Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$931.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$931.50
Rate for Payer: UnitedHealthcare Commercial	$983.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

10180 INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION

Facility

$5,246.00

Service Code	HCPCS 10180
Hospital Charge Code	3301018
Hospital Revenue Code	450
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 INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION

Facility

$5,246.00

Service Code	HCPCS 10180
Hospital Charge Code	3301018
Hospital Revenue Code	450
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

11004 Debride of skin, subQ tissue, muscle and fascia for necrotizing soft tissue infection

Facility

$1,660.00

Service Code	HCPCS 11004
Hospital Charge Code	3350215
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,577.00
Rate for Payer: Aetna Commercial	$1,494.00
Rate for Payer: UnitedHealthcare Commercial	$1,577.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11004 Debride of skin, subQ tissue, muscle and fascia for necrotizing soft tissue infection

Facility

$1,660.00

Service Code	HCPCS 11004
Hospital Charge Code	3350215
Hospital Revenue Code	360
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$1,577.00
Rate for Payer: Aetna Commercial	$1,494.00
Rate for Payer: Humana Medicare Advantage	$697.20
Rate for Payer: UnitedHealthcare Commercial	$1,577.00
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$996.00

11005 Debride of skin, subQ tissue, muscle/fascia for necrotizing soft tissue infection; abd wall

Facility

$2,372.00

Service Code	HCPCS 11005
Hospital Charge Code	3151005
Hospital Revenue Code	360
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$2,253.40
Rate for Payer: Aetna Commercial	$2,134.80
Rate for Payer: Humana Medicare Advantage	$996.24
Rate for Payer: UnitedHealthcare Commercial	$2,253.40
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$1,423.20

11005 Debride of skin, subQ tissue, muscle/fascia for necrotizing soft tissue infection; abd wall

Facility

$2,372.00

Service Code	HCPCS 11005
Hospital Charge Code	3151005
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,253.40
Rate for Payer: Aetna Commercial	$2,134.80
Rate for Payer: UnitedHealthcare Commercial	$2,253.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11012 DBRDMT FX&/DISLC SUBQ T/M/F BONE TechFee

Facility

$4,276.00

Service Code	HCPCS 11012
Hospital Charge Code	3351012
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,062.20
Rate for Payer: Aetna Commercial	$3,848.40
Rate for Payer: UnitedHealthcare Commercial	$4,062.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11012 DBRDMT FX&/DISLC SUBQ T/M/F BONE TechFee

Facility

$4,276.00

Service Code	HCPCS 11012
Hospital Charge Code	3351012
Hospital Revenue Code	450
Min. Negotiated Rate	$1,728.78
Max. Negotiated Rate	$4,062.20
Rate for Payer: Aetna Commercial	$3,848.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3,084.55
Rate for Payer: Humana Medicare Advantage	$1,795.92
Rate for Payer: UnitedHealthcare Commercial	$4,062.20
Rate for Payer: UnitedHealthcare Medicaid	$1,728.78
Rate for Payer: WPPA Medicare Advantage	$2,565.60

11042 DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< TechFee

Facility

$812.00

Service Code	HCPCS 11042
Hospital Charge Code	3301042
Hospital Revenue Code	450
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$771.40
Rate for Payer: Aetna Commercial	$730.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.17
Rate for Payer: Humana Medicare Advantage	$341.04
Rate for Payer: UnitedHealthcare Commercial	$771.40
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$487.20

11042 DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< TechFee

Facility

$812.00

Service Code	HCPCS 11042
Hospital Charge Code	3301042
Hospital Revenue Code	450
Min. Negotiated Rate	$730.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$730.80
Rate for Payer: UnitedHealthcare Commercial	$771.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11042 Debridement, subcut tissue first 20 sq cm or less

Facility

$812.00

Service Code	HCPCS 11042
Hospital Charge Code	3350220
Hospital Revenue Code	761
Min. Negotiated Rate	$730.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$730.80
Rate for Payer: UnitedHealthcare Commercial	$771.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11042 Debridement, subcut tissue first 20 sq cm or less

Facility

$812.00

Service Code	HCPCS 11042
Hospital Charge Code	3350220
Hospital Revenue Code	761
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$771.40
Rate for Payer: Aetna Commercial	$730.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.17
Rate for Payer: Humana Medicare Advantage	$341.04
Rate for Payer: UnitedHealthcare Commercial	$771.40
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$487.20

11042 DEB SUBQ TIS 20 SQ CM/<

Facility

$812.00

Service Code	HCPCS 11042
Hospital Charge Code	3350220
Hospital Revenue Code	761
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$771.40
Rate for Payer: Aetna Commercial	$730.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.17
Rate for Payer: Humana Medicare Advantage	$341.04
Rate for Payer: UnitedHealthcare Commercial	$771.40
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$487.20

