Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR Toe(s) 2+ Views Right

Facility

$237.00

Service Code	HCPCS 73660 RT
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

XR Toe(s) 2+ Views Right

Facility

$237.00

Service Code	HCPCS 73660 RT
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 Upper Extremity Infant 2 Views Left

Facility

$229.00

Service Code	HCPCS 73092 LT
Hospital Charge Code	3700896
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$217.55
Rate for Payer: Aetna Commercial	$206.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$103.14
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 Upper Extremity Infant 2 Views Left

Facility

$229.00

Service Code	HCPCS 73092 LT
Hospital Charge Code	3700896
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 Upper Extremity Infant 2 Views Right

Facility

$229.00

Service Code	HCPCS 73092 RT
Hospital Charge Code	3700896
Hospital Revenue Code	320
Min. Negotiated Rate	$59.96
Max. Negotiated Rate	$217.55
Rate for Payer: Aetna Commercial	$206.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$103.14
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 Upper Extremity Infant 2 Views Right

Facility

$229.00

Service Code	HCPCS 73092 RT
Hospital Charge Code	3700896
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 Wrist 2 Views Left

Facility

$229.00

Service Code	HCPCS 73100 LT
Hospital Charge Code	3700821
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 Wrist 2 Views Left

Facility

$229.00

Service Code	HCPCS 73100 LT
Hospital Charge Code	3700821
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	$96.64
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 Wrist 2 Views Right

Facility

$229.00

Service Code	HCPCS 73100 RT
Hospital Charge Code	3700821
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	$96.64
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 Wrist 2 Views Right

Facility

$229.00

Service Code	HCPCS 73100 RT
Hospital Charge Code	3700821
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 Wrist Complete 3+ Views Left

Facility

$316.00

Service Code	HCPCS 73110 LT
Hospital Charge Code	3700557
Hospital Revenue Code	320
Min. Negotiated Rate	$284.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$284.40
Rate for Payer: UnitedHealthcare Commercial	$300.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Wrist Complete 3+ Views Left

Facility

$316.00

Service Code	HCPCS 73110 TC
Hospital Charge Code	3700557
Hospital Revenue Code	320
Min. Negotiated Rate	$284.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$284.40
Rate for Payer: UnitedHealthcare Commercial	$300.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Wrist Complete 3+ Views Left

Facility

$316.00

Service Code	HCPCS 73110 TC
Hospital Charge Code	3700557
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$300.20
Rate for Payer: Aetna Commercial	$284.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$143.10
Rate for Payer: Humana Medicare Advantage	$132.72
Rate for Payer: UnitedHealthcare Commercial	$300.20
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$189.60

XR Wrist Complete 3+ Views Left

Facility

$316.00

Service Code	HCPCS 73110 LT
Hospital Charge Code	3700557
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$300.20
Rate for Payer: Aetna Commercial	$284.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$143.10
Rate for Payer: Humana Medicare Advantage	$132.72
Rate for Payer: UnitedHealthcare Commercial	$300.20
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$189.60

XR Wrist Complete 3+ Views Right

Facility

$316.00

Service Code	HCPCS 73110 TC
Hospital Charge Code	3700557
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$300.20
Rate for Payer: Aetna Commercial	$284.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$143.10
Rate for Payer: Humana Medicare Advantage	$132.72
Rate for Payer: UnitedHealthcare Commercial	$300.20
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$189.60

XR Wrist Complete 3+ Views Right

Facility

$316.00

Service Code	HCPCS 73110 TC
Hospital Charge Code	3700557
Hospital Revenue Code	320
Min. Negotiated Rate	$284.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$284.40
Rate for Payer: UnitedHealthcare Commercial	$300.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Wrist Complete 3+ Views Right

Facility

$316.00

Service Code	HCPCS 73110 RT
Hospital Charge Code	3700557
Hospital Revenue Code	320
Min. Negotiated Rate	$284.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$284.40
Rate for Payer: UnitedHealthcare Commercial	$300.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

XR Wrist Complete 3+ Views Right

Facility

$316.00

Service Code	HCPCS 73110 RT
Hospital Charge Code	3700557
Hospital Revenue Code	320
Min. Negotiated Rate	$48.74
Max. Negotiated Rate	$300.20
Rate for Payer: Aetna Commercial	$284.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$143.10
Rate for Payer: Humana Medicare Advantage	$132.72
Rate for Payer: UnitedHealthcare Commercial	$300.20
Rate for Payer: UnitedHealthcare Medicaid	$48.74
Rate for Payer: WPPA Medicare Advantage	$189.60

Yes - Mechanical Traction Charge

Facility

$88.00

Service Code	HCPCS 97012 GP
Hospital Charge Code	3950127
Hospital Revenue Code	420
Min. Negotiated Rate	$14.77
Max. Negotiated Rate	$83.60
Rate for Payer: Aetna Commercial	$79.20
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.36
Rate for Payer: Humana Medicare Advantage	$36.96
Rate for Payer: UnitedHealthcare Commercial	$83.60
Rate for Payer: UnitedHealthcare Medicaid	$14.77
Rate for Payer: WPPA Medicare Advantage	$52.80

Yes - Mechanical Traction Charge

Facility

$88.00

Service Code	HCPCS 97012 GP
Hospital Charge Code	3950127
Hospital Revenue Code	420
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$79.20
Rate for Payer: UnitedHealthcare Commercial	$83.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Yes - Other Thermal Charge

Facility

$26.00

Service Code	HCPCS 97010 GP
Hospital Charge Code	3950085
Hospital Revenue Code	420
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Yes - Other Thermal Charge

Facility

$26.00

Service Code	HCPCS 97010 GP
Hospital Charge Code	3950085
Hospital Revenue Code	420
Min. Negotiated Rate	$10.92
Max. Negotiated Rate	$24.70
Rate for Payer: Aetna Commercial	$23.40
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$21.21
Rate for Payer: Humana Medicare Advantage	$10.92
Rate for Payer: UnitedHealthcare Commercial	$24.70
Rate for Payer: UnitedHealthcare Medicaid	$15.57
Rate for Payer: WPPA Medicare Advantage	$15.60

Yes - OT Paraffin Bath Charge

Facility

$67.00

Service Code	HCPCS 97018 GO
Hospital Charge Code	3970175
Hospital Revenue Code	430
Min. Negotiated Rate	$13.96
Max. Negotiated Rate	$63.65
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$23.23
Rate for Payer: Humana Medicare Advantage	$28.14
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: UnitedHealthcare Medicaid	$13.96
Rate for Payer: WPPA Medicare Advantage	$40.20

Yes - OT Paraffin Bath Charge

Facility

$67.00

Service Code	HCPCS 97018 GO
Hospital Charge Code	3970175
Hospital Revenue Code	430
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$60.30
Rate for Payer: UnitedHealthcare Commercial	$63.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Yes - OT Unattended Electrical Therapy Charge

Facility

$84.00

Service Code	HCPCS 97014 GO
Hospital Charge Code	3970115
Hospital Revenue Code	430
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$75.60
Rate for Payer: UnitedHealthcare Commercial	$79.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Know your out-of-pocket cost for care.

All Charges