Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

DRSG Transparent 4 X 4.75 Compared to Op-Site

Facility

$4.55

Hospital Charge Code	3251506
Hospital Revenue Code	270
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.09
Rate for Payer: UnitedHealthcare Commercial	$4.32
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Unna Boot 4

Facility

$37.67

Hospital Charge Code	3250767
Hospital Revenue Code	270
Min. Negotiated Rate	$15.07
Max. Negotiated Rate	$35.79
Rate for Payer: Aetna Commercial	$33.90
Rate for Payer: Humana Medicare Advantage	$15.82
Rate for Payer: UnitedHealthcare Commercial	$35.79
Rate for Payer: UnitedHealthcare Medicaid	$15.07
Rate for Payer: WPPA Medicare Advantage	$22.60

DRSG Unna Boot 4

Facility

$37.67

Hospital Charge Code	3250767
Hospital Revenue Code	270
Min. Negotiated Rate	$33.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.90
Rate for Payer: UnitedHealthcare Commercial	$35.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG WOUND VAC GRANUFOAM LARGE

Facility

$195.00

Hospital Charge Code	3250308
Hospital Revenue Code	272
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$175.50
Rate for Payer: UnitedHealthcare Commercial	$185.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG WOUND VAC GRANUFOAM LARGE

Facility

$195.00

Hospital Charge Code	3250308
Hospital Revenue Code	272
Min. Negotiated Rate	$78.00
Max. Negotiated Rate	$185.25
Rate for Payer: Aetna Commercial	$175.50
Rate for Payer: Humana Medicare Advantage	$81.90
Rate for Payer: UnitedHealthcare Commercial	$185.25
Rate for Payer: UnitedHealthcare Medicaid	$78.00
Rate for Payer: WPPA Medicare Advantage	$117.00

DRSG WOUND VAC GRANUFOAM MEDIUM

Facility

$150.96

Hospital Charge Code	3250307
Hospital Revenue Code	270
Min. Negotiated Rate	$60.38
Max. Negotiated Rate	$143.41
Rate for Payer: Aetna Commercial	$135.86
Rate for Payer: Humana Medicare Advantage	$63.40
Rate for Payer: UnitedHealthcare Commercial	$143.41
Rate for Payer: UnitedHealthcare Medicaid	$60.38
Rate for Payer: WPPA Medicare Advantage	$90.58

DRSG WOUND VAC GRANUFOAM MEDIUM

Facility

$150.96

Hospital Charge Code	3250307
Hospital Revenue Code	270
Min. Negotiated Rate	$135.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$135.86
Rate for Payer: UnitedHealthcare Commercial	$143.41
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG WOUND VAC GRANUFOAM SMALL

Facility

$114.56

Hospital Charge Code	3250306
Hospital Revenue Code	272
Min. Negotiated Rate	$103.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$103.10
Rate for Payer: UnitedHealthcare Commercial	$108.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG WOUND VAC GRANUFOAM SMALL

Facility

$114.56

Hospital Charge Code	3250306
Hospital Revenue Code	272
Min. Negotiated Rate	$45.82
Max. Negotiated Rate	$108.83
Rate for Payer: Aetna Commercial	$103.10
Rate for Payer: Humana Medicare Advantage	$48.12
Rate for Payer: UnitedHealthcare Commercial	$108.83
Rate for Payer: UnitedHealthcare Medicaid	$45.82
Rate for Payer: WPPA Medicare Advantage	$68.74

DRSG Wound Vac Simplace Medium

Facility

$170.00

Hospital Charge Code	3250312
Hospital Revenue Code	270
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$161.50
Rate for Payer: Aetna Commercial	$153.00
Rate for Payer: Humana Medicare Advantage	$71.40
Rate for Payer: UnitedHealthcare Commercial	$161.50
Rate for Payer: UnitedHealthcare Medicaid	$68.00
Rate for Payer: WPPA Medicare Advantage	$102.00

DRSG Wound Vac Simplace Medium

Facility

$170.00

Hospital Charge Code	3250312
Hospital Revenue Code	270
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$153.00
Rate for Payer: UnitedHealthcare Commercial	$161.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG WOUND VAC SIMPLACE SMALL

Facility

$153.00

Hospital Charge Code	3250313
Hospital Revenue Code	270
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$145.35
Rate for Payer: Aetna Commercial	$137.70
Rate for Payer: Humana Medicare Advantage	$64.26
Rate for Payer: UnitedHealthcare Commercial	$145.35
Rate for Payer: UnitedHealthcare Medicaid	$61.20
Rate for Payer: WPPA Medicare Advantage	$91.80

DRSG WOUND VAC SIMPLACE SMALL

Facility

$153.00

Hospital Charge Code	3250313
Hospital Revenue Code	270
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$137.70
Rate for Payer: UnitedHealthcare Commercial	$145.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Wound Vac Whitefoam Large (Foam Only)

Facility

$51.00

Hospital Charge Code	3250310
Hospital Revenue Code	272
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG Wound Vac Whitefoam Large (Foam Only)

Facility

$51.00

Hospital Charge Code	3250310
Hospital Revenue Code	272
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$48.45
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: Humana Medicare Advantage	$21.42
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: WPPA Medicare Advantage	$30.60

DRSG WOUND VAC WHITEFOAM SMALL (FOAM ONLY)

Facility

$51.00

Hospital Charge Code	3250311
Hospital Revenue Code	272
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DRSG WOUND VAC WHITEFOAM SMALL (FOAM ONLY)

Facility

$51.00

Hospital Charge Code	3250311
Hospital Revenue Code	272
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$48.45
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: Humana Medicare Advantage	$21.42
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: WPPA Medicare Advantage	$30.60

DRSG Xeroform 2 X 2

Facility

$2.50

Hospital Charge Code	3256695
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 Xeroform 2 X 2

Facility

$2.50

Hospital Charge Code	3256695
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 Xeroform 4 X 4

Facility

$3.00

Hospital Charge Code	3254090
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 Xeroform 4 X 4

Facility

$3.00

Hospital Charge Code	3254090
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 Xeroform 5 X 9

Facility

$2.50

Hospital Charge Code	3253544
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 Xeroform 5 X 9

Facility

$2.50

Hospital Charge Code	3253544
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

Drug Induced Sleep Endoscopy (DISE)

Facility

$2,954.00

Service Code	HCPCS 42975
Hospital Charge Code	3152975
Hospital Revenue Code	360
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,806.30
Rate for Payer: Aetna Commercial	$2,658.60
Rate for Payer: UnitedHealthcare Commercial	$2,806.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drug Induced Sleep Endoscopy (DISE)

Facility

$2,954.00

Service Code	HCPCS 42975
Hospital Charge Code	3152975
Hospital Revenue Code	360
Min. Negotiated Rate	$109.28
Max. Negotiated Rate	$2,806.30
Rate for Payer: Aetna Commercial	$2,658.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$190.25
Rate for Payer: Humana Medicare Advantage	$1,240.68
Rate for Payer: UnitedHealthcare Commercial	$2,806.30
Rate for Payer: UnitedHealthcare Medicaid	$109.28
Rate for Payer: WPPA Medicare Advantage	$1,772.40

Know your out-of-pocket cost for care.

All Charges