Initial Hospital Care With Straightforward Or Low Level Of Medical Decision Making, Per Day, If Using Time, At Least 40 Minutes in Pennsylvania

Pennsylvania Pricing in Context

In Pennsylvania, CPT code 99221 (Initial Hospital Care With Straightforward Or Low Level Of Medical Decision Making, Per Day, If Using Time, At Least 40 Minutes) carries an average Medicare payment of $62.25 — 1% below the national benchmark of $62.62. 9.2K providers across the state submitted claims for this procedure in 2023, performing 63.3K total services. Individual payments in PA ranged from N/A at the low end to N/A at the high end, reflecting differences in provider setting (office vs. facility), modifiers, and the specific geographic locality code applied within the state.

The average billed charge in Pennsylvania is $237.80, which is the figure uninsured patients would most likely encounter before any negotiation or charity discount. Medicare, by statute, only reimburses the allowed amount — the balance between billed and paid is written off under provider participation agreements. Insured patients generally pay a negotiated rate that falls between these two figures; the exact amount depends on plan design, deductible status, and in-network participation. Because Pennsylvania sits below the national Medicare average, commercial rates in the state may also run lower than the US median.

Using RAND 2024 commercial-to-Medicare ratios for Hospital Visit procedures, the estimated commercial insurance price in Pennsylvania lands near $175.74, with self-pay cash prices typically around $125.31. Before scheduling, patients can request a Good Faith Estimate under the No Surprises Act, compare cash rates from hospital Machine-Readable Files, and confirm whether the provider is in-network with their specific plan. This page presents CMS reference data for informational use; it does not constitute medical or financial advice.