Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

Sodium w/o Creat U24 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

Sodium w/o Creat U24 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

SOF-CARE COMPANION OVERLAY

Facility

$117.56

Hospital Charge Code	3253025
Hospital Revenue Code	270
Min. Negotiated Rate	$105.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$105.80
Rate for Payer: UnitedHealthcare Commercial	$111.68
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SOF-CARE COMPANION OVERLAY

Facility

$117.56

Hospital Charge Code	3253025
Hospital Revenue Code	270
Min. Negotiated Rate	$47.02
Max. Negotiated Rate	$111.68
Rate for Payer: Aetna Commercial	$105.80
Rate for Payer: Humana Medicare Advantage	$49.38
Rate for Payer: UnitedHealthcare Commercial	$111.68
Rate for Payer: UnitedHealthcare Medicaid	$47.02
Rate for Payer: WPPA Medicare Advantage	$70.54

SOFT TISSUE PROCEDURES WITH CC

Facility

$6,608.16

Service Code	MSDRG 501
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,608.16
Rate for Payer: UnitedHealthcare Medicaid	$6,608.16
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SOFT TISSUE PROCEDURES WITH MCC

Facility

$11,977.29

Service Code	MSDRG 500
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$11,977.29
Rate for Payer: UnitedHealthcare Medicaid	$11,977.29
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SOFT TISSUE PROCEDURES WITHOUT CC/MCC

Facility

$5,083.20

Service Code	MSDRG 502
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,083.20
Rate for Payer: UnitedHealthcare Medicaid	$5,083.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

solifenacin 5 mg Tab [HMC]

Facility

$35.84

Service Code	NDC 51248015001
Hospital Charge Code	3800371
Hospital Revenue Code	250
Min. Negotiated Rate	$32.26
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$32.26
Rate for Payer: UnitedHealthcare Commercial	$34.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

solifenacin 5 mg Tab [HMC]

Facility

$34.30

Service Code	NDC 68462038630
Hospital Charge Code	3800371
Hospital Revenue Code	250
Min. Negotiated Rate	$30.87
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$30.87
Rate for Payer: UnitedHealthcare Commercial	$32.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

solifenacin 5 mg Tab [HMC]

Facility

$35.84

Service Code	NDC 51248015001
Hospital Charge Code	3800371
Hospital Revenue Code	250
Min. Negotiated Rate	$14.34
Max. Negotiated Rate	$34.05
Rate for Payer: Aetna Commercial	$32.26
Rate for Payer: Humana Medicare Advantage	$15.05
Rate for Payer: UnitedHealthcare Commercial	$34.05
Rate for Payer: UnitedHealthcare Medicaid	$14.34
Rate for Payer: WPPA Medicare Advantage	$21.50

solifenacin 5 mg Tab [HMC]

Facility

$34.30

Service Code	NDC 68462038630
Hospital Charge Code	3800371
Hospital Revenue Code	250
Min. Negotiated Rate	$13.72
Max. Negotiated Rate	$32.59
Rate for Payer: Aetna Commercial	$30.87
Rate for Payer: Humana Medicare Advantage	$14.41
Rate for Payer: UnitedHealthcare Commercial	$32.59
Rate for Payer: UnitedHealthcare Medicaid	$13.72
Rate for Payer: WPPA Medicare Advantage	$20.58

Soluble Liver Antigen (SLA) Autoantibody QST

Facility

$135.00

Service Code	HCPCS 83520
Hospital Charge Code	3558928
Hospital Revenue Code	300
Min. Negotiated Rate	$121.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$121.50
Rate for Payer: UnitedHealthcare Commercial	$128.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Soluble Liver Antigen (SLA) Autoantibody QST

Facility

$135.00

Service Code	HCPCS 83520
Hospital Charge Code	3558928
Hospital Revenue Code	300
Min. Negotiated Rate	$36.48
Max. Negotiated Rate	$128.25
Rate for Payer: Aetna Commercial	$121.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.48
Rate for Payer: Humana Medicare Advantage	$56.70
Rate for Payer: UnitedHealthcare Commercial	$128.25
Rate for Payer: UnitedHealthcare Medicaid	$54.00
Rate for Payer: WPPA Medicare Advantage	$81.00

SOLUM CONE REAMER 18MM

Facility

$676.80

Hospital Charge Code	3258136
Hospital Revenue Code	270
Min. Negotiated Rate	$609.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$609.12
Rate for Payer: UnitedHealthcare Commercial	$642.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SOLUM CONE REAMER 18MM

