Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$475.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$475.20
Rate for Payer: UnitedHealthcare Commercial	$501.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Spine Scoliosis 2-3 Views

Facility

$461.00

Service Code	HCPCS 72082 TC
Hospital Charge Code	3700065
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$437.95
Rate for Payer: Aetna Commercial	$414.90
Rate for Payer: Humana Medicare Advantage	$193.62
Rate for Payer: UnitedHealthcare Commercial	$437.95
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$276.60

XR Spine Scoliosis 2-3 Views

Facility

$461.00

Service Code	HCPCS 72082 TC
Hospital Charge Code	3700065
Hospital Revenue Code	320
Min. Negotiated Rate	$414.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$414.90
Rate for Payer: UnitedHealthcare Commercial	$437.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Spine Thoracic 2 Views

Facility

$296.00

Service Code	HCPCS 72070 TC
Hospital Charge Code	3700631
Hospital Revenue Code	320
Min. Negotiated Rate	$266.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$266.40
Rate for Payer: UnitedHealthcare Commercial	$281.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Spine Thoracic 2 Views

Facility

$296.00

Service Code	HCPCS 72070 TC
Hospital Charge Code	3700631
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$281.20
Rate for Payer: Aetna Commercial	$266.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$133.80
Rate for Payer: Humana Medicare Advantage	$124.32
Rate for Payer: UnitedHealthcare Commercial	$281.20
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$177.60

XR Spine Thoracic 3 Views

Facility

$444.00

Service Code	HCPCS 72072 TC
Hospital Charge Code	3700516
Hospital Revenue Code	320
Min. Negotiated Rate	$399.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$399.60
Rate for Payer: UnitedHealthcare Commercial	$421.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Spine Thoracic 3 Views

Facility

$444.00

Service Code	HCPCS 72072 TC
Hospital Charge Code	3700516
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$421.80
Rate for Payer: Aetna Commercial	$399.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$201.64
Rate for Payer: Humana Medicare Advantage	$186.48
Rate for Payer: UnitedHealthcare Commercial	$421.80
Rate for Payer: UnitedHealthcare Medicaid	$59.96
Rate for Payer: WPPA Medicare Advantage	$266.40

XR Spine Thoracolumbar 2+ Views

Facility

$252.00

Service Code	HCPCS 72080 TC
Hospital Charge Code	3700066
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 Thoracolumbar 2+ Views

Facility

$252.00

Service Code	HCPCS 72080 TC
Hospital Charge Code	3700066
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$239.40
Rate for Payer: Aetna Commercial	$226.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$192.34
Rate for Payer: Humana Medicare Advantage	$105.84
Rate for Payer: UnitedHealthcare Commercial	$239.40
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$151.20

XR Sternoclavicular Joint(s)

Facility

$378.00

Service Code	HCPCS 71130 TC
Hospital Charge Code	3700763
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$359.10
Rate for Payer: Aetna Commercial	$340.20
Rate for Payer: Humana Medicare Advantage	$158.76
Rate for Payer: UnitedHealthcare Commercial	$359.10
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$226.80

XR Sternoclavicular Joint(s)

Facility

$378.00

Service Code	HCPCS 71130 TC
Hospital Charge Code	3700763
Hospital Revenue Code	320
Min. Negotiated Rate	$340.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$340.20
Rate for Payer: UnitedHealthcare Commercial	$359.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Sternum 2+ Views

Facility

$321.00

Service Code	HCPCS 71120 TC
Hospital Charge Code	3700508
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
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	$48.74
Rate for Payer: WPPA Medicare Advantage	$192.60

XR Sternum 2+ Views

Facility

$321.00

Service Code	HCPCS 71120 TC
Hospital Charge Code	3700508
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 Tibia/Fibula Left

Facility

$315.00

Service Code	HCPCS 73590 LT
Hospital Charge Code	3700524
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$299.25
Rate for Payer: Aetna Commercial	$283.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$142.17
Rate for Payer: Humana Medicare Advantage	$132.30
Rate for Payer: UnitedHealthcare Commercial	$299.25
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$189.00

XR Tibia/Fibula Left

Facility

$315.00

Service Code	HCPCS 73590 LT
Hospital Charge Code	3700524
Hospital Revenue Code	320
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$283.50
Rate for Payer: UnitedHealthcare Commercial	$299.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Tibia/Fibula Right

Facility

$315.00

Service Code	HCPCS 73590 RT
Hospital Charge Code	3700524
Hospital Revenue Code	320
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$283.50
Rate for Payer: UnitedHealthcare Commercial	$299.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Tibia/Fibula Right

Facility

$315.00

Service Code	HCPCS 73590 RT
Hospital Charge Code	3700524
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$299.25
Rate for Payer: Aetna Commercial	$283.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$142.17
Rate for Payer: Humana Medicare Advantage	$132.30
Rate for Payer: UnitedHealthcare Commercial	$299.25
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$189.00

XR TMJ Open and Closed Bilateral

Facility

$381.00

Service Code	HCPCS 70330 TC
Hospital Charge Code	3701030
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$361.95
Rate for Payer: Aetna Commercial	$342.90
Rate for Payer: Humana Medicare Advantage	$160.02
Rate for Payer: UnitedHealthcare Commercial	$361.95
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$228.60

XR TMJ Open and Closed Bilateral

Facility

$381.00

Service Code	HCPCS 70330 TC
Hospital Charge Code	3701030
Hospital Revenue Code	320
Min. Negotiated Rate	$342.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$342.90
Rate for Payer: UnitedHealthcare Commercial	$361.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR TMJ Open and Closed Left

Facility

$229.00

Service Code	HCPCS 70328 LT
Hospital Charge Code	3700748
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 TMJ Open and Closed Left

Facility

$229.00

Service Code	HCPCS 70328 LT
Hospital Charge Code	3700748
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
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	$48.74
Rate for Payer: WPPA Medicare Advantage	$137.40

XR TMJ Open and Closed Right

Facility

$229.00

Service Code	HCPCS 70328 RT
Hospital Charge Code	3700748
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 TMJ Open and Closed Right

Facility

$229.00

Service Code	HCPCS 70328 RT
Hospital Charge Code	3700748
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
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	$48.74
Rate for Payer: WPPA Medicare Advantage	$137.40

XR Toe(s) 2+ Views Left

Facility

$237.00

Service Code	HCPCS 73660 LT
Hospital Charge Code	3700532
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 Toe(s) 2+ Views Left

Facility

$237.00

Service Code	HCPCS 73660 LT
Hospital Charge Code	3700532
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	$107.79
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

Know your out-of-pocket cost for care.

All Charges