Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

DRSG Mesalt 3/4 X 3' Roll

Facility

$8.37

Hospital Charge Code	3251420
Hospital Revenue Code	270
Min. Negotiated Rate	$7.53
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.53
Rate for Payer: UnitedHealthcare Commercial	$7.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Nose Tampon Large w/String wo/Airway 8 cm Long x 1.5 cm Thick x 2 cm High Nasal Packing

Facility

$61.70

Hospital Charge Code	3251464
Hospital Revenue Code	270
Min. Negotiated Rate	$55.53
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$55.53
Rate for Payer: UnitedHealthcare Commercial	$58.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Nose Tampon Large w/String wo/Airway 8 cm Long x 1.5 cm Thick x 2 cm High Nasal Packing

Facility

$61.70

Hospital Charge Code	3251464
Hospital Revenue Code	270
Min. Negotiated Rate	$24.68
Max. Negotiated Rate	$58.62
Rate for Payer: Aetna Commercial	$55.53
Rate for Payer: Humana Medicare Advantage	$25.91
Rate for Payer: UnitedHealthcare Commercial	$58.62
Rate for Payer: UnitedHealthcare Medicaid	$24.68
Rate for Payer: WPPA Medicare Advantage	$37.02

DRSG Nose Tampon Small w/String w/Airway 4.5 cm Long x 1.5 cm Thick x 2 cm High Nasal Packing

Facility

$82.76

Hospital Charge Code	3251465
Hospital Revenue Code	270
Min. Negotiated Rate	$33.10
Max. Negotiated Rate	$78.62
Rate for Payer: Aetna Commercial	$74.48
Rate for Payer: Humana Medicare Advantage	$34.76
Rate for Payer: UnitedHealthcare Commercial	$78.62
Rate for Payer: UnitedHealthcare Medicaid	$33.10
Rate for Payer: WPPA Medicare Advantage	$49.66

DRSG Nose Tampon Small w/String w/Airway 4.5 cm Long x 1.5 cm Thick x 2 cm High Nasal Packing

Facility

$82.76

Hospital Charge Code	3251465
Hospital Revenue Code	270
Min. Negotiated Rate	$74.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$74.48
Rate for Payer: UnitedHealthcare Commercial	$78.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Polymem 4 X 4

Facility

$13.37

Hospital Charge Code	3258204
Hospital Revenue Code	270
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$12.70
Rate for Payer: Aetna Commercial	$12.03
Rate for Payer: Humana Medicare Advantage	$5.62
Rate for Payer: UnitedHealthcare Commercial	$12.70
Rate for Payer: UnitedHealthcare Medicaid	$5.35
Rate for Payer: WPPA Medicare Advantage	$8.02

DRSG Polymem 4 X 4

Facility

$13.37

Hospital Charge Code	3258204
Hospital Revenue Code	270
Min. Negotiated Rate	$12.03
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.03
Rate for Payer: UnitedHealthcare Commercial	$12.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Pressure Emergency

Facility

$14.00

Hospital Charge Code	3250340
Hospital Revenue Code	272
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 Pressure Emergency

Facility

$14.00

Hospital Charge Code	3250340
Hospital Revenue Code	272
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 Prisma 4.34

Facility

$36.86

Hospital Charge Code	3253937
Hospital Revenue Code	272
Min. Negotiated Rate	$14.74
Max. Negotiated Rate	$35.02
Rate for Payer: Aetna Commercial	$33.17
Rate for Payer: Humana Medicare Advantage	$15.48
Rate for Payer: UnitedHealthcare Commercial	$35.02
Rate for Payer: UnitedHealthcare Medicaid	$14.74
Rate for Payer: WPPA Medicare Advantage	$22.12

DRSG Prisma 4.34

Facility

$36.86

Hospital Charge Code	3253937
Hospital Revenue Code	272
Min. Negotiated Rate	$33.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.17
Rate for Payer: UnitedHealthcare Commercial	$35.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Puracol Plus Collagen 2 X 2.25

Facility

$23.54

Hospital Charge Code	3259510
Hospital Revenue Code	270
Min. Negotiated Rate	$9.42
Max. Negotiated Rate	$22.36
Rate for Payer: Aetna Commercial	$21.19
Rate for Payer: Humana Medicare Advantage	$9.89
Rate for Payer: UnitedHealthcare Commercial	$22.36
Rate for Payer: UnitedHealthcare Medicaid	$9.42
Rate for Payer: WPPA Medicare Advantage	$14.12

DRSG Puracol Plus Collagen 2 X 2.25

Facility

$23.54

Hospital Charge Code	3259510
Hospital Revenue Code	270
Min. Negotiated Rate	$21.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.19
Rate for Payer: UnitedHealthcare Commercial	$22.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG QuikClot EMS 4 X 4 w/Hemostatic Agent

Facility

$134.00

Hospital Charge Code	3259495
Hospital Revenue Code	270
Min. Negotiated Rate	$53.60
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$53.60
Rate for Payer: WPPA Medicare Advantage	$80.40

DRSG QuikClot EMS 4 X 4 w/Hemostatic Agent

Facility

$134.00

Hospital Charge Code	3259495
Hospital Revenue Code	270
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG QuikClot Z-Folded 3 x 4 yds Hemostatic Dressing with Kaolin Vacuum Packed

Facility

$134.00

Hospital Charge Code	3259496
Hospital Revenue Code	270
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG QuikClot Z-Folded 3 x 4 yds Hemostatic Dressing with Kaolin Vacuum Packed

Facility

$134.00

Hospital Charge Code	3259496
Hospital Revenue Code	270
Min. Negotiated Rate	$53.60
Max. Negotiated Rate	$127.30
Rate for Payer: Aetna Commercial	$120.60
Rate for Payer: Humana Medicare Advantage	$56.28
Rate for Payer: UnitedHealthcare Commercial	$127.30
Rate for Payer: UnitedHealthcare Medicaid	$53.60
Rate for Payer: WPPA Medicare Advantage	$80.40

DRSG Silverlon 10 x 12 Wound Contact Dressing

Facility

$311.00

Hospital Charge Code	3259348
Hospital Revenue Code	270
Min. Negotiated Rate	$124.40
Max. Negotiated Rate	$295.45
Rate for Payer: Aetna Commercial	$279.90
Rate for Payer: Humana Medicare Advantage	$130.62
Rate for Payer: UnitedHealthcare Commercial	$295.45
Rate for Payer: UnitedHealthcare Medicaid	$124.40
Rate for Payer: WPPA Medicare Advantage	$186.60

DRSG Silverlon 10 x 12 Wound Contact Dressing

Facility

$311.00

Hospital Charge Code	3259348
Hospital Revenue Code	270
Min. Negotiated Rate	$279.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$279.90
Rate for Payer: UnitedHealthcare Commercial	$295.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Silverlon 4 x 5 Wound Contact Dressing

Facility

$58.00

Hospital Charge Code	3259344
Hospital Revenue Code	270
Min. Negotiated Rate	$23.20
Max. Negotiated Rate	$55.10
Rate for Payer: Aetna Commercial	$52.20
Rate for Payer: Humana Medicare Advantage	$24.36
Rate for Payer: UnitedHealthcare Commercial	$55.10
Rate for Payer: UnitedHealthcare Medicaid	$23.20
Rate for Payer: WPPA Medicare Advantage	$34.80

DRSG Silverlon 4 x 5 Wound Contact Dressing

Facility

$58.00

Hospital Charge Code	3259344
Hospital Revenue Code	270
Min. Negotiated Rate	$52.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$52.20
Rate for Payer: UnitedHealthcare Commercial	$55.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Sorbaview Ultimate

Facility

$15.30

Hospital Charge Code	3254248
Hospital Revenue Code	272
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$14.54
Rate for Payer: Aetna Commercial	$13.77
Rate for Payer: Humana Medicare Advantage	$6.43
Rate for Payer: UnitedHealthcare Commercial	$14.54
Rate for Payer: UnitedHealthcare Medicaid	$6.12
Rate for Payer: WPPA Medicare Advantage	$9.18

DRSG Sorbaview Ultimate

Facility

$15.30

Hospital Charge Code	3254248
Hospital Revenue Code	272
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.77
Rate for Payer: UnitedHealthcare Commercial	$14.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Surepress/Setopress High Compression 4 x 4 yds Bandage

Facility

$9.32

Hospital Charge Code	3250765
Hospital Revenue Code	270
Min. Negotiated Rate	$3.73
Max. Negotiated Rate	$8.85
Rate for Payer: Aetna Commercial	$8.39
Rate for Payer: Humana Medicare Advantage	$3.91
Rate for Payer: UnitedHealthcare Commercial	$8.85
Rate for Payer: UnitedHealthcare Medicaid	$3.73
Rate for Payer: WPPA Medicare Advantage	$5.59

DRSG Surepress/Setopress High Compression 4 x 4 yds Bandage

Facility

$9.32

Hospital Charge Code	3250765
Hospital Revenue Code	270
Min. Negotiated Rate	$8.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.39
Rate for Payer: UnitedHealthcare Commercial	$8.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges