Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR Sinuses Paranasal Complete

Facility

$432.00

Service Code	HCPCS 70220 TC
Hospital Charge Code	3700466
Hospital Revenue Code	320
Min. Negotiated Rate	$388.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$388.80
Rate for Payer: UnitedHealthcare Commercial	$410.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Sinuses Paranasal Complete

Facility

$432.00

Service Code	HCPCS 70220 TC
Hospital Charge Code	3700466
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$410.40
Rate for Payer: Aetna Commercial	$388.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$194.20
Rate for Payer: Humana Medicare Advantage	$181.44
Rate for Payer: UnitedHealthcare Commercial	$410.40
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$259.20

XR Skull < 4 Views

Facility

$317.00

Service Code	HCPCS 70250 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 Skull < 4 Views

Facility

$317.00

Service Code	HCPCS 70250 TC
Hospital Charge Code	3700664
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$301.15
Rate for Payer: Aetna Commercial	$285.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$143.10
Rate for Payer: Humana Medicare Advantage	$133.14
Rate for Payer: UnitedHealthcare Commercial	$301.15
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$190.20

XR Skull < 4 Views

Facility

$317.00

Service Code	HCPCS 70250
Hospital Charge Code	3700664
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$301.15
Rate for Payer: Aetna Commercial	$285.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$143.10
Rate for Payer: Humana Medicare Advantage	$133.14
Rate for Payer: UnitedHealthcare Commercial	$301.15
Rate for Payer: UnitedHealthcare Medicaid	$90.85
Rate for Payer: WPPA Medicare Advantage	$190.20

XR Skull < 4 Views

Facility

$317.00

Service Code	HCPCS 70250
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 Skull Complete

Facility

$380.00

Service Code	HCPCS 70260 TC
Hospital Charge Code	3700482
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$361.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$210.93
Rate for Payer: Humana Medicare Advantage	$159.60
Rate for Payer: UnitedHealthcare Commercial	$361.00
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$228.00

XR Skull Complete

Facility

$380.00

Service Code	HCPCS 70260 TC
Hospital Charge Code	3700482
Hospital Revenue Code	320
Min. Negotiated Rate	$342.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: UnitedHealthcare Commercial	$361.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Small Bowel w/ Multiple Series

Facility

$432.00

Service Code	HCPCS 74250 TC
Hospital Charge Code	3700490
Hospital Revenue Code	320
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$410.40
Rate for Payer: Aetna Commercial	$388.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$311.28
Rate for Payer: Humana Medicare Advantage	$181.44
Rate for Payer: UnitedHealthcare Commercial	$410.40
Rate for Payer: UnitedHealthcare Medicaid	$101.17
Rate for Payer: WPPA Medicare Advantage	$259.20

XR Small Bowel w/ Multiple Series

Facility

$432.00

Service Code	HCPCS 74250 TC
Hospital Charge Code	3700490
Hospital Revenue Code	320
Min. Negotiated Rate	$388.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$388.80
Rate for Payer: UnitedHealthcare Commercial	$410.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Spine 1 View Specify Level

Facility

$252.00

Service Code	HCPCS 72020
Hospital Charge Code	3702020
Hospital Revenue Code	320
Min. Negotiated Rate	$73.85
Max. Negotiated Rate	$239.40
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$170.97
Rate for Payer: Humana Medicare Advantage	$105.84
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: UnitedHealthcare Medicaid	$73.85
Rate for Payer: WPPA Medicare Advantage	$151.20

XR Spine 1 View Specify Level

Facility

$252.00

Service Code	HCPCS 72020
Hospital Charge Code	3702020
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 Spine Cervical 2 or 3 Views

Facility

$373.00

Service Code	HCPCS 72040 TC
Hospital Charge Code	3700060
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 Spine Cervical 2 or 3 Views

Facility

$373.00

Service Code	HCPCS 72040 TC
Hospital Charge Code	3700060
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$354.35
Rate for Payer: Aetna Commercial	$335.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$159.82
Rate for Payer: Humana Medicare Advantage	$156.66
Rate for Payer: UnitedHealthcare Commercial	$354.35
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$223.80

XR Spine Cervical 4 or 5 Views

Facility

$397.00

Service Code	HCPCS 72050 TC
Hospital Charge Code	3700052
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$377.15
Rate for Payer: Aetna Commercial	$357.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$230.44
Rate for Payer: Humana Medicare Advantage	$166.74
Rate for Payer: UnitedHealthcare Commercial	$377.15
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$238.20

XR Spine Cervical 4 or 5 Views

Facility

$397.00

Service Code	HCPCS 72050 TC
Hospital Charge Code	3700052
Hospital Revenue Code	320
Min. Negotiated Rate	$357.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$357.30
Rate for Payer: UnitedHealthcare Commercial	$377.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Spine Cervical 6+ Views

Facility

$600.00

Service Code	HCPCS 72052 TC
Hospital Charge Code	3700888
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$570.00
Rate for Payer: Aetna Commercial	$540.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$271.33
Rate for Payer: Humana Medicare Advantage	$252.00
Rate for Payer: UnitedHealthcare Commercial	$570.00
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$360.00

XR Spine Cervical 6+ Views

Facility

$600.00

Service Code	HCPCS 72052 TC
Hospital Charge Code	3700888
Hospital Revenue Code	320
Min. Negotiated Rate	$540.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$540.00
Rate for Payer: UnitedHealthcare Commercial	$570.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Spine Lumbosacral 2 or 3 Views

Facility

$387.00

Service Code	HCPCS 72100 TC
Hospital Charge Code	3700656
Hospital Revenue Code	320
Min. Negotiated Rate	$348.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$348.30
Rate for Payer: UnitedHealthcare Commercial	$367.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Spine Lumbosacral 2 or 3 Views

Facility

$387.00

Service Code	HCPCS 72100 TC
Hospital Charge Code	3700656
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$367.65
Rate for Payer: Aetna Commercial	$348.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$174.69
Rate for Payer: Humana Medicare Advantage	$162.54
Rate for Payer: UnitedHealthcare Commercial	$367.65
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$232.20

XR Spine Lumbosacral 4plus Views

Facility

$549.00

Service Code	HCPCS 72110 TC
Hospital Charge Code	3700359
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$521.55
Rate for Payer: Aetna Commercial	$494.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$248.10
Rate for Payer: Humana Medicare Advantage	$230.58
Rate for Payer: UnitedHealthcare Commercial	$521.55
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$329.40

XR Spine Lumbosacral 4plus Views

Facility

$549.00

Service Code	HCPCS 72110 TC
Hospital Charge Code	3700359
Hospital Revenue Code	320
Min. Negotiated Rate	$494.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$494.10
Rate for Payer: UnitedHealthcare Commercial	$521.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Spine Lumbosacral Bending 2-3 Views

Facility

$516.00

Service Code	HCPCS 72120 TC
Hospital Charge Code	3700789
Hospital Revenue Code	320
Min. Negotiated Rate	$464.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$464.40
Rate for Payer: UnitedHealthcare Commercial	$490.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Spine Lumbosacral Bending 2-3 Views

Facility

$516.00

Service Code	HCPCS 72120 TC
Hospital Charge Code	3700789
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$490.20
Rate for Payer: Aetna Commercial	$464.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$233.23
Rate for Payer: Humana Medicare Advantage	$216.72
Rate for Payer: UnitedHealthcare Commercial	$490.20
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$309.60

XR Spine Lumbosacral w/ Bending 6+ Views

Facility

$528.00

Service Code	HCPCS 72114 TC
Hospital Charge Code	3702114
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$501.60
Rate for Payer: Aetna Commercial	$475.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$299.20
Rate for Payer: Humana Medicare Advantage	$221.76
Rate for Payer: UnitedHealthcare Commercial	$501.60
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$316.80

Know your out-of-pocket cost for care.

All Charges