RC 404
Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
PET IMAGE W/CT FULL BODY
Smithville, TX
See all hospitals reporting RC 404 →Price type
Ascension Seton’s median price of $3.8k is 25% above the median hospital's median price ($3.0k), higher than 66% of the 1,496 hospitals reporting RC 404. The highlighted bar is where this hospital falls; shaded is the middle 50% of hospitals.
Negotiated rates from the hospital’s own file: 13 payers, 100 plan rates. A facility fee, a professional fee, a per diem and a case rate are different bills, so each is listed on its own. Open a payer to see it across hospitals.
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| # | |||||||
|---|---|---|---|---|---|---|---|
| 1 | Aetna 4658_medicare advantage aetna (smv) 20250811 percent of total billed charges · outpatientfrom % of charges | $568 | $568 | — | — | — | $568 – $568 |
| 2 | Devoted 4920_medicare advantage devoted health smv 20250811 percent of total billed charges · inpatientfrom % of charges | $568 | $568 | — | — | — | $568 – $568 |
| 3 | Humana 4663_medicare advantage humana (smv) 20250811 percent of total billed charges · outpatientfrom % of charges | $568 | $568 | — | — | — | $568 – $568 |
| 4 | Tricare 4964_tricare smv 20280811 percent of total billed charges · outpatientfrom % of charges | $568 | $568 | — | — | — | $568 – $568 |
| 5 | UnitedHealthcare 4689_medicare advantage united healthcare (smv) 20250811 percent of total billed charges · outpatientfrom % of charges | $568 | $568 | — | — | — | $568 – $568 |
| 6 | WellCare 4690_medicare advantage wellcare (smv) 20250811 percent of total billed charges · outpatientfrom % of charges | $568 | $568 | — | — | — | $568 – $568 |
| 7 | Oscar 4511_oscar health plan 20251001 per diem · outpatient | $1.3k | $1.3k | — | — | — | $1.3k – $1.3k |
| 8 | Blue Cross Blue Shield 4093_blue cross blue shield bav exchange (chi,dcn) 20250101 percent of total billed charges · outpatientfrom % of charges | $1.8k | $1.8k | — | — | — | $1.8k – $1.8k |
| 9 | UnitedHealthcare 4501_united healthcare nexus city hmo (aus,nw,sw,bas) 20250701 case rate · outpatient | $2.3k | $2.3k | — | — | — | $2.3k – $2.3k |
| 10 | UnitedHealthcare 4503_united healthcare nexus city hmo (wil,hays) 20250701 case rate · outpatient | $2.3k | $2.3k | — | — | — | $2.3k – $2.3k |
| 11 | UnitedHealthcare 4504_united healthcare nexus city ppo (aus,nw,sw,bas) 20250401 case rate · outpatient | $2.3k | $2.3k | — | — | — | $2.3k – $2.3k |
| 12 | UnitedHealthcare 4506_united healthcare nexus city ppo (wil,hays) 20250701 case rate · outpatient | $2.3k | $2.3k | — | — | — | $2.3k – $2.3k |
| 13 | UnitedHealthcare 4507_united healthcare standard nexus aco (aus,nw,sw,bas) 20250701 case rate · outpatient | $2.3k | $2.3k | — | — | — | $2.3k – $2.3k |
| 14 | UnitedHealthcare 4509_united healthcare standard nexus aco (wil,hays) 20250701 case rate · outpatient | $2.3k | $2.3k | — | — | — | $2.3k – $2.3k |
| 15 | Aetna 3438_aetna aco ppo 20240701 percent of total billed charges · outpatientfrom % of charges | $2.4k | $2.4k | — | — | — | $2.4k – $2.4k |
| 16 | Aetna 249_aetna ppo exchange 20140101 percent of total billed charges · outpatientfrom % of charges | $2.5k | $2.5k | — | — | — | $2.5k – $2.5k |
| 17 | Aetna 3426_aetna sha aisd (smv) 20240701 percent of total billed charges · outpatientfrom % of charges | $2.6k | $2.6k | — | — | — | $2.6k – $2.6k |
| 18 | Aetna 4495_aetna aco hmo (smv) 20250801 percent of total billed charges · outpatientfrom % of charges | $2.6k | $2.6k | — | — | — | $2.6k – $2.6k |
| 19 | Aetna 1377_aetna hmo exchange 20200101 case rate · outpatient | $2.8k | $2.8k | — | — | — | $2.8k – $2.8k |
| 20 | Aetna 4496_aetna multi-tier whole health (smv) 20250801 percent of total billed charges · outpatientfrom % of charges | $2.8k | $2.8k | — | — | — | $2.8k – $2.8k |
| 21 | Humana 387_humana exchange 20160101 percent of total billed charges · outpatientfrom % of charges | $2.8k | $2.8k | — | — | — | $2.8k – $2.8k |
| 22 | UnitedHealthcare 4498_united healthcare (aus,nw,sw, bas) 20250701 per diem · outpatient | $2.9k | $2.9k | — | — | — | $2.9k – $2.9k |
| 23 | UnitedHealthcare 4500_united healthcare (wil,hays) 20250701 per diem · outpatient | $2.9k | $2.9k | — | — | — | $2.9k – $2.9k |
| 24 | Aetna 4488_aetna ppo 20250801 percent of total billed charges · outpatientfrom % of charges | $2.9k | $2.9k | — | — | — | $2.9k – $2.9k |
| 25 | Humana 206_humana hmo custom 20140201 percent of total billed charges · outpatientfrom % of charges | $3.0k | $3.0k | — | — | — | $3.0k – $3.0k |
Last updated: Jan 1, 2026
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