|
XR SI Joint Arthrogram w Guidance R
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
CPT 27096 RT,FY
|
| Hospital Charge Code |
6100007
|
|
Hospital Revenue Code
|
320
|
| 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 R BCE
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
CPT 27096 RT,FY
|
| Hospital Charge Code |
6100007
|
|
Hospital Revenue Code
|
320
|
| 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 R BCE
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
CPT 27096 RT,FY
|
| Hospital Charge Code |
6100007
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$2,200.00
|
|
|
XR SI Joint Inj Anes an/or Arth w Gde 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 Inj Anes an/or Arth w Gde R
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
CPT 27096 RT,FY
|
| Hospital Charge Code |
6100007
|
|
Hospital Revenue Code
|
320
|
| 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 Sinuses Paranasal < 3 Views
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
CPT 70210 FY
|
| Hospital Charge Code |
3101490
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$188.25 |
| Rate for Payer: Aetna Commercial |
$27.56
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$32.41
|
| 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 |
$169.84
|
| Rate for Payer: Cash Price |
$169.84
|
| Rate for Payer: Cash Price |
$169.84
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$32.41
|
| 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 |
$32.41
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$125.45
|
| Rate for Payer: Multiplan Commercial |
$125.45
|
| Rate for Payer: Multiplan Workers Comp |
$125.45
|
| Rate for Payer: Parkland Medicaid |
$32.41
|
| 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 |
$32.41
|
| 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 Sinuses Paranasal < 3 Views BCE
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
CPT 70210 FY
|
| Hospital Charge Code |
3101490
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$188.25 |
| Rate for Payer: Aetna Commercial |
$27.56
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$32.41
|
| 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 |
$169.84
|
| Rate for Payer: Cash Price |
$169.84
|
| Rate for Payer: Cash Price |
$169.84
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$32.41
|
| 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 |
$32.41
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$125.45
|
| Rate for Payer: Multiplan Commercial |
$125.45
|
| Rate for Payer: Multiplan Workers Comp |
$125.45
|
| Rate for Payer: Parkland Medicaid |
$32.41
|
| 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 |
$32.41
|
| 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 Sinuses Paranasal < 3 Views BCE
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
CPT 70210 FY
|
| Hospital Charge Code |
3101490
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$169.84
|
|
|
XR Sinuses Paranasal Complete
|
Facility
|
OP
|
$433.00
|
|
|
Service Code
|
CPT 70220 FY
|
| Hospital Charge Code |
3100187
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$281.45 |
| Rate for Payer: Aetna Commercial |
$31.41
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$37.76
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Amerigroup Medicare |
$83.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$131.69
|
| Rate for Payer: BCBS of TX Blue Essentials |
$158.02
|
| Rate for Payer: BCBS of TX Medicare |
$83.10
|
| Rate for Payer: BCBS of TX PPO |
$176.38
|
| Rate for Payer: Cash Price |
$381.04
|
| Rate for Payer: Cash Price |
$381.04
|
| Rate for Payer: Cash Price |
$381.04
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$37.76
|
| Rate for Payer: Cigna Medicare |
$83.10
|
| Rate for Payer: Employer Direct Commercial |
$83.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$83.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$37.76
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$281.45
|
| Rate for Payer: Multiplan Commercial |
$281.45
|
| Rate for Payer: Multiplan Workers Comp |
$281.45
|
| Rate for Payer: Parkland Medicaid |
$37.76
|
| Rate for Payer: Scott and White EPO/PPO |
$1.49
|
| Rate for Payer: Scott and White Medicare |
$83.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$37.76
|
| Rate for Payer: Superior Health Plan EPO |
$83.10
|
| Rate for Payer: Superior Health Plan Medicare |
$83.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Universal American Medicare |
$83.10
|
| Rate for Payer: Wellcare Medicare |
$83.10
|
| Rate for Payer: Wellmed Medicare |
$83.10
|
|
|
XR Sinuses Paranasal Complete BCE
|
Facility
|
OP
|
$433.00
|
|
|
Service Code
|
CPT 70220 FY
|
| Hospital Charge Code |
3100187
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$281.45 |
| Rate for Payer: Aetna Commercial |
$31.41
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$37.76
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Amerigroup Medicare |
$83.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$131.69
|
| Rate for Payer: BCBS of TX Blue Essentials |
$158.02
|
| Rate for Payer: BCBS of TX Medicare |
$83.10
|
| Rate for Payer: BCBS of TX PPO |
$176.38
|
| Rate for Payer: Cash Price |
$381.04
|
| Rate for Payer: Cash Price |
$381.04
|
| Rate for Payer: Cash Price |
$381.04
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$37.76
|
| Rate for Payer: Cigna Medicare |
$83.10
|
| Rate for Payer: Employer Direct Commercial |
$83.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$83.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$37.76
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$281.45
|
| Rate for Payer: Multiplan Commercial |
$281.45
|
| Rate for Payer: Multiplan Workers Comp |
$281.45
|
| Rate for Payer: Parkland Medicaid |
$37.76
|
| Rate for Payer: Scott and White EPO/PPO |
$1.49
|
| Rate for Payer: Scott and White Medicare |
$83.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$37.76
|
| Rate for Payer: Superior Health Plan EPO |
$83.10
|
| Rate for Payer: Superior Health Plan Medicare |
$83.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Universal American Medicare |
$83.10
|
| Rate for Payer: Wellcare Medicare |
$83.10
|
| Rate for Payer: Wellmed Medicare |
$83.10
|
|
|
XR Sinuses Paranasal Complete BCE
|
Facility
|
IP
|
$433.00
|
|
|
Service Code
|
CPT 70220 FY
|
| Hospital Charge Code |
3100187
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$381.04
|
|
|
XR Sinus Tract SI
|
Facility
|
OP
|
$702.00
|
|
|
Service Code
|
CPT 76080 FY
|
| Hospital Charge Code |
2101855
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$9.02 |
| Max. Negotiated Rate |
$1,142.91 |
| Rate for Payer: Aetna Commercial |
$41.04
|
| Rate for Payer: Aetna Medicare |
$756.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$60.14
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$504.53
|
| Rate for Payer: Amerigroup Medicare |
$504.53
|
| Rate for Payer: BCBS of TX Blue Advantage |
$794.61
|
| Rate for Payer: BCBS of TX Blue Essentials |
$953.53
|
| Rate for Payer: BCBS of TX Medicare |
$504.53
|
| Rate for Payer: BCBS of TX PPO |
$1,064.29
|
| Rate for Payer: Cash Price |
$617.76
|
| Rate for Payer: Cash Price |
$617.76
|
| Rate for Payer: Cash Price |
$617.76
|
| Rate for Payer: Cigna Commercial |
$1,142.91
|
| Rate for Payer: Cigna Medicaid |
$60.14
|
| Rate for Payer: Cigna Medicare |
$504.53
|
| Rate for Payer: Employer Direct Commercial |
$504.53
|
| Rate for Payer: Humana Medicare/TRICARE |
$504.53
|
| Rate for Payer: Molina CHIP/Medicaid |
$60.14
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$504.53
|
| Rate for Payer: Molina Medicare |
$504.53
|
| Rate for Payer: Multiplan Auto |
$456.30
|
| Rate for Payer: Multiplan Commercial |
$456.30
|
| Rate for Payer: Multiplan Workers Comp |
$456.30
|
| Rate for Payer: Parkland Medicaid |
$60.14
|
| Rate for Payer: Scott and White EPO/PPO |
$9.02
|
| Rate for Payer: Scott and White Medicare |
$504.53
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$60.14
|
| Rate for Payer: Superior Health Plan EPO |
$504.53
|
| Rate for Payer: Superior Health Plan Medicare |
$504.53
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$504.53
|
| Rate for Payer: Universal American Medicare |
$504.53
|
| Rate for Payer: Wellcare Medicare |
$504.53
|
| Rate for Payer: Wellmed Medicare |
$504.53
|
|
|
XR Sinus Tract SI BCE
|
Facility
|
OP
|
$702.00
|
|
|
Service Code
|
CPT 76080 FY
|
| Hospital Charge Code |
2101855
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$9.02 |
| Max. Negotiated Rate |
$1,142.91 |
| Rate for Payer: Aetna Commercial |
$41.04
|
| Rate for Payer: Aetna Medicare |
$756.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$60.14
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$504.53
|
| Rate for Payer: Amerigroup Medicare |
$504.53
|
| Rate for Payer: BCBS of TX Blue Advantage |
$794.61
|
| Rate for Payer: BCBS of TX Blue Essentials |
$953.53
|
| Rate for Payer: BCBS of TX Medicare |
$504.53
|
| Rate for Payer: BCBS of TX PPO |
$1,064.29
|
| Rate for Payer: Cash Price |
$617.76
|
| Rate for Payer: Cash Price |
$617.76
|
| Rate for Payer: Cash Price |
$617.76
|
| Rate for Payer: Cigna Commercial |
$1,142.91
|
| Rate for Payer: Cigna Medicaid |
$60.14
|
| Rate for Payer: Cigna Medicare |
$504.53
|
| Rate for Payer: Employer Direct Commercial |
$504.53
|
| Rate for Payer: Humana Medicare/TRICARE |
$504.53
|
| Rate for Payer: Molina CHIP/Medicaid |
$60.14
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$504.53
|
| Rate for Payer: Molina Medicare |
$504.53
|
| Rate for Payer: Multiplan Auto |
$456.30
|
| Rate for Payer: Multiplan Commercial |
$456.30
|
| Rate for Payer: Multiplan Workers Comp |
$456.30
|
| Rate for Payer: Parkland Medicaid |
$60.14
|
| Rate for Payer: Scott and White EPO/PPO |
$9.02
|
| Rate for Payer: Scott and White Medicare |
$504.53
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$60.14
|
| Rate for Payer: Superior Health Plan EPO |
$504.53
|
| Rate for Payer: Superior Health Plan Medicare |
$504.53
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$504.53
|
| Rate for Payer: Universal American Medicare |
$504.53
|
| Rate for Payer: Wellcare Medicare |
$504.53
|
| Rate for Payer: Wellmed Medicare |
$504.53
|
|
|
XR Sinus Tract SI BCE
|
Facility
|
IP
|
$702.00
|
|
|
Service Code
|
CPT 76080 FY
|
| Hospital Charge Code |
2101855
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$617.76
|
|
|
XR Skull < 4 Views
|
Facility
|
OP
|
$443.00
|
|
|
Service Code
|
CPT 70250 FY
|
| Hospital Charge Code |
3100203
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$287.95 |
| Rate for Payer: Aetna Commercial |
$31.03
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$36.09
|
| 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 |
$389.84
|
| Rate for Payer: Cash Price |
$389.84
|
| Rate for Payer: Cash Price |
$389.84
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$36.09
|
| 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 |
$36.09
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$287.95
|
| Rate for Payer: Multiplan Commercial |
$287.95
|
| Rate for Payer: Multiplan Workers Comp |
$287.95
|
| Rate for Payer: Parkland Medicaid |
$36.09
|
| 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 |
$36.09
|
| 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 Skull < 4 Views BCE
|
Facility
|
IP
|
$443.00
|
|
|
Service Code
|
CPT 70250 FY
|
| Hospital Charge Code |
3100203
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$389.84
|
|
|
XR Skull < 4 Views BCE
|
Facility
|
OP
|
$443.00
|
|
|
Service Code
|
CPT 70250 FY
|
| Hospital Charge Code |
3100203
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$287.95 |
| Rate for Payer: Aetna Commercial |
$31.03
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$36.09
|
| 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 |
$389.84
|
| Rate for Payer: Cash Price |
$389.84
|
| Rate for Payer: Cash Price |
$389.84
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$36.09
|
| 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 |
$36.09
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$287.95
|
| Rate for Payer: Multiplan Commercial |
$287.95
|
| Rate for Payer: Multiplan Workers Comp |
$287.95
|
| Rate for Payer: Parkland Medicaid |
$36.09
|
| 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 |
$36.09
|
| 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 Skull Complete
|
Facility
|
OP
|
$637.00
|
|
|
Service Code
|
CPT 70260 FY
|
| Hospital Charge Code |
3100211
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$414.05 |
| Rate for Payer: Aetna Commercial |
$36.03
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$44.78
|
| 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 |
$560.56
|
| Rate for Payer: Cash Price |
$560.56
|
| Rate for Payer: Cash Price |
$560.56
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$44.78
|
| 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 |
$44.78
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$414.05
|
| Rate for Payer: Multiplan Commercial |
$414.05
|
| Rate for Payer: Multiplan Workers Comp |
$414.05
|
| Rate for Payer: Parkland Medicaid |
$44.78
|
| 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 |
$44.78
|
| 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 Skull Complete BCE
|
Facility
|
IP
|
$637.00
|
|
|
Service Code
|
CPT 70260 FY
|
| Hospital Charge Code |
3100211
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$560.56
|
|
|
XR Skull Complete BCE
|
Facility
|
OP
|
$637.00
|
|
|
Service Code
|
CPT 70260 FY
|
| Hospital Charge Code |
3100211
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$414.05 |
| Rate for Payer: Aetna Commercial |
$36.03
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$44.78
|
| 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 |
$560.56
|
| Rate for Payer: Cash Price |
$560.56
|
| Rate for Payer: Cash Price |
$560.56
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$44.78
|
| 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 |
$44.78
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$414.05
|
| Rate for Payer: Multiplan Commercial |
$414.05
|
| Rate for Payer: Multiplan Workers Comp |
$414.05
|
| Rate for Payer: Parkland Medicaid |
$44.78
|
| 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 |
$44.78
|
| 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 Small Bowel via Enteroclysis Tube
|
Facility
|
OP
|
$892.00
|
|
|
Service Code
|
CPT 74251 FY
|
| Hospital Charge Code |
4904251
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$579.80 |
| Rate for Payer: Aetna Commercial |
$203.23
|
| Rate for Payer: Aetna Medicare |
$252.04
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$180.34
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$168.03
|
| Rate for Payer: Amerigroup Medicare |
$168.03
|
| Rate for Payer: BCBS of TX Blue Advantage |
$300.66
|
| Rate for Payer: BCBS of TX Blue Essentials |
$360.80
|
| Rate for Payer: BCBS of TX Medicare |
$168.03
|
| Rate for Payer: BCBS of TX PPO |
$402.71
|
| Rate for Payer: Cash Price |
$784.96
|
| Rate for Payer: Cash Price |
$784.96
|
| Rate for Payer: Cash Price |
$784.96
|
| Rate for Payer: Cigna Commercial |
$380.65
|
| Rate for Payer: Cigna Medicaid |
$180.34
|
| Rate for Payer: Cigna Medicare |
$168.03
|
| Rate for Payer: Employer Direct Commercial |
$168.03
|
| Rate for Payer: Humana Medicare/TRICARE |
$168.03
|
| Rate for Payer: Molina CHIP/Medicaid |
$180.34
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$168.03
|
| Rate for Payer: Molina Medicare |
$168.03
|
| Rate for Payer: Multiplan Auto |
$579.80
|
| Rate for Payer: Multiplan Commercial |
$579.80
|
| Rate for Payer: Multiplan Workers Comp |
$579.80
|
| Rate for Payer: Parkland Medicaid |
$180.34
|
| Rate for Payer: Scott and White EPO/PPO |
$3.01
|
| Rate for Payer: Scott and White Medicare |
$168.03
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$180.34
|
| Rate for Payer: Superior Health Plan EPO |
$168.03
|
| Rate for Payer: Superior Health Plan Medicare |
$168.03
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$168.03
|
| Rate for Payer: Universal American Medicare |
$168.03
|
| Rate for Payer: Wellcare Medicare |
$168.03
|
| Rate for Payer: Wellmed Medicare |
$168.03
|
|
|
XR Small Bowel via Enteroclysis Tube BCE
|
Facility
|
IP
|
$892.00
|
|
|
Service Code
|
CPT 74251 FY
|
| Hospital Charge Code |
4904251
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$784.96
|
|
|
XR Small Bowel via Enteroclysis Tube BCE
|
Facility
|
OP
|
$892.00
|
|
|
Service Code
|
CPT 74251 FY
|
| Hospital Charge Code |
4904251
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$579.80 |
| Rate for Payer: Aetna Commercial |
$203.23
|
| Rate for Payer: Aetna Medicare |
$252.04
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$180.34
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$168.03
|
| Rate for Payer: Amerigroup Medicare |
$168.03
|
| Rate for Payer: BCBS of TX Blue Advantage |
$300.66
|
| Rate for Payer: BCBS of TX Blue Essentials |
$360.80
|
| Rate for Payer: BCBS of TX Medicare |
$168.03
|
| Rate for Payer: BCBS of TX PPO |
$402.71
|
| Rate for Payer: Cash Price |
$784.96
|
| Rate for Payer: Cash Price |
$784.96
|
| Rate for Payer: Cash Price |
$784.96
|
| Rate for Payer: Cigna Commercial |
$380.65
|
| Rate for Payer: Cigna Medicaid |
$180.34
|
| Rate for Payer: Cigna Medicare |
$168.03
|
| Rate for Payer: Employer Direct Commercial |
$168.03
|
| Rate for Payer: Humana Medicare/TRICARE |
$168.03
|
| Rate for Payer: Molina CHIP/Medicaid |
$180.34
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$168.03
|
| Rate for Payer: Molina Medicare |
$168.03
|
| Rate for Payer: Multiplan Auto |
$579.80
|
| Rate for Payer: Multiplan Commercial |
$579.80
|
| Rate for Payer: Multiplan Workers Comp |
$579.80
|
| Rate for Payer: Parkland Medicaid |
$180.34
|
| Rate for Payer: Scott and White EPO/PPO |
$3.01
|
| Rate for Payer: Scott and White Medicare |
$168.03
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$180.34
|
| Rate for Payer: Superior Health Plan EPO |
$168.03
|
| Rate for Payer: Superior Health Plan Medicare |
$168.03
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$168.03
|
| Rate for Payer: Universal American Medicare |
$168.03
|
| Rate for Payer: Wellcare Medicare |
$168.03
|
| Rate for Payer: Wellmed Medicare |
$168.03
|
|
|
XR Small Bowel w/ Multiple Series
|
Facility
|
OP
|
$685.00
|
|
|
Service Code
|
CPT 74250 FY
|
| Hospital Charge Code |
3101136
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$445.25 |
| Rate for Payer: Aetna Commercial |
$100.75
|
| Rate for Payer: Aetna Medicare |
$252.04
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$124.30
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$168.03
|
| Rate for Payer: Amerigroup Medicare |
$168.03
|
| Rate for Payer: BCBS of TX Blue Advantage |
$300.66
|
| Rate for Payer: BCBS of TX Blue Essentials |
$360.80
|
| Rate for Payer: BCBS of TX Medicare |
$168.03
|
| Rate for Payer: BCBS of TX PPO |
$402.71
|
| Rate for Payer: Cash Price |
$602.80
|
| Rate for Payer: Cash Price |
$602.80
|
| Rate for Payer: Cash Price |
$602.80
|
| Rate for Payer: Cigna Commercial |
$380.65
|
| Rate for Payer: Cigna Medicaid |
$124.30
|
| Rate for Payer: Cigna Medicare |
$168.03
|
| Rate for Payer: Employer Direct Commercial |
$168.03
|
| Rate for Payer: Humana Medicare/TRICARE |
$168.03
|
| Rate for Payer: Molina CHIP/Medicaid |
$124.30
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$168.03
|
| Rate for Payer: Molina Medicare |
$168.03
|
| Rate for Payer: Multiplan Auto |
$445.25
|
| Rate for Payer: Multiplan Commercial |
$445.25
|
| Rate for Payer: Multiplan Workers Comp |
$445.25
|
| Rate for Payer: Parkland Medicaid |
$124.30
|
| Rate for Payer: Scott and White EPO/PPO |
$3.01
|
| Rate for Payer: Scott and White Medicare |
$168.03
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$124.30
|
| Rate for Payer: Superior Health Plan EPO |
$168.03
|
| Rate for Payer: Superior Health Plan Medicare |
$168.03
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$168.03
|
| Rate for Payer: Universal American Medicare |
$168.03
|
| Rate for Payer: Wellcare Medicare |
$168.03
|
| Rate for Payer: Wellmed Medicare |
$168.03
|
|
|
XR Small Bowel w/ Multiple Series BCE
|
Facility
|
IP
|
$685.00
|
|
|
Service Code
|
CPT 74250 FY
|
| Hospital Charge Code |
3101136
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$602.80
|
|
