Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

DRSG Hydrofera Blue READY 4 x 5

Facility

$29.93

Hospital Charge Code	3259507
Hospital Revenue Code	270
Min. Negotiated Rate	$26.94
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.94
Rate for Payer: UnitedHealthcare Commercial	$28.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Hydrofera Blue READY 4 x 5

Facility

$29.93

Hospital Charge Code	3259507
Hospital Revenue Code	270
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$28.43
Rate for Payer: Aetna Commercial	$26.94
Rate for Payer: Humana Medicare Advantage	$12.57
Rate for Payer: UnitedHealthcare Commercial	$28.43
Rate for Payer: UnitedHealthcare Medicaid	$11.97
Rate for Payer: WPPA Medicare Advantage	$17.96

DRSG Iodoflex 4 cm x 6 cm Pad

Facility

$28.22

Hospital Charge Code	3256991
Hospital Revenue Code	270
Min. Negotiated Rate	$11.29
Max. Negotiated Rate	$26.81
Rate for Payer: Aetna Commercial	$25.40
Rate for Payer: Humana Medicare Advantage	$11.85
Rate for Payer: UnitedHealthcare Commercial	$26.81
Rate for Payer: UnitedHealthcare Medicaid	$11.29
Rate for Payer: WPPA Medicare Advantage	$16.93

DRSG Iodoflex 4 cm x 6 cm Pad

Facility

$28.22

Hospital Charge Code	3256991
Hospital Revenue Code	270
Min. Negotiated Rate	$25.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.40
Rate for Payer: UnitedHealthcare Commercial	$26.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Mefix Tape 4

Facility

$36.18

Hospital Charge Code	3258212
Hospital Revenue Code	270
Min. Negotiated Rate	$14.47
Max. Negotiated Rate	$34.37
Rate for Payer: Aetna Commercial	$32.56
Rate for Payer: Humana Medicare Advantage	$15.20
Rate for Payer: UnitedHealthcare Commercial	$34.37
Rate for Payer: UnitedHealthcare Medicaid	$14.47
Rate for Payer: WPPA Medicare Advantage	$21.71

DRSG Mefix Tape 4

Facility

$36.18

Hospital Charge Code	3258212
Hospital Revenue Code	270
Min. Negotiated Rate	$32.56
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$32.56
Rate for Payer: UnitedHealthcare Commercial	$34.37
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Mefix Tape 6

Facility

$56.79

Hospital Charge Code	3251091
Hospital Revenue Code	270
Min. Negotiated Rate	$51.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.11
Rate for Payer: UnitedHealthcare Commercial	$53.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Mefix Tape 6

Facility

$56.79

Hospital Charge Code	3251091
Hospital Revenue Code	270
Min. Negotiated Rate	$22.72
Max. Negotiated Rate	$53.95
Rate for Payer: Aetna Commercial	$51.11
Rate for Payer: Humana Medicare Advantage	$23.85
Rate for Payer: UnitedHealthcare Commercial	$53.95
Rate for Payer: UnitedHealthcare Medicaid	$22.72
Rate for Payer: WPPA Medicare Advantage	$34.07

DRSG Mepilex Border 6 x 8

Facility

$25.92

Hospital Charge Code	3250498
Hospital Revenue Code	270
Min. Negotiated Rate	$10.37
Max. Negotiated Rate	$24.62
Rate for Payer: Aetna Commercial	$23.33
Rate for Payer: Humana Medicare Advantage	$10.89
Rate for Payer: UnitedHealthcare Commercial	$24.62
Rate for Payer: UnitedHealthcare Medicaid	$10.37
Rate for Payer: WPPA Medicare Advantage	$15.55

DRSG Mepilex Border 6 x 8

Facility

$25.92

Hospital Charge Code	3250498
Hospital Revenue Code	270
Min. Negotiated Rate	$23.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.33
Rate for Payer: UnitedHealthcare Commercial	$24.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Mepilex Border Flex 3 X 3

Facility

$9.14

Hospital Charge Code	3250493
Hospital Revenue Code	270
Min. Negotiated Rate	$8.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.23
Rate for Payer: UnitedHealthcare Commercial	$8.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Mepilex Border Flex 3 X 3

Facility

$9.14

Hospital Charge Code	3250493
Hospital Revenue Code	270
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$8.68
Rate for Payer: Aetna Commercial	$8.23
Rate for Payer: Humana Medicare Advantage	$3.84
Rate for Payer: UnitedHealthcare Commercial	$8.68
Rate for Payer: UnitedHealthcare Medicaid	$3.66
Rate for Payer: WPPA Medicare Advantage	$5.48

