Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Surgical Patty X-Ray Codman 1/2 X 3 10ea/PK

Facility

$12.20

Hospital Charge Code	3259207
Hospital Revenue Code	270
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.98
Rate for Payer: UnitedHealthcare Commercial	$11.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Surgical Patty X-Ray Codman 1/2 X 3 10ea/PK

Facility

$12.20

Hospital Charge Code	3259207
Hospital Revenue Code	270
Min. Negotiated Rate	$4.88
Max. Negotiated Rate	$11.59
Rate for Payer: Aetna Commercial	$10.98
Rate for Payer: Humana Medicare Advantage	$5.12
Rate for Payer: UnitedHealthcare Commercial	$11.59
Rate for Payer: UnitedHealthcare Medicaid	$4.88
Rate for Payer: WPPA Medicare Advantage	$7.32

Surgifoam AGS SZ 12-7

Facility

$37.00

Hospital Charge Code	3252261
Hospital Revenue Code	270
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.30
Rate for Payer: UnitedHealthcare Commercial	$35.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Surgifoam AGS SZ 12-7

Facility

$37.00

Hospital Charge Code	3252261
Hospital Revenue Code	270
Min. Negotiated Rate	$14.80
Max. Negotiated Rate	$35.15
Rate for Payer: Aetna Commercial	$33.30
Rate for Payer: Humana Medicare Advantage	$15.54
Rate for Payer: UnitedHealthcare Commercial	$35.15
Rate for Payer: UnitedHealthcare Medicaid	$14.80
Rate for Payer: WPPA Medicare Advantage	$22.20

Surgifoam AGS SZ 50

Facility

$103.00

Hospital Charge Code	3252262
Hospital Revenue Code	270
Min. Negotiated Rate	$92.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$92.70
Rate for Payer: UnitedHealthcare Commercial	$97.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Surgifoam AGS SZ 50

Facility

$103.00

Hospital Charge Code	3252262
Hospital Revenue Code	270
Min. Negotiated Rate	$41.20
Max. Negotiated Rate	$97.85
Rate for Payer: Aetna Commercial	$92.70
Rate for Payer: Humana Medicare Advantage	$43.26
Rate for Payer: UnitedHealthcare Commercial	$97.85
Rate for Payer: UnitedHealthcare Medicaid	$41.20
Rate for Payer: WPPA Medicare Advantage	$61.80

Suture 0 Chromic CT-1

Facility

$12.00

Hospital Charge Code	3252561
Hospital Revenue Code	270
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.80
Rate for Payer: UnitedHealthcare Commercial	$11.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture 0 Chromic CT-1

Facility

$12.00

Hospital Charge Code	3252561
Hospital Revenue Code	270
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$11.40
Rate for Payer: Aetna Commercial	$10.80
Rate for Payer: Humana Medicare Advantage	$5.04
Rate for Payer: UnitedHealthcare Commercial	$11.40
Rate for Payer: UnitedHealthcare Medicaid	$4.80
Rate for Payer: WPPA Medicare Advantage	$7.20

Suture 0 Chromic CT-2

Facility

$13.00

Hospital Charge Code	3252538
Hospital Revenue Code	270
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$12.35
Rate for Payer: Aetna Commercial	$11.70
Rate for Payer: Humana Medicare Advantage	$5.46
Rate for Payer: UnitedHealthcare Commercial	$12.35
Rate for Payer: UnitedHealthcare Medicaid	$5.20
Rate for Payer: WPPA Medicare Advantage	$7.80

Suture 0 Chromic CT-2

Facility

$13.00

Hospital Charge Code	3252538
Hospital Revenue Code	270
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.70
Rate for Payer: UnitedHealthcare Commercial	$12.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture 0 Ethibond CT-1

Facility

$7.00

Hospital Charge Code	3258688
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: UnitedHealthcare Commercial	$6.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture 0 Ethibond CT-1

Facility

$7.00

Hospital Charge Code	3258688
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$6.65
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: Humana Medicare Advantage	$2.94
Rate for Payer: UnitedHealthcare Commercial	$6.65
Rate for Payer: UnitedHealthcare Medicaid	$2.80
Rate for Payer: WPPA Medicare Advantage	$4.20

