Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Trocar 12mm x 150mm VersaOne Optical w/Fixation Cannula - Covidien

Facility

$97.00

Hospital Charge Code	3258224
Hospital Revenue Code	270
Min. Negotiated Rate	$87.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Trocar 12mm x 150mm VersaOne Optical w/Fixation Cannula - Covidien

Facility

$97.00

Hospital Charge Code	3258224
Hospital Revenue Code	270
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$92.15
Rate for Payer: Aetna Commercial	$87.30
Rate for Payer: Humana Medicare Advantage	$40.74
Rate for Payer: UnitedHealthcare Commercial	$92.15
Rate for Payer: UnitedHealthcare Medicaid	$38.80
Rate for Payer: WPPA Medicare Advantage	$58.20

Trocar 5mm X 100mm Kii Fios Z-Thread Obturator and Sleeve

Facility

$248.00

Hospital Charge Code	3258235
Hospital Revenue Code	270
Min. Negotiated Rate	$99.20
Max. Negotiated Rate	$235.60
Rate for Payer: Aetna Commercial	$223.20
Rate for Payer: Humana Medicare Advantage	$104.16
Rate for Payer: UnitedHealthcare Commercial	$235.60
Rate for Payer: UnitedHealthcare Medicaid	$99.20
Rate for Payer: WPPA Medicare Advantage	$148.80

Trocar 5mm X 100mm Kii Fios Z-Thread Obturator and Sleeve

Facility

$248.00

Hospital Charge Code	3258235
Hospital Revenue Code	270
Min. Negotiated Rate	$223.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$223.20
Rate for Payer: UnitedHealthcare Commercial	$235.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Trocar 5mm x 100mm VersaOne Optical w/Fixation Cannula - Covidien

Facility

$72.00

Hospital Charge Code	3258226
Hospital Revenue Code	270
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Trocar 5mm x 100mm VersaOne Optical w/Fixation Cannula - Covidien

Facility

$72.00

Hospital Charge Code	3258226
Hospital Revenue Code	270
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: Humana Medicare Advantage	$30.24
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$28.80
Rate for Payer: WPPA Medicare Advantage	$43.20

Trocar 5mm x 150mm VersaOne Optical w/Fixation Cannula - Covidien

Facility

$72.00

Hospital Charge Code	3258228
Hospital Revenue Code	270
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: Humana Medicare Advantage	$30.24
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$28.80
Rate for Payer: WPPA Medicare Advantage	$43.20

Trocar 5mm x 150mm VersaOne Optical w/Fixation Cannula - Covidien

Facility

$72.00

Hospital Charge Code	3258228
Hospital Revenue Code	270
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Trocar Cannula 5mm x 100mm VersaOne Universal Fixation Style - Covidien

Facility

$29.43

Hospital Charge Code	3258227
Hospital Revenue Code	270
Min. Negotiated Rate	$26.49
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.49
Rate for Payer: UnitedHealthcare Commercial	$27.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Trocar Cannula 5mm x 100mm VersaOne Universal Fixation Style - Covidien

Facility

$29.43

Hospital Charge Code	3258227
Hospital Revenue Code	270
Min. Negotiated Rate	$11.77
Max. Negotiated Rate	$27.96
Rate for Payer: Aetna Commercial	$26.49
Rate for Payer: Humana Medicare Advantage	$12.36
Rate for Payer: UnitedHealthcare Commercial	$27.96
Rate for Payer: UnitedHealthcare Medicaid	$11.77
Rate for Payer: WPPA Medicare Advantage	$17.66

Trocar Cannula Seal Sleeve 5mm

Facility

$124.00

Hospital Charge Code	3258236
Hospital Revenue Code	270
Min. Negotiated Rate	$49.60
Max. Negotiated Rate	$117.80
Rate for Payer: Aetna Commercial	$111.60
Rate for Payer: Humana Medicare Advantage	$52.08
Rate for Payer: UnitedHealthcare Commercial	$117.80
Rate for Payer: UnitedHealthcare Medicaid	$49.60
Rate for Payer: WPPA Medicare Advantage	$74.40

Trocar Cannula Seal Sleeve 5mm

Facility

$124.00

Hospital Charge Code	3258236
Hospital Revenue Code	270
Min. Negotiated Rate	$111.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$111.60
Rate for Payer: UnitedHealthcare Commercial	$117.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TROCAR CANNULA VALVE 5MM

Facility

$86.00

Hospital Charge Code	3258245
Hospital Revenue Code	270
Min. Negotiated Rate	$77.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$77.40
Rate for Payer: UnitedHealthcare Commercial	$81.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TROCAR CANNULA VALVE 5MM

