Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

MG Mammo Diagnostic Bilateral w/ Tomo

Facility

$102.00

Service Code	HCPCS 77062 TC
Hospital Charge Code	3717062
Hospital Revenue Code	401
Min. Negotiated Rate	$15.67
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$26.66
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$15.67
Rate for Payer: WPPA Medicare Advantage	$61.20

MG Mammo Diagnostic Left w/ Tomo

Facility

$102.00

Service Code	HCPCS 77061 TC
Hospital Charge Code	3717061
Hospital Revenue Code	401
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Diagnostic Left w/ Tomo

Facility

$102.00

Service Code	HCPCS 77061 TC
Hospital Charge Code	3717061
Hospital Revenue Code	401
Min. Negotiated Rate	$15.67
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$16.00
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$15.67
Rate for Payer: WPPA Medicare Advantage	$61.20

MG Mammo Diagnostic Right w/ Tomo

Facility

$102.00

Service Code	HCPCS 77061 TC
Hospital Charge Code	3717061
Hospital Revenue Code	401
Min. Negotiated Rate	$15.67
Max. Negotiated Rate	$96.90
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$16.00
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: UnitedHealthcare Medicaid	$15.67
Rate for Payer: WPPA Medicare Advantage	$61.20

MG Mammo Diagnostic Right w/ Tomo

Facility

$102.00

Service Code	HCPCS 77061 TC
Hospital Charge Code	3717061
Hospital Revenue Code	401
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: UnitedHealthcare Commercial	$96.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Diagnostic Right w/ Tomo.

Facility

$303.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	3717065
Hospital Revenue Code	401
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Diagnostic Right w/ Tomo.

Facility

$303.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	3717065
Hospital Revenue Code	401
Min. Negotiated Rate	$48.20
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$123.22
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$48.20
Rate for Payer: WPPA Medicare Advantage	$181.80

MG Mammo Digital Diagnostic Bilat

Facility

$303.00

Service Code	HCPCS 77066 TC
Hospital Charge Code	3717066
Hospital Revenue Code	401
Min. Negotiated Rate	$59.88
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$123.22
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$59.88
Rate for Payer: WPPA Medicare Advantage	$181.80

MG Mammo Digital Diagnostic Bilat

Facility

$303.00

Service Code	HCPCS 77066 TC
Hospital Charge Code	3717066
Hospital Revenue Code	401
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Digital Diagnostic Left

Facility

$303.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	3717065
Hospital Revenue Code	401
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Digital Diagnostic Left

Facility

$303.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	3717065
Hospital Revenue Code	401
Min. Negotiated Rate	$48.20
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$123.22
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$48.20
Rate for Payer: WPPA Medicare Advantage	$181.80

MG Mammo Digital Diagnostic Right

Facility

$303.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	3717065
Hospital Revenue Code	401
Min. Negotiated Rate	$48.20
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$123.22
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$48.20
Rate for Payer: WPPA Medicare Advantage	$181.80

MG Mammo Digital Diagnostic Right

Facility

$303.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	3717065
Hospital Revenue Code	401
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Digital Screening Bilateral

Facility

$303.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Digital Screening Bilateral

Facility

$303.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$161.00
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$72.25
Rate for Payer: WPPA Medicare Advantage	$181.80

MG Mammo Digital Screening Left

Facility

$303.00

Service Code	HCPCS 77067 LT
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG Mammo Digital Screening Left

Facility

$303.00

Service Code	HCPCS 77067 LT
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$161.00
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$72.25
Rate for Payer: WPPA Medicare Advantage	$181.80

MG Mammo Digital Screening Right

Facility

$303.00

Service Code	HCPCS 77067 RT
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$161.00
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$72.25
Rate for Payer: WPPA Medicare Advantage	$181.80

MG Mammo Digital Screening Right

Facility

$303.00

Service Code	HCPCS 77067 RT
Hospital Charge Code	3717067
Hospital Revenue Code	403
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG MAMMOGRAM 2D DIAGNOSTIC BILATERAL Add-On

Facility

$303.00

Service Code	HCPCS 77066
Hospital Charge Code	3717066
Hospital Revenue Code	401
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG MAMMOGRAM 2D DIAGNOSTIC BILATERAL Add-On

Facility

$303.00

Service Code	HCPCS 77066
Hospital Charge Code	3717066
Hospital Revenue Code	401
Min. Negotiated Rate	$59.88
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$123.22
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$125.93
Rate for Payer: WPPA Medicare Advantage	$181.80

MG Mammogram 2D Diagnostic Left

Facility

$303.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	3717065
Hospital Revenue Code	401
Min. Negotiated Rate	$48.20
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$123.22
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$48.20
Rate for Payer: WPPA Medicare Advantage	$181.80

MG Mammogram 2D Diagnostic Left

Facility

$303.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	3717065
Hospital Revenue Code	401
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG MAMMOGRAM 2D DIAGNOSTIC UNILATERAL Add-On

Facility

$303.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	3717065
Hospital Revenue Code	401
Min. Negotiated Rate	$272.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MG MAMMOGRAM 2D DIAGNOSTIC UNILATERAL Add-On

Facility

$303.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	3717065
Hospital Revenue Code	401
Min. Negotiated Rate	$48.20
Max. Negotiated Rate	$287.85
Rate for Payer: Aetna Commercial	$272.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$123.22
Rate for Payer: Humana Medicare Advantage	$127.26
Rate for Payer: UnitedHealthcare Commercial	$287.85
Rate for Payer: UnitedHealthcare Medicaid	$48.20
Rate for Payer: WPPA Medicare Advantage	$181.80

Know your out-of-pocket cost for care.

All Charges