Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

IUD Skyla

Facility

$1,218.00

Hospital Charge Code	3254619
Hospital Revenue Code	270
Min. Negotiated Rate	$1,096.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,096.20
Rate for Payer: UnitedHealthcare Commercial	$1,157.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IUP Koala

Facility

$103.00

Hospital Charge Code	3253405
Hospital Revenue Code	270
Min. Negotiated Rate	$41.20
Max. Negotiated Rate	$97.85
Rate for Payer: Aetna Commercial	$92.70
Rate for Payer: Humana Medicare Advantage	$43.26
Rate for Payer: UnitedHealthcare Commercial	$97.85
Rate for Payer: UnitedHealthcare Medicaid	$41.20
Rate for Payer: WPPA Medicare Advantage	$61.80

IUP Koala

Facility

$103.00

Hospital Charge Code	3253405
Hospital Revenue Code	270
Min. Negotiated Rate	$92.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$92.70
Rate for Payer: UnitedHealthcare Commercial	$97.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IV CLV Blood Secondary Tubing

Facility

$11.25

Hospital Charge Code	3256570
Hospital Revenue Code	270
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$10.69
Rate for Payer: Aetna Commercial	$10.12
Rate for Payer: Humana Medicare Advantage	$4.72
Rate for Payer: UnitedHealthcare Commercial	$10.69
Rate for Payer: UnitedHealthcare Medicaid	$4.50
Rate for Payer: WPPA Medicare Advantage	$6.75

IV CLV Blood Secondary Tubing

Facility

$11.25

Hospital Charge Code	3256570
Hospital Revenue Code	270
Min. Negotiated Rate	$10.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.12
Rate for Payer: UnitedHealthcare Commercial	$10.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IV CLV Blood Y Tubing

Facility

$13.64

Hospital Charge Code	3252421
Hospital Revenue Code	270
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$12.96
Rate for Payer: Aetna Commercial	$12.28
Rate for Payer: Humana Medicare Advantage	$5.73
Rate for Payer: UnitedHealthcare Commercial	$12.96
Rate for Payer: UnitedHealthcare Medicaid	$5.46
Rate for Payer: WPPA Medicare Advantage	$8.18

IV CLV Blood Y Tubing

Facility

$13.64

Hospital Charge Code	3252421
Hospital Revenue Code	270
Min. Negotiated Rate	$12.28
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.28
Rate for Payer: UnitedHealthcare Commercial	$12.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IV CLV Blood Y Tubing w/Pump

Facility

$17.96

Hospital Charge Code	3252418
Hospital Revenue Code	270
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$17.06
Rate for Payer: Aetna Commercial	$16.16
Rate for Payer: Humana Medicare Advantage	$7.54
Rate for Payer: UnitedHealthcare Commercial	$17.06
Rate for Payer: UnitedHealthcare Medicaid	$7.18
Rate for Payer: WPPA Medicare Advantage	$10.78

IV CLV Blood Y Tubing w/Pump

Facility

$17.96

Hospital Charge Code	3252418
Hospital Revenue Code	270
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.16
Rate for Payer: UnitedHealthcare Commercial	$17.06
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IV CLV Male Port Adapter

Facility

$4.05

Hospital Charge Code	3259461
Hospital Revenue Code	270
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$3.85
Rate for Payer: Aetna Commercial	$3.65
Rate for Payer: Humana Medicare Advantage	$1.70
Rate for Payer: UnitedHealthcare Commercial	$3.85
Rate for Payer: UnitedHealthcare Medicaid	$1.62
Rate for Payer: WPPA Medicare Advantage	$2.43

IV CLV Male Port Adapter

Facility

$4.05

Hospital Charge Code	3259461
Hospital Revenue Code	270
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.65
Rate for Payer: UnitedHealthcare Commercial	$3.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IV CLV Microdrip Tubing

Facility

$17.87

Hospital Charge Code	3253957
Hospital Revenue Code	270
Min. Negotiated Rate	$16.08
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.08
Rate for Payer: UnitedHealthcare Commercial	$16.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IV CLV Microdrip Tubing

Facility

$17.87

Hospital Charge Code	3253957
Hospital Revenue Code	270
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$16.98
Rate for Payer: Aetna Commercial	$16.08
Rate for Payer: Humana Medicare Advantage	$7.51
Rate for Payer: UnitedHealthcare Commercial	$16.98
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: WPPA Medicare Advantage	$10.72

IVF D10 250 LC

Facility

$11.07

Hospital Charge Code	3254928
Hospital Revenue Code	259
Min. Negotiated Rate	$9.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.96
Rate for Payer: UnitedHealthcare Commercial	$10.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IVF D10 250 LC

Facility

$11.07

Hospital Charge Code	3254928
Hospital Revenue Code	259
Min. Negotiated Rate	$4.43
Max. Negotiated Rate	$10.52
Rate for Payer: Aetna Commercial	$9.96
Rate for Payer: Humana Medicare Advantage	$4.65
Rate for Payer: UnitedHealthcare Commercial	$10.52
Rate for Payer: UnitedHealthcare Medicaid	$4.43
Rate for Payer: WPPA Medicare Advantage	$6.64

IVF D10 500 LC

Facility

$14.00

Hospital Charge Code	3254922
Hospital Revenue Code	258
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$13.30
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: Humana Medicare Advantage	$5.88
Rate for Payer: UnitedHealthcare Commercial	$13.30
Rate for Payer: UnitedHealthcare Medicaid	$5.60
Rate for Payer: WPPA Medicare Advantage	$8.40

IVF D10 500 LC

Facility

$14.00

Hospital Charge Code	3254922
Hospital Revenue Code	258
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: UnitedHealthcare Commercial	$13.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IVF D5 1000 LC

Facility

$13.23

Service Code	HCPCS jJ7070
Hospital Charge Code	3250128
Hospital Revenue Code	636
Min. Negotiated Rate	$11.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.91
Rate for Payer: UnitedHealthcare Commercial	$12.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IVF D5 1000 LC

Facility

$13.23

Service Code	HCPCS jJ7070
Hospital Charge Code	3250128
Hospital Revenue Code	636
Min. Negotiated Rate	$5.29
Max. Negotiated Rate	$12.57
Rate for Payer: Aetna Commercial	$11.91
Rate for Payer: Humana Medicare Advantage	$5.56
Rate for Payer: UnitedHealthcare Commercial	$12.57
Rate for Payer: UnitedHealthcare Medicaid	$5.29
Rate for Payer: WPPA Medicare Advantage	$7.94

IVF D5 100 LC

Facility

$4.00

Hospital Charge Code	3255390
Hospital Revenue Code	258
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IVF D5 100 LC

Facility

$4.00

Hospital Charge Code	3255390
Hospital Revenue Code	258
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.80
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Humana Medicare Advantage	$1.68
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: UnitedHealthcare Medicaid	$1.60
Rate for Payer: WPPA Medicare Advantage	$2.40

IVF D5 1/2 NS 1000 LC

Facility

$13.14

Hospital Charge Code	3253932
Hospital Revenue Code	258
Min. Negotiated Rate	$11.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.83
Rate for Payer: UnitedHealthcare Commercial	$12.48
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IVF D5 1/2 NS 1000 LC

Facility

$13.14

Hospital Charge Code	3253932
Hospital Revenue Code	258
Min. Negotiated Rate	$5.26
Max. Negotiated Rate	$12.48
Rate for Payer: Aetna Commercial	$11.83
Rate for Payer: Humana Medicare Advantage	$5.52
Rate for Payer: UnitedHealthcare Commercial	$12.48
Rate for Payer: UnitedHealthcare Medicaid	$5.26
Rate for Payer: WPPA Medicare Advantage	$7.88

IVF D5 250 ADV

Facility

$8.00

Hospital Charge Code	3256901
Hospital Revenue Code	258
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.20
Rate for Payer: UnitedHealthcare Commercial	$7.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IVF D5 250 ADV

Facility

$8.00

Hospital Charge Code	3256901
Hospital Revenue Code	258
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$7.60
Rate for Payer: Aetna Commercial	$7.20
Rate for Payer: Humana Medicare Advantage	$3.36
Rate for Payer: UnitedHealthcare Commercial	$7.60
Rate for Payer: UnitedHealthcare Medicaid	$3.20
Rate for Payer: WPPA Medicare Advantage	$4.80

Know your out-of-pocket cost for care.

All Charges