Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Incentive Spirometer

Facility

$10.58

Hospital Charge Code	3251167
Hospital Revenue Code	270
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.52
Rate for Payer: UnitedHealthcare Commercial	$10.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

inclisiran 284 mg/1.5 mL Sol [HMC]

Facility

$4,068.09

Service Code	HCPCS J1306
Hospital Charge Code	3804014
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,864.69
Rate for Payer: Aetna Commercial	$3,661.28
Rate for Payer: UnitedHealthcare Commercial	$3,864.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

inclisiran 284 mg/1.5 mL Sol [HMC]

Facility

$4,068.09

Service Code	HCPCS J1306
Hospital Charge Code	3804014
Hospital Revenue Code	250
Min. Negotiated Rate	$12.69
Max. Negotiated Rate	$3,864.69
Rate for Payer: Aetna Commercial	$3,661.28
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.52
Rate for Payer: Humana Medicare Advantage	$1,708.60
Rate for Payer: UnitedHealthcare Commercial	$3,864.69
Rate for Payer: UnitedHealthcare Medicaid	$12.69
Rate for Payer: WPPA Medicare Advantage	$2,440.85

Incompatible - Serological Immediate Spin

Facility

$91.00

Service Code	HCPCS 86920
Hospital Charge Code	3560149
Hospital Revenue Code	300
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Incompatible - Serological Immediate Spin

Facility

$91.00

Service Code	HCPCS 86920
Hospital Charge Code	3560149
Hospital Revenue Code	300
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$86.45
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$46.33
Rate for Payer: Humana Medicare Advantage	$38.22
Rate for Payer: UnitedHealthcare Commercial	$86.45
Rate for Payer: UnitedHealthcare Medicaid	$36.40
Rate for Payer: WPPA Medicare Advantage	$54.60

Incompatible - XM AHG Gel Interp

Facility

$113.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$42.03
Max. Negotiated Rate	$107.35
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$42.03
Rate for Payer: Humana Medicare Advantage	$47.46
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: UnitedHealthcare Medicaid	$45.20
Rate for Payer: WPPA Medicare Advantage	$67.80

Incompatible - XM AHG Gel Interp

Facility

$113.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$101.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Incompatible - XM AHG Tube Interp

Facility

$113.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$42.03
Max. Negotiated Rate	$107.35
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$42.03
Rate for Payer: Humana Medicare Advantage	$47.46
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: UnitedHealthcare Medicaid	$45.20
Rate for Payer: WPPA Medicare Advantage	$67.80

Incompatible - XM AHG Tube Interp

Facility

$113.00

Service Code	HCPCS 86922
Hospital Charge Code	3560164
Hospital Revenue Code	300
Min. Negotiated Rate	$101.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

incubation

Facility

$113.00

Service Code	HCPCS 86921
Hospital Charge Code	3560156
Hospital Revenue Code	300
Min. Negotiated Rate	$45.20
Max. Negotiated Rate	$107.35
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$66.21
Rate for Payer: Humana Medicare Advantage	$47.46
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: UnitedHealthcare Medicaid	$45.20
Rate for Payer: WPPA Medicare Advantage	$67.80

incubation

Facility

$113.00

Service Code	HCPCS 86921
Hospital Charge Code	3560156
Hospital Revenue Code	300
Min. Negotiated Rate	$101.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$101.70
Rate for Payer: UnitedHealthcare Commercial	$107.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

indocyanine green 25 mg Pow [HMC]

Facility

$402.03

Service Code	NDC 70100042402
Hospital Charge Code	3801710
Hospital Revenue Code	250
Min. Negotiated Rate	$361.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$361.83
Rate for Payer: UnitedHealthcare Commercial	$381.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00

indocyanine green 25 mg Pow [HMC]

Facility

$402.03

Service Code	NDC 70100042402
Hospital Charge Code	3801710
Hospital Revenue Code	250
Min. Negotiated Rate	$160.81
Max. Negotiated Rate	$381.93
Rate for Payer: Aetna Commercial	$361.83
Rate for Payer: Humana Medicare Advantage	$168.85
Rate for Payer: UnitedHealthcare Commercial	$381.93
Rate for Payer: UnitedHealthcare Medicaid	$160.81
Rate for Payer: WPPA Medicare Advantage	$241.22

indomethacin 25 mg Cap [HMC]

Facility

$6.29

Service Code	NDC 50268043015
Hospital Charge Code	3805849
Hospital Revenue Code	250
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.98
Rate for Payer: Aetna Commercial	$5.66
Rate for Payer: Humana Medicare Advantage	$2.64
Rate for Payer: UnitedHealthcare Commercial	$5.98
Rate for Payer: UnitedHealthcare Medicaid	$2.52
Rate for Payer: WPPA Medicare Advantage	$3.77

indomethacin 25 mg Cap [HMC]

Facility

$6.21

Service Code	NDC 68462040601
Hospital Charge Code	3805849
Hospital Revenue Code	250
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$5.90
Rate for Payer: Aetna Commercial	$5.59
Rate for Payer: Humana Medicare Advantage	$2.61
Rate for Payer: UnitedHealthcare Commercial	$5.90
Rate for Payer: UnitedHealthcare Medicaid	$2.48
Rate for Payer: WPPA Medicare Advantage	$3.73

indomethacin 25 mg Cap [HMC]

Facility

$6.21

Service Code	NDC 68462040601
Hospital Charge Code	3805849
Hospital Revenue Code	250
Min. Negotiated Rate	$5.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.59
Rate for Payer: UnitedHealthcare Commercial	$5.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

indomethacin 25 mg Cap [HMC]

Facility

$6.29

Service Code	NDC 50268043015
Hospital Charge Code	3805849
Hospital Revenue Code	250
Min. Negotiated Rate	$5.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.66
Rate for Payer: UnitedHealthcare Commercial	$5.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Infant Climate Cover

Facility

$118.00

Hospital Charge Code	3250302
Hospital Revenue Code	270
Min. Negotiated Rate	$47.20
Max. Negotiated Rate	$112.10
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: Humana Medicare Advantage	$49.56
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: UnitedHealthcare Medicaid	$47.20
Rate for Payer: WPPA Medicare Advantage	$70.80

Infant Climate Cover

Facility

$118.00

Hospital Charge Code	3250302
Hospital Revenue Code	270
Min. Negotiated Rate	$106.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$106.20
Rate for Payer: UnitedHealthcare Commercial	$112.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Infant Percussor

Facility

$40.95

Hospital Charge Code	3255031
Hospital Revenue Code	270
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.85
Rate for Payer: UnitedHealthcare Commercial	$38.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Infant Percussor

Facility

$40.95

Hospital Charge Code	3255031
Hospital Revenue Code	270
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$38.90
Rate for Payer: Aetna Commercial	$36.85
Rate for Payer: Humana Medicare Advantage	$17.20
Rate for Payer: UnitedHealthcare Commercial	$38.90
Rate for Payer: UnitedHealthcare Medicaid	$16.38
Rate for Payer: WPPA Medicare Advantage	$24.57

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC

Facility

$2,732.22

Service Code	MSDRG 758
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,732.22
Rate for Payer: UnitedHealthcare Medicaid	$2,732.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$4,003.02

Service Code	MSDRG 757
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,003.02
Rate for Payer: UnitedHealthcare Medicaid	$4,003.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$1,874.43

Service Code	MSDRG 759
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,874.43
Rate for Payer: UnitedHealthcare Medicaid	$1,874.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC

Facility

$8,482.59

Service Code	MSDRG 854
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$8,482.59
Rate for Payer: UnitedHealthcare Medicaid	$8,482.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges