Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

MRI LE Joint w/o Contrast Right

Facility

$1,844.00

Service Code	HCPCS 73721 RT
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 Right

Facility

$1,844.00

Service Code	HCPCS 73721 RT
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

MRI LE Joint w/ + w/o Contrast Left

Facility

$2,062.00

Service Code	HCPCS 73723 LT
Hospital Charge Code	3750291
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/ + w/o Contrast Left

Facility

$2,062.00

Service Code	HCPCS 73723 LT
Hospital Charge Code	3750291
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 LE Joint w/ + w/o Contrast Right

Facility

$2,062.00

Service Code	HCPCS 73723 RT
Hospital Charge Code	3750291
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 LE Joint w/ + w/o Contrast Right

Facility

$2,062.00

Service Code	HCPCS 73723 RT
Hospital Charge Code	3750291
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 Non Joint w/ Contrast Lt

Facility

$1,954.00

Service Code	HCPCS 73719 TC
Hospital Charge Code	3750262
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 Non Joint w/ Contrast Lt

Facility

$1,954.00

Service Code	HCPCS 73719 TC
Hospital Charge Code	3750262
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 LE Non Joint w/ Contrast Rt

Facility

$1,954.00

Service Code	HCPCS 73719 TC
Hospital Charge Code	3750262
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 LE Non Joint w/ Contrast Rt

Facility

$1,954.00

Service Code	HCPCS 73719 TC
Hospital Charge Code	3750262
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 Non Joint w/o Contrast Lt

Facility

$1,844.00

Service Code	HCPCS 73718 TC
Hospital Charge Code	3750394
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 LE Non Joint w/o Contrast Lt

Facility

$1,844.00

Service Code	HCPCS 73718 TC
Hospital Charge Code	3750394
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 Non Joint w/o Contrast Rt

Facility

$1,844.00

Service Code	HCPCS 73718 TC
Hospital Charge Code	3750394
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 LE Non Joint w/o Contrast Rt

Facility

$1,844.00

Service Code	HCPCS 73718 TC
Hospital Charge Code	3750394
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 Non Joint w/ + w/o Contrast Lt

Facility

$2,062.00

Service Code	HCPCS 73720 TC
Hospital Charge Code	3750263
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 Non Joint w/ + w/o Contrast Lt

Facility

$2,062.00

Service Code	HCPCS 73720 TC
Hospital Charge Code	3750263
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 LE Non Joint w/ + w/o Contrast Rt

Facility

$2,062.00

Service Code	HCPCS 73720 TC
Hospital Charge Code	3750263
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 LE Non Joint w/ + w/o Contrast Rt

Facility

$2,062.00

Service Code	HCPCS 73720 TC
Hospital Charge Code	3750263
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 MRCP w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 74182 TC
Hospital Charge Code	3750325
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 MRCP w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 74182 TC
Hospital Charge Code	3750325
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 MRCP 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 MRCP 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 MRCP w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 74183 TC
Hospital Charge Code	3750333
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 MRCP w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 74183 TC
Hospital Charge Code	3750333
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 Neck 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

Know your out-of-pocket cost for care.

All Charges