Suture 0 Ethibond CT-2

Facility

$43.00

Hospital Charge Code	3258652
Hospital Revenue Code	270
Min. Negotiated Rate	$17.20
Max. Negotiated Rate	$40.85
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$18.06
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: UnitedHealthcare Medicaid	$17.20
Rate for Payer: WPPA Medicare Advantage	$25.80

Suture 0 Ethibond CT-2

Facility

$43.00

Hospital Charge Code	3258652
Hospital Revenue Code	270
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: UnitedHealthcare Commercial	$40.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture 0 Ethibond MO-6

Facility

$53.00

Hospital Charge Code	3259715
Hospital Revenue Code	270
Min. Negotiated Rate	$21.20
Max. Negotiated Rate	$50.35
Rate for Payer: Aetna Commercial	$47.70
Rate for Payer: Humana Medicare Advantage	$22.26
Rate for Payer: UnitedHealthcare Commercial	$50.35
Rate for Payer: UnitedHealthcare Medicaid	$21.20
Rate for Payer: WPPA Medicare Advantage	$31.80

Suture 0 Ethibond MO-6

Facility

$53.00

Hospital Charge Code	3259715
Hospital Revenue Code	270
Min. Negotiated Rate	$47.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$47.70
Rate for Payer: UnitedHealthcare Commercial	$50.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture 0 Monocryl CT-1

Facility

$8.28

Hospital Charge Code	3258639
Hospital Revenue Code	270
Min. Negotiated Rate	$7.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.45
Rate for Payer: UnitedHealthcare Commercial	$7.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture 0 Monocryl CT-1

Facility

$8.28

Hospital Charge Code	3258639
Hospital Revenue Code	270
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$7.87
Rate for Payer: Aetna Commercial	$7.45
Rate for Payer: Humana Medicare Advantage	$3.48
Rate for Payer: UnitedHealthcare Commercial	$7.87
Rate for Payer: UnitedHealthcare Medicaid	$3.31
Rate for Payer: WPPA Medicare Advantage	$4.97

Suture 0 PDS II CT-1

Facility

$10.00

Hospital Charge Code	3254977
Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.00
Rate for Payer: UnitedHealthcare Commercial	$9.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture 0 PDS II CT-1

Facility

$10.00

Hospital Charge Code	3254977
Hospital Revenue Code	270
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$9.50
Rate for Payer: Aetna Commercial	$9.00
Rate for Payer: Humana Medicare Advantage	$4.20
Rate for Payer: UnitedHealthcare Commercial	$9.50
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: WPPA Medicare Advantage	$6.00

Suture 0 PDS II CT-2

Facility

$11.00

Hospital Charge Code	3254986
Hospital Revenue Code	270
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$10.45
Rate for Payer: Aetna Commercial	$9.90
Rate for Payer: Humana Medicare Advantage	$4.62
Rate for Payer: UnitedHealthcare Commercial	$10.45
Rate for Payer: UnitedHealthcare Medicaid	$4.40
Rate for Payer: WPPA Medicare Advantage	$6.60

Suture 0 PDS II CT-2

Facility

$11.00

Hospital Charge Code	3254986
Hospital Revenue Code	270
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.90
Rate for Payer: UnitedHealthcare Commercial	$10.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture 0 PDS II Endoloop

Facility

$144.27

Hospital Charge Code	3254978
Hospital Revenue Code	270
Min. Negotiated Rate	$57.71
Max. Negotiated Rate	$137.06
Rate for Payer: Aetna Commercial	$129.84
Rate for Payer: Humana Medicare Advantage	$60.59
Rate for Payer: UnitedHealthcare Commercial	$137.06
Rate for Payer: UnitedHealthcare Medicaid	$57.71
Rate for Payer: WPPA Medicare Advantage	$86.56

Suture 0 PDS II Endoloop

Facility

$144.27

Hospital Charge Code	3254978
Hospital Revenue Code	270
Min. Negotiated Rate	$129.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$129.84
Rate for Payer: UnitedHealthcare Commercial	$137.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Suture 0 PDS II TP-1 Looped

Facility

$23.00

Hospital Charge Code	3258686
Hospital Revenue Code	270
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.70
Rate for Payer: UnitedHealthcare Commercial	$21.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges