Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR Chest 2 Views

Facility

$321.00

Service Code	HCPCS 71046 TC
Hospital Charge Code	3771046
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$304.95
Rate for Payer: Aetna Commercial	$288.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$150.77
Rate for Payer: Humana Medicare Advantage	$134.82
Rate for Payer: UnitedHealthcare Commercial	$304.95
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$192.60

XR Cholangiogram in OR

Facility

$491.00

Service Code	HCPCS 74300 TC
Hospital Charge Code	3700102
Hospital Revenue Code	320
Min. Negotiated Rate	$44.20
Max. Negotiated Rate	$466.45
Rate for Payer: Aetna Commercial	$441.90
Rate for Payer: Humana Medicare Advantage	$206.22
Rate for Payer: UnitedHealthcare Commercial	$466.45
Rate for Payer: UnitedHealthcare Medicaid	$44.20
Rate for Payer: WPPA Medicare Advantage	$294.60

XR Cholangiogram in OR

Facility

$491.00

Service Code	HCPCS 74300 TC
Hospital Charge Code	3700102
Hospital Revenue Code	320
Min. Negotiated Rate	$441.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$441.90
Rate for Payer: UnitedHealthcare Commercial	$466.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Clavicle Left

Facility

$252.00

Service Code	HCPCS 73000 LT
Hospital Charge Code	3700094
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 Clavicle Left

Facility

$252.00

Service Code	HCPCS 73000 LT
Hospital Charge Code	3700094
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 Clavicle Right

Facility

$252.00

Service Code	HCPCS 73000 RT
Hospital Charge Code	3700094
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 Clavicle Right

Facility

$252.00

Service Code	HCPCS 73000 RT
Hospital Charge Code	3700094
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 Elbow 2 Views Left

Facility

$250.00

Service Code	HCPCS 73070 LT
Hospital Charge Code	3700151
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$237.50
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$113.36
Rate for Payer: Humana Medicare Advantage	$105.00
Rate for Payer: UnitedHealthcare Commercial	$237.50
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$150.00

XR Elbow 2 Views Left

Facility

$250.00

Service Code	HCPCS 73070 LT
Hospital Charge Code	3700151
Hospital Revenue Code	320
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: UnitedHealthcare Commercial	$237.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Elbow 2 Views Right

Facility

$250.00

Service Code	HCPCS 73070 RT
Hospital Charge Code	3700151
Hospital Revenue Code	320
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: UnitedHealthcare Commercial	$237.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Elbow 2 Views Right

Facility

$250.00

Service Code	HCPCS 73070 RT
Hospital Charge Code	3700151
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$237.50
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$113.36
Rate for Payer: Humana Medicare Advantage	$105.00
Rate for Payer: UnitedHealthcare Commercial	$237.50
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$150.00

XR Elbow Complete 3+ Views Left

Facility

$336.00

Service Code	HCPCS 73080 TC
Hospital Charge Code	3700813
Hospital Revenue Code	320
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Elbow Complete 3+ Views Left

Facility

$336.00

Service Code	HCPCS 73080 LT
Hospital Charge Code	3700813
Hospital Revenue Code	320
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Elbow Complete 3+ Views Left

Facility

$336.00

Service Code	HCPCS 73080 TC
Hospital Charge Code	3700813
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$319.20
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$151.46
Rate for Payer: Humana Medicare Advantage	$141.12
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$201.60

XR Elbow Complete 3+ Views Left

Facility

$336.00

Service Code	HCPCS 73080 LT
Hospital Charge Code	3700813
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$319.20
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$151.46
Rate for Payer: Humana Medicare Advantage	$141.12
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$201.60

XR Elbow Complete 3+ Views Right

Facility

$336.00

Service Code	HCPCS 73080 TC
Hospital Charge Code	3700813
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$319.20
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$151.46
Rate for Payer: Humana Medicare Advantage	$141.12
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$201.60

XR Elbow Complete 3+ Views Right

Facility

$336.00

Service Code	HCPCS 73080 RT
Hospital Charge Code	3700813
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$319.20
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$151.46
Rate for Payer: Humana Medicare Advantage	$141.12
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$201.60

XR Elbow Complete 3+ Views Right

Facility

$336.00

Service Code	HCPCS 73080 TC
Hospital Charge Code	3700813
Hospital Revenue Code	320
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Elbow Complete 3+ Views Right

Facility

$336.00

Service Code	HCPCS 73080 RT
Hospital Charge Code	3700813
Hospital Revenue Code	320
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$302.40
Rate for Payer: UnitedHealthcare Commercial	$319.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Facial Bones < 3 Views

Facility

$397.00

Service Code	HCPCS 70140 TC
Hospital Charge Code	3700730
Hospital Revenue Code	320
Min. Negotiated Rate	$357.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$357.30
Rate for Payer: UnitedHealthcare Commercial	$377.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Facial Bones < 3 Views

Facility

$397.00

Service Code	HCPCS 70140 TC
Hospital Charge Code	3700730
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$377.15
Rate for Payer: Aetna Commercial	$357.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$179.34
Rate for Payer: Humana Medicare Advantage	$166.74
Rate for Payer: UnitedHealthcare Commercial	$377.15
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$238.20

XR Facial Bones 3+ Views

Facility

$328.00

Service Code	HCPCS 70150 TC
Hospital Charge Code	3700177
Hospital Revenue Code	320
Min. Negotiated Rate	$295.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$295.20
Rate for Payer: UnitedHealthcare Commercial	$311.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Facial Bones 3+ Views

Facility

$328.00

Service Code	HCPCS 70150 TC
Hospital Charge Code	3700177
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$311.60
Rate for Payer: Aetna Commercial	$295.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$189.56
Rate for Payer: Humana Medicare Advantage	$137.76
Rate for Payer: UnitedHealthcare Commercial	$311.60
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$196.80

XR Femur 2 Views Left

Facility

$229.00

Service Code	HCPCS 73552 LT
Hospital Charge Code	3700185
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 Femur 2 Views Left

Facility

$229.00

Service Code	HCPCS 73552 LT
Hospital Charge Code	3700185
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$217.55
Rate for Payer: Aetna Commercial	$206.10
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

Know your out-of-pocket cost for care.

All Charges