Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

96415 CHEMO ADM IV INF, EA ADDTL HR CHARGE

Facility

$372.00

Service Code	HCPCS 96415
Hospital Charge Code	3295054
Hospital Revenue Code	280
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$353.40
Rate for Payer: Aetna Commercial	$334.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$195.94
Rate for Payer: Humana Medicare Advantage	$156.24
Rate for Payer: UnitedHealthcare Commercial	$353.40
Rate for Payer: UnitedHealthcare Medicaid	$30.00
Rate for Payer: WPPA Medicare Advantage	$223.20

96415 CHEMO ADM IV INF, EA ADDTL HR CHARGE

Facility

$372.00

Service Code	HCPCS 96415
Hospital Charge Code	3295054
Hospital Revenue Code	280
Min. Negotiated Rate	$334.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$334.80
Rate for Payer: UnitedHealthcare Commercial	$353.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96417 CHEMO IV INFUS EACH ADDL SEQ =<1 HR

Facility

$125.00

Service Code	HCPCS 96417
Hospital Charge Code	3299617
Hospital Revenue Code	280
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$118.75
Rate for Payer: Aetna Commercial	$112.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$69.65
Rate for Payer: Humana Medicare Advantage	$52.50
Rate for Payer: UnitedHealthcare Commercial	$118.75
Rate for Payer: UnitedHealthcare Medicaid	$64.56
Rate for Payer: WPPA Medicare Advantage	$75.00

96417 CHEMO IV INFUS EACH ADDL SEQ =<1 HR

Facility

$125.00

Service Code	HCPCS 96417
Hospital Charge Code	3299617
Hospital Revenue Code	280
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$112.50
Rate for Payer: UnitedHealthcare Commercial	$118.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96425 - CHEMOTX ADMN IA NFS > 8 HR PRTBLE IMPLTBL PMP

Facility

$240.00

Service Code	HCPCS 96425
Hospital Charge Code	3296425
Hospital Revenue Code	280
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: UnitedHealthcare Commercial	$228.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96425 - CHEMOTX ADMN IA NFS > 8 HR PRTBLE IMPLTBL PMP

Facility

$240.00

Service Code	HCPCS 96425
Hospital Charge Code	3296425
Hospital Revenue Code	280
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.32
Rate for Payer: Humana Medicare Advantage	$100.80
Rate for Payer: UnitedHealthcare Commercial	$228.00
Rate for Payer: UnitedHealthcare Medicaid	$109.71
Rate for Payer: WPPA Medicare Advantage	$144.00

96523 - Irrigation IVA device

Facility

$184.00

Service Code	HCPCS 96523
Hospital Charge Code	3300160
Hospital Revenue Code	450
Min. Negotiated Rate	$54.54
Max. Negotiated Rate	$174.80
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.54
Rate for Payer: Humana Medicare Advantage	$77.28
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: UnitedHealthcare Medicaid	$73.60
Rate for Payer: WPPA Medicare Advantage	$110.40

96523 - Irrigation IVA device

Facility

$184.00

Service Code	HCPCS 96523
Hospital Charge Code	3300160
Hospital Revenue Code	450
Min. Negotiated Rate	$165.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96523 Irrigation of implanted venous access device for drug delivery (Port Flush)

Facility

$184.00

Service Code	HCPCS 96523
Hospital Charge Code	3290080
Hospital Revenue Code	761
Min. Negotiated Rate	$54.54
Max. Negotiated Rate	$174.80
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.54
Rate for Payer: Humana Medicare Advantage	$77.28
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: UnitedHealthcare Medicaid	$73.60
Rate for Payer: WPPA Medicare Advantage	$110.40

96523 Irrigation of implanted venous access device for drug delivery (Port Flush)

Facility

$184.00

Service Code	HCPCS 96523
Hospital Charge Code	3290080
Hospital Revenue Code	761
Min. Negotiated Rate	$165.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96523 IRRIGATION OF VENOUS PORT CHARGE

Facility

$184.00

Service Code	HCPCS 96523
Hospital Charge Code	3290080
Hospital Revenue Code	761
Min. Negotiated Rate	$54.54
Max. Negotiated Rate	$174.80
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.54
Rate for Payer: Humana Medicare Advantage	$77.28
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: UnitedHealthcare Medicaid	$73.60
Rate for Payer: WPPA Medicare Advantage	$110.40

96523 IRRIGATION OF VENOUS PORT CHARGE

Facility

$184.00

Service Code	HCPCS 96523
Hospital Charge Code	3290080
Hospital Revenue Code	761
Min. Negotiated Rate	$165.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96523 PORT FLUSH CHARGE

Facility

$184.00

Service Code	HCPCS 96523
Hospital Charge Code	3310184
Hospital Revenue Code	761
Min. Negotiated Rate	$165.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

