Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

97602 Remove devitalized tissue from wound, non-selective debridement, w/o anesthesia, per session

Facility

$309.00

Service Code	HCPCS 97602
Hospital Charge Code	3290147
Hospital Revenue Code	761
Min. Negotiated Rate	$129.78
Max. Negotiated Rate	$293.55
Rate for Payer: Aetna Commercial	$278.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$200.20
Rate for Payer: Humana Medicare Advantage	$129.78
Rate for Payer: UnitedHealthcare Commercial	$293.55
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$185.40

97602 Remove devitalized tissue from wound, non-selective debridement, w/o anesthesia, per session

Facility

$309.00

Service Code	HCPCS 97602
Hospital Charge Code	3290147
Hospital Revenue Code	761
Min. Negotiated Rate	$278.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$278.10
Rate for Payer: UnitedHealthcare Commercial	$293.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97602 REMOVE DEVITALIZED TISSUE, NON-SELECT W/O ANES, INCL TOP APPL, WND ASMT/SESS ProFee

Facility

$294.00

Service Code	HCPCS 97602
Hospital Charge Code	3950740
Hospital Revenue Code	360
Min. Negotiated Rate	$123.48
Max. Negotiated Rate	$279.30
Rate for Payer: Aetna Commercial	$264.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$200.20
Rate for Payer: Humana Medicare Advantage	$123.48
Rate for Payer: UnitedHealthcare Commercial	$279.30
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$176.40

97602 REMOVE DEVITALIZED TISSUE, NON-SELECT W/O ANES, INCL TOP APPL, WND ASMT/SESS ProFee

Facility

$294.00

Service Code	HCPCS 97602
Hospital Charge Code	3950740
Hospital Revenue Code	360
Min. Negotiated Rate	$264.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$264.60
Rate for Payer: UnitedHealthcare Commercial	$279.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97605 NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM CHARGE

Facility

$344.00

Service Code	HCPCS 97605
Hospital Charge Code	3290020
Hospital Revenue Code	360
Min. Negotiated Rate	$64.86
Max. Negotiated Rate	$326.80
Rate for Payer: Aetna Commercial	$309.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$223.75
Rate for Payer: Humana Medicare Advantage	$144.48
Rate for Payer: UnitedHealthcare Commercial	$326.80
Rate for Payer: UnitedHealthcare Medicaid	$64.86
Rate for Payer: WPPA Medicare Advantage	$206.40

97605 NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM CHARGE

Facility

$344.00

Service Code	HCPCS 97605
Hospital Charge Code	3290020
Hospital Revenue Code	360
Min. Negotiated Rate	$309.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$309.60
Rate for Payer: UnitedHealthcare Commercial	$326.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97605 Negative pressure wound therapy; total wound(s) surface area less than or equal to 50 sq cm

Facility

$361.00

Service Code	HCPCS 97605
Hospital Charge Code	3290020
Hospital Revenue Code	761
Min. Negotiated Rate	$324.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: UnitedHealthcare Commercial	$342.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97605 Negative pressure wound therapy; total wound(s) surface area less than or equal to 50 sq cm

Facility

$361.00

Service Code	HCPCS 97605
Hospital Charge Code	3290020
Hospital Revenue Code	761
Min. Negotiated Rate	$64.86
Max. Negotiated Rate	$342.95
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$223.75
Rate for Payer: Humana Medicare Advantage	$151.62
Rate for Payer: UnitedHealthcare Commercial	$342.95
Rate for Payer: UnitedHealthcare Medicaid	$64.86
Rate for Payer: WPPA Medicare Advantage	$216.60

97605 Neg Press Wound Tx < 50 CM Charges

Facility

$344.00

Service Code	HCPCS 97605
Hospital Charge Code	3157605
Hospital Revenue Code	360
Min. Negotiated Rate	$64.86
Max. Negotiated Rate	$326.80
Rate for Payer: Aetna Commercial	$309.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$223.75
Rate for Payer: Humana Medicare Advantage	$144.48
Rate for Payer: UnitedHealthcare Commercial	$326.80
Rate for Payer: UnitedHealthcare Medicaid	$64.86
Rate for Payer: WPPA Medicare Advantage	$206.40

97605 Neg Press Wound Tx < 50 CM Charges

Facility

$344.00

Service Code	HCPCS 97605
Hospital Charge Code	3157605
Hospital Revenue Code	360
Min. Negotiated Rate	$309.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$309.60
Rate for Payer: UnitedHealthcare Commercial	$326.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97605 WOUND VAC DRSG CHANGE

Facility

$361.00

Service Code	HCPCS 97605
Hospital Charge Code	3290020
Hospital Revenue Code	761
Min. Negotiated Rate	$64.86
Max. Negotiated Rate	$342.95
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$223.75
Rate for Payer: Humana Medicare Advantage	$151.62
Rate for Payer: UnitedHealthcare Commercial	$342.95
Rate for Payer: UnitedHealthcare Medicaid	$64.86
Rate for Payer: WPPA Medicare Advantage	$216.60

97605 WOUND VAC DRSG CHANGE

Facility

$361.00

Service Code	HCPCS 97605
Hospital Charge Code	3290020
Hospital Revenue Code	761
Min. Negotiated Rate	$324.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: UnitedHealthcare Commercial	$342.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97606 NEGATIVE PRESSURE WOUND THERAPY DME >50 SQ CM CHARGE

Facility

$663.00

Service Code	HCPCS 97606
Hospital Charge Code	3270030
Hospital Revenue Code	761
Min. Negotiated Rate	$45.36
Max. Negotiated Rate	$629.85
Rate for Payer: Aetna Commercial	$596.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$331.25
Rate for Payer: Humana Medicare Advantage	$278.46
Rate for Payer: UnitedHealthcare Commercial	$629.85
Rate for Payer: UnitedHealthcare Medicaid	$45.36
Rate for Payer: WPPA Medicare Advantage	$397.80

97606 NEGATIVE PRESSURE WOUND THERAPY DME >50 SQ CM CHARGE

Facility

$663.00

Service Code	HCPCS 97606
Hospital Charge Code	3270030
Hospital Revenue Code	761
Min. Negotiated Rate	$596.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$596.70
Rate for Payer: UnitedHealthcare Commercial	$629.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97606 Negative pressure wound therapy; total wound(s) surface area greater than 50 sq cm

Facility

$663.00

Service Code	HCPCS 97606
Hospital Charge Code	3270030
Hospital Revenue Code	761
Min. Negotiated Rate	$45.36
Max. Negotiated Rate	$629.85
Rate for Payer: Aetna Commercial	$596.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$331.25
Rate for Payer: Humana Medicare Advantage	$278.46
Rate for Payer: UnitedHealthcare Commercial	$629.85
Rate for Payer: UnitedHealthcare Medicaid	$45.36
Rate for Payer: WPPA Medicare Advantage	$397.80

97606 Negative pressure wound therapy; total wound(s) surface area greater than 50 sq cm

Facility

$663.00

Service Code	HCPCS 97606
Hospital Charge Code	3270030
Hospital Revenue Code	761
Min. Negotiated Rate	$596.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$596.70
Rate for Payer: UnitedHealthcare Commercial	$629.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97606 Neg Press Wound Tx > 50 CM Charges

Facility

$663.00

Service Code	HCPCS 97606
Hospital Charge Code	3299991
Hospital Revenue Code	360
Min. Negotiated Rate	$45.36
Max. Negotiated Rate	$629.85
Rate for Payer: Aetna Commercial	$596.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$331.25
Rate for Payer: Humana Medicare Advantage	$278.46
Rate for Payer: UnitedHealthcare Commercial	$629.85
Rate for Payer: UnitedHealthcare Medicaid	$45.36
Rate for Payer: WPPA Medicare Advantage	$397.80

97606 Neg Press Wound Tx > 50 CM Charges

Facility

$663.00

Service Code	HCPCS 97606
Hospital Charge Code	3299991
Hospital Revenue Code	360
Min. Negotiated Rate	$596.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$596.70
Rate for Payer: UnitedHealthcare Commercial	$629.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97607 Negative pressure wound therapy, (eg, vacuum assisted draina

Facility

$998.00

Service Code	HCPCS 97607
Hospital Charge Code	3297607
Hospital Revenue Code	761
Min. Negotiated Rate	$129.17
Max. Negotiated Rate	$948.10
Rate for Payer: Aetna Commercial	$898.20
Rate for Payer: Humana Medicare Advantage	$419.16
Rate for Payer: UnitedHealthcare Commercial	$948.10
Rate for Payer: UnitedHealthcare Medicaid	$129.17
Rate for Payer: WPPA Medicare Advantage	$598.80

97607 Negative pressure wound therapy, (eg, vacuum assisted draina

Facility

$998.00

Service Code	HCPCS 97607
Hospital Charge Code	3297607
Hospital Revenue Code	761
Min. Negotiated Rate	$898.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$898.20
Rate for Payer: UnitedHealthcare Commercial	$948.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97608 NEG PRESSURE WOUND THERAPY NON DME </= 50 SQ CM CHARGE

Facility

$486.00

Service Code	HCPCS 97608
Hospital Charge Code	3297608
Hospital Revenue Code	360
Min. Negotiated Rate	$437.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$437.40
Rate for Payer: UnitedHealthcare Commercial	$461.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97608 NEG PRESSURE WOUND THERAPY NON DME </= 50 SQ CM CHARGE

Facility

$486.00

Service Code	HCPCS 97608
Hospital Charge Code	3297608
Hospital Revenue Code	360
Min. Negotiated Rate	$45.36
Max. Negotiated Rate	$461.70
Rate for Payer: Aetna Commercial	$437.40
Rate for Payer: Humana Medicare Advantage	$204.12
Rate for Payer: UnitedHealthcare Commercial	$461.70
Rate for Payer: UnitedHealthcare Medicaid	$45.36
Rate for Payer: WPPA Medicare Advantage	$291.60

97802 MEDICAL NUTRITION THERAPY INITIAL 15 MIN CHARGE

Facility

$54.00

Service Code	HCPCS 97802
Hospital Charge Code	3350305
Hospital Revenue Code	942
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97802 MEDICAL NUTRITION THERAPY INITIAL 15 MIN CHARGE

Facility

$54.00

Service Code	HCPCS 97802
Hospital Charge Code	3350305
Hospital Revenue Code	942
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$48.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$14.70
Rate for Payer: Humana Medicare Advantage	$22.68
Rate for Payer: UnitedHealthcare Commercial	$51.30
Rate for Payer: UnitedHealthcare Medicaid	$21.60
Rate for Payer: WPPA Medicare Advantage	$32.40

97803 MNT RE ASSESS EA 15 MIN CHARGE

Facility

$56.00

Service Code	HCPCS 97803
Hospital Charge Code	3350310
Hospital Revenue Code	942
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges