|
MRI Ankle w/o Contrast Left
|
Facility
|
IP
|
$3,907.00
|
|
|
Service Code
|
HCPCS 73721 LT
|
| Hospital Charge Code |
3700036
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$2,656.76
|
|
|
MRI Ankle w/o Contrast Right
|
Facility
|
OP
|
$3,907.00
|
|
|
Service Code
|
HCPCS 73721 RT
|
| Hospital Charge Code |
3700283
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$208.84 |
| Max. Negotiated Rate |
$2,813.04 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$208.84
|
| 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 |
$2,656.76
|
| Rate for Payer: Cash Price |
$2,656.76
|
| Rate for Payer: Cash Price |
$2,656.76
|
| Rate for Payer: Cigna Commercial |
$506.65
|
| Rate for Payer: Cigna Medicaid |
$2,813.04
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,813.04
|
| Rate for Payer: Multiplan Auto |
$2,539.55
|
| Rate for Payer: Multiplan Commercial |
$2,539.55
|
| Rate for Payer: Multiplan Workers Comp |
$2,539.55
|
| Rate for Payer: Parkland Medicaid |
$2,813.04
|
| Rate for Payer: Scott and White EPO/PPO |
$1,953.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,813.04
|
| Rate for Payer: Superior Health Plan EPO |
$531.35
|
|
|
MRI Ankle w/o Contrast Right
|
Facility
|
IP
|
$3,907.00
|
|
|
Service Code
|
HCPCS 73721 RT
|
| Hospital Charge Code |
3700283
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$2,656.76
|
|
|
MRI Ankle w/ + w/o Contrast Left
|
Facility
|
IP
|
$5,347.00
|
|
|
Service Code
|
HCPCS 73723 LT
|
| Hospital Charge Code |
3750643
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$3,635.96
|
|
|
MRI Ankle w/ + w/o Contrast Left
|
Facility
|
OP
|
$5,347.00
|
|
|
Service Code
|
HCPCS 73723 LT
|
| Hospital Charge Code |
3750643
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$366.42 |
| Max. Negotiated Rate |
$3,849.84 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$366.42
|
| 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 |
$3,635.96
|
| Rate for Payer: Cash Price |
$3,635.96
|
| Rate for Payer: Cash Price |
$3,635.96
|
| Rate for Payer: Cigna Commercial |
$740.81
|
| Rate for Payer: Cigna Medicaid |
$3,849.84
|
| Rate for Payer: Molina CHIP/Medicaid |
$3,849.84
|
| 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 |
$3,849.84
|
| Rate for Payer: Scott and White EPO/PPO |
$2,673.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$3,849.84
|
| Rate for Payer: Superior Health Plan EPO |
$727.19
|
|
|
MRI Ankle w/ + w/o Contrast Right
|
Facility
|
OP
|
$5,347.00
|
|
|
Service Code
|
HCPCS 73723 RT
|
| Hospital Charge Code |
3750833
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$366.42 |
| Max. Negotiated Rate |
$3,849.84 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$366.42
|
| 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 |
$3,635.96
|
| Rate for Payer: Cash Price |
$3,635.96
|
| Rate for Payer: Cash Price |
$3,635.96
|
| Rate for Payer: Cigna Commercial |
$740.81
|
| Rate for Payer: Cigna Medicaid |
$3,849.84
|
| Rate for Payer: Molina CHIP/Medicaid |
$3,849.84
|
| 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 |
$3,849.84
|
| Rate for Payer: Scott and White EPO/PPO |
$2,673.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$3,849.84
|
| Rate for Payer: Superior Health Plan EPO |
$727.19
|
|
|
MRI Ankle w/ + w/o Contrast Right
|
Facility
|
IP
|
$5,347.00
|
|
|
Service Code
|
HCPCS 73723 RT
|
| Hospital Charge Code |
3750833
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$3,635.96
|
|
|
MRI Brain Stroke Protocol w/o Contrast
|
Facility
|
IP
|
$5,026.00
|
|
|
Service Code
|
HCPCS 70551
|
| Hospital Charge Code |
5250802
|
|
Hospital Revenue Code
|
611
|
| Rate for Payer: Cash Price |
$3,417.68
|
|
|
MRI Brain Stroke Protocol w/o Contrast
|
Facility
|
OP
|
$5,026.00
|
|
|
Service Code
|
HCPCS 70551
|
| Hospital Charge Code |
5250802
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$202.15 |
| Max. Negotiated Rate |
$3,618.72 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$202.15
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Amerigroup Medicare |
$239.69
|
| 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 |
$239.69
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$3,417.68
|
| Rate for Payer: Cash Price |
$3,417.68
|
| Rate for Payer: Cash Price |
$3,417.68
|
| Rate for Payer: Cigna Commercial |
$506.65
|
| Rate for Payer: Cigna Medicaid |
$3,618.72
|
| Rate for Payer: Cigna Medicare |
$239.69
|
| Rate for Payer: Employer Direct Commercial |
$239.69
|
| Rate for Payer: Humana Medicare/TRICARE |
$239.69
|
| Rate for Payer: Molina CHIP/Medicaid |
$3,618.72
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Molina Medicare |
$239.69
|
| Rate for Payer: Multiplan Auto |
$3,266.90
|
| Rate for Payer: Multiplan Commercial |
$3,266.90
|
| Rate for Payer: Multiplan Workers Comp |
$3,266.90
|
| Rate for Payer: Parkland Medicaid |
$3,618.72
|
| Rate for Payer: Scott and White EPO/PPO |
$249.07
|
| Rate for Payer: Scott and White Medicare |
$239.69
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$3,618.72
|
| Rate for Payer: Superior Health Plan EPO |
$239.69
|
| Rate for Payer: Superior Health Plan Medicare |
$239.69
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Universal American Medicare |
$239.69
|
| Rate for Payer: Wellcare Medicare |
$239.69
|
| Rate for Payer: Wellmed Medicare |
$239.69
|
|
|
MRI Brain w/ Contrast
|
Facility
|
OP
|
$5,843.00
|
|
|
Service Code
|
HCPCS 70552
|
| Hospital Charge Code |
3700200
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$278.66 |
| Max. Negotiated Rate |
$4,206.96 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$278.66
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Amerigroup Medicare |
$350.46
|
| Rate for Payer: BCBS of TX Blue Advantage |
$630.05
|
| Rate for Payer: BCBS of TX Blue Essentials |
$756.06
|
| Rate for Payer: BCBS of TX Medicare |
$350.46
|
| Rate for Payer: BCBS of TX PPO |
$843.89
|
| Rate for Payer: Cash Price |
$3,973.24
|
| Rate for Payer: Cash Price |
$3,973.24
|
| Rate for Payer: Cash Price |
$3,973.24
|
| Rate for Payer: Cigna Commercial |
$740.81
|
| Rate for Payer: Cigna Medicaid |
$4,206.96
|
| Rate for Payer: Cigna Medicare |
$350.46
|
| Rate for Payer: Employer Direct Commercial |
$350.46
|
| Rate for Payer: Humana Medicare/TRICARE |
$350.46
|
| Rate for Payer: Molina CHIP/Medicaid |
$4,206.96
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Molina Medicare |
$350.46
|
| Rate for Payer: Multiplan Auto |
$3,797.95
|
| Rate for Payer: Multiplan Commercial |
$3,797.95
|
| Rate for Payer: Multiplan Workers Comp |
$3,797.95
|
| Rate for Payer: Parkland Medicaid |
$4,206.96
|
| Rate for Payer: Scott and White EPO/PPO |
$343.40
|
| Rate for Payer: Scott and White Medicare |
$350.46
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$4,206.96
|
| Rate for Payer: Superior Health Plan EPO |
$350.46
|
| Rate for Payer: Superior Health Plan Medicare |
$350.46
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Universal American Medicare |
$350.46
|
| Rate for Payer: Wellcare Medicare |
$350.46
|
| Rate for Payer: Wellmed Medicare |
$350.46
|
|
|
MRI Brain w/ Contrast
|
Facility
|
IP
|
$5,843.00
|
|
|
Service Code
|
HCPCS 70552
|
| Hospital Charge Code |
3700200
|
|
Hospital Revenue Code
|
611
|
| Rate for Payer: Cash Price |
$3,973.24
|
|
|
MRI Brain w/o Contrast
|
Facility
|
OP
|
$5,026.00
|
|
|
Service Code
|
HCPCS 70551
|
| Hospital Charge Code |
3700192
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$202.15 |
| Max. Negotiated Rate |
$3,618.72 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$202.15
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Amerigroup Medicare |
$239.69
|
| 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 |
$239.69
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$3,417.68
|
| Rate for Payer: Cash Price |
$3,417.68
|
| Rate for Payer: Cash Price |
$3,417.68
|
| Rate for Payer: Cigna Commercial |
$506.65
|
| Rate for Payer: Cigna Medicaid |
$3,618.72
|
| Rate for Payer: Cigna Medicare |
$239.69
|
| Rate for Payer: Employer Direct Commercial |
$239.69
|
| Rate for Payer: Humana Medicare/TRICARE |
$239.69
|
| Rate for Payer: Molina CHIP/Medicaid |
$3,618.72
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Molina Medicare |
$239.69
|
| Rate for Payer: Multiplan Auto |
$3,266.90
|
| Rate for Payer: Multiplan Commercial |
$3,266.90
|
| Rate for Payer: Multiplan Workers Comp |
$3,266.90
|
| Rate for Payer: Parkland Medicaid |
$3,618.72
|
| Rate for Payer: Scott and White EPO/PPO |
$249.07
|
| Rate for Payer: Scott and White Medicare |
$239.69
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$3,618.72
|
| Rate for Payer: Superior Health Plan EPO |
$239.69
|
| Rate for Payer: Superior Health Plan Medicare |
$239.69
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Universal American Medicare |
$239.69
|
| Rate for Payer: Wellcare Medicare |
$239.69
|
| Rate for Payer: Wellmed Medicare |
$239.69
|
|
|
MRI Brain w/o Contrast
|
Facility
|
IP
|
$5,026.00
|
|
|
Service Code
|
HCPCS 70551
|
| Hospital Charge Code |
3700192
|
|
Hospital Revenue Code
|
611
|
| Rate for Payer: Cash Price |
$3,417.68
|
|
|
MRI Brain w/ + w/o Contrast
|
Facility
|
IP
|
$8,961.00
|
|
|
Service Code
|
HCPCS 70553
|
| Hospital Charge Code |
3700069
|
|
Hospital Revenue Code
|
611
|
| Rate for Payer: Cash Price |
$6,093.48
|
|
|
MRI Brain w/ + w/o Contrast
|
Facility
|
OP
|
$8,961.00
|
|
|
Service Code
|
HCPCS 70553
|
| Hospital Charge Code |
3700069
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$328.11 |
| Max. Negotiated Rate |
$6,451.92 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$328.11
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Amerigroup Medicare |
$350.46
|
| Rate for Payer: BCBS of TX Blue Advantage |
$630.05
|
| Rate for Payer: BCBS of TX Blue Essentials |
$756.06
|
| Rate for Payer: BCBS of TX Medicare |
$350.46
|
| Rate for Payer: BCBS of TX PPO |
$843.89
|
| Rate for Payer: Cash Price |
$6,093.48
|
| Rate for Payer: Cash Price |
$6,093.48
|
| Rate for Payer: Cash Price |
$6,093.48
|
| Rate for Payer: Cigna Commercial |
$740.81
|
| Rate for Payer: Cigna Medicaid |
$6,451.92
|
| Rate for Payer: Cigna Medicare |
$350.46
|
| Rate for Payer: Employer Direct Commercial |
$350.46
|
| Rate for Payer: Humana Medicare/TRICARE |
$350.46
|
| Rate for Payer: Molina CHIP/Medicaid |
$6,451.92
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Molina Medicare |
$350.46
|
| Rate for Payer: Multiplan Auto |
$5,824.65
|
| Rate for Payer: Multiplan Commercial |
$5,824.65
|
| Rate for Payer: Multiplan Workers Comp |
$5,824.65
|
| Rate for Payer: Parkland Medicaid |
$6,451.92
|
| Rate for Payer: Scott and White EPO/PPO |
$404.32
|
| Rate for Payer: Scott and White Medicare |
$350.46
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$6,451.92
|
| Rate for Payer: Superior Health Plan EPO |
$350.46
|
| Rate for Payer: Superior Health Plan Medicare |
$350.46
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Universal American Medicare |
$350.46
|
| Rate for Payer: Wellcare Medicare |
$350.46
|
| Rate for Payer: Wellmed Medicare |
$350.46
|
|
|
MRI Chest w/o Contrast
|
Facility
|
IP
|
$4,319.00
|
|
|
Service Code
|
HCPCS 71550
|
| Hospital Charge Code |
3700077
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$2,936.92
|
|
|
MRI Chest w/o Contrast
|
Facility
|
OP
|
$4,319.00
|
|
|
Service Code
|
HCPCS 71550
|
| Hospital Charge Code |
3700077
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$233.47 |
| Max. Negotiated Rate |
$3,109.68 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$233.47
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Amerigroup Medicare |
$239.69
|
| 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 |
$239.69
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$2,936.92
|
| Rate for Payer: Cash Price |
$2,936.92
|
| Rate for Payer: Cash Price |
$2,936.92
|
| Rate for Payer: Cigna Commercial |
$506.65
|
| Rate for Payer: Cigna Medicaid |
$3,109.68
|
| Rate for Payer: Cigna Medicare |
$239.69
|
| Rate for Payer: Employer Direct Commercial |
$239.69
|
| Rate for Payer: Humana Medicare/TRICARE |
$239.69
|
| Rate for Payer: Molina CHIP/Medicaid |
$3,109.68
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Molina Medicare |
$239.69
|
| Rate for Payer: Multiplan Auto |
$2,807.35
|
| Rate for Payer: Multiplan Commercial |
$2,807.35
|
| Rate for Payer: Multiplan Workers Comp |
$2,807.35
|
| Rate for Payer: Parkland Medicaid |
$3,109.68
|
| Rate for Payer: Scott and White EPO/PPO |
$429.55
|
| Rate for Payer: Scott and White Medicare |
$239.69
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$3,109.68
|
| Rate for Payer: Superior Health Plan EPO |
$239.69
|
| Rate for Payer: Superior Health Plan Medicare |
$239.69
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Universal American Medicare |
$239.69
|
| Rate for Payer: Wellcare Medicare |
$239.69
|
| Rate for Payer: Wellmed Medicare |
$239.69
|
|
|
MRI Chest w/ + w/o Contrast
|
Facility
|
OP
|
$5,884.00
|
|
|
Service Code
|
HCPCS 71552
|
| Hospital Charge Code |
3750767
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$350.46 |
| Max. Negotiated Rate |
$4,236.48 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$366.42
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Amerigroup Medicare |
$350.46
|
| Rate for Payer: BCBS of TX Blue Advantage |
$630.05
|
| Rate for Payer: BCBS of TX Blue Essentials |
$756.06
|
| Rate for Payer: BCBS of TX Medicare |
$350.46
|
| Rate for Payer: BCBS of TX PPO |
$843.89
|
| Rate for Payer: Cash Price |
$4,001.12
|
| Rate for Payer: Cash Price |
$4,001.12
|
| Rate for Payer: Cash Price |
$4,001.12
|
| Rate for Payer: Cigna Commercial |
$740.81
|
| Rate for Payer: Cigna Medicaid |
$4,236.48
|
| Rate for Payer: Cigna Medicare |
$350.46
|
| Rate for Payer: Employer Direct Commercial |
$350.46
|
| Rate for Payer: Humana Medicare/TRICARE |
$350.46
|
| Rate for Payer: Molina CHIP/Medicaid |
$4,236.48
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Molina Medicare |
$350.46
|
| Rate for Payer: Multiplan Auto |
$3,824.60
|
| Rate for Payer: Multiplan Commercial |
$3,824.60
|
| Rate for Payer: Multiplan Workers Comp |
$3,824.60
|
| Rate for Payer: Parkland Medicaid |
$4,236.48
|
| Rate for Payer: Scott and White EPO/PPO |
$599.23
|
| Rate for Payer: Scott and White Medicare |
$350.46
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$4,236.48
|
| Rate for Payer: Superior Health Plan EPO |
$350.46
|
| Rate for Payer: Superior Health Plan Medicare |
$350.46
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$350.46
|
| Rate for Payer: Universal American Medicare |
$350.46
|
| Rate for Payer: Wellcare Medicare |
$350.46
|
| Rate for Payer: Wellmed Medicare |
$350.46
|
|
|
MRI Chest w/ + w/o Contrast
|
Facility
|
IP
|
$5,884.00
|
|
|
Service Code
|
HCPCS 71552
|
| Hospital Charge Code |
3750767
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$4,001.12
|
|
|
MRI Elbow w/ Contrast Left
|
Facility
|
IP
|
$3,722.00
|
|
|
Service Code
|
HCPCS 73222 LT
|
| Hospital Charge Code |
3740072
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$2,530.96
|
|
|
MRI Elbow w/ Contrast Left
|
Facility
|
OP
|
$3,722.00
|
|
|
Service Code
|
HCPCS 73222 LT
|
| Hospital Charge Code |
3740072
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$323.10 |
| Max. Negotiated Rate |
$2,679.84 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$323.10
|
| 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 |
$2,530.96
|
| Rate for Payer: Cash Price |
$2,530.96
|
| Rate for Payer: Cash Price |
$2,530.96
|
| Rate for Payer: Cigna Commercial |
$1,664.61
|
| Rate for Payer: Cigna Medicaid |
$2,679.84
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,679.84
|
| 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 |
$2,679.84
|
| Rate for Payer: Scott and White EPO/PPO |
$1,861.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,679.84
|
| Rate for Payer: Superior Health Plan EPO |
$506.19
|
|
|
MRI Elbow w/ Contrast Right
|
Facility
|
OP
|
$3,722.00
|
|
|
Service Code
|
HCPCS 73222 RT
|
| Hospital Charge Code |
3750155
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$323.10 |
| Max. Negotiated Rate |
$2,679.84 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$323.10
|
| 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 |
$2,530.96
|
| Rate for Payer: Cash Price |
$2,530.96
|
| Rate for Payer: Cash Price |
$2,530.96
|
| Rate for Payer: Cigna Commercial |
$1,664.61
|
| Rate for Payer: Cigna Medicaid |
$2,679.84
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,679.84
|
| 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 |
$2,679.84
|
| Rate for Payer: Scott and White EPO/PPO |
$1,861.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,679.84
|
| Rate for Payer: Superior Health Plan EPO |
$506.19
|
|
|
MRI Elbow w/ Contrast Right
|
Facility
|
IP
|
$3,722.00
|
|
|
Service Code
|
HCPCS 73222 RT
|
| Hospital Charge Code |
3750155
|
|
Hospital Revenue Code
|
610
|
| Rate for Payer: Cash Price |
$2,530.96
|
|
|
MRI Face Neck Orbit w/o Contrast
|
Facility
|
OP
|
$3,625.00
|
|
|
Service Code
|
HCPCS 70540
|
| Hospital Charge Code |
3700085
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$233.23 |
| Max. Negotiated Rate |
$2,610.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$233.23
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Amerigroup Medicare |
$239.69
|
| 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 |
$239.69
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$2,465.00
|
| Rate for Payer: Cash Price |
$2,465.00
|
| Rate for Payer: Cash Price |
$2,465.00
|
| Rate for Payer: Cigna Commercial |
$506.65
|
| Rate for Payer: Cigna Medicaid |
$2,610.00
|
| Rate for Payer: Cigna Medicare |
$239.69
|
| Rate for Payer: Employer Direct Commercial |
$239.69
|
| Rate for Payer: Humana Medicare/TRICARE |
$239.69
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,610.00
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Molina Medicare |
$239.69
|
| Rate for Payer: Multiplan Auto |
$2,356.25
|
| Rate for Payer: Multiplan Commercial |
$2,356.25
|
| Rate for Payer: Multiplan Workers Comp |
$2,356.25
|
| Rate for Payer: Parkland Medicaid |
$2,610.00
|
| Rate for Payer: Scott and White EPO/PPO |
$287.44
|
| Rate for Payer: Scott and White Medicare |
$239.69
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,610.00
|
| Rate for Payer: Superior Health Plan EPO |
$239.69
|
| Rate for Payer: Superior Health Plan Medicare |
$239.69
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Universal American Medicare |
$239.69
|
| Rate for Payer: Wellcare Medicare |
$239.69
|
| Rate for Payer: Wellmed Medicare |
$239.69
|
|
|
MRI Face Neck Orbit w/o Contrast
|
Facility
|
IP
|
$3,625.00
|
|
|
Service Code
|
HCPCS 70540
|
| Hospital Charge Code |
3700085
|
|
Hospital Revenue Code
|
611
|
| Rate for Payer: Cash Price |
$2,465.00
|
|