Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

MRI Spine Cervical w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 72156 TC
Hospital Charge Code	3750176
Hospital Revenue Code	612
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 Spine Cervical w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 72156 TC
Hospital Charge Code	3750176
Hospital Revenue Code	612
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 Spine Cervical w/ + w/o Contrast Add-On

Facility

$2,062.00

Service Code	HCPCS 72156
Hospital Charge Code	3750176
Hospital Revenue Code	612
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	$313.17
Rate for Payer: WPPA Medicare Advantage	$1,237.20

MRI Spine Cervical w/ + w/o Contrast Add-On

Facility

$2,062.00

Service Code	HCPCS 72156
Hospital Charge Code	3750176
Hospital Revenue Code	612
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 Spine Entire w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 72149 TC
Hospital Charge Code	3750226
Hospital Revenue Code	612
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 Spine Entire w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 72149 TC
Hospital Charge Code	3750226
Hospital Revenue Code	612
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 Spine Entire w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 72148 TC
Hospital Charge Code	3750218
Hospital Revenue Code	612
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 Spine Entire w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 72148 TC
Hospital Charge Code	3750218
Hospital Revenue Code	612
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 Spine Entire w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 72158 TC
Hospital Charge Code	3750234
Hospital Revenue Code	612
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 Spine Entire w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 72158 TC
Hospital Charge Code	3750234
Hospital Revenue Code	612
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 Spine Lumbar w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 72149 TC
Hospital Charge Code	3750226
Hospital Revenue Code	612
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 Spine Lumbar w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 72149 TC
Hospital Charge Code	3750226
Hospital Revenue Code	612
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 Spine Lumbar w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 72148 TC
Hospital Charge Code	3750218
Hospital Revenue Code	612
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 Spine Lumbar w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 72148 TC
Hospital Charge Code	3750218
Hospital Revenue Code	612
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 Spine Lumbar w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 72158 TC
Hospital Charge Code	3750234
Hospital Revenue Code	612
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 Spine Lumbar w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 72158 TC
Hospital Charge Code	3750234
Hospital Revenue Code	612
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 Spine Thoracic w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 72147 TC
Hospital Charge Code	3750192
Hospital Revenue Code	612
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 Spine Thoracic w/ Contrast

Facility

$1,954.00

Service Code	HCPCS 72147 TC
Hospital Charge Code	3750192
Hospital Revenue Code	612
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 Spine Thoracic w/ Contrast Add-On

Facility

$1,954.00

Service Code	HCPCS 72147
Hospital Charge Code	3750192
Hospital Revenue Code	612
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	$313.17
Rate for Payer: WPPA Medicare Advantage	$1,172.40

MRI Spine Thoracic w/ Contrast Add-On

Facility

$1,954.00

Service Code	HCPCS 72147
Hospital Charge Code	3750192
Hospital Revenue Code	612
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 Spine Thoracic w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 72146 TC
Hospital Charge Code	3750184
Hospital Revenue Code	612
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 Spine Thoracic w/o Contrast

Facility

$1,844.00

Service Code	HCPCS 72146 TC
Hospital Charge Code	3750184
Hospital Revenue Code	612
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 Spine Thoracic w/o Contrast Add-On

Facility

$1,844.00

Service Code	HCPCS 72146
Hospital Charge Code	3750184
Hospital Revenue Code	612
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 Spine Thoracic w/o Contrast Add-On

Facility

$1,844.00

Service Code	HCPCS 72146
Hospital Charge Code	3750184
Hospital Revenue Code	612
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	$198.49
Rate for Payer: WPPA Medicare Advantage	$1,106.40

MRI Spine Thoracic w/ + w/o Contrast

Facility

$2,062.00

Service Code	HCPCS 72157 TC
Hospital Charge Code	3750200
Hospital Revenue Code	612
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

Know your out-of-pocket cost for care.

All Charges