|
EST PT HCY AGE 12 - 17
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
9499394
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$139.12 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$139.12
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$167.79
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.75
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 12 - 17
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
9899394
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$211.50
|
|
|
EST PT HCY AGE 12 - 17
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
9899394
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$139.12 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$139.12
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$167.79
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.75
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 12 - 17
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
9499394
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$211.50
|
|
|
EST PT HCY AGE 12 - 17
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
9299394
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$211.50
|
|
|
EST PT HCY AGE 12-17
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
5499394
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$139.12 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$139.12
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$167.79
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.75
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 12-17
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
5499394
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$211.50
|
|
|
EST PT HCY AGE 1 - 4
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
9299392
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$198.00
|
|
|
EST PT HCY AGE 1 - 4
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
5499392
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$130.24 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$130.24
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$157.08
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$146.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 1 - 4
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
9899392
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$198.00
|
|
|
EST PT HCY AGE 1 - 4
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
9499392
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$130.24 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$130.24
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$157.08
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$146.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 1 - 4
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
9499392
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$198.00
|
|
|
EST PT HCY AGE 1 - 4
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
9899392
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$130.24 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$130.24
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$157.08
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$146.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 1 - 4
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
5499392
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$198.00
|
|
|
EST PT HCY AGE 1 - 4
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
9299392
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$130.24 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$130.24
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$157.08
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$146.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 1-4
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
4199392
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$198.00
|
|
|
EST PT HCY AGE 1-4
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
4199392
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$130.24 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$130.24
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$157.08
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$146.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 18-39
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
5499395
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$229.50
|
|
|
EST PT HCY AGE 18-39
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
5499395
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$150.96 |
| Max. Negotiated Rate |
$182.07 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$150.96
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$182.07
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$170.09
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 40-64
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
5499396
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$168.72 |
| Max. Negotiated Rate |
$203.49 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$168.72
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$203.49
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$190.09
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 40-64
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
5499396
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$256.50
|
|
|
EST PT HCY AGE 5 - 11
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9299393
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$130.24 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$130.24
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$157.08
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$146.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 5 - 11
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9899393
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$198.00
|
|
|
EST PT HCY AGE 5 - 11
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9499393
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$130.24 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$130.24
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$157.08
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$146.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
EST PT HCY AGE 5 - 11
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9899393
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$130.24 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$130.24
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$157.08
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$146.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
