Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

MRA Neck w/ Contrast

Facility

$2,294.00

Service Code	HCPCS 70548 TC
Hospital Charge Code	3750382
Hospital Revenue Code	615
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,179.30
Rate for Payer: Aetna Commercial	$2,064.60
Rate for Payer: UnitedHealthcare Commercial	$2,179.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRA Neck w/ Contrast

Facility

$2,294.00

Service Code	HCPCS 70548 TC
Hospital Charge Code	3750382
Hospital Revenue Code	615
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$2,179.30
Rate for Payer: Aetna Commercial	$2,064.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$664.93
Rate for Payer: Humana Medicare Advantage	$963.48
Rate for Payer: UnitedHealthcare Commercial	$2,179.30
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,376.40

MRA Neck w/o Contrast

Facility

$2,185.00

Service Code	HCPCS 70547 TC
Hospital Charge Code	3750378
Hospital Revenue Code	615
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,075.75
Rate for Payer: Aetna Commercial	$1,966.50
Rate for Payer: UnitedHealthcare Commercial	$2,075.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRA Neck w/o Contrast

Facility

$2,185.00

Service Code	HCPCS 70547 TC
Hospital Charge Code	3750378
Hospital Revenue Code	615
Min. Negotiated Rate	$131.00
Max. Negotiated Rate	$2,075.75
Rate for Payer: Aetna Commercial	$1,966.50
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$664.93
Rate for Payer: Humana Medicare Advantage	$917.70
Rate for Payer: UnitedHealthcare Commercial	$2,075.75
Rate for Payer: UnitedHealthcare Medicaid	$131.00
Rate for Payer: WPPA Medicare Advantage	$1,311.00

MRA Neck w/ + w/o Contrast

Facility

$2,403.00

Service Code	HCPCS 70549 TC
Hospital Charge Code	3750386
Hospital Revenue Code	615
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$664.93
Rate for Payer: Humana Medicare Advantage	$1,009.26
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,441.80

MRA Neck w/ + w/o Contrast

Facility

$2,403.00

Service Code	HCPCS 70549 TC
Hospital Charge Code	3750386
Hospital Revenue Code	615
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRA Spinal Contents w/ + w/o Contrast

Facility

$2,403.00

Service Code	HCPCS 72159 TC
Hospital Charge Code	3752159
Hospital Revenue Code	612
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRA Spinal Contents w/ + w/o Contrast

Facility

$2,403.00

Service Code	HCPCS 72159 TC
Hospital Charge Code	3752159
Hospital Revenue Code	612
Min. Negotiated Rate	$195.00
Max. Negotiated Rate	$2,282.85
Rate for Payer: Aetna Commercial	$2,162.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$664.93
Rate for Payer: Humana Medicare Advantage	$1,009.26
Rate for Payer: UnitedHealthcare Commercial	$2,282.85
Rate for Payer: UnitedHealthcare Medicaid	$195.00
Rate for Payer: WPPA Medicare Advantage	$1,441.80

MRI Abdomen w/ Contrast

Facility

$1,861.00

Service Code	HCPCS 74182 TC
Hospital Charge Code	3750325
Hospital Revenue Code	610
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$1,767.95
Rate for Payer: Aetna Commercial	$1,674.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$552.52
Rate for Payer: Humana Medicare Advantage	$781.62
Rate for Payer: UnitedHealthcare Commercial	$1,767.95
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,116.60

MRI Abdomen w/ Contrast

Facility

$1,861.00

Service Code	HCPCS 74182 TC
Hospital Charge Code	3750325
Hospital Revenue Code	610
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,767.95
Rate for Payer: Aetna Commercial	$1,674.90
Rate for Payer: UnitedHealthcare Commercial	$1,767.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRI Abdomen w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 74181 TC
Hospital Charge Code	3750317
Hospital Revenue Code	610
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,751.80
Rate for Payer: Aetna Commercial	$1,659.60
Rate for Payer: UnitedHealthcare Commercial	$1,751.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRI Abdomen w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 74181 TC
Hospital Charge Code	3750317
Hospital Revenue Code	610
Min. Negotiated Rate	$131.00
Max. Negotiated Rate	$1,751.80
Rate for Payer: Aetna Commercial	$1,659.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$552.52
Rate for Payer: Humana Medicare Advantage	$774.48
Rate for Payer: UnitedHealthcare Commercial	$1,751.80
Rate for Payer: UnitedHealthcare Medicaid	$131.00
Rate for Payer: WPPA Medicare Advantage	$1,106.40

MRI Abdomen w/ + w/o Contrast

Facility

$1,964.00

Service Code	HCPCS 74183 TC
Hospital Charge Code	3750333
Hospital Revenue Code	610
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$1,865.80
Rate for Payer: Aetna Commercial	$1,767.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$552.52
Rate for Payer: Humana Medicare Advantage	$824.88
Rate for Payer: UnitedHealthcare Commercial	$1,865.80
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,178.40

MRI Abdomen w/ + w/o Contrast

Facility

$1,964.00

Service Code	HCPCS 74183 TC
Hospital Charge Code	3750333
Hospital Revenue Code	610
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,865.80
Rate for Payer: Aetna Commercial	$1,767.60
Rate for Payer: UnitedHealthcare Commercial	$1,865.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRI Brachial Plexus w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 73219 TC
Hospital Charge Code	3750260
Hospital Revenue Code	610
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,856.30
Rate for Payer: Aetna Commercial	$1,758.60
Rate for Payer: UnitedHealthcare Commercial	$1,856.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRI Brachial Plexus w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 73219 TC
Hospital Charge Code	3750260
Hospital Revenue Code	610
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$1,856.30
Rate for Payer: Aetna Commercial	$1,758.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$552.52
Rate for Payer: Humana Medicare Advantage	$820.68
Rate for Payer: UnitedHealthcare Commercial	$1,856.30
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,172.40

MRI Brachial Plexus w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 73218 TC
Hospital Charge Code	3750265
Hospital Revenue Code	610
Min. Negotiated Rate	$131.00
Max. Negotiated Rate	$1,751.80
Rate for Payer: Aetna Commercial	$1,659.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$552.52
Rate for Payer: Humana Medicare Advantage	$774.48
Rate for Payer: UnitedHealthcare Commercial	$1,751.80
Rate for Payer: UnitedHealthcare Medicaid	$131.00
Rate for Payer: WPPA Medicare Advantage	$1,106.40

MRI Brachial Plexus w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 73218 TC
Hospital Charge Code	3750265
Hospital Revenue Code	610
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,751.80
Rate for Payer: Aetna Commercial	$1,659.60
Rate for Payer: UnitedHealthcare Commercial	$1,751.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRI Brachial Plexus w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 73220 TC
Hospital Charge Code	3750261
Hospital Revenue Code	610
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,958.90
Rate for Payer: Aetna Commercial	$1,855.80
Rate for Payer: UnitedHealthcare Commercial	$1,958.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRI Brachial Plexus w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 73220 TC
Hospital Charge Code	3750261
Hospital Revenue Code	610
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$1,958.90
Rate for Payer: Aetna Commercial	$1,855.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$552.52
Rate for Payer: Humana Medicare Advantage	$866.04
Rate for Payer: UnitedHealthcare Commercial	$1,958.90
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,237.20

MRI Brain and IAC w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 70552 TC
Hospital Charge Code	3750101
Hospital Revenue Code	611
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$1,856.30
Rate for Payer: Aetna Commercial	$1,758.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$552.52
Rate for Payer: Humana Medicare Advantage	$820.68
Rate for Payer: UnitedHealthcare Commercial	$1,856.30
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,172.40

MRI Brain and IAC w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 70552 TC
Hospital Charge Code	3750101
Hospital Revenue Code	611
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,856.30
Rate for Payer: Aetna Commercial	$1,758.60
Rate for Payer: UnitedHealthcare Commercial	$1,856.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRI Brain and IAC w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 70551 TC
Hospital Charge Code	3750093
Hospital Revenue Code	611
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,751.80
Rate for Payer: Aetna Commercial	$1,659.60
Rate for Payer: UnitedHealthcare Commercial	$1,751.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

MRI Brain and IAC w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 70551 TC
Hospital Charge Code	3750093
Hospital Revenue Code	611
Min. Negotiated Rate	$131.00
Max. Negotiated Rate	$1,751.80
Rate for Payer: Aetna Commercial	$1,659.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$552.52
Rate for Payer: Humana Medicare Advantage	$774.48
Rate for Payer: UnitedHealthcare Commercial	$1,751.80
Rate for Payer: UnitedHealthcare Medicaid	$131.00
Rate for Payer: WPPA Medicare Advantage	$1,106.40

MRI Brain and IAC w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 70553 TC
Hospital Charge Code	3750119
Hospital Revenue Code	611
Min. Negotiated Rate	$206.69
Max. Negotiated Rate	$1,958.90
Rate for Payer: Aetna Commercial	$1,855.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$552.52
Rate for Payer: Humana Medicare Advantage	$866.04
Rate for Payer: UnitedHealthcare Commercial	$1,958.90
Rate for Payer: UnitedHealthcare Medicaid	$206.69
Rate for Payer: WPPA Medicare Advantage	$1,237.20

Know your out-of-pocket cost for care.

All Charges