Facility

$86.00

Hospital Charge Code	3258245
Hospital Revenue Code	270
Min. Negotiated Rate	$34.40
Max. Negotiated Rate	$81.70
Rate for Payer: Aetna Commercial	$77.40
Rate for Payer: Humana Medicare Advantage	$36.12
Rate for Payer: UnitedHealthcare Commercial	$81.70
Rate for Payer: UnitedHealthcare Medicaid	$34.40
Rate for Payer: WPPA Medicare Advantage	$51.60

TROCAR KII BALLOON BLUNT

Facility

$287.00

Hospital Charge Code	3258280
Hospital Revenue Code	270
Min. Negotiated Rate	$258.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$258.30
Rate for Payer: UnitedHealthcare Commercial	$272.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TROCAR KII BALLOON BLUNT

Facility

$287.00

Hospital Charge Code	3258280
Hospital Revenue Code	270
Min. Negotiated Rate	$114.80
Max. Negotiated Rate	$272.65
Rate for Payer: Aetna Commercial	$258.30
Rate for Payer: Humana Medicare Advantage	$120.54
Rate for Payer: UnitedHealthcare Commercial	$272.65
Rate for Payer: UnitedHealthcare Medicaid	$114.80
Rate for Payer: WPPA Medicare Advantage	$172.20

Trocar Kit Spacemaker Blunt Tip with Oval Dissection Balloon

Facility

$971.00

Hospital Charge Code	3258960
Hospital Revenue Code	270
Min. Negotiated Rate	$873.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$873.90
Rate for Payer: UnitedHealthcare Commercial	$922.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Trocar Kit Spacemaker Blunt Tip with Oval Dissection Balloon

Facility

$971.00

Hospital Charge Code	3258960
Hospital Revenue Code	270
Min. Negotiated Rate	$388.40
Max. Negotiated Rate	$922.45
Rate for Payer: Aetna Commercial	$873.90
Rate for Payer: Humana Medicare Advantage	$407.82
Rate for Payer: UnitedHealthcare Commercial	$922.45
Rate for Payer: UnitedHealthcare Medicaid	$388.40
Rate for Payer: WPPA Medicare Advantage	$582.60

Trocar Procedure Valve and Insert Kit

Facility

$140.00

Hospital Charge Code	3258240
Hospital Revenue Code	270
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$133.00
Rate for Payer: Aetna Commercial	$126.00
Rate for Payer: Humana Medicare Advantage	$58.80
Rate for Payer: UnitedHealthcare Commercial	$133.00
Rate for Payer: UnitedHealthcare Medicaid	$56.00
Rate for Payer: WPPA Medicare Advantage	$84.00

Trocar Procedure Valve and Insert Kit

Facility

$140.00

Hospital Charge Code	3258240
Hospital Revenue Code	270
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$126.00
Rate for Payer: UnitedHealthcare Commercial	$133.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TROCAR VALVE/REDUCER 5-12

Facility

$92.72

Hospital Charge Code	3258242
Hospital Revenue Code	270
Min. Negotiated Rate	$83.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$83.45
Rate for Payer: UnitedHealthcare Commercial	$88.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

TROCAR VALVE/REDUCER 5-12

Facility

$92.72

Hospital Charge Code	3258242
Hospital Revenue Code	270
Min. Negotiated Rate	$37.09
Max. Negotiated Rate	$88.08
Rate for Payer: Aetna Commercial	$83.45
Rate for Payer: Humana Medicare Advantage	$38.94
Rate for Payer: UnitedHealthcare Commercial	$88.08
Rate for Payer: UnitedHealthcare Medicaid	$37.09
Rate for Payer: WPPA Medicare Advantage	$55.63

Trocar XCEL 12mm Bladeless

Facility

$335.00

Hospital Charge Code	3258268
Hospital Revenue Code	270
Min. Negotiated Rate	$134.00
Max. Negotiated Rate	$318.25
Rate for Payer: Aetna Commercial	$301.50
Rate for Payer: Humana Medicare Advantage	$140.70
Rate for Payer: UnitedHealthcare Commercial	$318.25
Rate for Payer: UnitedHealthcare Medicaid	$134.00
Rate for Payer: WPPA Medicare Advantage	$201.00

Trocar XCEL 12mm Bladeless

Facility

$335.00

Hospital Charge Code	3258268
Hospital Revenue Code	270
Min. Negotiated Rate	$301.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$301.50
Rate for Payer: UnitedHealthcare Commercial	$318.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Trocar XCEL 5mm Bladeless X-Long 150mm Length Single Patient Use

Facility

$210.00

Hospital Charge Code	3258267
Hospital Revenue Code	270
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$199.50
Rate for Payer: Aetna Commercial	$189.00
Rate for Payer: Humana Medicare Advantage	$88.20
Rate for Payer: UnitedHealthcare Commercial	$199.50
Rate for Payer: UnitedHealthcare Medicaid	$84.00
Rate for Payer: WPPA Medicare Advantage	$126.00

Know your out-of-pocket cost for care.

All Charges