Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR Foot 2 Views Left Add-On

Facility

$229.00

Service Code	HCPCS 73620 LT
Hospital Charge Code	3700847
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 Foot 2 Views Right

Facility

$229.00

Service Code	HCPCS 73620 RT
Hospital Charge Code	3700847
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 Foot 2 Views Right

Facility

$229.00

Service Code	HCPCS 73620 RT
Hospital Charge Code	3700847
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	$94.78
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 FOOT 3+ VIEWS Add-On

Facility

$298.00

Service Code	HCPCS 73630 TC
Hospital Charge Code	3700219
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 FOOT 3+ VIEWS Add-On

Facility

$298.00

Service Code	HCPCS 73630 TC
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Bilateral

Facility

$298.00

Service Code	HCPCS 73630 RT
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Bilateral

Facility

$298.00

Service Code	HCPCS 73630 TC
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Bilateral

Facility

$298.00

Service Code	HCPCS 73630 RT
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Bilateral

Facility

$298.00

Service Code	HCPCS 73630 TC
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Left

Facility

$298.00

Service Code	HCPCS 73630 LT
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Left

Facility

$298.00

Service Code	HCPCS 73630 LT
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Left Add-On

Facility

$298.00

Service Code	HCPCS 73630 LT
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Left Add-On

Facility

$298.00

Service Code	HCPCS 73630 TC
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Left Add-On

Facility

$298.00

Service Code	HCPCS 73630 LT
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Left Add-On

Facility

$298.00

Service Code	HCPCS 73630 TC
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Right

Facility

$298.00

Service Code	HCPCS 73630 RT
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Right

Facility

$298.00

Service Code	HCPCS 73630 TC
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Right

Facility

$298.00

Service Code	HCPCS 73630 TC
Hospital Charge Code	3700219
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 Foot Complete 3+ Views Right

Facility

$298.00

Service Code	HCPCS 73630 RT
Hospital Charge Code	3700219
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 Forearm 2 Views Left

Facility

$274.00

Service Code	HCPCS 73090 LT
Hospital Charge Code	3700227
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$260.30
Rate for Payer: Aetna Commercial	$246.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$124.51
Rate for Payer: Humana Medicare Advantage	$115.08
Rate for Payer: UnitedHealthcare Commercial	$260.30
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$164.40

XR Forearm 2 Views Left

Facility

$274.00

Service Code	HCPCS 73090 LT
Hospital Charge Code	3700227
Hospital Revenue Code	320
Min. Negotiated Rate	$246.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$246.60
Rate for Payer: UnitedHealthcare Commercial	$260.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Forearm 2 Views Right

Facility

$274.00

Service Code	HCPCS 73090 RT
Hospital Charge Code	3700227
Hospital Revenue Code	320
Min. Negotiated Rate	$246.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$246.60
Rate for Payer: UnitedHealthcare Commercial	$260.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Forearm 2 Views Right

Facility

$274.00

Service Code	HCPCS 73090 RT
Hospital Charge Code	3700227
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$260.30
Rate for Payer: Aetna Commercial	$246.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$124.51
Rate for Payer: Humana Medicare Advantage	$115.08
Rate for Payer: UnitedHealthcare Commercial	$260.30
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$164.40

XR Foreign Body Localization Child 1 Vw

Facility

$229.00

Service Code	HCPCS 76010 TC
Hospital Charge Code	3701065
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 Foreign Body Localization Child 1 Vw

Facility

$229.00

Service Code	HCPCS 76010 TC
Hospital Charge Code	3701065
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	$112.43
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