Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

96368-Infusion Concurrent Greater Than 15 mins

Facility

$63.00

Service Code	HCPCS 96368
Hospital Charge Code	3300152
Hospital Revenue Code	761
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$59.85
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.01
Rate for Payer: Humana Medicare Advantage	$26.46
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: UnitedHealthcare Medicaid	$25.20
Rate for Payer: WPPA Medicare Advantage	$37.80

96368-Infusion Concurrent Greater Than 15 mins

Facility

$63.00

Service Code	HCPCS 96368
Hospital Charge Code	3300152
Hospital Revenue Code	761
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

96368 IV INF CONCURRENT CHARGE

Facility

$27.00

Service Code	HCPCS 96368
Hospital Charge Code	3310188
Hospital Revenue Code	760
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96368 IV INF CONCURRENT CHARGE

Facility

$27.00

Service Code	HCPCS 96368
Hospital Charge Code	3310188
Hospital Revenue Code	760
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.01
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: WPPA Medicare Advantage	$16.20

96372-59 SQ/IM Injection w/ Modification

Facility

$167.00

Service Code	HCPCS 96372
Hospital Charge Code	3319637
Hospital Revenue Code	760
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$83.90
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$16.83
Rate for Payer: WPPA Medicare Advantage	$100.20

96372-59 SQ/IM Injection w/ Modification

Facility

$167.00

Service Code	HCPCS 96372
Hospital Charge Code	3319637
Hospital Revenue Code	760
Min. Negotiated Rate	$150.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96372 ED Subq/IM Injection

Facility

$167.00

Service Code	HCPCS 96372
Hospital Charge Code	3300138
Hospital Revenue Code	450
Min. Negotiated Rate	$150.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96372 ED Subq/IM Injection

Facility

$167.00

Service Code	HCPCS 96372
Hospital Charge Code	3300138
Hospital Revenue Code	450
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$83.90
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$16.83
Rate for Payer: WPPA Medicare Advantage	$100.20

96372 INJECTION IM/SQ-THER, PROPHY, DIAGNOSTIC

Facility

$167.00

Service Code	HCPCS 96372
Hospital Charge Code	3290145
Hospital Revenue Code	761
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$83.90
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$16.83
Rate for Payer: WPPA Medicare Advantage	$100.20

96372 INJECTION IM/SQ-THER, PROPHY, DIAGNOSTIC

Facility

$167.00

Service Code	HCPCS 96372
Hospital Charge Code	3290145
Hospital Revenue Code	761
Min. Negotiated Rate	$150.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96372 INJ IM/SUBQ CHARGE

Facility

$167.00

Service Code	HCPCS 96372
Hospital Charge Code	3319637
Hospital Revenue Code	760
Min. Negotiated Rate	$150.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96372 INJ IM/SUBQ CHARGE

Facility

$167.00

Service Code	HCPCS 96372
Hospital Charge Code	3319637
Hospital Revenue Code	760
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$83.90
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$16.83
Rate for Payer: WPPA Medicare Advantage	$100.20

96372 SQ/IM INJECTION CHARGE

Facility

$167.00

Service Code	HCPCS 96372
Hospital Charge Code	3310166
Hospital Revenue Code	761
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$83.90
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$16.83
Rate for Payer: WPPA Medicare Advantage	$100.20

96372 SQ/IM INJECTION CHARGE

Facility

$167.00

Service Code	HCPCS 96372
Hospital Charge Code	3310166
Hospital Revenue Code	761
Min. Negotiated Rate	$150.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96374-59 IV Push Initial Drug Addl Site w/ Modification

Facility

$167.00

Service Code	HCPCS 96374
Hospital Charge Code	3316374
Hospital Revenue Code	760
Min. Negotiated Rate	$150.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96374-59 IV Push Initial Drug Addl Site w/ Modification

Facility

$167.00

Service Code	HCPCS 96374
Hospital Charge Code	3316374
Hospital Revenue Code	760
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$255.27
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$255.27
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: WPPA Medicare Advantage	$100.20

96374- ED Injection, single/initial

Facility

$167.00

Service Code	HCPCS 96374
Hospital Charge Code	3300146
Hospital Revenue Code	450
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$255.27
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$255.27
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: WPPA Medicare Advantage	$100.20

96374- ED Injection, single/initial

Facility

$167.00

Service Code	HCPCS 96374
Hospital Charge Code	3300146
Hospital Revenue Code	450
Min. Negotiated Rate	$150.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96374 INJ IV PUSH INITIAL

Facility

$167.00

Service Code	HCPCS 96374
Hospital Charge Code	3290090
Hospital Revenue Code	761
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$255.27
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$255.27
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: WPPA Medicare Advantage	$100.20

96374 INJ IV PUSH INITIAL

Facility

$167.00

Service Code	HCPCS 96374
Hospital Charge Code	3290090
Hospital Revenue Code	761
Min. Negotiated Rate	$150.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96374 IV INJECTION INITIAL DRUG

Facility

$167.00

Service Code	HCPCS 96374
Hospital Charge Code	3316374
Hospital Revenue Code	760
Min. Negotiated Rate	$150.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96374 IV INJECTION INITIAL DRUG

Facility

$167.00

Service Code	HCPCS 96374
Hospital Charge Code	3316374
Hospital Revenue Code	760
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$255.27
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$255.27
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: WPPA Medicare Advantage	$100.20

96374 IV PUSH SINGLE OR INITIAL DRUG CHARGE

Facility

$167.00

Service Code	HCPCS 96374
Hospital Charge Code	3310158
Hospital Revenue Code	761
Min. Negotiated Rate	$150.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96374 IV PUSH SINGLE OR INITIAL DRUG CHARGE

Facility

$167.00

Service Code	HCPCS 96374
Hospital Charge Code	3310158
Hospital Revenue Code	761
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$255.27
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$255.27
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: WPPA Medicare Advantage	$100.20

Know your out-of-pocket cost for care.

All Charges