Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

CT Spine Cervical w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 72125 TC
Hospital Charge Code	3740345
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 Spine Cervical w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 72125 TC
Hospital Charge Code	3740345
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 Spine Cervical w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 72127 TC
Hospital Charge Code	3740685
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 Spine Cervical w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 72127 TC
Hospital Charge Code	3740685
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 Spine Lumbar w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 72132 TC
Hospital Charge Code	3740830
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 Lumbar w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 72132 TC
Hospital Charge Code	3740830
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 Spine Lumbar w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 72131 TC
Hospital Charge Code	3740386
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 Spine Lumbar w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 72131 TC
Hospital Charge Code	3740386
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 Spine Lumbar w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 72133 TC
Hospital Charge Code	3740394
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 Spine Lumbar w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 72133 TC
Hospital Charge Code	3740394
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 Spine Thoracic w/ Contrast

Facility

$771.00

Service Code	HCPCS 72129 TC
Hospital Charge Code	3742129
Hospital Revenue Code	350
Min. Negotiated Rate	$693.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$693.90
Rate for Payer: UnitedHealthcare Commercial	$732.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

CT Spine Thoracic w/ Contrast

Facility

$771.00

Service Code	HCPCS 72129 TC
Hospital Charge Code	3742129
Hospital Revenue Code	350
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$732.45
Rate for Payer: Aetna Commercial	$693.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$480.41
Rate for Payer: Humana Medicare Advantage	$323.82
Rate for Payer: UnitedHealthcare Commercial	$732.45
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$462.60

CT Spine Thoracic w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 72128 TC
Hospital Charge Code	3740360
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 Spine Thoracic w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 72128 TC
Hospital Charge Code	3740360
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 Spine Thoracic w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 72130 TC
Hospital Charge Code	3740378
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 Spine Thoracic w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 72130 TC
Hospital Charge Code	3740378
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 Sternoclavicular Jts w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 71250 TC
Hospital Charge Code	3741250
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 Sternoclavicular Jts w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 71250 TC
Hospital Charge Code	3741250
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 Stone Protocol

Facility

$1,453.00

Service Code	HCPCS 74176 TC
Hospital Charge Code	3740695
Hospital Revenue Code	350
Min. Negotiated Rate	$131.00
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	$131.00
Rate for Payer: WPPA Medicare Advantage	$871.80

CT Stone Protocol

Facility

$1,453.00

Service Code	HCPCS 74176 TC
Hospital Charge Code	3740695
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 Temporal Bones w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 70481 TC
Hospital Charge Code	3740481
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 Temporal Bones w/ Contrast

Facility

$1,496.00

Service Code	HCPCS 70481 TC
Hospital Charge Code	3740481
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 Temporal Bones w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 70480 TC
Hospital Charge Code	3740220
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 Temporal Bones w/o Contrast

Facility

$1,453.00

Service Code	HCPCS 70480 TC
Hospital Charge Code	3740220
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 Temporal Bones w/ + w/o Contrast

Facility

$1,607.00

Service Code	HCPCS 70482 TC
Hospital Charge Code	3740810
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

Know your out-of-pocket cost for care.

All Charges