11042 DEB SUBQ TIS 20 SQ CM/<

Facility

$812.00

Service Code	HCPCS 11042
Hospital Charge Code	3350220
Hospital Revenue Code	761
Min. Negotiated Rate	$730.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$730.80
Rate for Payer: UnitedHealthcare Commercial	$771.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11042 OP 761 DEBRIDEMENT SKIN & SUBCUTANEOUS TIS CHARGE

Facility

$812.00

Service Code	HCPCS 11042
Hospital Charge Code	3150726
Hospital Revenue Code	360
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$771.40
Rate for Payer: Aetna Commercial	$730.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$451.17
Rate for Payer: Humana Medicare Advantage	$341.04
Rate for Payer: UnitedHealthcare Commercial	$771.40
Rate for Payer: UnitedHealthcare Medicaid	$286.00
Rate for Payer: WPPA Medicare Advantage	$487.20

11042 OP 761 DEBRIDEMENT SKIN & SUBCUTANEOUS TIS CHARGE

Facility

$812.00

Service Code	HCPCS 11042
Hospital Charge Code	3150726
Hospital Revenue Code	360
Min. Negotiated Rate	$730.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$730.80
Rate for Payer: UnitedHealthcare Commercial	$771.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11043 Debridement, muscle and/or fascia; first 20 sq cm or less

Facility

$970.00

Service Code	HCPCS 11043
Hospital Charge Code	3301043
Hospital Revenue Code	761
Min. Negotiated Rate	$228.80
Max. Negotiated Rate	$921.50
Rate for Payer: Aetna Commercial	$873.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$700.21
Rate for Payer: Humana Medicare Advantage	$407.40
Rate for Payer: UnitedHealthcare Commercial	$921.50
Rate for Payer: UnitedHealthcare Medicaid	$228.80
Rate for Payer: WPPA Medicare Advantage	$582.00

11043 Debridement, muscle and/or fascia; first 20 sq cm or less

Facility

$970.00

Service Code	HCPCS 11043
Hospital Charge Code	3301043
Hospital Revenue Code	761
Min. Negotiated Rate	$873.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$873.00
Rate for Payer: UnitedHealthcare Commercial	$921.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11043 - Debridement Skin- SQ Tis, Muscle,1st 20sqcm

Facility

$970.00

Service Code	HCPCS 11043
Hospital Charge Code	3291043
Hospital Revenue Code	360
Min. Negotiated Rate	$228.80
Max. Negotiated Rate	$921.50
Rate for Payer: Aetna Commercial	$873.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$700.21
Rate for Payer: Humana Medicare Advantage	$407.40
Rate for Payer: UnitedHealthcare Commercial	$921.50
Rate for Payer: UnitedHealthcare Medicaid	$228.80
Rate for Payer: WPPA Medicare Advantage	$582.00

11043 - Debridement Skin- SQ Tis, Muscle,1st 20sqcm

Facility

$970.00

Service Code	HCPCS 11043
Hospital Charge Code	3291043
Hospital Revenue Code	360
Min. Negotiated Rate	$873.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$873.00
Rate for Payer: UnitedHealthcare Commercial	$921.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11044 Debridement, bone: first 20sq cm or less

Facility

$2,502.00

Service Code	HCPCS 11044
Hospital Charge Code	3151044
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,376.90
Rate for Payer: Aetna Commercial	$2,251.80
Rate for Payer: UnitedHealthcare Commercial	$2,376.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11044 Debridement, bone: first 20sq cm or less

Facility

$2,502.00

Service Code	HCPCS 11044
Hospital Charge Code	3151044
Hospital Revenue Code	360
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$2,376.90
Rate for Payer: Aetna Commercial	$2,251.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,805.43
Rate for Payer: Humana Medicare Advantage	$1,050.84
Rate for Payer: UnitedHealthcare Commercial	$2,376.90
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,501.20

11044 Debridement, bone; first 20 sq cm or less

Facility

$2,502.00

Service Code	HCPCS 11044
Hospital Charge Code	3351044
Hospital Revenue Code	761
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,376.90
Rate for Payer: Aetna Commercial	$2,251.80
Rate for Payer: UnitedHealthcare Commercial	$2,376.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

11044 Debridement, bone; first 20 sq cm or less

Facility

$2,502.00

Service Code	HCPCS 11044
Hospital Charge Code	3351044
Hospital Revenue Code	761
Min. Negotiated Rate	$525.22
Max. Negotiated Rate	$2,376.90
Rate for Payer: Aetna Commercial	$2,251.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,805.43
Rate for Payer: Humana Medicare Advantage	$1,050.84
Rate for Payer: UnitedHealthcare Commercial	$2,376.90
Rate for Payer: UnitedHealthcare Medicaid	$525.22
Rate for Payer: WPPA Medicare Advantage	$1,501.20

Know your out-of-pocket cost for care.

All Charges