|
US Breast Complete Left BCE
|
Facility
|
OP
|
$589.00
|
|
|
Service Code
|
CPT 76641 LT
|
| Hospital Charge Code |
3530061
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna Commercial |
$79.57
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$103.91
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Amerigroup Medicare |
$100.55
|
| Rate for Payer: BCBS of TX Blue Advantage |
$184.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$221.92
|
| Rate for Payer: BCBS of TX Medicare |
$100.55
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$518.32
|
| Rate for Payer: Cash Price |
$518.32
|
| Rate for Payer: Cash Price |
$518.32
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$27.80
|
| Rate for Payer: Cigna Medicare |
$100.55
|
| Rate for Payer: Employer Direct Commercial |
$100.55
|
| Rate for Payer: Humana Medicare/TRICARE |
$100.55
|
| Rate for Payer: Molina CHIP/Medicaid |
$27.80
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$382.85
|
| Rate for Payer: Multiplan Commercial |
$382.85
|
| Rate for Payer: Multiplan Workers Comp |
$382.85
|
| Rate for Payer: Parkland Medicaid |
$27.80
|
| Rate for Payer: Scott and White EPO/PPO |
$1.80
|
| Rate for Payer: Scott and White Medicare |
$100.55
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$27.80
|
| Rate for Payer: Superior Health Plan EPO |
$100.55
|
| Rate for Payer: Superior Health Plan Medicare |
$100.55
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Universal American Medicare |
$100.55
|
| Rate for Payer: Wellcare Medicare |
$100.55
|
| Rate for Payer: Wellmed Medicare |
$100.55
|
|
|
US Breast Complete Right
|
Facility
|
OP
|
$589.00
|
|
|
Service Code
|
CPT 76641 RT
|
| Hospital Charge Code |
3530060
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna Commercial |
$79.57
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$103.91
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Amerigroup Medicare |
$100.55
|
| Rate for Payer: BCBS of TX Blue Advantage |
$184.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$221.92
|
| Rate for Payer: BCBS of TX Medicare |
$100.55
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$518.32
|
| Rate for Payer: Cash Price |
$518.32
|
| Rate for Payer: Cash Price |
$518.32
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$27.80
|
| Rate for Payer: Cigna Medicare |
$100.55
|
| Rate for Payer: Employer Direct Commercial |
$100.55
|
| Rate for Payer: Humana Medicare/TRICARE |
$100.55
|
| Rate for Payer: Molina CHIP/Medicaid |
$27.80
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$382.85
|
| Rate for Payer: Multiplan Commercial |
$382.85
|
| Rate for Payer: Multiplan Workers Comp |
$382.85
|
| Rate for Payer: Parkland Medicaid |
$27.80
|
| Rate for Payer: Scott and White EPO/PPO |
$1.80
|
| Rate for Payer: Scott and White Medicare |
$100.55
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$27.80
|
| Rate for Payer: Superior Health Plan EPO |
$100.55
|
| Rate for Payer: Superior Health Plan Medicare |
$100.55
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Universal American Medicare |
$100.55
|
| Rate for Payer: Wellcare Medicare |
$100.55
|
| Rate for Payer: Wellmed Medicare |
$100.55
|
|
|
US Breast Complete Right BCE
|
Facility
|
IP
|
$589.00
|
|
|
Service Code
|
CPT 76641 RT
|
| Hospital Charge Code |
3530060
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$518.32
|
|
|
US Breast Complete Right BCE
|
Facility
|
OP
|
$589.00
|
|
|
Service Code
|
CPT 76641 RT
|
| Hospital Charge Code |
3530060
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna Commercial |
$79.57
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$103.91
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Amerigroup Medicare |
$100.55
|
| Rate for Payer: BCBS of TX Blue Advantage |
$184.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$221.92
|
| Rate for Payer: BCBS of TX Medicare |
$100.55
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$518.32
|
| Rate for Payer: Cash Price |
$518.32
|
| Rate for Payer: Cash Price |
$518.32
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$27.80
|
| Rate for Payer: Cigna Medicare |
$100.55
|
| Rate for Payer: Employer Direct Commercial |
$100.55
|
| Rate for Payer: Humana Medicare/TRICARE |
$100.55
|
| Rate for Payer: Molina CHIP/Medicaid |
$27.80
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$382.85
|
| Rate for Payer: Multiplan Commercial |
$382.85
|
| Rate for Payer: Multiplan Workers Comp |
$382.85
|
| Rate for Payer: Parkland Medicaid |
$27.80
|
| Rate for Payer: Scott and White EPO/PPO |
$1.80
|
| Rate for Payer: Scott and White Medicare |
$100.55
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$27.80
|
| Rate for Payer: Superior Health Plan EPO |
$100.55
|
| Rate for Payer: Superior Health Plan Medicare |
$100.55
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Universal American Medicare |
$100.55
|
| Rate for Payer: Wellcare Medicare |
$100.55
|
| Rate for Payer: Wellmed Medicare |
$100.55
|
|
|
US Breast Cyst Aspiration Left
|
Facility
|
OP
|
$647.00
|
|
|
Service Code
|
CPT 19000 LT
|
| Hospital Charge Code |
3520058
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$14.19 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$59.25
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$130.18
|
| Rate for Payer: BCBS of TX Blue Essentials |
$155.90
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$196.43
|
| Rate for Payer: Cash Price |
$569.36
|
| Rate for Payer: Cash Price |
$569.36
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$33.41
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$33.41
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| 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 |
$33.41
|
| Rate for Payer: Scott and White EPO/PPO |
$14.19
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$59.25
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
US Breast Cyst Aspiration Left BCE
|
Facility
|
OP
|
$647.00
|
|
|
Service Code
|
CPT 19000 LT
|
| Hospital Charge Code |
3520058
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$14.19 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$59.25
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$130.18
|
| Rate for Payer: BCBS of TX Blue Essentials |
$155.90
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$196.43
|
| Rate for Payer: Cash Price |
$569.36
|
| Rate for Payer: Cash Price |
$569.36
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$33.41
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$33.41
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| 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 |
$33.41
|
| Rate for Payer: Scott and White EPO/PPO |
$14.19
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$59.25
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
US Breast Cyst Aspiration Right
|
Facility
|
OP
|
$647.00
|
|
|
Service Code
|
CPT 19000 RT
|
| Hospital Charge Code |
3520058
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$14.19 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$59.25
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$130.18
|
| Rate for Payer: BCBS of TX Blue Essentials |
$155.90
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$196.43
|
| Rate for Payer: Cash Price |
$569.36
|
| Rate for Payer: Cash Price |
$569.36
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$33.41
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$33.41
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| 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 |
$33.41
|
| Rate for Payer: Scott and White EPO/PPO |
$14.19
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$59.25
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
US Breast Cyst Aspiration Right BCE
|
Facility
|
IP
|
$647.00
|
|
|
Service Code
|
CPT 19000 RT
|
| Hospital Charge Code |
3520058
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$569.36
|
|
|
US Breast Cyst Aspiration Right BCE
|
Facility
|
OP
|
$647.00
|
|
|
Service Code
|
CPT 19000 RT
|
| Hospital Charge Code |
3520058
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$14.19 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$59.25
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$130.18
|
| Rate for Payer: BCBS of TX Blue Essentials |
$155.90
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$196.43
|
| Rate for Payer: Cash Price |
$569.36
|
| Rate for Payer: Cash Price |
$569.36
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$33.41
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$33.41
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| 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 |
$33.41
|
| Rate for Payer: Scott and White EPO/PPO |
$14.19
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$59.25
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
US Breast Device Plcmnt w/US Guide Left
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
CPT 19285 LT
|
| Hospital Charge Code |
3530041
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$1,537.23 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$135.00
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,018.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,220.02
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$1,537.23
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$66.29
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$66.29
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| Rate for Payer: Multiplan Auto |
$975.00
|
| Rate for Payer: Multiplan Commercial |
$975.00
|
| Rate for Payer: Multiplan Workers Comp |
$975.00
|
| Rate for Payer: Parkland Medicaid |
$66.29
|
| Rate for Payer: Scott and White EPO/PPO |
$11.51
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$66.29
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
US Breast Device Plcmnt w/US Guide Left BCE
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
CPT 19285 LT
|
| Hospital Charge Code |
3530041
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$1,537.23 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$135.00
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,018.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,220.02
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$1,537.23
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$66.29
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$66.29
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| Rate for Payer: Multiplan Auto |
$975.00
|
| Rate for Payer: Multiplan Commercial |
$975.00
|
| Rate for Payer: Multiplan Workers Comp |
$975.00
|
| Rate for Payer: Parkland Medicaid |
$66.29
|
| Rate for Payer: Scott and White EPO/PPO |
$11.51
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$66.29
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
US Breast Device Plcmnt w/US Guide Left BCE
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
CPT 19285 LT
|
| Hospital Charge Code |
3530041
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$1,320.00
|
|
|
US Breast Device Plcmnt w/US Guide Right
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
CPT 19285 RT
|
| Hospital Charge Code |
3530039
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$1,537.23 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$135.00
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,018.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,220.02
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$1,537.23
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$66.29
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$66.29
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| Rate for Payer: Multiplan Auto |
$975.00
|
| Rate for Payer: Multiplan Commercial |
$975.00
|
| Rate for Payer: Multiplan Workers Comp |
$975.00
|
| Rate for Payer: Parkland Medicaid |
$66.29
|
| Rate for Payer: Scott and White EPO/PPO |
$11.51
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$66.29
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
US Breast Device Plcmnt w/US Guide Right BCE
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
CPT 19285 RT
|
| Hospital Charge Code |
3530039
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$1,537.23 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$135.00
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,018.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,220.02
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$1,537.23
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$66.29
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$66.29
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| Rate for Payer: Multiplan Auto |
$975.00
|
| Rate for Payer: Multiplan Commercial |
$975.00
|
| Rate for Payer: Multiplan Workers Comp |
$975.00
|
| Rate for Payer: Parkland Medicaid |
$66.29
|
| Rate for Payer: Scott and White EPO/PPO |
$11.51
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$66.29
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
US Breast Device Plcmnt w/US Guide Right BCE
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
CPT 19285 RT
|
| Hospital Charge Code |
3530039
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$1,320.00
|
|
|
US Breast Limited Left
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
CPT 76642 LT
|
| Hospital Charge Code |
3530063
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$337.35 |
| Rate for Payer: Aetna Commercial |
$60.69
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$85.54
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Amerigroup Medicare |
$83.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$131.69
|
| Rate for Payer: BCBS of TX Blue Essentials |
$158.02
|
| Rate for Payer: BCBS of TX Medicare |
$83.10
|
| Rate for Payer: BCBS of TX PPO |
$176.38
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$25.93
|
| Rate for Payer: Cigna Medicare |
$83.10
|
| Rate for Payer: Employer Direct Commercial |
$83.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$83.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$25.93
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$337.35
|
| Rate for Payer: Multiplan Commercial |
$337.35
|
| Rate for Payer: Multiplan Workers Comp |
$337.35
|
| Rate for Payer: Parkland Medicaid |
$25.93
|
| Rate for Payer: Scott and White EPO/PPO |
$1.49
|
| Rate for Payer: Scott and White Medicare |
$83.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$25.93
|
| Rate for Payer: Superior Health Plan EPO |
$83.10
|
| Rate for Payer: Superior Health Plan Medicare |
$83.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Universal American Medicare |
$83.10
|
| Rate for Payer: Wellcare Medicare |
$83.10
|
| Rate for Payer: Wellmed Medicare |
$83.10
|
|
|
US Breast Limited Left BCE
|
Facility
|
IP
|
$519.00
|
|
|
Service Code
|
CPT 76642 LT
|
| Hospital Charge Code |
3530063
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$456.72
|
|
|
US Breast Limited Left BCE
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
CPT 76642 LT
|
| Hospital Charge Code |
3530063
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$337.35 |
| Rate for Payer: Aetna Commercial |
$60.69
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$85.54
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Amerigroup Medicare |
$83.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$131.69
|
| Rate for Payer: BCBS of TX Blue Essentials |
$158.02
|
| Rate for Payer: BCBS of TX Medicare |
$83.10
|
| Rate for Payer: BCBS of TX PPO |
$176.38
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$25.93
|
| Rate for Payer: Cigna Medicare |
$83.10
|
| Rate for Payer: Employer Direct Commercial |
$83.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$83.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$25.93
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$337.35
|
| Rate for Payer: Multiplan Commercial |
$337.35
|
| Rate for Payer: Multiplan Workers Comp |
$337.35
|
| Rate for Payer: Parkland Medicaid |
$25.93
|
| Rate for Payer: Scott and White EPO/PPO |
$1.49
|
| Rate for Payer: Scott and White Medicare |
$83.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$25.93
|
| Rate for Payer: Superior Health Plan EPO |
$83.10
|
| Rate for Payer: Superior Health Plan Medicare |
$83.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Universal American Medicare |
$83.10
|
| Rate for Payer: Wellcare Medicare |
$83.10
|
| Rate for Payer: Wellmed Medicare |
$83.10
|
|
|
US Breast Limited Right
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
CPT 76642 RT
|
| Hospital Charge Code |
3530062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$337.35 |
| Rate for Payer: Aetna Commercial |
$60.69
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$85.54
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Amerigroup Medicare |
$83.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$131.69
|
| Rate for Payer: BCBS of TX Blue Essentials |
$158.02
|
| Rate for Payer: BCBS of TX Medicare |
$83.10
|
| Rate for Payer: BCBS of TX PPO |
$176.38
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$25.93
|
| Rate for Payer: Cigna Medicare |
$83.10
|
| Rate for Payer: Employer Direct Commercial |
$83.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$83.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$25.93
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$337.35
|
| Rate for Payer: Multiplan Commercial |
$337.35
|
| Rate for Payer: Multiplan Workers Comp |
$337.35
|
| Rate for Payer: Parkland Medicaid |
$25.93
|
| Rate for Payer: Scott and White EPO/PPO |
$1.49
|
| Rate for Payer: Scott and White Medicare |
$83.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$25.93
|
| Rate for Payer: Superior Health Plan EPO |
$83.10
|
| Rate for Payer: Superior Health Plan Medicare |
$83.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Universal American Medicare |
$83.10
|
| Rate for Payer: Wellcare Medicare |
$83.10
|
| Rate for Payer: Wellmed Medicare |
$83.10
|
|
|
US Breast Limited Right BCE
|
Facility
|
IP
|
$519.00
|
|
|
Service Code
|
CPT 76642 RT
|
| Hospital Charge Code |
3530062
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$456.72
|
|
|
US Breast Limited Right BCE
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
CPT 76642 RT
|
| Hospital Charge Code |
3530062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$337.35 |
| Rate for Payer: Aetna Commercial |
$60.69
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$85.54
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Amerigroup Medicare |
$83.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$131.69
|
| Rate for Payer: BCBS of TX Blue Essentials |
$158.02
|
| Rate for Payer: BCBS of TX Medicare |
$83.10
|
| Rate for Payer: BCBS of TX PPO |
$176.38
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cash Price |
$456.72
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$25.93
|
| Rate for Payer: Cigna Medicare |
$83.10
|
| Rate for Payer: Employer Direct Commercial |
$83.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$83.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$25.93
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$337.35
|
| Rate for Payer: Multiplan Commercial |
$337.35
|
| Rate for Payer: Multiplan Workers Comp |
$337.35
|
| Rate for Payer: Parkland Medicaid |
$25.93
|
| Rate for Payer: Scott and White EPO/PPO |
$1.49
|
| Rate for Payer: Scott and White Medicare |
$83.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$25.93
|
| Rate for Payer: Superior Health Plan EPO |
$83.10
|
| Rate for Payer: Superior Health Plan Medicare |
$83.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Universal American Medicare |
$83.10
|
| Rate for Payer: Wellcare Medicare |
$83.10
|
| Rate for Payer: Wellmed Medicare |
$83.10
|
|
|
US Carotid Duplex Bilateral
|
Facility
|
OP
|
$3,317.00
|
|
|
Service Code
|
CPT 93880
|
| Hospital Charge Code |
3500139
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$4.01 |
| Max. Negotiated Rate |
$2,156.05 |
| Rate for Payer: Aetna Commercial |
$312.54
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$298.53
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Amerigroup Medicare |
$224.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$285.95
|
| Rate for Payer: BCBS of TX Blue Essentials |
$341.83
|
| Rate for Payer: BCBS of TX Medicare |
$224.10
|
| Rate for Payer: BCBS of TX PPO |
$381.27
|
| Rate for Payer: Cash Price |
$2,918.96
|
| Rate for Payer: Cash Price |
$2,918.96
|
| Rate for Payer: Cash Price |
$2,918.96
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$191.46
|
| 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 |
$191.46
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Molina Medicare |
$224.10
|
| Rate for Payer: Multiplan Auto |
$2,156.05
|
| Rate for Payer: Multiplan Commercial |
$2,156.05
|
| Rate for Payer: Multiplan Workers Comp |
$2,156.05
|
| Rate for Payer: Parkland Medicaid |
$191.46
|
| Rate for Payer: Scott and White EPO/PPO |
$4.01
|
| Rate for Payer: Scott and White Medicare |
$224.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$191.46
|
| 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
|
|
|
US Carotid Duplex Bilateral BCE
|
Facility
|
OP
|
$3,317.00
|
|
|
Service Code
|
CPT 93880
|
| Hospital Charge Code |
3500139
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$4.01 |
| Max. Negotiated Rate |
$2,156.05 |
| Rate for Payer: Aetna Commercial |
$312.54
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$298.53
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Amerigroup Medicare |
$224.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$285.95
|
| Rate for Payer: BCBS of TX Blue Essentials |
$341.83
|
| Rate for Payer: BCBS of TX Medicare |
$224.10
|
| Rate for Payer: BCBS of TX PPO |
$381.27
|
| Rate for Payer: Cash Price |
$2,918.96
|
| Rate for Payer: Cash Price |
$2,918.96
|
| Rate for Payer: Cash Price |
$2,918.96
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$191.46
|
| 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 |
$191.46
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Molina Medicare |
$224.10
|
| Rate for Payer: Multiplan Auto |
$2,156.05
|
| Rate for Payer: Multiplan Commercial |
$2,156.05
|
| Rate for Payer: Multiplan Workers Comp |
$2,156.05
|
| Rate for Payer: Parkland Medicaid |
$191.46
|
| Rate for Payer: Scott and White EPO/PPO |
$4.01
|
| Rate for Payer: Scott and White Medicare |
$224.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$191.46
|
| 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
|
|
|
US Carotid Duplex Bilateral BCE
|
Facility
|
IP
|
$3,317.00
|
|
|
Service Code
|
CPT 93880
|
| Hospital Charge Code |
3500139
|
|
Hospital Revenue Code
|
921
|
| Rate for Payer: Cash Price |
$2,918.96
|
|
|
US Carotid Duplex Left
|
Facility
|
OP
|
$1,338.00
|
|
|
Service Code
|
CPT 93882 LT
|
| Hospital Charge Code |
5036540
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$869.70 |
| Rate for Payer: Aetna Commercial |
$206.12
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$120.42
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Amerigroup Medicare |
$100.55
|
| Rate for Payer: BCBS of TX Blue Advantage |
$183.73
|
| Rate for Payer: BCBS of TX Blue Essentials |
$219.63
|
| Rate for Payer: BCBS of TX Medicare |
$100.55
|
| Rate for Payer: BCBS of TX PPO |
$244.97
|
| Rate for Payer: Cash Price |
$1,177.44
|
| Rate for Payer: Cash Price |
$1,177.44
|
| Rate for Payer: Cash Price |
$1,177.44
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$106.88
|
| Rate for Payer: Cigna Medicare |
$100.55
|
| Rate for Payer: Employer Direct Commercial |
$100.55
|
| Rate for Payer: Humana Medicare/TRICARE |
$100.55
|
| Rate for Payer: Molina CHIP/Medicaid |
$106.88
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$869.70
|
| Rate for Payer: Multiplan Commercial |
$869.70
|
| Rate for Payer: Multiplan Workers Comp |
$869.70
|
| Rate for Payer: Parkland Medicaid |
$106.88
|
| Rate for Payer: Scott and White EPO/PPO |
$1.80
|
| Rate for Payer: Scott and White Medicare |
$100.55
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$106.88
|
| Rate for Payer: Superior Health Plan EPO |
$100.55
|
| Rate for Payer: Superior Health Plan Medicare |
$100.55
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Universal American Medicare |
$100.55
|
| Rate for Payer: Wellcare Medicare |
$100.55
|
| Rate for Payer: Wellmed Medicare |
$100.55
|
|