Facility

$676.80

Hospital Charge Code	3258136
Hospital Revenue Code	270
Min. Negotiated Rate	$270.72
Max. Negotiated Rate	$642.96
Rate for Payer: Aetna Commercial	$609.12
Rate for Payer: Humana Medicare Advantage	$284.26
Rate for Payer: UnitedHealthcare Commercial	$642.96
Rate for Payer: UnitedHealthcare Medicaid	$270.72
Rate for Payer: WPPA Medicare Advantage	$406.08

SOLUM CUP REAMER 18MM

Facility

$676.80

Hospital Charge Code	3258135
Hospital Revenue Code	270
Min. Negotiated Rate	$609.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$609.12
Rate for Payer: UnitedHealthcare Commercial	$642.96
Rate for Payer: WPPA Medicare Advantage	$1,200.00

SOLUM CUP REAMER 18MM

Facility

$676.80

Hospital Charge Code	3258135
Hospital Revenue Code	270
Min. Negotiated Rate	$270.72
Max. Negotiated Rate	$642.96
Rate for Payer: Aetna Commercial	$609.12
Rate for Payer: Humana Medicare Advantage	$284.26
Rate for Payer: UnitedHealthcare Commercial	$642.96
Rate for Payer: UnitedHealthcare Medicaid	$270.72
Rate for Payer: WPPA Medicare Advantage	$406.08

sotalol 80 mg Tab [HMC]

Facility

$11.96

Service Code	NDC 68084065401
Hospital Charge Code	3808323
Hospital Revenue Code	250
Min. Negotiated Rate	$4.78
Max. Negotiated Rate	$11.36
Rate for Payer: Aetna Commercial	$10.76
Rate for Payer: Humana Medicare Advantage	$5.02
Rate for Payer: UnitedHealthcare Commercial	$11.36
Rate for Payer: UnitedHealthcare Medicaid	$4.78
Rate for Payer: WPPA Medicare Advantage	$7.18

sotalol 80 mg Tab [HMC]

Facility

$9.02

Service Code	NDC 00904714361
Hospital Charge Code	3808323
Hospital Revenue Code	250
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.12
Rate for Payer: UnitedHealthcare Commercial	$8.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sotalol 80 mg Tab [HMC]

Facility

$9.02

Service Code	NDC 00904714361
Hospital Charge Code	3808323
Hospital Revenue Code	250
Min. Negotiated Rate	$3.61
Max. Negotiated Rate	$8.57
Rate for Payer: Aetna Commercial	$8.12
Rate for Payer: Humana Medicare Advantage	$3.79
Rate for Payer: UnitedHealthcare Commercial	$8.57
Rate for Payer: UnitedHealthcare Medicaid	$3.61
Rate for Payer: WPPA Medicare Advantage	$5.41

sotalol 80 mg Tab [HMC]

Facility

$11.96

Service Code	NDC 68084065401
Hospital Charge Code	3808323
Hospital Revenue Code	250
Min. Negotiated Rate	$10.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.76
Rate for Payer: UnitedHealthcare Commercial	$11.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sotrovimab 500 mg/8 mL Sol [HMC]

Facility

$3,800.00

Service Code	HCPCS Q0247
Hospital Charge Code	3850210
Hospital Revenue Code	250
Min. Negotiated Rate	$1,520.00
Max. Negotiated Rate	$3,610.00
Rate for Payer: Aetna Commercial	$3,420.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$2,848.86
Rate for Payer: Humana Medicare Advantage	$1,596.00
Rate for Payer: UnitedHealthcare Commercial	$3,610.00
Rate for Payer: UnitedHealthcare Medicaid	$1,520.00
Rate for Payer: WPPA Medicare Advantage	$2,280.00

sotrovimab 500 mg/8 mL Sol [HMC]

Facility

$3,800.00

Service Code	HCPCS Q0247
Hospital Charge Code	3850210
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$3,610.00
Rate for Payer: Aetna Commercial	$3,420.00
Rate for Payer: UnitedHealthcare Commercial	$3,610.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Soybean (F14) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552819
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

Soybean (F14) IgE QST

Facility

$21.00

Service Code	HCPCS 86003
Hospital Charge Code	3552819
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$12.60

Know your out-of-pocket cost for care.

All Charges