Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR Foreign Body Localization Eye

Facility

$229.00

Service Code	HCPCS 70030 TC
Hospital Charge Code	3700938
Hospital Revenue Code	320
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$217.55
Rate for Payer: Aetna Commercial	$206.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$83.63
Rate for Payer: Humana Medicare Advantage	$96.18
Rate for Payer: UnitedHealthcare Commercial	$217.55
Rate for Payer: UnitedHealthcare Medicaid	$8.84
Rate for Payer: WPPA Medicare Advantage	$137.40

XR Foreign Body Localization Eye

Facility

$229.00

Service Code	HCPCS 70030 TC
Hospital Charge Code	3700938
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 Hand 2 Views Bilateral

Facility

$218.00

Service Code	HCPCS 73120 LT
Hospital Charge Code	3700912
Hospital Revenue Code	320
Min. Negotiated Rate	$196.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hand 2 Views Bilateral

Facility

$218.00

Service Code	HCPCS 73120 TC
Hospital Charge Code	3700912
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$207.10
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$104.07
Rate for Payer: Humana Medicare Advantage	$91.56
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$130.80

XR Hand 2 Views Bilateral

Facility

$218.00

Service Code	HCPCS 73120 TC
Hospital Charge Code	3700912
Hospital Revenue Code	320
Min. Negotiated Rate	$196.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hand 2 Views Bilateral

Facility

$218.00

Service Code	HCPCS 73120 LT
Hospital Charge Code	3700912
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$207.10
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$104.07
Rate for Payer: Humana Medicare Advantage	$91.56
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$130.80

XR Hand 2 Views Left

Facility

$229.00

Service Code	HCPCS 73120 LT
Hospital Charge Code	3700912
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 Hand 2 Views Left

Facility

$229.00

Service Code	HCPCS 73120 LT
Hospital Charge Code	3700912
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
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	$59.96
Rate for Payer: WPPA Medicare Advantage	$137.40

XR Hand 2 Views Right

Facility

$229.00

Service Code	HCPCS 73120 RT
Hospital Charge Code	3700912
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
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	$59.96
Rate for Payer: WPPA Medicare Advantage	$137.40

XR Hand 2 Views Right

Facility

$229.00

Service Code	HCPCS 73120 RT
Hospital Charge Code	3700912
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 Hand 2 Views Right Add-On

Facility

$218.00

Service Code	HCPCS 73120 TC
Hospital Charge Code	3700912
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$207.10
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$104.07
Rate for Payer: Humana Medicare Advantage	$91.56
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$130.80

XR Hand 2 Views Right Add-On

Facility

$218.00

Service Code	HCPCS 73120 RT
Hospital Charge Code	3700912
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$207.10
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$104.07
Rate for Payer: Humana Medicare Advantage	$91.56
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$130.80

XR Hand 2 Views Right Add-On

Facility

$218.00

Service Code	HCPCS 73120 RT
Hospital Charge Code	3700912
Hospital Revenue Code	320
Min. Negotiated Rate	$196.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hand 2 Views Right Add-On

Facility

$218.00

Service Code	HCPCS 73120 TC
Hospital Charge Code	3700912
Hospital Revenue Code	320
Min. Negotiated Rate	$196.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$196.20
Rate for Payer: UnitedHealthcare Commercial	$207.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hand Complete 3+ Views Bilateral

Facility

$302.00

Service Code	HCPCS 73130 TC
Hospital Charge Code	3700243
Hospital Revenue Code	320
Min. Negotiated Rate	$271.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hand Complete 3+ Views Bilateral

Facility

$302.00

Service Code	HCPCS 73130 TC
Hospital Charge Code	3700243
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$286.90
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$136.59
Rate for Payer: Humana Medicare Advantage	$126.84
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$181.20

XR Hand Complete 3+ Views Bilateral

Facility

$302.00

Service Code	HCPCS 73130 LT
Hospital Charge Code	3700243
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$286.90
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$136.59
Rate for Payer: Humana Medicare Advantage	$126.84
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$181.20

XR Hand Complete 3+ Views Bilateral

Facility

$302.00

Service Code	HCPCS 73130 LT
Hospital Charge Code	3700243
Hospital Revenue Code	320
Min. Negotiated Rate	$271.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hand Complete 3+ Views Left

Facility

$302.00

Service Code	HCPCS 73130 LT
Hospital Charge Code	3700243
Hospital Revenue Code	320
Min. Negotiated Rate	$271.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hand Complete 3+ Views Left

Facility

$302.00

Service Code	HCPCS 73130 LT
Hospital Charge Code	3700243
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$286.90
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$136.59
Rate for Payer: Humana Medicare Advantage	$126.84
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$181.20

XR Hand Complete 3+ Views Right

Facility

$302.00

Service Code	HCPCS 73130 RT
Hospital Charge Code	3700243
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$286.90
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$136.59
Rate for Payer: Humana Medicare Advantage	$126.84
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$181.20

XR Hand Complete 3+ Views Right

Facility

$302.00

Service Code	HCPCS 73130 RT
Hospital Charge Code	3700243
Hospital Revenue Code	320
Min. Negotiated Rate	$271.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hand Complete 3+ Views Right Add-On

Facility

$302.00

Service Code	HCPCS 73130 RT
Hospital Charge Code	3700243
Hospital Revenue Code	320
Min. Negotiated Rate	$271.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hand Complete 3+ Views Right Add-On

Facility

$302.00

Service Code	HCPCS 73130 TC
Hospital Charge Code	3700243
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$286.90
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$136.59
Rate for Payer: Humana Medicare Advantage	$126.84
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$181.20

XR Hand Complete 3+ Views Right Add-On

Facility

$302.00

Service Code	HCPCS 73130 TC
Hospital Charge Code	3700243
Hospital Revenue Code	320
Min. Negotiated Rate	$271.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: UnitedHealthcare Commercial	$286.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges