Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

Facility

$50.51

Service Code	HCPCS J1569
Hospital Charge Code	3803556
Hospital Revenue Code	636
Min. Negotiated Rate	$21.21
Max. Negotiated Rate	$55.60
Rate for Payer: Aetna Commercial	$45.46
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$55.60
Rate for Payer: Humana Medicare Advantage	$21.21
Rate for Payer: UnitedHealthcare Commercial	$47.98
Rate for Payer: UnitedHealthcare Medicaid	$47.29
Rate for Payer: WPPA Medicare Advantage	$30.31

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

Facility

$50.51

Service Code	HCPCS J1569
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% Sol [HMC]

Facility

$454.97

Service Code	HCPCS J1561
Hospital Charge Code	3800442
Hospital Revenue Code	250
Min. Negotiated Rate	$49.08
Max. Negotiated Rate	$432.22
Rate for Payer: Aetna Commercial	$409.47
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$63.59
Rate for Payer: Humana Medicare Advantage	$191.09
Rate for Payer: UnitedHealthcare Commercial	$432.22
Rate for Payer: UnitedHealthcare Medicaid	$49.08
Rate for Payer: WPPA Medicare Advantage	$272.98

immune globulin intravenous and subcutaneous 10% Sol [HMC]

Facility

$454.97

Service Code	HCPCS J1561
Hospital Charge Code	3800442
Hospital Revenue Code	250
Min. Negotiated Rate	$409.47
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$409.47
Rate for Payer: UnitedHealthcare Commercial	$432.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Immunofixation, Serum QST

Facility

$172.00

Service Code	HCPCS 86334
Hospital Charge Code	3556396
Hospital Revenue Code	300
Min. Negotiated Rate	$68.80
Max. Negotiated Rate	$163.40
Rate for Payer: Aetna Commercial	$154.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$97.05
Rate for Payer: Humana Medicare Advantage	$72.24
Rate for Payer: UnitedHealthcare Commercial	$163.40
Rate for Payer: UnitedHealthcare Medicaid	$68.80
Rate for Payer: WPPA Medicare Advantage	$103.20

Immunofixation, Serum QST

Facility

$172.00

Service Code	HCPCS 86334
Hospital Charge Code	3556396
Hospital Revenue Code	300
Min. Negotiated Rate	$154.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$154.80
Rate for Payer: UnitedHealthcare Commercial	$163.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Immunofixation, Urine QST

Facility

$183.00

Service Code	HCPCS 86335
Hospital Charge Code	3556397
Hospital Revenue Code	300
Min. Negotiated Rate	$29.35
Max. Negotiated Rate	$173.85
Rate for Payer: Aetna Commercial	$164.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$64.18
Rate for Payer: Humana Medicare Advantage	$76.86
Rate for Payer: UnitedHealthcare Commercial	$173.85
Rate for Payer: UnitedHealthcare Medicaid	$29.35
Rate for Payer: WPPA Medicare Advantage	$109.80

Immunofixation, Urine QST

Facility

$183.00

Service Code	HCPCS 86335
Hospital Charge Code	3556397
Hospital Revenue Code	300
Min. Negotiated Rate	$164.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$164.70
Rate for Payer: UnitedHealthcare Commercial	$173.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Immunoglobulin E QST

Facility

$21.00

Service Code	HCPCS 82785
Hospital Charge Code	3551781
Hospital Revenue Code	300
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$63.27
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$63.27
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$13.99
Rate for Payer: WPPA Medicare Advantage	$12.60

Immunoglobulin E QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1014
Hospital Revenue Code	300
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Immunoglobulin E QST

Facility

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1014
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$16.20

Immunoglobulin E QST

Facility

$21.00

Service Code	HCPCS 82785
Hospital Charge Code	3551781
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Immunoglobulin G Subclasses Panel QST

Facility

$181.00

Service Code	HCPCS 82787
Hospital Charge Code	3552787
Hospital Revenue Code	300
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$162.90
Rate for Payer: UnitedHealthcare Commercial	$171.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Immunoglobulin G Subclasses Panel QST

Facility

$181.00

Service Code	HCPCS 82787
Hospital Charge Code	3552787
Hospital Revenue Code	300
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$171.95
Rate for Payer: Aetna Commercial	$162.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$33.74
Rate for Payer: Humana Medicare Advantage	$76.02
Rate for Payer: UnitedHealthcare Commercial	$171.95
Rate for Payer: UnitedHealthcare Medicaid	$8.02
Rate for Payer: WPPA Medicare Advantage	$108.60

Immunoglobulins A/E/G/M,Serum QST

Facility

$172.00

Service Code	HCPCS 86334
Hospital Charge Code	3556396
Hospital Revenue Code	300
Min. Negotiated Rate	$68.80
Max. Negotiated Rate	$163.40
Rate for Payer: Aetna Commercial	$154.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$97.05
Rate for Payer: Humana Medicare Advantage	$72.24
Rate for Payer: UnitedHealthcare Commercial	$163.40
Rate for Payer: UnitedHealthcare Medicaid	$68.80
Rate for Payer: WPPA Medicare Advantage	$103.20

Immunoglobulins A/E/G/M,Serum QST

Facility

$172.00

Service Code	HCPCS 86334
Hospital Charge Code	3556396
Hospital Revenue Code	300
Min. Negotiated Rate	$154.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$154.80
Rate for Payer: UnitedHealthcare Commercial	$163.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Immunoglobulins QST

Facility

$132.00

Service Code	HCPCS 82784
Hospital Charge Code	3554827
Hospital Revenue Code	300
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Immunoglobulins QST

Facility

$132.00

Service Code	HCPCS 82784
Hospital Charge Code	3554827
Hospital Revenue Code	300
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$125.40
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$49.24
Rate for Payer: Humana Medicare Advantage	$55.44
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: UnitedHealthcare Medicaid	$9.30
Rate for Payer: WPPA Medicare Advantage	$79.20

Implant 19.5MM Dia. 2.0MM Burr, Straight

Facility

$1,168.00

Hospital Charge Code	3258536
Hospital Revenue Code	270
Min. Negotiated Rate	$467.20
Max. Negotiated Rate	$1,109.60
Rate for Payer: Aetna Commercial	$1,051.20
Rate for Payer: Humana Medicare Advantage	$490.56
Rate for Payer: UnitedHealthcare Commercial	$1,109.60
Rate for Payer: UnitedHealthcare Medicaid	$467.20
Rate for Payer: WPPA Medicare Advantage	$700.80

Implant 19.5MM Dia. 2.0MM Burr, Straight

Facility

$1,168.00

Hospital Charge Code	3258536
Hospital Revenue Code	270
Min. Negotiated Rate	$1,051.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,051.20
Rate for Payer: UnitedHealthcare Commercial	$1,109.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Implant 2.0mm Drill Bit Cmp Ft Calibrated

Facility

$812.50

Hospital Charge Code	3258534
Hospital Revenue Code	270
Min. Negotiated Rate	$325.00
Max. Negotiated Rate	$771.88
Rate for Payer: Aetna Commercial	$731.25
Rate for Payer: Humana Medicare Advantage	$341.25
Rate for Payer: UnitedHealthcare Commercial	$771.88
Rate for Payer: UnitedHealthcare Medicaid	$325.00
Rate for Payer: WPPA Medicare Advantage	$487.50

Implant 2.0mm Drill Bit Cmp Ft Calibrated

Facility

$812.50

Hospital Charge Code	3258534
Hospital Revenue Code	270
Min. Negotiated Rate	$731.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$731.25
Rate for Payer: UnitedHealthcare Commercial	$771.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Implant 2.9mm BC Pushlock, DX, Disposables

Facility

$656.00

Hospital Charge Code	3258527
Hospital Revenue Code	270
Min. Negotiated Rate	$590.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$590.40
Rate for Payer: UnitedHealthcare Commercial	$623.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Implant 2.9mm BC Pushlock, DX, Disposables

Facility

$656.00

Hospital Charge Code	3258527
Hospital Revenue Code	270
Min. Negotiated Rate	$262.40
Max. Negotiated Rate	$623.20
Rate for Payer: Aetna Commercial	$590.40
Rate for Payer: Humana Medicare Advantage	$275.52
Rate for Payer: UnitedHealthcare Commercial	$623.20
Rate for Payer: UnitedHealthcare Medicaid	$262.40
Rate for Payer: WPPA Medicare Advantage	$393.60

Implant 2.9mm Biocomp Pushlock, DX

Facility

$2,402.00

Hospital Charge Code	3258526
Hospital Revenue Code	270
Min. Negotiated Rate	$960.80
Max. Negotiated Rate	$2,281.90
Rate for Payer: Aetna Commercial	$2,161.80
Rate for Payer: Humana Medicare Advantage	$1,008.84
Rate for Payer: UnitedHealthcare Commercial	$2,281.90
Rate for Payer: UnitedHealthcare Medicaid	$960.80
Rate for Payer: WPPA Medicare Advantage	$1,441.20

Know your out-of-pocket cost for care.

All Charges