|
XR Myelogram Lumbosacral Spine BCE
|
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
|
|
|
XR Myelogram Lumbosacral Spine BCE
|
Facility
|
IP
|
$2,214.00
|
|
|
Service Code
|
CPT 72265 FY
|
| Hospital Charge Code |
3180010
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$1,948.32
|
|
|
XR Myelogram Lumb/Thorac SP W/Lumbar 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 Thoracic Spine
|
Facility
|
OP
|
$2,309.00
|
|
|
Service Code
|
CPT 72255 FY
|
| Hospital Charge Code |
2100220
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$1,658.78 |
| Rate for Payer: Aetna Commercial |
$84.58
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$120.63
|
| 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 |
$2,031.92
|
| Rate for Payer: Cash Price |
$2,031.92
|
| Rate for Payer: Cash Price |
$2,031.92
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicaid |
$120.63
|
| 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 |
$120.63
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| Rate for Payer: Multiplan Auto |
$1,500.85
|
| Rate for Payer: Multiplan Commercial |
$1,500.85
|
| Rate for Payer: Multiplan Workers Comp |
$1,500.85
|
| Rate for Payer: Parkland Medicaid |
$120.63
|
| 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 |
$120.63
|
| 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 Thoracic Spine BCE
|
Facility
|
IP
|
$2,309.00
|
|
|
Service Code
|
CPT 72255 FY
|
| Hospital Charge Code |
2100220
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$2,031.92
|
|
|
XR Myelogram Thoracic Spine BCE
|
Facility
|
OP
|
$2,309.00
|
|
|
Service Code
|
CPT 72255 FY
|
| Hospital Charge Code |
2100220
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$1,658.78 |
| Rate for Payer: Aetna Commercial |
$84.58
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$120.63
|
| 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 |
$2,031.92
|
| Rate for Payer: Cash Price |
$2,031.92
|
| Rate for Payer: Cash Price |
$2,031.92
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicaid |
$120.63
|
| 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 |
$120.63
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| Rate for Payer: Multiplan Auto |
$1,500.85
|
| Rate for Payer: Multiplan Commercial |
$1,500.85
|
| Rate for Payer: Multiplan Workers Comp |
$1,500.85
|
| Rate for Payer: Parkland Medicaid |
$120.63
|
| 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 |
$120.63
|
| 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 Thoracic Spine W/Lumbar Inj
|
Facility
|
OP
|
$3,159.00
|
|
|
Service Code
|
CPT 62303 FY
|
| Hospital Charge Code |
4902302
|
|
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 Thoracic Spine W/Lumbar Inj BCE
|
Facility
|
OP
|
$3,159.00
|
|
|
Service Code
|
CPT 62303 FY
|
| Hospital Charge Code |
4902302
|
|
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 Thoracic Spine W/Lumbar Inj BCE
|
Facility
|
IP
|
$3,159.00
|
|
|
Service Code
|
CPT 62303 FY
|
| Hospital Charge Code |
4902302
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$2,779.92
|
|
|
XR Myelography 2 or More Regions
|
Facility
|
OP
|
$3,190.00
|
|
|
Service Code
|
CPT 72270 FY
|
| Hospital Charge Code |
3180011
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$2,073.50 |
| Rate for Payer: Aetna Commercial |
$116.94
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$165.06
|
| 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 |
$2,807.20
|
| Rate for Payer: Cash Price |
$2,807.20
|
| Rate for Payer: Cash Price |
$2,807.20
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicaid |
$165.06
|
| 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 |
$165.06
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| Rate for Payer: Multiplan Auto |
$2,073.50
|
| Rate for Payer: Multiplan Commercial |
$2,073.50
|
| Rate for Payer: Multiplan Workers Comp |
$2,073.50
|
| Rate for Payer: Parkland Medicaid |
$165.06
|
| 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 |
$165.06
|
| 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 Myelography 2 or More Regions BCE
|
Facility
|
OP
|
$3,190.00
|
|
|
Service Code
|
CPT 72270 FY
|
| Hospital Charge Code |
3180011
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$2,073.50 |
| Rate for Payer: Aetna Commercial |
$116.94
|
| Rate for Payer: Aetna Medicare |
$1,098.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$165.06
|
| 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 |
$2,807.20
|
| Rate for Payer: Cash Price |
$2,807.20
|
| Rate for Payer: Cash Price |
$2,807.20
|
| Rate for Payer: Cigna Commercial |
$1,658.78
|
| Rate for Payer: Cigna Medicaid |
$165.06
|
| 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 |
$165.06
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$732.26
|
| Rate for Payer: Molina Medicare |
$732.26
|
| Rate for Payer: Multiplan Auto |
$2,073.50
|
| Rate for Payer: Multiplan Commercial |
$2,073.50
|
| Rate for Payer: Multiplan Workers Comp |
$2,073.50
|
| Rate for Payer: Parkland Medicaid |
$165.06
|
| 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 |
$165.06
|
| 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 Myelography 2 or More Regions BCE
|
Facility
|
IP
|
$3,190.00
|
|
|
Service Code
|
CPT 72270 FY
|
| Hospital Charge Code |
3180011
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$2,807.20
|
|
|
XR Nasal Bones 3+ Views
|
Facility
|
OP
|
$387.00
|
|
|
Service Code
|
CPT 70160 FY
|
| Hospital Charge Code |
3100153
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$251.55 |
| Rate for Payer: Aetna Commercial |
$34.11
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$38.43
|
| 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 |
$340.56
|
| Rate for Payer: Cash Price |
$340.56
|
| Rate for Payer: Cash Price |
$340.56
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$38.43
|
| 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 |
$38.43
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$251.55
|
| Rate for Payer: Multiplan Commercial |
$251.55
|
| Rate for Payer: Multiplan Workers Comp |
$251.55
|
| Rate for Payer: Parkland Medicaid |
$38.43
|
| 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 |
$38.43
|
| 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 Nasal Bones 3+ Views BCE
|
Facility
|
IP
|
$387.00
|
|
|
Service Code
|
CPT 70160 FY
|
| Hospital Charge Code |
3100153
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$340.56
|
|
|
XR Nasal Bones 3+ Views BCE
|
Facility
|
OP
|
$387.00
|
|
|
Service Code
|
CPT 70160 FY
|
| Hospital Charge Code |
3100153
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$251.55 |
| Rate for Payer: Aetna Commercial |
$34.11
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$38.43
|
| 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 |
$340.56
|
| Rate for Payer: Cash Price |
$340.56
|
| Rate for Payer: Cash Price |
$340.56
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$38.43
|
| 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 |
$38.43
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$251.55
|
| Rate for Payer: Multiplan Commercial |
$251.55
|
| Rate for Payer: Multiplan Workers Comp |
$251.55
|
| Rate for Payer: Parkland Medicaid |
$38.43
|
| 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 |
$38.43
|
| 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 Neck Soft Tissue
|
Facility
|
OP
|
$667.00
|
|
|
Service Code
|
CPT 70360 FY
|
| Hospital Charge Code |
3100245
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$433.55 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$31.74
|
| 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 |
$586.96
|
| Rate for Payer: Cash Price |
$586.96
|
| Rate for Payer: Cash Price |
$586.96
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$31.74
|
| 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 |
$31.74
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$433.55
|
| Rate for Payer: Multiplan Commercial |
$433.55
|
| Rate for Payer: Multiplan Workers Comp |
$433.55
|
| Rate for Payer: Parkland Medicaid |
$31.74
|
| 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 |
$31.74
|
| 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 Neck Soft Tissue BCE
|
Facility
|
IP
|
$667.00
|
|
|
Service Code
|
CPT 70360 FY
|
| Hospital Charge Code |
3100245
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$586.96
|
|
|
XR Neck Soft Tissue BCE
|
Facility
|
OP
|
$667.00
|
|
|
Service Code
|
CPT 70360 FY
|
| Hospital Charge Code |
3100245
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$433.55 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$31.74
|
| 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 |
$586.96
|
| Rate for Payer: Cash Price |
$586.96
|
| Rate for Payer: Cash Price |
$586.96
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$31.74
|
| 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 |
$31.74
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$433.55
|
| Rate for Payer: Multiplan Commercial |
$433.55
|
| Rate for Payer: Multiplan Workers Comp |
$433.55
|
| Rate for Payer: Parkland Medicaid |
$31.74
|
| 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 |
$31.74
|
| 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 Orbits Complete
|
Facility
|
OP
|
$349.00
|
|
|
Service Code
|
CPT 70200 FY
|
| Hospital Charge Code |
3150067
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$247.70 |
| Rate for Payer: Aetna Commercial |
$40.27
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$48.11
|
| 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 |
$307.12
|
| Rate for Payer: Cash Price |
$307.12
|
| Rate for Payer: Cash Price |
$307.12
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$48.11
|
| 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 |
$48.11
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$226.85
|
| Rate for Payer: Multiplan Commercial |
$226.85
|
| Rate for Payer: Multiplan Workers Comp |
$226.85
|
| Rate for Payer: Parkland Medicaid |
$48.11
|
| 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 |
$48.11
|
| 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 Orbits Complete BCE
|
Facility
|
IP
|
$349.00
|
|
|
Service Code
|
CPT 70200 FY
|
| Hospital Charge Code |
3150067
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$307.12
|
|
|
XR Orbits Complete BCE
|
Facility
|
OP
|
$349.00
|
|
|
Service Code
|
CPT 70200 FY
|
| Hospital Charge Code |
3150067
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$247.70 |
| Rate for Payer: Aetna Commercial |
$40.27
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$48.11
|
| 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 |
$307.12
|
| Rate for Payer: Cash Price |
$307.12
|
| Rate for Payer: Cash Price |
$307.12
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$48.11
|
| 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 |
$48.11
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$226.85
|
| Rate for Payer: Multiplan Commercial |
$226.85
|
| Rate for Payer: Multiplan Workers Comp |
$226.85
|
| Rate for Payer: Parkland Medicaid |
$48.11
|
| 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 |
$48.11
|
| 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 Osseous Survey Complete
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
CPT 77075 FY
|
| Hospital Charge Code |
3120078
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$308.75 |
| Rate for Payer: Aetna Commercial |
$84.19
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$100.24
|
| 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 |
$418.00
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$100.24
|
| 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 |
$100.24
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$308.75
|
| Rate for Payer: Multiplan Commercial |
$308.75
|
| Rate for Payer: Multiplan Workers Comp |
$308.75
|
| Rate for Payer: Parkland Medicaid |
$100.24
|
| 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 |
$100.24
|
| 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 Osseous Survey Complete BCE
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
CPT 77075 FY
|
| Hospital Charge Code |
3120078
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$308.75 |
| Rate for Payer: Aetna Commercial |
$84.19
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$100.24
|
| 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 |
$418.00
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$100.24
|
| 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 |
$100.24
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$308.75
|
| Rate for Payer: Multiplan Commercial |
$308.75
|
| Rate for Payer: Multiplan Workers Comp |
$308.75
|
| Rate for Payer: Parkland Medicaid |
$100.24
|
| 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 |
$100.24
|
| 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 Osseous Survey Complete BCE
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
CPT 77075 FY
|
| Hospital Charge Code |
3120078
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$418.00
|
|
|
XR Osseous Survey Infant
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
CPT 77076 FY
|
| Hospital Charge Code |
3120086
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$324.35 |
| Rate for Payer: Aetna Commercial |
$84.96
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$106.88
|
| 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 |
$439.12
|
| Rate for Payer: Cash Price |
$439.12
|
| Rate for Payer: Cash Price |
$439.12
|
| 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 |
$324.35
|
| Rate for Payer: Multiplan Commercial |
$324.35
|
| Rate for Payer: Multiplan Workers Comp |
$324.35
|
| 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
|
|
