Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

IVF NS 250 ADV

Facility

$15.66

Service Code	HCPCS J7030
Hospital Charge Code	3256919
Hospital Revenue Code	636
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$14.88
Rate for Payer: Aetna Commercial	$14.09
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.39
Rate for Payer: Humana Medicare Advantage	$6.58
Rate for Payer: UnitedHealthcare Commercial	$14.88
Rate for Payer: UnitedHealthcare Medicaid	$1.99
Rate for Payer: WPPA Medicare Advantage	$9.40

IVF NS 250 LC

Facility

$9.95

Hospital Charge Code	3253981
Hospital Revenue Code	259
Min. Negotiated Rate	$3.98
Max. Negotiated Rate	$9.45
Rate for Payer: Aetna Commercial	$8.96
Rate for Payer: Humana Medicare Advantage	$4.18
Rate for Payer: UnitedHealthcare Commercial	$9.45
Rate for Payer: UnitedHealthcare Medicaid	$3.98
Rate for Payer: WPPA Medicare Advantage	$5.97

IVF NS 250 LC

Facility

$9.95

Hospital Charge Code	3253981
Hospital Revenue Code	259
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.96
Rate for Payer: UnitedHealthcare Commercial	$9.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IVF NS 500 LC

Facility

$11.43

Service Code	HCPCS J7040
Hospital Charge Code	3253999
Hospital Revenue Code	636
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$10.86
Rate for Payer: Aetna Commercial	$10.29
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.68
Rate for Payer: Humana Medicare Advantage	$4.80
Rate for Payer: UnitedHealthcare Commercial	$10.86
Rate for Payer: UnitedHealthcare Medicaid	$1.29
Rate for Payer: WPPA Medicare Advantage	$6.86

IVF NS 500 LC

Facility

$11.43

Service Code	HCPCS J7040
Hospital Charge Code	3253999
Hospital Revenue Code	636
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

IVF Sterile Water for Inhalation 1000ml LC Bag

Facility

$15.44

Hospital Charge Code	3256945
Hospital Revenue Code	270
Min. Negotiated Rate	$13.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.90
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IVF Sterile Water for Inhalation 1000ml LC Bag

Facility

$15.44

Hospital Charge Code	3256945
Hospital Revenue Code	270
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$14.67
Rate for Payer: Aetna Commercial	$13.90
Rate for Payer: Humana Medicare Advantage	$6.48
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicaid	$6.18
Rate for Payer: WPPA Medicare Advantage	$9.26

IVF Sterile Water for Injection USP 1,000ml Bag

Facility

$12.83

Service Code	HCPCS A4217
Hospital Charge Code	3256944
Hospital Revenue Code	258
Min. Negotiated Rate	$3.34
Max. Negotiated Rate	$12.19
Rate for Payer: Aetna Commercial	$11.55
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.34
Rate for Payer: Humana Medicare Advantage	$5.39
Rate for Payer: UnitedHealthcare Commercial	$12.19
Rate for Payer: UnitedHealthcare Medicaid	$5.13
Rate for Payer: WPPA Medicare Advantage	$7.70

IVF Sterile Water for Injection USP 1,000ml Bag

Facility

$12.83

Service Code	HCPCS A4217
Hospital Charge Code	3256944
Hospital Revenue Code	258
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$11.55
Rate for Payer: UnitedHealthcare Commercial	$12.19
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IVF Sterile Water for Irrigation 1000ml LC

Facility

$11.00

Hospital Charge Code	3257525
Hospital Revenue Code	270
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$10.45
Rate for Payer: Aetna Commercial	$9.90
Rate for Payer: Humana Medicare Advantage	$4.62
Rate for Payer: UnitedHealthcare Commercial	$10.45
Rate for Payer: UnitedHealthcare Medicaid	$4.40
Rate for Payer: WPPA Medicare Advantage	$6.60

IVF Sterile Water for Irrigation 1000ml LC

Facility

$11.00

Hospital Charge Code	3257525
Hospital Revenue Code	270
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.90
Rate for Payer: UnitedHealthcare Commercial	$10.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IV PCA CADD Flow Stop 78 Standard Administration Set w/Bag Spike Clamp and 1-Way Check Valve with M

Facility

$38.03

Hospital Charge Code	3255935
Hospital Revenue Code	270
Min. Negotiated Rate	$15.21
Max. Negotiated Rate	$36.13
Rate for Payer: Aetna Commercial	$34.23
Rate for Payer: Humana Medicare Advantage	$15.97
Rate for Payer: UnitedHealthcare Commercial	$36.13
Rate for Payer: UnitedHealthcare Medicaid	$15.21
Rate for Payer: WPPA Medicare Advantage	$22.82

IV PCA CADD Flow Stop 78 Standard Administration Set w/Bag Spike Clamp and 1-Way Check Valve with M

Facility

$38.03

Hospital Charge Code	3255935
Hospital Revenue Code	270
Min. Negotiated Rate	$34.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.23
Rate for Payer: UnitedHealthcare Commercial	$36.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

IV Plum Nitro Pump Tubing No CLV

Facility

$27.00

Hospital Charge Code	3257503
Hospital Revenue Code	270
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: WPPA Medicare Advantage	$16.20

IV Plum Nitro Pump Tubing No CLV

Facility

$27.00

Hospital Charge Code	3257503
Hospital Revenue Code	270
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Jaw Bra TMJ Ice Pack #93

Facility

$93.00

Hospital Charge Code	3251417
Hospital Revenue Code	270
Min. Negotiated Rate	$83.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$83.70
Rate for Payer: UnitedHealthcare Commercial	$88.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Jaw Bra TMJ Ice Pack #93

Facility

$93.00

Hospital Charge Code	3251417
Hospital Revenue Code	270
Min. Negotiated Rate	$37.20
Max. Negotiated Rate	$88.35
Rate for Payer: Aetna Commercial	$83.70
Rate for Payer: Humana Medicare Advantage	$39.06
Rate for Payer: UnitedHealthcare Commercial	$88.35
Rate for Payer: UnitedHealthcare Medicaid	$37.20
Rate for Payer: WPPA Medicare Advantage	$55.80

JCV Ab, Stratify UNMC

Facility

$1,748.00

Service Code	HCPCS 86711
Hospital Charge Code	3556711
Hospital Revenue Code	300
Min. Negotiated Rate	$41.42
Max. Negotiated Rate	$1,660.60
Rate for Payer: Aetna Commercial	$1,573.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$41.42
Rate for Payer: Humana Medicare Advantage	$734.16
Rate for Payer: UnitedHealthcare Commercial	$1,660.60
Rate for Payer: UnitedHealthcare Medicaid	$699.20
Rate for Payer: WPPA Medicare Advantage	$1,048.80

JCV Ab, Stratify UNMC

Facility

$1,748.00

Service Code	HCPCS 86711
Hospital Charge Code	3556711
Hospital Revenue Code	300
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,660.60
Rate for Payer: Aetna Commercial	$1,573.20
Rate for Payer: UnitedHealthcare Commercial	$1,660.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Jo-1 Antibody QST

Facility

$72.00

Service Code	HCPCS 86235
Hospital Charge Code	3556404
Hospital Revenue Code	300
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$52.26
Rate for Payer: Humana Medicare Advantage	$30.24
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$17.93
Rate for Payer: WPPA Medicare Advantage	$43.20

Jo-1 Antibody QST

Facility

$72.00

Service Code	HCPCS 86235
Hospital Charge Code	3556404
Hospital Revenue Code	300
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Kangaroo Enternal Feeding Pump w/Flush Bag Anti-Free Flow 1000mL for EPump

Facility

$24.35

Hospital Charge Code	3257688
Hospital Revenue Code	270
Min. Negotiated Rate	$21.91
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.91
Rate for Payer: UnitedHealthcare Commercial	$23.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Kangaroo Enternal Feeding Pump w/Flush Bag Anti-Free Flow 1000mL for EPump

Facility

$24.35

Hospital Charge Code	3257688
Hospital Revenue Code	270
Min. Negotiated Rate	$9.74
Max. Negotiated Rate	$23.13
Rate for Payer: Aetna Commercial	$21.91
Rate for Payer: Humana Medicare Advantage	$10.23
Rate for Payer: UnitedHealthcare Commercial	$23.13
Rate for Payer: UnitedHealthcare Medicaid	$9.74
Rate for Payer: WPPA Medicare Advantage	$14.61

Kappa/Lambda Light Chain,Total,Serum QST

Facility

$93.00

Service Code	HCPCS 83883
Hospital Charge Code	3557096
Hospital Revenue Code	300
Min. Negotiated Rate	$37.20
Max. Negotiated Rate	$88.35
Rate for Payer: Aetna Commercial	$83.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$49.63
Rate for Payer: Humana Medicare Advantage	$39.06
Rate for Payer: UnitedHealthcare Commercial	$88.35
Rate for Payer: UnitedHealthcare Medicaid	$37.20
Rate for Payer: WPPA Medicare Advantage	$55.80

Kappa/Lambda Light Chain,Total,Serum QST

Facility

$93.00

Service Code	HCPCS 83883
Hospital Charge Code	3557096
Hospital Revenue Code	300
Min. Negotiated Rate	$83.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$83.70
Rate for Payer: UnitedHealthcare Commercial	$88.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges