Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

99426 PRINCIPAL CARE MGMT SVC 1ST 30 CLINICAL STAFF

Facility

$84.00

Service Code	HCPCS 99426
Hospital Charge Code	3299426
Hospital Revenue Code	780
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$75.60
Rate for Payer: UnitedHealthcare Commercial	$79.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99426 PRINCIPAL CARE MGMT SVC 1ST 30 CLINICAL STAFF

Facility

$84.00

Service Code	HCPCS 99426
Hospital Charge Code	3299426
Hospital Revenue Code	780
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$79.80
Rate for Payer: Aetna Commercial	$75.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.01
Rate for Payer: Humana Medicare Advantage	$35.28
Rate for Payer: UnitedHealthcare Commercial	$79.80
Rate for Payer: UnitedHealthcare Medicaid	$33.60
Rate for Payer: WPPA Medicare Advantage	$50.40

99427 PRINCIPAL CARE MGMT SVC EA ADDL 30 CLINICAL STAFF

Facility

$63.00

Service Code	HCPCS 99427
Hospital Charge Code	3299427
Hospital Revenue Code	780
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$59.85
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.01
Rate for Payer: Humana Medicare Advantage	$26.46
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: UnitedHealthcare Medicaid	$25.20
Rate for Payer: WPPA Medicare Advantage	$37.80

99427 PRINCIPAL CARE MGMT SVC EA ADDL 30 CLINICAL STAFF

Facility

$63.00

Service Code	HCPCS 99427
Hospital Charge Code	3299427
Hospital Revenue Code	780
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: UnitedHealthcare Commercial	$59.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99442 Telephone Visit - Established Patient; 11-20 Min (SP PRO)

Facility

$122.00

Service Code	HCPCS 98013
Hospital Charge Code	SCC99442SP
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

99442 Telephone Visit - Established Patient; 11-20 Min (SP PRO)

Facility

$122.00

Service Code	HCPCS 98013
Hospital Charge Code	SCC99442SP
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

99453-Remote monitoring of physiologic parameter(s)

Facility

$26.00

Service Code	HCPCS 99453
Hospital Charge Code	3299453
Hospital Revenue Code	780
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

99453-Remote monitoring of physiologic parameter(s)

Facility

$26.00

Service Code	HCPCS 99453
Hospital Charge Code	3299453
Hospital Revenue Code	780
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

99454-Remote monitoring of physiologic parameter(s)

Facility

$57.00

Service Code	HCPCS 99454
Hospital Charge Code	3299454
Hospital Revenue Code	780
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99454-Remote monitoring of physiologic parameter(s)

Facility

$57.00

Service Code	HCPCS 99454
Hospital Charge Code	3299454
Hospital Revenue Code	780
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$54.15
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Humana Medicare Advantage	$23.94
Rate for Payer: UnitedHealthcare Commercial	$54.15
Rate for Payer: UnitedHealthcare Medicaid	$22.80
Rate for Payer: WPPA Medicare Advantage	$34.20

99457-Remote physiologic monitoring treatment management services

Facility

$64.00

Service Code	HCPCS 99457
Hospital Charge Code	3299457
Hospital Revenue Code	780
Min. Negotiated Rate	$25.60
Max. Negotiated Rate	$60.80
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: Humana Medicare Advantage	$26.88
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: UnitedHealthcare Medicaid	$25.60
Rate for Payer: WPPA Medicare Advantage	$38.40

99457-Remote physiologic monitoring treatment management services

Facility

$64.00

Service Code	HCPCS 99457
Hospital Charge Code	3299457
Hospital Revenue Code	780
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$57.60
Rate for Payer: UnitedHealthcare Commercial	$60.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99458-Remote physiologic monitoring treatment management services

Facility

$51.00

Service Code	HCPCS 99458
Hospital Charge Code	3299458
Hospital Revenue Code	780
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$48.45
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: Humana Medicare Advantage	$21.42
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: WPPA Medicare Advantage	$30.60

99458-Remote physiologic monitoring treatment management services

Facility

$51.00

Service Code	HCPCS 99458
Hospital Charge Code	3299458
Hospital Revenue Code	780
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: UnitedHealthcare Commercial	$48.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99483 Assessment of and care planning for a patient with cognitive impairment, requiring an independ

Facility

$511.00

Service Code	HCPCS 99483
Hospital Charge Code	3359483
Hospital Revenue Code	761
Min. Negotiated Rate	$459.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$459.90
Rate for Payer: UnitedHealthcare Commercial	$485.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

99483 Assessment of and care planning for a patient with cognitive impairment, requiring an independ

Facility

$511.00

Service Code	HCPCS 99483
Hospital Charge Code	3359483
Hospital Revenue Code	761
Min. Negotiated Rate	$204.40
Max. Negotiated Rate	$485.45
Rate for Payer: Aetna Commercial	$459.90
Rate for Payer: Humana Medicare Advantage	$214.62
Rate for Payer: UnitedHealthcare Commercial	$485.45
Rate for Payer: UnitedHealthcare Medicaid	$204.40
Rate for Payer: WPPA Medicare Advantage	$306.60

99999 PT OUTSOURCING THERAPIST

Facility

$22.00

Hospital Charge Code	5605728
Hospital Revenue Code	922
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$20.90
Rate for Payer: Aetna Commercial	$19.80
Rate for Payer: Humana Medicare Advantage	$9.24
Rate for Payer: UnitedHealthcare Commercial	$20.90
Rate for Payer: UnitedHealthcare Medicaid	$8.80
Rate for Payer: WPPA Medicare Advantage	$13.20

99999 PT OUTSOURCING THERAPIST

Facility

$22.00

Hospital Charge Code	5605728
Hospital Revenue Code	922
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.80
Rate for Payer: UnitedHealthcare Commercial	$20.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

A0422 Ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation TechFee

Facility

$147.00

Service Code	HCPCS A0422 QN
Hospital Charge Code	4550072
Hospital Revenue Code	544
Min. Negotiated Rate	$17.39
Max. Negotiated Rate	$139.65
Rate for Payer: Aetna Commercial	$132.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$17.39
Rate for Payer: Humana Medicare Advantage	$61.74
Rate for Payer: UnitedHealthcare Commercial	$139.65
Rate for Payer: UnitedHealthcare Medicaid	$58.80
Rate for Payer: WPPA Medicare Advantage	$88.20

A0422 Ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation TechFee

Facility

$147.00

Service Code	HCPCS A0422 QN
Hospital Charge Code	4550072
Hospital Revenue Code	544
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$132.30
Rate for Payer: UnitedHealthcare Commercial	$139.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

A0425 Ground mileage TechFee

Facility

$24.00

Service Code	HCPCS A0425 QN
Hospital Charge Code	4550064
Hospital Revenue Code	540
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.60
Rate for Payer: UnitedHealthcare Commercial	$22.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

A0425 Ground mileage TechFee

Facility

$24.00

Service Code	HCPCS A0425 QN
Hospital Charge Code	4550064
Hospital Revenue Code	540
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$22.80
Rate for Payer: Aetna Commercial	$21.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$13.17
Rate for Payer: Humana Medicare Advantage	$10.08
Rate for Payer: UnitedHealthcare Commercial	$22.80
Rate for Payer: UnitedHealthcare Medicaid	$9.60
Rate for Payer: WPPA Medicare Advantage	$14.40

A0426 Als 1 TechFee

Facility

$469.00

Service Code	HCPCS A0426 QN
Hospital Charge Code	4550122
Hospital Revenue Code	540
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

A0426 Als 1 TechFee

Facility

$469.00

Service Code	HCPCS A0426 QN
Hospital Charge Code	4550122
Hospital Revenue Code	540
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$481.34
Rate for Payer: Aetna Commercial	$422.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$481.34
Rate for Payer: Humana Medicare Advantage	$196.98
Rate for Payer: UnitedHealthcare Commercial	$445.55
Rate for Payer: UnitedHealthcare Medicaid	$187.60
Rate for Payer: WPPA Medicare Advantage	$281.40

A0426 AMBULANCE ALS NON-EMERGENT TRANSPORT TechFee

Facility

$228.00

Service Code	HCPCS A0426 QN
Hospital Charge Code	4550130
Hospital Revenue Code	540
Min. Negotiated Rate	$91.20
Max. Negotiated Rate	$481.34
Rate for Payer: Aetna Commercial	$205.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$481.34
Rate for Payer: Humana Medicare Advantage	$95.76
Rate for Payer: UnitedHealthcare Commercial	$216.60
Rate for Payer: UnitedHealthcare Medicaid	$91.20
Rate for Payer: WPPA Medicare Advantage	$136.80

Know your out-of-pocket cost for care.

All Charges