Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Skin Graft Blade Dermatome Blade Zimmer Air 8801

Facility

$193.00

Hospital Charge Code	3259630
Hospital Revenue Code	270
Min. Negotiated Rate	$173.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$173.70
Rate for Payer: UnitedHealthcare Commercial	$183.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Skin Graft Carrier Dermacarrier II 1.5:1

Facility

$85.50

Hospital Charge Code	3259645
Hospital Revenue Code	270
Min. Negotiated Rate	$76.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: UnitedHealthcare Commercial	$81.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Skin Graft Carrier Dermacarrier II 1.5:1

Facility

$85.50

Hospital Charge Code	3259645
Hospital Revenue Code	270
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$81.22
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Humana Medicare Advantage	$35.91
Rate for Payer: UnitedHealthcare Commercial	$81.22
Rate for Payer: UnitedHealthcare Medicaid	$34.20
Rate for Payer: WPPA Medicare Advantage	$51.30

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$8,641.44

Service Code	MSDRG 577
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,641.44
Rate for Payer: UnitedHealthcare Medicaid	$8,641.44
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$15,980.31

Service Code	MSDRG 576
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$15,980.31
Rate for Payer: UnitedHealthcare Medicaid	$15,980.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$5,242.05

Service Code	MSDRG 578
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,242.05
Rate for Payer: UnitedHealthcare Medicaid	$5,242.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$11,310.12

Service Code	MSDRG 574
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,310.12
Rate for Payer: UnitedHealthcare Medicaid	$11,310.12
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$21,381.21

Service Code	MSDRG 573
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$21,381.21
Rate for Payer: UnitedHealthcare Medicaid	$21,381.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$5,877.45

Service Code	MSDRG 575
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,877.45
Rate for Payer: UnitedHealthcare Medicaid	$5,877.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Skin Graft Full Thickness

Facility

$625.00

Service Code	HCPCS 15221
Hospital Charge Code	3155240
Hospital Revenue Code	360
Min. Negotiated Rate	$562.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$562.50
Rate for Payer: UnitedHealthcare Commercial	$593.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Skin Graft Full Thickness

Facility

$625.00

Service Code	HCPCS 15221
Hospital Charge Code	3155240
Hospital Revenue Code	360
Min. Negotiated Rate	$250.00
Max. Negotiated Rate	$593.75
Rate for Payer: Aetna Commercial	$562.50
Rate for Payer: Humana Medicare Advantage	$262.50
Rate for Payer: UnitedHealthcare Commercial	$593.75
Rate for Payer: UnitedHealthcare Medicaid	$250.00
Rate for Payer: WPPA Medicare Advantage	$375.00

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$6,385.77

Service Code	MSDRG 623
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,385.77
Rate for Payer: UnitedHealthcare Medicaid	$6,385.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$12,708.00

Service Code	MSDRG 622
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,708.00
Rate for Payer: UnitedHealthcare Medicaid	$12,708.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$4,479.57

Service Code	MSDRG 624
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,479.57
Rate for Payer: UnitedHealthcare Medicaid	$4,479.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN GRAFTS FOR INJURIES WITH CC/MCC

Facility

$12,866.85

Service Code	MSDRG 904
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,866.85
Rate for Payer: UnitedHealthcare Medicaid	$12,866.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC

Facility

$5,210.28

Service Code	MSDRG 905
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,210.28
Rate for Payer: UnitedHealthcare Medicaid	$5,210.28
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Skin Graft Topical Dermal Substitute PriMatrix AG Meshed 4 x 4 cm

Facility

$3,650.00

Hospital Charge Code	3253895
Hospital Revenue Code	270
Min. Negotiated Rate	$1,460.00
Max. Negotiated Rate	$3,467.50
Rate for Payer: Aetna Commercial	$3,285.00
Rate for Payer: Humana Medicare Advantage	$1,533.00
Rate for Payer: UnitedHealthcare Commercial	$3,467.50
Rate for Payer: UnitedHealthcare Medicaid	$1,460.00
Rate for Payer: WPPA Medicare Advantage	$2,190.00

Skin Graft Topical Dermal Substitute PriMatrix AG Meshed 4 x 4 cm

Facility

$3,650.00

Hospital Charge Code	3253895
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,467.50
Rate for Payer: Aetna Commercial	$3,285.00
Rate for Payer: UnitedHealthcare Commercial	$3,467.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Skin Stapler Remover

Facility

$3.87

Hospital Charge Code	3253718
Hospital Revenue Code	270
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$3.68
Rate for Payer: Aetna Commercial	$3.48
Rate for Payer: Humana Medicare Advantage	$1.63
Rate for Payer: UnitedHealthcare Commercial	$3.68
Rate for Payer: UnitedHealthcare Medicaid	$1.55
Rate for Payer: WPPA Medicare Advantage	$2.32

Skin Stapler Remover

Facility

$3.87

Hospital Charge Code	3253718
Hospital Revenue Code	270
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.48
Rate for Payer: UnitedHealthcare Commercial	$3.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN ULCERS WITH CC

Facility

$5,559.75

Service Code	MSDRG 593
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,559.75
Rate for Payer: UnitedHealthcare Medicaid	$5,559.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN ULCERS WITH MCC

Facility

$9,054.45

Service Code	MSDRG 592
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,054.45
Rate for Payer: UnitedHealthcare Medicaid	$9,054.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SKIN ULCERS WITHOUT CC/MCC

Facility

$4,066.56

Service Code	MSDRG 594
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,066.56
Rate for Payer: UnitedHealthcare Medicaid	$4,066.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

S Lambda Light Chain, Free QST

Facility

$119.00

Service Code	HCPCS 83521
Hospital Charge Code	3553521
Hospital Revenue Code	300
Min. Negotiated Rate	$32.39
Max. Negotiated Rate	$113.05
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$32.39
Rate for Payer: Humana Medicare Advantage	$49.98
Rate for Payer: UnitedHealthcare Commercial	$113.05
Rate for Payer: UnitedHealthcare Medicaid	$47.60
Rate for Payer: WPPA Medicare Advantage	$71.40

S Lambda Light Chain, Free QST

Facility

$119.00

Service Code	HCPCS 83521
Hospital Charge Code	3553521
Hospital Revenue Code	300
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: UnitedHealthcare Commercial	$113.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges