Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Wound Cleanser Anasept 8oz Spray Bottle

Facility

$72.68

Hospital Charge Code	3259501
Hospital Revenue Code	270
Min. Negotiated Rate	$29.07
Max. Negotiated Rate	$69.05
Rate for Payer: Aetna Commercial	$65.41
Rate for Payer: Humana Medicare Advantage	$30.53
Rate for Payer: UnitedHealthcare Commercial	$69.05
Rate for Payer: UnitedHealthcare Medicaid	$29.07
Rate for Payer: WPPA Medicare Advantage	$43.61

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$9,340.38

Service Code	MSDRG 464
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,340.38
Rate for Payer: UnitedHealthcare Medicaid	$9,340.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$21,571.83

Service Code	MSDRG 463
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$21,571.83
Rate for Payer: UnitedHealthcare Medicaid	$21,571.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$6,894.09

Service Code	MSDRG 465
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,894.09
Rate for Payer: UnitedHealthcare Medicaid	$6,894.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Wound Debridement Pad Debrisoft 4 x4

Facility

$50.00

Hospital Charge Code	3259505
Hospital Revenue Code	270
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Wound Debridement Pad Debrisoft 4 x4

Facility

$50.00

Hospital Charge Code	3259505
Hospital Revenue Code	270
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$47.50
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: Humana Medicare Advantage	$21.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: UnitedHealthcare Medicaid	$20.00
Rate for Payer: WPPA Medicare Advantage	$30.00

WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$6,703.47

Service Code	MSDRG 902
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,703.47
Rate for Payer: UnitedHealthcare Medicaid	$6,703.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00

WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$14,709.51

Service Code	MSDRG 901
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$14,709.51
Rate for Payer: UnitedHealthcare Medicaid	$14,709.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$4,098.33

Service Code	MSDRG 903
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,098.33
Rate for Payer: UnitedHealthcare Medicaid	$4,098.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Wound Drainage Pouch 3 x 4.3

Facility

$10.00

Hospital Charge Code	3252235
Hospital Revenue Code	270
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$9.50
Rate for Payer: Aetna Commercial	$9.00
Rate for Payer: Humana Medicare Advantage	$4.20
Rate for Payer: UnitedHealthcare Commercial	$9.50
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: WPPA Medicare Advantage	$6.00

Wound Drainage Pouch 3 x 4.3

Facility

$10.00

Hospital Charge Code	3252235
Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.00
Rate for Payer: UnitedHealthcare Commercial	$9.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Wound Gel Anasept 3oz Tube

Facility

$89.84

Hospital Charge Code	3259503
Hospital Revenue Code	270
Min. Negotiated Rate	$80.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$80.86
Rate for Payer: UnitedHealthcare Commercial	$85.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Wound Gel Anasept 3oz Tube

Facility

$89.84

Hospital Charge Code	3259503
Hospital Revenue Code	270
Min. Negotiated Rate	$35.94
Max. Negotiated Rate	$85.35
Rate for Payer: Aetna Commercial	$80.86
Rate for Payer: Humana Medicare Advantage	$37.73
Rate for Payer: UnitedHealthcare Commercial	$85.35
Rate for Payer: UnitedHealthcare Medicaid	$35.94
Rate for Payer: WPPA Medicare Advantage	$53.90

Wound Ostomy Wafer Barrier 4 OD for use with 839261

Facility

$3.00

Hospital Charge Code	3252236
Hospital Revenue Code	270
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Wound Ostomy Wafer Barrier 4 OD for use with 839261

Facility

$3.00

Hospital Charge Code	3252236
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Humana Medicare Advantage	$1.26
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: WPPA Medicare Advantage	$1.80

Wound Vac Canister Prevena Plus 150mL

Facility

$98.00

Hospital Charge Code	3250320
Hospital Revenue Code	270
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$93.10
Rate for Payer: Aetna Commercial	$88.20
Rate for Payer: Humana Medicare Advantage	$41.16
Rate for Payer: UnitedHealthcare Commercial	$93.10
Rate for Payer: UnitedHealthcare Medicaid	$39.20
Rate for Payer: WPPA Medicare Advantage	$58.80

Wound Vac Canister Prevena Plus 150mL

Facility

$98.00

Hospital Charge Code	3250320
Hospital Revenue Code	270
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$88.20
Rate for Payer: UnitedHealthcare Commercial	$93.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

WOUND VAC CANISTER W/GEL INFO-VAC

Facility

$131.00

Hospital Charge Code	3250304
Hospital Revenue Code	270
Min. Negotiated Rate	$117.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$117.90
Rate for Payer: UnitedHealthcare Commercial	$124.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

WOUND VAC CANISTER W/GEL INFO-VAC

Facility

$131.00

Hospital Charge Code	3250304
Hospital Revenue Code	270
Min. Negotiated Rate	$52.40
Max. Negotiated Rate	$124.45
Rate for Payer: Aetna Commercial	$117.90
Rate for Payer: Humana Medicare Advantage	$55.02
Rate for Payer: UnitedHealthcare Commercial	$124.45
Rate for Payer: UnitedHealthcare Medicaid	$52.40
Rate for Payer: WPPA Medicare Advantage	$78.60

WOUND VAC PUMP DAILY CHARGE

Facility

$205.00

Hospital Charge Code	3250300
Hospital Revenue Code	272
Min. Negotiated Rate	$82.00
Max. Negotiated Rate	$194.75
Rate for Payer: Aetna Commercial	$184.50
Rate for Payer: Humana Medicare Advantage	$86.10
Rate for Payer: UnitedHealthcare Commercial	$194.75
Rate for Payer: UnitedHealthcare Medicaid	$82.00
Rate for Payer: WPPA Medicare Advantage	$123.00

WOUND VAC PUMP DAILY CHARGE

Facility

$205.00

Hospital Charge Code	3250300
Hospital Revenue Code	272
Min. Negotiated Rate	$184.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$184.50
Rate for Payer: UnitedHealthcare Commercial	$194.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Abdomen 2 Views

Facility

$336.00

Service Code	HCPCS 74019 TC
Hospital Charge Code	3774019
Hospital Revenue Code	320
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Abdomen 2 Views

Facility

$336.00

Service Code	HCPCS 74019 TC
Hospital Charge Code	3774019
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$319.20
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$100.35
Rate for Payer: Humana Medicare Advantage	$141.12
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$201.60

XR Abdomen KUB 1 View

Facility

$298.00

Service Code	HCPCS 74018
Hospital Charge Code	3774018
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$134.73
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$73.85
Rate for Payer: WPPA Medicare Advantage	$178.80

XR Abdomen KUB 1 View

Facility

$298.00

Service Code	HCPCS 74018 TC
Hospital Charge Code	3774018
Hospital Revenue Code	320
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges