Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$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 Tibia/Fibula 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

CT Tibia/Fibula w/ Contrast Left

Facility

$1,496.00

Service Code	HCPCS 73701 LT
Hospital Charge Code	3740444
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 Tibia/Fibula w/ Contrast Right

Facility

$1,496.00

Service Code	HCPCS 73701 RT
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

CT Tibia/Fibula w/ Contrast Right

Facility

$1,496.00

Service Code	HCPCS 73701 RT
Hospital Charge Code	3740444
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 Tibia/Fibula w/o Contrast Left

Facility

$1,453.00

Service Code	HCPCS 73700 LT
Hospital Charge Code	3740436
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 Tibia/Fibula w/o Contrast Left

Facility

$1,453.00

Service Code	HCPCS 73700 LT
Hospital Charge Code	3740436
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 Tibia/Fibula w/o Contrast Right

Facility

$1,453.00

Service Code	HCPCS 73700 RT
Hospital Charge Code	3740436
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 Tibia/Fibula w/o Contrast Right

Facility

$1,453.00

Service Code	HCPCS 73700 RT
Hospital Charge Code	3740436
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 Tibia/Fibula 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 Tibia/Fibula 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 Tibia/Fibula 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 Tibia/Fibula 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 Urogram

Facility

$1,607.00

Service Code	HCPCS 74178 TC
Hospital Charge Code	3740710
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 Urogram

Facility

$1,607.00

Service Code	HCPCS 74178 TC
Hospital Charge Code	3740710
Hospital Revenue Code	350
Min. Negotiated Rate	$206.69
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	$206.69
Rate for Payer: WPPA Medicare Advantage	$964.20

CT Venogram Abdomen and Pelvis

Facility

$1,496.00

Service Code	HCPCS 74177 TC
Hospital Charge Code	3740705
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 Venogram Abdomen and Pelvis

Facility

$1,496.00

Service Code	HCPCS 74177 TC
Hospital Charge Code	3740705
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 Venogram 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 Venogram 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 Venogram Neck

Facility

$2,564.00

Service Code	HCPCS 70498 TC
Hospital Charge Code	3740615
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 Venogram Neck

Facility

$2,564.00

Service Code	HCPCS 70498 TC
Hospital Charge Code	3740615
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 Wrist 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 Wrist 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 Wrist 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 Wrist 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

Know your out-of-pocket cost for care.

All Charges