Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

96375 IV ADD ON DIFF DRUG CHARGE

Facility

$167.00

Service Code	HCPCS 96375
Hospital Charge Code	3296375
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

96375 IV ADD ON DIFF DRUG CHARGE

Facility

$167.00

Service Code	HCPCS 96375
Hospital Charge Code	3296375
Hospital Revenue Code	761
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$56.57
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

96375-IV Injection, add new drug

Facility

$167.00

Service Code	HCPCS 96375
Hospital Charge Code	3300162
Hospital Revenue Code	450
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$56.57
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

96375-IV Injection, add new drug

Facility

$167.00

Service Code	HCPCS 96375
Hospital Charge Code	3300162
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

96375-IV Push Each Additional New Drug

Facility

$167.00

Service Code	HCPCS 96375
Hospital Charge Code	3300162
Hospital Revenue Code	761
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$56.57
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

96375-IV Push Each Additional New Drug

Facility

$167.00

Service Code	HCPCS 96375
Hospital Charge Code	3300162
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

96375 IV PUSH SEQUENTIAL NEW DRUG CHARGE

Facility

$72.00

Service Code	HCPCS 96375
Hospital Charge Code	3310182
Hospital Revenue Code	760
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96375 IV PUSH SEQUENTIAL NEW DRUG CHARGE

Facility

$72.00

Service Code	HCPCS 96375
Hospital Charge Code	3310182
Hospital Revenue Code	760
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$56.57
Rate for Payer: Humana Medicare Advantage	$30.24
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$24.42
Rate for Payer: WPPA Medicare Advantage	$43.20

96376 ADDL INJECTION SAME DRUG CHARGE

Facility

$167.00

Service Code	HCPCS 96376
Hospital Charge Code	3296376
Hospital Revenue Code	761
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$43.43
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: WPPA Medicare Advantage	$100.20

96376 ADDL INJECTION SAME DRUG CHARGE

Facility

$167.00

Service Code	HCPCS 96376
Hospital Charge Code	3296376
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

96376- ED IV Injection, add same drug

Facility

$167.00

Service Code	HCPCS 96376
Hospital Charge Code	3300164
Hospital Revenue Code	450
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$43.43
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: WPPA Medicare Advantage	$100.20

96376- ED IV Injection, add same drug

Facility

$167.00

Service Code	HCPCS 96376
Hospital Charge Code	3300164
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

96376-IV Push Addl Same Drug Greater Than 30 mins

Facility

$167.00

Service Code	HCPCS 96376
Hospital Charge Code	3296376
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

96376-IV Push Addl Same Drug Greater Than 30 mins

Facility

$167.00

Service Code	HCPCS 96376
Hospital Charge Code	3296376
Hospital Revenue Code	761
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$43.43
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: WPPA Medicare Advantage	$100.20

96376 IV PUSH SEQUENTIAL SAME DRUG CHARGE

Facility

$72.00

Service Code	HCPCS 96376
Hospital Charge Code	3290245
Hospital Revenue Code	760
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96376 IV PUSH SEQUENTIAL SAME DRUG CHARGE

Facility

$72.00

Service Code	HCPCS 96376
Hospital Charge Code	3290245
Hospital Revenue Code	760
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$43.43
Rate for Payer: Humana Medicare Advantage	$30.24
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: WPPA Medicare Advantage	$43.20

96401 CHEMO ADMIN NON HORMONAL SQ/IM CHARGE

Facility

$174.00

Service Code	HCPCS 96401
Hospital Charge Code	3295050
Hospital Revenue Code	280
Min. Negotiated Rate	$42.83
Max. Negotiated Rate	$165.30
Rate for Payer: Aetna Commercial	$156.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$83.90
Rate for Payer: Humana Medicare Advantage	$73.08
Rate for Payer: UnitedHealthcare Commercial	$165.30
Rate for Payer: UnitedHealthcare Medicaid	$42.83
Rate for Payer: WPPA Medicare Advantage	$104.40

96401 CHEMO ADMIN NON HORMONAL SQ/IM CHARGE

Facility

$174.00

Service Code	HCPCS 96401
Hospital Charge Code	3295050
Hospital Revenue Code	280
Min. Negotiated Rate	$156.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$156.60
Rate for Payer: UnitedHealthcare Commercial	$165.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96402 CHEMO ADMIN HORMONAL SQ/IM CHARGE

Facility

$167.00

Service Code	HCPCS 96402
Hospital Charge Code	3355051
Hospital Revenue Code	280
Min. Negotiated Rate	$35.35
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$35.35
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$42.83
Rate for Payer: WPPA Medicare Advantage	$100.20

96402 CHEMO ADMIN HORMONAL SQ/IM CHARGE

Facility

$167.00

Service Code	HCPCS 96402
Hospital Charge Code	3355051
Hospital Revenue Code	280
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

96409 CHEMO IV PUSH SINGLE DRUG CHARGE

Facility

$411.00

Service Code	HCPCS 96409
Hospital Charge Code	3295052
Hospital Revenue Code	280
Min. Negotiated Rate	$369.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$369.90
Rate for Payer: UnitedHealthcare Commercial	$390.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96409 CHEMO IV PUSH SINGLE DRUG CHARGE

Facility

$411.00

Service Code	HCPCS 96409
Hospital Charge Code	3295052
Hospital Revenue Code	280
Min. Negotiated Rate	$42.83
Max. Negotiated Rate	$390.45
Rate for Payer: Aetna Commercial	$369.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$172.62
Rate for Payer: UnitedHealthcare Commercial	$390.45
Rate for Payer: UnitedHealthcare Medicaid	$42.83
Rate for Payer: WPPA Medicare Advantage	$246.60

96411 CHEMO ADMIN IVP ADD'L CHARGE

Facility

$246.00

Service Code	HCPCS 96411
Hospital Charge Code	3295053
Hospital Revenue Code	280
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

96411 CHEMO ADMIN IVP ADD'L CHARGE

Facility

$246.00

Service Code	HCPCS 96411
Hospital Charge Code	3295053
Hospital Revenue Code	280
Min. Negotiated Rate	$42.83
Max. Negotiated Rate	$233.70
Rate for Payer: Aetna Commercial	$221.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$115.42
Rate for Payer: Humana Medicare Advantage	$103.32
Rate for Payer: UnitedHealthcare Commercial	$233.70
Rate for Payer: UnitedHealthcare Medicaid	$42.83
Rate for Payer: WPPA Medicare Advantage	$147.60

96413 CHEMO ADM IV INF 1 HR, INITIAL CHARGE

Facility

$862.00

Service Code	HCPCS 96413
Hospital Charge Code	3295054
Hospital Revenue Code	280
Min. Negotiated Rate	$775.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$775.80
Rate for Payer: UnitedHealthcare Commercial	$818.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges