Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Iron Level

Facility

$87.00

Service Code	HCPCS 83540
Hospital Charge Code	3550494
Hospital Revenue Code	300
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$82.65
Rate for Payer: Aetna Commercial	$78.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$25.62
Rate for Payer: Humana Medicare Advantage	$36.54
Rate for Payer: UnitedHealthcare Commercial	$82.65
Rate for Payer: UnitedHealthcare Medicaid	$5.50
Rate for Payer: WPPA Medicare Advantage	$52.20

Iron Level

Facility

$87.00

Service Code	HCPCS 83540
Hospital Charge Code	3550494
Hospital Revenue Code	300
Min. Negotiated Rate	$78.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$78.30
Rate for Payer: UnitedHealthcare Commercial	$82.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

iron sucrose 20 mg/mL IV Sol [HMC]

Facility

$161.34

Service Code	HCPCS J1756
Hospital Charge Code	3803915
Hospital Revenue Code	250
Min. Negotiated Rate	$145.21
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$145.21
Rate for Payer: UnitedHealthcare Commercial	$153.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

iron sucrose 20 mg/mL IV Sol [HMC]

Facility

$161.34

Service Code	HCPCS J1756
Hospital Charge Code	3803915
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$153.27
Rate for Payer: Aetna Commercial	$145.21
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$0.29
Rate for Payer: Humana Medicare Advantage	$67.76
Rate for Payer: UnitedHealthcare Commercial	$153.27
Rate for Payer: UnitedHealthcare Medicaid	$0.24
Rate for Payer: WPPA Medicare Advantage	$96.80

Irrigation Bulb Syringe 60ml Sterile

Facility

$9.00

Hospital Charge Code	3251207
Hospital Revenue Code	270
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$8.55
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: Humana Medicare Advantage	$3.78
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: WPPA Medicare Advantage	$5.40

Irrigation Bulb Syringe 60ml Sterile

Facility

$9.00

Hospital Charge Code	3251207
Hospital Revenue Code	270
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.10
Rate for Payer: UnitedHealthcare Commercial	$8.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Irrigation Sodium Chloride 3000 LC

Facility

$24.00

Hospital Charge Code	3258451
Hospital Revenue Code	270
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.60
Rate for Payer: UnitedHealthcare Commercial	$22.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Irrigation Sodium Chloride 3000 LC

Facility

$24.00

Hospital Charge Code	3258451
Hospital Revenue Code	270
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$22.80
Rate for Payer: Aetna Commercial	$21.60
Rate for Payer: Humana Medicare Advantage	$10.08
Rate for Payer: UnitedHealthcare Commercial	$22.80
Rate for Payer: UnitedHealthcare Medicaid	$9.60
Rate for Payer: WPPA Medicare Advantage	$14.40

Irrigation Sodium Chloride 500ML

Facility

$11.43

Hospital Charge Code	3252263
Hospital Revenue Code	270
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$10.86
Rate for Payer: Aetna Commercial	$10.29
Rate for Payer: Humana Medicare Advantage	$4.80
Rate for Payer: UnitedHealthcare Commercial	$10.86
Rate for Payer: UnitedHealthcare Medicaid	$4.57
Rate for Payer: WPPA Medicare Advantage	$6.86

Irrigation Sodium Chloride 500ML

Facility

$11.43

Hospital Charge Code	3252263
Hospital Revenue Code	270
Min. Negotiated Rate	$10.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.29
Rate for Payer: UnitedHealthcare Commercial	$10.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Irrigation Sterile Water1000ML

Facility

$12.74

Hospital Charge Code	3254237
Hospital Revenue Code	270
Min. Negotiated Rate	$11.47
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.47
Rate for Payer: UnitedHealthcare Commercial	$12.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Irrigation Sterile Water1000ML

Facility

$12.74

Hospital Charge Code	3254237
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$12.10
Rate for Payer: Aetna Commercial	$11.47
Rate for Payer: Humana Medicare Advantage	$5.35
Rate for Payer: UnitedHealthcare Commercial	$12.10
Rate for Payer: UnitedHealthcare Medicaid	$5.10
Rate for Payer: WPPA Medicare Advantage	$7.64

Irrigation Sterile Water 500mL in Plastic Bottle

Facility

$12.92

Hospital Charge Code	3252255
Hospital Revenue Code	270
Min. Negotiated Rate	$11.63
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.63
Rate for Payer: UnitedHealthcare Commercial	$12.27
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Irrigation Sterile Water 500mL in Plastic Bottle

Facility

$12.92

Hospital Charge Code	3252255
Hospital Revenue Code	270
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$12.27
Rate for Payer: Aetna Commercial	$11.63
Rate for Payer: Humana Medicare Advantage	$5.43
Rate for Payer: UnitedHealthcare Commercial	$12.27
Rate for Payer: UnitedHealthcare Medicaid	$5.17
Rate for Payer: WPPA Medicare Advantage	$7.75

Irrigation Tray Bulb & Basin

Facility

$10.26

Hospital Charge Code	3251209
Hospital Revenue Code	270
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$9.75
Rate for Payer: Aetna Commercial	$9.23
Rate for Payer: Humana Medicare Advantage	$4.31
Rate for Payer: UnitedHealthcare Commercial	$9.75
Rate for Payer: UnitedHealthcare Medicaid	$4.10
Rate for Payer: WPPA Medicare Advantage	$6.16

Irrigation Tray Bulb & Basin

Facility

$10.26

Hospital Charge Code	3251209
Hospital Revenue Code	270
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.23
Rate for Payer: UnitedHealthcare Commercial	$9.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

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

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

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC

Facility

$7,942.50

Service Code	MSDRG 062
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,942.50
Rate for Payer: UnitedHealthcare Medicaid	$7,942.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC

Facility

$12,485.61

Service Code	MSDRG 061
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$12,485.61
Rate for Payer: UnitedHealthcare Medicaid	$12,485.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC

Facility

$6,354.00

Service Code	MSDRG 063
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,354.00
Rate for Payer: UnitedHealthcare Medicaid	$6,354.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Islet Cell Ab Scr w/ Rfx To Titer QST

Facility

$158.00

Service Code	HCPCS 86341
Hospital Charge Code	3556341
Hospital Revenue Code	300
Min. Negotiated Rate	$63.20
Max. Negotiated Rate	$150.10
Rate for Payer: Aetna Commercial	$142.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$79.87
Rate for Payer: Humana Medicare Advantage	$66.36
Rate for Payer: UnitedHealthcare Commercial	$150.10
Rate for Payer: UnitedHealthcare Medicaid	$63.20
Rate for Payer: WPPA Medicare Advantage	$94.80

Islet Cell Ab Scr w/ Rfx To Titer QST

Facility

$158.00

Service Code	HCPCS 86341
Hospital Charge Code	3556341
Hospital Revenue Code	300
Min. Negotiated Rate	$142.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$142.20
Rate for Payer: UnitedHealthcare Commercial	$150.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

isosorbide dinitrate 10 mg Tab [HMC]

Facility

$10.76

Service Code	NDC 00904215161
Hospital Charge Code	3802003
Hospital Revenue Code	250
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$10.22
Rate for Payer: Aetna Commercial	$9.68
Rate for Payer: Humana Medicare Advantage	$4.52
Rate for Payer: UnitedHealthcare Commercial	$10.22
Rate for Payer: UnitedHealthcare Medicaid	$4.30
Rate for Payer: WPPA Medicare Advantage	$6.46

isosorbide dinitrate 10 mg Tab [HMC]

Facility

$7.29

Service Code	NDC 00904661961
Hospital Charge Code	3802003
Hospital Revenue Code	250
Min. Negotiated Rate	$6.56
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.56
Rate for Payer: UnitedHealthcare Commercial	$6.93
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges