Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$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 Sacroiliac Joints 3+ Views

Facility

$321.00

Service Code	HCPCS 72202 TC
Hospital Charge Code	3700474
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$304.95
Rate for Payer: Aetna Commercial	$288.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$144.96
Rate for Payer: Humana Medicare Advantage	$134.82
Rate for Payer: UnitedHealthcare Commercial	$304.95
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$192.60

XR Sacroiliac Joints 3+ Views

Facility

$321.00

Service Code	HCPCS 72202 TC
Hospital Charge Code	3700474
Hospital Revenue Code	320
Min. Negotiated Rate	$288.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$288.90
Rate for Payer: UnitedHealthcare Commercial	$304.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Sacrum/Coccyx 2+ Views

Facility

$249.00

Service Code	HCPCS 72220 TC
Hospital Charge Code	3700433
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$236.55
Rate for Payer: Aetna Commercial	$224.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$143.10
Rate for Payer: Humana Medicare Advantage	$104.58
Rate for Payer: UnitedHealthcare Commercial	$236.55
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$149.40

XR Sacrum/Coccyx 2+ Views

Facility

$249.00

Service Code	HCPCS 72220 TC
Hospital Charge Code	3700433
Hospital Revenue Code	320
Min. Negotiated Rate	$224.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$224.10
Rate for Payer: UnitedHealthcare Commercial	$236.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Scapula Left

Facility

$252.00

Service Code	HCPCS 73010 LT
Hospital Charge Code	3700441
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$239.40
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$117.08
Rate for Payer: Humana Medicare Advantage	$105.84
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$151.20

XR Scapula Left

Facility

$252.00

Service Code	HCPCS 73010 LT
Hospital Charge Code	3700441
Hospital Revenue Code	320
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Scapula Right

Facility

$252.00

Service Code	HCPCS 73010 RT
Hospital Charge Code	3700441
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$239.40
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$117.08
Rate for Payer: Humana Medicare Advantage	$105.84
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$151.20

XR Scapula Right

Facility

$252.00

Service Code	HCPCS 73010 RT
Hospital Charge Code	3700441
Hospital Revenue Code	320
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Shoulder 1 View Left

Facility

$234.00

Service Code	HCPCS 73020 LT
Hospital Charge Code	3700805
Hospital Revenue Code	320
Min. Negotiated Rate	$210.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$210.60
Rate for Payer: UnitedHealthcare Commercial	$222.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Shoulder 1 View Left

Facility

$234.00

Service Code	HCPCS 73020 LT
Hospital Charge Code	3700805
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$222.30
Rate for Payer: Aetna Commercial	$210.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$105.93
Rate for Payer: Humana Medicare Advantage	$98.28
Rate for Payer: UnitedHealthcare Commercial	$222.30
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$140.40

XR Shoulder 1 View Right

Facility

$234.00

Service Code	HCPCS 73020 RT
Hospital Charge Code	3700805
Hospital Revenue Code	320
Min. Negotiated Rate	$210.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$210.60
Rate for Payer: UnitedHealthcare Commercial	$222.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Shoulder 1 View Right

Facility

$234.00

Service Code	HCPCS 73020 RT
Hospital Charge Code	3700805
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$222.30
Rate for Payer: Aetna Commercial	$210.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$105.93
Rate for Payer: Humana Medicare Advantage	$98.28
Rate for Payer: UnitedHealthcare Commercial	$222.30
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$140.40

XR Shoulder Complete 2+ Views Left

Facility

$310.00

Service Code	HCPCS 73030 LT
Hospital Charge Code	3700458
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$294.50
Rate for Payer: Aetna Commercial	$279.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$140.31
Rate for Payer: Humana Medicare Advantage	$130.20
Rate for Payer: UnitedHealthcare Commercial	$294.50
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$186.00

XR Shoulder Complete 2+ Views Left

Facility

$310.00

Service Code	HCPCS 73030 LT
Hospital Charge Code	3700458
Hospital Revenue Code	320
Min. Negotiated Rate	$279.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$279.00
Rate for Payer: UnitedHealthcare Commercial	$294.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Shoulder Complete 2+ Views Right

Facility

$310.00

Service Code	HCPCS 73030 RT
Hospital Charge Code	3700458
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$294.50
Rate for Payer: Aetna Commercial	$279.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$140.31
Rate for Payer: Humana Medicare Advantage	$130.20
Rate for Payer: UnitedHealthcare Commercial	$294.50
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$186.00

XR Shoulder Complete 2+ Views Right

Facility

$310.00

Service Code	HCPCS 73030 RT
Hospital Charge Code	3700458
Hospital Revenue Code	320
Min. Negotiated Rate	$279.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$279.00
Rate for Payer: UnitedHealthcare Commercial	$294.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Shunt Series

Facility

$317.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	3700664
Hospital Revenue Code	320
Min. Negotiated Rate	$285.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$285.30
Rate for Payer: UnitedHealthcare Commercial	$301.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Shunt Series

Facility

$317.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	3700664
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$301.15
Rate for Payer: Aetna Commercial	$285.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$123.58
Rate for Payer: Humana Medicare Advantage	$133.14
Rate for Payer: UnitedHealthcare Commercial	$301.15
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$190.20

XR Shunt Series

Facility

$237.00

Service Code	HCPCS 71045
Hospital Charge Code	3771045
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 Shunt Series

Facility

$237.00

Service Code	HCPCS 71045
Hospital Charge Code	3771045
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	$123.58
Rate for Payer: Humana Medicare Advantage	$99.54
Rate for Payer: UnitedHealthcare Commercial	$225.15
Rate for Payer: UnitedHealthcare Medicaid	$73.85
Rate for Payer: WPPA Medicare Advantage	$142.20

XR Shunt Series.

Facility

$298.00

Service Code	HCPCS 74018
Hospital Charge Code	3774018
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
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	$73.85
Rate for Payer: WPPA Medicare Advantage	$178.80

XR Shunt Series.

Facility

$298.00

Service Code	HCPCS 74018
Hospital Charge Code	3774018
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 Sinuses Paranasal < 3 Views

Facility

$196.00

Service Code	HCPCS 70210 TC
Hospital Charge Code	3700672
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$186.20
Rate for Payer: Aetna Commercial	$176.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$106.86
Rate for Payer: Humana Medicare Advantage	$82.32
Rate for Payer: UnitedHealthcare Commercial	$186.20
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$117.60

XR Sinuses Paranasal < 3 Views

Facility

$196.00

Service Code	HCPCS 70210 TC
Hospital Charge Code	3700672
Hospital Revenue Code	320
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$176.40
Rate for Payer: UnitedHealthcare Commercial	$186.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges