Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

95976 Simple cranial nerve neurostimulator pulse generator/transmitter programming

Facility

$275.00

Service Code	HCPCS 95976
Hospital Charge Code	3355976
Hospital Revenue Code	761
Min. Negotiated Rate	$247.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$247.50
Rate for Payer: UnitedHealthcare Commercial	$261.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95977 Complex cranial nerve neurostimulator pulse generator/transmitter programming

Facility

$139.00

Service Code	HCPCS 95977
Hospital Charge Code	3355977
Hospital Revenue Code	761
Min. Negotiated Rate	$125.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$125.10
Rate for Payer: UnitedHealthcare Commercial	$132.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

95977 Complex cranial nerve neurostimulator pulse generator/transmitter programming

Facility

$139.00

Service Code	HCPCS 95977
Hospital Charge Code	3355977
Hospital Revenue Code	761
Min. Negotiated Rate	$58.38
Max. Negotiated Rate	$132.05
Rate for Payer: Aetna Commercial	$125.10
Rate for Payer: Humana Medicare Advantage	$58.38
Rate for Payer: UnitedHealthcare Commercial	$132.05
Rate for Payer: UnitedHealthcare Medicaid	$84.04
Rate for Payer: WPPA Medicare Advantage	$83.40

95991 REFILL/MAIN IMPLANT PUMP ProFee

Facility

$515.00

Service Code	HCPCS 95991
Hospital Charge Code	3185991
Hospital Revenue Code	360
Min. Negotiated Rate	$206.00
Max. Negotiated Rate	$489.25
Rate for Payer: Aetna Commercial	$463.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$371.68
Rate for Payer: Humana Medicare Advantage	$216.30
Rate for Payer: UnitedHealthcare Commercial	$489.25
Rate for Payer: UnitedHealthcare Medicaid	$206.00
Rate for Payer: WPPA Medicare Advantage	$309.00

95991 REFILL/MAIN IMPLANT PUMP ProFee

Facility

$515.00

Service Code	HCPCS 95991
Hospital Charge Code	3185991
Hospital Revenue Code	360
Min. Negotiated Rate	$463.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$463.50
Rate for Payer: UnitedHealthcare Commercial	$489.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96360-59 IV Hydration Initial Addl Site w/ Modification

Facility

$298.00

Service Code	HCPCS 96360
Hospital Charge Code	3300158
Hospital Revenue Code	450
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96360-59 IV Hydration Initial Addl Site w/ Modification

Facility

$298.00

Service Code	HCPCS 96360
Hospital Charge Code	3300158
Hospital Revenue Code	450
Min. Negotiated Rate	$49.81
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$255.28
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$49.81
Rate for Payer: WPPA Medicare Advantage	$178.80

96360 - ED Hydration, first hour

Facility

$298.00

Service Code	HCPCS 96360
Hospital Charge Code	3300158
Hospital Revenue Code	450
Min. Negotiated Rate	$49.81
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$255.28
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$49.81
Rate for Payer: WPPA Medicare Advantage	$178.80

96360 - ED Hydration, first hour

Facility

$298.00

Service Code	HCPCS 96360
Hospital Charge Code	3300158
Hospital Revenue Code	450
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96360-IV Hydration Initial 31 min - 1 hr

Facility

$298.00

Service Code	HCPCS 96360
Hospital Charge Code	3300158
Hospital Revenue Code	450
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96360-IV Hydration Initial 31 min - 1 hr

Facility

$298.00

Service Code	HCPCS 96360
Hospital Charge Code	3300158
Hospital Revenue Code	450
Min. Negotiated Rate	$49.81
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$255.28
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$49.81
Rate for Payer: WPPA Medicare Advantage	$178.80

96360 IV INFUSION,HYDRATION 1HR CHARGE

Facility

$246.00

Service Code	HCPCS 96360
Hospital Charge Code	3310170
Hospital Revenue Code	761
Min. Negotiated Rate	$49.81
Max. Negotiated Rate	$255.28
Rate for Payer: Aetna Commercial	$221.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$255.28
Rate for Payer: Humana Medicare Advantage	$103.32
Rate for Payer: UnitedHealthcare Commercial	$233.70
Rate for Payer: UnitedHealthcare Medicaid	$49.81
Rate for Payer: WPPA Medicare Advantage	$147.60

96360 IV INFUSION,HYDRATION 1HR CHARGE

Facility

$246.00

Service Code	HCPCS 96360
Hospital Charge Code	3310170
Hospital Revenue Code	761
Min. Negotiated Rate	$221.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$221.40
Rate for Payer: UnitedHealthcare Commercial	$233.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96360 - IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR

Facility

$298.00

Service Code	HCPCS 96360
Hospital Charge Code	3319636
Hospital Revenue Code	760
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96360 - IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR

Facility

$298.00

Service Code	HCPCS 96360
Hospital Charge Code	3319636
Hospital Revenue Code	760
Min. Negotiated Rate	$49.81
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$255.28
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$49.81
Rate for Payer: WPPA Medicare Advantage	$178.80

96361- ED Hydration, each additional hour

Facility

$237.00

Service Code	HCPCS 96361
Hospital Charge Code	3300156
Hospital Revenue Code	450
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$225.15
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$99.54
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: UnitedHealthcare Medicaid	$16.83
Rate for Payer: WPPA Medicare Advantage	$142.20

96361- ED Hydration, each additional hour

Facility

$237.00

Service Code	HCPCS 96361
Hospital Charge Code	3300156
Hospital Revenue Code	450
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96361 HYDRATION IV ADD'L HRS CHARGE

Facility

$237.00

Service Code	HCPCS 96361
Hospital Charge Code	3236361
Hospital Revenue Code	761
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96361 HYDRATION IV ADD'L HRS CHARGE

Facility

$237.00

Service Code	HCPCS 96361
Hospital Charge Code	3236361
Hospital Revenue Code	761
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$225.15
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$99.54
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: UnitedHealthcare Medicaid	$16.83
Rate for Payer: WPPA Medicare Advantage	$142.20

96361-IV Hydration Each Addl Hour Greater Than 30 mins

Facility

$237.00

Service Code	HCPCS 96361
Hospital Charge Code	3300156
Hospital Revenue Code	450
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96361-IV Hydration Each Addl Hour Greater Than 30 mins

Facility

$237.00

Service Code	HCPCS 96361
Hospital Charge Code	3300156
Hospital Revenue Code	450
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$225.15
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$99.54
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: UnitedHealthcare Medicaid	$16.83
Rate for Payer: WPPA Medicare Advantage	$142.20

96361 IV INFUSION HYDRATION ADDTL HR CHARGE

Facility

$237.00

Service Code	HCPCS 96361
Hospital Charge Code	3310172
Hospital Revenue Code	760
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$225.15
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$99.54
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: UnitedHealthcare Medicaid	$16.83
Rate for Payer: WPPA Medicare Advantage	$142.20

96361 IV INFUSION HYDRATION ADDTL HR CHARGE

Facility

$237.00

Service Code	HCPCS 96361
Hospital Charge Code	3310172
Hospital Revenue Code	760
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96365-59 Infusion Initial Addl Site w/ Modification

Facility

$459.00

Service Code	HCPCS 96365
Hospital Charge Code	3300205
Hospital Revenue Code	450
Min. Negotiated Rate	$86.94
Max. Negotiated Rate	$436.05
Rate for Payer: Aetna Commercial	$413.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$255.28
Rate for Payer: Humana Medicare Advantage	$192.78
Rate for Payer: UnitedHealthcare Commercial	$436.05
Rate for Payer: UnitedHealthcare Medicaid	$86.94
Rate for Payer: WPPA Medicare Advantage	$275.40

96365-59 Infusion Initial Addl Site w/ Modification

Facility

$459.00

Service Code	HCPCS 96365
Hospital Charge Code	3300205
Hospital Revenue Code	450
Min. Negotiated Rate	$413.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$413.10
Rate for Payer: UnitedHealthcare Commercial	$436.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges