Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR Knee 3 Views Right

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 Complete 4+ Views Bilateral

Facility

$478.00

Service Code	HCPCS 73564 RT
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$454.10
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$216.50
Rate for Payer: Humana Medicare Advantage	$200.76
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$286.80

XR Knee Complete 4+ Views Bilateral

Facility

$478.00

Service Code	HCPCS 73564 TC
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$454.10
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$216.50
Rate for Payer: Humana Medicare Advantage	$200.76
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$286.80

XR Knee Complete 4+ Views Bilateral

Facility

$478.00

Service Code	HCPCS 73564 RT
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Knee Complete 4+ Views Bilateral

Facility

$478.00

Service Code	HCPCS 73564 TC
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Knee Complete 4+ Views Left

Facility

$478.00

Service Code	HCPCS 73564 LT
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$454.10
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$216.50
Rate for Payer: Humana Medicare Advantage	$200.76
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$286.80

XR Knee Complete 4+ Views Left

Facility

$478.00

Service Code	HCPCS 73564 LT
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Knee Complete 4+ Views Left Add-On

Facility

$478.00

Service Code	HCPCS 73564 LT
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$454.10
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$216.50
Rate for Payer: Humana Medicare Advantage	$200.76
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$286.80

XR Knee Complete 4+ Views Left Add-On

Facility

$478.00

Service Code	HCPCS 73564 TC
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$454.10
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$216.50
Rate for Payer: Humana Medicare Advantage	$200.76
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$286.80

XR Knee Complete 4+ Views Left Add-On

Facility

$478.00

Service Code	HCPCS 73564 LT
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Knee Complete 4+ Views Left Add-On

Facility

$478.00

Service Code	HCPCS 73564 TC
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Knee Complete 4+ Views Right

Facility

$478.00

Service Code	HCPCS 73564 RT
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$454.10
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$216.50
Rate for Payer: Humana Medicare Advantage	$200.76
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$286.80

XR Knee Complete 4+ Views Right

Facility

$478.00

Service Code	HCPCS 73564 RT
Hospital Charge Code	3701005
Hospital Revenue Code	320
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$430.20
Rate for Payer: UnitedHealthcare Commercial	$454.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Lower Extremity Infant 2 Views Left

Facility

$305.00

Service Code	HCPCS 73592 LT
Hospital Charge Code	3700904
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 Lower Extremity Infant 2 Views Left

Facility

$305.00

Service Code	HCPCS 73592 LT
Hospital Charge Code	3700904
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	$138.45
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 Lower Extremity Infant 2 Views Right

Facility

$305.00

Service Code	HCPCS 73592 RT
Hospital Charge Code	3700904
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	$138.45
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 Lower Extremity Infant 2 Views Right

Facility

$305.00

Service Code	HCPCS 73592 RT
Hospital Charge Code	3700904
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 Mandible Complete 4+ Views

Facility

$373.00

Service Code	HCPCS 70110 TC
Hospital Charge Code	3700367
Hospital Revenue Code	320
Min. Negotiated Rate	$335.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$335.70
Rate for Payer: UnitedHealthcare Commercial	$354.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Mandible Complete 4+ Views

Facility

$373.00

Service Code	HCPCS 70110 TC
Hospital Charge Code	3700367
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$354.35
Rate for Payer: Aetna Commercial	$335.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$210.93
Rate for Payer: Humana Medicare Advantage	$156.66
Rate for Payer: UnitedHealthcare Commercial	$354.35
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$223.80

XR Mandible Less Than 4 Views

Facility

$306.00

Service Code	HCPCS 70100 TC
Hospital Charge Code	3701010
Hospital Revenue Code	320
Min. Negotiated Rate	$275.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$275.40
Rate for Payer: UnitedHealthcare Commercial	$290.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Mandible Less Than 4 Views

Facility

$306.00

Service Code	HCPCS 70100 TC
Hospital Charge Code	3701010
Hospital Revenue Code	320
Min. Negotiated Rate	$16.75
Max. Negotiated Rate	$290.70
Rate for Payer: Aetna Commercial	$275.40
Rate for Payer: Humana Medicare Advantage	$128.52
Rate for Payer: UnitedHealthcare Commercial	$290.70
Rate for Payer: UnitedHealthcare Medicaid	$16.75
Rate for Payer: WPPA Medicare Advantage	$183.60

XR Mastoids < 3 Views Bilateral

Facility

$229.00

Service Code	HCPCS 70120 TC
Hospital Charge Code	3700722
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 Mastoids < 3 Views Bilateral

Facility

$229.00

Service Code	HCPCS 70120 TC
Hospital Charge Code	3700722
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 Nasal Bones 3+ Views

Facility

$326.00

Service Code	HCPCS 70160 TC
Hospital Charge Code	3700375
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$309.70
Rate for Payer: Aetna Commercial	$293.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$147.74
Rate for Payer: Humana Medicare Advantage	$136.92
Rate for Payer: UnitedHealthcare Commercial	$309.70
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$195.60

XR Nasal Bones 3+ Views

Facility

$326.00

Service Code	HCPCS 70160 TC
Hospital Charge Code	3700375
Hospital Revenue Code	320
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$293.40
Rate for Payer: UnitedHealthcare Commercial	$309.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges