|
MRI Lower Extremity Joint w + w/o Conttast Left BCE
|
Facility
|
IP
|
$5,347.00
|
|
|
Service Code
|
CPT 73723 LT
|
| Hospital Charge Code |
3750643
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$4,705.36
|
|
|
MRI Lower Extremity Joint w + w/o Conttast Right BCE
|
Facility
|
OP
|
$5,347.00
|
|
|
Service Code
|
CPT 73723 RT
|
| Hospital Charge Code |
3750833
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$368.43 |
| Max. Negotiated Rate |
$3,475.55 |
| Rate for Payer: Aetna Commercial |
$454.62
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$368.43
|
| 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 |
$4,705.36
|
| Rate for Payer: Cash Price |
$4,705.36
|
| Rate for Payer: Cash Price |
$4,705.36
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$368.43
|
| Rate for Payer: Molina CHIP/Medicaid |
$368.43
|
| Rate for Payer: Multiplan Auto |
$3,475.55
|
| Rate for Payer: Multiplan Commercial |
$3,475.55
|
| Rate for Payer: Multiplan Workers Comp |
$3,475.55
|
| Rate for Payer: Parkland Medicaid |
$368.43
|
| Rate for Payer: Scott and White EPO/PPO |
$2,673.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$368.43
|
| Rate for Payer: Superior Health Plan EPO |
$727.19
|
|
|
MRI Lower Extremity Joint w + w/o Conttast Right BCE
|
Facility
|
IP
|
$5,347.00
|
|
|
Service Code
|
CPT 73723 RT
|
| Hospital Charge Code |
3750833
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$4,705.36
|
|
|
MRI Lower Extremity Non Joint w/o Contrast Left BCE
|
Facility
|
OP
|
$3,635.00
|
|
|
Service Code
|
CPT 73718 LT
|
| Hospital Charge Code |
3750601
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$233.52 |
| Max. Negotiated Rate |
$2,362.75 |
| Rate for Payer: Aetna Commercial |
$252.33
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$233.52
|
| Rate for Payer: BCBS of TX Blue Advantage |
$384.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$461.42
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$3,198.80
|
| Rate for Payer: Cash Price |
$3,198.80
|
| Rate for Payer: Cash Price |
$3,198.80
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$233.52
|
| Rate for Payer: Molina CHIP/Medicaid |
$233.52
|
| Rate for Payer: Multiplan Auto |
$2,362.75
|
| Rate for Payer: Multiplan Commercial |
$2,362.75
|
| Rate for Payer: Multiplan Workers Comp |
$2,362.75
|
| Rate for Payer: Parkland Medicaid |
$233.52
|
| Rate for Payer: Scott and White EPO/PPO |
$1,817.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$233.52
|
| Rate for Payer: Superior Health Plan EPO |
$494.36
|
|
|
MRI Lower Extremity Non Joint w/o Contrast Right BCE
|
Facility
|
OP
|
$3,635.00
|
|
|
Service Code
|
CPT 73718 RT
|
| Hospital Charge Code |
3750619
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$233.52 |
| Max. Negotiated Rate |
$2,362.75 |
| Rate for Payer: Aetna Commercial |
$252.33
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$233.52
|
| Rate for Payer: BCBS of TX Blue Advantage |
$384.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$461.42
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$3,198.80
|
| Rate for Payer: Cash Price |
$3,198.80
|
| Rate for Payer: Cash Price |
$3,198.80
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$233.52
|
| Rate for Payer: Molina CHIP/Medicaid |
$233.52
|
| Rate for Payer: Multiplan Auto |
$2,362.75
|
| Rate for Payer: Multiplan Commercial |
$2,362.75
|
| Rate for Payer: Multiplan Workers Comp |
$2,362.75
|
| Rate for Payer: Parkland Medicaid |
$233.52
|
| Rate for Payer: Scott and White EPO/PPO |
$1,817.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$233.52
|
| Rate for Payer: Superior Health Plan EPO |
$494.36
|
|
|
MRI Lower Extremity Non Joint w/ +w/o Contrast Left BCE
|
Facility
|
OP
|
$4,568.00
|
|
|
Service Code
|
CPT 73720 LT
|
| Hospital Charge Code |
3700028
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$353.51 |
| Max. Negotiated Rate |
$2,969.20 |
| Rate for Payer: Aetna Commercial |
$375.10
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$353.51
|
| 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 |
$4,019.84
|
| Rate for Payer: Cash Price |
$4,019.84
|
| Rate for Payer: Cash Price |
$4,019.84
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$353.51
|
| Rate for Payer: Molina CHIP/Medicaid |
$353.51
|
| Rate for Payer: Multiplan Auto |
$2,969.20
|
| Rate for Payer: Multiplan Commercial |
$2,969.20
|
| Rate for Payer: Multiplan Workers Comp |
$2,969.20
|
| Rate for Payer: Parkland Medicaid |
$353.51
|
| Rate for Payer: Scott and White EPO/PPO |
$2,284.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$353.51
|
| Rate for Payer: Superior Health Plan EPO |
$621.25
|
|
|
MRI Lower Extremity Non Joint w/ +w/o Contrast Right BCE
|
Facility
|
OP
|
$4,568.00
|
|
|
Service Code
|
CPT 73720 RT
|
| Hospital Charge Code |
3700275
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$353.51 |
| Max. Negotiated Rate |
$2,969.20 |
| Rate for Payer: Aetna Commercial |
$375.10
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$353.51
|
| 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 |
$4,019.84
|
| Rate for Payer: Cash Price |
$4,019.84
|
| Rate for Payer: Cash Price |
$4,019.84
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$353.51
|
| Rate for Payer: Molina CHIP/Medicaid |
$353.51
|
| Rate for Payer: Multiplan Auto |
$2,969.20
|
| Rate for Payer: Multiplan Commercial |
$2,969.20
|
| Rate for Payer: Multiplan Workers Comp |
$2,969.20
|
| Rate for Payer: Parkland Medicaid |
$353.51
|
| Rate for Payer: Scott and White EPO/PPO |
$2,284.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$353.51
|
| Rate for Payer: Superior Health Plan EPO |
$621.25
|
|
|
MRI Pelvis w/ Contrast
|
Facility
|
OP
|
$5,770.00
|
|
|
Service Code
|
CPT 72196
|
| Hospital Charge Code |
3700168
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$281.34 |
| Max. Negotiated Rate |
$3,750.50 |
| Rate for Payer: Aetna Commercial |
$297.01
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$281.34
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Amerigroup Medicare |
$351.71
|
| 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 |
$351.71
|
| Rate for Payer: BCBS of TX PPO |
$843.89
|
| Rate for Payer: Cash Price |
$5,077.60
|
| Rate for Payer: Cash Price |
$5,077.60
|
| Rate for Payer: Cash Price |
$5,077.60
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$281.34
|
| Rate for Payer: Cigna Medicare |
$351.71
|
| Rate for Payer: Employer Direct Commercial |
$351.71
|
| Rate for Payer: Humana Medicare/TRICARE |
$351.71
|
| Rate for Payer: Molina CHIP/Medicaid |
$281.34
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Molina Medicare |
$351.71
|
| Rate for Payer: Multiplan Auto |
$3,750.50
|
| Rate for Payer: Multiplan Commercial |
$3,750.50
|
| Rate for Payer: Multiplan Workers Comp |
$3,750.50
|
| Rate for Payer: Parkland Medicaid |
$281.34
|
| Rate for Payer: Scott and White EPO/PPO |
$340.93
|
| Rate for Payer: Scott and White Medicare |
$351.71
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$281.34
|
| Rate for Payer: Superior Health Plan EPO |
$351.71
|
| Rate for Payer: Superior Health Plan Medicare |
$351.71
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Universal American Medicare |
$351.71
|
| Rate for Payer: Wellcare Medicare |
$351.71
|
| Rate for Payer: Wellmed Medicare |
$351.71
|
|
|
MRI Pelvis w/ Contrast BCE
|
Facility
|
IP
|
$5,770.00
|
|
|
Service Code
|
CPT 72196
|
| Hospital Charge Code |
3700168
|
|
Hospital Revenue Code
|
612
|
| Rate for Payer: Cash Price |
$5,077.60
|
|
|
MRI Pelvis w/ Contrast BCE
|
Facility
|
OP
|
$5,770.00
|
|
|
Service Code
|
CPT 72196
|
| Hospital Charge Code |
3700168
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$281.34 |
| Max. Negotiated Rate |
$3,750.50 |
| Rate for Payer: Aetna Commercial |
$297.01
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$281.34
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Amerigroup Medicare |
$351.71
|
| 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 |
$351.71
|
| Rate for Payer: BCBS of TX PPO |
$843.89
|
| Rate for Payer: Cash Price |
$5,077.60
|
| Rate for Payer: Cash Price |
$5,077.60
|
| Rate for Payer: Cash Price |
$5,077.60
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$281.34
|
| Rate for Payer: Cigna Medicare |
$351.71
|
| Rate for Payer: Employer Direct Commercial |
$351.71
|
| Rate for Payer: Humana Medicare/TRICARE |
$351.71
|
| Rate for Payer: Molina CHIP/Medicaid |
$281.34
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Molina Medicare |
$351.71
|
| Rate for Payer: Multiplan Auto |
$3,750.50
|
| Rate for Payer: Multiplan Commercial |
$3,750.50
|
| Rate for Payer: Multiplan Workers Comp |
$3,750.50
|
| Rate for Payer: Parkland Medicaid |
$281.34
|
| Rate for Payer: Scott and White EPO/PPO |
$340.93
|
| Rate for Payer: Scott and White Medicare |
$351.71
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$281.34
|
| Rate for Payer: Superior Health Plan EPO |
$351.71
|
| Rate for Payer: Superior Health Plan Medicare |
$351.71
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Universal American Medicare |
$351.71
|
| Rate for Payer: Wellcare Medicare |
$351.71
|
| Rate for Payer: Wellmed Medicare |
$351.71
|
|
|
MRI Pelvis w/o Contrast
|
Facility
|
OP
|
$5,478.00
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
3750510
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$224.10 |
| Max. Negotiated Rate |
$3,560.70 |
| Rate for Payer: Aetna Commercial |
$254.31
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$233.52
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Amerigroup Medicare |
$224.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$384.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$461.42
|
| Rate for Payer: BCBS of TX Medicare |
$224.10
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$4,820.64
|
| Rate for Payer: Cash Price |
$4,820.64
|
| Rate for Payer: Cash Price |
$4,820.64
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$233.52
|
| Rate for Payer: Cigna Medicare |
$224.10
|
| Rate for Payer: Employer Direct Commercial |
$224.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$224.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$233.52
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Molina Medicare |
$224.10
|
| Rate for Payer: Multiplan Auto |
$3,560.70
|
| Rate for Payer: Multiplan Commercial |
$3,560.70
|
| Rate for Payer: Multiplan Workers Comp |
$3,560.70
|
| Rate for Payer: Parkland Medicaid |
$233.52
|
| Rate for Payer: Scott and White EPO/PPO |
$291.11
|
| Rate for Payer: Scott and White Medicare |
$224.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$233.52
|
| Rate for Payer: Superior Health Plan EPO |
$224.10
|
| Rate for Payer: Superior Health Plan Medicare |
$224.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Universal American Medicare |
$224.10
|
| Rate for Payer: Wellcare Medicare |
$224.10
|
| Rate for Payer: Wellmed Medicare |
$224.10
|
|
|
MRI Pelvis w/o Contrast BCE
|
Facility
|
IP
|
$5,478.00
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
3750510
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$4,820.64
|
|
|
MRI Pelvis w/o Contrast BCE
|
Facility
|
OP
|
$5,478.00
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
3750510
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$224.10 |
| Max. Negotiated Rate |
$3,560.70 |
| Rate for Payer: Aetna Commercial |
$254.31
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$233.52
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Amerigroup Medicare |
$224.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$384.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$461.42
|
| Rate for Payer: BCBS of TX Medicare |
$224.10
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$4,820.64
|
| Rate for Payer: Cash Price |
$4,820.64
|
| Rate for Payer: Cash Price |
$4,820.64
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$233.52
|
| Rate for Payer: Cigna Medicare |
$224.10
|
| Rate for Payer: Employer Direct Commercial |
$224.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$224.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$233.52
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Molina Medicare |
$224.10
|
| Rate for Payer: Multiplan Auto |
$3,560.70
|
| Rate for Payer: Multiplan Commercial |
$3,560.70
|
| Rate for Payer: Multiplan Workers Comp |
$3,560.70
|
| Rate for Payer: Parkland Medicaid |
$233.52
|
| Rate for Payer: Scott and White EPO/PPO |
$291.11
|
| Rate for Payer: Scott and White Medicare |
$224.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$233.52
|
| Rate for Payer: Superior Health Plan EPO |
$224.10
|
| Rate for Payer: Superior Health Plan Medicare |
$224.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Universal American Medicare |
$224.10
|
| Rate for Payer: Wellcare Medicare |
$224.10
|
| Rate for Payer: Wellmed Medicare |
$224.10
|
|
|
MRI Pelvis w/ + w/o Contrast
|
Facility
|
OP
|
$7,227.00
|
|
|
Service Code
|
CPT 72197
|
| Hospital Charge Code |
3750528
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$351.71 |
| Max. Negotiated Rate |
$4,697.55 |
| Rate for Payer: Aetna Commercial |
$371.65
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$353.18
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Amerigroup Medicare |
$351.71
|
| 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 |
$351.71
|
| Rate for Payer: BCBS of TX PPO |
$843.89
|
| Rate for Payer: Cash Price |
$6,359.76
|
| Rate for Payer: Cash Price |
$6,359.76
|
| Rate for Payer: Cash Price |
$6,359.76
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$353.18
|
| Rate for Payer: Cigna Medicare |
$351.71
|
| Rate for Payer: Employer Direct Commercial |
$351.71
|
| Rate for Payer: Humana Medicare/TRICARE |
$351.71
|
| Rate for Payer: Molina CHIP/Medicaid |
$353.18
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Molina Medicare |
$351.71
|
| Rate for Payer: Multiplan Auto |
$4,697.55
|
| Rate for Payer: Multiplan Commercial |
$4,697.55
|
| Rate for Payer: Multiplan Workers Comp |
$4,697.55
|
| Rate for Payer: Parkland Medicaid |
$353.18
|
| Rate for Payer: Scott and White EPO/PPO |
$427.86
|
| Rate for Payer: Scott and White Medicare |
$351.71
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$353.18
|
| Rate for Payer: Superior Health Plan EPO |
$351.71
|
| Rate for Payer: Superior Health Plan Medicare |
$351.71
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Universal American Medicare |
$351.71
|
| Rate for Payer: Wellcare Medicare |
$351.71
|
| Rate for Payer: Wellmed Medicare |
$351.71
|
|
|
MRI Pelvis w/ + w/o Contrast BCE
|
Facility
|
OP
|
$7,227.00
|
|
|
Service Code
|
CPT 72197
|
| Hospital Charge Code |
3750528
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$351.71 |
| Max. Negotiated Rate |
$4,697.55 |
| Rate for Payer: Aetna Commercial |
$371.65
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$353.18
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Amerigroup Medicare |
$351.71
|
| 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 |
$351.71
|
| Rate for Payer: BCBS of TX PPO |
$843.89
|
| Rate for Payer: Cash Price |
$6,359.76
|
| Rate for Payer: Cash Price |
$6,359.76
|
| Rate for Payer: Cash Price |
$6,359.76
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$353.18
|
| Rate for Payer: Cigna Medicare |
$351.71
|
| Rate for Payer: Employer Direct Commercial |
$351.71
|
| Rate for Payer: Humana Medicare/TRICARE |
$351.71
|
| Rate for Payer: Molina CHIP/Medicaid |
$353.18
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Molina Medicare |
$351.71
|
| Rate for Payer: Multiplan Auto |
$4,697.55
|
| Rate for Payer: Multiplan Commercial |
$4,697.55
|
| Rate for Payer: Multiplan Workers Comp |
$4,697.55
|
| Rate for Payer: Parkland Medicaid |
$353.18
|
| Rate for Payer: Scott and White EPO/PPO |
$427.86
|
| Rate for Payer: Scott and White Medicare |
$351.71
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$353.18
|
| Rate for Payer: Superior Health Plan EPO |
$351.71
|
| Rate for Payer: Superior Health Plan Medicare |
$351.71
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$351.71
|
| Rate for Payer: Universal American Medicare |
$351.71
|
| Rate for Payer: Wellcare Medicare |
$351.71
|
| Rate for Payer: Wellmed Medicare |
$351.71
|
|
|
MRI Pelvis w/ + w/o Contrast BCE
|
Facility
|
IP
|
$7,227.00
|
|
|
Service Code
|
CPT 72197
|
| Hospital Charge Code |
3750528
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$6,359.76
|
|
|
MRI Shoulder w/ Contrast Left
|
Facility
|
OP
|
$3,722.00
|
|
|
Service Code
|
CPT 73222 LT
|
| Hospital Charge Code |
3740071
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$328.45 |
| Max. Negotiated Rate |
$2,419.30 |
| Rate for Payer: Aetna Commercial |
$375.55
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$328.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,123.35
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,348.02
|
| Rate for Payer: BCBS of TX PPO |
$1,504.61
|
| Rate for Payer: Cash Price |
$3,275.36
|
| Rate for Payer: Cash Price |
$3,275.36
|
| Rate for Payer: Cash Price |
$3,275.36
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicaid |
$328.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$328.45
|
| Rate for Payer: Multiplan Auto |
$2,419.30
|
| Rate for Payer: Multiplan Commercial |
$2,419.30
|
| Rate for Payer: Multiplan Workers Comp |
$2,419.30
|
| Rate for Payer: Parkland Medicaid |
$328.45
|
| Rate for Payer: Scott and White EPO/PPO |
$1,861.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$328.45
|
| Rate for Payer: Superior Health Plan EPO |
$506.19
|
|
|
MRI Shoulder w/ Contrast Right
|
Facility
|
OP
|
$3,722.00
|
|
|
Service Code
|
CPT 73222 RT
|
| Hospital Charge Code |
3740072
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$328.45 |
| Max. Negotiated Rate |
$2,419.30 |
| Rate for Payer: Aetna Commercial |
$375.55
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$328.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,123.35
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,348.02
|
| Rate for Payer: BCBS of TX PPO |
$1,504.61
|
| Rate for Payer: Cash Price |
$3,275.36
|
| Rate for Payer: Cash Price |
$3,275.36
|
| Rate for Payer: Cash Price |
$3,275.36
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicaid |
$328.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$328.45
|
| Rate for Payer: Multiplan Auto |
$2,419.30
|
| Rate for Payer: Multiplan Commercial |
$2,419.30
|
| Rate for Payer: Multiplan Workers Comp |
$2,419.30
|
| Rate for Payer: Parkland Medicaid |
$328.45
|
| Rate for Payer: Scott and White EPO/PPO |
$1,861.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$328.45
|
| Rate for Payer: Superior Health Plan EPO |
$506.19
|
|
|
MRI Shoulder w/o Contrast Left
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
CPT 73221 LT
|
| Hospital Charge Code |
3700051
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$211.18 |
| Max. Negotiated Rate |
$2,177.50 |
| Rate for Payer: Aetna Commercial |
$216.02
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$211.18
|
| Rate for Payer: BCBS of TX Blue Advantage |
$384.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$461.42
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$2,948.00
|
| Rate for Payer: Cash Price |
$2,948.00
|
| Rate for Payer: Cash Price |
$2,948.00
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$211.18
|
| Rate for Payer: Molina CHIP/Medicaid |
$211.18
|
| Rate for Payer: Multiplan Auto |
$2,177.50
|
| Rate for Payer: Multiplan Commercial |
$2,177.50
|
| Rate for Payer: Multiplan Workers Comp |
$2,177.50
|
| Rate for Payer: Parkland Medicaid |
$211.18
|
| Rate for Payer: Scott and White EPO/PPO |
$1,675.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$211.18
|
| Rate for Payer: Superior Health Plan EPO |
$455.60
|
|
|
MRI Shoulder w/o Contrast Right
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
CPT 73221 RT
|
| Hospital Charge Code |
3700267
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$211.18 |
| Max. Negotiated Rate |
$2,177.50 |
| Rate for Payer: Aetna Commercial |
$216.02
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$211.18
|
| Rate for Payer: BCBS of TX Blue Advantage |
$384.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$461.42
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$2,948.00
|
| Rate for Payer: Cash Price |
$2,948.00
|
| Rate for Payer: Cash Price |
$2,948.00
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$211.18
|
| Rate for Payer: Molina CHIP/Medicaid |
$211.18
|
| Rate for Payer: Multiplan Auto |
$2,177.50
|
| Rate for Payer: Multiplan Commercial |
$2,177.50
|
| Rate for Payer: Multiplan Workers Comp |
$2,177.50
|
| Rate for Payer: Parkland Medicaid |
$211.18
|
| Rate for Payer: Scott and White EPO/PPO |
$1,675.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$211.18
|
| Rate for Payer: Superior Health Plan EPO |
$455.60
|
|
|
MRI Shoulder w/ + w/o Contrast Left
|
Facility
|
OP
|
$3,908.00
|
|
|
Service Code
|
CPT 73223 LT
|
| Hospital Charge Code |
3750585
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$368.43 |
| Max. Negotiated Rate |
$2,540.20 |
| Rate for Payer: Aetna Commercial |
$456.08
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$368.43
|
| 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 |
$3,439.04
|
| Rate for Payer: Cash Price |
$3,439.04
|
| Rate for Payer: Cash Price |
$3,439.04
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$368.43
|
| Rate for Payer: Molina CHIP/Medicaid |
$368.43
|
| Rate for Payer: Multiplan Auto |
$2,540.20
|
| Rate for Payer: Multiplan Commercial |
$2,540.20
|
| Rate for Payer: Multiplan Workers Comp |
$2,540.20
|
| Rate for Payer: Parkland Medicaid |
$368.43
|
| Rate for Payer: Scott and White EPO/PPO |
$1,954.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$368.43
|
| Rate for Payer: Superior Health Plan EPO |
$531.49
|
|
|
MRI Shoulder w/ + w/o Contrast Right
|
Facility
|
OP
|
$3,908.00
|
|
|
Service Code
|
CPT 73223 RT
|
| Hospital Charge Code |
3750593
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$368.43 |
| Max. Negotiated Rate |
$2,540.20 |
| Rate for Payer: Aetna Commercial |
$456.08
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$368.43
|
| 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 |
$3,439.04
|
| Rate for Payer: Cash Price |
$3,439.04
|
| Rate for Payer: Cash Price |
$3,439.04
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$368.43
|
| Rate for Payer: Molina CHIP/Medicaid |
$368.43
|
| Rate for Payer: Multiplan Auto |
$2,540.20
|
| Rate for Payer: Multiplan Commercial |
$2,540.20
|
| Rate for Payer: Multiplan Workers Comp |
$2,540.20
|
| Rate for Payer: Parkland Medicaid |
$368.43
|
| Rate for Payer: Scott and White EPO/PPO |
$1,954.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$368.43
|
| Rate for Payer: Superior Health Plan EPO |
$531.49
|
|
|
MRI Spine Cervical w/o Contrast
|
Facility
|
OP
|
$6,546.00
|
|
|
Service Code
|
CPT 72141
|
| Hospital Charge Code |
3700143
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$190.49 |
| Max. Negotiated Rate |
$4,254.90 |
| Rate for Payer: Aetna Commercial |
$190.49
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$198.48
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Amerigroup Medicare |
$224.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$384.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$461.42
|
| Rate for Payer: BCBS of TX Medicare |
$224.10
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$5,760.48
|
| Rate for Payer: Cash Price |
$5,760.48
|
| Rate for Payer: Cash Price |
$5,760.48
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$198.48
|
| Rate for Payer: Cigna Medicare |
$224.10
|
| Rate for Payer: Employer Direct Commercial |
$224.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$224.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$198.48
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Molina Medicare |
$224.10
|
| Rate for Payer: Multiplan Auto |
$4,254.90
|
| Rate for Payer: Multiplan Commercial |
$4,254.90
|
| Rate for Payer: Multiplan Workers Comp |
$4,254.90
|
| Rate for Payer: Parkland Medicaid |
$198.48
|
| Rate for Payer: Scott and White EPO/PPO |
$242.06
|
| Rate for Payer: Scott and White Medicare |
$224.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$198.48
|
| Rate for Payer: Superior Health Plan EPO |
$224.10
|
| Rate for Payer: Superior Health Plan Medicare |
$224.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Universal American Medicare |
$224.10
|
| Rate for Payer: Wellcare Medicare |
$224.10
|
| Rate for Payer: Wellmed Medicare |
$224.10
|
|
|
MRI Spine Cervical w/o Contrast BCE
|
Facility
|
OP
|
$6,546.00
|
|
|
Service Code
|
CPT 72141
|
| Hospital Charge Code |
3700143
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$190.49 |
| Max. Negotiated Rate |
$4,254.90 |
| Rate for Payer: Aetna Commercial |
$190.49
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$198.48
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Amerigroup Medicare |
$224.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$384.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$461.42
|
| Rate for Payer: BCBS of TX Medicare |
$224.10
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$5,760.48
|
| Rate for Payer: Cash Price |
$5,760.48
|
| Rate for Payer: Cash Price |
$5,760.48
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$198.48
|
| Rate for Payer: Cigna Medicare |
$224.10
|
| Rate for Payer: Employer Direct Commercial |
$224.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$224.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$198.48
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Molina Medicare |
$224.10
|
| Rate for Payer: Multiplan Auto |
$4,254.90
|
| Rate for Payer: Multiplan Commercial |
$4,254.90
|
| Rate for Payer: Multiplan Workers Comp |
$4,254.90
|
| Rate for Payer: Parkland Medicaid |
$198.48
|
| Rate for Payer: Scott and White EPO/PPO |
$242.06
|
| Rate for Payer: Scott and White Medicare |
$224.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$198.48
|
| Rate for Payer: Superior Health Plan EPO |
$224.10
|
| Rate for Payer: Superior Health Plan Medicare |
$224.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Universal American Medicare |
$224.10
|
| Rate for Payer: Wellcare Medicare |
$224.10
|
| Rate for Payer: Wellmed Medicare |
$224.10
|
|
|
MRI Spine Cervical w/o Contrast BCE
|
Facility
|
IP
|
$6,546.00
|
|
|
Service Code
|
CPT 72141
|
| Hospital Charge Code |
3700143
|
|
Hospital Revenue Code
|
612
|
| Rate for Payer: Cash Price |
$5,760.48
|
|
