Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Sponge Vaginal Packing 4 x 36 Sterile X-Ray Detectable Gauze

Facility

$3.02

Hospital Charge Code	3253592
Hospital Revenue Code	270
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$2.87
Rate for Payer: Aetna Commercial	$2.72
Rate for Payer: Humana Medicare Advantage	$1.27
Rate for Payer: UnitedHealthcare Commercial	$2.87
Rate for Payer: UnitedHealthcare Medicaid	$1.21
Rate for Payer: WPPA Medicare Advantage	$1.81

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC

Facility

$5,845.68

Service Code	MSDRG 537
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,845.68
Rate for Payer: UnitedHealthcare Medicaid	$5,845.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC

Facility

$4,416.03

Service Code	MSDRG 538
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,416.03
Rate for Payer: UnitedHealthcare Medicaid	$4,416.03
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Standardized Cognitive Eval Charge

Facility

$240.00

Service Code	HCPCS 96125 GN
Hospital Charge Code	4056125
Hospital Revenue Code	440
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: UnitedHealthcare Commercial	$228.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Standardized Cognitive Eval Charge

Facility

$240.00

Service Code	HCPCS 96125 GN
Hospital Charge Code	4056125
Hospital Revenue Code	440
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: Humana Medicare Advantage	$100.80
Rate for Payer: UnitedHealthcare Commercial	$228.00
Rate for Payer: UnitedHealthcare Medicaid	$96.00
Rate for Payer: WPPA Medicare Advantage	$144.00

Staple Nitinol 10 X 10

Facility

$4,507.00

Hospital Charge Code	3258587
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,281.65
Rate for Payer: Aetna Commercial	$4,056.30
Rate for Payer: UnitedHealthcare Commercial	$4,281.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Staple Nitinol 10 X 10

Facility

$4,507.00

Hospital Charge Code	3258587
Hospital Revenue Code	270
Min. Negotiated Rate	$1,802.80
Max. Negotiated Rate	$4,281.65
Rate for Payer: Aetna Commercial	$4,056.30
Rate for Payer: Humana Medicare Advantage	$1,892.94
Rate for Payer: UnitedHealthcare Commercial	$4,281.65
Rate for Payer: UnitedHealthcare Medicaid	$1,802.80
Rate for Payer: WPPA Medicare Advantage	$2,704.20

Staple Orthopedic Fixation XSM w/Spikes Richards Implant for Knee Replc

Facility

$1,287.00

Hospital Charge Code	3251055
Hospital Revenue Code	270
Min. Negotiated Rate	$514.80
Max. Negotiated Rate	$1,222.65
Rate for Payer: Aetna Commercial	$1,158.30
Rate for Payer: Humana Medicare Advantage	$540.54
Rate for Payer: UnitedHealthcare Commercial	$1,222.65
Rate for Payer: UnitedHealthcare Medicaid	$514.80
Rate for Payer: WPPA Medicare Advantage	$772.20

Staple Orthopedic Fixation XSM w/Spikes Richards Implant for Knee Replc

Facility

$1,287.00

Hospital Charge Code	3251055
Hospital Revenue Code	270
Min. Negotiated Rate	$1,158.30
Max. Negotiated Rate	$1,222.65
Rate for Payer: Aetna Commercial	$1,158.30
Rate for Payer: UnitedHealthcare Commercial	$1,222.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Stapler Circular 25mm Curved Intraluminal Proximate Cutter

Facility

$752.00

Hospital Charge Code	3251030
Hospital Revenue Code	270
Min. Negotiated Rate	$676.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$676.80
Rate for Payer: UnitedHealthcare Commercial	$714.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Stapler Circular 25mm Curved Intraluminal Proximate Cutter

Facility

$752.00

Hospital Charge Code	3251030
Hospital Revenue Code	270
Min. Negotiated Rate	$300.80
Max. Negotiated Rate	$714.40
Rate for Payer: Aetna Commercial	$676.80
Rate for Payer: Humana Medicare Advantage	$315.84
Rate for Payer: UnitedHealthcare Commercial	$714.40
Rate for Payer: UnitedHealthcare Medicaid	$300.80
Rate for Payer: WPPA Medicare Advantage	$451.20

Stapler Circular 29mm Curved Intraluminal Proximate Cutter

Facility

$665.00

Hospital Charge Code	3251031
Hospital Revenue Code	270
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$631.75
Rate for Payer: Aetna Commercial	$598.50
Rate for Payer: Humana Medicare Advantage	$279.30
Rate for Payer: UnitedHealthcare Commercial	$631.75
Rate for Payer: UnitedHealthcare Medicaid	$266.00
Rate for Payer: WPPA Medicare Advantage	$399.00

Stapler Circular 29mm Curved Intraluminal Proximate Cutter

Facility

$665.00

Hospital Charge Code	3251031
Hospital Revenue Code	270
Min. Negotiated Rate	$598.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$598.50
Rate for Payer: UnitedHealthcare Commercial	$631.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Stapler Curved Blue Cutter Contour

Facility

$1,181.00

Hospital Charge Code	3251050
Hospital Revenue Code	270
Min. Negotiated Rate	$1,062.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,062.90
Rate for Payer: UnitedHealthcare Commercial	$1,121.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Stapler Curved Blue Cutter Contour

Facility

$1,181.00

Hospital Charge Code	3251050
Hospital Revenue Code	270
Min. Negotiated Rate	$472.40
Max. Negotiated Rate	$1,121.95
Rate for Payer: Aetna Commercial	$1,062.90
Rate for Payer: Humana Medicare Advantage	$496.02
Rate for Payer: UnitedHealthcare Commercial	$1,121.95
Rate for Payer: UnitedHealthcare Medicaid	$472.40
Rate for Payer: WPPA Medicare Advantage	$708.60

Stapler Lap 35mm Powered Articulating 320mm Length Echelon Flex

Facility

$1,143.98

Hospital Charge Code	3251025
Hospital Revenue Code	270
Min. Negotiated Rate	$1,029.58
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,029.58
Rate for Payer: UnitedHealthcare Commercial	$1,086.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Stapler Lap 35mm Powered Articulating 320mm Length Echelon Flex

Facility

$1,143.98

Hospital Charge Code	3251025
Hospital Revenue Code	270
Min. Negotiated Rate	$457.59
Max. Negotiated Rate	$1,086.78
Rate for Payer: Aetna Commercial	$1,029.58
Rate for Payer: Humana Medicare Advantage	$480.47
Rate for Payer: UnitedHealthcare Commercial	$1,086.78
Rate for Payer: UnitedHealthcare Medicaid	$457.59
Rate for Payer: WPPA Medicare Advantage	$686.39

Stapler Lap 45mm Powered Plus Articulating 340mm Length Echelon Flex

Facility

$1,135.43

Hospital Charge Code	3251020
Hospital Revenue Code	270
Min. Negotiated Rate	$454.17
Max. Negotiated Rate	$1,078.66
Rate for Payer: Aetna Commercial	$1,021.89
Rate for Payer: Humana Medicare Advantage	$476.88
Rate for Payer: UnitedHealthcare Commercial	$1,078.66
Rate for Payer: UnitedHealthcare Medicaid	$454.17
Rate for Payer: WPPA Medicare Advantage	$681.26

Stapler Lap 45mm Powered Plus Articulating 340mm Length Echelon Flex

Facility

$1,135.43

Hospital Charge Code	3251020
Hospital Revenue Code	270
Min. Negotiated Rate	$1,021.89
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,021.89
Rate for Payer: UnitedHealthcare Commercial	$1,078.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Stapler Lap 60mm Powered Plus Articulating 340mm Length Echelon Flex

Facility

$1,090.00

Hospital Charge Code	3251015
Hospital Revenue Code	270
Min. Negotiated Rate	$981.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$981.00
Rate for Payer: UnitedHealthcare Commercial	$1,035.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Stapler Lap 60mm Powered Plus Articulating 340mm Length Echelon Flex

Facility

$1,090.00

Hospital Charge Code	3251015
Hospital Revenue Code	270
Min. Negotiated Rate	$436.00
Max. Negotiated Rate	$1,035.50
Rate for Payer: Aetna Commercial	$981.00
Rate for Payer: Humana Medicare Advantage	$457.80
Rate for Payer: UnitedHealthcare Commercial	$1,035.50
Rate for Payer: UnitedHealthcare Medicaid	$436.00
Rate for Payer: WPPA Medicare Advantage	$654.00

Stapler Reload 35mm White Lap Powered Articulating Echelon Flex

Facility

$626.23

Hospital Charge Code	3251026
Hospital Revenue Code	270
Min. Negotiated Rate	$250.49
Max. Negotiated Rate	$594.92
Rate for Payer: Aetna Commercial	$563.61
Rate for Payer: Humana Medicare Advantage	$263.02
Rate for Payer: UnitedHealthcare Commercial	$594.92
Rate for Payer: UnitedHealthcare Medicaid	$250.49
Rate for Payer: WPPA Medicare Advantage	$375.74

Stapler Reload 35mm White Lap Powered Articulating Echelon Flex

Facility

$626.23

Hospital Charge Code	3251026
Hospital Revenue Code	270
Min. Negotiated Rate	$563.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$563.61
Rate for Payer: UnitedHealthcare Commercial	$594.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Stapler Reload 45mm Blue Lap Powered Articulating Echelon Flex

Facility

$735.87

Hospital Charge Code	3251022
Hospital Revenue Code	270
Min. Negotiated Rate	$294.35
Max. Negotiated Rate	$699.08
Rate for Payer: Aetna Commercial	$662.28
Rate for Payer: Humana Medicare Advantage	$309.07
Rate for Payer: UnitedHealthcare Commercial	$699.08
Rate for Payer: UnitedHealthcare Medicaid	$294.35
Rate for Payer: WPPA Medicare Advantage	$441.52

Stapler Reload 45mm Blue Lap Powered Articulating Echelon Flex

Facility

$735.87

Hospital Charge Code	3251022
Hospital Revenue Code	270
Min. Negotiated Rate	$662.28
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$662.28
Rate for Payer: UnitedHealthcare Commercial	$699.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges