Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR Knee 1 or 2 Views Add-on

Facility

$229.00

Service Code	HCPCS 73560 TC
Hospital Charge Code	3700318
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	$107.79
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 Knee 1 or 2 Views Add-on

Facility

$229.00

Service Code	HCPCS 73560 LT
Hospital Charge Code	3700318
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	$107.79
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 Knee 1 or 2 Views Add-on

Facility

$229.00

Service Code	HCPCS 73560 TC
Hospital Charge Code	3700318
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 Knee 1 or 2 Views Add-on

Facility

$229.00

Service Code	HCPCS 73560 LT
Hospital Charge Code	3700318
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 Knee 1 or 2 Views Bilateral

Facility

$229.00

Service Code	HCPCS 73560 TC
Hospital Charge Code	3700318
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	$107.79
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 Knee 1 or 2 Views Bilateral

Facility

$229.00

Service Code	HCPCS 73560 RT
Hospital Charge Code	3700318
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 Knee 1 or 2 Views Bilateral

Facility

$229.00

Service Code	HCPCS 73560 TC
Hospital Charge Code	3700318
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 Knee 1 or 2 Views Bilateral

Facility

$229.00

Service Code	HCPCS 73560 RT
Hospital Charge Code	3700318
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	$107.79
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 Knee 1 or 2 Views Left

Facility

$229.00

Service Code	HCPCS 73560 LT
Hospital Charge Code	3700318
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	$107.79
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 Knee 1 or 2 Views Left

Facility

$229.00

Service Code	HCPCS 73560 LT
Hospital Charge Code	3700318
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 Knee 1 or 2 Views Right

Facility

$229.00

Service Code	HCPCS 73560 RT
Hospital Charge Code	3700318
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 Knee 1 or 2 Views Right

Facility

$229.00

Service Code	HCPCS 73560 RT
Hospital Charge Code	3700318
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	$107.79
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 Knee 1 View Standing AP Bilateral

Facility

$322.00

Service Code	HCPCS 73565 TC
Hospital Charge Code	3700330
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 Knee 1 View Standing AP Bilateral

Facility

$322.00

Service Code	HCPCS 73565 TC
Hospital Charge Code	3700330
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	$109.65
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 Knee 3 Views Bilateral

Facility

$291.00

Service Code	HCPCS 73562 RT
Hospital Charge Code	3700623
Hospital Revenue Code	320
Min. Negotiated Rate	$261.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Knee 3 Views Bilateral

Facility

$291.00

Service Code	HCPCS 73562 TC
Hospital Charge Code	3700623
Hospital Revenue Code	320
Min. Negotiated Rate	$261.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Knee 3 Views Bilateral

Facility

$291.00

Service Code	HCPCS 73562 RT
Hospital Charge Code	3700623
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$276.45
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$149.60
Rate for Payer: Humana Medicare Advantage	$122.22
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$174.60

XR Knee 3 Views Bilateral

Facility

$291.00

Service Code	HCPCS 73562 TC
Hospital Charge Code	3700623
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$276.45
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$149.60
Rate for Payer: Humana Medicare Advantage	$122.22
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$174.60

XR Knee 3 Views Left

Facility

$291.00

Service Code	HCPCS 73562 LT
Hospital Charge Code	3700623
Hospital Revenue Code	320
Min. Negotiated Rate	$261.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Knee 3 Views Left

Facility

$291.00

Service Code	HCPCS 73562 LT
Hospital Charge Code	3700623
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$276.45
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$149.60
Rate for Payer: Humana Medicare Advantage	$122.22
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$174.60

XR Knee 3 Views Left Add-On

Facility

$291.00

Service Code	HCPCS 73562 LT
Hospital Charge Code	3700318
Hospital Revenue Code	320
Min. Negotiated Rate	$261.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Knee 3 Views Left Add-On

Facility

$291.00

Service Code	HCPCS 73562 TC
Hospital Charge Code	3700318
Hospital Revenue Code	320
Min. Negotiated Rate	$261.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Knee 3 Views Left Add-On

Facility

$291.00

Service Code	HCPCS 73562 LT
Hospital Charge Code	3700318
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$276.45
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$149.60
Rate for Payer: Humana Medicare Advantage	$122.22
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$174.60

XR Knee 3 Views Left Add-On

Facility

$291.00

Service Code	HCPCS 73562 TC
Hospital Charge Code	3700318
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$276.45
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$149.60
Rate for Payer: Humana Medicare Advantage	$122.22
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$174.60

XR Knee 3 Views Right

Facility

$291.00

Service Code	HCPCS 73562 RT
Hospital Charge Code	3700623
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$276.45
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$149.60
Rate for Payer: Humana Medicare Advantage	$122.22
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$174.60

Know your out-of-pocket cost for care.

All Charges