Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

DRSG Allevyn Life Sacrum Small

Facility

$24.93

Hospital Charge Code	3256727
Hospital Revenue Code	270
Min. Negotiated Rate	$9.97
Max. Negotiated Rate	$23.68
Rate for Payer: Aetna Commercial	$22.44
Rate for Payer: Humana Medicare Advantage	$10.47
Rate for Payer: UnitedHealthcare Commercial	$23.68
Rate for Payer: UnitedHealthcare Medicaid	$9.97
Rate for Payer: WPPA Medicare Advantage	$14.96

DRSG Allevyn Life Sacrum Small

Facility

$24.93

Hospital Charge Code	3256727
Hospital Revenue Code	270
Min. Negotiated Rate	$22.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.44
Rate for Payer: UnitedHealthcare Commercial	$23.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Aquacel AG Extra 4 X 5

Facility

$33.84

Hospital Charge Code	3256984
Hospital Revenue Code	270
Min. Negotiated Rate	$30.46
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.46
Rate for Payer: UnitedHealthcare Commercial	$32.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Aquacel AG Extra 4 X 5

Facility

$33.84

Hospital Charge Code	3256984
Hospital Revenue Code	270
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$32.15
Rate for Payer: Aetna Commercial	$30.46
Rate for Payer: Humana Medicare Advantage	$14.21
Rate for Payer: UnitedHealthcare Commercial	$32.15
Rate for Payer: UnitedHealthcare Medicaid	$13.54
Rate for Payer: WPPA Medicare Advantage	$20.30

DRSG Aquacel AG Extra 6 X 6

Facility

$78.62

Hospital Charge Code	3256983
Hospital Revenue Code	270
Min. Negotiated Rate	$70.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.76
Rate for Payer: UnitedHealthcare Commercial	$74.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Aquacel AG Extra 6 X 6

Facility

$78.62

Hospital Charge Code	3256983
Hospital Revenue Code	270
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$74.69
Rate for Payer: Aetna Commercial	$70.76
Rate for Payer: Humana Medicare Advantage	$33.02
Rate for Payer: UnitedHealthcare Commercial	$74.69
Rate for Payer: UnitedHealthcare Medicaid	$31.45
Rate for Payer: WPPA Medicare Advantage	$47.17

DRSG Aquacel AG Extra 8 X 12 Hydrofiber

Facility

$100.28

Hospital Charge Code	3256987
Hospital Revenue Code	270
Min. Negotiated Rate	$90.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: UnitedHealthcare Commercial	$95.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Aquacel AG Extra 8 X 12 Hydrofiber

Facility

$100.28

Hospital Charge Code	3256987
Hospital Revenue Code	270
Min. Negotiated Rate	$40.11
Max. Negotiated Rate	$95.27
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Humana Medicare Advantage	$42.12
Rate for Payer: UnitedHealthcare Commercial	$95.27
Rate for Payer: UnitedHealthcare Medicaid	$40.11
Rate for Payer: WPPA Medicare Advantage	$60.17

DRSG Aquacel AG Ribbon 3/4 X 18

Facility

$50.00

Hospital Charge Code	3256980
Hospital Revenue Code	272
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

DRSG Aquacel AG Ribbon 3/4 X 18

Facility

$50.00

Hospital Charge Code	3256980
Hospital Revenue Code	272
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

DRSG Aquacel AG Surgical 3-1/2 X 12

Facility

$117.39

Hospital Charge Code	3256986
Hospital Revenue Code	270
Min. Negotiated Rate	$46.96
Max. Negotiated Rate	$111.52
Rate for Payer: Aetna Commercial	$105.65
Rate for Payer: Humana Medicare Advantage	$49.30
Rate for Payer: UnitedHealthcare Commercial	$111.52
Rate for Payer: UnitedHealthcare Medicaid	$46.96
Rate for Payer: WPPA Medicare Advantage	$70.43

DRSG Aquacel AG Surgical 3-1/2 X 12

Facility

$117.39

Hospital Charge Code	3256986
Hospital Revenue Code	270
Min. Negotiated Rate	$105.65
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$105.65
Rate for Payer: UnitedHealthcare Commercial	$111.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Aquacel Extra 4 X 5 Hydrofiber

Facility

$13.73

Hospital Charge Code	3256982
Hospital Revenue Code	272
Min. Negotiated Rate	$5.49
Max. Negotiated Rate	$13.04
Rate for Payer: Aetna Commercial	$12.36
Rate for Payer: Humana Medicare Advantage	$5.77
Rate for Payer: UnitedHealthcare Commercial	$13.04
Rate for Payer: UnitedHealthcare Medicaid	$5.49
Rate for Payer: WPPA Medicare Advantage	$8.24

DRSG Aquacel Extra 4 X 5 Hydrofiber

Facility

$13.73

Hospital Charge Code	3256982
Hospital Revenue Code	272
Min. Negotiated Rate	$12.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.36
Rate for Payer: UnitedHealthcare Commercial	$13.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Aquacel Ribbon Hydrofiber 3/4 X 18

Facility

$44.00

Hospital Charge Code	3256981
Hospital Revenue Code	270
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$41.80
Rate for Payer: Aetna Commercial	$39.60
Rate for Payer: Humana Medicare Advantage	$18.48
Rate for Payer: UnitedHealthcare Commercial	$41.80
Rate for Payer: UnitedHealthcare Medicaid	$17.60
Rate for Payer: WPPA Medicare Advantage	$26.40

DRSG Aquacel Ribbon Hydrofiber 3/4 X 18

Facility

$44.00

Hospital Charge Code	3256981
Hospital Revenue Code	270
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.60
Rate for Payer: UnitedHealthcare Commercial	$41.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Biopatch Disc Hemostatic W/CHG Chlorahexadine

Facility

$27.72

Hospital Charge Code	3256680
Hospital Revenue Code	270
Min. Negotiated Rate	$11.09
Max. Negotiated Rate	$26.33
Rate for Payer: Aetna Commercial	$24.95
Rate for Payer: Humana Medicare Advantage	$11.64
Rate for Payer: UnitedHealthcare Commercial	$26.33
Rate for Payer: UnitedHealthcare Medicaid	$11.09
Rate for Payer: WPPA Medicare Advantage	$16.63

DRSG Biopatch Disc Hemostatic W/CHG Chlorahexadine

Facility

$27.72

Hospital Charge Code	3256680
Hospital Revenue Code	270
Min. Negotiated Rate	$24.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.95
Rate for Payer: UnitedHealthcare Commercial	$26.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Burn Water-Jel 4 X 4

Facility

$19.94

Hospital Charge Code	3254965
Hospital Revenue Code	270
Min. Negotiated Rate	$17.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.95
Rate for Payer: UnitedHealthcare Commercial	$18.94
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Burn Water-Jel 4 X 4

Facility

$19.94

Hospital Charge Code	3254965
Hospital Revenue Code	270
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$18.94
Rate for Payer: Aetna Commercial	$17.95
Rate for Payer: Humana Medicare Advantage	$8.37
Rate for Payer: UnitedHealthcare Commercial	$18.94
Rate for Payer: UnitedHealthcare Medicaid	$7.98
Rate for Payer: WPPA Medicare Advantage	$11.96

DRSG Calcium Aglinate 4 X 4

Facility

$10.00

Hospital Charge Code	3256990
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

DRSG Calcium Aglinate 4 X 4

Facility

$10.00

Hospital Charge Code	3256990
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

DRSG Calcium Alginate 12 Roll/Rope

Facility

$16.00

Hospital Charge Code	3256985
Hospital Revenue Code	272
Min. Negotiated Rate	$6.40
Max. Negotiated Rate	$15.20
Rate for Payer: Aetna Commercial	$14.40
Rate for Payer: Humana Medicare Advantage	$6.72
Rate for Payer: UnitedHealthcare Commercial	$15.20
Rate for Payer: UnitedHealthcare Medicaid	$6.40
Rate for Payer: WPPA Medicare Advantage	$9.60

DRSG Calcium Alginate 12 Roll/Rope

Facility

$16.00

Hospital Charge Code	3256985
Hospital Revenue Code	272
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$14.40
Rate for Payer: UnitedHealthcare Commercial	$15.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Change Tray Central/Port

Facility

$17.00

Hospital Charge Code	3257495
Hospital Revenue Code	270
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$16.15
Rate for Payer: Aetna Commercial	$15.30
Rate for Payer: Humana Medicare Advantage	$7.14
Rate for Payer: UnitedHealthcare Commercial	$16.15
Rate for Payer: UnitedHealthcare Medicaid	$6.80
Rate for Payer: WPPA Medicare Advantage	$10.20

Know your out-of-pocket cost for care.

All Charges