DRSG Mepilex Border Flex 4 X 4

Facility

$12.42

Hospital Charge Code	3250495
Hospital Revenue Code	272
Min. Negotiated Rate	$4.97
Max. Negotiated Rate	$11.80
Rate for Payer: Aetna Commercial	$11.18
Rate for Payer: Humana Medicare Advantage	$5.22
Rate for Payer: UnitedHealthcare Commercial	$11.80
Rate for Payer: UnitedHealthcare Medicaid	$4.97
Rate for Payer: WPPA Medicare Advantage	$7.45

DRSG Mepilex Border Flex 4 X 4

Facility

$12.42

Hospital Charge Code	3250495
Hospital Revenue Code	272
Min. Negotiated Rate	$11.18
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.18
Rate for Payer: UnitedHealthcare Commercial	$11.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Mepilex Border Flex 6 X 6

Facility

$21.06

Hospital Charge Code	3250494
Hospital Revenue Code	270
Min. Negotiated Rate	$8.42
Max. Negotiated Rate	$20.01
Rate for Payer: Aetna Commercial	$18.95
Rate for Payer: Humana Medicare Advantage	$8.85
Rate for Payer: UnitedHealthcare Commercial	$20.01
Rate for Payer: UnitedHealthcare Medicaid	$8.42
Rate for Payer: WPPA Medicare Advantage	$12.64

DRSG Mepilex Border Flex 6 X 6

Facility

$21.06

Hospital Charge Code	3250494
Hospital Revenue Code	270
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.95
Rate for Payer: UnitedHealthcare Commercial	$20.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Mepilex Border Flex LITE 1.6 X 2

Facility

$6.21

Hospital Charge Code	3250499
Hospital Revenue Code	270
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$5.90
Rate for Payer: Aetna Commercial	$5.59
Rate for Payer: Humana Medicare Advantage	$2.61
Rate for Payer: UnitedHealthcare Commercial	$5.90
Rate for Payer: UnitedHealthcare Medicaid	$2.48
Rate for Payer: WPPA Medicare Advantage	$3.73

DRSG Mepilex Border Flex LITE 1.6 X 2

Facility

$6.21

Hospital Charge Code	3250499
Hospital Revenue Code	270
Min. Negotiated Rate	$5.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.59
Rate for Payer: UnitedHealthcare Commercial	$5.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Mepilex Borderless Lite 6 X 6 Absorbant Thin Foam

Facility

$20.52

Hospital Charge Code	3250496
Hospital Revenue Code	270
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.47
Rate for Payer: UnitedHealthcare Commercial	$19.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Mepilex Borderless Lite 6 X 6 Absorbant Thin Foam

Facility

$20.52

Hospital Charge Code	3250496
Hospital Revenue Code	270
Min. Negotiated Rate	$8.21
Max. Negotiated Rate	$19.49
Rate for Payer: Aetna Commercial	$18.47
Rate for Payer: Humana Medicare Advantage	$8.62
Rate for Payer: UnitedHealthcare Commercial	$19.49
Rate for Payer: UnitedHealthcare Medicaid	$8.21
Rate for Payer: WPPA Medicare Advantage	$12.31

DRSG Mepilex Border Post-Op 4x14 Sterile

Facility

$44.00

Hospital Charge Code	3250497
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 Mepilex Border Post-Op 4x14 Sterile

Facility

$44.00

Hospital Charge Code	3250497
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 Mepitel Ag Contact Layer 4x6

Facility

$63.18

Hospital Charge Code	3251421
Hospital Revenue Code	270
Min. Negotiated Rate	$25.27
Max. Negotiated Rate	$60.02
Rate for Payer: Aetna Commercial	$56.86
Rate for Payer: Humana Medicare Advantage	$26.54
Rate for Payer: UnitedHealthcare Commercial	$60.02
Rate for Payer: UnitedHealthcare Medicaid	$25.27
Rate for Payer: WPPA Medicare Advantage	$37.91

DRSG Mepitel Ag Contact Layer 4x6

Facility

$63.18

Hospital Charge Code	3251421
Hospital Revenue Code	270
Min. Negotiated Rate	$56.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.86
Rate for Payer: UnitedHealthcare Commercial	$60.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Mesalt 3/4 X 3' Roll

Facility

$8.37

Hospital Charge Code	3251420
Hospital Revenue Code	270
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$7.95
Rate for Payer: Aetna Commercial	$7.53
Rate for Payer: Humana Medicare Advantage	$3.52
Rate for Payer: UnitedHealthcare Commercial	$7.95
Rate for Payer: UnitedHealthcare Medicaid	$3.35
Rate for Payer: WPPA Medicare Advantage	$5.02

Know your out-of-pocket cost for care.

All Charges