Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

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	$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/ + w/o Contrast Add-On

Facility

$2,062.00

Service Code	HCPCS 72157
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

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

Facility

$2,062.00

Service Code	HCPCS 72157
Hospital Charge Code	3750200
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 UE Joint w/ Contrast Left

Facility

$1,954.00

Service Code	HCPCS 73222 LT
Hospital Charge Code	3750259
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 UE Joint w/ Contrast Left

Facility

$1,954.00

Service Code	HCPCS 73222 LT
Hospital Charge Code	3750259
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 UE Joint w/ Contrast Right

Facility

$1,954.00

Service Code	HCPCS 73222 RT
Hospital Charge Code	3750259
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 UE Joint w/ Contrast Right

Facility

$1,954.00

Service Code	HCPCS 73222 RT
Hospital Charge Code	3750259
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 UE Joint w/o Contrast Left

Facility

$1,844.00

Service Code	HCPCS 73221 LT
Hospital Charge Code	3750242
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 UE Joint w/o Contrast Left

Facility

$1,844.00

Service Code	HCPCS 73221 LT
Hospital Charge Code	3750242
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 UE Joint w/o Contrast Right

Facility

$1,844.00

Service Code	HCPCS 73221 RT
Hospital Charge Code	3750242
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 UE Joint w/o Contrast Right

Facility

$1,844.00

Service Code	HCPCS 73221 RT
Hospital Charge Code	3750242
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 UE Joint w/ + w/o Contrast Left

Facility

$2,062.00

Service Code	HCPCS 73223 LT
Hospital Charge Code	3750267
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 UE Joint w/ + w/o Contrast Left

Facility

$2,062.00

Service Code	HCPCS 73223 LT
Hospital Charge Code	3750267
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 UE Joint w/ + w/o Contrast Right

Facility

$2,062.00

Service Code	HCPCS 73223 RT
Hospital Charge Code	3750267
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 UE Joint w/ + w/o Contrast Right

Facility

$2,062.00

Service Code	HCPCS 73223 RT
Hospital Charge Code	3750267
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 UE Non Joint w/ Contrast Lt

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 UE Non Joint w/ Contrast Lt

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 UE Non Joint w/ Contrast Rt

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 UE Non Joint w/ Contrast Rt

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 UE Non Joint w/o Contrast Lt

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 UE Non Joint w/o Contrast Lt

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 UE Non Joint w/o Contrast Rt

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 UE Non Joint w/o Contrast Rt

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 UE Non Joint w/ + w/o Contrast Lt

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 UE Non Joint w/ + w/o Contrast Lt

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

Know your out-of-pocket cost for care.

All Charges