Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Sodium Chloride 0.45% IV Sol 1000 mL [HMC]

Facility

$36.69

Service Code	NDC 63323062610
Hospital Charge Code	3254005
Hospital Revenue Code	250
Min. Negotiated Rate	$33.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.02
Rate for Payer: UnitedHealthcare Commercial	$34.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sodium Chloride 0.45% IV Sol 1000 mL [HMC]

Facility

$36.69

Service Code	NDC 63323062610
Hospital Charge Code	3254005
Hospital Revenue Code	250
Min. Negotiated Rate	$14.68
Max. Negotiated Rate	$34.86
Rate for Payer: Aetna Commercial	$33.02
Rate for Payer: Humana Medicare Advantage	$15.41
Rate for Payer: UnitedHealthcare Commercial	$34.86
Rate for Payer: UnitedHealthcare Medicaid	$14.68
Rate for Payer: WPPA Medicare Advantage	$22.01

Sodium Chloride 0.45% IV Sol 1000 mL [HMC]

Facility

$40.83

Service Code	NDC 00409798509
Hospital Charge Code	3254005
Hospital Revenue Code	250
Min. Negotiated Rate	$36.75
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.75
Rate for Payer: UnitedHealthcare Commercial	$38.79
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium chloride 0.9% Inh Sol 3 mL [HMC]

Facility

$21.72

Service Code	NDC 76204030003
Hospital Charge Code	3807209
Hospital Revenue Code	259
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.55
Rate for Payer: UnitedHealthcare Commercial	$20.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium chloride 0.9% Inh Sol 3 mL [HMC]

Facility

$21.72

Service Code	NDC 76204030003
Hospital Charge Code	3807209
Hospital Revenue Code	259
Min. Negotiated Rate	$8.69
Max. Negotiated Rate	$20.63
Rate for Payer: Aetna Commercial	$19.55
Rate for Payer: Humana Medicare Advantage	$9.12
Rate for Payer: UnitedHealthcare Commercial	$20.63
Rate for Payer: UnitedHealthcare Medicaid	$8.69
Rate for Payer: WPPA Medicare Advantage	$13.03

sodium chloride 0.9% Inj Sol 10 mL [HMC]

Facility

$23.11

Service Code	HCPCS A4216
Hospital Charge Code	3808934
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$21.95
Rate for Payer: Aetna Commercial	$20.80
Rate for Payer: Aetna Commercial	$21.01
Rate for Payer: Aetna Commercial	$23.09
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.57
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.57
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.57
Rate for Payer: Humana Medicare Advantage	$9.80
Rate for Payer: Humana Medicare Advantage	$9.71
Rate for Payer: Humana Medicare Advantage	$10.77
Rate for Payer: UnitedHealthcare Commercial	$24.37
Rate for Payer: UnitedHealthcare Commercial	$21.95
Rate for Payer: UnitedHealthcare Commercial	$22.17
Rate for Payer: UnitedHealthcare Medicaid	$10.26
Rate for Payer: UnitedHealthcare Medicaid	$9.34
Rate for Payer: UnitedHealthcare Medicaid	$9.24
Rate for Payer: WPPA Medicare Advantage	$13.87
Rate for Payer: WPPA Medicare Advantage	$14.00
Rate for Payer: WPPA Medicare Advantage	$15.39

sodium chloride 0.9% Inj Sol 10 mL [HMC]

Facility

$23.11

Service Code	NDC 08290306546
Hospital Charge Code	3808934
Hospital Revenue Code	250
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$21.95
Rate for Payer: Aetna Commercial	$20.80
Rate for Payer: Humana Medicare Advantage	$9.71
Rate for Payer: UnitedHealthcare Commercial	$21.95
Rate for Payer: UnitedHealthcare Medicaid	$9.24
Rate for Payer: WPPA Medicare Advantage	$13.87

sodium chloride 0.9% Inj Sol 10 mL [HMC]

Facility

$23.11

Service Code	NDC 08290306546
Hospital Charge Code	3808934
Hospital Revenue Code	250
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.80
Rate for Payer: UnitedHealthcare Commercial	$21.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium chloride 0.9% Inj Sol 10 mL [HMC]

