Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

CT Knee w/ + w/o Contrast Left

Facility

$1,607.00

Service Code	HCPCS 73702 LT
Hospital Charge Code	3740451
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,526.65
Rate for Payer: Aetna Commercial	$1,446.30
Rate for Payer: UnitedHealthcare Commercial	$1,526.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Knee w/ + w/o Contrast Left

Facility

$1,607.00

Service Code	HCPCS 73702 LT
Hospital Charge Code	3740451
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,526.65
Rate for Payer: Aetna Commercial	$1,446.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$674.94
Rate for Payer: UnitedHealthcare Commercial	$1,526.65
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$964.20

CT Knee w/ + w/o Contrast Right

Facility

$1,607.00

Service Code	HCPCS 73702 RT
Hospital Charge Code	3740451
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,526.65
Rate for Payer: Aetna Commercial	$1,446.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$674.94
Rate for Payer: UnitedHealthcare Commercial	$1,526.65
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$964.20

CT Knee w/ + w/o Contrast Right

Facility

$1,607.00

Service Code	HCPCS 73702 RT
Hospital Charge Code	3740451
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,526.65
Rate for Payer: Aetna Commercial	$1,446.30
Rate for Payer: UnitedHealthcare Commercial	$1,526.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Low Dose Lung Screening

Facility

$810.00

Service Code	HCPCS 71271 TC
Hospital Charge Code	3740297
Hospital Revenue Code	350
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$769.50
Rate for Payer: Aetna Commercial	$729.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$340.20
Rate for Payer: UnitedHealthcare Commercial	$769.50
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$486.00

CT Low Dose Lung Screening

Facility

$810.00

Service Code	HCPCS 71271 TC
Hospital Charge Code	3740297
Hospital Revenue Code	350
Min. Negotiated Rate	$729.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$729.00
Rate for Payer: UnitedHealthcare Commercial	$769.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Maxillofacial w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 70487 TC
Hospital Charge Code	3740487
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

CT Maxillofacial w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 70487 TC
Hospital Charge Code	3740487
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,421.20
Rate for Payer: Aetna Commercial	$1,346.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$628.32
Rate for Payer: UnitedHealthcare Commercial	$1,421.20
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$897.60

CT Maxillofacial w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 70486 TC
Hospital Charge Code	3740469
Hospital Revenue Code	350
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$610.26
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$871.80

CT Maxillofacial w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 70486 TC
Hospital Charge Code	3740469
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Maxillofacial w/ + w/o Contrast

Facility

$1,530.00

Service Code	HCPCS 70488 TC
Hospital Charge Code	3740485
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,453.50
Rate for Payer: Aetna Commercial	$1,377.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$642.60
Rate for Payer: UnitedHealthcare Commercial	$1,453.50
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$918.00

CT Maxillofacial w/ + w/o Contrast

Facility

$1,530.00

Service Code	HCPCS 70488 TC
Hospital Charge Code	3740485
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,453.50
Rate for Payer: Aetna Commercial	$1,377.00
Rate for Payer: UnitedHealthcare Commercial	$1,453.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Neck Soft Tissue w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 70491 TC
Hospital Charge Code	3740261
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

CT Neck Soft Tissue w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 70491 TC
Hospital Charge Code	3740261
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,421.20
Rate for Payer: Aetna Commercial	$1,346.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$628.32
Rate for Payer: UnitedHealthcare Commercial	$1,421.20
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$897.60

CT Neck Soft Tissue w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 70490 TC
Hospital Charge Code	3740253
Hospital Revenue Code	350
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$610.26
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$871.80

CT Neck Soft Tissue w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 70490 TC
Hospital Charge Code	3740253
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Neck Soft Tissue w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 70492 TC
Hospital Charge Code	3740279
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,526.65
Rate for Payer: Aetna Commercial	$1,446.30
Rate for Payer: UnitedHealthcare Commercial	$1,526.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Neck Soft Tissue w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 70492 TC
Hospital Charge Code	3740279
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,526.65
Rate for Payer: Aetna Commercial	$1,446.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$674.94
Rate for Payer: UnitedHealthcare Commercial	$1,526.65
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$964.20

CT Orbits Sella w/ Contrast

Facility

$1,453.00

Service Code	HCPCS 70481 TC
Hospital Charge Code	3740481
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$610.26
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$871.80

CT Orbits Sella w/ Contrast

Facility

$1,453.00

Service Code	HCPCS 70481 TC
Hospital Charge Code	3740481
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,380.35
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: UnitedHealthcare Commercial	$1,380.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Orbits Sella w/o Contrast

Facility

$1,384.00

Service Code	HCPCS 70480 TC
Hospital Charge Code	3740220
Hospital Revenue Code	350
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$1,314.80
Rate for Payer: Aetna Commercial	$1,245.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$581.28
Rate for Payer: UnitedHealthcare Commercial	$1,314.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$830.40

CT Orbits Sella w/o Contrast

Facility

$1,384.00

Service Code	HCPCS 70480 TC
Hospital Charge Code	3740220
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,314.80
Rate for Payer: Aetna Commercial	$1,245.60
Rate for Payer: UnitedHealthcare Commercial	$1,314.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Orbits Sella w/ + w/o Contrast

Facility

$1,530.00

Service Code	HCPCS 70482 TC
Hospital Charge Code	3740810
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,453.50
Rate for Payer: Aetna Commercial	$1,377.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$642.60
Rate for Payer: UnitedHealthcare Commercial	$1,453.50
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$918.00

CT Orbits Sella w/ + w/o Contrast

Facility

$1,530.00

Service Code	HCPCS 70482 TC
Hospital Charge Code	3740810
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,453.50
Rate for Payer: Aetna Commercial	$1,377.00
Rate for Payer: UnitedHealthcare Commercial	$1,453.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Pelvis w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 72193 TC
Hospital Charge Code	3740337
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