Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

DRSG Change Tray Central/Port

Facility

$17.00

Hospital Charge Code	3257495
Hospital Revenue Code	270
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.30
Rate for Payer: UnitedHealthcare Commercial	$16.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Change Tray Sensitive Skin Central/Port

Facility

$9.00

Hospital Charge Code	3257480
Hospital Revenue Code	270
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Change Tray Sensitive Skin Central/Port

Facility

$9.00

Hospital Charge Code	3257480
Hospital Revenue Code	270
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$8.55
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: Humana Medicare Advantage	$3.78
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: WPPA Medicare Advantage	$5.40

DRSG COPA Hydrophilic Foam Plus 4 X 4 Non-Adhesive without Border

Facility

$7.00

Hospital Charge Code	3259509
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 COPA Hydrophilic Foam Plus 4 X 4 Non-Adhesive without Border

Facility

$7.00

Hospital Charge Code	3259509
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 Cutimed 3 X 3 Siltec Sorbact

Facility

$25.43

Hospital Charge Code	3256710
Hospital Revenue Code	270
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$24.16
Rate for Payer: Aetna Commercial	$22.89
Rate for Payer: Humana Medicare Advantage	$10.68
Rate for Payer: UnitedHealthcare Commercial	$24.16
Rate for Payer: UnitedHealthcare Medicaid	$10.17
Rate for Payer: WPPA Medicare Advantage	$15.26

DRSG Cutimed 3 X 3 Siltec Sorbact

Facility

$25.43

Hospital Charge Code	3256710
Hospital Revenue Code	270
Min. Negotiated Rate	$22.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.89
Rate for Payer: UnitedHealthcare Commercial	$24.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Cutimed 4 X 4 Sorbion Sorbact

Facility

$28.89

Hospital Charge Code	3256705
Hospital Revenue Code	270
Min. Negotiated Rate	$11.56
Max. Negotiated Rate	$27.45
Rate for Payer: Aetna Commercial	$26.00
Rate for Payer: Humana Medicare Advantage	$12.13
Rate for Payer: UnitedHealthcare Commercial	$27.45
Rate for Payer: UnitedHealthcare Medicaid	$11.56
Rate for Payer: WPPA Medicare Advantage	$17.33

DRSG Cutimed 4 X 4 Sorbion Sorbact

Facility

$28.89

Hospital Charge Code	3256705
Hospital Revenue Code	270
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.00
Rate for Payer: UnitedHealthcare Commercial	$27.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Cutimed 5 X 5 Siltec Sorbact

Facility

$45.59

Hospital Charge Code	3256715
Hospital Revenue Code	270
Min. Negotiated Rate	$18.24
Max. Negotiated Rate	$43.31
Rate for Payer: Aetna Commercial	$41.03
Rate for Payer: Humana Medicare Advantage	$19.15
Rate for Payer: UnitedHealthcare Commercial	$43.31
Rate for Payer: UnitedHealthcare Medicaid	$18.24
Rate for Payer: WPPA Medicare Advantage	$27.35

DRSG Cutimed 5 X 5 Siltec Sorbact

Facility

$45.59

Hospital Charge Code	3256715
Hospital Revenue Code	270
Min. Negotiated Rate	$41.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.03
Rate for Payer: UnitedHealthcare Commercial	$43.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Cutimed Sorbact Gel 3 X 6

Facility

$33.00

Hospital Charge Code	3259335
Hospital Revenue Code	270
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$31.35
Rate for Payer: Aetna Commercial	$29.70
Rate for Payer: Humana Medicare Advantage	$13.86
Rate for Payer: UnitedHealthcare Commercial	$31.35
Rate for Payer: UnitedHealthcare Medicaid	$13.20
Rate for Payer: WPPA Medicare Advantage	$19.80

DRSG Cutimed Sorbact Gel 3 X 6

Facility

$33.00

Hospital Charge Code	3259335
Hospital Revenue Code	270
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$29.70
Rate for Payer: UnitedHealthcare Commercial	$31.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Duoderm CGF 4 X 4

