Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

99202 Office Visit New Pt. Level 2

Facility

$182.00

Service Code	HCPCS 99202
Hospital Charge Code	3291250
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 Visit New Pt. Level 2

Facility

$182.00

Service Code	HCPCS 99202
Hospital Charge Code	3291250
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 Office Visit New Pt. Level 2 (SP Pro)

Facility

$191.00

Service Code	HCPCS 99202
Hospital Charge Code	SCC99202SP
Hospital Revenue Code	521
Min. Negotiated Rate	$171.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$171.90
Rate for Payer: UnitedHealthcare Commercial	$181.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99202 Office Visit New Pt. Level 2 (SP Pro)

Facility

$191.00

Service Code	HCPCS 99202
Hospital Charge Code	SCC99202SP
Hospital Revenue Code	521
Min. Negotiated Rate	$67.67
Max. Negotiated Rate	$181.45
Rate for Payer: Aetna Commercial	$171.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$67.67
Rate for Payer: Humana Medicare Advantage	$80.22
Rate for Payer: UnitedHealthcare Commercial	$181.45
Rate for Payer: UnitedHealthcare Medicaid	$76.40
Rate for Payer: WPPA Medicare Advantage	$114.60

99203 CRNA-NEW OFFICE/OUTPNT, LEV 3, LOW MDM, 30 + MIN

Facility

$240.00

Service Code	HCPCS 99203
Hospital Charge Code	3189203
Hospital Revenue Code	761
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
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

99203 CRNA-NEW OFFICE/OUTPNT, LEV 3, LOW MDM, 30 + MIN

Facility

$240.00

Service Code	HCPCS 99203
Hospital Charge Code	3189203
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

99203 - Office/Outpatient - New Patient, Low (30-44 mins)

Facility

$240.00

Service Code	HCPCS 99203
Hospital Charge Code	3359203
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

99203 - Office/Outpatient - New Patient, Low (30-44 mins)

Facility

$240.00

Service Code	HCPCS 99203
Hospital Charge Code	3359203
Hospital Revenue Code	761
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
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

99203 Office Visit New Pt Level 3

Facility

$240.00

Service Code	HCPCS 99203
Hospital Charge Code	3291300
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

99203 Office Visit New Pt Level 3

Facility

$240.00

Service Code	HCPCS 99203
Hospital Charge Code	3291300
Hospital Revenue Code	761
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
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

99203 Office Visit New Pt. Level 3 (SP Pro)

Facility

$221.00

Service Code	HCPCS 99203
Hospital Charge Code	SCC99203SP
Hospital Revenue Code	521
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$209.95
Rate for Payer: Aetna Commercial	$198.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
Rate for Payer: Humana Medicare Advantage	$92.82
Rate for Payer: UnitedHealthcare Commercial	$209.95
Rate for Payer: UnitedHealthcare Medicaid	$88.40
Rate for Payer: WPPA Medicare Advantage	$132.60

99203 Office Visit New Pt. Level 3 (SP Pro)

Facility

$221.00

Service Code	HCPCS 99203
Hospital Charge Code	SCC99203SP
Hospital Revenue Code	521
Min. Negotiated Rate	$198.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$198.90
Rate for Payer: UnitedHealthcare Commercial	$209.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99204 LEVEL 4 VISIT NEW PT ProFee

Facility

$336.00

Service Code	HCPCS 99204
Hospital Charge Code	3291350
Hospital Revenue Code	761
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$319.20
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
Rate for Payer: Humana Medicare Advantage	$141.12
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: UnitedHealthcare Medicaid	$134.40
Rate for Payer: WPPA Medicare Advantage	$201.60

99204 LEVEL 4 VISIT NEW PT ProFee

Facility

$336.00

Service Code	HCPCS 99204
Hospital Charge Code	3291350
Hospital Revenue Code	761
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99204 - Office/Outpatient - New Patient, Moderate (45-59 mins)

Facility

$336.00

Service Code	HCPCS 99204
Hospital Charge Code	3359204
Hospital Revenue Code	761
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$319.20
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
Rate for Payer: Humana Medicare Advantage	$141.12
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: UnitedHealthcare Medicaid	$134.40
Rate for Payer: WPPA Medicare Advantage	$201.60

99204 - Office/Outpatient - New Patient, Moderate (45-59 mins)

Facility

$336.00

Service Code	HCPCS 99204
Hospital Charge Code	3359204
Hospital Revenue Code	761
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99204 Office/Outpatient Visit - New Patient, Level 4

Facility

$336.00

Service Code	HCPCS 99204
Hospital Charge Code	3159204
Hospital Revenue Code	360
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$319.20
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
Rate for Payer: Humana Medicare Advantage	$141.12
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: UnitedHealthcare Medicaid	$134.40
Rate for Payer: WPPA Medicare Advantage	$201.60

99204 Office/Outpatient Visit - New Patient, Level 4

Facility

$336.00

Service Code	HCPCS 99204
Hospital Charge Code	3159204
Hospital Revenue Code	360
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99204 Office Visit New Pt Level 4

Facility

$336.00

Service Code	HCPCS 99204
Hospital Charge Code	3291350
Hospital Revenue Code	761
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$319.20
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
Rate for Payer: Humana Medicare Advantage	$141.12
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: UnitedHealthcare Medicaid	$134.40
Rate for Payer: WPPA Medicare Advantage	$201.60

99204 Office Visit New Pt Level 4

Facility

$336.00

Service Code	HCPCS 99204
Hospital Charge Code	3291350
Hospital Revenue Code	761
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99204 Office Visit New Pt. Level 4 (SP Pro)

Facility

$335.00

Service Code	HCPCS 99204
Hospital Charge Code	SCC99204SP
Hospital Revenue Code	521
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$318.25
Rate for Payer: Aetna Commercial	$301.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$101.00
Rate for Payer: Humana Medicare Advantage	$140.70
Rate for Payer: UnitedHealthcare Commercial	$318.25
Rate for Payer: UnitedHealthcare Medicaid	$134.00
Rate for Payer: WPPA Medicare Advantage	$201.00

99204 Office Visit New Pt. Level 4 (SP Pro)

Facility

$335.00

Service Code	HCPCS 99204
Hospital Charge Code	SCC99204SP
Hospital Revenue Code	521
Min. Negotiated Rate	$301.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$301.50
Rate for Payer: UnitedHealthcare Commercial	$318.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99205 - Office/Outpatient - New Patient, High (60-74 mins)

Facility

$495.00

Service Code	HCPCS 99205
Hospital Charge Code	3359205
Hospital Revenue Code	761
Min. Negotiated Rate	$168.67
Max. Negotiated Rate	$470.25
Rate for Payer: Aetna Commercial	$445.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$168.67
Rate for Payer: Humana Medicare Advantage	$207.90
Rate for Payer: UnitedHealthcare Commercial	$470.25
Rate for Payer: UnitedHealthcare Medicaid	$198.00
Rate for Payer: WPPA Medicare Advantage	$297.00

99205 - Office/Outpatient - New Patient, High (60-74 mins)

Facility

$495.00

Service Code	HCPCS 99205
Hospital Charge Code	3359205
Hospital Revenue Code	761
Min. Negotiated Rate	$445.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$445.50
Rate for Payer: UnitedHealthcare Commercial	$470.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99205 Office Visit New Pt Level 5

Facility

$495.00

Service Code	HCPCS 99205
Hospital Charge Code	3270080
Hospital Revenue Code	761
Min. Negotiated Rate	$445.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$445.50
Rate for Payer: UnitedHealthcare Commercial	$470.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges