Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

venlafaxine 75 mg ERCap [HMC]

Facility

$17.59

Service Code	NDC 68084070901
Hospital Charge Code	3800287
Hospital Revenue Code	250
Min. Negotiated Rate	$7.04
Max. Negotiated Rate	$16.71
Rate for Payer: Aetna Commercial	$15.83
Rate for Payer: Humana Medicare Advantage	$7.39
Rate for Payer: UnitedHealthcare Commercial	$16.71
Rate for Payer: UnitedHealthcare Medicaid	$7.04
Rate for Payer: WPPA Medicare Advantage	$10.55

venlafaxine 75 mg ERCap [HMC]

Facility

$17.59

Service Code	NDC 68084070901
Hospital Charge Code	3800287
Hospital Revenue Code	250
Min. Negotiated Rate	$15.83
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$15.83
Rate for Payer: UnitedHealthcare Commercial	$16.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

venlafaxine 75 mg ERCap [HMC]

Facility

$6.88

Service Code	NDC 50268081815
Hospital Charge Code	3800287
Hospital Revenue Code	250
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$6.54
Rate for Payer: Aetna Commercial	$6.19
Rate for Payer: Humana Medicare Advantage	$2.89
Rate for Payer: UnitedHealthcare Commercial	$6.54
Rate for Payer: UnitedHealthcare Medicaid	$2.75
Rate for Payer: WPPA Medicare Advantage	$4.13

venlafaxine 75 mg ERCap [HMC]

Facility

$6.88

Service Code	NDC 00904707761
Hospital Charge Code	3800287
Hospital Revenue Code	250
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.19
Rate for Payer: UnitedHealthcare Commercial	$6.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

venlafaxine 75 mg ERCap [HMC]

Facility

$6.88

Service Code	NDC 50268081815
Hospital Charge Code	3800287
Hospital Revenue Code	250
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.19
Rate for Payer: UnitedHealthcare Commercial	$6.54
Rate for Payer: WPPA Medicare Advantage	$1,200.00

venlafaxine 75 mg ERCap [HMC]

Facility

$19.00

Service Code	NDC 68382003510
Hospital Charge Code	3800287
Hospital Revenue Code	250
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: UnitedHealthcare Commercial	$18.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

venlafaxine 75 mg ERCap [HMC]

Facility

$19.00

Service Code	NDC 68382003510
Hospital Charge Code	3800287
Hospital Revenue Code	250
Min. Negotiated Rate	$7.60
Max. Negotiated Rate	$18.05
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Humana Medicare Advantage	$7.98
Rate for Payer: UnitedHealthcare Commercial	$18.05
Rate for Payer: UnitedHealthcare Medicaid	$7.60
Rate for Payer: WPPA Medicare Advantage	$11.40

Ventilator Inspiratory Filter Puritan Bennett 840 Inhalation Bacterial Filter

Facility

$21.15

Hospital Charge Code	3255016
Hospital Revenue Code	270
Min. Negotiated Rate	$19.04
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.04
Rate for Payer: UnitedHealthcare Commercial	$20.09
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Ventilator Inspiratory Filter Puritan Bennett 840 Inhalation Bacterial Filter

Facility

$21.15

Hospital Charge Code	3255016
Hospital Revenue Code	270
Min. Negotiated Rate	$8.46
Max. Negotiated Rate	$20.09
Rate for Payer: Aetna Commercial	$19.04
Rate for Payer: Humana Medicare Advantage	$8.88
Rate for Payer: UnitedHealthcare Commercial	$20.09
Rate for Payer: UnitedHealthcare Medicaid	$8.46
Rate for Payer: WPPA Medicare Advantage	$12.69

VENTRICULAR SHUNT PROCEDURES WITH CC

Facility

$7,751.88

Service Code	MSDRG 032
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$7,751.88
Rate for Payer: UnitedHealthcare Medicaid	$7,751.88
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VENTRICULAR SHUNT PROCEDURES WITH MCC

Facility

$16,298.01

Service Code	MSDRG 031
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$16,298.01
Rate for Payer: UnitedHealthcare Medicaid	$16,298.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC

Facility

$6,068.07

Service Code	MSDRG 033
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$6,068.07
Rate for Payer: UnitedHealthcare Medicaid	$6,068.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

verapamil 120 mg ER Tab [HMC]

Facility

$8.22

Service Code	NDC 75834032001
Hospital Charge Code	3807605
Hospital Revenue Code	250
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$7.81
Rate for Payer: Aetna Commercial	$7.40
Rate for Payer: Humana Medicare Advantage	$3.45
Rate for Payer: UnitedHealthcare Commercial	$7.81
Rate for Payer: UnitedHealthcare Medicaid	$3.29
Rate for Payer: WPPA Medicare Advantage	$4.93

verapamil 120 mg ER Tab [HMC]

