Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

99214 CRNA-ESTABLISHED OFFICE/OUTPNT, LEV 4, MODERATE MDM, 30+ MIN

Facility

$261.00

Service Code	HCPCS 99214
Hospital Charge Code	3189214
Hospital Revenue Code	761
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$247.95
Rate for Payer: Aetna Commercial	$234.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$188.57
Rate for Payer: Humana Medicare Advantage	$109.62
Rate for Payer: UnitedHealthcare Commercial	$247.95
Rate for Payer: UnitedHealthcare Medicaid	$104.40
Rate for Payer: WPPA Medicare Advantage	$156.60

99214 CRNA-ESTABLISHED OFFICE/OUTPNT, LEV 4, MODERATE MDM, 30+ MIN

Facility

$261.00

Service Code	HCPCS 99214
Hospital Charge Code	3189214
Hospital Revenue Code	761
Min. Negotiated Rate	$234.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$234.90
Rate for Payer: UnitedHealthcare Commercial	$247.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99214 EST 40-60 MIN NURSING CHARGE

Facility

$261.00

Service Code	HCPCS 99214
Hospital Charge Code	3350120
Hospital Revenue Code	761
Min. Negotiated Rate	$234.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$234.90
Rate for Payer: UnitedHealthcare Commercial	$247.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99214 EST 40-60 MIN NURSING CHARGE

Facility

$261.00

Service Code	HCPCS 99214
Hospital Charge Code	3350120
Hospital Revenue Code	761
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$247.95
Rate for Payer: Aetna Commercial	$234.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$188.57
Rate for Payer: Humana Medicare Advantage	$109.62
Rate for Payer: UnitedHealthcare Commercial	$247.95
Rate for Payer: UnitedHealthcare Medicaid	$104.40
Rate for Payer: WPPA Medicare Advantage	$156.60

99214 Office Visit Established Pt Level 4

Facility

$261.00

Service Code	HCPCS 99214
Hospital Charge Code	3291200
Hospital Revenue Code	761
Min. Negotiated Rate	$234.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$234.90
Rate for Payer: UnitedHealthcare Commercial	$247.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99214 Office Visit Established Pt Level 4

Facility

$261.00

Service Code	HCPCS 99214
Hospital Charge Code	3291200
Hospital Revenue Code	761
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$247.95
Rate for Payer: Aetna Commercial	$234.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$188.57
Rate for Payer: Humana Medicare Advantage	$109.62
Rate for Payer: UnitedHealthcare Commercial	$247.95
Rate for Payer: UnitedHealthcare Medicaid	$104.40
Rate for Payer: WPPA Medicare Advantage	$156.60

99214 Office Visit Established Pt. Level 4 (SP Pro)

Facility

$204.00

Service Code	HCPCS 99214
Hospital Charge Code	SCC99214SP
Hospital Revenue Code	521
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$183.60
Rate for Payer: UnitedHealthcare Commercial	$193.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99214 Office Visit Established Pt. Level 4 (SP Pro)

Facility

$204.00

Service Code	HCPCS 99214
Hospital Charge Code	SCC99214SP
Hospital Revenue Code	521
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$193.80
Rate for Payer: Aetna Commercial	$183.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$188.57
Rate for Payer: Humana Medicare Advantage	$85.68
Rate for Payer: UnitedHealthcare Commercial	$193.80
Rate for Payer: UnitedHealthcare Medicaid	$81.60
Rate for Payer: WPPA Medicare Advantage	$122.40

99215 CRNA-ESTABLISHED OFFICE/OUTPNT, LEV 5, HIGH MDM, 40 + MIN

Facility

$310.00

Service Code	HCPCS 99215
Hospital Charge Code	3159921
Hospital Revenue Code	761
Min. Negotiated Rate	$279.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$279.00
Rate for Payer: UnitedHealthcare Commercial	$294.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99215 CRNA-ESTABLISHED OFFICE/OUTPNT, LEV 5, HIGH MDM, 40 + MIN

Facility

$310.00

Service Code	HCPCS 99215
Hospital Charge Code	3159921
Hospital Revenue Code	761
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$294.50
Rate for Payer: Aetna Commercial	$279.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$266.24
Rate for Payer: Humana Medicare Advantage	$130.20
Rate for Payer: UnitedHealthcare Commercial	$294.50
Rate for Payer: UnitedHealthcare Medicaid	$124.00
Rate for Payer: WPPA Medicare Advantage	$186.00

99215 Office Visit Established Pt Level 5

Facility

$205.00

Service Code	HCPCS 99215
Hospital Charge Code	3299215
Hospital Revenue Code	761
Min. Negotiated Rate	$184.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$184.50
Rate for Payer: UnitedHealthcare Commercial	$194.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99215 Office Visit Established Pt Level 5

Facility

$205.00

Service Code	HCPCS 99215
Hospital Charge Code	3299215
Hospital Revenue Code	761
Min. Negotiated Rate	$82.00
Max. Negotiated Rate	$266.24
Rate for Payer: Aetna Commercial	$184.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$266.24
Rate for Payer: Humana Medicare Advantage	$86.10
Rate for Payer: UnitedHealthcare Commercial	$194.75
Rate for Payer: UnitedHealthcare Medicaid	$82.00
Rate for Payer: WPPA Medicare Advantage	$123.00

99242 ANESTHESIA PAT CONSULT

Facility

$137.00

Service Code	HCPCS 99242
Hospital Charge Code	3189242
Hospital Revenue Code	360
Min. Negotiated Rate	$123.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$123.30
Rate for Payer: UnitedHealthcare Commercial	$130.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99242 ANESTHESIA PAT CONSULT

Facility

$137.00

Service Code	HCPCS 99242
Hospital Charge Code	3189242
Hospital Revenue Code	360
Min. Negotiated Rate	$54.80
Max. Negotiated Rate	$130.15
Rate for Payer: Aetna Commercial	$123.30
Rate for Payer: Humana Medicare Advantage	$57.54
Rate for Payer: UnitedHealthcare Commercial	$130.15
Rate for Payer: UnitedHealthcare Medicaid	$54.80
Rate for Payer: WPPA Medicare Advantage	$82.20

99281 ED VISIT FOR E&M PATIENT, LEV 1, MAY NOT REQ PRESENCE OF PHYSICIAN OR OTHER, CC

Facility

$302.00

Service Code	HCPCS 99281
Hospital Charge Code	3300170
Hospital Revenue Code	450
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$286.90
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$170.31
Rate for Payer: Humana Medicare Advantage	$126.84
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: UnitedHealthcare Medicaid	$105.00
Rate for Payer: WPPA Medicare Advantage	$181.20

99281 ED VISIT FOR E&M PATIENT, LEV 1, MAY NOT REQ PRESENCE OF PHYSICIAN OR OTHER, CC

Facility

$302.00

Service Code	HCPCS 99281
Hospital Charge Code	3300170
Hospital Revenue Code	450
Min. Negotiated Rate	$271.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99282 ED VISIT E&M PATIENT, LEV 2, REQ MED APPROP HSTRY/EXAM/MDM, CC

Facility

$469.00

Service Code	HCPCS 99282
Hospital Charge Code	3300175
Hospital Revenue Code	450
Min. Negotiated Rate	$422.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$422.10
Rate for Payer: UnitedHealthcare Commercial	$445.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99282 ED VISIT E&M PATIENT, LEV 2, REQ MED APPROP HSTRY/EXAM/MDM, CC

Facility

$469.00

Service Code	HCPCS 99282
Hospital Charge Code	3300175
Hospital Revenue Code	450
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$445.55
Rate for Payer: Aetna Commercial	$422.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$265.31
Rate for Payer: Humana Medicare Advantage	$196.98
Rate for Payer: UnitedHealthcare Commercial	$445.55
Rate for Payer: UnitedHealthcare Medicaid	$105.00
Rate for Payer: WPPA Medicare Advantage	$281.40

99283 ED VISIT E&M PATIENT, LEV 3, REQ MED APPROP HSTRY/EXAM/LOW MDM, CC

Facility

$721.00

Service Code	HCPCS 99283
Hospital Charge Code	3300180
Hospital Revenue Code	450
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$684.95
Rate for Payer: Aetna Commercial	$648.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$407.79
Rate for Payer: Humana Medicare Advantage	$302.82
Rate for Payer: UnitedHealthcare Commercial	$684.95
Rate for Payer: UnitedHealthcare Medicaid	$105.00
Rate for Payer: WPPA Medicare Advantage	$432.60

99283 ED VISIT E&M PATIENT, LEV 3, REQ MED APPROP HSTRY/EXAM/LOW MDM, CC

Facility

$721.00

Service Code	HCPCS 99283
Hospital Charge Code	3300180
Hospital Revenue Code	450
Min. Negotiated Rate	$648.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$648.90
Rate for Payer: UnitedHealthcare Commercial	$684.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99284 ED VISIT E&M PATIENT, LEV 4, REQ MED APPROP HSTRY/EXAM/MODERATE MDM, CC

Facility

$1,230.00

Service Code	HCPCS 99284
Hospital Charge Code	3300185
Hospital Revenue Code	450
Min. Negotiated Rate	$1,107.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,107.00
Rate for Payer: UnitedHealthcare Commercial	$1,168.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99284 ED VISIT E&M PATIENT, LEV 4, REQ MED APPROP HSTRY/EXAM/MODERATE MDM, CC

Facility

$1,230.00

Service Code	HCPCS 99284
Hospital Charge Code	3300185
Hospital Revenue Code	450
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$1,168.50
Rate for Payer: Aetna Commercial	$1,107.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$695.24
Rate for Payer: Humana Medicare Advantage	$516.60
Rate for Payer: UnitedHealthcare Commercial	$1,168.50
Rate for Payer: UnitedHealthcare Medicaid	$105.00
Rate for Payer: WPPA Medicare Advantage	$738.00

99285 ED VISIT E M PATIENT, LEV 5, REQ MED APPROP HSTRY/EXAM/HIGH MDM, CC

Facility

$1,910.00

Service Code	HCPCS 99285
Hospital Charge Code	3300190
Hospital Revenue Code	450
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$1,814.50
Rate for Payer: Aetna Commercial	$1,719.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,080.54
Rate for Payer: Humana Medicare Advantage	$802.20
Rate for Payer: UnitedHealthcare Commercial	$1,814.50
Rate for Payer: UnitedHealthcare Medicaid	$105.00
Rate for Payer: WPPA Medicare Advantage	$1,146.00

99285 ED VISIT E M PATIENT, LEV 5, REQ MED APPROP HSTRY/EXAM/HIGH MDM, CC

Facility

$1,910.00

Service Code	HCPCS 99285
Hospital Charge Code	3300190
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,814.50
Rate for Payer: Aetna Commercial	$1,719.00
Rate for Payer: UnitedHealthcare Commercial	$1,814.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99291 CRITICAL CARE (Mag Sulfate Infusion, PPH) FIRST 30-74 MIN CHARGE

Facility

$1,806.00

Service Code	HCPCS 99291
Hospital Charge Code	3209291
Hospital Revenue Code	729
Min. Negotiated Rate	$122.27
Max. Negotiated Rate	$1,715.70
Rate for Payer: Aetna Commercial	$1,625.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,021.79
Rate for Payer: Humana Medicare Advantage	$758.52
Rate for Payer: UnitedHealthcare Commercial	$1,715.70
Rate for Payer: UnitedHealthcare Medicaid	$122.27
Rate for Payer: WPPA Medicare Advantage	$1,083.60

Know your out-of-pocket cost for care.

All Charges