Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

CT Angio Abdomen and Pelvis

Facility

$3,015.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	3740820
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,864.25
Rate for Payer: Aetna Commercial	$2,713.50
Rate for Payer: UnitedHealthcare Commercial	$2,864.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Abdomen and Pelvis

Facility

$3,015.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	3740820
Hospital Revenue Code	350
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$2,864.25
Rate for Payer: Aetna Commercial	$2,713.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,704.15
Rate for Payer: Humana Medicare Advantage	$1,266.30
Rate for Payer: UnitedHealthcare Commercial	$2,864.25
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,809.00

CT Angio Abdomen/Pelvis w/Runoff

Facility

$2,528.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	3740570
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Abdomen/Pelvis w/Runoff

Facility

$2,528.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	3740570
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,249.77
Rate for Payer: Humana Medicare Advantage	$1,061.76
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$1,516.80

CT Angio Brain/Head

Facility

$2,560.00

Service Code	HCPCS 70496 TC
Hospital Charge Code	3740590
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,432.00
Rate for Payer: Aetna Commercial	$2,304.00
Rate for Payer: UnitedHealthcare Commercial	$2,432.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Brain/Head

Facility

$2,560.00

Service Code	HCPCS 70496 TC
Hospital Charge Code	3740590
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,432.00
Rate for Payer: Aetna Commercial	$2,304.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,158.71
Rate for Payer: Humana Medicare Advantage	$1,075.20
Rate for Payer: UnitedHealthcare Commercial	$2,432.00
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$1,536.00

CT Angio Chest

Facility

$2,528.00

Service Code	HCPCS 71275 TC
Hospital Charge Code	3740690
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,143.85
Rate for Payer: Humana Medicare Advantage	$1,061.76
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$1,516.80

CT Angio Chest

Facility

$2,528.00

Service Code	HCPCS 71275 TC
Hospital Charge Code	3740690
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Chest PE

Facility

$2,528.00

Service Code	HCPCS 71275 TC
Hospital Charge Code	3740690
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,143.85
Rate for Payer: Humana Medicare Advantage	$1,061.76
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$1,516.80

CT Angio Chest PE

Facility

$2,528.00

Service Code	HCPCS 71275 TC
Hospital Charge Code	3740690
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Head/Neck

Facility

$2,560.00

Service Code	HCPCS 70496 TC
Hospital Charge Code	3740590
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,432.00
Rate for Payer: Aetna Commercial	$2,304.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,158.71
Rate for Payer: Humana Medicare Advantage	$1,075.20
Rate for Payer: UnitedHealthcare Commercial	$2,432.00
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$1,536.00

CT Angio Head/Neck

Facility

$2,560.00

Service Code	HCPCS 70496 TC
Hospital Charge Code	3740590
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,432.00
Rate for Payer: Aetna Commercial	$2,304.00
Rate for Payer: UnitedHealthcare Commercial	$2,432.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Lower Extremity Left

Facility

$2,528.00

Service Code	HCPCS 73706 LT
Hospital Charge Code	3740610
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: Humana Medicare Advantage	$1,061.76
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$1,516.80

CT Angio Lower Extremity Left

Facility

$2,528.00

Service Code	HCPCS 73706 LT
Hospital Charge Code	3740610
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Lower Extremity Right

Facility

$2,528.00

Service Code	HCPCS 73706 RT
Hospital Charge Code	3740610
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Lower Extremity Right

Facility

$2,528.00

Service Code	HCPCS 73706 RT
Hospital Charge Code	3740610
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: Humana Medicare Advantage	$1,061.76
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$1,516.80

CT Angio Neck

Facility

$2,564.00

Service Code	HCPCS 70498
Hospital Charge Code	3740595
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,435.80
Rate for Payer: Aetna Commercial	$2,307.60
Rate for Payer: UnitedHealthcare Commercial	$2,435.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Neck

Facility

$2,564.00

Service Code	HCPCS 70498 TC
Hospital Charge Code	3740595
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,435.80
Rate for Payer: Aetna Commercial	$2,307.60
Rate for Payer: UnitedHealthcare Commercial	$2,435.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Neck

Facility

$2,564.00

Service Code	HCPCS 70498 TC
Hospital Charge Code	3740595
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,435.80
Rate for Payer: Aetna Commercial	$2,307.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,159.64
Rate for Payer: Humana Medicare Advantage	$1,076.88
Rate for Payer: UnitedHealthcare Commercial	$2,435.80
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$1,538.40

CT Angio Neck

Facility

$2,564.00

Service Code	HCPCS 70498
Hospital Charge Code	3740595
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,435.80
Rate for Payer: Aetna Commercial	$2,307.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1,159.64
Rate for Payer: Humana Medicare Advantage	$1,076.88
Rate for Payer: UnitedHealthcare Commercial	$2,435.80
Rate for Payer: UnitedHealthcare Medicaid	$153.29
Rate for Payer: WPPA Medicare Advantage	$1,538.40

CT Angio Upper Extremity Left

Facility

$2,528.00

Service Code	HCPCS 73206 LT
Hospital Charge Code	3740605
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: Humana Medicare Advantage	$1,061.76
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$1,516.80

CT Angio Upper Extremity Left

Facility

$2,528.00

Service Code	HCPCS 73206 LT
Hospital Charge Code	3740605
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Upper Extremity Right

Facility

$2,528.00

Service Code	HCPCS 73206 RT
Hospital Charge Code	3740605
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Angio Upper Extremity Right

Facility

$2,528.00

Service Code	HCPCS 73206 RT
Hospital Charge Code	3740605
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$2,401.60
Rate for Payer: Aetna Commercial	$2,275.20
Rate for Payer: Humana Medicare Advantage	$1,061.76
Rate for Payer: UnitedHealthcare Commercial	$2,401.60
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$1,516.80

CT Ankle w/ Contrast Left

Facility

$1,496.00

Service Code	HCPCS 73701 LT
Hospital Charge Code	3740444
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,421.20
Rate for Payer: Aetna Commercial	$1,346.40
Rate for Payer: UnitedHealthcare Commercial	$1,421.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges