Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

valproic acid 100 mg/mL [HMC]

Facility

$51.12

Service Code	NDC 00143978510
Hospital Charge Code	3800339
Hospital Revenue Code	250
Min. Negotiated Rate	$20.45
Max. Negotiated Rate	$48.56
Rate for Payer: Aetna Commercial	$46.01
Rate for Payer: Humana Medicare Advantage	$21.47
Rate for Payer: UnitedHealthcare Commercial	$48.56
Rate for Payer: UnitedHealthcare Medicaid	$20.45
Rate for Payer: WPPA Medicare Advantage	$30.67

valproic acid 250 mg/5 mL Oral Syrup [HMC]

Facility

$53.92

Service Code	NDC 00121467505
Hospital Charge Code	3800113
Hospital Revenue Code	250
Min. Negotiated Rate	$48.53
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.53
Rate for Payer: UnitedHealthcare Commercial	$51.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valproic acid 250 mg/5 mL Oral Syrup [HMC]

Facility

$53.92

Service Code	NDC 00121467505
Hospital Charge Code	3800113
Hospital Revenue Code	250
Min. Negotiated Rate	$21.57
Max. Negotiated Rate	$51.22
Rate for Payer: Aetna Commercial	$48.53
Rate for Payer: Humana Medicare Advantage	$22.65
Rate for Payer: UnitedHealthcare Commercial	$51.22
Rate for Payer: UnitedHealthcare Medicaid	$21.57
Rate for Payer: WPPA Medicare Advantage	$32.35

valproic acid 250 mg/5 mL Oral Syrup [HMC]

Facility

$15.40

Service Code	NDC 00121467540
Hospital Charge Code	3800113
Hospital Revenue Code	250
Min. Negotiated Rate	$13.86
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$13.86
Rate for Payer: UnitedHealthcare Commercial	$14.63
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valproic acid 250 mg/5 mL Oral Syrup [HMC]

Facility

$15.40

Service Code	NDC 00121467540
Hospital Charge Code	3800113
Hospital Revenue Code	250
Min. Negotiated Rate	$6.16
Max. Negotiated Rate	$14.63
Rate for Payer: Aetna Commercial	$13.86
Rate for Payer: Humana Medicare Advantage	$6.47
Rate for Payer: UnitedHealthcare Commercial	$14.63
Rate for Payer: UnitedHealthcare Medicaid	$6.16
Rate for Payer: WPPA Medicare Advantage	$9.24

Valproic Acid QST

Facility

$107.00

Service Code	HCPCS 80164
Hospital Charge Code	3551500
Hospital Revenue Code	300
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$101.65
Rate for Payer: Aetna Commercial	$96.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$65.50
Rate for Payer: Humana Medicare Advantage	$44.94
Rate for Payer: UnitedHealthcare Commercial	$101.65
Rate for Payer: UnitedHealthcare Medicaid	$13.54
Rate for Payer: WPPA Medicare Advantage	$64.20

Valproic Acid QST

Facility

$107.00

Service Code	HCPCS 80164
Hospital Charge Code	3551500
Hospital Revenue Code	300
Min. Negotiated Rate	$96.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$96.30
Rate for Payer: UnitedHealthcare Commercial	$101.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valsartan 80 mg Tab [HMC]

Facility

$8.87

Service Code	NDC 60687062301
Hospital Charge Code	3802515
Hospital Revenue Code	250
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$8.43
Rate for Payer: Aetna Commercial	$7.98
Rate for Payer: Humana Medicare Advantage	$3.73
Rate for Payer: UnitedHealthcare Commercial	$8.43
Rate for Payer: UnitedHealthcare Medicaid	$3.55
Rate for Payer: WPPA Medicare Advantage	$5.32

valsartan 80 mg Tab [HMC]

Facility

$18.84

Service Code	NDC 67877041690
Hospital Charge Code	3802515
Hospital Revenue Code	250
Min. Negotiated Rate	$7.54
Max. Negotiated Rate	$17.90
Rate for Payer: Aetna Commercial	$16.96
Rate for Payer: Humana Medicare Advantage	$7.91
Rate for Payer: UnitedHealthcare Commercial	$17.90
Rate for Payer: UnitedHealthcare Medicaid	$7.54
Rate for Payer: WPPA Medicare Advantage	$11.30

valsartan 80 mg Tab [HMC]

