Negotiated Rate	$385.70
Rate for Payer: Aetna Commercial	$365.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$230.28
Rate for Payer: Humana Medicare Advantage	$170.52
Rate for Payer: UnitedHealthcare Commercial	$385.70
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$243.60

29105-Long Arm

Facility

$406.00

Service Code	HCPCS 29105
Hospital Charge Code	3304690
Hospital Revenue Code	450
Min. Negotiated Rate	$365.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$365.40
Rate for Payer: UnitedHealthcare Commercial	$385.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

29125 APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC TechFee

Facility

$584.00

Service Code	HCPCS 29125
Hospital Charge Code	3304743
Hospital Revenue Code	450
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$554.80
Rate for Payer: Aetna Commercial	$525.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$230.28
Rate for Payer: Humana Medicare Advantage	$245.28
Rate for Payer: UnitedHealthcare Commercial	$554.80
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$350.40

29125 APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC TechFee

Facility

$584.00

Service Code	HCPCS 29125
Hospital Charge Code	3304743
Hospital Revenue Code	450
Min. Negotiated Rate	$525.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$525.60
Rate for Payer: UnitedHealthcare Commercial	$554.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

29125 OT APPL ARM SPLINT STATIC

Facility

$613.00

Service Code	HCPCS 29125 GO
Hospital Charge Code	3970140
Hospital Revenue Code	430
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$582.35
Rate for Payer: Aetna Commercial	$551.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$230.28
Rate for Payer: Humana Medicare Advantage	$257.46
Rate for Payer: UnitedHealthcare Commercial	$582.35
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$367.80

29125 OT APPL ARM SPLINT STATIC

Facility

$613.00

Service Code	HCPCS 29125 GO
Hospital Charge Code	3970140
Hospital Revenue Code	430
Min. Negotiated Rate	$551.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$551.70
Rate for Payer: UnitedHealthcare Commercial	$582.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges