Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

ibuprofen 40 mg/mL Oral Susp [HMC]

Facility

$22.11

Service Code	NDC 24385055010
Hospital Charge Code	3802195
Hospital Revenue Code	250
Min. Negotiated Rate	$19.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.90
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IgA-

Facility

$78.00

Service Code	HCPCS 82784
Hospital Charge Code	3551933
Hospital Revenue Code	300
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: UnitedHealthcare Commercial	$74.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IgA-

Facility

$78.00

Service Code	HCPCS 82784
Hospital Charge Code	3551933
Hospital Revenue Code	300
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$74.10
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$49.24
Rate for Payer: Humana Medicare Advantage	$32.76
Rate for Payer: UnitedHealthcare Commercial	$74.10
Rate for Payer: UnitedHealthcare Medicaid	$9.30
Rate for Payer: WPPA Medicare Advantage	$46.80

IGF 1, LC/MS QST

Facility

$238.00

Service Code	HCPCS 84305
Hospital Charge Code	3558430
Hospital Revenue Code	300
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$226.10
Rate for Payer: Aetna Commercial	$214.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$120.74
Rate for Payer: Humana Medicare Advantage	$99.96
Rate for Payer: UnitedHealthcare Commercial	$226.10
Rate for Payer: UnitedHealthcare Medicaid	$21.00
Rate for Payer: WPPA Medicare Advantage	$142.80

IGF 1, LC/MS QST

Facility

$238.00

Service Code	HCPCS 84305
Hospital Charge Code	3558430
Hospital Revenue Code	300
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$214.20
Rate for Payer: UnitedHealthcare Commercial	$226.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

imipenem-cilastatin 500 mg-500 mg Pow [HMC]

Facility

$50.00

Service Code	NDC 63323032293
Hospital Charge Code	3809759
Hospital Revenue Code	250
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

imipenem-cilastatin 500 mg-500 mg Pow [HMC]

Facility

$73.96

Service Code	NDC 63323032225
Hospital Charge Code	3809759
Hospital Revenue Code	250
Min. Negotiated Rate	$29.58
Max. Negotiated Rate	$70.26
Rate for Payer: Aetna Commercial	$66.56
Rate for Payer: Humana Medicare Advantage	$31.06
Rate for Payer: UnitedHealthcare Commercial	$70.26
Rate for Payer: UnitedHealthcare Medicaid	$29.58
Rate for Payer: WPPA Medicare Advantage	$44.38

imipenem-cilastatin 500 mg-500 mg Pow [HMC]

Facility

$50.00

Service Code	NDC 63323032293
Hospital Charge Code	3809759
Hospital Revenue Code	250
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$47.50
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: Humana Medicare Advantage	$21.00
Rate for Payer: UnitedHealthcare Commercial	$47.50
Rate for Payer: UnitedHealthcare Medicaid	$20.00
Rate for Payer: WPPA Medicare Advantage	$30.00

imipenem-cilastatin 500 mg-500 mg Pow [HMC]

Facility

$73.96

Service Code	NDC 63323032225
Hospital Charge Code	3809759
Hospital Revenue Code	250
Min. Negotiated Rate	$66.56
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$66.56
Rate for Payer: UnitedHealthcare Commercial	$70.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

immune globulin 10% IV Sol 100 mL [HMC]

Facility

$1,759.88

Service Code	HCPCS J1599
Hospital Charge Code	3800446
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,671.89
Rate for Payer: Aetna Commercial	$1,583.89
Rate for Payer: UnitedHealthcare Commercial	$1,671.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

immune globulin 10% IV Sol 100 mL [HMC]

Facility

$1,759.88

Service Code	HCPCS J1599
Hospital Charge Code	3800446
Hospital Revenue Code	250
Min. Negotiated Rate	$74.48
Max. Negotiated Rate	$1,671.89
Rate for Payer: Aetna Commercial	$1,583.89
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$74.48
Rate for Payer: Humana Medicare Advantage	$739.15
Rate for Payer: UnitedHealthcare Commercial	$1,671.89
Rate for Payer: UnitedHealthcare Medicaid	$107.50
Rate for Payer: WPPA Medicare Advantage	$1,055.93

immune globulin 5% IV Sol 100 mL [HMC]

Facility

$1,942.85

Service Code	HCPCS J1599
Hospital Charge Code	3850298
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,845.71
Rate for Payer: Aetna Commercial	$1,748.57
Rate for Payer: UnitedHealthcare Commercial	$1,845.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

immune globulin 5% IV Sol 100 mL [HMC]

Facility

$1,942.85

Service Code	HCPCS J1599
Hospital Charge Code	3850298
Hospital Revenue Code	250
Min. Negotiated Rate	$74.48
Max. Negotiated Rate	$1,845.71
Rate for Payer: Aetna Commercial	$1,748.57
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$74.48
Rate for Payer: Humana Medicare Advantage	$816.00
Rate for Payer: UnitedHealthcare Commercial	$1,845.71
Rate for Payer: UnitedHealthcare Medicaid	$107.50
Rate for Payer: WPPA Medicare Advantage	$1,165.71

immune globulin 5% IV Sol 200 mL [HMC]

Facility

$3,575.47

Service Code	HCPCS J1599
Hospital Charge Code	3800037
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,396.70
Rate for Payer: Aetna Commercial	$3,217.92
Rate for Payer: UnitedHealthcare Commercial	$3,396.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

immune globulin 5% IV Sol 200 mL [HMC]

Facility

$3,575.47

Service Code	HCPCS J1599
Hospital Charge Code	3800037
Hospital Revenue Code	250
Min. Negotiated Rate	$74.48
Max. Negotiated Rate	$3,396.70
Rate for Payer: Aetna Commercial	$3,217.92
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$74.48
Rate for Payer: Humana Medicare Advantage	$1,501.70
Rate for Payer: UnitedHealthcare Commercial	$3,396.70
Rate for Payer: UnitedHealthcare Medicaid	$107.50
Rate for Payer: WPPA Medicare Advantage	$2,145.28

immune globulin 5% IV Sol 400 mL [HMC]

Facility

$7,711.40

Service Code	HCPCS J1599
Hospital Charge Code	3850290
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,325.83
Rate for Payer: Aetna Commercial	$6,940.26
Rate for Payer: UnitedHealthcare Commercial	$7,325.83
Rate for Payer: WPPA Medicare Advantage	$1,200.00

immune globulin 5% IV Sol 400 mL [HMC]

Facility

$7,711.40

Service Code	HCPCS J1599
Hospital Charge Code	3850290
Hospital Revenue Code	250
Min. Negotiated Rate	$74.48
Max. Negotiated Rate	$7,325.83
Rate for Payer: Aetna Commercial	$6,940.26
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$74.48
Rate for Payer: Humana Medicare Advantage	$3,238.79
Rate for Payer: UnitedHealthcare Commercial	$7,325.83
Rate for Payer: UnitedHealthcare Medicaid	$107.50
Rate for Payer: WPPA Medicare Advantage	$4,626.84

immune globulin intravenous and subcutaneous 10% 100 mL [HMC]

Facility

$1,759.88

Service Code	HCPCS J1561
Hospital Charge Code	3850043
Hospital Revenue Code	250
Min. Negotiated Rate	$49.08
Max. Negotiated Rate	$1,671.89
Rate for Payer: Aetna Commercial	$1,583.89
Rate for Payer: Aetna Commercial	$3,348.44
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$63.59
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$63.59
Rate for Payer: Humana Medicare Advantage	$1,562.61
Rate for Payer: Humana Medicare Advantage	$739.15
Rate for Payer: UnitedHealthcare Commercial	$3,534.47
Rate for Payer: UnitedHealthcare Commercial	$1,671.89
Rate for Payer: UnitedHealthcare Medicaid	$49.08
Rate for Payer: UnitedHealthcare Medicaid	$49.08
Rate for Payer: WPPA Medicare Advantage	$1,055.93
Rate for Payer: WPPA Medicare Advantage	$2,232.29

immune globulin intravenous and subcutaneous 10% 100 mL [HMC]

Facility

$3,720.49

Service Code	HCPCS J1561
Hospital Charge Code	3850043
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,534.47
Rate for Payer: Aetna Commercial	$3,348.44
Rate for Payer: Aetna Commercial	$1,583.89
Rate for Payer: UnitedHealthcare Commercial	$1,671.89
Rate for Payer: UnitedHealthcare Commercial	$3,534.47
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

immune globulin intravenous and subcutaneous 10% 1g Sol [HMC]

Facility

$50.51

Service Code	HCPCS J1561
Hospital Charge Code	3803556
Hospital Revenue Code	636
Min. Negotiated Rate	$21.21
Max. Negotiated Rate	$63.59
Rate for Payer: Aetna Commercial	$45.46
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$63.59
Rate for Payer: Humana Medicare Advantage	$21.21
Rate for Payer: UnitedHealthcare Commercial	$47.98
Rate for Payer: UnitedHealthcare Medicaid	$49.08
Rate for Payer: WPPA Medicare Advantage	$30.31

immune globulin intravenous and subcutaneous 10% 1g Sol [HMC]

Facility

$50.51

Service Code	HCPCS J1561
Hospital Charge Code	3803556
Hospital Revenue Code	636
Min. Negotiated Rate	$45.46
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.46
Rate for Payer: UnitedHealthcare Commercial	$47.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

immune globulin intravenous and subcutaneous 10% 200 mL [HMC]

Facility

$9,868.03

Service Code	HCPCS J1561
Hospital Charge Code	3850047
Hospital Revenue Code	250
Min. Negotiated Rate	$49.08
Max. Negotiated Rate	$9,374.63
Rate for Payer: Aetna Commercial	$8,881.23
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$63.59
Rate for Payer: Humana Medicare Advantage	$4,144.57
Rate for Payer: UnitedHealthcare Commercial	$9,374.63
Rate for Payer: UnitedHealthcare Medicaid	$49.08
Rate for Payer: WPPA Medicare Advantage	$5,920.82

immune globulin intravenous and subcutaneous 10% 200 mL [HMC]

Facility

$9,868.03

Service Code	HCPCS J1561
Hospital Charge Code	3850047
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$9,374.63
Rate for Payer: Aetna Commercial	$8,881.23
Rate for Payer: UnitedHealthcare Commercial	$9,374.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

immune globulin intravenous and subcutaneous 10% [HMC]

Facility

$3,499.76

Service Code	HCPCS J1561
Hospital Charge Code	3800441
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,324.77
Rate for Payer: Aetna Commercial	$3,149.78
Rate for Payer: UnitedHealthcare Commercial	$3,324.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

immune globulin intravenous and subcutaneous 10% [HMC]

Facility

$3,499.76

Service Code	HCPCS J1561
Hospital Charge Code	3800441
Hospital Revenue Code	250
Min. Negotiated Rate	$49.08
Max. Negotiated Rate	$3,324.77
Rate for Payer: Aetna Commercial	$3,149.78
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$63.59
Rate for Payer: Humana Medicare Advantage	$1,469.90
Rate for Payer: UnitedHealthcare Commercial	$3,324.77
Rate for Payer: UnitedHealthcare Medicaid	$49.08
Rate for Payer: WPPA Medicare Advantage	$2,099.86

Know your out-of-pocket cost for care.

All Charges