Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$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 Hip 1 View Left

Facility

$229.00

Service Code	HCPCS 73501 LT
Hospital Charge Code	3700250
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 Hip 1 View Left

Facility

$229.00

Service Code	HCPCS 73501 LT
Hospital Charge Code	3700250
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	$142.01
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 Hip 1 View Right

Facility

$229.00

Service Code	HCPCS 73501 RT
Hospital Charge Code	3700250
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 Hip 1 View Right

Facility

$229.00

Service Code	HCPCS 73501 RT
Hospital Charge Code	3700250
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	$142.01
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 Hip 2-3 Views Left

Facility

$229.00

Service Code	HCPCS 73502 LT
Hospital Charge Code	3701045
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	$173.25
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 Hip 2-3 Views Left

Facility

$229.00

Service Code	HCPCS 73502 LT
Hospital Charge Code	3701045
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 Hip 2-3 Views Right

Facility

$229.00

Service Code	HCPCS 73502 RT
Hospital Charge Code	3701045
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	$173.25
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 Hip 2-3 Views Right

Facility

$229.00

Service Code	HCPCS 73502 RT
Hospital Charge Code	3701045
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 Hip 4+ Views Left

Facility

$492.00

Service Code	HCPCS 73503 LT
Hospital Charge Code	3703503
Hospital Revenue Code	320
Min. Negotiated Rate	$442.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$442.80
Rate for Payer: UnitedHealthcare Commercial	$467.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hip 4+ Views Left

Facility

$492.00

Service Code	HCPCS 73503 LT
Hospital Charge Code	3703503
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$467.40
Rate for Payer: Aetna Commercial	$442.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$213.01
Rate for Payer: Humana Medicare Advantage	$206.64
Rate for Payer: UnitedHealthcare Commercial	$467.40
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$295.20

XR Hip 4+ Views Right

Facility

$492.00

Service Code	HCPCS 73503 RT
Hospital Charge Code	3703503
Hospital Revenue Code	320
Min. Negotiated Rate	$442.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$442.80
Rate for Payer: UnitedHealthcare Commercial	$467.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hip 4+ Views Right

Facility

$492.00

Service Code	HCPCS 73503 RT
Hospital Charge Code	3703503
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$467.40
Rate for Payer: Aetna Commercial	$442.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$213.01
Rate for Payer: Humana Medicare Advantage	$206.64
Rate for Payer: UnitedHealthcare Commercial	$467.40
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$295.20

XR Hips 2 Views Bilat

Facility

$229.00

Service Code	HCPCS 73521 TC
Hospital Charge Code	3700268
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 Hips 2 Views Bilat

Facility

$229.00

Service Code	HCPCS 73521 TC
Hospital Charge Code	3700268
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
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	$59.96
Rate for Payer: WPPA Medicare Advantage	$137.40

XR Hips 5+ Views Bilat

Facility

$617.00

Service Code	HCPCS 73523 TC
Hospital Charge Code	3703523
Hospital Revenue Code	320
Min. Negotiated Rate	$555.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$555.30
Rate for Payer: UnitedHealthcare Commercial	$586.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Hips 5+ Views Bilat

Facility

$617.00

Service Code	HCPCS 73523 TC
Hospital Charge Code	3703523
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$586.15
Rate for Payer: Aetna Commercial	$555.30
Rate for Payer: Humana Medicare Advantage	$259.14
Rate for Payer: UnitedHealthcare Commercial	$586.15
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$370.20

XR Humerus Left

Facility

$305.00

Service Code	HCPCS 73060 LT
Hospital Charge Code	3700292
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$289.75
Rate for Payer: Aetna Commercial	$274.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$137.52
Rate for Payer: Humana Medicare Advantage	$128.10
Rate for Payer: UnitedHealthcare Commercial	$289.75
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$183.00

XR Humerus Left

Facility

$305.00

Service Code	HCPCS 73060 LT
Hospital Charge Code	3700292
Hospital Revenue Code	320
Min. Negotiated Rate	$274.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$274.50
Rate for Payer: UnitedHealthcare Commercial	$289.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Humerus Right

Facility

$305.00

Service Code	HCPCS 73060 RT
Hospital Charge Code	3700292
Hospital Revenue Code	320
Min. Negotiated Rate	$274.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$274.50
Rate for Payer: UnitedHealthcare Commercial	$289.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Humerus Right

Facility

$305.00

Service Code	HCPCS 73060 RT
Hospital Charge Code	3700292
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$289.75
Rate for Payer: Aetna Commercial	$274.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$137.52
Rate for Payer: Humana Medicare Advantage	$128.10
Rate for Payer: UnitedHealthcare Commercial	$289.75
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$183.00

XR IVP

Facility

$881.00

Service Code	HCPCS 74400 TC
Hospital Charge Code	3700300
Hospital Revenue Code	320
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$836.95
Rate for Payer: Aetna Commercial	$792.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$481.33
Rate for Payer: Humana Medicare Advantage	$370.02
Rate for Payer: UnitedHealthcare Commercial	$836.95
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$528.60

XR IVP

Facility

$881.00

Service Code	HCPCS 74400 TC
Hospital Charge Code	3700300
Hospital Revenue Code	320
Min. Negotiated Rate	$792.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$792.90
Rate for Payer: UnitedHealthcare Commercial	$836.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Joint Survey Single View 2+ Joints

Facility

$229.00

Service Code	HCPCS 77077 TC
Hospital Charge Code	3700245
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
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	$59.96
Rate for Payer: WPPA Medicare Advantage	$137.40

XR Joint Survey Single View 2+ Joints

Facility

$229.00

Service Code	HCPCS 77077 TC
Hospital Charge Code	3700245
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

Know your out-of-pocket cost for care.

All Charges