96523 PORT FLUSH CHARGE

Facility

$184.00

Service Code	HCPCS 96523
Hospital Charge Code	3310184
Hospital Revenue Code	761
Min. Negotiated Rate	$54.54
Max. Negotiated Rate	$174.80
Rate for Payer: Aetna Commercial	$165.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$54.54
Rate for Payer: Humana Medicare Advantage	$77.28
Rate for Payer: UnitedHealthcare Commercial	$174.80
Rate for Payer: UnitedHealthcare Medicaid	$73.60
Rate for Payer: WPPA Medicare Advantage	$110.40

97597 Debridement, open wound; first 20 sq cm or less

Facility

$292.00

Service Code	HCPCS 97597
Hospital Charge Code	3297597
Hospital Revenue Code	761
Min. Negotiated Rate	$122.64
Max. Negotiated Rate	$278.76
Rate for Payer: Aetna Commercial	$262.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$278.76
Rate for Payer: Humana Medicare Advantage	$122.64
Rate for Payer: UnitedHealthcare Commercial	$277.40
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$175.20

97597 Debridement, open wound; first 20 sq cm or less

Facility

$292.00

Service Code	HCPCS 97597
Hospital Charge Code	3297597
Hospital Revenue Code	761
Min. Negotiated Rate	$262.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$262.80
Rate for Payer: UnitedHealthcare Commercial	$277.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97597 Debride Select 1st 20cm or less Charges

Facility

$386.00

Service Code	HCPCS 97597
Hospital Charge Code	3297595
Hospital Revenue Code	360
Min. Negotiated Rate	$347.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$347.40
Rate for Payer: UnitedHealthcare Commercial	$366.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97597 Debride Select 1st 20cm or less Charges

Facility

$386.00

Service Code	HCPCS 97597
Hospital Charge Code	3297595
Hospital Revenue Code	360
Min. Negotiated Rate	$162.12
Max. Negotiated Rate	$366.70
Rate for Payer: Aetna Commercial	$347.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$278.76
Rate for Payer: Humana Medicare Advantage	$162.12
Rate for Payer: UnitedHealthcare Commercial	$366.70
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$231.60

97598 Debridement, open wound; each additional 20 sq cm, or part thereof

Facility

$292.00

Service Code	HCPCS 97598
Hospital Charge Code	3299759
Hospital Revenue Code	761
Min. Negotiated Rate	$262.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$262.80
Rate for Payer: UnitedHealthcare Commercial	$277.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97598 Debridement, open wound; each additional 20 sq cm, or part thereof

Facility

$292.00

Service Code	HCPCS 97598
Hospital Charge Code	3299759
Hospital Revenue Code	761
Min. Negotiated Rate	$122.64
Max. Negotiated Rate	$277.40
Rate for Payer: Aetna Commercial	$262.80
Rate for Payer: Humana Medicare Advantage	$122.64
Rate for Payer: UnitedHealthcare Commercial	$277.40
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$175.20

97602 DRSG CHANGE WET TO DRY CHARGE

Facility

$309.00

Service Code	HCPCS 97602
Hospital Charge Code	3290147
Hospital Revenue Code	761
Min. Negotiated Rate	$278.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$278.10
Rate for Payer: UnitedHealthcare Commercial	$293.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97602 DRSG CHANGE WET TO DRY CHARGE

Facility

$309.00

Service Code	HCPCS 97602
Hospital Charge Code	3290147
Hospital Revenue Code	761
Min. Negotiated Rate	$129.78
Max. Negotiated Rate	$293.55
Rate for Payer: Aetna Commercial	$278.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$200.20
Rate for Payer: Humana Medicare Advantage	$129.78
Rate for Payer: UnitedHealthcare Commercial	$293.55
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$185.40

97602 NONSELECTIVE DEBRID CHARGE

Facility

$294.00

Service Code	HCPCS 97602
Hospital Charge Code	3290147
Hospital Revenue Code	761
Min. Negotiated Rate	$264.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$264.60
Rate for Payer: UnitedHealthcare Commercial	$279.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

97602 NONSELECTIVE DEBRID CHARGE

Facility

$294.00

Service Code	HCPCS 97602
Hospital Charge Code	3290147
Hospital Revenue Code	761
Min. Negotiated Rate	$123.48
Max. Negotiated Rate	$279.30
Rate for Payer: Aetna Commercial	$264.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$200.20
Rate for Payer: Humana Medicare Advantage	$123.48
Rate for Payer: UnitedHealthcare Commercial	$279.30
Rate for Payer: UnitedHealthcare Medicaid	$208.00
Rate for Payer: WPPA Medicare Advantage	$176.40

Know your out-of-pocket cost for care.

All Charges