|
Injection(s), anesthetic agent(s) and/or steroid trigeminal nerve, each branch (ie, ophthalmic, max
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64400
|
| Hospital Charge Code |
36064400
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$67.55 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$67.55
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$308.35
|
| Rate for Payer: Amerigroup Medicare |
$308.35
|
| Rate for Payer: BCBS of TX Blue Advantage |
$127.77
|
| Rate for Payer: BCBS of TX Blue Essentials |
$153.02
|
| Rate for Payer: BCBS of TX Medicare |
$308.35
|
| Rate for Payer: BCBS of TX PPO |
$192.81
|
| Rate for Payer: Cigna Commercial |
$651.79
|
| Rate for Payer: Cigna Medicare |
$308.35
|
| Rate for Payer: Employer Direct Commercial |
$308.35
|
| Rate for Payer: Humana Medicare/TRICARE |
$308.35
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$308.35
|
| Rate for Payer: Molina Medicare |
$308.35
|
| 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 |
$570.45
|
| Rate for Payer: Scott and White Medicare |
$308.35
|
| Rate for Payer: Superior Health Plan EPO |
$308.35
|
| Rate for Payer: Superior Health Plan Medicare |
$308.35
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$308.35
|
| Rate for Payer: Universal American Medicare |
$308.35
|
| Rate for Payer: Wellcare Medicare |
$308.35
|
| Rate for Payer: Wellmed Medicare |
$308.35
|
|
|
Injection(s), anesthetic agent(s) and/or steroid trigeminal nerve, each branch (ie, ophthalmic, max
|
Facility
|
IP
|
$1,567.02
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
9900778
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,065.57
|
|
|
Injection(s), anesthetic agent(s) and/or steroid trigeminal nerve, each branch (ie, ophthalmic, max
|
Facility
|
OP
|
$1,567.02
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
9900778
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$67.55 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Molina Dual Medicare/Medicaid |
$308.35
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$67.55
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$308.35
|
| Rate for Payer: Amerigroup Medicare |
$308.35
|
| Rate for Payer: BCBS of TX Blue Advantage |
$127.77
|
| Rate for Payer: BCBS of TX Blue Essentials |
$153.02
|
| Rate for Payer: BCBS of TX Medicare |
$308.35
|
| Rate for Payer: BCBS of TX PPO |
$192.81
|
| Rate for Payer: Cash Price |
$1,065.57
|
| Rate for Payer: Cash Price |
$1,065.57
|
| Rate for Payer: Cash Price |
$1,065.57
|
| Rate for Payer: Cigna Commercial |
$651.79
|
| Rate for Payer: Cigna Medicaid |
$1,128.25
|
| Rate for Payer: Cigna Medicare |
$308.35
|
| Rate for Payer: Employer Direct Commercial |
$308.35
|
| Rate for Payer: Humana Medicare/TRICARE |
$308.35
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,128.25
|
| Rate for Payer: Molina Medicare |
$308.35
|
| 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 |
$1,128.25
|
| Rate for Payer: Scott and White EPO/PPO |
$570.45
|
| Rate for Payer: Scott and White Medicare |
$308.35
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,128.25
|
| Rate for Payer: Superior Health Plan EPO |
$308.35
|
| Rate for Payer: Superior Health Plan Medicare |
$308.35
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$308.35
|
| Rate for Payer: Universal American Medicare |
$308.35
|
| Rate for Payer: Wellcare Medicare |
$308.35
|
| Rate for Payer: Wellmed Medicare |
$308.35
|
|
|
Injection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bon
|
Facility
|
IP
|
$8,676.84
|
|
|
Service Code
|
HCPCS 0707T
|
| Hospital Charge Code |
9900915
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$5,900.25
|
|
|
Injection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bon
|
Facility
|
OP
|
$8,676.84
|
|
|
Service Code
|
HCPCS 0707T
|
| Hospital Charge Code |
9900915
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$780.92 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$780.92
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,286.91
|
| Rate for Payer: Amerigroup Medicare |
$3,286.91
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,830.11
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,784.56
|
| Rate for Payer: BCBS of TX Medicare |
$3,286.91
|
| Rate for Payer: BCBS of TX PPO |
$7,288.55
|
| Rate for Payer: Cash Price |
$5,900.25
|
| Rate for Payer: Cash Price |
$5,900.25
|
| Rate for Payer: Cash Price |
$5,900.25
|
| Rate for Payer: Cigna Commercial |
$6,947.94
|
| Rate for Payer: Cigna Medicaid |
$6,247.32
|
| Rate for Payer: Cigna Medicare |
$3,286.91
|
| Rate for Payer: Employer Direct Commercial |
$3,286.91
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,286.91
|
| Rate for Payer: Molina CHIP/Medicaid |
$6,247.32
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,286.91
|
| Rate for Payer: Molina Medicare |
$3,286.91
|
| 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 |
$6,247.32
|
| Rate for Payer: Scott and White EPO/PPO |
$4,338.42
|
| Rate for Payer: Scott and White Medicare |
$3,286.91
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$6,247.32
|
| Rate for Payer: Superior Health Plan EPO |
$3,286.91
|
| Rate for Payer: Superior Health Plan Medicare |
$3,286.91
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,286.91
|
| Rate for Payer: Universal American Medicare |
$3,286.91
|
| Rate for Payer: Wellcare Medicare |
$3,286.91
|
| Rate for Payer: Wellmed Medicare |
$3,286.91
|
|
|
Injection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bon
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 0707T
|
| Hospital Charge Code |
3600707T
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,286.91 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,286.91
|
| Rate for Payer: Amerigroup Medicare |
$3,286.91
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,830.11
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,784.56
|
| Rate for Payer: BCBS of TX Medicare |
$3,286.91
|
| Rate for Payer: BCBS of TX PPO |
$7,288.55
|
| Rate for Payer: Cigna Commercial |
$6,947.94
|
| Rate for Payer: Cigna Medicare |
$3,286.91
|
| Rate for Payer: Employer Direct Commercial |
$3,286.91
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,286.91
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,286.91
|
| Rate for Payer: Molina Medicare |
$3,286.91
|
| 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 Medicare |
$3,286.91
|
| Rate for Payer: Superior Health Plan EPO |
$3,286.91
|
| Rate for Payer: Superior Health Plan Medicare |
$3,286.91
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,286.91
|
| Rate for Payer: Universal American Medicare |
$3,286.91
|
| Rate for Payer: Wellcare Medicare |
$3,286.91
|
| Rate for Payer: Wellmed Medicare |
$3,286.91
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophys
|
Facility
|
IP
|
$1,681.46
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
9900805
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,143.39
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophys
|
Facility
|
OP
|
$1,681.46
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
9900805
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$151.33 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$151.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$504.44
|
| Rate for Payer: BCBS of TX Blue Essentials |
$605.33
|
| Rate for Payer: BCBS of TX PPO |
$672.58
|
| Rate for Payer: Cash Price |
$1,143.39
|
| Rate for Payer: Cash Price |
$1,143.39
|
| Rate for Payer: Cigna Medicaid |
$1,210.65
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,210.65
|
| 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 |
$1,210.65
|
| Rate for Payer: Scott and White EPO/PPO |
$840.73
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,210.65
|
| Rate for Payer: Superior Health Plan EPO |
$228.68
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophys
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
36064495
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$10,000.00 |
| 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
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
OP
|
$1,681.46
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
9900804
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$151.33 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$151.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$504.44
|
| Rate for Payer: BCBS of TX Blue Essentials |
$605.33
|
| Rate for Payer: BCBS of TX PPO |
$672.58
|
| Rate for Payer: Cash Price |
$1,143.39
|
| Rate for Payer: Cash Price |
$1,143.39
|
| Rate for Payer: Cigna Medicaid |
$1,210.65
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,210.65
|
| 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 |
$1,210.65
|
| Rate for Payer: Scott and White EPO/PPO |
$840.73
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,210.65
|
| Rate for Payer: Superior Health Plan EPO |
$228.68
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64491
|
| Hospital Charge Code |
36064491
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$10,000.00 |
| 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
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
36064493
|
|
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 |
$1,643.72
|
| 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
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
OP
|
$1,681.46
|
|
|
Service Code
|
HCPCS 64491
|
| Hospital Charge Code |
9900801
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$151.33 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$151.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$504.44
|
| Rate for Payer: BCBS of TX Blue Essentials |
$605.33
|
| Rate for Payer: BCBS of TX PPO |
$672.58
|
| Rate for Payer: Cash Price |
$1,143.39
|
| Rate for Payer: Cash Price |
$1,143.39
|
| Rate for Payer: Cigna Medicaid |
$1,210.65
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,210.65
|
| 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 |
$1,210.65
|
| Rate for Payer: Scott and White EPO/PPO |
$840.73
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,210.65
|
| Rate for Payer: Superior Health Plan EPO |
$228.68
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
OP
|
$2,467.38
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
9900803
|
|
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 |
$1,643.72
|
| 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
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
IP
|
$1,681.46
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
9900804
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,143.39
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
IP
|
$2,467.38
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
9900800
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,677.82
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
36064494
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$10,000.00 |
| 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
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64490
|
| Hospital Charge Code |
36064490
|
|
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 |
$1,643.72
|
| 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
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
IP
|
$1,681.46
|
|
|
Service Code
|
HCPCS 64491
|
| Hospital Charge Code |
9900801
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,143.39
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
IP
|
$2,467.38
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
9900803
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,677.82
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
|
Facility
|
OP
|
$2,467.38
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
9900800
|
|
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 |
$1,643.72
|
| 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
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves
|
Facility
|
OP
|
$1,681.46
|
|
|
Service Code
|
HCPCS 64492
|
| Hospital Charge Code |
9900802
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$151.33 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$151.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$504.44
|
| Rate for Payer: BCBS of TX Blue Essentials |
$605.33
|
| Rate for Payer: BCBS of TX PPO |
$672.58
|
| Rate for Payer: Cash Price |
$1,143.39
|
| Rate for Payer: Cash Price |
$1,143.39
|
| Rate for Payer: Cigna Medicaid |
$1,210.65
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,210.65
|
| 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 |
$1,210.65
|
| Rate for Payer: Scott and White EPO/PPO |
$840.73
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,210.65
|
| Rate for Payer: Superior Health Plan EPO |
$228.68
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves
|
Facility
|
IP
|
$1,681.46
|
|
|
Service Code
|
HCPCS 64492
|
| Hospital Charge Code |
9900802
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,143.39
|
|
|
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64492
|
| Hospital Charge Code |
36064492
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$10,000.00 |
| 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
|
|
|
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of
|
Facility
|
OP
|
$13,844.27
|
|
|
Service Code
|
HCPCS 62326
|
| Hospital Charge Code |
9900750
|
|
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 |
$9,414.10
|
| Rate for Payer: Cash Price |
$9,414.10
|
| Rate for Payer: Cash Price |
$9,414.10
|
| Rate for Payer: Cigna Commercial |
$1,878.13
|
| Rate for Payer: Cigna Medicaid |
$9,967.87
|
| 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 |
$9,967.87
|
| 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 |
$9,967.87
|
| Rate for Payer: Scott and White EPO/PPO |
$1,643.72
|
| Rate for Payer: Scott and White Medicare |
$888.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$9,967.87
|
| 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
|
|
