Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC

Facility

$28,624.77

Service Code	MSDRG 020
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$28,624.77
Rate for Payer: UnitedHealthcare Medicaid	$28,624.77
Rate for Payer: WPPA Medicare Advantage	$1,200.00

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC

Facility

$11,564.28

Service Code	MSDRG 022
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,564.28
Rate for Payer: UnitedHealthcare Medicaid	$11,564.28
Rate for Payer: WPPA Medicare Advantage	$1,200.00

INTRAOCULAR PROCEDURES WITH CC/MCC

Facility

$6,322.23

Service Code	MSDRG 116
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,322.23
Rate for Payer: UnitedHealthcare Medicaid	$6,322.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00

INTRAOCULAR PROCEDURES WITHOUT CC/MCC

Facility

$3,812.40

Service Code	MSDRG 117
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,812.40
Rate for Payer: UnitedHealthcare Medicaid	$3,812.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Intrinsic Factor Blocking Ab QST

Facility

$105.00

Service Code	HCPCS 86340
Hospital Charge Code	3556340
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$94.50
Rate for Payer: UnitedHealthcare Commercial	$99.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Intrinsic Factor Blocking Ab QST

Facility

$105.00

Service Code	HCPCS 86340
Hospital Charge Code	3556340
Hospital Revenue Code	300
Min. Negotiated Rate	$15.08
Max. Negotiated Rate	$99.75
Rate for Payer: Aetna Commercial	$94.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$52.68
Rate for Payer: Humana Medicare Advantage	$44.10
Rate for Payer: UnitedHealthcare Commercial	$99.75
Rate for Payer: UnitedHealthcare Medicaid	$15.08
Rate for Payer: WPPA Medicare Advantage	$63.00

Intubation Cook Retrograde 11.0-70-38J-110

Facility

$449.00

Hospital Charge Code	3252202
Hospital Revenue Code	270
Min. Negotiated Rate	$179.60
Max. Negotiated Rate	$426.55
Rate for Payer: Aetna Commercial	$404.10
Rate for Payer: Humana Medicare Advantage	$188.58
Rate for Payer: UnitedHealthcare Commercial	$426.55
Rate for Payer: UnitedHealthcare Medicaid	$179.60
Rate for Payer: WPPA Medicare Advantage	$269.40

Intubation Cook Retrograde 11.0-70-38J-110

Facility

$449.00

Hospital Charge Code	3252202
Hospital Revenue Code	270
Min. Negotiated Rate	$404.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$404.10
Rate for Payer: UnitedHealthcare Commercial	$426.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Iodine, Serum/Plasma QST

Facility

$83.00

Service Code	HCPCS 82542
Hospital Charge Code	3552542
Hospital Revenue Code	300
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$194.29
Rate for Payer: Aetna Commercial	$74.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$194.29
Rate for Payer: Humana Medicare Advantage	$34.86
Rate for Payer: UnitedHealthcare Commercial	$78.85
Rate for Payer: UnitedHealthcare Medicaid	$20.48
Rate for Payer: WPPA Medicare Advantage	$49.80

Iodine, Serum/Plasma QST

Facility

$83.00

Service Code	HCPCS 82542
Hospital Charge Code	3552542
Hospital Revenue Code	300
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$74.70
Rate for Payer: UnitedHealthcare Commercial	$78.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

iodixanol 320 mg/mL Sol [HMC]

Facility

$224.28

Service Code	HCPCS Q9967
Hospital Charge Code	3740615
Hospital Revenue Code	250
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$213.07
Rate for Payer: Aetna Commercial	$201.85
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5.05
Rate for Payer: Humana Medicare Advantage	$94.20
Rate for Payer: UnitedHealthcare Commercial	$213.07
Rate for Payer: UnitedHealthcare Medicaid	$89.71
Rate for Payer: WPPA Medicare Advantage	$134.57

iodixanol 320 mg/mL Sol [HMC]

Facility

$224.28

Service Code	HCPCS Q9967
Hospital Charge Code	3740615
Hospital Revenue Code	250
Min. Negotiated Rate	$201.85
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$201.85
Rate for Payer: UnitedHealthcare Commercial	$213.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

iohexol 180 mg/mL Inj Sol [HMC]

Facility

$104.01

Service Code	HCPCS Q9965
Hospital Charge Code	3170481
Hospital Revenue Code	250
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$98.81
Rate for Payer: Aetna Commercial	$93.61
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5.05
Rate for Payer: Humana Medicare Advantage	$43.68
Rate for Payer: UnitedHealthcare Commercial	$98.81
Rate for Payer: UnitedHealthcare Medicaid	$41.60
Rate for Payer: WPPA Medicare Advantage	$62.41

iohexol 180 mg/mL Inj Sol [HMC]