Facility

$23.34

Service Code	HCPCS A4216
Hospital Charge Code	3808934
Hospital Revenue Code	250
Min. Negotiated Rate	$21.01
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.01
Rate for Payer: Aetna Commercial	$20.80
Rate for Payer: Aetna Commercial	$23.09
Rate for Payer: UnitedHealthcare Commercial	$24.37
Rate for Payer: UnitedHealthcare Commercial	$22.17
Rate for Payer: UnitedHealthcare Commercial	$21.95
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

sodium chloride 0.9% Inj Sol 2 mL [HMC]

Facility

$37.62

Service Code	HCPCS A4216
Hospital Charge Code	3807241
Hospital Revenue Code	250
Min. Negotiated Rate	$33.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.86
Rate for Payer: UnitedHealthcare Commercial	$35.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium chloride 0.9% Inj Sol 2 mL [HMC]

Facility

$37.62

Service Code	HCPCS A4216
Hospital Charge Code	3807241
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$35.74
Rate for Payer: Aetna Commercial	$33.86
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.57
Rate for Payer: Humana Medicare Advantage	$15.80
Rate for Payer: UnitedHealthcare Commercial	$35.74
Rate for Payer: UnitedHealthcare Medicaid	$15.05
Rate for Payer: WPPA Medicare Advantage	$22.57

sodium chloride 0.9% Inj Sol 3 mL [HMC]

Facility

$22.95

Service Code	HCPCS A4216
Hospital Charge Code	3807209
Hospital Revenue Code	259
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$21.80
Rate for Payer: Aetna Commercial	$20.66
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.57
Rate for Payer: Humana Medicare Advantage	$9.64
Rate for Payer: UnitedHealthcare Commercial	$21.80
Rate for Payer: UnitedHealthcare Medicaid	$9.18
Rate for Payer: WPPA Medicare Advantage	$13.77

sodium chloride 0.9% Inj Sol 3 mL [HMC]

Facility

$22.95

Service Code	HCPCS A4216
Hospital Charge Code	3807209
Hospital Revenue Code	250
Min. Negotiated Rate	$20.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.66
Rate for Payer: UnitedHealthcare Commercial	$21.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium chloride 0.9% Inj Sol 3 mL [HMC]

Facility

$22.95

Service Code	HCPCS A4216
Hospital Charge Code	3807209
Hospital Revenue Code	259
Min. Negotiated Rate	$20.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.66
Rate for Payer: UnitedHealthcare Commercial	$21.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium chloride 0.9% Inj Sol 3 mL [HMC]

Facility

$22.95

Service Code	HCPCS A4216
Hospital Charge Code	3807209
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$21.80
Rate for Payer: Aetna Commercial	$20.66
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.57
Rate for Payer: Humana Medicare Advantage	$9.64
Rate for Payer: UnitedHealthcare Commercial	$21.80
Rate for Payer: UnitedHealthcare Medicaid	$9.18
Rate for Payer: WPPA Medicare Advantage	$13.77

sodium chloride 0.9% Inj Sol 50 mL [HMC]

Facility

$39.27

Service Code	HCPCS A4216
Hospital Charge Code	3807233
Hospital Revenue Code	250
Min. Negotiated Rate	$35.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.34
Rate for Payer: UnitedHealthcare Commercial	$37.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium chloride 0.9% Inj Sol 50 mL [HMC]

Facility

$39.27

Service Code	HCPCS A4216
Hospital Charge Code	3807233
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$37.31
Rate for Payer: Aetna Commercial	$35.34
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.57
Rate for Payer: Humana Medicare Advantage	$16.49
Rate for Payer: UnitedHealthcare Commercial	$37.31
Rate for Payer: UnitedHealthcare Medicaid	$15.71
Rate for Payer: WPPA Medicare Advantage	$23.56

sodium chloride 0.9% Inj Sol 5 mL [HMC]

Facility

$23.00

Service Code	HCPCS A4216
Hospital Charge Code	3807217
Hospital Revenue Code	259
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.70
Rate for Payer: UnitedHealthcare Commercial	$21.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium chloride 0.9% Inj Sol 5 mL [HMC]

Facility

$23.00

Service Code	HCPCS A4216
Hospital Charge Code	3807217
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$21.85
Rate for Payer: Aetna Commercial	$20.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.57
Rate for Payer: Humana Medicare Advantage	$9.66
Rate for Payer: UnitedHealthcare Commercial	$21.85
Rate for Payer: UnitedHealthcare Medicaid	$9.20
Rate for Payer: WPPA Medicare Advantage	$13.80

sodium chloride 0.9% Inj Sol 5 mL [HMC]

Facility

$23.00

Service Code	HCPCS A4216
Hospital Charge Code	3807217
Hospital Revenue Code	259
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$21.85
Rate for Payer: Aetna Commercial	$20.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.57
Rate for Payer: Humana Medicare Advantage	$9.66
Rate for Payer: UnitedHealthcare Commercial	$21.85
Rate for Payer: UnitedHealthcare Medicaid	$9.20
Rate for Payer: WPPA Medicare Advantage	$13.80

sodium chloride 0.9% Inj Sol 5 mL [HMC]

Facility

$23.00

Service Code	HCPCS A4216
Hospital Charge Code	3807217
Hospital Revenue Code	250
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$20.70
Rate for Payer: UnitedHealthcare Commercial	$21.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sodium Chloride 0.9% IV Sol 1000 mL [HMC]

Facility

$39.68

Service Code	NDC 00409798309
Hospital Charge Code	3253973
Hospital Revenue Code	250
Min. Negotiated Rate	$35.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.71
Rate for Payer: UnitedHealthcare Commercial	$37.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sodium Chloride 0.9% IV Sol 1000 mL [HMC]

Facility

$39.68

Service Code	NDC 00409798309
Hospital Charge Code	3253973
Hospital Revenue Code	250
Min. Negotiated Rate	$15.87
Max. Negotiated Rate	$37.70
Rate for Payer: Aetna Commercial	$35.71
Rate for Payer: Humana Medicare Advantage	$16.67
Rate for Payer: UnitedHealthcare Commercial	$37.70
Rate for Payer: UnitedHealthcare Medicaid	$15.87
Rate for Payer: WPPA Medicare Advantage	$23.81

Sodium Chloride 0.9% IV Sol 1000 mL [HMC]

Facility

$38.28

Service Code	HCPCS J7040
Hospital Charge Code	3253973
Hospital Revenue Code	250
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$36.37
Rate for Payer: Aetna Commercial	$34.45
Rate for Payer: Aetna Commercial	$25.93
Rate for Payer: Aetna Commercial	$35.71
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.68
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.68
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.68
Rate for Payer: Humana Medicare Advantage	$16.67
Rate for Payer: Humana Medicare Advantage	$12.10
Rate for Payer: Humana Medicare Advantage	$16.08
Rate for Payer: UnitedHealthcare Commercial	$37.70
Rate for Payer: UnitedHealthcare Commercial	$36.37
Rate for Payer: UnitedHealthcare Commercial	$27.37
Rate for Payer: UnitedHealthcare Medicaid	$1.29
Rate for Payer: UnitedHealthcare Medicaid	$1.29
Rate for Payer: UnitedHealthcare Medicaid	$1.29
Rate for Payer: WPPA Medicare Advantage	$22.97
Rate for Payer: WPPA Medicare Advantage	$17.29
Rate for Payer: WPPA Medicare Advantage	$23.81

Sodium Chloride 0.9% IV Sol 1000 mL [HMC]

Facility

$38.28

Service Code	HCPCS J7040
Hospital Charge Code	3253973
Hospital Revenue Code	250
Min. Negotiated Rate	$34.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.45
Rate for Payer: Aetna Commercial	$25.93
Rate for Payer: Aetna Commercial	$35.71
Rate for Payer: UnitedHealthcare Commercial	$36.37
Rate for Payer: UnitedHealthcare Commercial	$27.37
Rate for Payer: UnitedHealthcare Commercial	$37.70
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

Know your out-of-pocket cost for care.

All Charges