Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$297.42
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$297.42
Rate for Payer: UnitedHealthcare Commercial	$313.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IPPB Tubing/Nebulizer Universal Manifolds

Facility

$18.00

Hospital Charge Code	3251183
Hospital Revenue Code	270
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna Commercial	$16.20
Rate for Payer: Humana Medicare Advantage	$7.56
Rate for Payer: UnitedHealthcare Commercial	$17.10
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: WPPA Medicare Advantage	$10.80

IPPB Tubing/Nebulizer Universal Manifolds

Facility

$18.00

Hospital Charge Code	3251183
Hospital Revenue Code	270
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.20
Rate for Payer: UnitedHealthcare Commercial	$17.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ipratropium 0.02% Inh Sol 2 mL [HMC]

Facility

$13.52

Service Code	NDC 76204010025
Hospital Charge Code	3805864
Hospital Revenue Code	250
Min. Negotiated Rate	$12.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.17
Rate for Payer: UnitedHealthcare Commercial	$12.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ipratropium 0.02% Inh Sol 2 mL [HMC]

Facility

$12.64

Service Code	HCPCS J7644
Hospital Charge Code	3805864
Hospital Revenue Code	250
Min. Negotiated Rate	$11.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.38
Rate for Payer: Aetna Commercial	$9.66
Rate for Payer: Aetna Commercial	$12.17
Rate for Payer: Aetna Commercial	$12.18
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Commercial	$12.85
Rate for Payer: UnitedHealthcare Commercial	$12.84
Rate for Payer: UnitedHealthcare Commercial	$10.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ipratropium 0.02% Inh Sol 2 mL [HMC]

Facility

$13.52

Service Code	NDC 76204010025
Hospital Charge Code	3805864
Hospital Revenue Code	250
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$12.84
Rate for Payer: Aetna Commercial	$12.17
Rate for Payer: Humana Medicare Advantage	$5.68
Rate for Payer: UnitedHealthcare Commercial	$12.84
Rate for Payer: UnitedHealthcare Medicaid	$5.41
Rate for Payer: WPPA Medicare Advantage	$8.11

ipratropium 0.02% Inh Sol 2 mL [HMC]

Facility

$12.64

Service Code	HCPCS J7644
Hospital Charge Code	3805864
Hospital Revenue Code	250
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$12.01
Rate for Payer: Aetna Commercial	$11.38
Rate for Payer: Aetna Commercial	$12.18
Rate for Payer: Aetna Commercial	$12.17
Rate for Payer: Aetna Commercial	$9.66
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.49
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.49
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.49
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.49
Rate for Payer: Humana Medicare Advantage	$5.31
Rate for Payer: Humana Medicare Advantage	$4.51
Rate for Payer: Humana Medicare Advantage	$5.68
Rate for Payer: Humana Medicare Advantage	$5.68
Rate for Payer: UnitedHealthcare Commercial	$12.85
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Commercial	$10.19
Rate for Payer: UnitedHealthcare Commercial	$12.84
Rate for Payer: UnitedHealthcare Medicaid	$5.41
Rate for Payer: UnitedHealthcare Medicaid	$4.29
Rate for Payer: UnitedHealthcare Medicaid	$5.06
Rate for Payer: UnitedHealthcare Medicaid	$5.41
Rate for Payer: WPPA Medicare Advantage	$7.58
Rate for Payer: WPPA Medicare Advantage	$6.44
Rate for Payer: WPPA Medicare Advantage	$8.12
Rate for Payer: WPPA Medicare Advantage	$8.11

ipratropium CFC free 17 mcg/inh Inh Aer [HMC]

Facility

$784.74

Service Code	NDC 00597008717
Hospital Charge Code	3805576
Hospital Revenue Code	250
Min. Negotiated Rate	$313.90
Max. Negotiated Rate	$745.50
Rate for Payer: Aetna Commercial	$706.27
Rate for Payer: Humana Medicare Advantage	$329.59
Rate for Payer: UnitedHealthcare Commercial	$745.50
Rate for Payer: UnitedHealthcare Medicaid	$313.90
Rate for Payer: WPPA Medicare Advantage	$470.84

ipratropium CFC free 17 mcg/inh Inh Aer [HMC]

Facility

$784.74

Service Code	NDC 00597008717
Hospital Charge Code	3805576
Hospital Revenue Code	250
Min. Negotiated Rate	$706.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$706.27
Rate for Payer: UnitedHealthcare Commercial	$745.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ipratropium Nasal 0.03% Spry 30 mL [HMC]

Facility

$81.60

Service Code	NDC 24208039830
Hospital Charge Code	3800516
Hospital Revenue Code	250
Min. Negotiated Rate	$73.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$73.44
Rate for Payer: UnitedHealthcare Commercial	$77.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ipratropium Nasal 0.03% Spry 30 mL [HMC]

Facility

$81.60

Service Code	NDC 24208039830
Hospital Charge Code	3800516
Hospital Revenue Code	250
Min. Negotiated Rate	$32.64
Max. Negotiated Rate	$77.52
Rate for Payer: Aetna Commercial	$73.44
Rate for Payer: Humana Medicare Advantage	$34.27
Rate for Payer: UnitedHealthcare Commercial	$77.52
Rate for Payer: UnitedHealthcare Medicaid	$32.64
Rate for Payer: WPPA Medicare Advantage	$48.96

ipratropium Nasal 0.03% Spry [HMC]

Facility

$170.75

Service Code	NDC 00054004544
Hospital Charge Code	3802663
Hospital Revenue Code	250
Min. Negotiated Rate	$153.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$153.68
Rate for Payer: UnitedHealthcare Commercial	$162.21
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ipratropium Nasal 0.03% Spry [HMC]

Facility

$170.75

Service Code	NDC 00054004544
Hospital Charge Code	3802663
Hospital Revenue Code	250
Min. Negotiated Rate	$68.30
Max. Negotiated Rate	$162.21
Rate for Payer: Aetna Commercial	$153.68
Rate for Payer: Humana Medicare Advantage	$71.72
Rate for Payer: UnitedHealthcare Commercial	$162.21
Rate for Payer: UnitedHealthcare Medicaid	$68.30
Rate for Payer: WPPA Medicare Advantage	$102.45

irbesartan 150 mg Tab [HMC]

Facility

$14.21

Service Code	NDC 31722073030
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.79
Rate for Payer: UnitedHealthcare Commercial	$13.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

irbesartan 150 mg Tab [HMC]

Facility

$14.21

Service Code	NDC 62332004230
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.79
Rate for Payer: UnitedHealthcare Commercial	$13.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

irbesartan 150 mg Tab [HMC]

Facility

$14.21

Service Code	NDC 59746044830
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.79
Rate for Payer: UnitedHealthcare Commercial	$13.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

irbesartan 150 mg Tab [HMC]

Facility

$14.21

Service Code	NDC 31722073030
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$5.68
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna Commercial	$12.79
Rate for Payer: Humana Medicare Advantage	$5.97
Rate for Payer: UnitedHealthcare Commercial	$13.50
Rate for Payer: UnitedHealthcare Medicaid	$5.68
Rate for Payer: WPPA Medicare Advantage	$8.53

irbesartan 150 mg Tab [HMC]

Facility

$14.21

Service Code	NDC 59746044830
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$5.68
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna Commercial	$12.79
Rate for Payer: Humana Medicare Advantage	$5.97
Rate for Payer: UnitedHealthcare Commercial	$13.50
Rate for Payer: UnitedHealthcare Medicaid	$5.68
Rate for Payer: WPPA Medicare Advantage	$8.53

irbesartan 150 mg Tab [HMC]

Facility

$14.21

Service Code	NDC 62332004230
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$5.68
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna Commercial	$12.79
Rate for Payer: Humana Medicare Advantage	$5.97
Rate for Payer: UnitedHealthcare Commercial	$13.50
Rate for Payer: UnitedHealthcare Medicaid	$5.68
Rate for Payer: WPPA Medicare Advantage	$8.53

irbesartan 150 mg Tab [HMC]

Facility

$14.21

Service Code	NDC 33342004807
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.79
Rate for Payer: UnitedHealthcare Commercial	$13.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

irbesartan 150 mg Tab [HMC]

Facility

$14.21

Service Code	NDC 33342004807
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$5.68
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna Commercial	$12.79
Rate for Payer: Humana Medicare Advantage	$5.97
Rate for Payer: UnitedHealthcare Commercial	$13.50
Rate for Payer: UnitedHealthcare Medicaid	$5.68
Rate for Payer: WPPA Medicare Advantage	$8.53

irbesartan 75 mg Tab [HMC]

Facility

$13.75

Service Code	NDC 68180041006
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$13.06
Rate for Payer: Aetna Commercial	$12.38
Rate for Payer: Humana Medicare Advantage	$5.78
Rate for Payer: UnitedHealthcare Commercial	$13.06
Rate for Payer: UnitedHealthcare Medicaid	$5.50
Rate for Payer: WPPA Medicare Advantage	$8.25

irbesartan 75 mg Tab [HMC]

Facility

$13.75

Service Code	NDC 68180041006
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.38
Rate for Payer: UnitedHealthcare Commercial	$13.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

irbesartan 75 mg Tab [HMC]

Facility

$13.75

Service Code	NDC 00093746456
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.38
Rate for Payer: UnitedHealthcare Commercial	$13.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

irbesartan 75 mg Tab [HMC]

Facility

$13.75

Service Code	NDC 00093746456
Hospital Charge Code	3802007
Hospital Revenue Code	250
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$13.06
Rate for Payer: Aetna Commercial	$12.38
Rate for Payer: Humana Medicare Advantage	$5.78
Rate for Payer: UnitedHealthcare Commercial	$13.06
Rate for Payer: UnitedHealthcare Medicaid	$5.50
Rate for Payer: WPPA Medicare Advantage	$8.25

Know your out-of-pocket cost for care.

All Charges