Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

lidocaine Top Patch 5% film [HMC]

Facility

$28.40

Service Code	NDC 00591352530
Hospital Charge Code	3800937
Hospital Revenue Code	250
Min. Negotiated Rate	$11.36
Max. Negotiated Rate	$26.98
Rate for Payer: Aetna Commercial	$25.56
Rate for Payer: Humana Medicare Advantage	$11.93
Rate for Payer: UnitedHealthcare Commercial	$26.98
Rate for Payer: UnitedHealthcare Medicaid	$11.36
Rate for Payer: WPPA Medicare Advantage	$17.04

Ligasure Lap 5mm Blunt

Facility

$440.00

Hospital Charge Code	3255678
Hospital Revenue Code	270
Min. Negotiated Rate	$176.00
Max. Negotiated Rate	$418.00
Rate for Payer: Aetna Commercial	$396.00
Rate for Payer: Humana Medicare Advantage	$184.80
Rate for Payer: UnitedHealthcare Commercial	$418.00
Rate for Payer: UnitedHealthcare Medicaid	$176.00
Rate for Payer: WPPA Medicare Advantage	$264.00

Ligasure Lap 5mm Blunt

Facility

$440.00

Hospital Charge Code	3255678
Hospital Revenue Code	270
Min. Negotiated Rate	$396.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$396.00
Rate for Payer: UnitedHealthcare Commercial	$418.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ligasure Lap 5mm Maryland Jaw Nano-Coated

Facility

$1,200.00

Hospital Charge Code	3255675
Hospital Revenue Code	270
Min. Negotiated Rate	$1,080.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,080.00
Rate for Payer: UnitedHealthcare Commercial	$1,140.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ligasure Lap 5mm Maryland Jaw Nano-Coated

Facility

$1,200.00

Hospital Charge Code	3255675
Hospital Revenue Code	270
Min. Negotiated Rate	$480.00
Max. Negotiated Rate	$1,140.00
Rate for Payer: Aetna Commercial	$1,080.00
Rate for Payer: Humana Medicare Advantage	$504.00
Rate for Payer: UnitedHealthcare Commercial	$1,140.00
Rate for Payer: UnitedHealthcare Medicaid	$480.00
Rate for Payer: WPPA Medicare Advantage	$720.00

Ligasure Open Small Jaw

Facility

$1,468.04

Hospital Charge Code	3258435
Hospital Revenue Code	270
Min. Negotiated Rate	$587.22
Max. Negotiated Rate	$1,394.64
Rate for Payer: Aetna Commercial	$1,321.24
Rate for Payer: Humana Medicare Advantage	$616.58
Rate for Payer: UnitedHealthcare Commercial	$1,394.64
Rate for Payer: UnitedHealthcare Medicaid	$587.22
Rate for Payer: WPPA Medicare Advantage	$880.82

Ligasure Open Small Jaw

Facility

$1,468.04

Hospital Charge Code	3258435
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,394.64
Rate for Payer: Aetna Commercial	$1,321.24
Rate for Payer: UnitedHealthcare Commercial	$1,394.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ligation Clip Lap 5mm Rotating Shaft

Facility

$419.31

Hospital Charge Code	3258296
Hospital Revenue Code	270
Min. Negotiated Rate	$377.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$377.38
Rate for Payer: UnitedHealthcare Commercial	$398.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ligation Clip Lap 5mm Rotating Shaft

Facility

$419.31

Hospital Charge Code	3258296
Hospital Revenue Code	270
Min. Negotiated Rate	$167.72
Max. Negotiated Rate	$398.34
Rate for Payer: Aetna Commercial	$377.38
Rate for Payer: Humana Medicare Advantage	$176.11
Rate for Payer: UnitedHealthcare Commercial	$398.34
Rate for Payer: UnitedHealthcare Medicaid	$167.72
Rate for Payer: WPPA Medicare Advantage	$251.59

LIGATION CLIP OPEN LARGE

Facility

$337.00

Hospital Charge Code	3258436
Hospital Revenue Code	270
Min. Negotiated Rate	$303.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$303.30
Rate for Payer: UnitedHealthcare Commercial	$320.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LIGATION CLIP OPEN LARGE

Facility

$337.00

Hospital Charge Code	3258436
Hospital Revenue Code	270
Min. Negotiated Rate	$134.80
Max. Negotiated Rate	$320.15
Rate for Payer: Aetna Commercial	$303.30
Rate for Payer: Humana Medicare Advantage	$141.54
Rate for Payer: UnitedHealthcare Commercial	$320.15
Rate for Payer: UnitedHealthcare Medicaid	$134.80
Rate for Payer: WPPA Medicare Advantage	$202.20

LIGATION CLIP OPEN MEDIUM

Facility

$227.29

Hospital Charge Code	3250475
Hospital Revenue Code	278
Min. Negotiated Rate	$90.92
Max. Negotiated Rate	$215.93
Rate for Payer: Aetna Commercial	$204.56
Rate for Payer: Humana Medicare Advantage	$95.46
Rate for Payer: UnitedHealthcare Commercial	$215.93
Rate for Payer: UnitedHealthcare Medicaid	$90.92
Rate for Payer: WPPA Medicare Advantage	$136.37

