Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

97803 MNT RE ASSESS EA 15 MIN CHARGE

Facility

$56.00

Service Code	HCPCS 97803
Hospital Charge Code	3350310
Hospital Revenue Code	942
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$53.20
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$14.70
Rate for Payer: Humana Medicare Advantage	$23.52
Rate for Payer: UnitedHealthcare Commercial	$53.20
Rate for Payer: UnitedHealthcare Medicaid	$22.40
Rate for Payer: WPPA Medicare Advantage	$33.60

98012 TELEPHONE EVAL, ESTABLISHED PATIENT, 10-19 MIN

Facility

$182.00

Service Code	HCPCS 98012
Hospital Charge Code	3359441
Hospital Revenue Code	761
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$172.90
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: Humana Medicare Advantage	$76.44
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: UnitedHealthcare Medicaid	$72.80
Rate for Payer: WPPA Medicare Advantage	$109.20

98012 TELEPHONE EVAL, ESTABLISHED PATIENT, 10-19 MIN

Facility

$182.00

Service Code	HCPCS 98012
Hospital Charge Code	3359441
Hospital Revenue Code	761
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

98013 EST. PATIENT; LOW; 20 MIN

Facility

$240.00

Service Code	HCPCS 98013
Hospital Charge Code	3359442
Hospital Revenue Code	761
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: Humana Medicare Advantage	$100.80
Rate for Payer: UnitedHealthcare Commercial	$228.00
Rate for Payer: UnitedHealthcare Medicaid	$96.00
Rate for Payer: WPPA Medicare Advantage	$144.00

98013 EST. PATIENT; LOW; 20 MIN

Facility

$240.00

Service Code	HCPCS 98013
Hospital Charge Code	3359442
Hospital Revenue Code	761
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

98014 EST. PATIENT; MODERATE; 30 MIN

Facility

$297.00

Service Code	HCPCS 98014
Hospital Charge Code	3359443
Hospital Revenue Code	761
Min. Negotiated Rate	$267.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$267.30
Rate for Payer: UnitedHealthcare Commercial	$282.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

98014 EST. PATIENT; MODERATE; 30 MIN

Facility

$297.00

Service Code	HCPCS 98014
Hospital Charge Code	3359443
Hospital Revenue Code	761
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$282.15
Rate for Payer: Aetna Commercial	$267.30
Rate for Payer: Humana Medicare Advantage	$124.74
Rate for Payer: UnitedHealthcare Commercial	$282.15
Rate for Payer: UnitedHealthcare Medicaid	$118.80
Rate for Payer: WPPA Medicare Advantage	$178.20

98975 Remote Therapeutic Monitoring

Facility

$26.00

Service Code	HCPCS 98975
Hospital Charge Code	3298975
Hospital Revenue Code	761
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$24.70
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: Humana Medicare Advantage	$10.92
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: UnitedHealthcare Medicaid	$10.40
Rate for Payer: WPPA Medicare Advantage	$15.60

98975 Remote Therapeutic Monitoring

Facility

$26.00

Service Code	HCPCS 98975
Hospital Charge Code	3298975
Hospital Revenue Code	761
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

98980 Remote Therapeutic Monitoring First 20 Min

Facility

$61.00

Service Code	HCPCS 98980
Hospital Charge Code	3298980
Hospital Revenue Code	780
Min. Negotiated Rate	$24.40
Max. Negotiated Rate	$57.95
Rate for Payer: Aetna Commercial	$54.90
Rate for Payer: Humana Medicare Advantage	$25.62
Rate for Payer: UnitedHealthcare Commercial	$57.95
Rate for Payer: UnitedHealthcare Medicaid	$24.40
Rate for Payer: WPPA Medicare Advantage	$36.60

98980 Remote Therapeutic Monitoring First 20 Min

Facility

$61.00

Service Code	HCPCS 98980
Hospital Charge Code	3298980
Hospital Revenue Code	780
Min. Negotiated Rate	$54.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$54.90
Rate for Payer: UnitedHealthcare Commercial	$57.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

98981 Remote Therapeutic Monitoring Each Additional 20 min

Facility

$40.00

Service Code	HCPCS 98981
Hospital Charge Code	3298981
Hospital Revenue Code	780
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.00
Rate for Payer: UnitedHealthcare Commercial	$38.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

98981 Remote Therapeutic Monitoring Each Additional 20 min

Facility

$40.00

Service Code	HCPCS 98981
Hospital Charge Code	3298981
Hospital Revenue Code	780
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.00
Rate for Payer: Humana Medicare Advantage	$16.80
Rate for Payer: UnitedHealthcare Commercial	$38.00
Rate for Payer: UnitedHealthcare Medicaid	$16.00
Rate for Payer: WPPA Medicare Advantage	$24.00

99153 CONSCIOUS SEDATION SAME MD EA ADDL 15 MIN

Facility

$167.00

Service Code	HCPCS 99153
Hospital Charge Code	3180240
Hospital Revenue Code	360
Min. Negotiated Rate	$66.80
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$66.80
Rate for Payer: WPPA Medicare Advantage	$100.20

99153 CONSCIOUS SEDATION SAME MD EA ADDL 15 MIN

Facility

$167.00

Service Code	HCPCS 99153
Hospital Charge Code	3180240
Hospital Revenue Code	360
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

99155 CONSCIOUS SEDATION DIFF MD <5 YRS INIT 15 MIN

Facility

$188.00

Service Code	HCPCS 99155
Hospital Charge Code	3309148
Hospital Revenue Code	360
Min. Negotiated Rate	$169.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99155 CONSCIOUS SEDATION DIFF MD <5 YRS INIT 15 MIN

Facility

$188.00

Service Code	HCPCS 99155
Hospital Charge Code	3309148
Hospital Revenue Code	360
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna Commercial	$169.20
Rate for Payer: Humana Medicare Advantage	$78.96
Rate for Payer: UnitedHealthcare Commercial	$178.60
Rate for Payer: UnitedHealthcare Medicaid	$75.20
Rate for Payer: WPPA Medicare Advantage	$112.80

99156 Moderate sedation; initial 15 minutes

Facility

$177.00

Service Code	HCPCS 99156
Hospital Charge Code	3180236
Hospital Revenue Code	360
Min. Negotiated Rate	$70.80
Max. Negotiated Rate	$168.15
Rate for Payer: Aetna Commercial	$159.30
Rate for Payer: Humana Medicare Advantage	$74.34
Rate for Payer: UnitedHealthcare Commercial	$168.15
Rate for Payer: UnitedHealthcare Medicaid	$70.80
Rate for Payer: WPPA Medicare Advantage	$106.20

99156 Moderate sedation; initial 15 minutes

Facility

$177.00

Service Code	HCPCS 99156
Hospital Charge Code	3180236
Hospital Revenue Code	360
Min. Negotiated Rate	$159.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$159.30
Rate for Payer: UnitedHealthcare Commercial	$168.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99157 Moderate sedation each additional 15 minutes

Facility

$167.00

Service Code	HCPCS 99157
Hospital Charge Code	3180241
Hospital Revenue Code	360
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

99157 Moderate sedation each additional 15 minutes

Facility

$167.00

Service Code	HCPCS 99157
Hospital Charge Code	3180241
Hospital Revenue Code	360
Min. Negotiated Rate	$66.80
Max. Negotiated Rate	$158.65
Rate for Payer: Aetna Commercial	$150.30
Rate for Payer: Humana Medicare Advantage	$70.14
Rate for Payer: UnitedHealthcare Commercial	$158.65
Rate for Payer: UnitedHealthcare Medicaid	$66.80
Rate for Payer: WPPA Medicare Advantage	$100.20

99202 CRNA-NEW OFFICE/OUTPNT, LEV 2, STRAIGHTFORWARD MDM, 15+ MIN

Facility

$182.00

Service Code	HCPCS 99202
Hospital Charge Code	3189202
Hospital Revenue Code	761
Min. Negotiated Rate	$67.67
Max. Negotiated Rate	$172.90
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.67
Rate for Payer: Humana Medicare Advantage	$76.44
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: UnitedHealthcare Medicaid	$72.80
Rate for Payer: WPPA Medicare Advantage	$109.20

99202 CRNA-NEW OFFICE/OUTPNT, LEV 2, STRAIGHTFORWARD MDM, 15+ MIN

Facility

$182.00

Service Code	HCPCS 99202
Hospital Charge Code	3189202
Hospital Revenue Code	761
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99202 Office/Outpatient Visit - New Patient, Level 2 15-29 minutes

Facility

$182.00

Service Code	HCPCS 99202
Hospital Charge Code	3299202
Hospital Revenue Code	761
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99202 Office/Outpatient Visit - New Patient, Level 2 15-29 minutes

Facility

$182.00

Service Code	HCPCS 99202
Hospital Charge Code	3299202
Hospital Revenue Code	761
Min. Negotiated Rate	$67.67
Max. Negotiated Rate	$172.90
Rate for Payer: Aetna Commercial	$163.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.67
Rate for Payer: Humana Medicare Advantage	$76.44
Rate for Payer: UnitedHealthcare Commercial	$172.90
Rate for Payer: UnitedHealthcare Medicaid	$72.80
Rate for Payer: WPPA Medicare Advantage	$109.20

Know your out-of-pocket cost for care.

All Charges