Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR Abdomen KUB 1 View

Facility

$298.00

Service Code	HCPCS 74018 TC
Hospital Charge Code	3774018
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$283.10
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$134.73
Rate for Payer: Humana Medicare Advantage	$125.16
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$178.80

XR Abdomen KUB 1 View

Facility

$298.00

Service Code	HCPCS 74018
Hospital Charge Code	3774018
Hospital Revenue Code	320
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: UnitedHealthcare Commercial	$283.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Abdomen Series + Chest 1 View

Facility

$585.00

Service Code	HCPCS 74022 TC
Hospital Charge Code	3700345
Hospital Revenue Code	320
Min. Negotiated Rate	$526.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$526.50
Rate for Payer: UnitedHealthcare Commercial	$555.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Abdomen Series + Chest 1 View

Facility

$585.00

Service Code	HCPCS 74022 TC
Hospital Charge Code	3700345
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$555.75
Rate for Payer: Aetna Commercial	$526.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$263.89
Rate for Payer: Humana Medicare Advantage	$245.70
Rate for Payer: UnitedHealthcare Commercial	$555.75
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$351.00

XR AC Joints Bilateral

Facility

$322.00

Service Code	HCPCS 73050 TC
Hospital Charge Code	3700029
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$305.90
Rate for Payer: Aetna Commercial	$289.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$146.81
Rate for Payer: Humana Medicare Advantage	$135.24
Rate for Payer: UnitedHealthcare Commercial	$305.90
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$193.20

XR AC Joints Bilateral

Facility

$322.00

Service Code	HCPCS 73050 TC
Hospital Charge Code	3700029
Hospital Revenue Code	320
Min. Negotiated Rate	$289.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$289.80
Rate for Payer: UnitedHealthcare Commercial	$305.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Ankle 2 Views Left

Facility

$229.00

Service Code	HCPCS 73600 LT
Hospital Charge Code	3700839
Hospital Revenue Code	320
Min. Negotiated Rate	$206.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$206.10
Rate for Payer: UnitedHealthcare Commercial	$217.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Ankle 2 Views Left

Facility

$229.00

Service Code	HCPCS 73600 LT
Hospital Charge Code	3700839
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$217.55
Rate for Payer: Aetna Commercial	$206.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$104.07
Rate for Payer: Humana Medicare Advantage	$96.18
Rate for Payer: UnitedHealthcare Commercial	$217.55
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$137.40

XR Ankle 2 Views Right

Facility

$229.00

Service Code	HCPCS 73600 RT
Hospital Charge Code	3700839
Hospital Revenue Code	320
Min. Negotiated Rate	$206.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$206.10
Rate for Payer: UnitedHealthcare Commercial	$217.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Ankle 2 Views Right

Facility

$229.00

Service Code	HCPCS 73600 RT
Hospital Charge Code	3700839
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$217.55
Rate for Payer: Aetna Commercial	$206.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$104.07
Rate for Payer: Humana Medicare Advantage	$96.18
Rate for Payer: UnitedHealthcare Commercial	$217.55
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$137.40

XR Ankle Complete 3+ Views Left

Facility

$308.00

Service Code	HCPCS 73610 LT
Hospital Charge Code	3700037
Hospital Revenue Code	320
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$277.20
Rate for Payer: UnitedHealthcare Commercial	$292.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Ankle Complete 3+ Views Left

Facility

$308.00

Service Code	HCPCS 73610 LT
Hospital Charge Code	3700037
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$292.60
Rate for Payer: Aetna Commercial	$277.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$139.38
Rate for Payer: Humana Medicare Advantage	$129.36
Rate for Payer: UnitedHealthcare Commercial	$292.60
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$184.80

XR Ankle Complete 3+ Views Right

Facility

$308.00

Service Code	HCPCS 73610 RT
Hospital Charge Code	3700037
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$292.60
Rate for Payer: Aetna Commercial	$277.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$139.38
Rate for Payer: Humana Medicare Advantage	$129.36
Rate for Payer: UnitedHealthcare Commercial	$292.60
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$184.80

XR Ankle Complete 3+ Views Right

Facility

$308.00

Service Code	HCPCS 73610 RT
Hospital Charge Code	3700037
Hospital Revenue Code	320
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$277.20
Rate for Payer: UnitedHealthcare Commercial	$292.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Bone Age Studies

Facility

$308.00

Service Code	HCPCS 77072 TC
Hospital Charge Code	3707072
Hospital Revenue Code	320
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$277.20
Rate for Payer: UnitedHealthcare Commercial	$292.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Bone Age Studies

Facility

$308.00

Service Code	HCPCS 77072 TC
Hospital Charge Code	3707072
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$292.60
Rate for Payer: Aetna Commercial	$277.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$139.38
Rate for Payer: Humana Medicare Advantage	$129.36
Rate for Payer: UnitedHealthcare Commercial	$292.60
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$184.80

XR Bone Length Study

Facility

$528.00

Service Code	HCPCS 77073 TC
Hospital Charge Code	3701060
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$501.60
Rate for Payer: Aetna Commercial	$475.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$239.73
Rate for Payer: Humana Medicare Advantage	$221.76
Rate for Payer: UnitedHealthcare Commercial	$501.60
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$316.80

XR Bone Length Study

Facility

$528.00

Service Code	HCPCS 77073 TC
Hospital Charge Code	3701060
Hospital Revenue Code	320
Min. Negotiated Rate	$475.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$475.20
Rate for Payer: UnitedHealthcare Commercial	$501.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Calcaneus Left

Facility

$252.00

Service Code	HCPCS 73650 LT
Hospital Charge Code	3700045
Hospital Revenue Code	320
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Calcaneus Left

Facility

$252.00

Service Code	HCPCS 73650 LT
Hospital Charge Code	3700045
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$239.40
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$114.29
Rate for Payer: Humana Medicare Advantage	$105.84
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$151.20

XR Calcaneus Right

Facility

$252.00

Service Code	HCPCS 73650 RT
Hospital Charge Code	3700045
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$239.40
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$114.29
Rate for Payer: Humana Medicare Advantage	$105.84
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$151.20

XR Calcaneus Right

Facility

$252.00

Service Code	HCPCS 73650 RT
Hospital Charge Code	3700045
Hospital Revenue Code	320
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Chest 1 View

Facility

$237.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	3771045
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$225.15
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$123.58
Rate for Payer: Humana Medicare Advantage	$99.54
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$142.20

XR Chest 1 View

Facility

$237.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	3771045
Hospital Revenue Code	320
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Chest 2 Views

Facility

$321.00

Service Code	HCPCS 71046 TC
Hospital Charge Code	3771046
Hospital Revenue Code	320
Min. Negotiated Rate	$288.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$288.90
Rate for Payer: UnitedHealthcare Commercial	$304.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges