Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$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 Brain 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 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 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 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 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

MRI Brain w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 70553 TC
Hospital Charge Code	3750119
Hospital Revenue Code	611
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 Chest w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 71551 TC
Hospital Charge Code	3750135
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 Chest w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 71551 TC
Hospital Charge Code	3750135
Hospital Revenue Code	610
Min. Negotiated Rate	$415.56
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	$415.56
Rate for Payer: WPPA Medicare Advantage	$1,172.40

MRI Chest w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 71550 TC
Hospital Charge Code	3750127
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 Chest w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 71550 TC
Hospital Charge Code	3750127
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 Chest w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 71552 TC
Hospital Charge Code	3750143
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 Chest w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 71552 TC
Hospital Charge Code	3750143
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 Face w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 70542 TC
Hospital Charge Code	3750375
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 Face w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 70542 TC
Hospital Charge Code	3750375
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 Face w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 70540 TC
Hospital Charge Code	3750540
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 Face w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 70540 TC
Hospital Charge Code	3750540
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 Face w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 70543 TC
Hospital Charge Code	3750374
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 Face w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 70543 TC
Hospital Charge Code	3750374
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 LE Joint w/ Contrast Left

Facility

$1,954.00

Service Code	HCPCS 73722 LT
Hospital Charge Code	3750283
Hospital Revenue Code	610
Min. Negotiated Rate	$415.56
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	$415.56
Rate for Payer: WPPA Medicare Advantage	$1,172.40

MRI LE Joint w/ Contrast Left

Facility

$1,954.00

Service Code	HCPCS 73722 LT
Hospital Charge Code	3750283
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 LE Joint w/ Contrast Right

Facility

$1,954.00

Service Code	HCPCS 73722 RT
Hospital Charge Code	3750283
Hospital Revenue Code	610
Min. Negotiated Rate	$415.56
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	$415.56
Rate for Payer: WPPA Medicare Advantage	$1,172.40

MRI LE Joint w/ Contrast Right

Facility

$1,954.00

Service Code	HCPCS 73722 RT
Hospital Charge Code	3750283
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 LE Joint w/o Contrast Left

Facility

$1,844.00

Service Code	HCPCS 73721 LT
Hospital Charge Code	3750275
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 LE Joint w/o Contrast Left

Facility

$1,844.00

Service Code	HCPCS 73721 LT
Hospital Charge Code	3750275
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

Know your out-of-pocket cost for care.

All Charges