Facility

$19.54

Service Code	NDC 00378581377
Hospital Charge Code	3802515
Hospital Revenue Code	250
Min. Negotiated Rate	$17.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.59
Rate for Payer: UnitedHealthcare Commercial	$18.56
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valsartan 80 mg Tab [HMC]

Facility

$19.54

Service Code	NDC 00378581377
Hospital Charge Code	3802515
Hospital Revenue Code	250
Min. Negotiated Rate	$7.82
Max. Negotiated Rate	$18.56
Rate for Payer: Aetna Commercial	$17.59
Rate for Payer: Humana Medicare Advantage	$8.21
Rate for Payer: UnitedHealthcare Commercial	$18.56
Rate for Payer: UnitedHealthcare Medicaid	$7.82
Rate for Payer: WPPA Medicare Advantage	$11.72

valsartan 80 mg Tab [HMC]

Facility

$8.87

Service Code	NDC 60687062301
Hospital Charge Code	3802515
Hospital Revenue Code	250
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.98
Rate for Payer: UnitedHealthcare Commercial	$8.43
Rate for Payer: WPPA Medicare Advantage	$1,200.00

valsartan 80 mg Tab [HMC]

Facility

$18.84

Service Code	NDC 67877041690
Hospital Charge Code	3802515
Hospital Revenue Code	250
Min. Negotiated Rate	$16.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.96
Rate for Payer: UnitedHealthcare Commercial	$17.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

vancomycin 1 g IV Inj [HMC]

Facility

$38.75

Service Code	NDC 47781059791
Hospital Charge Code	3805675
Hospital Revenue Code	250
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$36.81
Rate for Payer: Aetna Commercial	$34.88
Rate for Payer: Humana Medicare Advantage	$16.27
Rate for Payer: UnitedHealthcare Commercial	$36.81
Rate for Payer: UnitedHealthcare Medicaid	$15.50
Rate for Payer: WPPA Medicare Advantage	$23.25

vancomycin 1 g IV Inj [HMC]

Facility

$37.14

Service Code	HCPCS J3373
Hospital Charge Code	3805675
Hospital Revenue Code	250
Min. Negotiated Rate	$14.86
Max. Negotiated Rate	$35.28
Rate for Payer: Aetna Commercial	$33.43
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Commercial	$33.67
Rate for Payer: Aetna Commercial	$30.71
Rate for Payer: Aetna Commercial	$34.88
Rate for Payer: Humana Medicare Advantage	$16.27
Rate for Payer: Humana Medicare Advantage	$14.33
Rate for Payer: Humana Medicare Advantage	$15.60
Rate for Payer: Humana Medicare Advantage	$15.71
Rate for Payer: Humana Medicare Advantage	$28.82
Rate for Payer: UnitedHealthcare Commercial	$32.41
Rate for Payer: UnitedHealthcare Commercial	$65.18
Rate for Payer: UnitedHealthcare Commercial	$35.28
Rate for Payer: UnitedHealthcare Commercial	$35.54
Rate for Payer: UnitedHealthcare Commercial	$36.81
Rate for Payer: UnitedHealthcare Medicaid	$15.50
Rate for Payer: UnitedHealthcare Medicaid	$14.86
Rate for Payer: UnitedHealthcare Medicaid	$13.65
Rate for Payer: UnitedHealthcare Medicaid	$27.44
Rate for Payer: UnitedHealthcare Medicaid	$14.96
Rate for Payer: WPPA Medicare Advantage	$22.28
Rate for Payer: WPPA Medicare Advantage	$22.45
Rate for Payer: WPPA Medicare Advantage	$20.47
Rate for Payer: WPPA Medicare Advantage	$23.25
Rate for Payer: WPPA Medicare Advantage	$41.17

vancomycin 1 g IV Inj [HMC]

Facility

$38.75

Service Code	HCPCS J3373
Hospital Charge Code	3805675
Hospital Revenue Code	250
Min. Negotiated Rate	$34.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.88
Rate for Payer: Aetna Commercial	$30.71
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Commercial	$33.43
Rate for Payer: Aetna Commercial	$33.67
Rate for Payer: UnitedHealthcare Commercial	$32.41
Rate for Payer: UnitedHealthcare Commercial	$36.81
Rate for Payer: UnitedHealthcare Commercial	$35.54
Rate for Payer: UnitedHealthcare Commercial	$65.18
Rate for Payer: UnitedHealthcare Commercial	$35.28
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
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

vancomycin 1 g IV Inj [HMC]

Facility

$38.75

Service Code	NDC 47781059791
Hospital Charge Code	3805675
Hospital Revenue Code	250
Min. Negotiated Rate	$34.88
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.88
Rate for Payer: UnitedHealthcare Commercial	$36.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

vancomycin 1 g Pow [HMC]

Facility

$38.80

Service Code	HCPCS J3373
Hospital Charge Code	3805675
Hospital Revenue Code	250
Min. Negotiated Rate	$15.52
Max. Negotiated Rate	$36.86
Rate for Payer: Aetna Commercial	$34.92
Rate for Payer: Humana Medicare Advantage	$16.30
Rate for Payer: UnitedHealthcare Commercial	$36.86
Rate for Payer: UnitedHealthcare Medicaid	$15.52
Rate for Payer: WPPA Medicare Advantage	$23.28

vancomycin 1 g Pow [HMC]

Facility

$38.80

Service Code	NDC 00143916210
Hospital Charge Code	3805675
Hospital Revenue Code	250
Min. Negotiated Rate	$15.52
Max. Negotiated Rate	$36.86
Rate for Payer: Aetna Commercial	$34.92
Rate for Payer: Humana Medicare Advantage	$16.30
Rate for Payer: UnitedHealthcare Commercial	$36.86
Rate for Payer: UnitedHealthcare Medicaid	$15.52
Rate for Payer: WPPA Medicare Advantage	$23.28

vancomycin 1 g Pow [HMC]

Facility

$38.80

Service Code	NDC 00143916210
Hospital Charge Code	3805675
Hospital Revenue Code	250
Min. Negotiated Rate	$34.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.92
Rate for Payer: UnitedHealthcare Commercial	$36.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

vancomycin 1 g Pow [HMC]

Facility

$38.80

Service Code	HCPCS J3373
Hospital Charge Code	3805675
Hospital Revenue Code	250
Min. Negotiated Rate	$34.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.92
Rate for Payer: UnitedHealthcare Commercial	$36.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

vancomycin 1 g Pow Inj [HMC]

Facility

$67.74

Service Code	HCPCS J3373
Hospital Charge Code	3805675
Hospital Revenue Code	250
Min. Negotiated Rate	$27.10
Max. Negotiated Rate	$64.35
Rate for Payer: Aetna Commercial	$60.97
Rate for Payer: Humana Medicare Advantage	$28.45
Rate for Payer: UnitedHealthcare Commercial	$64.35
Rate for Payer: UnitedHealthcare Medicaid	$27.10
Rate for Payer: WPPA Medicare Advantage	$40.64

vancomycin 1 g Pow Inj [HMC]

Facility

$67.74

Service Code	HCPCS J3373
Hospital Charge Code	3805675
Hospital Revenue Code	250
Min. Negotiated Rate	$60.97
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$60.97
Rate for Payer: UnitedHealthcare Commercial	$64.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

vancomycin 2 g/400 mL Sol Premix Bag [HMC]

Facility

$77.20

Service Code	HCPCS J3370
Hospital Charge Code	3805676
Hospital Revenue Code	250
Min. Negotiated Rate	$3.89
Max. Negotiated Rate	$73.34
Rate for Payer: Aetna Commercial	$69.48
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.89
Rate for Payer: Humana Medicare Advantage	$32.42
Rate for Payer: UnitedHealthcare Commercial	$73.34
Rate for Payer: UnitedHealthcare Medicaid	$30.88
Rate for Payer: WPPA Medicare Advantage	$46.32

vancomycin 2 g/400 mL Sol Premix Bag [HMC]

Facility

$77.20

Service Code	HCPCS J3370
Hospital Charge Code	3805676
Hospital Revenue Code	250
Min. Negotiated Rate	$69.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$69.48
Rate for Payer: UnitedHealthcare Commercial	$73.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges