|
OTAH PT Mechanical Traction Assistant Units BCE
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS 97012
|
| Hospital Charge Code |
9238556
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$16.38
|
| Rate for Payer: BCBS of TX Blue Advantage |
$54.60
|
| Rate for Payer: BCBS of TX Blue Essentials |
$65.52
|
| Rate for Payer: BCBS of TX PPO |
$72.80
|
| Rate for Payer: Cash Price |
$123.76
|
| Rate for Payer: Cash Price |
$123.76
|
| Rate for Payer: Cash Price |
$123.76
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$131.04
|
| Rate for Payer: Molina CHIP/Medicaid |
$131.04
|
| Rate for Payer: Multiplan Auto |
$118.30
|
| Rate for Payer: Multiplan Commercial |
$118.30
|
| Rate for Payer: Multiplan Workers Comp |
$118.30
|
| Rate for Payer: Parkland Medicaid |
$131.04
|
| Rate for Payer: Scott and White EPO/PPO |
$17.30
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$131.04
|
| Rate for Payer: Superior Health Plan EPO |
$24.75
|
|
|
OTAH PT Mechanical Traction Assistant Units BCE
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS 97012
|
| Hospital Charge Code |
9238556
|
|
Hospital Revenue Code
|
420
|
| Rate for Payer: Cash Price |
$123.76
|
|
|
OTAH PT Mechanical Traction Units BCE
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS 97012
|
| Hospital Charge Code |
9238555
|
|
Hospital Revenue Code
|
420
|
| Rate for Payer: Cash Price |
$123.76
|
|
|
OTAH PT Mechanical Traction Units BCE
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS 97012
|
| Hospital Charge Code |
9238555
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$16.38
|
| Rate for Payer: BCBS of TX Blue Advantage |
$54.60
|
| Rate for Payer: BCBS of TX Blue Essentials |
$65.52
|
| Rate for Payer: BCBS of TX PPO |
$72.80
|
| Rate for Payer: Cash Price |
$123.76
|
| Rate for Payer: Cash Price |
$123.76
|
| Rate for Payer: Cash Price |
$123.76
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$131.04
|
| Rate for Payer: Molina CHIP/Medicaid |
$131.04
|
| Rate for Payer: Multiplan Auto |
$118.30
|
| Rate for Payer: Multiplan Commercial |
$118.30
|
| Rate for Payer: Multiplan Workers Comp |
$118.30
|
| Rate for Payer: Parkland Medicaid |
$131.04
|
| Rate for Payer: Scott and White EPO/PPO |
$17.30
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$131.04
|
| Rate for Payer: Superior Health Plan EPO |
$24.75
|
|
|
OTAH PT Negative-Pressure Wound Therapy <50cm Units BCE
|
Facility
|
OP
|
$794.80
|
|
|
Service Code
|
HCPCS 97605
|
| Hospital Charge Code |
5707614
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$29.71 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$71.53
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Amerigroup Medicare |
$201.55
|
| Rate for Payer: BCBS of TX Blue Advantage |
$238.44
|
| Rate for Payer: BCBS of TX Blue Essentials |
$286.13
|
| Rate for Payer: BCBS of TX Medicare |
$201.55
|
| Rate for Payer: BCBS of TX PPO |
$317.92
|
| Rate for Payer: Cash Price |
$540.46
|
| Rate for Payer: Cash Price |
$540.46
|
| Rate for Payer: Cash Price |
$540.46
|
| Rate for Payer: Cigna Commercial |
$426.04
|
| Rate for Payer: Cigna Medicaid |
$572.26
|
| Rate for Payer: Cigna Medicare |
$201.55
|
| Rate for Payer: Employer Direct Commercial |
$201.55
|
| Rate for Payer: Humana Medicare/TRICARE |
$201.55
|
| Rate for Payer: Molina CHIP/Medicaid |
$572.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Molina Medicare |
$201.55
|
| 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 |
$572.26
|
| Rate for Payer: Scott and White EPO/PPO |
$29.71
|
| Rate for Payer: Scott and White Medicare |
$201.55
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$572.26
|
| Rate for Payer: Superior Health Plan EPO |
$201.55
|
| Rate for Payer: Superior Health Plan Medicare |
$201.55
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Universal American Medicare |
$201.55
|
| Rate for Payer: Wellcare Medicare |
$201.55
|
| Rate for Payer: Wellmed Medicare |
$201.55
|
|
|
OTAH PT Negative-Pressure Wound Therapy <50cm Units BCE
|
Facility
|
IP
|
$794.80
|
|
|
Service Code
|
HCPCS 97605
|
| Hospital Charge Code |
5707614
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$540.46
|
|
|
OTAH PT Negative-Pressure Wound Therapy >50cm Units BCE
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 97606
|
| Hospital Charge Code |
9238558
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$32.61 |
| Max. Negotiated Rate |
$408.37 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$36.00
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Amerigroup Medicare |
$408.37
|
| Rate for Payer: BCBS of TX Blue Advantage |
$120.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$144.00
|
| Rate for Payer: BCBS of TX Medicare |
$408.37
|
| Rate for Payer: BCBS of TX PPO |
$160.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$288.00
|
| Rate for Payer: Cigna Medicare |
$408.37
|
| Rate for Payer: Employer Direct Commercial |
$408.37
|
| Rate for Payer: Humana Medicare/TRICARE |
$408.37
|
| Rate for Payer: Molina CHIP/Medicaid |
$288.00
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Molina Medicare |
$408.37
|
| Rate for Payer: Multiplan Auto |
$260.00
|
| Rate for Payer: Multiplan Commercial |
$260.00
|
| Rate for Payer: Multiplan Workers Comp |
$260.00
|
| Rate for Payer: Parkland Medicaid |
$288.00
|
| Rate for Payer: Scott and White EPO/PPO |
$32.61
|
| Rate for Payer: Scott and White Medicare |
$408.37
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$288.00
|
| Rate for Payer: Superior Health Plan EPO |
$408.37
|
| Rate for Payer: Superior Health Plan Medicare |
$408.37
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Universal American Medicare |
$408.37
|
| Rate for Payer: Wellcare Medicare |
$408.37
|
| Rate for Payer: Wellmed Medicare |
$408.37
|
|
|
OTAH PT Negative-Pressure Wound Therapy >50cm Units BCE
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 97606
|
| Hospital Charge Code |
9238560
|
|
Hospital Revenue Code
|
420
|
| Rate for Payer: Cash Price |
$272.00
|
|
|
OTAH PT Negative-Pressure Wound Therapy >50cm Units BCE
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 97606
|
| Hospital Charge Code |
9238560
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$32.61 |
| Max. Negotiated Rate |
$408.37 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$36.00
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Amerigroup Medicare |
$408.37
|
| Rate for Payer: BCBS of TX Blue Advantage |
$120.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$144.00
|
| Rate for Payer: BCBS of TX Medicare |
$408.37
|
| Rate for Payer: BCBS of TX PPO |
$160.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$288.00
|
| Rate for Payer: Cigna Medicare |
$408.37
|
| Rate for Payer: Employer Direct Commercial |
$408.37
|
| Rate for Payer: Humana Medicare/TRICARE |
$408.37
|
| Rate for Payer: Molina CHIP/Medicaid |
$288.00
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Molina Medicare |
$408.37
|
| Rate for Payer: Multiplan Auto |
$260.00
|
| Rate for Payer: Multiplan Commercial |
$260.00
|
| Rate for Payer: Multiplan Workers Comp |
$260.00
|
| Rate for Payer: Parkland Medicaid |
$288.00
|
| Rate for Payer: Scott and White EPO/PPO |
$32.61
|
| Rate for Payer: Scott and White Medicare |
$408.37
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$288.00
|
| Rate for Payer: Superior Health Plan EPO |
$408.37
|
| Rate for Payer: Superior Health Plan Medicare |
$408.37
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Universal American Medicare |
$408.37
|
| Rate for Payer: Wellcare Medicare |
$408.37
|
| Rate for Payer: Wellmed Medicare |
$408.37
|
|
|
OTAH PT Negative-Pressure Wound Therapy >50cm Units BCE
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 97606
|
| Hospital Charge Code |
9238558
|
|
Hospital Revenue Code
|
420
|
| Rate for Payer: Cash Price |
$272.00
|
|
|
OTAH PT Neg-Pressure Wound Therapy <50cm Assist Units BCE
|
Facility
|
IP
|
$794.80
|
|
|
Service Code
|
HCPCS 97605
|
| Hospital Charge Code |
9238559
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$540.46
|
|
|
OTAH PT Neg-Pressure Wound Therapy <50cm Assist Units BCE
|
Facility
|
OP
|
$794.80
|
|
|
Service Code
|
HCPCS 97605
|
| Hospital Charge Code |
9238559
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$29.71 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$71.53
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Amerigroup Medicare |
$201.55
|
| Rate for Payer: BCBS of TX Blue Advantage |
$238.44
|
| Rate for Payer: BCBS of TX Blue Essentials |
$286.13
|
| Rate for Payer: BCBS of TX Medicare |
$201.55
|
| Rate for Payer: BCBS of TX PPO |
$317.92
|
| Rate for Payer: Cash Price |
$540.46
|
| Rate for Payer: Cash Price |
$540.46
|
| Rate for Payer: Cash Price |
$540.46
|
| Rate for Payer: Cigna Commercial |
$426.04
|
| Rate for Payer: Cigna Medicaid |
$572.26
|
| Rate for Payer: Cigna Medicare |
$201.55
|
| Rate for Payer: Employer Direct Commercial |
$201.55
|
| Rate for Payer: Humana Medicare/TRICARE |
$201.55
|
| Rate for Payer: Molina CHIP/Medicaid |
$572.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Molina Medicare |
$201.55
|
| 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 |
$572.26
|
| Rate for Payer: Scott and White EPO/PPO |
$29.71
|
| Rate for Payer: Scott and White Medicare |
$201.55
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$572.26
|
| Rate for Payer: Superior Health Plan EPO |
$201.55
|
| Rate for Payer: Superior Health Plan Medicare |
$201.55
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Universal American Medicare |
$201.55
|
| Rate for Payer: Wellcare Medicare |
$201.55
|
| Rate for Payer: Wellmed Medicare |
$201.55
|
|
|
OTAH PT Neg-Pressure Wound Therapy <50cm Assist Units BCE
|
Facility
|
OP
|
$794.80
|
|
|
Service Code
|
HCPCS 97605
|
| Hospital Charge Code |
9238557
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$29.71 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$71.53
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Amerigroup Medicare |
$201.55
|
| Rate for Payer: BCBS of TX Blue Advantage |
$238.44
|
| Rate for Payer: BCBS of TX Blue Essentials |
$286.13
|
| Rate for Payer: BCBS of TX Medicare |
$201.55
|
| Rate for Payer: BCBS of TX PPO |
$317.92
|
| Rate for Payer: Cash Price |
$540.46
|
| Rate for Payer: Cash Price |
$540.46
|
| Rate for Payer: Cash Price |
$540.46
|
| Rate for Payer: Cigna Commercial |
$426.04
|
| Rate for Payer: Cigna Medicaid |
$572.26
|
| Rate for Payer: Cigna Medicare |
$201.55
|
| Rate for Payer: Employer Direct Commercial |
$201.55
|
| Rate for Payer: Humana Medicare/TRICARE |
$201.55
|
| Rate for Payer: Molina CHIP/Medicaid |
$572.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Molina Medicare |
$201.55
|
| 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 |
$572.26
|
| Rate for Payer: Scott and White EPO/PPO |
$29.71
|
| Rate for Payer: Scott and White Medicare |
$201.55
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$572.26
|
| Rate for Payer: Superior Health Plan EPO |
$201.55
|
| Rate for Payer: Superior Health Plan Medicare |
$201.55
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Universal American Medicare |
$201.55
|
| Rate for Payer: Wellcare Medicare |
$201.55
|
| Rate for Payer: Wellmed Medicare |
$201.55
|
|
|
OTAH PT Neg-Pressure Wound Therapy <50cm Assist Units BCE
|
Facility
|
IP
|
$794.80
|
|
|
Service Code
|
HCPCS 97605
|
| Hospital Charge Code |
9238557
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$540.46
|
|
|
OTAH PT Neg-Pressure Wound Therapy >50cm Assist Units BCE
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 97606
|
| Hospital Charge Code |
7150626
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$32.61 |
| Max. Negotiated Rate |
$408.37 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$36.00
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Amerigroup Medicare |
$408.37
|
| Rate for Payer: BCBS of TX Blue Advantage |
$120.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$144.00
|
| Rate for Payer: BCBS of TX Medicare |
$408.37
|
| Rate for Payer: BCBS of TX PPO |
$160.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$288.00
|
| Rate for Payer: Cigna Medicare |
$408.37
|
| Rate for Payer: Employer Direct Commercial |
$408.37
|
| Rate for Payer: Humana Medicare/TRICARE |
$408.37
|
| Rate for Payer: Molina CHIP/Medicaid |
$288.00
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Molina Medicare |
$408.37
|
| Rate for Payer: Multiplan Auto |
$260.00
|
| Rate for Payer: Multiplan Commercial |
$260.00
|
| Rate for Payer: Multiplan Workers Comp |
$260.00
|
| Rate for Payer: Parkland Medicaid |
$288.00
|
| Rate for Payer: Scott and White EPO/PPO |
$32.61
|
| Rate for Payer: Scott and White Medicare |
$408.37
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$288.00
|
| Rate for Payer: Superior Health Plan EPO |
$408.37
|
| Rate for Payer: Superior Health Plan Medicare |
$408.37
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Universal American Medicare |
$408.37
|
| Rate for Payer: Wellcare Medicare |
$408.37
|
| Rate for Payer: Wellmed Medicare |
$408.37
|
|
|
OTAH PT Neg-Pressure Wound Therapy >50cm Assist Units BCE
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 97606
|
| Hospital Charge Code |
7150626
|
|
Hospital Revenue Code
|
420
|
| Rate for Payer: Cash Price |
$272.00
|
|
|
OTAH PT Neuromuscular Reeducation Assistant Units BCE
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS 97112
|
| Hospital Charge Code |
9238562
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$11.61 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.61
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38.70
|
| Rate for Payer: BCBS of TX Blue Essentials |
$46.44
|
| Rate for Payer: BCBS of TX PPO |
$51.60
|
| Rate for Payer: Cash Price |
$87.72
|
| Rate for Payer: Cash Price |
$87.72
|
| Rate for Payer: Cash Price |
$87.72
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$92.88
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.88
|
| Rate for Payer: Multiplan Auto |
$83.85
|
| Rate for Payer: Multiplan Commercial |
$83.85
|
| Rate for Payer: Multiplan Workers Comp |
$83.85
|
| Rate for Payer: Parkland Medicaid |
$92.88
|
| Rate for Payer: Scott and White EPO/PPO |
$41.66
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.88
|
| Rate for Payer: Superior Health Plan EPO |
$17.54
|
|
|
OTAH PT Neuromuscular Reeducation Assistant Units BCE
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS 97112
|
| Hospital Charge Code |
9238562
|
|
Hospital Revenue Code
|
420
|
| Rate for Payer: Cash Price |
$87.72
|
|
|
OTAH PT Neuromuscular Reeducation Units BCE
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS 97112
|
| Hospital Charge Code |
9238561
|
|
Hospital Revenue Code
|
420
|
| Rate for Payer: Cash Price |
$87.72
|
|
|
OTAH PT Neuromuscular Reeducation Units BCE
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS 97112
|
| Hospital Charge Code |
9238561
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$11.61 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.61
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38.70
|
| Rate for Payer: BCBS of TX Blue Essentials |
$46.44
|
| Rate for Payer: BCBS of TX PPO |
$51.60
|
| Rate for Payer: Cash Price |
$87.72
|
| Rate for Payer: Cash Price |
$87.72
|
| Rate for Payer: Cash Price |
$87.72
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$92.88
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.88
|
| Rate for Payer: Multiplan Auto |
$83.85
|
| Rate for Payer: Multiplan Commercial |
$83.85
|
| Rate for Payer: Multiplan Workers Comp |
$83.85
|
| Rate for Payer: Parkland Medicaid |
$92.88
|
| Rate for Payer: Scott and White EPO/PPO |
$41.66
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.88
|
| Rate for Payer: Superior Health Plan EPO |
$17.54
|
|
|
OTAH PT Orthotic Management, Train Assistant Units BCE
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS 97760
|
| Hospital Charge Code |
9238564
|
|
Hospital Revenue Code
|
420
|
| Rate for Payer: Cash Price |
$119.00
|
|
|
OTAH PT Orthotic Management, Train Assistant Units BCE
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS 97760
|
| Hospital Charge Code |
9238564
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$15.75
|
| Rate for Payer: BCBS of TX Blue Advantage |
$52.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$63.00
|
| Rate for Payer: BCBS of TX PPO |
$70.00
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$126.00
|
| Rate for Payer: Molina CHIP/Medicaid |
$126.00
|
| Rate for Payer: Multiplan Auto |
$113.75
|
| Rate for Payer: Multiplan Commercial |
$113.75
|
| Rate for Payer: Multiplan Workers Comp |
$113.75
|
| Rate for Payer: Parkland Medicaid |
$126.00
|
| Rate for Payer: Scott and White EPO/PPO |
$58.96
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$126.00
|
| Rate for Payer: Superior Health Plan EPO |
$23.80
|
|
|
OTAH PT Orthotic Management, Train Units BCE
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS 97760
|
| Hospital Charge Code |
9238563
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$15.75
|
| Rate for Payer: BCBS of TX Blue Advantage |
$52.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$63.00
|
| Rate for Payer: BCBS of TX PPO |
$70.00
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$126.00
|
| Rate for Payer: Molina CHIP/Medicaid |
$126.00
|
| Rate for Payer: Multiplan Auto |
$113.75
|
| Rate for Payer: Multiplan Commercial |
$113.75
|
| Rate for Payer: Multiplan Workers Comp |
$113.75
|
| Rate for Payer: Parkland Medicaid |
$126.00
|
| Rate for Payer: Scott and White EPO/PPO |
$58.96
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$126.00
|
| Rate for Payer: Superior Health Plan EPO |
$23.80
|
|
|
OTAH PT Orthotic Management, Train Units BCE
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS 97760
|
| Hospital Charge Code |
9238563
|
|
Hospital Revenue Code
|
420
|
| Rate for Payer: Cash Price |
$119.00
|
|
|
OTAH PT Orthotic/Prosthetic Manage,Train Assistant Units BCE
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
HCPCS 97763
|
| Hospital Charge Code |
9238566
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.18 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$18.18
|
| Rate for Payer: BCBS of TX Blue Advantage |
$60.60
|
| Rate for Payer: BCBS of TX Blue Essentials |
$72.72
|
| Rate for Payer: BCBS of TX PPO |
$80.80
|
| Rate for Payer: Cash Price |
$137.36
|
| Rate for Payer: Cash Price |
$137.36
|
| Rate for Payer: Cash Price |
$137.36
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$145.44
|
| Rate for Payer: Molina CHIP/Medicaid |
$145.44
|
| 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 |
$145.44
|
| Rate for Payer: Scott and White EPO/PPO |
$64.74
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$145.44
|
| Rate for Payer: Superior Health Plan EPO |
$27.47
|
|