LIGATION CLIP OPEN MEDIUM

Facility

$227.29

Hospital Charge Code	3250475
Hospital Revenue Code	278
Min. Negotiated Rate	$204.56
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$204.56
Rate for Payer: UnitedHealthcare Commercial	$215.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LIGATION CLIP OPEN SMALL

Facility

$216.27

Hospital Charge Code	3250487
Hospital Revenue Code	278
Min. Negotiated Rate	$86.51
Max. Negotiated Rate	$205.46
Rate for Payer: Aetna Commercial	$194.64
Rate for Payer: Humana Medicare Advantage	$90.83
Rate for Payer: UnitedHealthcare Commercial	$205.46
Rate for Payer: UnitedHealthcare Medicaid	$86.51
Rate for Payer: WPPA Medicare Advantage	$129.76

LIGATION CLIP OPEN SMALL

Facility

$216.27

Hospital Charge Code	3250487
Hospital Revenue Code	278
Min. Negotiated Rate	$194.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$194.64
Rate for Payer: UnitedHealthcare Commercial	$205.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$6,894.09

Service Code	MSDRG 956
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,894.09
Rate for Payer: UnitedHealthcare Medicaid	$6,894.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

linaclotide 145 mcg Cap [HMC]

Facility

$26.64

Service Code	NDC 00456120130
Hospital Charge Code	3800362
Hospital Revenue Code	250
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$25.31
Rate for Payer: Aetna Commercial	$23.98
Rate for Payer: Humana Medicare Advantage	$11.19
Rate for Payer: UnitedHealthcare Commercial	$25.31
Rate for Payer: UnitedHealthcare Medicaid	$10.66
Rate for Payer: WPPA Medicare Advantage	$15.98

linaclotide 145 mcg Cap [HMC]

Facility

$26.64

Service Code	NDC 00456120130
Hospital Charge Code	3800362
Hospital Revenue Code	250
Min. Negotiated Rate	$23.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.98
Rate for Payer: UnitedHealthcare Commercial	$25.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Linear Cutter Lap GIA Stapler 12mm

Facility

$907.00

Hospital Charge Code	3251006
Hospital Revenue Code	270
Min. Negotiated Rate	$816.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$816.30
Rate for Payer: UnitedHealthcare Commercial	$861.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Linear Cutter Lap GIA Stapler 12mm

Facility

$907.00

Hospital Charge Code	3251006
Hospital Revenue Code	270
Min. Negotiated Rate	$362.80
Max. Negotiated Rate	$861.65
Rate for Payer: Aetna Commercial	$816.30
Rate for Payer: Humana Medicare Advantage	$380.94
Rate for Payer: UnitedHealthcare Commercial	$861.65
Rate for Payer: UnitedHealthcare Medicaid	$362.80
Rate for Payer: WPPA Medicare Advantage	$544.20

Linear Cutter Lap GIA Stapler Reloads 30-2.5mm

Facility

$756.00

Hospital Charge Code	3251007
Hospital Revenue Code	270
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$718.20
Rate for Payer: Aetna Commercial	$680.40
Rate for Payer: Humana Medicare Advantage	$317.52
Rate for Payer: UnitedHealthcare Commercial	$718.20
Rate for Payer: UnitedHealthcare Medicaid	$302.40
Rate for Payer: WPPA Medicare Advantage	$453.60

Linear Cutter Lap GIA Stapler Reloads 30-2.5mm

Facility

$756.00

Hospital Charge Code	3251007
Hospital Revenue Code	270
Min. Negotiated Rate	$680.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$680.40
Rate for Payer: UnitedHealthcare Commercial	$718.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Linear Cutter Lap GIA Stapler Reloads 30-3.5mm

Facility

$727.00

Hospital Charge Code	3251008
Hospital Revenue Code	270
Min. Negotiated Rate	$654.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$654.30
Rate for Payer: UnitedHealthcare Commercial	$690.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Linear Cutter Lap GIA Stapler Reloads 30-3.5mm

Facility

$727.00

Hospital Charge Code	3251008
Hospital Revenue Code	270
Min. Negotiated Rate	$290.80
Max. Negotiated Rate	$690.65
Rate for Payer: Aetna Commercial	$654.30
Rate for Payer: Humana Medicare Advantage	$305.34
Rate for Payer: UnitedHealthcare Commercial	$690.65
Rate for Payer: UnitedHealthcare Medicaid	$290.80
Rate for Payer: WPPA Medicare Advantage	$436.20

Linear Cutter Open Proximate Stapler 55-3.81mm

Facility

$347.00

Hospital Charge Code	3251011
Hospital Revenue Code	270
Min. Negotiated Rate	$138.80
Max. Negotiated Rate	$329.65
Rate for Payer: Aetna Commercial	$312.30
Rate for Payer: Humana Medicare Advantage	$145.74
Rate for Payer: UnitedHealthcare Commercial	$329.65
Rate for Payer: UnitedHealthcare Medicaid	$138.80
Rate for Payer: WPPA Medicare Advantage	$208.20

Know your out-of-pocket cost for care.

All Charges