Facility

$104.01

Service Code	HCPCS Q9965
Hospital Charge Code	3170481
Hospital Revenue Code	250
Min. Negotiated Rate	$93.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$93.61
Rate for Payer: UnitedHealthcare Commercial	$98.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

iohexol 240 mg/mL Inj Sol [HMC]

Facility

$116.53

Service Code	HCPCS Q9966
Hospital Charge Code	3805130
Hospital Revenue Code	250
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$110.70
Rate for Payer: Aetna Commercial	$104.88
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5.05
Rate for Payer: Humana Medicare Advantage	$48.94
Rate for Payer: UnitedHealthcare Commercial	$110.70
Rate for Payer: UnitedHealthcare Medicaid	$46.61
Rate for Payer: WPPA Medicare Advantage	$69.92

iohexol 240 mg/mL Inj Sol [HMC]

Facility

$116.53

Service Code	HCPCS Q9966
Hospital Charge Code	3805130
Hospital Revenue Code	250
Min. Negotiated Rate	$104.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$104.88
Rate for Payer: UnitedHealthcare Commercial	$110.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

iohexol 300 mg/mL Inj Sol [HMC]

Facility

$104.33

Service Code	HCPCS Q9967
Hospital Charge Code	3170183
Hospital Revenue Code	250
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$99.11
Rate for Payer: Aetna Commercial	$93.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5.05
Rate for Payer: Humana Medicare Advantage	$43.82
Rate for Payer: UnitedHealthcare Commercial	$99.11
Rate for Payer: UnitedHealthcare Medicaid	$41.73
Rate for Payer: WPPA Medicare Advantage	$62.60

iohexol 300 mg/mL Inj Sol [HMC]

Facility

$104.33

Service Code	HCPCS Q9967
Hospital Charge Code	3170183
Hospital Revenue Code	250
Min. Negotiated Rate	$93.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$93.90
Rate for Payer: UnitedHealthcare Commercial	$99.11
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Iontophoresis Charges

Facility

$89.00

Service Code	HCPCS 97033 GO
Hospital Charge Code	3970160
Hospital Revenue Code	430
Min. Negotiated Rate	$80.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Iontophoresis Charges

Facility

$89.00

Service Code	HCPCS 97033 GP
Hospital Charge Code	3950242
Hospital Revenue Code	420
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$84.55
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$38.38
Rate for Payer: Humana Medicare Advantage	$37.38
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: UnitedHealthcare Medicaid	$8.58
Rate for Payer: WPPA Medicare Advantage	$53.40

Iontophoresis Charges

Facility

$89.00

Service Code	HCPCS 97033 GO
Hospital Charge Code	3970160
Hospital Revenue Code	430
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$84.55
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$38.38
Rate for Payer: Humana Medicare Advantage	$37.38
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: UnitedHealthcare Medicaid	$8.58
Rate for Payer: WPPA Medicare Advantage	$53.40

Iontophoresis Charges

Facility

$89.00

Service Code	HCPCS 97033 GP
Hospital Charge Code	3950242
Hospital Revenue Code	420
Min. Negotiated Rate	$80.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

iopamidol 41% intrathecal Sol 10 mL [HMC]

Facility

$136.32

Service Code	HCPCS Q9966
Hospital Charge Code	3170019
Hospital Revenue Code	250
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$129.50
Rate for Payer: Aetna Commercial	$122.69
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5.05
Rate for Payer: Humana Medicare Advantage	$57.25
Rate for Payer: UnitedHealthcare Commercial	$129.50
Rate for Payer: UnitedHealthcare Medicaid	$54.53
Rate for Payer: WPPA Medicare Advantage	$81.79

iopamidol 41% intrathecal Sol 10 mL [HMC]

Facility

$136.32

Service Code	HCPCS Q9966
Hospital Charge Code	3170019
Hospital Revenue Code	250
Min. Negotiated Rate	$122.69
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$122.69
Rate for Payer: UnitedHealthcare Commercial	$129.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

iopamidol 76% Inj Sol 200 mL [HMC]

Facility

$330.47

Service Code	HCPCS Q9967
Hospital Charge Code	3174835
Hospital Revenue Code	250
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$313.95
Rate for Payer: Aetna Commercial	$297.42
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$5.05
Rate for Payer: Humana Medicare Advantage	$138.80
Rate for Payer: UnitedHealthcare Commercial	$313.95
Rate for Payer: UnitedHealthcare Medicaid	$132.19
Rate for Payer: WPPA Medicare Advantage	$198.28

Know your out-of-pocket cost for care.

All Charges