|
XR Lower Extremity Infant (0-1yr) Right BCE
|
Facility
|
OP
|
$553.00
|
|
|
Service Code
|
CPT 73592 RT,FY
|
| Hospital Charge Code |
3101706
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$359.45 |
| Rate for Payer: Aetna Commercial |
$27.56
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$80.90
|
| 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 |
$486.64
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$80.90
|
| 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 |
$80.90
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$359.45
|
| Rate for Payer: Multiplan Commercial |
$359.45
|
| Rate for Payer: Multiplan Workers Comp |
$359.45
|
| Rate for Payer: Parkland Medicaid |
$80.90
|
| 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 |
$80.90
|
| 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
|
|
|
XR Mandible Complete 4+ Views
|
Facility
|
OP
|
$341.00
|
|
|
Service Code
|
CPT 70110 FY
|
| Hospital Charge Code |
3100120
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$247.70 |
| Rate for Payer: Aetna Commercial |
$36.80
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$43.44
|
| 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 |
$300.08
|
| Rate for Payer: Cash Price |
$300.08
|
| Rate for Payer: Cash Price |
$300.08
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$43.44
|
| 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 |
$43.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$221.65
|
| Rate for Payer: Multiplan Commercial |
$221.65
|
| Rate for Payer: Multiplan Workers Comp |
$221.65
|
| Rate for Payer: Parkland Medicaid |
$43.44
|
| 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 |
$43.44
|
| 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
|
|
|
XR Mandible Complete 4+ Views BCE
|
Facility
|
IP
|
$341.00
|
|
|
Service Code
|
CPT 70110 FY
|
| Hospital Charge Code |
3100120
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$300.08
|
|
|
XR Mandible Complete 4+ Views BCE
|
Facility
|
OP
|
$341.00
|
|
|
Service Code
|
CPT 70110 FY
|
| Hospital Charge Code |
3100120
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$247.70 |
| Rate for Payer: Aetna Commercial |
$36.80
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$43.44
|
| 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 |
$300.08
|
| Rate for Payer: Cash Price |
$300.08
|
| Rate for Payer: Cash Price |
$300.08
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$43.44
|
| 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 |
$43.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$221.65
|
| Rate for Payer: Multiplan Commercial |
$221.65
|
| Rate for Payer: Multiplan Workers Comp |
$221.65
|
| Rate for Payer: Parkland Medicaid |
$43.44
|
| 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 |
$43.44
|
| 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
|
|
|
XR Mandible Less Than 4 Views
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
CPT 70100 FY
|
| Hospital Charge Code |
3100112
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$188.25 |
| Rate for Payer: Aetna Commercial |
$34.11
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$38.76
|
| 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 |
$177.76
|
| Rate for Payer: Cash Price |
$177.76
|
| Rate for Payer: Cash Price |
$177.76
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$38.76
|
| 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 |
$38.76
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$131.30
|
| Rate for Payer: Multiplan Commercial |
$131.30
|
| Rate for Payer: Multiplan Workers Comp |
$131.30
|
| Rate for Payer: Parkland Medicaid |
$38.76
|
| 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 |
$38.76
|
| 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
|
|
|
XR Mandible Less Than 4 Views BCE
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
CPT 70100 FY
|
| Hospital Charge Code |
3100112
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$188.25 |
| Rate for Payer: Aetna Commercial |
$34.11
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$38.76
|
| 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 |
$177.76
|
| Rate for Payer: Cash Price |
$177.76
|
| Rate for Payer: Cash Price |
$177.76
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$38.76
|
| 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 |
$38.76
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$131.30
|
| Rate for Payer: Multiplan Commercial |
$131.30
|
| Rate for Payer: Multiplan Workers Comp |
$131.30
|
| Rate for Payer: Parkland Medicaid |
$38.76
|
| 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 |
$38.76
|
| 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
|
|
|
XR Mandible Less Than 4 Views BCE
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
CPT 70100 FY
|
| Hospital Charge Code |
3100112
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$177.76
|
|
|
XR Mastoids < 3 Views Bilateral
|
Facility
|
OP
|
$478.00
|
|
|
Service Code
|
CPT 70120 FY
|
| Hospital Charge Code |
4930120
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$310.70 |
| Rate for Payer: Aetna Commercial |
$34.49
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$38.76
|
| 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 |
$420.64
|
| Rate for Payer: Cash Price |
$420.64
|
| Rate for Payer: Cash Price |
$420.64
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$38.76
|
| 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 |
$38.76
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$310.70
|
| Rate for Payer: Multiplan Commercial |
$310.70
|
| Rate for Payer: Multiplan Workers Comp |
$310.70
|
| Rate for Payer: Parkland Medicaid |
$38.76
|
| 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 |
$38.76
|
| 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
|
|
|
XR Mastoids < 3 Views Bilateral BCE
|
Facility
|
OP
|
$478.00
|
|
|
Service Code
|
CPT 70120 FY
|
| Hospital Charge Code |
4930120
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$310.70 |
| Rate for Payer: Aetna Commercial |
$34.49
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$38.76
|
| 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 |
$420.64
|
| Rate for Payer: Cash Price |
$420.64
|
| Rate for Payer: Cash Price |
$420.64
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$38.76
|
| 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 |
$38.76
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$310.70
|
| Rate for Payer: Multiplan Commercial |
$310.70
|
| Rate for Payer: Multiplan Workers Comp |
$310.70
|
| Rate for Payer: Parkland Medicaid |
$38.76
|
| 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 |
$38.76
|
| 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
|
|
|
XR Mastoids < 3 Views Bilateral BCE
|
Facility
|
IP
|
$478.00
|
|
|
Service Code
|
CPT 70120 FY
|
| Hospital Charge Code |
4930120
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$420.64
|
|
|
XR Myelogram Cervical Spine
|
Facility
|
OP
|
$2,267.00
|
|
|
Service Code
|
CPT 72240 FY
|
| Hospital Charge Code |
3180008
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$1,658.78 |
| Rate for Payer: Aetna Commercial |
$83.04
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$115.28
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Amerigroup Medicare |
$732.26
|
| 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 Medicare |
$732.26
|
| Rate for Payer: BCBS of TX PPO |
$1,504.61
|
| Rate for Payer: Cash Price |
$1,994.96
|
| Rate for Payer: Cash Price |
$1,994.96
|
| Rate for Payer: Cash Price |
$1,994.96
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicaid |
$115.28
|
| Rate for Payer: Cigna Medicare |
$732.26
|
| Rate for Payer: Employer Direct Commercial |
$732.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$732.26
|
| Rate for Payer: Molina CHIP/Medicaid |
$115.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| Rate for Payer: Multiplan Auto |
$1,473.55
|
| Rate for Payer: Multiplan Commercial |
$1,473.55
|
| Rate for Payer: Multiplan Workers Comp |
$1,473.55
|
| Rate for Payer: Parkland Medicaid |
$115.28
|
| Rate for Payer: Scott and White EPO/PPO |
$13.10
|
| Rate for Payer: Scott and White Medicare |
$732.26
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$115.28
|
| Rate for Payer: Superior Health Plan EPO |
$732.26
|
| Rate for Payer: Superior Health Plan Medicare |
$732.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Universal American Medicare |
$732.26
|
| Rate for Payer: Wellcare Medicare |
$732.26
|
| Rate for Payer: Wellmed Medicare |
$732.26
|
|
|
XR Myelogram Cervical Spine BCE
|
Facility
|
OP
|
$2,267.00
|
|
|
Service Code
|
CPT 72240 FY
|
| Hospital Charge Code |
3180008
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$1,658.78 |
| Rate for Payer: Aetna Commercial |
$83.04
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$115.28
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Amerigroup Medicare |
$732.26
|
| 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 Medicare |
$732.26
|
| Rate for Payer: BCBS of TX PPO |
$1,504.61
|
| Rate for Payer: Cash Price |
$1,994.96
|
| Rate for Payer: Cash Price |
$1,994.96
|
| Rate for Payer: Cash Price |
$1,994.96
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicaid |
$115.28
|
| Rate for Payer: Cigna Medicare |
$732.26
|
| Rate for Payer: Employer Direct Commercial |
$732.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$732.26
|
| Rate for Payer: Molina CHIP/Medicaid |
$115.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| Rate for Payer: Multiplan Auto |
$1,473.55
|
| Rate for Payer: Multiplan Commercial |
$1,473.55
|
| Rate for Payer: Multiplan Workers Comp |
$1,473.55
|
| Rate for Payer: Parkland Medicaid |
$115.28
|
| Rate for Payer: Scott and White EPO/PPO |
$13.10
|
| Rate for Payer: Scott and White Medicare |
$732.26
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$115.28
|
| Rate for Payer: Superior Health Plan EPO |
$732.26
|
| Rate for Payer: Superior Health Plan Medicare |
$732.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Universal American Medicare |
$732.26
|
| Rate for Payer: Wellcare Medicare |
$732.26
|
| Rate for Payer: Wellmed Medicare |
$732.26
|
|
|
XR Myelogram Cervical Spine BCE
|
Facility
|
IP
|
$2,267.00
|
|
|
Service Code
|
CPT 72240 FY
|
| Hospital Charge Code |
3180008
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$1,994.96
|
|
|
XR Myelogram Cervical Spine W/Lumbar Inj
|
Facility
|
OP
|
$2,568.00
|
|
|
Service Code
|
CPT 62302 FY
|
| Hospital Charge Code |
3181100
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$231.12
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Amerigroup Medicare |
$732.26
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,136.97
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,361.64
|
| Rate for Payer: BCBS of TX Medicare |
$732.26
|
| Rate for Payer: BCBS of TX PPO |
$1,715.67
|
| Rate for Payer: Cash Price |
$2,259.84
|
| Rate for Payer: Cash Price |
$2,259.84
|
| Rate for Payer: Cash Price |
$2,259.84
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicare |
$732.26
|
| Rate for Payer: Employer Direct Commercial |
$732.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$732.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| 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 |
$16.15
|
| Rate for Payer: Scott and White Medicare |
$732.26
|
| Rate for Payer: Superior Health Plan EPO |
$732.26
|
| Rate for Payer: Superior Health Plan Medicare |
$732.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Universal American Medicare |
$732.26
|
| Rate for Payer: Wellcare Medicare |
$732.26
|
| Rate for Payer: Wellmed Medicare |
$732.26
|
|
|
XR Myelogram Cervical Spine W/Lumbar Inj BCE
|
Facility
|
IP
|
$2,568.00
|
|
|
Service Code
|
CPT 62302 FY
|
| Hospital Charge Code |
3181100
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$2,259.84
|
|
|
XR Myelogram Cervical Spine W/Lumbar Inj BCE
|
Facility
|
OP
|
$2,568.00
|
|
|
Service Code
|
CPT 62302 FY
|
| Hospital Charge Code |
3181100
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$231.12
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Amerigroup Medicare |
$732.26
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,136.97
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,361.64
|
| Rate for Payer: BCBS of TX Medicare |
$732.26
|
| Rate for Payer: BCBS of TX PPO |
$1,715.67
|
| Rate for Payer: Cash Price |
$2,259.84
|
| Rate for Payer: Cash Price |
$2,259.84
|
| Rate for Payer: Cash Price |
$2,259.84
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicare |
$732.26
|
| Rate for Payer: Employer Direct Commercial |
$732.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$732.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| 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 |
$16.15
|
| Rate for Payer: Scott and White Medicare |
$732.26
|
| Rate for Payer: Superior Health Plan EPO |
$732.26
|
| Rate for Payer: Superior Health Plan Medicare |
$732.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Universal American Medicare |
$732.26
|
| Rate for Payer: Wellcare Medicare |
$732.26
|
| Rate for Payer: Wellmed Medicare |
$732.26
|
|
|
XR Myelogram Cervical/Thorac W/Lumb Inj
|
Facility
|
OP
|
$3,159.00
|
|
|
Service Code
|
CPT 62305 FY
|
| Hospital Charge Code |
3181103
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$284.31
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Amerigroup Medicare |
$732.26
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,136.97
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,361.64
|
| Rate for Payer: BCBS of TX Medicare |
$732.26
|
| Rate for Payer: BCBS of TX PPO |
$1,715.67
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicare |
$732.26
|
| Rate for Payer: Employer Direct Commercial |
$732.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$732.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| 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 |
$16.15
|
| Rate for Payer: Scott and White Medicare |
$732.26
|
| Rate for Payer: Superior Health Plan EPO |
$732.26
|
| Rate for Payer: Superior Health Plan Medicare |
$732.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Universal American Medicare |
$732.26
|
| Rate for Payer: Wellcare Medicare |
$732.26
|
| Rate for Payer: Wellmed Medicare |
$732.26
|
|
|
XR Myelogram Complete Spine W/Lumb Inj
|
Facility
|
OP
|
$3,159.00
|
|
|
Service Code
|
CPT 62305 FY
|
| Hospital Charge Code |
3181103
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$284.31
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Amerigroup Medicare |
$732.26
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,136.97
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,361.64
|
| Rate for Payer: BCBS of TX Medicare |
$732.26
|
| Rate for Payer: BCBS of TX PPO |
$1,715.67
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicare |
$732.26
|
| Rate for Payer: Employer Direct Commercial |
$732.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$732.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| 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 |
$16.15
|
| Rate for Payer: Scott and White Medicare |
$732.26
|
| Rate for Payer: Superior Health Plan EPO |
$732.26
|
| Rate for Payer: Superior Health Plan Medicare |
$732.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Universal American Medicare |
$732.26
|
| Rate for Payer: Wellcare Medicare |
$732.26
|
| Rate for Payer: Wellmed Medicare |
$732.26
|
|
|
XR Myelogram Complete Spine W/Lumb Inj BCE
|
Facility
|
OP
|
$3,159.00
|
|
|
Service Code
|
CPT 62305 FY
|
| Hospital Charge Code |
3181103
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$284.31
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Amerigroup Medicare |
$732.26
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,136.97
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,361.64
|
| Rate for Payer: BCBS of TX Medicare |
$732.26
|
| Rate for Payer: BCBS of TX PPO |
$1,715.67
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicare |
$732.26
|
| Rate for Payer: Employer Direct Commercial |
$732.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$732.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| 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 |
$16.15
|
| Rate for Payer: Scott and White Medicare |
$732.26
|
| Rate for Payer: Superior Health Plan EPO |
$732.26
|
| Rate for Payer: Superior Health Plan Medicare |
$732.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Universal American Medicare |
$732.26
|
| Rate for Payer: Wellcare Medicare |
$732.26
|
| Rate for Payer: Wellmed Medicare |
$732.26
|
|
|
XR Myelogram Complete Spine W/Lumb Inj BCE
|
Facility
|
IP
|
$3,159.00
|
|
|
Service Code
|
CPT 62305 FY
|
| Hospital Charge Code |
3181103
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$2,779.92
|
|
|
XR Myelogram Lumbar Spine W/Lumbar Inj
|
Facility
|
OP
|
$2,520.00
|
|
|
Service Code
|
CPT 62304 FY
|
| Hospital Charge Code |
3181102
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$226.80
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Amerigroup Medicare |
$732.26
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,136.97
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,361.64
|
| Rate for Payer: BCBS of TX Medicare |
$732.26
|
| Rate for Payer: BCBS of TX PPO |
$1,715.67
|
| Rate for Payer: Cash Price |
$2,217.60
|
| Rate for Payer: Cash Price |
$2,217.60
|
| Rate for Payer: Cash Price |
$2,217.60
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicare |
$732.26
|
| Rate for Payer: Employer Direct Commercial |
$732.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$732.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| 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 |
$16.15
|
| Rate for Payer: Scott and White Medicare |
$732.26
|
| Rate for Payer: Superior Health Plan EPO |
$732.26
|
| Rate for Payer: Superior Health Plan Medicare |
$732.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Universal American Medicare |
$732.26
|
| Rate for Payer: Wellcare Medicare |
$732.26
|
| Rate for Payer: Wellmed Medicare |
$732.26
|
|
|
XR Myelogram Lumbar Spine W/Lumbar Inj BCE
|
Facility
|
IP
|
$2,520.00
|
|
|
Service Code
|
CPT 62304 FY
|
| Hospital Charge Code |
3181102
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$2,217.60
|
|
|
XR Myelogram Lumbar Spine W/Lumbar Inj BCE
|
Facility
|
OP
|
$2,520.00
|
|
|
Service Code
|
CPT 62304 FY
|
| Hospital Charge Code |
3181102
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$226.80
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Amerigroup Medicare |
$732.26
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,136.97
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,361.64
|
| Rate for Payer: BCBS of TX Medicare |
$732.26
|
| Rate for Payer: BCBS of TX PPO |
$1,715.67
|
| Rate for Payer: Cash Price |
$2,217.60
|
| Rate for Payer: Cash Price |
$2,217.60
|
| Rate for Payer: Cash Price |
$2,217.60
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicare |
$732.26
|
| Rate for Payer: Employer Direct Commercial |
$732.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$732.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| 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 |
$16.15
|
| Rate for Payer: Scott and White Medicare |
$732.26
|
| Rate for Payer: Superior Health Plan EPO |
$732.26
|
| Rate for Payer: Superior Health Plan Medicare |
$732.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Universal American Medicare |
$732.26
|
| Rate for Payer: Wellcare Medicare |
$732.26
|
| Rate for Payer: Wellmed Medicare |
$732.26
|
|
|
XR Myelogram Lumb/Cervical SP W/Lumb Inj
|
Facility
|
OP
|
$3,159.00
|
|
|
Service Code
|
CPT 62305 FY
|
| Hospital Charge Code |
3181103
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$284.31
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Amerigroup Medicare |
$732.26
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,136.97
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,361.64
|
| Rate for Payer: BCBS of TX Medicare |
$732.26
|
| Rate for Payer: BCBS of TX PPO |
$1,715.67
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cash Price |
$2,779.92
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicare |
$732.26
|
| Rate for Payer: Employer Direct Commercial |
$732.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$732.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| 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 |
$16.15
|
| Rate for Payer: Scott and White Medicare |
$732.26
|
| Rate for Payer: Superior Health Plan EPO |
$732.26
|
| Rate for Payer: Superior Health Plan Medicare |
$732.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Universal American Medicare |
$732.26
|
| Rate for Payer: Wellcare Medicare |
$732.26
|
| Rate for Payer: Wellmed Medicare |
$732.26
|
|
|
XR Myelogram Lumbosacral Spine
|
Facility
|
OP
|
$2,214.00
|
|
|
Service Code
|
CPT 72265 FY
|
| Hospital Charge Code |
3180010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$1,658.78 |
| Rate for Payer: Aetna Commercial |
$81.11
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$109.93
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Amerigroup Medicare |
$732.26
|
| 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 Medicare |
$732.26
|
| Rate for Payer: BCBS of TX PPO |
$1,504.61
|
| Rate for Payer: Cash Price |
$1,948.32
|
| Rate for Payer: Cash Price |
$1,948.32
|
| Rate for Payer: Cash Price |
$1,948.32
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicaid |
$109.93
|
| Rate for Payer: Cigna Medicare |
$732.26
|
| Rate for Payer: Employer Direct Commercial |
$732.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$732.26
|
| Rate for Payer: Molina CHIP/Medicaid |
$109.93
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| Rate for Payer: Multiplan Auto |
$1,439.10
|
| Rate for Payer: Multiplan Commercial |
$1,439.10
|
| Rate for Payer: Multiplan Workers Comp |
$1,439.10
|
| Rate for Payer: Parkland Medicaid |
$109.93
|
| Rate for Payer: Scott and White EPO/PPO |
$13.10
|
| Rate for Payer: Scott and White Medicare |
$732.26
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$109.93
|
| Rate for Payer: Superior Health Plan EPO |
$732.26
|
| Rate for Payer: Superior Health Plan Medicare |
$732.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Universal American Medicare |
$732.26
|
| Rate for Payer: Wellcare Medicare |
$732.26
|
| Rate for Payer: Wellmed Medicare |
$732.26
|
|