Facility

$6.12

Hospital Charge Code	3253407
Hospital Revenue Code	270
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.51
Rate for Payer: UnitedHealthcare Commercial	$5.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Duoderm CGF 4 X 4

Facility

$6.12

Hospital Charge Code	3253407
Hospital Revenue Code	270
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$5.81
Rate for Payer: Aetna Commercial	$5.51
Rate for Payer: Humana Medicare Advantage	$2.57
Rate for Payer: UnitedHealthcare Commercial	$5.81
Rate for Payer: UnitedHealthcare Medicaid	$2.45
Rate for Payer: WPPA Medicare Advantage	$3.67

DRSG Duoderm CGF 6 X 6

Facility

$25.00

Hospital Charge Code	3253409
Hospital Revenue Code	270
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$23.75
Rate for Payer: Aetna Commercial	$22.50
Rate for Payer: Humana Medicare Advantage	$10.50
Rate for Payer: UnitedHealthcare Commercial	$23.75
Rate for Payer: UnitedHealthcare Medicaid	$10.00
Rate for Payer: WPPA Medicare Advantage	$15.00

DRSG Duoderm CGF 6 X 6

Facility

$25.00

Hospital Charge Code	3253409
Hospital Revenue Code	270
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$22.50
Rate for Payer: UnitedHealthcare Commercial	$23.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Duoderm Extra Thin 4 X 4

Facility

$4.82

Hospital Charge Code	3256456
Hospital Revenue Code	270
Min. Negotiated Rate	$4.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.34
Rate for Payer: UnitedHealthcare Commercial	$4.58
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Duoderm Extra Thin 4 X 4

Facility

$4.82

Hospital Charge Code	3256456
Hospital Revenue Code	270
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$4.58
Rate for Payer: Aetna Commercial	$4.34
Rate for Payer: Humana Medicare Advantage	$2.02
Rate for Payer: UnitedHealthcare Commercial	$4.58
Rate for Payer: UnitedHealthcare Medicaid	$1.93
Rate for Payer: WPPA Medicare Advantage	$2.89

DRSG Endoform 2x2 Collagen Non-Fenestrated Dressing

Facility

$60.00

Hospital Charge Code	3253930
Hospital Revenue Code	270
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: Humana Medicare Advantage	$25.20
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: UnitedHealthcare Medicaid	$24.00
Rate for Payer: WPPA Medicare Advantage	$36.00

DRSG Endoform 2x2 Collagen Non-Fenestrated Dressing

Facility

$60.00

Hospital Charge Code	3253930
Hospital Revenue Code	270
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: UnitedHealthcare Commercial	$57.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Gelling Fiber Wound Dressing 4 X 5 Opticell AG+ Silver

Facility

$30.38

Hospital Charge Code	CDM
Hospital Revenue Code	270
Min. Negotiated Rate	$12.15
Max. Negotiated Rate	$28.86
Rate for Payer: Aetna Commercial	$27.34
Rate for Payer: Humana Medicare Advantage	$12.76
Rate for Payer: UnitedHealthcare Commercial	$28.86
Rate for Payer: UnitedHealthcare Medicaid	$12.15
Rate for Payer: WPPA Medicare Advantage	$18.23

DRSG Gelling Fiber Wound Dressing 4 X 5 Opticell AG+ Silver

Facility

$30.38

Hospital Charge Code	CDM
Hospital Revenue Code	270
Min. Negotiated Rate	$27.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.34
Rate for Payer: UnitedHealthcare Commercial	$28.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Hydrofera Blue Classic Borderless 4x4

Facility

$30.00

Hospital Charge Code	3259508
Hospital Revenue Code	270
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$28.50
Rate for Payer: Aetna Commercial	$27.00
Rate for Payer: Humana Medicare Advantage	$12.60
Rate for Payer: UnitedHealthcare Commercial	$28.50
Rate for Payer: UnitedHealthcare Medicaid	$12.00
Rate for Payer: WPPA Medicare Advantage	$18.00

DRSG Hydrofera Blue Classic Borderless 4x4

Facility

$30.00

Hospital Charge Code	3259508
Hospital Revenue Code	270
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.00
Rate for Payer: UnitedHealthcare Commercial	$28.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges