Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Drain with Trocar, Silicone Channel, Round Hubless, Full-Fluted, Radiopaque,19FR

Facility

$68.36

Hospital Charge Code	3257341
Hospital Revenue Code	270
Min. Negotiated Rate	$61.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$61.52
Rate for Payer: UnitedHealthcare Commercial	$64.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drill 2.0mm X 120mm Cannulated AO

Facility

$774.00

Hospital Charge Code	3258379
Hospital Revenue Code	270
Min. Negotiated Rate	$696.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$696.60
Rate for Payer: UnitedHealthcare Commercial	$735.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drill 2.0mm X 120mm Cannulated AO

Facility

$774.00

Hospital Charge Code	3258379
Hospital Revenue Code	270
Min. Negotiated Rate	$309.60
Max. Negotiated Rate	$735.30
Rate for Payer: Aetna Commercial	$696.60
Rate for Payer: Humana Medicare Advantage	$325.08
Rate for Payer: UnitedHealthcare Commercial	$735.30
Rate for Payer: UnitedHealthcare Medicaid	$309.60
Rate for Payer: WPPA Medicare Advantage	$464.40

Drill 2.75mm Cannulated

Facility

$774.00

Hospital Charge Code	3258375
Hospital Revenue Code	270
Min. Negotiated Rate	$309.60
Max. Negotiated Rate	$735.30
Rate for Payer: Aetna Commercial	$696.60
Rate for Payer: Humana Medicare Advantage	$325.08
Rate for Payer: UnitedHealthcare Commercial	$735.30
Rate for Payer: UnitedHealthcare Medicaid	$309.60
Rate for Payer: WPPA Medicare Advantage	$464.40

Drill 2.75mm Cannulated

Facility

$774.00

Hospital Charge Code	3258375
Hospital Revenue Code	270
Min. Negotiated Rate	$696.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$696.60
Rate for Payer: UnitedHealthcare Commercial	$735.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drill AO 2.0 mm Cannulated

Facility

$606.30

Hospital Charge Code	3258574
Hospital Revenue Code	270
Min. Negotiated Rate	$242.52
Max. Negotiated Rate	$575.99
Rate for Payer: Aetna Commercial	$545.67
Rate for Payer: Humana Medicare Advantage	$254.65
Rate for Payer: UnitedHealthcare Commercial	$575.99
Rate for Payer: UnitedHealthcare Medicaid	$242.52
Rate for Payer: WPPA Medicare Advantage	$363.78

Drill AO 2.0 mm Cannulated

Facility

$606.30

Hospital Charge Code	3258574
Hospital Revenue Code	270
Min. Negotiated Rate	$545.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$545.67
Rate for Payer: UnitedHealthcare Commercial	$575.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drill Bit 2.2mm Cannulated

Facility

$835.00

Hospital Charge Code	3258584
Hospital Revenue Code	270
Min. Negotiated Rate	$751.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$751.50
Rate for Payer: UnitedHealthcare Commercial	$793.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drill Bit 2.2mm Cannulated

Facility

$835.00

Hospital Charge Code	3258584
Hospital Revenue Code	270
Min. Negotiated Rate	$334.00
Max. Negotiated Rate	$793.25
Rate for Payer: Aetna Commercial	$751.50
Rate for Payer: Humana Medicare Advantage	$350.70
Rate for Payer: UnitedHealthcare Commercial	$793.25
Rate for Payer: UnitedHealthcare Medicaid	$334.00
Rate for Payer: WPPA Medicare Advantage	$501.00

DRILL BIT 2.5MM

Facility

$315.00

Hospital Charge Code	3258139
Hospital Revenue Code	270
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$283.50
Rate for Payer: UnitedHealthcare Commercial	$299.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRILL BIT 2.5MM

Facility

$315.00

Hospital Charge Code	3258139
Hospital Revenue Code	270
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$299.25
Rate for Payer: Aetna Commercial	$283.50
Rate for Payer: Humana Medicare Advantage	$132.30
Rate for Payer: UnitedHealthcare Commercial	$299.25
Rate for Payer: UnitedHealthcare Medicaid	$126.00
Rate for Payer: WPPA Medicare Advantage	$189.00

Drill Kit w/ Drill Bit 2.0mm Single Patient Use

Facility

$1,221.00

Hospital Charge Code	3258320
Hospital Revenue Code	270
Min. Negotiated Rate	$1,098.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,098.90
Rate for Payer: UnitedHealthcare Commercial	$1,159.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drill Kit w/ Drill Bit 2.0mm Single Patient Use

Facility

$1,221.00

Hospital Charge Code	3258320
Hospital Revenue Code	270
Min. Negotiated Rate	$488.40
Max. Negotiated Rate	$1,159.95
Rate for Payer: Aetna Commercial	$1,098.90
Rate for Payer: Humana Medicare Advantage	$512.82
Rate for Payer: UnitedHealthcare Commercial	$1,159.95
Rate for Payer: UnitedHealthcare Medicaid	$488.40
Rate for Payer: WPPA Medicare Advantage	$732.60

DRSG Acticoat 4x4

Facility

$42.00

Hospital Charge Code	3256675
Hospital Revenue Code	270
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$39.90
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: Humana Medicare Advantage	$17.64
Rate for Payer: UnitedHealthcare Commercial	$39.90
Rate for Payer: UnitedHealthcare Medicaid	$16.80
Rate for Payer: WPPA Medicare Advantage	$25.20

DRSG Acticoat 4x4

Facility

$42.00

Hospital Charge Code	3256675
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: UnitedHealthcare Commercial	$39.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Adaptic 3 X 16

Facility

$7.00

Hospital Charge Code	3256539
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$6.65
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: Humana Medicare Advantage	$2.94
Rate for Payer: UnitedHealthcare Commercial	$6.65
Rate for Payer: UnitedHealthcare Medicaid	$2.80
Rate for Payer: WPPA Medicare Advantage	$4.20

DRSG Adaptic 3 X 16

Facility

$7.00

Hospital Charge Code	3256539
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: UnitedHealthcare Commercial	$6.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Adaptic 3 X 3

Facility

$3.00

Hospital Charge Code	3256380
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

DRSG Adaptic 3 X 3

Facility

$3.00

Hospital Charge Code	3256380
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

DRSG Adaptic 3 X 8

Facility

$3.00

Hospital Charge Code	3250243
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

DRSG Adaptic 3 X 8

Facility

$3.00

Hospital Charge Code	3250243
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

DRSG Allevyn Life 4 X 4 Foam Size Small

Facility

$14.00

Hospital Charge Code	3256725
Hospital Revenue Code	270
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$13.30
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: Humana Medicare Advantage	$5.88
Rate for Payer: UnitedHealthcare Commercial	$13.30
Rate for Payer: UnitedHealthcare Medicaid	$5.60
Rate for Payer: WPPA Medicare Advantage	$8.40

DRSG Allevyn Life 4 X 4 Foam Size Small

Facility

$14.00

Hospital Charge Code	3256725
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: UnitedHealthcare Commercial	$13.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Allevyn Life 5-1/16 X 5-1/16 Foam Size Medium

Facility

$11.12

Hospital Charge Code	3256720
Hospital Revenue Code	270
Min. Negotiated Rate	$10.01
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.01
Rate for Payer: UnitedHealthcare Commercial	$10.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Allevyn Life 5-1/16 X 5-1/16 Foam Size Medium

Facility

$11.12

Hospital Charge Code	3256720
Hospital Revenue Code	270
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna Commercial	$10.01
Rate for Payer: Humana Medicare Advantage	$4.67
Rate for Payer: UnitedHealthcare Commercial	$10.56
Rate for Payer: UnitedHealthcare Medicaid	$4.45
Rate for Payer: WPPA Medicare Advantage	$6.67

Know your out-of-pocket cost for care.

All Charges