|
CT Sacroplasty Bilat 2 or more needles
|
Facility
|
OP
|
$21,024.00
|
|
|
Service Code
|
HCPCS 0201T
|
| Hospital Charge Code |
5052898
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,892.16 |
| Max. Negotiated Rate |
$15,408.22 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,892.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Amerigroup Medicare |
$7,289.28
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9,989.86
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11,963.90
|
| Rate for Payer: BCBS of TX Medicare |
$7,289.28
|
| Rate for Payer: BCBS of TX PPO |
$15,074.51
|
| Rate for Payer: Cash Price |
$14,296.32
|
| Rate for Payer: Cash Price |
$14,296.32
|
| Rate for Payer: Cash Price |
$14,296.32
|
| Rate for Payer: Cigna Commercial |
$15,408.22
|
| Rate for Payer: Cigna Medicaid |
$15,137.28
|
| Rate for Payer: Cigna Medicare |
$7,289.28
|
| Rate for Payer: Employer Direct Commercial |
$7,289.28
|
| Rate for Payer: Humana Medicare/TRICARE |
$7,289.28
|
| Rate for Payer: Molina CHIP/Medicaid |
$15,137.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Molina Medicare |
$7,289.28
|
| Rate for Payer: Multiplan Auto |
$10,000.00
|
| Rate for Payer: Multiplan Commercial |
$10,000.00
|
| Rate for Payer: Multiplan Workers Comp |
$10,000.00
|
| Rate for Payer: Parkland Medicaid |
$15,137.28
|
| Rate for Payer: Scott and White EPO/PPO |
$10,512.00
|
| Rate for Payer: Scott and White Medicare |
$7,289.28
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$15,137.28
|
| Rate for Payer: Superior Health Plan EPO |
$7,289.28
|
| Rate for Payer: Superior Health Plan Medicare |
$7,289.28
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Universal American Medicare |
$7,289.28
|
| Rate for Payer: Wellcare Medicare |
$7,289.28
|
| Rate for Payer: Wellmed Medicare |
$7,289.28
|
|
|
CT Sacroplasty Bilat 2 or more needles
|
Facility
|
OP
|
$21,024.00
|
|
|
Service Code
|
HCPCS 0201T
|
| Hospital Charge Code |
4612011
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,892.16 |
| Max. Negotiated Rate |
$15,408.22 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,892.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Amerigroup Medicare |
$7,289.28
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9,989.86
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11,963.90
|
| Rate for Payer: BCBS of TX Medicare |
$7,289.28
|
| Rate for Payer: BCBS of TX PPO |
$15,074.51
|
| Rate for Payer: Cash Price |
$14,296.32
|
| Rate for Payer: Cash Price |
$14,296.32
|
| Rate for Payer: Cash Price |
$14,296.32
|
| Rate for Payer: Cigna Commercial |
$15,408.22
|
| Rate for Payer: Cigna Medicaid |
$15,137.28
|
| Rate for Payer: Cigna Medicare |
$7,289.28
|
| Rate for Payer: Employer Direct Commercial |
$7,289.28
|
| Rate for Payer: Humana Medicare/TRICARE |
$7,289.28
|
| Rate for Payer: Molina CHIP/Medicaid |
$15,137.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Molina Medicare |
$7,289.28
|
| Rate for Payer: Multiplan Auto |
$10,000.00
|
| Rate for Payer: Multiplan Commercial |
$10,000.00
|
| Rate for Payer: Multiplan Workers Comp |
$10,000.00
|
| Rate for Payer: Parkland Medicaid |
$15,137.28
|
| Rate for Payer: Scott and White EPO/PPO |
$10,512.00
|
| Rate for Payer: Scott and White Medicare |
$7,289.28
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$15,137.28
|
| Rate for Payer: Superior Health Plan EPO |
$7,289.28
|
| Rate for Payer: Superior Health Plan Medicare |
$7,289.28
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Universal American Medicare |
$7,289.28
|
| Rate for Payer: Wellcare Medicare |
$7,289.28
|
| Rate for Payer: Wellmed Medicare |
$7,289.28
|
|
|
CT Sacroplasty Unilat 1 or more needles
|
Facility
|
OP
|
$14,016.00
|
|
|
Service Code
|
HCPCS 0200T
|
| Hospital Charge Code |
4610200
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,261.44 |
| Max. Negotiated Rate |
$15,408.22 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,261.44
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Amerigroup Medicare |
$7,289.28
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9,989.86
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11,963.90
|
| Rate for Payer: BCBS of TX Medicare |
$7,289.28
|
| Rate for Payer: BCBS of TX PPO |
$15,074.51
|
| Rate for Payer: Cash Price |
$9,530.88
|
| Rate for Payer: Cash Price |
$9,530.88
|
| Rate for Payer: Cash Price |
$9,530.88
|
| Rate for Payer: Cigna Commercial |
$15,408.22
|
| Rate for Payer: Cigna Medicaid |
$10,091.52
|
| Rate for Payer: Cigna Medicare |
$7,289.28
|
| Rate for Payer: Employer Direct Commercial |
$7,289.28
|
| Rate for Payer: Humana Medicare/TRICARE |
$7,289.28
|
| Rate for Payer: Molina CHIP/Medicaid |
$10,091.52
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Molina Medicare |
$7,289.28
|
| Rate for Payer: Multiplan Auto |
$10,000.00
|
| Rate for Payer: Multiplan Commercial |
$10,000.00
|
| Rate for Payer: Multiplan Workers Comp |
$10,000.00
|
| Rate for Payer: Parkland Medicaid |
$10,091.52
|
| Rate for Payer: Scott and White EPO/PPO |
$7,008.00
|
| Rate for Payer: Scott and White Medicare |
$7,289.28
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$10,091.52
|
| Rate for Payer: Superior Health Plan EPO |
$7,289.28
|
| Rate for Payer: Superior Health Plan Medicare |
$7,289.28
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Universal American Medicare |
$7,289.28
|
| Rate for Payer: Wellcare Medicare |
$7,289.28
|
| Rate for Payer: Wellmed Medicare |
$7,289.28
|
|
|
CT Sacroplasty Unilat 1 or more needles
|
Facility
|
IP
|
$14,016.00
|
|
|
Service Code
|
HCPCS 0200T
|
| Hospital Charge Code |
4610200
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$9,530.88
|
|
|
CT Shoulder w/ Contrast Left
|
Facility
|
OP
|
$3,312.00
|
|
|
Service Code
|
HCPCS 73201 LT
|
| Hospital Charge Code |
3800281
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$206.49 |
| Max. Negotiated Rate |
$2,384.64 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$206.49
|
| Rate for Payer: BCBS of TX Blue Advantage |
$630.05
|
| Rate for Payer: BCBS of TX Blue Essentials |
$756.06
|
| Rate for Payer: BCBS of TX PPO |
$843.89
|
| Rate for Payer: Cash Price |
$2,252.16
|
| Rate for Payer: Cash Price |
$2,252.16
|
| Rate for Payer: Cash Price |
$2,252.16
|
| Rate for Payer: Cigna Commercial |
$740.81
|
| Rate for Payer: Cigna Medicaid |
$2,384.64
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,384.64
|
| Rate for Payer: Multiplan Auto |
$2,152.80
|
| Rate for Payer: Multiplan Commercial |
$2,152.80
|
| Rate for Payer: Multiplan Workers Comp |
$2,152.80
|
| Rate for Payer: Parkland Medicaid |
$2,384.64
|
| Rate for Payer: Scott and White EPO/PPO |
$1,656.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,384.64
|
| Rate for Payer: Superior Health Plan EPO |
$450.43
|
|
|
CT Shoulder w/ Contrast Left
|
Facility
|
IP
|
$3,312.00
|
|
|
Service Code
|
HCPCS 73201 LT
|
| Hospital Charge Code |
3800281
|
|
Hospital Revenue Code
|
352
|
| Rate for Payer: Cash Price |
$2,252.16
|
|
|
CT Shoulder w/ Contrast Right
|
Facility
|
OP
|
$3,312.00
|
|
|
Service Code
|
HCPCS 73201 RT
|
| Hospital Charge Code |
3801842
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$206.49 |
| Max. Negotiated Rate |
$2,384.64 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$206.49
|
| Rate for Payer: BCBS of TX Blue Advantage |
$630.05
|
| Rate for Payer: BCBS of TX Blue Essentials |
$756.06
|
| Rate for Payer: BCBS of TX PPO |
$843.89
|
| Rate for Payer: Cash Price |
$2,252.16
|
| Rate for Payer: Cash Price |
$2,252.16
|
| Rate for Payer: Cash Price |
$2,252.16
|
| Rate for Payer: Cigna Commercial |
$740.81
|
| Rate for Payer: Cigna Medicaid |
$2,384.64
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,384.64
|
| Rate for Payer: Multiplan Auto |
$2,152.80
|
| Rate for Payer: Multiplan Commercial |
$2,152.80
|
| Rate for Payer: Multiplan Workers Comp |
$2,152.80
|
| Rate for Payer: Parkland Medicaid |
$2,384.64
|
| Rate for Payer: Scott and White EPO/PPO |
$1,656.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,384.64
|
| Rate for Payer: Superior Health Plan EPO |
$450.43
|
|
|
CT Shoulder w/ Contrast Right
|
Facility
|
IP
|
$3,312.00
|
|
|
Service Code
|
HCPCS 73201 RT
|
| Hospital Charge Code |
3801842
|
|
Hospital Revenue Code
|
352
|
| Rate for Payer: Cash Price |
$2,252.16
|
|
|
CT Shoulder w/o Contrast Left
|
Facility
|
OP
|
$1,788.00
|
|
|
Service Code
|
HCPCS 73200 LT
|
| Hospital Charge Code |
3800943
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$104.75 |
| Max. Negotiated Rate |
$1,287.36 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$104.75
|
| Rate for Payer: BCBS of TX Blue Advantage |
$184.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$221.92
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$1,215.84
|
| Rate for Payer: Cash Price |
$1,215.84
|
| Rate for Payer: Cash Price |
$1,215.84
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$1,287.36
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,287.36
|
| Rate for Payer: Multiplan Auto |
$1,162.20
|
| Rate for Payer: Multiplan Commercial |
$1,162.20
|
| Rate for Payer: Multiplan Workers Comp |
$1,162.20
|
| Rate for Payer: Parkland Medicaid |
$1,287.36
|
| Rate for Payer: Scott and White EPO/PPO |
$894.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,287.36
|
| Rate for Payer: Superior Health Plan EPO |
$243.17
|
|
|
CT Shoulder w/o Contrast Left
|
Facility
|
IP
|
$1,788.00
|
|
|
Service Code
|
HCPCS 73200 LT
|
| Hospital Charge Code |
3800943
|
|
Hospital Revenue Code
|
352
|
| Rate for Payer: Cash Price |
$1,215.84
|
|
|
CT Shoulder w/o Contrast Right
|
Facility
|
OP
|
$1,788.00
|
|
|
Service Code
|
HCPCS 73200 RT
|
| Hospital Charge Code |
3801834
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$104.75 |
| Max. Negotiated Rate |
$1,287.36 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$104.75
|
| Rate for Payer: BCBS of TX Blue Advantage |
$184.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$221.92
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$1,215.84
|
| Rate for Payer: Cash Price |
$1,215.84
|
| Rate for Payer: Cash Price |
$1,215.84
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$1,287.36
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,287.36
|
| Rate for Payer: Multiplan Auto |
$1,162.20
|
| Rate for Payer: Multiplan Commercial |
$1,162.20
|
| Rate for Payer: Multiplan Workers Comp |
$1,162.20
|
| Rate for Payer: Parkland Medicaid |
$1,287.36
|
| Rate for Payer: Scott and White EPO/PPO |
$894.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,287.36
|
| Rate for Payer: Superior Health Plan EPO |
$243.17
|
|
|
CT Shoulder w/o Contrast Right
|
Facility
|
IP
|
$1,788.00
|
|
|
Service Code
|
HCPCS 73200 RT
|
| Hospital Charge Code |
3801834
|
|
Hospital Revenue Code
|
352
|
| Rate for Payer: Cash Price |
$1,215.84
|
|
|
CT Sinus w/ + w/o Contrast
|
Facility
|
OP
|
$5,171.00
|
|
|
Service Code
|
HCPCS 70488
|
| Hospital Charge Code |
3840121
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$175.06 |
| Max. Negotiated Rate |
$3,723.12 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$175.06
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Amerigroup Medicare |
$176.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$300.66
|
| Rate for Payer: BCBS of TX Blue Essentials |
$360.80
|
| Rate for Payer: BCBS of TX Medicare |
$176.20
|
| Rate for Payer: BCBS of TX PPO |
$402.71
|
| Rate for Payer: Cash Price |
$3,516.28
|
| Rate for Payer: Cash Price |
$3,516.28
|
| Rate for Payer: Cash Price |
$3,516.28
|
| Rate for Payer: Cigna Commercial |
$372.46
|
| Rate for Payer: Cigna Medicaid |
$3,723.12
|
| Rate for Payer: Cigna Medicare |
$176.20
|
| Rate for Payer: Employer Direct Commercial |
$176.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$176.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$3,723.12
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Molina Medicare |
$176.20
|
| Rate for Payer: Multiplan Auto |
$3,361.15
|
| Rate for Payer: Multiplan Commercial |
$3,361.15
|
| Rate for Payer: Multiplan Workers Comp |
$3,361.15
|
| Rate for Payer: Parkland Medicaid |
$3,723.12
|
| Rate for Payer: Scott and White EPO/PPO |
$2,585.50
|
| Rate for Payer: Scott and White Medicare |
$176.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$3,723.12
|
| Rate for Payer: Superior Health Plan EPO |
$176.20
|
| Rate for Payer: Superior Health Plan Medicare |
$176.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Universal American Medicare |
$176.20
|
| Rate for Payer: Wellcare Medicare |
$176.20
|
| Rate for Payer: Wellmed Medicare |
$176.20
|
|
|
CT Sinus w/ + w/o Contrast
|
Facility
|
IP
|
$5,171.00
|
|
|
Service Code
|
HCPCS 70488
|
| Hospital Charge Code |
3840121
|
|
Hospital Revenue Code
|
351
|
| Rate for Payer: Cash Price |
$3,516.28
|
|
|
Ct-Smac With Cefixime and Tellurite, For E. Coli O157, 15 x 100 mm Plate
|
Facility
|
OP
|
$8.71
|
|
| Hospital Charge Code |
993356
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$6.27 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.78
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.61
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3.14
|
| Rate for Payer: BCBS of TX PPO |
$3.48
|
| Rate for Payer: Cash Price |
$5.92
|
| Rate for Payer: Cigna Medicaid |
$6.27
|
| Rate for Payer: Molina CHIP/Medicaid |
$6.27
|
| Rate for Payer: Multiplan Auto |
$5.66
|
| Rate for Payer: Multiplan Commercial |
$5.66
|
| Rate for Payer: Multiplan Workers Comp |
$5.66
|
| Rate for Payer: Parkland Medicaid |
$6.27
|
| Rate for Payer: Scott and White EPO/PPO |
$4.36
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$6.27
|
| Rate for Payer: Superior Health Plan EPO |
$1.18
|
|
|
Ct-Smac With Cefixime and Tellurite, For E. Coli O157, 15 x 100 mm Plate
|
Facility
|
IP
|
$8.71
|
|
| Hospital Charge Code |
993356
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$5.92
|
|
|
CT Spine Cervical w/ Contrast
|
Facility
|
OP
|
$6,442.00
|
|
|
Service Code
|
HCPCS 72126
|
| Hospital Charge Code |
3800273
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$173.41 |
| Max. Negotiated Rate |
$4,638.24 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$173.41
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Amerigroup Medicare |
$350.46
|
| Rate for Payer: BCBS of TX Blue Advantage |
$630.05
|
| Rate for Payer: BCBS of TX Blue Essentials |
$756.06
|
| Rate for Payer: BCBS of TX Medicare |
$350.46
|
| Rate for Payer: BCBS of TX PPO |
$843.89
|
| Rate for Payer: Cash Price |
$4,380.56
|
| Rate for Payer: Cash Price |
$4,380.56
|
| Rate for Payer: Cash Price |
$4,380.56
|
| Rate for Payer: Cigna Commercial |
$740.81
|
| Rate for Payer: Cigna Medicaid |
$4,638.24
|
| Rate for Payer: Cigna Medicare |
$350.46
|
| Rate for Payer: Employer Direct Commercial |
$350.46
|
| Rate for Payer: Humana Medicare/TRICARE |
$350.46
|
| Rate for Payer: Molina CHIP/Medicaid |
$4,638.24
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Molina Medicare |
$350.46
|
| Rate for Payer: Multiplan Auto |
$4,187.30
|
| Rate for Payer: Multiplan Commercial |
$4,187.30
|
| Rate for Payer: Multiplan Workers Comp |
$4,187.30
|
| Rate for Payer: Parkland Medicaid |
$4,638.24
|
| Rate for Payer: Scott and White EPO/PPO |
$3,221.00
|
| Rate for Payer: Scott and White Medicare |
$350.46
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$4,638.24
|
| Rate for Payer: Superior Health Plan EPO |
$350.46
|
| Rate for Payer: Superior Health Plan Medicare |
$350.46
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Universal American Medicare |
$350.46
|
| Rate for Payer: Wellcare Medicare |
$350.46
|
| Rate for Payer: Wellmed Medicare |
$350.46
|
|
|
CT Spine Cervical w/ Contrast
|
Facility
|
IP
|
$6,442.00
|
|
|
Service Code
|
HCPCS 72126
|
| Hospital Charge Code |
3800273
|
|
Hospital Revenue Code
|
352
|
| Rate for Payer: Cash Price |
$4,380.56
|
|
|
CT Spine Cervical w/o Contrast
|
Facility
|
IP
|
$5,916.00
|
|
|
Service Code
|
HCPCS 72125
|
| Hospital Charge Code |
3800133
|
|
Hospital Revenue Code
|
352
|
| Rate for Payer: Cash Price |
$4,022.88
|
|
|
CT Spine Cervical w/o Contrast
|
Facility
|
OP
|
$5,916.00
|
|
|
Service Code
|
HCPCS 72125
|
| Hospital Charge Code |
3800133
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$104.75 |
| Max. Negotiated Rate |
$4,259.52 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$104.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| Rate for Payer: BCBS of TX Blue Advantage |
$184.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$221.92
|
| Rate for Payer: BCBS of TX Medicare |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$4,022.88
|
| Rate for Payer: Cash Price |
$4,022.88
|
| Rate for Payer: Cash Price |
$4,022.88
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$4,259.52
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$4,259.52
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$3,845.40
|
| Rate for Payer: Multiplan Commercial |
$3,845.40
|
| Rate for Payer: Multiplan Workers Comp |
$3,845.40
|
| Rate for Payer: Parkland Medicaid |
$4,259.52
|
| Rate for Payer: Scott and White EPO/PPO |
$2,958.00
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$4,259.52
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
CT Spine Lumbar w/ Contrast
|
Facility
|
OP
|
$6,598.00
|
|
|
Service Code
|
HCPCS 72132
|
| Hospital Charge Code |
3800901
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$173.75 |
| Max. Negotiated Rate |
$4,750.56 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$173.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Amerigroup Medicare |
$350.46
|
| Rate for Payer: BCBS of TX Blue Advantage |
$630.05
|
| Rate for Payer: BCBS of TX Blue Essentials |
$756.06
|
| Rate for Payer: BCBS of TX Medicare |
$350.46
|
| Rate for Payer: BCBS of TX PPO |
$843.89
|
| Rate for Payer: Cash Price |
$4,486.64
|
| Rate for Payer: Cash Price |
$4,486.64
|
| Rate for Payer: Cash Price |
$4,486.64
|
| Rate for Payer: Cigna Commercial |
$740.81
|
| Rate for Payer: Cigna Medicaid |
$4,750.56
|
| Rate for Payer: Cigna Medicare |
$350.46
|
| Rate for Payer: Employer Direct Commercial |
$350.46
|
| Rate for Payer: Humana Medicare/TRICARE |
$350.46
|
| Rate for Payer: Molina CHIP/Medicaid |
$4,750.56
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Molina Medicare |
$350.46
|
| Rate for Payer: Multiplan Auto |
$4,288.70
|
| Rate for Payer: Multiplan Commercial |
$4,288.70
|
| Rate for Payer: Multiplan Workers Comp |
$4,288.70
|
| Rate for Payer: Parkland Medicaid |
$4,750.56
|
| Rate for Payer: Scott and White EPO/PPO |
$3,299.00
|
| Rate for Payer: Scott and White Medicare |
$350.46
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$4,750.56
|
| Rate for Payer: Superior Health Plan EPO |
$350.46
|
| Rate for Payer: Superior Health Plan Medicare |
$350.46
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Universal American Medicare |
$350.46
|
| Rate for Payer: Wellcare Medicare |
$350.46
|
| Rate for Payer: Wellmed Medicare |
$350.46
|
|
|
CT Spine Lumbar w/ Contrast
|
Facility
|
IP
|
$6,598.00
|
|
|
Service Code
|
HCPCS 72132
|
| Hospital Charge Code |
3800901
|
|
Hospital Revenue Code
|
352
|
| Rate for Payer: Cash Price |
$4,486.64
|
|
|
CT Spine Lumbar w/o Contrast
|
Facility
|
OP
|
$5,120.00
|
|
|
Service Code
|
HCPCS 72131
|
| Hospital Charge Code |
3800893
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$104.75 |
| Max. Negotiated Rate |
$3,686.40 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$104.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| Rate for Payer: BCBS of TX Blue Advantage |
$184.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$221.92
|
| Rate for Payer: BCBS of TX Medicare |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$3,481.60
|
| Rate for Payer: Cash Price |
$3,481.60
|
| Rate for Payer: Cash Price |
$3,481.60
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$3,686.40
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$3,686.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$3,328.00
|
| Rate for Payer: Multiplan Commercial |
$3,328.00
|
| Rate for Payer: Multiplan Workers Comp |
$3,328.00
|
| Rate for Payer: Parkland Medicaid |
$3,686.40
|
| Rate for Payer: Scott and White EPO/PPO |
$2,560.00
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$3,686.40
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
CT Spine Lumbar w/o Contrast
|
Facility
|
IP
|
$5,120.00
|
|
|
Service Code
|
HCPCS 72131
|
| Hospital Charge Code |
3800893
|
|
Hospital Revenue Code
|
352
|
| Rate for Payer: Cash Price |
$3,481.60
|
|
|
CT Spine Lumbar w/ + w/o Contrast
|
Facility
|
OP
|
$6,928.00
|
|
|
Service Code
|
HCPCS 72133
|
| Hospital Charge Code |
3800919
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$175.06 |
| Max. Negotiated Rate |
$4,988.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$175.06
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Amerigroup Medicare |
$176.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$300.66
|
| Rate for Payer: BCBS of TX Blue Essentials |
$360.80
|
| Rate for Payer: BCBS of TX Medicare |
$176.20
|
| Rate for Payer: BCBS of TX PPO |
$402.71
|
| Rate for Payer: Cash Price |
$4,711.04
|
| Rate for Payer: Cash Price |
$4,711.04
|
| Rate for Payer: Cash Price |
$4,711.04
|
| Rate for Payer: Cigna Commercial |
$372.46
|
| Rate for Payer: Cigna Medicaid |
$4,988.16
|
| Rate for Payer: Cigna Medicare |
$176.20
|
| Rate for Payer: Employer Direct Commercial |
$176.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$176.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$4,988.16
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Molina Medicare |
$176.20
|
| Rate for Payer: Multiplan Auto |
$4,503.20
|
| Rate for Payer: Multiplan Commercial |
$4,503.20
|
| Rate for Payer: Multiplan Workers Comp |
$4,503.20
|
| Rate for Payer: Parkland Medicaid |
$4,988.16
|
| Rate for Payer: Scott and White EPO/PPO |
$3,464.00
|
| Rate for Payer: Scott and White Medicare |
$176.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$4,988.16
|
| Rate for Payer: Superior Health Plan EPO |
$176.20
|
| Rate for Payer: Superior Health Plan Medicare |
$176.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Universal American Medicare |
$176.20
|
| Rate for Payer: Wellcare Medicare |
$176.20
|
| Rate for Payer: Wellmed Medicare |
$176.20
|
|