Facility

$8.22

Service Code	NDC 75834032001
Hospital Charge Code	3807605
Hospital Revenue Code	250
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.40
Rate for Payer: UnitedHealthcare Commercial	$7.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

verapamil 120 mg ER Tab [HMC]

Facility

$10.07

Service Code	NDC 60687049301
Hospital Charge Code	3807605
Hospital Revenue Code	250
Min. Negotiated Rate	$9.06
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.06
Rate for Payer: UnitedHealthcare Commercial	$9.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

verapamil 120 mg ER Tab [HMC]

Facility

$8.22

Service Code	NDC 68462029201
Hospital Charge Code	3807605
Hospital Revenue Code	250
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$7.81
Rate for Payer: Aetna Commercial	$7.40
Rate for Payer: Humana Medicare Advantage	$3.45
Rate for Payer: UnitedHealthcare Commercial	$7.81
Rate for Payer: UnitedHealthcare Medicaid	$3.29
Rate for Payer: WPPA Medicare Advantage	$4.93

verapamil 120 mg ER Tab [HMC]

Facility

$10.07

Service Code	NDC 60687049301
Hospital Charge Code	3807605
Hospital Revenue Code	250
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$9.57
Rate for Payer: Aetna Commercial	$9.06
Rate for Payer: Humana Medicare Advantage	$4.23
Rate for Payer: UnitedHealthcare Commercial	$9.57
Rate for Payer: UnitedHealthcare Medicaid	$4.03
Rate for Payer: WPPA Medicare Advantage	$6.04

verapamil 120 mg ER Tab [HMC]

Facility

$8.22

Service Code	NDC 68462029201
Hospital Charge Code	3807605
Hospital Revenue Code	250
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.40
Rate for Payer: UnitedHealthcare Commercial	$7.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00

verapamil 2.5 mg/mL IV Sol [HMC]

Facility

$72.88

Service Code	NDC 00409114405
Hospital Charge Code	3807621
Hospital Revenue Code	250
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$65.59
Rate for Payer: UnitedHealthcare Commercial	$69.24
Rate for Payer: WPPA Medicare Advantage	$1,200.00

verapamil 2.5 mg/mL IV Sol [HMC]

Facility

$72.88

Service Code	NDC 00409114405
Hospital Charge Code	3807621
Hospital Revenue Code	250
Min. Negotiated Rate	$29.15
Max. Negotiated Rate	$69.24
Rate for Payer: Aetna Commercial	$65.59
Rate for Payer: Humana Medicare Advantage	$30.61
Rate for Payer: UnitedHealthcare Commercial	$69.24
Rate for Payer: UnitedHealthcare Medicaid	$29.15
Rate for Payer: WPPA Medicare Advantage	$43.73

verapamil 80 mg Tab [HMC]

Facility

$5.92

Service Code	NDC 23155002601
Hospital Charge Code	3807647
Hospital Revenue Code	250
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$5.62
Rate for Payer: Aetna Commercial	$5.33
Rate for Payer: Humana Medicare Advantage	$2.49
Rate for Payer: UnitedHealthcare Commercial	$5.62
Rate for Payer: UnitedHealthcare Medicaid	$2.37
Rate for Payer: WPPA Medicare Advantage	$3.55

verapamil 80 mg Tab [HMC]

Facility

$5.92

Service Code	NDC 23155002601
Hospital Charge Code	3807647
Hospital Revenue Code	250
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.33
Rate for Payer: UnitedHealthcare Commercial	$5.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

vibegron 75 mg Tab [HMC]

Facility

$25.64

Service Code	NDC 73336007530
Hospital Charge Code	3800223
Hospital Revenue Code	250
Min. Negotiated Rate	$23.08
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.08
Rate for Payer: UnitedHealthcare Commercial	$24.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

vibegron 75 mg Tab [HMC]

Facility

$25.64

Service Code	NDC 73336007530
Hospital Charge Code	3800223
Hospital Revenue Code	250
Min. Negotiated Rate	$10.26
Max. Negotiated Rate	$24.36
Rate for Payer: Aetna Commercial	$23.08
Rate for Payer: Humana Medicare Advantage	$10.77
Rate for Payer: UnitedHealthcare Commercial	$24.36
Rate for Payer: UnitedHealthcare Medicaid	$10.26
Rate for Payer: WPPA Medicare Advantage	$15.38

Vicair Adjuster O2 Adjustable Wheelchair Cushion 18x16x4 w/Incotec Cover

Facility

$735.00

Hospital Charge Code	3259244
Hospital Revenue Code	270
Min. Negotiated Rate	$661.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$661.50
Rate for Payer: UnitedHealthcare Commercial	$698.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges