|
XR Sacroiliac Joints 3+ Views BCE
|
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 Sacrum/Coccyx 2+ Views
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
CPT 72220 FY
|
| Hospital Charge Code |
3100542
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$223.60 |
| Rate for Payer: Aetna Commercial |
$27.56
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$32.75
|
| 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 |
$302.72
|
| Rate for Payer: Cash Price |
$302.72
|
| Rate for Payer: Cash Price |
$302.72
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$32.75
|
| 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 |
$32.75
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$223.60
|
| Rate for Payer: Multiplan Commercial |
$223.60
|
| Rate for Payer: Multiplan Workers Comp |
$223.60
|
| Rate for Payer: Parkland Medicaid |
$32.75
|
| 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 |
$32.75
|
| 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 Sacrum/Coccyx 2+ Views BCE
|
Facility
|
IP
|
$344.00
|
|
|
Service Code
|
CPT 72220 FY
|
| Hospital Charge Code |
3100542
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$302.72
|
|
|
XR Sacrum/Coccyx 2+ Views BCE
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
CPT 72220 FY
|
| Hospital Charge Code |
3100542
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$223.60 |
| Rate for Payer: Aetna Commercial |
$27.56
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$32.75
|
| 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 |
$302.72
|
| Rate for Payer: Cash Price |
$302.72
|
| Rate for Payer: Cash Price |
$302.72
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$32.75
|
| 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 |
$32.75
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$223.60
|
| Rate for Payer: Multiplan Commercial |
$223.60
|
| Rate for Payer: Multiplan Workers Comp |
$223.60
|
| Rate for Payer: Parkland Medicaid |
$32.75
|
| 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 |
$32.75
|
| 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 Scapula Left
|
Facility
|
OP
|
$382.00
|
|
|
Service Code
|
CPT 73010 LT,FY
|
| Hospital Charge Code |
3100575
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$248.30 |
| Rate for Payer: Aetna Commercial |
$17.15
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$23.73
|
| 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 |
$336.16
|
| Rate for Payer: Cash Price |
$336.16
|
| Rate for Payer: Cash Price |
$336.16
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$23.73
|
| 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 |
$23.73
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$248.30
|
| Rate for Payer: Multiplan Commercial |
$248.30
|
| Rate for Payer: Multiplan Workers Comp |
$248.30
|
| Rate for Payer: Parkland Medicaid |
$23.73
|
| 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 |
$23.73
|
| 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 Scapula Left BCE
|
Facility
|
IP
|
$382.00
|
|
|
Service Code
|
CPT 73010 LT,FY
|
| Hospital Charge Code |
3100575
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$336.16
|
|
|
XR Scapula Left BCE
|
Facility
|
OP
|
$382.00
|
|
|
Service Code
|
CPT 73010 LT,FY
|
| Hospital Charge Code |
3100575
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$248.30 |
| Rate for Payer: Aetna Commercial |
$17.15
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$23.73
|
| 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 |
$336.16
|
| Rate for Payer: Cash Price |
$336.16
|
| Rate for Payer: Cash Price |
$336.16
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$23.73
|
| 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 |
$23.73
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$248.30
|
| Rate for Payer: Multiplan Commercial |
$248.30
|
| Rate for Payer: Multiplan Workers Comp |
$248.30
|
| Rate for Payer: Parkland Medicaid |
$23.73
|
| 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 |
$23.73
|
| 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 Scapula Right
|
Facility
|
OP
|
$382.00
|
|
|
Service Code
|
CPT 73010 RT,FY
|
| Hospital Charge Code |
3100583
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$248.30 |
| Rate for Payer: Aetna Commercial |
$17.15
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$23.73
|
| 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 |
$336.16
|
| Rate for Payer: Cash Price |
$336.16
|
| Rate for Payer: Cash Price |
$336.16
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$23.73
|
| 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 |
$23.73
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$248.30
|
| Rate for Payer: Multiplan Commercial |
$248.30
|
| Rate for Payer: Multiplan Workers Comp |
$248.30
|
| Rate for Payer: Parkland Medicaid |
$23.73
|
| 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 |
$23.73
|
| 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 Scapula Right BCE
|
Facility
|
OP
|
$382.00
|
|
|
Service Code
|
CPT 73010 RT,FY
|
| Hospital Charge Code |
3100583
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$248.30 |
| Rate for Payer: Aetna Commercial |
$17.15
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$23.73
|
| 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 |
$336.16
|
| Rate for Payer: Cash Price |
$336.16
|
| Rate for Payer: Cash Price |
$336.16
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$23.73
|
| 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 |
$23.73
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$248.30
|
| Rate for Payer: Multiplan Commercial |
$248.30
|
| Rate for Payer: Multiplan Workers Comp |
$248.30
|
| Rate for Payer: Parkland Medicaid |
$23.73
|
| 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 |
$23.73
|
| 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 Scapula Right BCE
|
Facility
|
IP
|
$382.00
|
|
|
Service Code
|
CPT 73010 RT,FY
|
| Hospital Charge Code |
3100583
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$336.16
|
|
|
XR Shoulder 1 View Left
|
Facility
|
OP
|
$507.00
|
|
|
Service Code
|
CPT 73020 LT,FY
|
| Hospital Charge Code |
3101565
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$329.55 |
| Rate for Payer: Aetna Commercial |
$16.00
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$21.71
|
| 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 |
$446.16
|
| Rate for Payer: Cash Price |
$446.16
|
| Rate for Payer: Cash Price |
$446.16
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$21.71
|
| 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 |
$21.71
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$329.55
|
| Rate for Payer: Multiplan Commercial |
$329.55
|
| Rate for Payer: Multiplan Workers Comp |
$329.55
|
| Rate for Payer: Parkland Medicaid |
$21.71
|
| 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 |
$21.71
|
| 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 Shoulder 1 View Left BCE
|
Facility
|
OP
|
$507.00
|
|
|
Service Code
|
CPT 73020 LT,FY
|
| Hospital Charge Code |
3101565
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$329.55 |
| Rate for Payer: Aetna Commercial |
$16.00
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$21.71
|
| 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 |
$446.16
|
| Rate for Payer: Cash Price |
$446.16
|
| Rate for Payer: Cash Price |
$446.16
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$21.71
|
| 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 |
$21.71
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$329.55
|
| Rate for Payer: Multiplan Commercial |
$329.55
|
| Rate for Payer: Multiplan Workers Comp |
$329.55
|
| Rate for Payer: Parkland Medicaid |
$21.71
|
| 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 |
$21.71
|
| 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 Shoulder 1 View Left BCE
|
Facility
|
IP
|
$507.00
|
|
|
Service Code
|
CPT 73020 LT,FY
|
| Hospital Charge Code |
3101565
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$446.16
|
|
|
XR Shoulder 1 View Right
|
Facility
|
OP
|
$507.00
|
|
|
Service Code
|
CPT 73020 RT,FY
|
| Hospital Charge Code |
3101672
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$329.55 |
| Rate for Payer: Aetna Commercial |
$16.00
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$21.71
|
| 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 |
$446.16
|
| Rate for Payer: Cash Price |
$446.16
|
| Rate for Payer: Cash Price |
$446.16
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$21.71
|
| 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 |
$21.71
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$329.55
|
| Rate for Payer: Multiplan Commercial |
$329.55
|
| Rate for Payer: Multiplan Workers Comp |
$329.55
|
| Rate for Payer: Parkland Medicaid |
$21.71
|
| 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 |
$21.71
|
| 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 Shoulder 1 View Right BCE
|
Facility
|
IP
|
$507.00
|
|
|
Service Code
|
CPT 73020 RT,FY
|
| Hospital Charge Code |
3101672
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$446.16
|
|
|
XR Shoulder 1 View Right BCE
|
Facility
|
OP
|
$507.00
|
|
|
Service Code
|
CPT 73020 RT,FY
|
| Hospital Charge Code |
3101672
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$329.55 |
| Rate for Payer: Aetna Commercial |
$16.00
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$21.71
|
| 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 |
$446.16
|
| Rate for Payer: Cash Price |
$446.16
|
| Rate for Payer: Cash Price |
$446.16
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$21.71
|
| 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 |
$21.71
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$329.55
|
| Rate for Payer: Multiplan Commercial |
$329.55
|
| Rate for Payer: Multiplan Workers Comp |
$329.55
|
| Rate for Payer: Parkland Medicaid |
$21.71
|
| 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 |
$21.71
|
| 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 Shoulder Complete 2+ Views Left
|
Facility
|
OP
|
$624.00
|
|
|
Service Code
|
CPT 73030 LT,FY
|
| Hospital Charge Code |
3100591
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$405.60 |
| Rate for Payer: Aetna Commercial |
$29.10
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$34.75
|
| 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 |
$549.12
|
| Rate for Payer: Cash Price |
$549.12
|
| Rate for Payer: Cash Price |
$549.12
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$34.75
|
| 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 |
$34.75
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$405.60
|
| Rate for Payer: Multiplan Commercial |
$405.60
|
| Rate for Payer: Multiplan Workers Comp |
$405.60
|
| Rate for Payer: Parkland Medicaid |
$34.75
|
| 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 |
$34.75
|
| 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 Shoulder Complete 2+ Views Left BCE
|
Facility
|
OP
|
$624.00
|
|
|
Service Code
|
CPT 73030 LT,FY
|
| Hospital Charge Code |
3100591
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$405.60 |
| Rate for Payer: Aetna Commercial |
$29.10
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$34.75
|
| 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 |
$549.12
|
| Rate for Payer: Cash Price |
$549.12
|
| Rate for Payer: Cash Price |
$549.12
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$34.75
|
| 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 |
$34.75
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$405.60
|
| Rate for Payer: Multiplan Commercial |
$405.60
|
| Rate for Payer: Multiplan Workers Comp |
$405.60
|
| Rate for Payer: Parkland Medicaid |
$34.75
|
| 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 |
$34.75
|
| 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 Shoulder Complete 2+ Views Left BCE
|
Facility
|
IP
|
$624.00
|
|
|
Service Code
|
CPT 73030 LT,FY
|
| Hospital Charge Code |
3100591
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$549.12
|
|
|
XR Shoulder Complete 2+ Views Right
|
Facility
|
OP
|
$624.00
|
|
|
Service Code
|
CPT 73030 RT,FY
|
| Hospital Charge Code |
3100609
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$405.60 |
| Rate for Payer: Aetna Commercial |
$29.10
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$34.75
|
| 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 |
$549.12
|
| Rate for Payer: Cash Price |
$549.12
|
| Rate for Payer: Cash Price |
$549.12
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$34.75
|
| 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 |
$34.75
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$405.60
|
| Rate for Payer: Multiplan Commercial |
$405.60
|
| Rate for Payer: Multiplan Workers Comp |
$405.60
|
| Rate for Payer: Parkland Medicaid |
$34.75
|
| 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 |
$34.75
|
| 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 Shoulder Complete 2+ Views Right BCE
|
Facility
|
OP
|
$624.00
|
|
|
Service Code
|
CPT 73030 RT,FY
|
| Hospital Charge Code |
3100609
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$405.60 |
| Rate for Payer: Aetna Commercial |
$29.10
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$34.75
|
| 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 |
$549.12
|
| Rate for Payer: Cash Price |
$549.12
|
| Rate for Payer: Cash Price |
$549.12
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$34.75
|
| 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 |
$34.75
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$405.60
|
| Rate for Payer: Multiplan Commercial |
$405.60
|
| Rate for Payer: Multiplan Workers Comp |
$405.60
|
| Rate for Payer: Parkland Medicaid |
$34.75
|
| 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 |
$34.75
|
| 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 Shoulder Complete 2+ Views Right BCE
|
Facility
|
IP
|
$624.00
|
|
|
Service Code
|
CPT 73030 RT,FY
|
| Hospital Charge Code |
3100609
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$549.12
|
|
|
XR SI Joint Arthrogram w Guidance L
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
CPT 27096 LT,FY
|
| Hospital Charge Code |
6110530
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.24 |
| Max. Negotiated Rate |
$1,625.00 |
| Rate for Payer: Aetna Commercial |
$1,375.00
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$225.00
|
| Rate for Payer: BCBS of TX Blue Advantage |
$143.24
|
| Rate for Payer: BCBS of TX Blue Essentials |
$171.54
|
| Rate for Payer: BCBS of TX PPO |
$216.14
|
| Rate for Payer: Cash Price |
$2,200.00
|
| Rate for Payer: Cash Price |
$2,200.00
|
| Rate for Payer: Multiplan Auto |
$1,625.00
|
| Rate for Payer: Multiplan Commercial |
$1,625.00
|
| Rate for Payer: Multiplan Workers Comp |
$1,625.00
|
| Rate for Payer: Scott and White EPO/PPO |
$1,250.00
|
| Rate for Payer: Superior Health Plan EPO |
$340.00
|
|
|
XR SI Joint Arthrogram w Guidance L BCE
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
CPT 27096 LT,FY
|
| Hospital Charge Code |
6110530
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.24 |
| Max. Negotiated Rate |
$1,625.00 |
| Rate for Payer: Aetna Commercial |
$1,375.00
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$225.00
|
| Rate for Payer: BCBS of TX Blue Advantage |
$143.24
|
| Rate for Payer: BCBS of TX Blue Essentials |
$171.54
|
| Rate for Payer: BCBS of TX PPO |
$216.14
|
| Rate for Payer: Cash Price |
$2,200.00
|
| Rate for Payer: Cash Price |
$2,200.00
|
| Rate for Payer: Multiplan Auto |
$1,625.00
|
| Rate for Payer: Multiplan Commercial |
$1,625.00
|
| Rate for Payer: Multiplan Workers Comp |
$1,625.00
|
| Rate for Payer: Scott and White EPO/PPO |
$1,250.00
|
| Rate for Payer: Superior Health Plan EPO |
$340.00
|
|
|
XR SI Joint Arthrogram w Guidance L BCE
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
CPT 27096 LT,FY
|
| Hospital Charge Code |
6110530
|
|
Hospital Revenue Code
|
761
|
| Rate for Payer: Cash Price |
$2,200.00
|
|
