Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR Neck Soft Tissue

Facility

$229.00

Service Code	HCPCS 70360 TC
Hospital Charge Code	3700698
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 Neck Soft Tissue

Facility

$229.00

Service Code	HCPCS 70360 TC
Hospital Charge Code	3700698
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	$129.16
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 Orbits Complete

Facility

$403.00

Service Code	HCPCS 70200 TC
Hospital Charge Code	3700920
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$382.85
Rate for Payer: Aetna Commercial	$362.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$182.12
Rate for Payer: Humana Medicare Advantage	$169.26
Rate for Payer: UnitedHealthcare Commercial	$382.85
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$241.80

XR Orbits Complete

Facility

$403.00

Service Code	HCPCS 70200 TC
Hospital Charge Code	3700920
Hospital Revenue Code	320
Min. Negotiated Rate	$362.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$362.70
Rate for Payer: UnitedHealthcare Commercial	$382.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Osseous Survey Complete

Facility

$1,119.00

Service Code	HCPCS 77075 TC
Hospital Charge Code	3700633
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$1,063.05
Rate for Payer: Aetna Commercial	$1,007.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$506.41
Rate for Payer: Humana Medicare Advantage	$469.98
Rate for Payer: UnitedHealthcare Commercial	$1,063.05
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$671.40

XR Osseous Survey Complete

Facility

$1,119.00

Service Code	HCPCS 77075 TC
Hospital Charge Code	3700633
Hospital Revenue Code	320
Min. Negotiated Rate	$1,007.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$1,007.10
Rate for Payer: UnitedHealthcare Commercial	$1,063.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Osseous Survey Infant

Facility

$229.00

Service Code	HCPCS 77076 TC
Hospital Charge Code	3700634
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 Osseous Survey Infant

Facility

$229.00

Service Code	HCPCS 77076 TC
Hospital Charge Code	3700634
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 Osseous Survey Limited

Facility

$229.00

Service Code	HCPCS 77074 TC
Hospital Charge Code	3700632
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 Osseous Survey Limited

Facility

$229.00

Service Code	HCPCS 77074 TC
Hospital Charge Code	3700632
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 Pelvis 1 or 2 Views

Facility

$280.00

Service Code	HCPCS 72170 TC
Hospital Charge Code	3700391
Hospital Revenue Code	320
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$252.00
Rate for Payer: UnitedHealthcare Commercial	$266.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Pelvis 1 or 2 Views

Facility

$280.00

Service Code	HCPCS 72170 TC
Hospital Charge Code	3700391
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$266.00
Rate for Payer: Aetna Commercial	$252.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$126.37
Rate for Payer: Humana Medicare Advantage	$117.60
Rate for Payer: UnitedHealthcare Commercial	$266.00
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$168.00

XR Pelvis Complete 3+ Views

Facility

$301.00

Service Code	HCPCS 72190 TC
Hospital Charge Code	3701050
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$285.95
Rate for Payer: Aetna Commercial	$270.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$135.66
Rate for Payer: Humana Medicare Advantage	$126.42
Rate for Payer: UnitedHealthcare Commercial	$285.95
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$180.60

XR Pelvis Complete 3+ Views

Facility

$301.00

Service Code	HCPCS 72190 TC
Hospital Charge Code	3701050
Hospital Revenue Code	320
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$270.90
Rate for Payer: UnitedHealthcare Commercial	$285.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Ribs 2 Views Left

Facility

$237.00

Service Code	HCPCS 71100 LT
Hospital Charge Code	3700755
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$225.15
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.80
Rate for Payer: Humana Medicare Advantage	$99.54
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$142.20

XR Ribs 2 Views Left

Facility

$237.00

Service Code	HCPCS 71100 LT
Hospital Charge Code	3700755
Hospital Revenue Code	320
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Ribs 2 Views Right

Facility

$237.00

Service Code	HCPCS 71100 RT
Hospital Charge Code	3700755
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$225.15
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.80
Rate for Payer: Humana Medicare Advantage	$99.54
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$142.20

XR Ribs 2 Views Right

Facility

$237.00

Service Code	HCPCS 71100 RT
Hospital Charge Code	3700755
Hospital Revenue Code	320
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$213.30
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Ribs 3 Views Bilateral

Facility

$298.00

Service Code	HCPCS 71110 TC
Hospital Charge Code	3701015
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 Ribs 3 Views Bilateral

Facility

$298.00

Service Code	HCPCS 71110 TC
Hospital Charge Code	3701015
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
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	$59.96
Rate for Payer: WPPA Medicare Advantage	$178.80

XR Ribs w/ PA Chest Bilateral

Facility

$543.00

Service Code	HCPCS 71111 TC
Hospital Charge Code	3701020
Hospital Revenue Code	320
Min. Negotiated Rate	$488.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$488.70
Rate for Payer: UnitedHealthcare Commercial	$515.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Ribs w/ PA Chest Bilateral

Facility

$543.00

Service Code	HCPCS 71111 TC
Hospital Charge Code	3701020
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$515.85
Rate for Payer: Aetna Commercial	$488.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$245.31
Rate for Payer: Humana Medicare Advantage	$228.06
Rate for Payer: UnitedHealthcare Commercial	$515.85
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$325.80

XR Ribs w/ PA Chest Left

Facility

$441.00

Service Code	HCPCS 71101 LT
Hospital Charge Code	3700425
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$418.95
Rate for Payer: Aetna Commercial	$396.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$199.78
Rate for Payer: Humana Medicare Advantage	$185.22
Rate for Payer: UnitedHealthcare Commercial	$418.95
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$264.60

XR Ribs w/ PA Chest Left

Facility

$441.00

Service Code	HCPCS 71101 LT
Hospital Charge Code	3700425
Hospital Revenue Code	320
Min. Negotiated Rate	$396.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$396.90
Rate for Payer: UnitedHealthcare Commercial	$418.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Ribs w/ PA Chest Right

Facility

$441.00

Service Code	HCPCS 71101 RT
Hospital Charge Code	3700425
Hospital Revenue Code	320
Min. Negotiated Rate	$396.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$396.90
Rate for Payer: UnitedHealthcare Commercial	$418.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges