Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Inspire Implantable Pulse Generator V with Built-in Respiratory Sensing Lead (Replaces System IV Gen

Facility

$43,200.00

Service Code	HCPCS C1767
Hospital Charge Code	3257115
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$41,040.00
Rate for Payer: Aetna Commercial	$38,880.00
Rate for Payer: UnitedHealthcare Commercial	$41,040.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Inspire Respiratory Sensing Lead System IV (Built into Pulse Generator in Inspire V and no longer ne

Facility

$7,088.00

Service Code	HCPCS C1778
Hospital Charge Code	3257112
Hospital Revenue Code	278
Min. Negotiated Rate	$2,835.20
Max. Negotiated Rate	$6,733.60
Rate for Payer: Aetna Commercial	$6,379.20
Rate for Payer: Humana Medicare Advantage	$2,976.96
Rate for Payer: UnitedHealthcare Commercial	$6,733.60
Rate for Payer: UnitedHealthcare Medicaid	$2,835.20
Rate for Payer: WPPA Medicare Advantage	$4,252.80

Inspire Respiratory Sensing Lead System IV (Built into Pulse Generator in Inspire V and no longer ne

Facility

$7,088.00

Service Code	HCPCS C1778
Hospital Charge Code	3257112
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,733.60
Rate for Payer: Aetna Commercial	$6,379.20
Rate for Payer: UnitedHealthcare Commercial	$6,733.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Inspire Sleep Remote for Systems IV & V

Facility

$2,940.00

Service Code	HCPCS C1787
Hospital Charge Code	3257113
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.00
Max. Negotiated Rate	$2,793.00
Rate for Payer: Aetna Commercial	$2,646.00
Rate for Payer: Humana Medicare Advantage	$1,234.80
Rate for Payer: UnitedHealthcare Commercial	$2,793.00
Rate for Payer: UnitedHealthcare Medicaid	$1,176.00
Rate for Payer: WPPA Medicare Advantage	$1,764.00

Inspire Sleep Remote for Systems IV & V

Facility

$2,940.00

Service Code	HCPCS C1787
Hospital Charge Code	3257113
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,793.00
Rate for Payer: Aetna Commercial	$2,646.00
Rate for Payer: UnitedHealthcare Commercial	$2,793.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Inspire Stimulation Lead for Systems IV & V

Facility

$4,095.00

Service Code	HCPCS C1778
Hospital Charge Code	3257111
Hospital Revenue Code	278
Min. Negotiated Rate	$1,638.00
Max. Negotiated Rate	$3,890.25
Rate for Payer: Aetna Commercial	$3,685.50
Rate for Payer: Humana Medicare Advantage	$1,719.90
Rate for Payer: UnitedHealthcare Commercial	$3,890.25
Rate for Payer: UnitedHealthcare Medicaid	$1,638.00
Rate for Payer: WPPA Medicare Advantage	$2,457.00

Inspire Stimulation Lead for Systems IV & V

Facility

$4,095.00

Service Code	HCPCS C1778
Hospital Charge Code	3257111
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,890.25
Rate for Payer: Aetna Commercial	$3,685.50
Rate for Payer: UnitedHealthcare Commercial	$3,890.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

INST Myringotomy Blade Tapered Disposable

Facility

$62.37

Hospital Charge Code	3256966
Hospital Revenue Code	270
Min. Negotiated Rate	$24.95
Max. Negotiated Rate	$59.25
Rate for Payer: Aetna Commercial	$56.13
Rate for Payer: Humana Medicare Advantage	$26.20
Rate for Payer: UnitedHealthcare Commercial	$59.25
Rate for Payer: UnitedHealthcare Medicaid	$24.95
Rate for Payer: WPPA Medicare Advantage	$37.42

INST Myringotomy Blade Tapered Disposable

Facility

$62.37

Hospital Charge Code	3256966
Hospital Revenue Code	270
Min. Negotiated Rate	$56.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.13
Rate for Payer: UnitedHealthcare Commercial	$59.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

insulin aspart 100 units/mL [HMC]

Facility

$221.18

Service Code	HCPCS J1815
Hospital Charge Code	3800776
Hospital Revenue Code	250
Min. Negotiated Rate	$199.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$199.06
Rate for Payer: Aetna Commercial	$63.27
Rate for Payer: UnitedHealthcare Commercial	$210.12
Rate for Payer: UnitedHealthcare Commercial	$66.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

insulin aspart 100 units/mL [HMC]

Facility

$70.30

Service Code	HCPCS J1815
Hospital Charge Code	3800776
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$66.78
Rate for Payer: Aetna Commercial	$63.27
Rate for Payer: Aetna Commercial	$199.06
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.27
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.27
Rate for Payer: Humana Medicare Advantage	$92.90
Rate for Payer: Humana Medicare Advantage	$29.53
Rate for Payer: UnitedHealthcare Commercial	$66.78
Rate for Payer: UnitedHealthcare Commercial	$210.12
Rate for Payer: UnitedHealthcare Medicaid	$0.13
Rate for Payer: UnitedHealthcare Medicaid	$0.13
Rate for Payer: WPPA Medicare Advantage	$132.71
Rate for Payer: WPPA Medicare Advantage	$42.18

insulin aspart-insulin aspart protamine 30 units-70 units/mL SQ Susp 3ml [HMC]

Facility

$70.30

Service Code	HCPCS J1815
Hospital Charge Code	3800655
Hospital Revenue Code	250
Min. Negotiated Rate	$63.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.27
Rate for Payer: UnitedHealthcare Commercial	$66.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

insulin aspart-insulin aspart protamine 30 units-70 units/mL SQ Susp 3ml [HMC]

Facility

$70.30

Service Code	HCPCS J1815
Hospital Charge Code	3800655
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$66.78
Rate for Payer: Aetna Commercial	$63.27
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.27
Rate for Payer: Humana Medicare Advantage	$29.53
Rate for Payer: UnitedHealthcare Commercial	$66.78
Rate for Payer: UnitedHealthcare Medicaid	$0.13
Rate for Payer: WPPA Medicare Advantage	$42.18

insulin aspart-insulin aspart protamine 30 units-70 units/mL SubQ Susp 3 mL [HMC]

Facility

$70.30

Service Code	HCPCS J1815
Hospital Charge Code	3800655
Hospital Revenue Code	250
Min. Negotiated Rate	$63.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.27
Rate for Payer: UnitedHealthcare Commercial	$66.78
Rate for Payer: WPPA Medicare Advantage	$1,200.00

insulin aspart-insulin aspart protamine 30 units-70 units/mL SubQ Susp 3 mL [HMC]

Facility

$70.30

Service Code	HCPCS J1815
Hospital Charge Code	3800655
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$66.78
Rate for Payer: Aetna Commercial	$63.27
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.27
Rate for Payer: Humana Medicare Advantage	$29.53
Rate for Payer: UnitedHealthcare Commercial	$66.78
Rate for Payer: UnitedHealthcare Medicaid	$0.13
Rate for Payer: WPPA Medicare Advantage	$42.18

Insulin Autoantibody QST

Facility

$263.00

Service Code	HCPCS 86337
Hospital Charge Code	3556178
Hospital Revenue Code	300
Min. Negotiated Rate	$236.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$236.70
Rate for Payer: UnitedHealthcare Commercial	$249.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Insulin Autoantibody QST

Facility

$263.00

Service Code	HCPCS 86337
Hospital Charge Code	3556178
Hospital Revenue Code	300
Min. Negotiated Rate	$21.41
Max. Negotiated Rate	$249.85
Rate for Payer: Aetna Commercial	$236.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$84.13
Rate for Payer: Humana Medicare Advantage	$110.46
Rate for Payer: UnitedHealthcare Commercial	$249.85
Rate for Payer: UnitedHealthcare Medicaid	$21.41
Rate for Payer: WPPA Medicare Advantage	$157.80

insulin degludec 100 units/mL Sol [HMC]

Facility

$203.04

Service Code	NDC 00169266015
Hospital Charge Code	3800481
Hospital Revenue Code	636
Min. Negotiated Rate	$182.74
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$182.74
Rate for Payer: UnitedHealthcare Commercial	$192.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

insulin degludec 100 units/mL Sol [HMC]

Facility

$203.04

Service Code	NDC 00169266015
Hospital Charge Code	3800481
Hospital Revenue Code	636
Min. Negotiated Rate	$81.22
Max. Negotiated Rate	$192.89
Rate for Payer: Aetna Commercial	$182.74
Rate for Payer: Humana Medicare Advantage	$85.28
Rate for Payer: UnitedHealthcare Commercial	$192.89
Rate for Payer: UnitedHealthcare Medicaid	$81.22
Rate for Payer: WPPA Medicare Advantage	$121.82

insulin detemir 100 units/mL SC Sol [HMC]

Facility

$186.40

Service Code	HCPCS J1815
Hospital Charge Code	3800020
Hospital Revenue Code	250
Min. Negotiated Rate	$167.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$167.76
Rate for Payer: UnitedHealthcare Commercial	$177.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

insulin detemir 100 units/mL SC Sol [HMC]

Facility

$186.40

Service Code	HCPCS J1815
Hospital Charge Code	3800020
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$177.08
Rate for Payer: Aetna Commercial	$167.76
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.27
Rate for Payer: Humana Medicare Advantage	$78.29
Rate for Payer: UnitedHealthcare Commercial	$177.08
Rate for Payer: UnitedHealthcare Medicaid	$0.13
Rate for Payer: WPPA Medicare Advantage	$111.84

insulin detemir 100 units/mL SC Sol [HMC]

Facility

$186.40

Service Code	NDC 00169643210
Hospital Charge Code	3800020
Hospital Revenue Code	250
Min. Negotiated Rate	$74.56
Max. Negotiated Rate	$177.08
Rate for Payer: Aetna Commercial	$167.76
Rate for Payer: Humana Medicare Advantage	$78.29
Rate for Payer: UnitedHealthcare Commercial	$177.08
Rate for Payer: UnitedHealthcare Medicaid	$74.56
Rate for Payer: WPPA Medicare Advantage	$111.84

insulin detemir 100 units/mL SC Sol [HMC]

Facility

$186.40

Service Code	NDC 00169643210
Hospital Charge Code	3800020
Hospital Revenue Code	250
Min. Negotiated Rate	$167.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$167.76
Rate for Payer: UnitedHealthcare Commercial	$177.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

insulin glargine 100 units/mL SubQ Sol [HMC]

Facility

$173.11

Service Code	HCPCS J1815
Hospital Charge Code	3808637
Hospital Revenue Code	250
Min. Negotiated Rate	$155.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$155.80
Rate for Payer: UnitedHealthcare Commercial	$164.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

insulin glargine 100 units/mL SubQ Sol [HMC]

Facility

$173.11

Service Code	HCPCS J1815
Hospital Charge Code	3808637
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$164.45
Rate for Payer: Aetna Commercial	$155.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.27
Rate for Payer: Humana Medicare Advantage	$72.71
Rate for Payer: UnitedHealthcare Commercial	$164.45
Rate for Payer: UnitedHealthcare Medicaid	$0.13
Rate for Payer: WPPA Medicare Advantage	$103.87

Know your out-of-pocket cost for care.

All Charges