|
NM Cisternography
|
Facility
|
OP
|
$1,254.00
|
|
|
Service Code
|
CPT 78630
|
| Hospital Charge Code |
5218630
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$1,119.78 |
| Rate for Payer: Aetna Commercial |
$331.17
|
| Rate for Payer: Aetna Medicare |
$741.48
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$314.09
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Amerigroup Medicare |
$494.32
|
| Rate for Payer: BCBS of TX Blue Advantage |
$522.09
|
| Rate for Payer: BCBS of TX Blue Essentials |
$626.51
|
| Rate for Payer: BCBS of TX Medicare |
$494.32
|
| Rate for Payer: BCBS of TX PPO |
$699.29
|
| Rate for Payer: Cash Price |
$1,103.52
|
| Rate for Payer: Cash Price |
$1,103.52
|
| Rate for Payer: Cash Price |
$1,103.52
|
| Rate for Payer: Cigna Commercial |
$1,119.78
|
| Rate for Payer: Cigna Medicaid |
$314.09
|
| Rate for Payer: Cigna Medicare |
$494.32
|
| Rate for Payer: Employer Direct Commercial |
$494.32
|
| Rate for Payer: Humana Medicare/TRICARE |
$494.32
|
| Rate for Payer: Molina CHIP/Medicaid |
$314.09
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Molina Medicare |
$494.32
|
| Rate for Payer: Multiplan Auto |
$815.10
|
| Rate for Payer: Multiplan Commercial |
$815.10
|
| Rate for Payer: Multiplan Workers Comp |
$815.10
|
| Rate for Payer: Parkland Medicaid |
$314.09
|
| Rate for Payer: Scott and White EPO/PPO |
$8.84
|
| Rate for Payer: Scott and White Medicare |
$494.32
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$314.09
|
| Rate for Payer: Superior Health Plan EPO |
$494.32
|
| Rate for Payer: Superior Health Plan Medicare |
$494.32
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Universal American Medicare |
$494.32
|
| Rate for Payer: Wellcare Medicare |
$494.32
|
| Rate for Payer: Wellmed Medicare |
$494.32
|
|
|
NM Cisternography Delay 1 BCE
|
Facility
|
IP
|
$1,254.00
|
|
|
Service Code
|
CPT 78630
|
| Hospital Charge Code |
5218630
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$1,103.52
|
|
|
NM Cisternography Delay 1 BCE
|
Facility
|
OP
|
$1,254.00
|
|
|
Service Code
|
CPT 78630
|
| Hospital Charge Code |
5218630
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$1,119.78 |
| Rate for Payer: Aetna Commercial |
$331.17
|
| Rate for Payer: Aetna Medicare |
$741.48
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$314.09
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Amerigroup Medicare |
$494.32
|
| Rate for Payer: BCBS of TX Blue Advantage |
$522.09
|
| Rate for Payer: BCBS of TX Blue Essentials |
$626.51
|
| Rate for Payer: BCBS of TX Medicare |
$494.32
|
| Rate for Payer: BCBS of TX PPO |
$699.29
|
| Rate for Payer: Cash Price |
$1,103.52
|
| Rate for Payer: Cash Price |
$1,103.52
|
| Rate for Payer: Cash Price |
$1,103.52
|
| Rate for Payer: Cigna Commercial |
$1,119.78
|
| Rate for Payer: Cigna Medicaid |
$314.09
|
| Rate for Payer: Cigna Medicare |
$494.32
|
| Rate for Payer: Employer Direct Commercial |
$494.32
|
| Rate for Payer: Humana Medicare/TRICARE |
$494.32
|
| Rate for Payer: Molina CHIP/Medicaid |
$314.09
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Molina Medicare |
$494.32
|
| Rate for Payer: Multiplan Auto |
$815.10
|
| Rate for Payer: Multiplan Commercial |
$815.10
|
| Rate for Payer: Multiplan Workers Comp |
$815.10
|
| Rate for Payer: Parkland Medicaid |
$314.09
|
| Rate for Payer: Scott and White EPO/PPO |
$8.84
|
| Rate for Payer: Scott and White Medicare |
$494.32
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$314.09
|
| Rate for Payer: Superior Health Plan EPO |
$494.32
|
| Rate for Payer: Superior Health Plan Medicare |
$494.32
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Universal American Medicare |
$494.32
|
| Rate for Payer: Wellcare Medicare |
$494.32
|
| Rate for Payer: Wellmed Medicare |
$494.32
|
|
|
NM Gastric Emptying Study
|
Facility
|
OP
|
$2,237.00
|
|
|
Service Code
|
CPT 78264
|
| Hospital Charge Code |
3400579
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$1,454.05 |
| Rate for Payer: Aetna Commercial |
$317.31
|
| Rate for Payer: Aetna Medicare |
$565.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$308.08
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Amerigroup Medicare |
$377.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$508.41
|
| Rate for Payer: BCBS of TX Blue Essentials |
$610.10
|
| Rate for Payer: BCBS of TX Medicare |
$377.20
|
| Rate for Payer: BCBS of TX PPO |
$680.97
|
| Rate for Payer: Cash Price |
$1,968.56
|
| Rate for Payer: Cash Price |
$1,968.56
|
| Rate for Payer: Cash Price |
$1,968.56
|
| Rate for Payer: Cigna Commercial |
$854.47
|
| Rate for Payer: Cigna Medicaid |
$308.08
|
| Rate for Payer: Cigna Medicare |
$377.20
|
| Rate for Payer: Employer Direct Commercial |
$377.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$377.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$308.08
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Molina Medicare |
$377.20
|
| Rate for Payer: Multiplan Auto |
$1,454.05
|
| Rate for Payer: Multiplan Commercial |
$1,454.05
|
| Rate for Payer: Multiplan Workers Comp |
$1,454.05
|
| Rate for Payer: Parkland Medicaid |
$308.08
|
| Rate for Payer: Scott and White EPO/PPO |
$6.75
|
| Rate for Payer: Scott and White Medicare |
$377.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$308.08
|
| Rate for Payer: Superior Health Plan EPO |
$377.20
|
| Rate for Payer: Superior Health Plan Medicare |
$377.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Universal American Medicare |
$377.20
|
| Rate for Payer: Wellcare Medicare |
$377.20
|
| Rate for Payer: Wellmed Medicare |
$377.20
|
|
|
NM Gastric Emptying Study BCE
|
Facility
|
IP
|
$2,237.00
|
|
|
Service Code
|
CPT 78264
|
| Hospital Charge Code |
3400579
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$1,968.56
|
|
|
NM Gastric Emptying Study BCE
|
Facility
|
OP
|
$2,237.00
|
|
|
Service Code
|
CPT 78264
|
| Hospital Charge Code |
3400579
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$1,454.05 |
| Rate for Payer: Aetna Commercial |
$317.31
|
| Rate for Payer: Aetna Medicare |
$565.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$308.08
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Amerigroup Medicare |
$377.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$508.41
|
| Rate for Payer: BCBS of TX Blue Essentials |
$610.10
|
| Rate for Payer: BCBS of TX Medicare |
$377.20
|
| Rate for Payer: BCBS of TX PPO |
$680.97
|
| Rate for Payer: Cash Price |
$1,968.56
|
| Rate for Payer: Cash Price |
$1,968.56
|
| Rate for Payer: Cash Price |
$1,968.56
|
| Rate for Payer: Cigna Commercial |
$854.47
|
| Rate for Payer: Cigna Medicaid |
$308.08
|
| Rate for Payer: Cigna Medicare |
$377.20
|
| Rate for Payer: Employer Direct Commercial |
$377.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$377.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$308.08
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Molina Medicare |
$377.20
|
| Rate for Payer: Multiplan Auto |
$1,454.05
|
| Rate for Payer: Multiplan Commercial |
$1,454.05
|
| Rate for Payer: Multiplan Workers Comp |
$1,454.05
|
| Rate for Payer: Parkland Medicaid |
$308.08
|
| Rate for Payer: Scott and White EPO/PPO |
$6.75
|
| Rate for Payer: Scott and White Medicare |
$377.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$308.08
|
| Rate for Payer: Superior Health Plan EPO |
$377.20
|
| Rate for Payer: Superior Health Plan Medicare |
$377.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Universal American Medicare |
$377.20
|
| Rate for Payer: Wellcare Medicare |
$377.20
|
| Rate for Payer: Wellmed Medicare |
$377.20
|
|
|
NM GI Blood Loss 24 hour delay
|
Facility
|
IP
|
$1,075.00
|
|
|
Service Code
|
CPT 78278
|
| Hospital Charge Code |
3400413
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$946.00
|
|
|
NM GI Blood Loss 24 hour delay
|
Facility
|
OP
|
$1,075.00
|
|
|
Service Code
|
CPT 78278
|
| Hospital Charge Code |
3400413
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$854.47 |
| Rate for Payer: Aetna Commercial |
$326.16
|
| Rate for Payer: Aetna Medicare |
$565.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$324.78
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Amerigroup Medicare |
$377.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$515.56
|
| Rate for Payer: BCBS of TX Blue Essentials |
$618.67
|
| Rate for Payer: BCBS of TX Medicare |
$377.20
|
| Rate for Payer: BCBS of TX PPO |
$690.54
|
| Rate for Payer: Cash Price |
$946.00
|
| Rate for Payer: Cash Price |
$946.00
|
| Rate for Payer: Cash Price |
$946.00
|
| Rate for Payer: Cigna Commercial |
$854.47
|
| Rate for Payer: Cigna Medicaid |
$324.78
|
| Rate for Payer: Cigna Medicare |
$377.20
|
| Rate for Payer: Employer Direct Commercial |
$377.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$377.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$324.78
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Molina Medicare |
$377.20
|
| Rate for Payer: Multiplan Auto |
$698.75
|
| Rate for Payer: Multiplan Commercial |
$698.75
|
| Rate for Payer: Multiplan Workers Comp |
$698.75
|
| Rate for Payer: Parkland Medicaid |
$324.78
|
| Rate for Payer: Scott and White EPO/PPO |
$6.75
|
| Rate for Payer: Scott and White Medicare |
$377.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$324.78
|
| Rate for Payer: Superior Health Plan EPO |
$377.20
|
| Rate for Payer: Superior Health Plan Medicare |
$377.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Universal American Medicare |
$377.20
|
| Rate for Payer: Wellcare Medicare |
$377.20
|
| Rate for Payer: Wellmed Medicare |
$377.20
|
|
|
NM GI Blood Loss Initial delay
|
Facility
|
OP
|
$1,075.00
|
|
|
Service Code
|
CPT 78278
|
| Hospital Charge Code |
3400066
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$854.47 |
| Rate for Payer: Aetna Commercial |
$326.16
|
| Rate for Payer: Aetna Medicare |
$565.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$324.78
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Amerigroup Medicare |
$377.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$515.56
|
| Rate for Payer: BCBS of TX Blue Essentials |
$618.67
|
| Rate for Payer: BCBS of TX Medicare |
$377.20
|
| Rate for Payer: BCBS of TX PPO |
$690.54
|
| Rate for Payer: Cash Price |
$946.00
|
| Rate for Payer: Cash Price |
$946.00
|
| Rate for Payer: Cash Price |
$946.00
|
| Rate for Payer: Cigna Commercial |
$854.47
|
| Rate for Payer: Cigna Medicaid |
$324.78
|
| Rate for Payer: Cigna Medicare |
$377.20
|
| Rate for Payer: Employer Direct Commercial |
$377.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$377.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$324.78
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Molina Medicare |
$377.20
|
| Rate for Payer: Multiplan Auto |
$698.75
|
| Rate for Payer: Multiplan Commercial |
$698.75
|
| Rate for Payer: Multiplan Workers Comp |
$698.75
|
| Rate for Payer: Parkland Medicaid |
$324.78
|
| Rate for Payer: Scott and White EPO/PPO |
$6.75
|
| Rate for Payer: Scott and White Medicare |
$377.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$324.78
|
| Rate for Payer: Superior Health Plan EPO |
$377.20
|
| Rate for Payer: Superior Health Plan Medicare |
$377.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Universal American Medicare |
$377.20
|
| Rate for Payer: Wellcare Medicare |
$377.20
|
| Rate for Payer: Wellmed Medicare |
$377.20
|
|
|
NM GI Blood Loss Initial delay BCE
|
Facility
|
OP
|
$1,075.00
|
|
|
Service Code
|
CPT 78278
|
| Hospital Charge Code |
3400066
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$854.47 |
| Rate for Payer: Aetna Commercial |
$326.16
|
| Rate for Payer: Aetna Medicare |
$565.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$324.78
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Amerigroup Medicare |
$377.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$515.56
|
| Rate for Payer: BCBS of TX Blue Essentials |
$618.67
|
| Rate for Payer: BCBS of TX Medicare |
$377.20
|
| Rate for Payer: BCBS of TX PPO |
$690.54
|
| Rate for Payer: Cash Price |
$946.00
|
| Rate for Payer: Cash Price |
$946.00
|
| Rate for Payer: Cash Price |
$946.00
|
| Rate for Payer: Cigna Commercial |
$854.47
|
| Rate for Payer: Cigna Medicaid |
$324.78
|
| Rate for Payer: Cigna Medicare |
$377.20
|
| Rate for Payer: Employer Direct Commercial |
$377.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$377.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$324.78
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Molina Medicare |
$377.20
|
| Rate for Payer: Multiplan Auto |
$698.75
|
| Rate for Payer: Multiplan Commercial |
$698.75
|
| Rate for Payer: Multiplan Workers Comp |
$698.75
|
| Rate for Payer: Parkland Medicaid |
$324.78
|
| Rate for Payer: Scott and White EPO/PPO |
$6.75
|
| Rate for Payer: Scott and White Medicare |
$377.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$324.78
|
| Rate for Payer: Superior Health Plan EPO |
$377.20
|
| Rate for Payer: Superior Health Plan Medicare |
$377.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Universal American Medicare |
$377.20
|
| Rate for Payer: Wellcare Medicare |
$377.20
|
| Rate for Payer: Wellmed Medicare |
$377.20
|
|
|
NM GI Blood Loss Initial delay BCE
|
Facility
|
IP
|
$1,075.00
|
|
|
Service Code
|
CPT 78278
|
| Hospital Charge Code |
3400066
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$946.00
|
|
|
NM Hepatobiliary Imaging
|
Facility
|
OP
|
$2,704.00
|
|
|
Service Code
|
CPT 78226
|
| Hospital Charge Code |
3400008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$1,757.60 |
| Rate for Payer: Aetna Commercial |
$314.23
|
| Rate for Payer: Aetna Medicare |
$565.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$303.06
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Amerigroup Medicare |
$377.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$504.26
|
| Rate for Payer: BCBS of TX Blue Essentials |
$605.11
|
| Rate for Payer: BCBS of TX Medicare |
$377.20
|
| Rate for Payer: BCBS of TX PPO |
$675.40
|
| Rate for Payer: Cash Price |
$2,379.52
|
| Rate for Payer: Cash Price |
$2,379.52
|
| Rate for Payer: Cash Price |
$2,379.52
|
| Rate for Payer: Cigna Commercial |
$854.47
|
| Rate for Payer: Cigna Medicaid |
$303.06
|
| Rate for Payer: Cigna Medicare |
$377.20
|
| Rate for Payer: Employer Direct Commercial |
$377.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$377.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$303.06
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Molina Medicare |
$377.20
|
| Rate for Payer: Multiplan Auto |
$1,757.60
|
| Rate for Payer: Multiplan Commercial |
$1,757.60
|
| Rate for Payer: Multiplan Workers Comp |
$1,757.60
|
| Rate for Payer: Parkland Medicaid |
$303.06
|
| Rate for Payer: Scott and White EPO/PPO |
$6.75
|
| Rate for Payer: Scott and White Medicare |
$377.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$303.06
|
| Rate for Payer: Superior Health Plan EPO |
$377.20
|
| Rate for Payer: Superior Health Plan Medicare |
$377.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Universal American Medicare |
$377.20
|
| Rate for Payer: Wellcare Medicare |
$377.20
|
| Rate for Payer: Wellmed Medicare |
$377.20
|
|
|
NM Hepatobiliary Imaging Injection/Scan BCE
|
Facility
|
IP
|
$2,704.00
|
|
|
Service Code
|
CPT 78226
|
| Hospital Charge Code |
3400008
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$2,379.52
|
|
|
NM Hepatobiliary Imaging Injection/Scan BCE
|
Facility
|
OP
|
$2,704.00
|
|
|
Service Code
|
CPT 78226
|
| Hospital Charge Code |
3400008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$1,757.60 |
| Rate for Payer: Aetna Commercial |
$314.23
|
| Rate for Payer: Aetna Medicare |
$565.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$303.06
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Amerigroup Medicare |
$377.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$504.26
|
| Rate for Payer: BCBS of TX Blue Essentials |
$605.11
|
| Rate for Payer: BCBS of TX Medicare |
$377.20
|
| Rate for Payer: BCBS of TX PPO |
$675.40
|
| Rate for Payer: Cash Price |
$2,379.52
|
| Rate for Payer: Cash Price |
$2,379.52
|
| Rate for Payer: Cash Price |
$2,379.52
|
| Rate for Payer: Cigna Commercial |
$854.47
|
| Rate for Payer: Cigna Medicaid |
$303.06
|
| Rate for Payer: Cigna Medicare |
$377.20
|
| Rate for Payer: Employer Direct Commercial |
$377.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$377.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$303.06
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Molina Medicare |
$377.20
|
| Rate for Payer: Multiplan Auto |
$1,757.60
|
| Rate for Payer: Multiplan Commercial |
$1,757.60
|
| Rate for Payer: Multiplan Workers Comp |
$1,757.60
|
| Rate for Payer: Parkland Medicaid |
$303.06
|
| Rate for Payer: Scott and White EPO/PPO |
$6.75
|
| Rate for Payer: Scott and White Medicare |
$377.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$303.06
|
| Rate for Payer: Superior Health Plan EPO |
$377.20
|
| Rate for Payer: Superior Health Plan Medicare |
$377.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$377.20
|
| Rate for Payer: Universal American Medicare |
$377.20
|
| Rate for Payer: Wellcare Medicare |
$377.20
|
| Rate for Payer: Wellmed Medicare |
$377.20
|
|
|
NM Hepatobiliary Imaging w/ CCK Delay 1 BCE
|
Facility
|
IP
|
$3,439.00
|
|
|
Service Code
|
CPT 78227
|
| Hospital Charge Code |
3400009
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$3,026.32
|
|
|
NM Hepatobiliary Imaging w/ CCK Delay 1 BCE
|
Facility
|
OP
|
$3,439.00
|
|
|
Service Code
|
CPT 78227
|
| Hospital Charge Code |
3400009
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$2,235.35 |
| Rate for Payer: Aetna Commercial |
$427.89
|
| Rate for Payer: Aetna Medicare |
$741.48
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$407.30
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Amerigroup Medicare |
$494.32
|
| Rate for Payer: BCBS of TX Blue Advantage |
$689.78
|
| Rate for Payer: BCBS of TX Blue Essentials |
$827.74
|
| Rate for Payer: BCBS of TX Medicare |
$494.32
|
| Rate for Payer: BCBS of TX PPO |
$923.89
|
| Rate for Payer: Cash Price |
$3,026.32
|
| Rate for Payer: Cash Price |
$3,026.32
|
| Rate for Payer: Cash Price |
$3,026.32
|
| Rate for Payer: Cigna Commercial |
$1,119.78
|
| Rate for Payer: Cigna Medicaid |
$407.30
|
| Rate for Payer: Cigna Medicare |
$494.32
|
| Rate for Payer: Employer Direct Commercial |
$494.32
|
| Rate for Payer: Humana Medicare/TRICARE |
$494.32
|
| Rate for Payer: Molina CHIP/Medicaid |
$407.30
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Molina Medicare |
$494.32
|
| Rate for Payer: Multiplan Auto |
$2,235.35
|
| Rate for Payer: Multiplan Commercial |
$2,235.35
|
| Rate for Payer: Multiplan Workers Comp |
$2,235.35
|
| Rate for Payer: Parkland Medicaid |
$407.30
|
| Rate for Payer: Scott and White EPO/PPO |
$8.84
|
| Rate for Payer: Scott and White Medicare |
$494.32
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$407.30
|
| Rate for Payer: Superior Health Plan EPO |
$494.32
|
| Rate for Payer: Superior Health Plan Medicare |
$494.32
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Universal American Medicare |
$494.32
|
| Rate for Payer: Wellcare Medicare |
$494.32
|
| Rate for Payer: Wellmed Medicare |
$494.32
|
|
|
NM Hepatobiliary Imaging w/ Drug
|
Facility
|
OP
|
$3,439.00
|
|
|
Service Code
|
CPT 78227
|
| Hospital Charge Code |
3400009
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$2,235.35 |
| Rate for Payer: Aetna Commercial |
$427.89
|
| Rate for Payer: Aetna Medicare |
$741.48
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$407.30
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Amerigroup Medicare |
$494.32
|
| Rate for Payer: BCBS of TX Blue Advantage |
$689.78
|
| Rate for Payer: BCBS of TX Blue Essentials |
$827.74
|
| Rate for Payer: BCBS of TX Medicare |
$494.32
|
| Rate for Payer: BCBS of TX PPO |
$923.89
|
| Rate for Payer: Cash Price |
$3,026.32
|
| Rate for Payer: Cash Price |
$3,026.32
|
| Rate for Payer: Cash Price |
$3,026.32
|
| Rate for Payer: Cigna Commercial |
$1,119.78
|
| Rate for Payer: Cigna Medicaid |
$407.30
|
| Rate for Payer: Cigna Medicare |
$494.32
|
| Rate for Payer: Employer Direct Commercial |
$494.32
|
| Rate for Payer: Humana Medicare/TRICARE |
$494.32
|
| Rate for Payer: Molina CHIP/Medicaid |
$407.30
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Molina Medicare |
$494.32
|
| Rate for Payer: Multiplan Auto |
$2,235.35
|
| Rate for Payer: Multiplan Commercial |
$2,235.35
|
| Rate for Payer: Multiplan Workers Comp |
$2,235.35
|
| Rate for Payer: Parkland Medicaid |
$407.30
|
| Rate for Payer: Scott and White EPO/PPO |
$8.84
|
| Rate for Payer: Scott and White Medicare |
$494.32
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$407.30
|
| Rate for Payer: Superior Health Plan EPO |
$494.32
|
| Rate for Payer: Superior Health Plan Medicare |
$494.32
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$494.32
|
| Rate for Payer: Universal American Medicare |
$494.32
|
| Rate for Payer: Wellcare Medicare |
$494.32
|
| Rate for Payer: Wellmed Medicare |
$494.32
|
|
|
NMI F-18 FDG DIAGNOSTIC PER DOSE
|
Facility
|
OP
|
$1,645.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
3403029
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$148.05 |
| Max. Negotiated Rate |
$1,069.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$148.05
|
| Rate for Payer: BCBS of TX Blue Advantage |
$493.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$592.20
|
| Rate for Payer: BCBS of TX PPO |
$658.00
|
| Rate for Payer: Cash Price |
$1,447.60
|
| Rate for Payer: Multiplan Auto |
$1,069.25
|
| Rate for Payer: Multiplan Commercial |
$1,069.25
|
| Rate for Payer: Multiplan Workers Comp |
$1,069.25
|
| Rate for Payer: Scott and White EPO/PPO |
$822.50
|
| Rate for Payer: Superior Health Plan EPO |
$223.72
|
|
|
NMI F-18 FDG DIAGNOSTIC PER DOSE BCE
|
Facility
|
OP
|
$1,645.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
3403029
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$148.05 |
| Max. Negotiated Rate |
$1,069.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$148.05
|
| Rate for Payer: BCBS of TX Blue Advantage |
$493.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$592.20
|
| Rate for Payer: BCBS of TX PPO |
$658.00
|
| Rate for Payer: Cash Price |
$1,447.60
|
| Rate for Payer: Multiplan Auto |
$1,069.25
|
| Rate for Payer: Multiplan Commercial |
$1,069.25
|
| Rate for Payer: Multiplan Workers Comp |
$1,069.25
|
| Rate for Payer: Scott and White EPO/PPO |
$822.50
|
| Rate for Payer: Superior Health Plan EPO |
$223.72
|
|
|
NMI F-18 FDG DIAGNOSTIC PER DOSE BCE
|
Facility
|
IP
|
$1,645.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
3403029
|
|
Hospital Revenue Code
|
343
|
| Rate for Payer: Cash Price |
$1,447.60
|
|
|
NMI I-123 IODIDE/100UCI UP TO 999UCI
|
Facility
|
OP
|
$1,105.00
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
3401882
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$99.45 |
| Max. Negotiated Rate |
$718.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$99.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$331.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$397.80
|
| Rate for Payer: BCBS of TX PPO |
$442.00
|
| Rate for Payer: Cash Price |
$972.40
|
| Rate for Payer: Multiplan Auto |
$718.25
|
| Rate for Payer: Multiplan Commercial |
$718.25
|
| Rate for Payer: Multiplan Workers Comp |
$718.25
|
| Rate for Payer: Scott and White EPO/PPO |
$552.50
|
| Rate for Payer: Superior Health Plan EPO |
$150.28
|
|
|
NMI I-123 IODIDE/100UCI UP TO 999UCI BCE
|
Facility
|
OP
|
$1,105.00
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
3401882
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$99.45 |
| Max. Negotiated Rate |
$718.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$99.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$331.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$397.80
|
| Rate for Payer: BCBS of TX PPO |
$442.00
|
| Rate for Payer: Cash Price |
$972.40
|
| Rate for Payer: Multiplan Auto |
$718.25
|
| Rate for Payer: Multiplan Commercial |
$718.25
|
| Rate for Payer: Multiplan Workers Comp |
$718.25
|
| Rate for Payer: Scott and White EPO/PPO |
$552.50
|
| Rate for Payer: Superior Health Plan EPO |
$150.28
|
|
|
NMI I-123 IODIDE/100UCI UP TO 999UCI BCE
|
Facility
|
IP
|
$1,105.00
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
3401882
|
|
Hospital Revenue Code
|
343
|
| Rate for Payer: Cash Price |
$972.40
|
|
|
NMI I-131 IODIDE THERAPY CAP PER MCI
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
HCPCS A9517
|
| Hospital Charge Code |
3406162
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$50.05 |
| Rate for Payer: Aetna Medicare |
$32.01
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$6.93
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$21.34
|
| Rate for Payer: Amerigroup Medicare |
$21.34
|
| Rate for Payer: BCBS of TX Blue Advantage |
$23.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$27.72
|
| Rate for Payer: BCBS of TX Medicare |
$21.34
|
| Rate for Payer: BCBS of TX PPO |
$30.80
|
| Rate for Payer: Cash Price |
$67.76
|
| Rate for Payer: Cash Price |
$67.76
|
| Rate for Payer: Cigna Medicare |
$21.34
|
| Rate for Payer: Employer Direct Commercial |
$21.34
|
| Rate for Payer: Humana Medicare/TRICARE |
$21.34
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$21.34
|
| Rate for Payer: Molina Medicare |
$21.34
|
| Rate for Payer: Multiplan Auto |
$50.05
|
| Rate for Payer: Multiplan Commercial |
$50.05
|
| Rate for Payer: Multiplan Workers Comp |
$50.05
|
| Rate for Payer: Scott and White EPO/PPO |
$38.50
|
| Rate for Payer: Scott and White Medicare |
$21.34
|
| Rate for Payer: Superior Health Plan EPO |
$21.34
|
| Rate for Payer: Superior Health Plan Medicare |
$21.34
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$21.34
|
| Rate for Payer: Universal American Medicare |
$21.34
|
| Rate for Payer: Wellcare Medicare |
$21.34
|
| Rate for Payer: Wellmed Medicare |
$21.34
|
|
|
NMI I-131 IODIDE THERAPY CAP PER MCI BCE
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
HCPCS A9517
|
| Hospital Charge Code |
3406162
|
|
Hospital Revenue Code
|
344
|
| Rate for Payer: Cash Price |
$67.76
|
|
