|
DESTINATION 6FR 65CN STRAIGHT CCV 35CM
|
Facility
|
OP
|
$547.71
|
|
| Hospital Charge Code |
993906
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.29 |
| Max. Negotiated Rate |
$394.35 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$49.29
|
| Rate for Payer: BCBS of TX Blue Advantage |
$164.31
|
| Rate for Payer: BCBS of TX Blue Essentials |
$197.18
|
| Rate for Payer: BCBS of TX PPO |
$219.08
|
| Rate for Payer: Cash Price |
$372.44
|
| Rate for Payer: Cigna Medicaid |
$394.35
|
| Rate for Payer: Molina CHIP/Medicaid |
$394.35
|
| Rate for Payer: Multiplan Auto |
$356.01
|
| Rate for Payer: Multiplan Commercial |
$356.01
|
| Rate for Payer: Multiplan Workers Comp |
$356.01
|
| Rate for Payer: Parkland Medicaid |
$394.35
|
| Rate for Payer: Scott and White EPO/PPO |
$273.86
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$394.35
|
| Rate for Payer: Superior Health Plan EPO |
$74.49
|
|
|
DESTINATION 6FR 65CN STRAIGHT CCV 35CM
|
Facility
|
IP
|
$547.71
|
|
| Hospital Charge Code |
993906
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$372.44
|
|
|
Destroy lumb/sac facet jnt
|
Facility
|
IP
|
$17,576.65
|
|
|
Service Code
|
HCPCS 64635
|
| Hospital Charge Code |
9900830
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$11,952.12
|
|
|
Destroy lumb/sac facet jnt
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64635
|
| Hospital Charge Code |
36064635
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$659.94 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$659.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Amerigroup Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,871.31
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,438.70
|
| Rate for Payer: BCBS of TX Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX PPO |
$4,332.76
|
| Rate for Payer: Cigna Commercial |
$4,146.52
|
| Rate for Payer: Cigna Medicare |
$1,961.62
|
| Rate for Payer: Employer Direct Commercial |
$1,961.62
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,961.62
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Molina Medicare |
$1,961.62
|
| 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: Scott and White EPO/PPO |
$3,266.71
|
| Rate for Payer: Scott and White Medicare |
$1,961.62
|
| Rate for Payer: Superior Health Plan EPO |
$1,961.62
|
| Rate for Payer: Superior Health Plan Medicare |
$1,961.62
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Universal American Medicare |
$1,961.62
|
| Rate for Payer: Wellcare Medicare |
$1,961.62
|
| Rate for Payer: Wellmed Medicare |
$1,961.62
|
|
|
Destroy lumb/sac facet jnt
|
Facility
|
OP
|
$17,576.65
|
|
|
Service Code
|
HCPCS 64635
|
| Hospital Charge Code |
9900830
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$659.94 |
| Max. Negotiated Rate |
$12,655.19 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$659.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Amerigroup Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,871.31
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,438.70
|
| Rate for Payer: BCBS of TX Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX PPO |
$4,332.76
|
| Rate for Payer: Cash Price |
$11,952.12
|
| Rate for Payer: Cash Price |
$11,952.12
|
| Rate for Payer: Cash Price |
$11,952.12
|
| Rate for Payer: Cigna Commercial |
$4,146.52
|
| Rate for Payer: Cigna Medicaid |
$12,655.19
|
| Rate for Payer: Cigna Medicare |
$1,961.62
|
| Rate for Payer: Employer Direct Commercial |
$1,961.62
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,961.62
|
| Rate for Payer: Molina CHIP/Medicaid |
$12,655.19
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Molina Medicare |
$1,961.62
|
| 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 |
$12,655.19
|
| Rate for Payer: Scott and White EPO/PPO |
$3,266.71
|
| Rate for Payer: Scott and White Medicare |
$1,961.62
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$12,655.19
|
| Rate for Payer: Superior Health Plan EPO |
$1,961.62
|
| Rate for Payer: Superior Health Plan Medicare |
$1,961.62
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Universal American Medicare |
$1,961.62
|
| Rate for Payer: Wellcare Medicare |
$1,961.62
|
| Rate for Payer: Wellmed Medicare |
$1,961.62
|
|
|
Destroy lumb/sac facet jnt addl lvl
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64636
|
| Hospital Charge Code |
36064636
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$71.33 |
| Max. Negotiated Rate |
$10,000.00 |
| 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: Scott and White EPO/PPO |
$71.33
|
|
|
Destroy lumb/sac facet jnt addl lvl
|
Facility
|
IP
|
$17,576.65
|
|
|
Service Code
|
HCPCS 64636
|
| Hospital Charge Code |
9900831
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$11,952.12
|
|
|
Destroy lumb/sac facet jnt addl lvl
|
Facility
|
OP
|
$17,576.65
|
|
|
Service Code
|
HCPCS 64636
|
| Hospital Charge Code |
9900831
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,581.90 |
| Max. Negotiated Rate |
$12,655.19 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,581.90
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,272.99
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,327.59
|
| Rate for Payer: BCBS of TX PPO |
$7,030.66
|
| Rate for Payer: Cash Price |
$11,952.12
|
| Rate for Payer: Cash Price |
$11,952.12
|
| Rate for Payer: Cigna Medicaid |
$12,655.19
|
| Rate for Payer: Molina CHIP/Medicaid |
$12,655.19
|
| 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 |
$12,655.19
|
| Rate for Payer: Scott and White EPO/PPO |
$8,788.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$12,655.19
|
| Rate for Payer: Superior Health Plan EPO |
$2,390.42
|
|
|
Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64624
|
| Hospital Charge Code |
36064624
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$532.18 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$659.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Amerigroup Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX Blue Advantage |
$532.18
|
| Rate for Payer: BCBS of TX Blue Essentials |
$637.34
|
| Rate for Payer: BCBS of TX Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX PPO |
$803.05
|
| Rate for Payer: Cigna Commercial |
$4,146.52
|
| Rate for Payer: Cigna Medicare |
$1,961.62
|
| Rate for Payer: Employer Direct Commercial |
$1,961.62
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,961.62
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Molina Medicare |
$1,961.62
|
| 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: Scott and White EPO/PPO |
$3,266.71
|
| Rate for Payer: Scott and White Medicare |
$1,961.62
|
| Rate for Payer: Superior Health Plan EPO |
$1,961.62
|
| Rate for Payer: Superior Health Plan Medicare |
$1,961.62
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Universal American Medicare |
$1,961.62
|
| Rate for Payer: Wellcare Medicare |
$1,961.62
|
| Rate for Payer: Wellmed Medicare |
$1,961.62
|
|
|
Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
|
Facility
|
IP
|
$9,210.80
|
|
|
Service Code
|
HCPCS 64624
|
| Hospital Charge Code |
9900823
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$6,263.34
|
|
|
Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
|
Facility
|
OP
|
$9,210.80
|
|
|
Service Code
|
HCPCS 64624
|
| Hospital Charge Code |
9900823
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$532.18 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$659.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Amerigroup Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX Blue Advantage |
$532.18
|
| Rate for Payer: BCBS of TX Blue Essentials |
$637.34
|
| Rate for Payer: BCBS of TX Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX PPO |
$803.05
|
| Rate for Payer: Cash Price |
$6,263.34
|
| Rate for Payer: Cash Price |
$6,263.34
|
| Rate for Payer: Cash Price |
$6,263.34
|
| Rate for Payer: Cigna Commercial |
$4,146.52
|
| Rate for Payer: Cigna Medicaid |
$6,631.78
|
| Rate for Payer: Cigna Medicare |
$1,961.62
|
| Rate for Payer: Employer Direct Commercial |
$1,961.62
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,961.62
|
| Rate for Payer: Molina CHIP/Medicaid |
$6,631.78
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Molina Medicare |
$1,961.62
|
| 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 |
$6,631.78
|
| Rate for Payer: Scott and White EPO/PPO |
$3,266.71
|
| Rate for Payer: Scott and White Medicare |
$1,961.62
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$6,631.78
|
| Rate for Payer: Superior Health Plan EPO |
$1,961.62
|
| Rate for Payer: Superior Health Plan Medicare |
$1,961.62
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Universal American Medicare |
$1,961.62
|
| Rate for Payer: Wellcare Medicare |
$1,961.62
|
| Rate for Payer: Wellmed Medicare |
$1,961.62
|
|
|
Destruction by neurolytic agent, intercostal nerve
|
Facility
|
IP
|
$2,467.38
|
|
|
Service Code
|
HCPCS 64620
|
| Hospital Charge Code |
9900822
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,677.82
|
|
|
Destruction by neurolytic agent, intercostal nerve
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64620
|
| Hospital Charge Code |
36064620
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$340.77 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$340.77
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Amerigroup Medicare |
$888.50
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,356.12
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,624.10
|
| Rate for Payer: BCBS of TX Medicare |
$888.50
|
| Rate for Payer: BCBS of TX PPO |
$2,046.37
|
| Rate for Payer: Cigna Commercial |
$1,878.13
|
| Rate for Payer: Cigna Medicare |
$888.50
|
| Rate for Payer: Employer Direct Commercial |
$888.50
|
| Rate for Payer: Humana Medicare/TRICARE |
$888.50
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Molina Medicare |
$888.50
|
| 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: Scott and White EPO/PPO |
$1,542.14
|
| Rate for Payer: Scott and White Medicare |
$888.50
|
| Rate for Payer: Superior Health Plan EPO |
$888.50
|
| Rate for Payer: Superior Health Plan Medicare |
$888.50
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Universal American Medicare |
$888.50
|
| Rate for Payer: Wellcare Medicare |
$888.50
|
| Rate for Payer: Wellmed Medicare |
$888.50
|
|
|
Destruction by neurolytic agent, intercostal nerve
|
Facility
|
OP
|
$2,467.38
|
|
|
Service Code
|
HCPCS 64620
|
| Hospital Charge Code |
9900822
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$340.77 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$340.77
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Amerigroup Medicare |
$888.50
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,356.12
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,624.10
|
| Rate for Payer: BCBS of TX Medicare |
$888.50
|
| Rate for Payer: BCBS of TX PPO |
$2,046.37
|
| Rate for Payer: Cash Price |
$1,677.82
|
| Rate for Payer: Cash Price |
$1,677.82
|
| Rate for Payer: Cash Price |
$1,677.82
|
| Rate for Payer: Cigna Commercial |
$1,878.13
|
| Rate for Payer: Cigna Medicaid |
$1,776.51
|
| Rate for Payer: Cigna Medicare |
$888.50
|
| Rate for Payer: Employer Direct Commercial |
$888.50
|
| Rate for Payer: Humana Medicare/TRICARE |
$888.50
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,776.51
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Molina Medicare |
$888.50
|
| 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 |
$1,776.51
|
| Rate for Payer: Scott and White EPO/PPO |
$1,542.14
|
| Rate for Payer: Scott and White Medicare |
$888.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,776.51
|
| Rate for Payer: Superior Health Plan EPO |
$888.50
|
| Rate for Payer: Superior Health Plan Medicare |
$888.50
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Universal American Medicare |
$888.50
|
| Rate for Payer: Wellcare Medicare |
$888.50
|
| Rate for Payer: Wellmed Medicare |
$888.50
|
|
|
Destruction by neurolytic agent other peripheral nerve or branch
|
Facility
|
OP
|
$2,467.38
|
|
|
Service Code
|
HCPCS 64640
|
| Hospital Charge Code |
9900832
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$145.34 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$145.34
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Amerigroup Medicare |
$888.50
|
| Rate for Payer: BCBS of TX Blue Advantage |
$294.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$352.96
|
| Rate for Payer: BCBS of TX Medicare |
$888.50
|
| Rate for Payer: BCBS of TX PPO |
$444.73
|
| Rate for Payer: Cash Price |
$1,677.82
|
| Rate for Payer: Cash Price |
$1,677.82
|
| Rate for Payer: Cash Price |
$1,677.82
|
| Rate for Payer: Cigna Commercial |
$1,878.13
|
| Rate for Payer: Cigna Medicaid |
$1,776.51
|
| Rate for Payer: Cigna Medicare |
$888.50
|
| Rate for Payer: Employer Direct Commercial |
$888.50
|
| Rate for Payer: Humana Medicare/TRICARE |
$888.50
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,776.51
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Molina Medicare |
$888.50
|
| 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 |
$1,776.51
|
| Rate for Payer: Scott and White EPO/PPO |
$1,542.14
|
| Rate for Payer: Scott and White Medicare |
$888.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,776.51
|
| Rate for Payer: Superior Health Plan EPO |
$888.50
|
| Rate for Payer: Superior Health Plan Medicare |
$888.50
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Universal American Medicare |
$888.50
|
| Rate for Payer: Wellcare Medicare |
$888.50
|
| Rate for Payer: Wellmed Medicare |
$888.50
|
|
|
Destruction by neurolytic agent other peripheral nerve or branch
|
Facility
|
IP
|
$2,467.38
|
|
|
Service Code
|
HCPCS 64640
|
| Hospital Charge Code |
9900832
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,677.82
|
|
|
Destruction by neurolytic agent other peripheral nerve or branch
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64640
|
| Hospital Charge Code |
36064640
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$145.34 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$145.34
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Amerigroup Medicare |
$888.50
|
| Rate for Payer: BCBS of TX Blue Advantage |
$294.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$352.96
|
| Rate for Payer: BCBS of TX Medicare |
$888.50
|
| Rate for Payer: BCBS of TX PPO |
$444.73
|
| Rate for Payer: Cigna Commercial |
$1,878.13
|
| Rate for Payer: Cigna Medicare |
$888.50
|
| Rate for Payer: Employer Direct Commercial |
$888.50
|
| Rate for Payer: Humana Medicare/TRICARE |
$888.50
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Molina Medicare |
$888.50
|
| 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: Scott and White EPO/PPO |
$1,542.14
|
| Rate for Payer: Scott and White Medicare |
$888.50
|
| Rate for Payer: Superior Health Plan EPO |
$888.50
|
| Rate for Payer: Superior Health Plan Medicare |
$888.50
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Universal American Medicare |
$888.50
|
| Rate for Payer: Wellcare Medicare |
$888.50
|
| Rate for Payer: Wellmed Medicare |
$888.50
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluorosc
|
Facility
|
IP
|
$17,548.57
|
|
|
Service Code
|
HCPCS 64633
|
| Hospital Charge Code |
9900828
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$11,933.03
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluorosc
|
Facility
|
IP
|
$17,548.57
|
|
|
Service Code
|
HCPCS 64634
|
| Hospital Charge Code |
9900829
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$11,933.03
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluorosc
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64634
|
| Hospital Charge Code |
36064634
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$81.55 |
| Max. Negotiated Rate |
$10,000.00 |
| 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: Scott and White EPO/PPO |
$81.55
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluorosc
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64633
|
| Hospital Charge Code |
36064633
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$659.94 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$659.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Amerigroup Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,871.31
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,438.70
|
| Rate for Payer: BCBS of TX Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX PPO |
$4,332.76
|
| Rate for Payer: Cigna Commercial |
$4,146.52
|
| Rate for Payer: Cigna Medicare |
$1,961.62
|
| Rate for Payer: Employer Direct Commercial |
$1,961.62
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,961.62
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Molina Medicare |
$1,961.62
|
| 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: Scott and White EPO/PPO |
$3,266.71
|
| Rate for Payer: Scott and White Medicare |
$1,961.62
|
| Rate for Payer: Superior Health Plan EPO |
$1,961.62
|
| Rate for Payer: Superior Health Plan Medicare |
$1,961.62
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Universal American Medicare |
$1,961.62
|
| Rate for Payer: Wellcare Medicare |
$1,961.62
|
| Rate for Payer: Wellmed Medicare |
$1,961.62
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluorosc
|
Facility
|
OP
|
$17,548.57
|
|
|
Service Code
|
HCPCS 64633
|
| Hospital Charge Code |
9900828
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$659.94 |
| Max. Negotiated Rate |
$12,634.97 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$659.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Amerigroup Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,871.31
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,438.70
|
| Rate for Payer: BCBS of TX Medicare |
$1,961.62
|
| Rate for Payer: BCBS of TX PPO |
$4,332.76
|
| Rate for Payer: Cash Price |
$11,933.03
|
| Rate for Payer: Cash Price |
$11,933.03
|
| Rate for Payer: Cash Price |
$11,933.03
|
| Rate for Payer: Cigna Commercial |
$4,146.52
|
| Rate for Payer: Cigna Medicaid |
$12,634.97
|
| Rate for Payer: Cigna Medicare |
$1,961.62
|
| Rate for Payer: Employer Direct Commercial |
$1,961.62
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,961.62
|
| Rate for Payer: Molina CHIP/Medicaid |
$12,634.97
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Molina Medicare |
$1,961.62
|
| 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 |
$12,634.97
|
| Rate for Payer: Scott and White EPO/PPO |
$3,266.71
|
| Rate for Payer: Scott and White Medicare |
$1,961.62
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$12,634.97
|
| Rate for Payer: Superior Health Plan EPO |
$1,961.62
|
| Rate for Payer: Superior Health Plan Medicare |
$1,961.62
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,961.62
|
| Rate for Payer: Universal American Medicare |
$1,961.62
|
| Rate for Payer: Wellcare Medicare |
$1,961.62
|
| Rate for Payer: Wellmed Medicare |
$1,961.62
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluorosc
|
Facility
|
OP
|
$17,548.57
|
|
|
Service Code
|
HCPCS 64634
|
| Hospital Charge Code |
9900829
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,579.37 |
| Max. Negotiated Rate |
$12,634.97 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,579.37
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,264.57
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,317.49
|
| Rate for Payer: BCBS of TX PPO |
$7,019.43
|
| Rate for Payer: Cash Price |
$11,933.03
|
| Rate for Payer: Cash Price |
$11,933.03
|
| Rate for Payer: Cigna Medicaid |
$12,634.97
|
| Rate for Payer: Molina CHIP/Medicaid |
$12,634.97
|
| 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 |
$12,634.97
|
| Rate for Payer: Scott and White EPO/PPO |
$8,774.28
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$12,634.97
|
| Rate for Payer: Superior Health Plan EPO |
$2,386.61
|
|
|
Destruction by neurolytic agent pudendal nerve
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64630
|
| Hospital Charge Code |
36064630
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$340.77 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$340.77
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Amerigroup Medicare |
$888.50
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,356.12
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,624.10
|
| Rate for Payer: BCBS of TX Medicare |
$888.50
|
| Rate for Payer: BCBS of TX PPO |
$2,046.37
|
| Rate for Payer: Cigna Commercial |
$1,878.13
|
| Rate for Payer: Cigna Medicare |
$888.50
|
| Rate for Payer: Employer Direct Commercial |
$888.50
|
| Rate for Payer: Humana Medicare/TRICARE |
$888.50
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Molina Medicare |
$888.50
|
| 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: Scott and White EPO/PPO |
$1,542.14
|
| Rate for Payer: Scott and White Medicare |
$888.50
|
| Rate for Payer: Superior Health Plan EPO |
$888.50
|
| Rate for Payer: Superior Health Plan Medicare |
$888.50
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$888.50
|
| Rate for Payer: Universal American Medicare |
$888.50
|
| Rate for Payer: Wellcare Medicare |
$888.50
|
| Rate for Payer: Wellmed Medicare |
$888.50
|
|
|
Destruction by neurolytic agent pudendal nerve
|
Facility
|
IP
|
$8,551.07
|
|
|
Service Code
|
HCPCS 64630
|
| Hospital Charge Code |
9900827
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$5,814.73
|
|
