Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

96365- ED IV tx, first hour

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

96365- ED IV tx, first hour

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-Infusion Drug Initial up to 1 hr Greater Than 15 mins

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-Infusion Drug Initial up to 1 hr Greater Than 15 mins

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

96365 IV INFUSION 1ST HR Charge

Facility

$459.00

Service Code	HCPCS 96365
Hospital Charge Code	3290006
Hospital Revenue Code	761
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

96365 IV INFUSION 1ST HR Charge

Facility

$459.00

Service Code	HCPCS 96365
Hospital Charge Code	3290006
Hospital Revenue Code	761
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 OBS IV INFUSION, INITIAL UP TO 1 HR

Facility

$459.00

Service Code	HCPCS 96365
Hospital Charge Code	3310174
Hospital Revenue Code	760
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

96365 OBS IV INFUSION, INITIAL UP TO 1 HR

Facility

$459.00

Service Code	HCPCS 96365
Hospital Charge Code	3310174
Hospital Revenue Code	760
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

96366 EACH ADDITIONAL HOUR CHARGE

Facility

$298.00

Service Code	HCPCS 96366
Hospital Charge Code	3316366
Hospital Revenue Code	760
Min. Negotiated Rate	$23.14
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$23.14
Rate for Payer: WPPA Medicare Advantage	$178.80

96366 EACH ADDITIONAL HOUR CHARGE

Facility

$298.00

Service Code	HCPCS 96366
Hospital Charge Code	3316366
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

96366- ED IV tx, each additional hour

Facility

$298.00

Service Code	HCPCS 96366
Hospital Charge Code	3300154
Hospital Revenue Code	450
Min. Negotiated Rate	$23.14
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$23.14
Rate for Payer: WPPA Medicare Advantage	$178.80

96366- ED IV tx, each additional hour

Facility

$298.00

Service Code	HCPCS 96366
Hospital Charge Code	3300154
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

96366-Infuse Drug Each Addl Hour Greater Than 30 mins

Facility

$298.00

Service Code	HCPCS 96366
Hospital Charge Code	3316366
Hospital Revenue Code	760
Min. Negotiated Rate	$23.14
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$23.14
Rate for Payer: WPPA Medicare Advantage	$178.80

96366-Infuse Drug Each Addl Hour Greater Than 30 mins

Facility

$298.00

Service Code	HCPCS 96366
Hospital Charge Code	3316366
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

96366 THER/PROPH/DG IV INF,ADD-ON CHARGE

Facility

$298.00

Service Code	HCPCS 96366
Hospital Charge Code	3310176
Hospital Revenue Code	761
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

96366 THER/PROPH/DG IV INF,ADD-ON CHARGE

Facility

$298.00

Service Code	HCPCS 96366
Hospital Charge Code	3310176
Hospital Revenue Code	761
Min. Negotiated Rate	$23.14
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$23.14
Rate for Payer: WPPA Medicare Advantage	$178.80

96367- ED IV tx, sequential infusion

Facility

$298.00

Service Code	HCPCS 96367
Hospital Charge Code	3300150
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

96367- ED IV tx, sequential infusion

Facility

$298.00

Service Code	HCPCS 96367
Hospital Charge Code	3300150
Hospital Revenue Code	450
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: WPPA Medicare Advantage	$178.80

96367-Infusion Sequential 1 hr Greater Than 15 mins

Facility

$298.00

Service Code	HCPCS 96367
Hospital Charge Code	3300150
Hospital Revenue Code	450
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: WPPA Medicare Advantage	$178.80

96367-Infusion Sequential 1 hr Greater Than 15 mins

Facility

$298.00

Service Code	HCPCS 96367
Hospital Charge Code	3300150
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

96367 IV INF ADD SEQ 1 HR CHARGE

Facility

$298.00

Service Code	HCPCS 96367
Hospital Charge Code	3290050
Hospital Revenue Code	761
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

96367 IV INF ADD SEQ 1 HR CHARGE

Facility

$298.00

Service Code	HCPCS 96367
Hospital Charge Code	3290050
Hospital Revenue Code	761
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: WPPA Medicare Advantage	$178.80

96367 OBS IV INFUSION, ADDL SEQ NEW DRUG

Facility

$298.00

Service Code	HCPCS 96367
Hospital Charge Code	3310178
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

96367 OBS IV INFUSION, ADDL SEQ NEW DRUG

Facility

$298.00

Service Code	HCPCS 96367
Hospital Charge Code	3310178
Hospital Revenue Code	760
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: WPPA Medicare Advantage	$178.80

96368- ED IV tx, concurrent infusion

Facility

$63.00

Service Code	HCPCS 96368
Hospital Charge Code	3300152
Hospital Revenue Code	450
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges