|
XR Osseous Survey Infant BCE
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
CPT 77076 FY
|
| Hospital Charge Code |
3120086
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$439.12
|
|
|
XR Osseous Survey Infant BCE
|
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
|
|
|
XR Osseous Survey Limited
|
Facility
|
OP
|
$452.00
|
|
|
Service Code
|
CPT 77074 FY
|
| Hospital Charge Code |
4906060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$293.80 |
| Rate for Payer: Aetna Commercial |
$51.06
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$65.15
|
| 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 |
$397.76
|
| Rate for Payer: Cash Price |
$397.76
|
| Rate for Payer: Cash Price |
$397.76
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$65.15
|
| 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 |
$65.15
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$293.80
|
| Rate for Payer: Multiplan Commercial |
$293.80
|
| Rate for Payer: Multiplan Workers Comp |
$293.80
|
| Rate for Payer: Parkland Medicaid |
$65.15
|
| 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 |
$65.15
|
| 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 Limited BCE
|
Facility
|
OP
|
$452.00
|
|
|
Service Code
|
CPT 77074 FY
|
| Hospital Charge Code |
4906060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$293.80 |
| Rate for Payer: Aetna Commercial |
$51.06
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$65.15
|
| 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 |
$397.76
|
| Rate for Payer: Cash Price |
$397.76
|
| Rate for Payer: Cash Price |
$397.76
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$65.15
|
| 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 |
$65.15
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$293.80
|
| Rate for Payer: Multiplan Commercial |
$293.80
|
| Rate for Payer: Multiplan Workers Comp |
$293.80
|
| Rate for Payer: Parkland Medicaid |
$65.15
|
| 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 |
$65.15
|
| 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 Limited BCE
|
Facility
|
IP
|
$452.00
|
|
|
Service Code
|
CPT 77074 FY
|
| Hospital Charge Code |
4906060
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$397.76
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
|
OP
|
$546.00
|
|
|
Service Code
|
CPT 72170 FY
|
| Hospital Charge Code |
3100518
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$354.90 |
| Rate for Payer: Aetna Commercial |
$22.16
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$28.06
|
| 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 |
$480.48
|
| Rate for Payer: Cash Price |
$480.48
|
| Rate for Payer: Cash Price |
$480.48
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$28.06
|
| 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 |
$28.06
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$354.90
|
| Rate for Payer: Multiplan Commercial |
$354.90
|
| Rate for Payer: Multiplan Workers Comp |
$354.90
|
| Rate for Payer: Parkland Medicaid |
$28.06
|
| 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 |
$28.06
|
| 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 Pelvis 1 or 2 Views BCE
|
Facility
|
OP
|
$546.00
|
|
|
Service Code
|
CPT 72170 FY
|
| Hospital Charge Code |
3100518
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$354.90 |
| Rate for Payer: Aetna Commercial |
$22.16
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$28.06
|
| 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 |
$480.48
|
| Rate for Payer: Cash Price |
$480.48
|
| Rate for Payer: Cash Price |
$480.48
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$28.06
|
| 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 |
$28.06
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$354.90
|
| Rate for Payer: Multiplan Commercial |
$354.90
|
| Rate for Payer: Multiplan Workers Comp |
$354.90
|
| Rate for Payer: Parkland Medicaid |
$28.06
|
| 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 |
$28.06
|
| 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 Pelvis 1 or 2 Views BCE
|
Facility
|
IP
|
$546.00
|
|
|
Service Code
|
CPT 72170 FY
|
| Hospital Charge Code |
3100518
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$480.48
|
|
|
XR Pelvis Complete 3+ Views
|
Facility
|
OP
|
$603.00
|
|
|
Service Code
|
CPT 72190 FY
|
| Hospital Charge Code |
3160132
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$391.95 |
| Rate for Payer: Aetna Commercial |
$34.49
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$42.44
|
| 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 |
$530.64
|
| Rate for Payer: Cash Price |
$530.64
|
| Rate for Payer: Cash Price |
$530.64
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$42.44
|
| 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 |
$42.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$391.95
|
| Rate for Payer: Multiplan Commercial |
$391.95
|
| Rate for Payer: Multiplan Workers Comp |
$391.95
|
| Rate for Payer: Parkland Medicaid |
$42.44
|
| 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 |
$42.44
|
| 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 Pelvis Complete 3+ Views BCE
|
Facility
|
OP
|
$603.00
|
|
|
Service Code
|
CPT 72190 FY
|
| Hospital Charge Code |
3160132
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$391.95 |
| Rate for Payer: Aetna Commercial |
$34.49
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$42.44
|
| 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 |
$530.64
|
| Rate for Payer: Cash Price |
$530.64
|
| Rate for Payer: Cash Price |
$530.64
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$42.44
|
| 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 |
$42.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$391.95
|
| Rate for Payer: Multiplan Commercial |
$391.95
|
| Rate for Payer: Multiplan Workers Comp |
$391.95
|
| Rate for Payer: Parkland Medicaid |
$42.44
|
| 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 |
$42.44
|
| 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 Pelvis Complete 3+ Views BCE
|
Facility
|
IP
|
$603.00
|
|
|
Service Code
|
CPT 72190 FY
|
| Hospital Charge Code |
3160132
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$530.64
|
|
|
XR Replace Duodenostomy Tube
|
Facility
|
OP
|
$1,591.00
|
|
|
Service Code
|
CPT 49451 FY
|
| Hospital Charge Code |
4906589
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$2,200.00
|
| Rate for Payer: Aetna Medicare |
$1,243.53
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$334.95
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Amerigroup Medicare |
$829.02
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,312.49
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,571.84
|
| Rate for Payer: BCBS of TX Medicare |
$829.02
|
| Rate for Payer: BCBS of TX PPO |
$1,980.52
|
| Rate for Payer: Cash Price |
$1,400.08
|
| Rate for Payer: Cash Price |
$1,400.08
|
| Rate for Payer: Cigna Commercial |
$1,877.98
|
| Rate for Payer: Cigna Medicaid |
$334.95
|
| Rate for Payer: Cigna Medicare |
$829.02
|
| Rate for Payer: Employer Direct Commercial |
$829.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$829.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$334.95
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Molina Medicare |
$829.02
|
| 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 |
$334.95
|
| Rate for Payer: Scott and White EPO/PPO |
$18.29
|
| Rate for Payer: Scott and White Medicare |
$829.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$334.95
|
| Rate for Payer: Superior Health Plan EPO |
$829.02
|
| Rate for Payer: Superior Health Plan Medicare |
$829.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Universal American Medicare |
$829.02
|
| Rate for Payer: Wellcare Medicare |
$829.02
|
| Rate for Payer: Wellmed Medicare |
$829.02
|
|
|
XR Replace Duodenostomy Tube BCE
|
Facility
|
OP
|
$1,591.00
|
|
|
Service Code
|
CPT 49451 FY
|
| Hospital Charge Code |
4906589
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$2,200.00
|
| Rate for Payer: Aetna Medicare |
$1,243.53
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$334.95
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Amerigroup Medicare |
$829.02
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,312.49
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,571.84
|
| Rate for Payer: BCBS of TX Medicare |
$829.02
|
| Rate for Payer: BCBS of TX PPO |
$1,980.52
|
| Rate for Payer: Cash Price |
$1,400.08
|
| Rate for Payer: Cash Price |
$1,400.08
|
| Rate for Payer: Cigna Commercial |
$1,877.98
|
| Rate for Payer: Cigna Medicaid |
$334.95
|
| Rate for Payer: Cigna Medicare |
$829.02
|
| Rate for Payer: Employer Direct Commercial |
$829.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$829.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$334.95
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Molina Medicare |
$829.02
|
| 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 |
$334.95
|
| Rate for Payer: Scott and White EPO/PPO |
$18.29
|
| Rate for Payer: Scott and White Medicare |
$829.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$334.95
|
| Rate for Payer: Superior Health Plan EPO |
$829.02
|
| Rate for Payer: Superior Health Plan Medicare |
$829.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Universal American Medicare |
$829.02
|
| Rate for Payer: Wellcare Medicare |
$829.02
|
| Rate for Payer: Wellmed Medicare |
$829.02
|
|
|
XR Replace Duodenostomy Tube BCE
|
Facility
|
IP
|
$1,591.00
|
|
|
Service Code
|
CPT 49451 FY
|
| Hospital Charge Code |
4906589
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,400.08
|
|
|
XR Ribs 2 Views Left
|
Facility
|
OP
|
$727.00
|
|
|
Service Code
|
CPT 71100 LT,FY
|
| Hospital Charge Code |
3100351
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$472.55 |
| Rate for Payer: Aetna Commercial |
$29.87
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$37.09
|
| 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 |
$639.76
|
| Rate for Payer: Cash Price |
$639.76
|
| Rate for Payer: Cash Price |
$639.76
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$37.09
|
| 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 |
$37.09
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$472.55
|
| Rate for Payer: Multiplan Commercial |
$472.55
|
| Rate for Payer: Multiplan Workers Comp |
$472.55
|
| Rate for Payer: Parkland Medicaid |
$37.09
|
| 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 |
$37.09
|
| 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 Ribs 2 Views Left BCE
|
Facility
|
IP
|
$727.00
|
|
|
Service Code
|
CPT 71100 LT,FY
|
| Hospital Charge Code |
3100351
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$639.76
|
|
|
XR Ribs 2 Views Left BCE
|
Facility
|
OP
|
$727.00
|
|
|
Service Code
|
CPT 71100 LT,FY
|
| Hospital Charge Code |
3100351
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$472.55 |
| Rate for Payer: Aetna Commercial |
$29.87
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$37.09
|
| 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 |
$639.76
|
| Rate for Payer: Cash Price |
$639.76
|
| Rate for Payer: Cash Price |
$639.76
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$37.09
|
| 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 |
$37.09
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$472.55
|
| Rate for Payer: Multiplan Commercial |
$472.55
|
| Rate for Payer: Multiplan Workers Comp |
$472.55
|
| Rate for Payer: Parkland Medicaid |
$37.09
|
| 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 |
$37.09
|
| 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 Ribs 2 Views Right
|
Facility
|
OP
|
$727.00
|
|
|
Service Code
|
CPT 71100 RT,FY
|
| Hospital Charge Code |
3100369
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$472.55 |
| Rate for Payer: Aetna Commercial |
$29.87
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$37.09
|
| 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 |
$639.76
|
| Rate for Payer: Cash Price |
$639.76
|
| Rate for Payer: Cash Price |
$639.76
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$37.09
|
| 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 |
$37.09
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$472.55
|
| Rate for Payer: Multiplan Commercial |
$472.55
|
| Rate for Payer: Multiplan Workers Comp |
$472.55
|
| Rate for Payer: Parkland Medicaid |
$37.09
|
| 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 |
$37.09
|
| 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 Ribs 2 Views Right BCE
|
Facility
|
IP
|
$727.00
|
|
|
Service Code
|
CPT 71100 RT,FY
|
| Hospital Charge Code |
3100369
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$639.76
|
|
|
XR Ribs 2 Views Right BCE
|
Facility
|
OP
|
$727.00
|
|
|
Service Code
|
CPT 71100 RT,FY
|
| Hospital Charge Code |
3100369
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$472.55 |
| Rate for Payer: Aetna Commercial |
$29.87
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$37.09
|
| 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 |
$639.76
|
| Rate for Payer: Cash Price |
$639.76
|
| Rate for Payer: Cash Price |
$639.76
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$37.09
|
| 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 |
$37.09
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$472.55
|
| Rate for Payer: Multiplan Commercial |
$472.55
|
| Rate for Payer: Multiplan Workers Comp |
$472.55
|
| Rate for Payer: Parkland Medicaid |
$37.09
|
| 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 |
$37.09
|
| 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 Ribs 3 Views Bilateral
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
CPT 71110 FY
|
| Hospital Charge Code |
3170015
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Aetna Commercial |
$34.49
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$44.10
|
| 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 |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$44.10
|
| 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 |
$44.10
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$585.00
|
| Rate for Payer: Multiplan Commercial |
$585.00
|
| Rate for Payer: Multiplan Workers Comp |
$585.00
|
| Rate for Payer: Parkland Medicaid |
$44.10
|
| 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 |
$44.10
|
| 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 Ribs 3 Views Bilateral BCE
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
CPT 71110 FY
|
| Hospital Charge Code |
3170015
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$792.00
|
|
|
XR Ribs 3 Views Bilateral BCE
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
CPT 71110 FY
|
| Hospital Charge Code |
3170015
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Aetna Commercial |
$34.49
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$44.10
|
| 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 |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$44.10
|
| 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 |
$44.10
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$585.00
|
| Rate for Payer: Multiplan Commercial |
$585.00
|
| Rate for Payer: Multiplan Workers Comp |
$585.00
|
| Rate for Payer: Parkland Medicaid |
$44.10
|
| 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 |
$44.10
|
| 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 Sacroiliac Joints 3+ Views
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 72202 FY
|
| Hospital Charge Code |
3100534
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$247.70 |
| Rate for Payer: Aetna Commercial |
$32.57
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$39.43
|
| 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 |
$212.08
|
| Rate for Payer: Cash Price |
$212.08
|
| Rate for Payer: Cash Price |
$212.08
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$39.43
|
| 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 |
$39.43
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$156.65
|
| Rate for Payer: Multiplan Commercial |
$156.65
|
| Rate for Payer: Multiplan Workers Comp |
$156.65
|
| Rate for Payer: Parkland Medicaid |
$39.43
|
| 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 |
$39.43
|
| 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 Sacroiliac Joints 3+ Views BCE
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 72202 FY
|
| Hospital Charge Code |
3100534
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$212.08
|
|
