Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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

CT Pelvis w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 72192 TC
Hospital Charge Code	3740329
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 Pelvis w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 72192 TC
Hospital Charge Code	3740329
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 Pelvis w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 72194 TC
Hospital Charge Code	3740196
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 Pelvis w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 72194 TC
Hospital Charge Code	3740196
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 Shoulder w/ Contrast Left

Facility

$1,496.00

Service Code	HCPCS 73201 LT
Hospital Charge Code	3740410
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 Shoulder w/ Contrast Left

Facility

$1,496.00

Service Code	HCPCS 73201 LT
Hospital Charge Code	3740410
Hospital Revenue Code	350
Min. Negotiated Rate	$206.69
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	$206.69
Rate for Payer: WPPA Medicare Advantage	$897.60

CT Shoulder w/ Contrast Right

Facility

$1,496.00

Service Code	HCPCS 73201 RT
Hospital Charge Code	3740410
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 Shoulder w/ Contrast Right

Facility

$1,496.00

Service Code	HCPCS 73201 RT
Hospital Charge Code	3740410
Hospital Revenue Code	350
Min. Negotiated Rate	$206.69
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	$206.69
Rate for Payer: WPPA Medicare Advantage	$897.60

CT Shoulder w/o Contrast Left

Facility

$1,453.00

Service Code	HCPCS 73200 LT
Hospital Charge Code	3740402
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 Shoulder w/o Contrast Left

Facility

$1,453.00

Service Code	HCPCS 73200 LT
Hospital Charge Code	3740402
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 Shoulder w/o Contrast Right

Facility

$1,453.00

Service Code	HCPCS 73200 RT
Hospital Charge Code	3740402
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 Shoulder w/o Contrast Right

Facility

$1,453.00

Service Code	HCPCS 73200 RT
Hospital Charge Code	3740402
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 Shoulder w/ + w/o Contrast Left

Facility

$1,607.00

Service Code	HCPCS 73202 LT
Hospital Charge Code	3740428
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 Shoulder w/ + w/o Contrast Left

Facility

$1,607.00

Service Code	HCPCS 73202 LT
Hospital Charge Code	3740428
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 Shoulder w/ + w/o Contrast Right

Facility

$1,607.00

Service Code	HCPCS 73202 RT
Hospital Charge Code	3740428
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 Shoulder w/ + w/o Contrast Right

Facility

$1,607.00

Service Code	HCPCS 73202 RT
Hospital Charge Code	3740428
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 Sinus w/o Contrast

Facility

$1,425.00

Service Code	HCPCS 70487 TC
Hospital Charge Code	3740487
Hospital Revenue Code	350
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,353.75
Rate for Payer: Aetna Commercial	$1,282.50
Rate for Payer: UnitedHealthcare Commercial	$1,353.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Sinus w/o Contrast

Facility

$1,425.00

Service Code	HCPCS 70487 TC
Hospital Charge Code	3740487
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,353.75
Rate for Payer: Aetna Commercial	$1,282.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$598.50
Rate for Payer: UnitedHealthcare Commercial	$1,353.75
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$855.00

CT Sinus 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 Sinus 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 Sinus 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 Sinus 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 Spine Cervical w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 72126 TC
Hospital Charge Code	3740352
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 Spine Cervical w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 72126 TC
Hospital Charge Code	3740352
Hospital Revenue Code	350
Min. Negotiated Rate	$206.69
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	$206.69
Rate for Payer: WPPA Medicare Advantage	$897.60

Know your out-of-pocket cost for care.

All Charges