Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$1,200.00
Max. Negotiated Rate	$1,715.70
Rate for Payer: Aetna Commercial	$1,625.40
Rate for Payer: UnitedHealthcare Commercial	$1,715.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99291 Facility Level Critical Care Ill/Injured Patient Init 30-74 Min

Facility

$1,808.00

Service Code	HCPCS 99291
Hospital Charge Code	3300195
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,717.60
Rate for Payer: Aetna Commercial	$1,627.20
Rate for Payer: UnitedHealthcare Commercial	$1,717.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99291 Facility Level Critical Care Ill/Injured Patient Init 30-74 Min

Facility

$1,808.00

Service Code	HCPCS 99291
Hospital Charge Code	3300195
Hospital Revenue Code	450
Min. Negotiated Rate	$122.27
Max. Negotiated Rate	$1,717.60
Rate for Payer: Aetna Commercial	$1,627.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,021.79
Rate for Payer: Humana Medicare Advantage	$759.36
Rate for Payer: UnitedHealthcare Commercial	$1,717.60
Rate for Payer: UnitedHealthcare Medicaid	$122.27
Rate for Payer: WPPA Medicare Advantage	$1,084.80

99292 CRITICAL CARE (Mag Sulfate Infusion, PPH) EACH ADD 30 MIN CHARGE

Facility

$538.00

Service Code	HCPCS 99292
Hospital Charge Code	3209292
Hospital Revenue Code	729
Min. Negotiated Rate	$484.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$484.20
Rate for Payer: UnitedHealthcare Commercial	$511.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99292 CRITICAL CARE (Mag Sulfate Infusion, PPH) EACH ADD 30 MIN CHARGE

Facility

$538.00

Service Code	HCPCS 99292
Hospital Charge Code	3209292
Hospital Revenue Code	729
Min. Negotiated Rate	$58.86
Max. Negotiated Rate	$511.10
Rate for Payer: Aetna Commercial	$484.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$303.29
Rate for Payer: Humana Medicare Advantage	$225.96
Rate for Payer: UnitedHealthcare Commercial	$511.10
Rate for Payer: UnitedHealthcare Medicaid	$58.86
Rate for Payer: WPPA Medicare Advantage	$322.80

99406 Smoking/Tobacco Cessation Counseling 3-10 Min

Facility

$46.00

Service Code	HCPCS 99406
Hospital Charge Code	3359406
Hospital Revenue Code	761
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.40
Rate for Payer: UnitedHealthcare Commercial	$43.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99406 Smoking/Tobacco Cessation Counseling 3-10 Min

Facility

$46.00

Service Code	HCPCS 99406
Hospital Charge Code	3359406
Hospital Revenue Code	761
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$43.70
Rate for Payer: Aetna Commercial	$41.40
Rate for Payer: Humana Medicare Advantage	$19.32
Rate for Payer: UnitedHealthcare Commercial	$43.70
Rate for Payer: UnitedHealthcare Medicaid	$18.40
Rate for Payer: WPPA Medicare Advantage	$27.60

99417 PROLONG OFFICE E/M EA 15 MIN

Facility

$105.00

Service Code	HCPCS 99417
Hospital Charge Code	3299417
Hospital Revenue Code	761
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$94.50
Rate for Payer: UnitedHealthcare Commercial	$99.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99417 PROLONG OFFICE E/M EA 15 MIN

Facility

$105.00

Service Code	HCPCS 99417
Hospital Charge Code	3299417
Hospital Revenue Code	761
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$99.75
Rate for Payer: Aetna Commercial	$94.50
Rate for Payer: Humana Medicare Advantage	$44.10
Rate for Payer: UnitedHealthcare Commercial	$99.75
Rate for Payer: UnitedHealthcare Medicaid	$42.00
Rate for Payer: WPPA Medicare Advantage	$63.00

99421 - Online digital E&M service, established patient, up to 7 days; 5-10 mins (SP PRO)

Facility

$83.00

Service Code	HCPCS 99421
Hospital Charge Code	SCC99421SP
Hospital Revenue Code	521
Min. Negotiated Rate	$33.20
Max. Negotiated Rate	$78.85
Rate for Payer: Aetna Commercial	$74.70
Rate for Payer: Humana Medicare Advantage	$34.86
Rate for Payer: UnitedHealthcare Commercial	$78.85
Rate for Payer: UnitedHealthcare Medicaid	$33.20
Rate for Payer: WPPA Medicare Advantage	$49.80

99421 - Online digital E&M service, established patient, up to 7 days; 5-10 mins (SP PRO)

Facility

$83.00

Service Code	HCPCS 99421
Hospital Charge Code	SCC99421SP
Hospital Revenue Code	521
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$74.70
Rate for Payer: UnitedHealthcare Commercial	$78.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99421 Online digital E/M service, for Est Pt up to 7 days, cumulative time 5_x0096_10 minutes

Facility

$173.00

Service Code	HCPCS 99421
Hospital Charge Code	3359421
Hospital Revenue Code	761
Min. Negotiated Rate	$155.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$155.70
Rate for Payer: UnitedHealthcare Commercial	$164.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99421 Online digital E/M service, for Est Pt up to 7 days, cumulative time 5_x0096_10 minutes

Facility

$173.00

Service Code	HCPCS 99421
Hospital Charge Code	3359421
Hospital Revenue Code	761
Min. Negotiated Rate	$69.20
Max. Negotiated Rate	$164.35
Rate for Payer: Aetna Commercial	$155.70
Rate for Payer: Humana Medicare Advantage	$72.66
Rate for Payer: UnitedHealthcare Commercial	$164.35
Rate for Payer: UnitedHealthcare Medicaid	$69.20
Rate for Payer: WPPA Medicare Advantage	$103.80

99421 Online Digital E/M SVC 5-10 minutes

Facility

$182.00

Service Code	HCPCS 99421
Hospital Charge Code	3359421
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

99421 Online Digital E/M SVC 5-10 minutes

Facility

$182.00

Service Code	HCPCS 99421
Hospital Charge Code	3359421
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

99422 Online Digital E&M 11-22 mins

Facility

$240.00

Service Code	HCPCS 99422
Hospital Charge Code	3359422
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

99422 Online Digital E&M 11-22 mins

Facility

$240.00

Service Code	HCPCS 99422
Hospital Charge Code	3359422
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

99422 Online E/M service, for Est Pt up to 7 days, cumulative time 11_x0096_ 20 minutes

Facility

$240.00

Service Code	HCPCS 99422
Hospital Charge Code	3359422
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

99422 Online E/M service, for Est Pt up to 7 days, cumulative time 11_x0096_ 20 minutes

Facility

$240.00

Service Code	HCPCS 99422
Hospital Charge Code	3359422
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

99423 Online digital E/M estab 21 min or >

Facility

$295.00

Service Code	HCPCS 99423
Hospital Charge Code	3359423
Hospital Revenue Code	761
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$280.25
Rate for Payer: Aetna Commercial	$265.50
Rate for Payer: Humana Medicare Advantage	$123.90
Rate for Payer: UnitedHealthcare Commercial	$280.25
Rate for Payer: UnitedHealthcare Medicaid	$118.00
Rate for Payer: WPPA Medicare Advantage	$177.00

99423 Online digital E/M estab 21 min or >

Facility

$295.00

Service Code	HCPCS 99423
Hospital Charge Code	3359423
Hospital Revenue Code	761
Min. Negotiated Rate	$265.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$265.50
Rate for Payer: UnitedHealthcare Commercial	$280.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99423 - Online digital E&M service, established patient, up to 7 days; 21+ mins (SP PRO)

Facility

$122.00

Service Code	HCPCS 99423
Hospital Charge Code	SCC99423SP
Hospital Revenue Code	521
Min. Negotiated Rate	$109.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99423 - Online digital E&M service, established patient, up to 7 days; 21+ mins (SP PRO)

Facility

$122.00

Service Code	HCPCS 99423
Hospital Charge Code	SCC99423SP
Hospital Revenue Code	521
Min. Negotiated Rate	$48.80
Max. Negotiated Rate	$115.90
Rate for Payer: Aetna Commercial	$109.80
Rate for Payer: Humana Medicare Advantage	$51.24
Rate for Payer: UnitedHealthcare Commercial	$115.90
Rate for Payer: UnitedHealthcare Medicaid	$48.80
Rate for Payer: WPPA Medicare Advantage	$73.20

99423 Online E/M service, for Est Pt up to 7 days, cumulative time 21 or more minutes

Facility

$281.00

Service Code	HCPCS 99423
Hospital Charge Code	3359423
Hospital Revenue Code	761
Min. Negotiated Rate	$112.40
Max. Negotiated Rate	$266.95
Rate for Payer: Aetna Commercial	$252.90
Rate for Payer: Humana Medicare Advantage	$118.02
Rate for Payer: UnitedHealthcare Commercial	$266.95
Rate for Payer: UnitedHealthcare Medicaid	$112.40
Rate for Payer: WPPA Medicare Advantage	$168.60

99423 Online E/M service, for Est Pt up to 7 days, cumulative time 21 or more minutes

Facility

$281.00

Service Code	HCPCS 99423
Hospital Charge Code	3359423
Hospital Revenue Code	761
Min. Negotiated Rate	$252.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$252.90
Rate for Payer: UnitedHealthcare Commercial	$266.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges