Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

DRSG Tegaderm 4 X 4 Original Frame Style

Facility

$2.50

Hospital Charge Code	3250343
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

DRSG Tegaderm 4 X 4 Original Frame Style

Facility

$2.50

Hospital Charge Code	3250343
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Tegaderm 6 X 8 Original Frame Style

Facility

$5.31

Hospital Charge Code	3250344
Hospital Revenue Code	270
Min. Negotiated Rate	$4.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.78
Rate for Payer: UnitedHealthcare Commercial	$5.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Tegaderm 6 X 8 Original Frame Style

Facility

$5.31

Hospital Charge Code	3250344
Hospital Revenue Code	270
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$5.04
Rate for Payer: Aetna Commercial	$4.78
Rate for Payer: Humana Medicare Advantage	$2.23
Rate for Payer: UnitedHealthcare Commercial	$5.04
Rate for Payer: UnitedHealthcare Medicaid	$2.12
Rate for Payer: WPPA Medicare Advantage	$3.19

DRSG Tegaderm AG 4 X 5

Facility

$33.00

Hospital Charge Code	3256690
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 Tegaderm AG 4 X 5

Facility

$33.00

Hospital Charge Code	3256690
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 Tegaderm Foam 5-1/2 X 5-1/2 Heal Adhesive w/Border

Facility

$17.91

Hospital Charge Code	3251130
Hospital Revenue Code	270
Min. Negotiated Rate	$16.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.12
Rate for Payer: UnitedHealthcare Commercial	$17.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Tegaderm Foam 5-1/2 X 5-1/2 Heal Adhesive w/Border

Facility

$17.91

Hospital Charge Code	3251130
Hospital Revenue Code	270
Min. Negotiated Rate	$7.16
Max. Negotiated Rate	$17.01
Rate for Payer: Aetna Commercial	$16.12
Rate for Payer: Humana Medicare Advantage	$7.52
Rate for Payer: UnitedHealthcare Commercial	$17.01
Rate for Payer: UnitedHealthcare Medicaid	$7.16
Rate for Payer: WPPA Medicare Advantage	$10.75

DRSG Tegaderm W/Pad 3-1/2 X 4

Facility

$3.11

Hospital Charge Code	3250342
Hospital Revenue Code	272
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.80
Rate for Payer: UnitedHealthcare Commercial	$2.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Tegaderm W/Pad 3-1/2 X 4

Facility

$3.11

Hospital Charge Code	3250342
Hospital Revenue Code	272
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$2.95
Rate for Payer: Aetna Commercial	$2.80
Rate for Payer: Humana Medicare Advantage	$1.31
Rate for Payer: UnitedHealthcare Commercial	$2.95
Rate for Payer: UnitedHealthcare Medicaid	$1.24
Rate for Payer: WPPA Medicare Advantage	$1.87

DRSG Telfa 2 X 3

Facility

$3.00

Hospital Charge Code	3254302
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 Telfa 2 X 3

Facility

$3.00

Hospital Charge Code	3254302
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 Telfa 3 X 4

Facility

$2.50

Hospital Charge Code	3254310
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

DRSG Telfa 3 X 4

Facility

$2.50

Hospital Charge Code	3254310
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Telfa 3 X 6

Facility

$3.00

Hospital Charge Code	3254075
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 Telfa 3 X 6

Facility

$3.00

Hospital Charge Code	3254075
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 Telfa 3 X 8

Facility

$2.50

Hospital Charge Code	3254328
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Telfa 3 X 8

Facility

$2.50

Hospital Charge Code	3254328
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

DRSG Telfa Island 2 X 3-3/4

Facility

$2.50

Hospital Charge Code	3251037
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Telfa Island 2 X 3-3/4

Facility

$2.50

Hospital Charge Code	3251037
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

DRSG Telfa Island 4 X 10

Facility

$3.33

Hospital Charge Code	3259818
Hospital Revenue Code	270
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$3.16
Rate for Payer: Aetna Commercial	$3.00
Rate for Payer: Humana Medicare Advantage	$1.40
Rate for Payer: UnitedHealthcare Commercial	$3.16
Rate for Payer: UnitedHealthcare Medicaid	$1.33
Rate for Payer: WPPA Medicare Advantage	$2.00

DRSG Telfa Island 4 X 10

Facility

$3.33

Hospital Charge Code	3259818
Hospital Revenue Code	270
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.00
Rate for Payer: UnitedHealthcare Commercial	$3.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Telfa Island 4 X 5

Facility

$2.50

Hospital Charge Code	3252240
Hospital Revenue Code	270
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Humana Medicare Advantage	$1.05
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: WPPA Medicare Advantage	$1.50

DRSG Telfa Island 4 X 5

Facility

$2.50

Hospital Charge Code	3252240
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: UnitedHealthcare Commercial	$2.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Transparent 4 X 4.75 Compared to Op-Site

Facility

$4.55

Hospital Charge Code	3251506
Hospital Revenue Code	270
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$4.32
Rate for Payer: Aetna Commercial	$4.09
Rate for Payer: Humana Medicare Advantage	$1.91
Rate for Payer: UnitedHealthcare Commercial	$4.32
Rate for Payer: UnitedHealthcare Medicaid	$1.82
Rate for Payer: WPPA Medicare Advantage	$2.73

Know your out-of-pocket cost for care.

All Charges