Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

sodium chloride 7% Inh Sol 4 ml [HMC]

Facility

$11.68

Service Code	NDC 70756066460
Hospital Charge Code	3800515
Hospital Revenue Code	250
Min. Negotiated Rate	$10.51
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.51
Rate for Payer: UnitedHealthcare Commercial	$11.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium chloride 7% Inh Sol 4 mL [HMC]

Facility

$11.77

Service Code	NDC 83490020760
Hospital Charge Code	3800515
Hospital Revenue Code	250
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$11.18
Rate for Payer: Aetna Commercial	$10.59
Rate for Payer: Humana Medicare Advantage	$4.94
Rate for Payer: UnitedHealthcare Commercial	$11.18
Rate for Payer: UnitedHealthcare Medicaid	$4.71
Rate for Payer: WPPA Medicare Advantage	$7.06

sodium chloride 7% Inh Sol 4 mL [HMC]

Facility

$11.77

Service Code	NDC 83490020760
Hospital Charge Code	3800515
Hospital Revenue Code	250
Min. Negotiated Rate	$10.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.59
Rate for Payer: UnitedHealthcare Commercial	$11.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium chloride nasal 0.65% Gel [HMC]

Facility

$26.68

Service Code	NDC 00225052547
Hospital Charge Code	3800553
Hospital Revenue Code	250
Min. Negotiated Rate	$10.67
Max. Negotiated Rate	$25.35
Rate for Payer: Aetna Commercial	$24.01
Rate for Payer: Humana Medicare Advantage	$11.21
Rate for Payer: UnitedHealthcare Commercial	$25.35
Rate for Payer: UnitedHealthcare Medicaid	$10.67
Rate for Payer: WPPA Medicare Advantage	$16.01

sodium chloride nasal 0.65% Gel [HMC]

Facility

$26.68

Service Code	NDC 00225052547
Hospital Charge Code	3800553
Hospital Revenue Code	250
Min. Negotiated Rate	$24.01
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.01
Rate for Payer: UnitedHealthcare Commercial	$25.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium chloride Nasal 0.65% Spry [HMC]

Facility

$24.20

Service Code	NDC 00904386575
Hospital Charge Code	3805187
Hospital Revenue Code	250
Min. Negotiated Rate	$9.68
Max. Negotiated Rate	$22.99
Rate for Payer: Aetna Commercial	$21.78
Rate for Payer: Humana Medicare Advantage	$10.16
Rate for Payer: UnitedHealthcare Commercial	$22.99
Rate for Payer: UnitedHealthcare Medicaid	$9.68
Rate for Payer: WPPA Medicare Advantage	$14.52

sodium chloride Nasal 0.65% Spry [HMC]

Facility

$24.20

Service Code	NDC 00904386575
Hospital Charge Code	3805187
Hospital Revenue Code	250
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.78
Rate for Payer: UnitedHealthcare Commercial	$22.99
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium ferric gluconate complex 12.5 mg/mL IV Sol [HMC]

Facility

$86.32

Service Code	NDC 00143957010
Hospital Charge Code	3851258
Hospital Revenue Code	250
Min. Negotiated Rate	$77.69
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$77.69
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium ferric gluconate complex 12.5 mg/mL IV Sol [HMC]

Facility

$86.32

Service Code	NDC 00143957010
Hospital Charge Code	3851258
Hospital Revenue Code	250
Min. Negotiated Rate	$34.53
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.69
Rate for Payer: Humana Medicare Advantage	$36.25
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: UnitedHealthcare Medicaid	$34.53
Rate for Payer: WPPA Medicare Advantage	$51.79

sodium ferric gluconate complex 12.5 mg/mL IV Sol [HMC]

Facility

$41.90

Service Code	HCPCS J2916
Hospital Charge Code	3851258
Hospital Revenue Code	250
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$39.80
Rate for Payer: Aetna Commercial	$37.71
Rate for Payer: Aetna Commercial	$77.69
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.81
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2.81
Rate for Payer: Humana Medicare Advantage	$36.25
Rate for Payer: Humana Medicare Advantage	$17.60
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: UnitedHealthcare Commercial	$39.80
Rate for Payer: UnitedHealthcare Medicaid	$2.21
Rate for Payer: UnitedHealthcare Medicaid	$2.21
Rate for Payer: WPPA Medicare Advantage	$25.14
Rate for Payer: WPPA Medicare Advantage	$51.79

sodium ferric gluconate complex 12.5 mg/mL IV Sol [HMC]

Facility

$41.90

Service Code	HCPCS J2916
Hospital Charge Code	3851258
Hospital Revenue Code	250
Min. Negotiated Rate	$37.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$37.71
Rate for Payer: Aetna Commercial	$77.69
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: UnitedHealthcare Commercial	$39.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium hyaluronate 10 mg/mL intra-articular Sol 2 mL [HMC]

Facility

$669.13

Service Code	HCPCS J7321
Hospital Charge Code	3850074
Hospital Revenue Code	250
Min. Negotiated Rate	$72.97
Max. Negotiated Rate	$635.67
Rate for Payer: Aetna Commercial	$602.22
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$94.03
Rate for Payer: Humana Medicare Advantage	$281.03
Rate for Payer: UnitedHealthcare Commercial	$635.67
Rate for Payer: UnitedHealthcare Medicaid	$72.97
Rate for Payer: WPPA Medicare Advantage	$401.48

sodium hyaluronate 10 mg/mL intra-articular Sol 2 mL [HMC]

Facility

$669.13

Service Code	HCPCS J7321
Hospital Charge Code	3850074
Hospital Revenue Code	250
Min. Negotiated Rate	$602.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$602.22
Rate for Payer: UnitedHealthcare Commercial	$635.67
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium hyaluronate 10 mg/mL intra-articular Sol [HMC]

Facility

$362.00

Service Code	HCPCS J7321
Hospital Charge Code	3803828
Hospital Revenue Code	250
Min. Negotiated Rate	$72.97
Max. Negotiated Rate	$343.90
Rate for Payer: Aetna Commercial	$325.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$94.03
Rate for Payer: Humana Medicare Advantage	$152.04
Rate for Payer: UnitedHealthcare Commercial	$343.90
Rate for Payer: UnitedHealthcare Medicaid	$72.97
Rate for Payer: WPPA Medicare Advantage	$217.20

sodium hyaluronate 10 mg/mL intra-articular Sol [HMC]

Facility

$362.00

Service Code	HCPCS J7321
Hospital Charge Code	3803828
Hospital Revenue Code	250
Min. Negotiated Rate	$325.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$325.80
Rate for Payer: UnitedHealthcare Commercial	$343.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium hypochlorite Top 0.25% Sol [HMC]

Facility

$43.40

Service Code	NDC 00436093616
Hospital Charge Code	3800251
Hospital Revenue Code	250
Min. Negotiated Rate	$39.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$39.06
Rate for Payer: UnitedHealthcare Commercial	$41.23
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium hypochlorite Top 0.25% Sol [HMC]

Facility

$43.40

Service Code	NDC 00436093616
Hospital Charge Code	3800251
Hospital Revenue Code	250
Min. Negotiated Rate	$17.36
Max. Negotiated Rate	$41.23
Rate for Payer: Aetna Commercial	$39.06
Rate for Payer: Humana Medicare Advantage	$18.23
Rate for Payer: UnitedHealthcare Commercial	$41.23
Rate for Payer: UnitedHealthcare Medicaid	$17.36
Rate for Payer: WPPA Medicare Advantage	$26.04

Sodium Level

Facility

$21.00

Service Code	HCPCS 84295
Hospital Charge Code	3550742
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sodium Level

Facility

$21.00

Service Code	HCPCS 84295
Hospital Charge Code	3550742
Hospital Revenue Code	300
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$10.33
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: WPPA Medicare Advantage	$12.60

sodium polystyrene sulfonate 15 g/60 mL Sus UD [HMC]

Facility

$51.85

Service Code	NDC 46287000660
Hospital Charge Code	3807258
Hospital Revenue Code	250
Min. Negotiated Rate	$46.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$46.66
Rate for Payer: UnitedHealthcare Commercial	$49.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium polystyrene sulfonate 15 g/60 mL Sus UD [HMC]

Facility

$51.85

Service Code	NDC 62559035601
Hospital Charge Code	3807258
Hospital Revenue Code	250
Min. Negotiated Rate	$20.74
Max. Negotiated Rate	$49.26
Rate for Payer: Aetna Commercial	$46.66
Rate for Payer: Humana Medicare Advantage	$21.78
Rate for Payer: UnitedHealthcare Commercial	$49.26
Rate for Payer: UnitedHealthcare Medicaid	$20.74
Rate for Payer: WPPA Medicare Advantage	$31.11

sodium polystyrene sulfonate 15 g/60 mL Sus UD [HMC]

Facility

$51.85

Service Code	NDC 46287000660
Hospital Charge Code	3807258
Hospital Revenue Code	250
Min. Negotiated Rate	$20.74
Max. Negotiated Rate	$49.26
Rate for Payer: Aetna Commercial	$46.66
Rate for Payer: Humana Medicare Advantage	$21.78
Rate for Payer: UnitedHealthcare Commercial	$49.26
Rate for Payer: UnitedHealthcare Medicaid	$20.74
Rate for Payer: WPPA Medicare Advantage	$31.11

sodium polystyrene sulfonate 15 g/60 mL Sus UD [HMC]

Facility

$51.85

Service Code	NDC 62559035601
Hospital Charge Code	3807258
Hospital Revenue Code	250
Min. Negotiated Rate	$46.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$46.66
Rate for Payer: UnitedHealthcare Commercial	$49.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Sodium, U (w/o Creatinine) QST

Facility

$78.00

Service Code	HCPCS 84300
Hospital Charge Code	3550745
Hospital Revenue Code	300
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$74.10
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$19.53
Rate for Payer: Humana Medicare Advantage	$32.76
Rate for Payer: UnitedHealthcare Commercial	$74.10
Rate for Payer: UnitedHealthcare Medicaid	$4.30
Rate for Payer: WPPA Medicare Advantage	$46.80

Sodium, U (w/o Creatinine) QST

Facility

$78.00

Service Code	HCPCS 84300
Hospital Charge Code	3550745
Hospital Revenue Code	300
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: UnitedHealthcare Commercial	$74.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges