|
XR Small Bowel w/ Multiple Series BCE
|
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 Speech Evaluation w/ Cine Video
|
Facility
|
OP
|
$719.00
|
|
|
Service Code
|
CPT 70371 FY
|
| Hospital Charge Code |
3160413
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$4.01 |
| Max. Negotiated Rate |
$515.02 |
| Rate for Payer: Aetna Commercial |
$74.55
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$108.59
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Amerigroup Medicare |
$224.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$384.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$461.42
|
| Rate for Payer: BCBS of TX Medicare |
$224.10
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$632.72
|
| Rate for Payer: Cash Price |
$632.72
|
| Rate for Payer: Cash Price |
$632.72
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$108.59
|
| Rate for Payer: Cigna Medicare |
$224.10
|
| Rate for Payer: Employer Direct Commercial |
$224.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$224.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$108.59
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Molina Medicare |
$224.10
|
| Rate for Payer: Multiplan Auto |
$467.35
|
| Rate for Payer: Multiplan Commercial |
$467.35
|
| Rate for Payer: Multiplan Workers Comp |
$467.35
|
| Rate for Payer: Parkland Medicaid |
$108.59
|
| Rate for Payer: Scott and White EPO/PPO |
$4.01
|
| Rate for Payer: Scott and White Medicare |
$224.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$108.59
|
| Rate for Payer: Superior Health Plan EPO |
$224.10
|
| Rate for Payer: Superior Health Plan Medicare |
$224.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Universal American Medicare |
$224.10
|
| Rate for Payer: Wellcare Medicare |
$224.10
|
| Rate for Payer: Wellmed Medicare |
$224.10
|
|
|
XR Speech Evaluation w/ Cine Video BCE
|
Facility
|
IP
|
$719.00
|
|
|
Service Code
|
CPT 70371 FY
|
| Hospital Charge Code |
3160413
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$632.72
|
|
|
XR Speech Evaluation w/ Cine Video BCE
|
Facility
|
OP
|
$719.00
|
|
|
Service Code
|
CPT 70371 FY
|
| Hospital Charge Code |
3160413
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$4.01 |
| Max. Negotiated Rate |
$515.02 |
| Rate for Payer: Aetna Commercial |
$74.55
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$108.59
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Amerigroup Medicare |
$224.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$384.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$461.42
|
| Rate for Payer: BCBS of TX Medicare |
$224.10
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$632.72
|
| Rate for Payer: Cash Price |
$632.72
|
| Rate for Payer: Cash Price |
$632.72
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$108.59
|
| Rate for Payer: Cigna Medicare |
$224.10
|
| Rate for Payer: Employer Direct Commercial |
$224.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$224.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$108.59
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Molina Medicare |
$224.10
|
| Rate for Payer: Multiplan Auto |
$467.35
|
| Rate for Payer: Multiplan Commercial |
$467.35
|
| Rate for Payer: Multiplan Workers Comp |
$467.35
|
| Rate for Payer: Parkland Medicaid |
$108.59
|
| Rate for Payer: Scott and White EPO/PPO |
$4.01
|
| Rate for Payer: Scott and White Medicare |
$224.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$108.59
|
| Rate for Payer: Superior Health Plan EPO |
$224.10
|
| Rate for Payer: Superior Health Plan Medicare |
$224.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$224.10
|
| Rate for Payer: Universal American Medicare |
$224.10
|
| Rate for Payer: Wellcare Medicare |
$224.10
|
| Rate for Payer: Wellmed Medicare |
$224.10
|
|
|
XR Spinal Puncture Therapeutic
|
Facility
|
OP
|
$1,519.00
|
|
|
Service Code
|
CPT 62272 FY
|
| Hospital Charge Code |
2161020
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$13.95 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$948.68
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$262.86
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$632.45
|
| Rate for Payer: Amerigroup Medicare |
$632.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,043.83
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,250.10
|
| Rate for Payer: BCBS of TX Medicare |
$632.45
|
| Rate for Payer: BCBS of TX PPO |
$1,575.13
|
| Rate for Payer: Cash Price |
$1,336.72
|
| Rate for Payer: Cash Price |
$1,336.72
|
| Rate for Payer: Cigna Commercial |
$1,432.68
|
| Rate for Payer: Cigna Medicaid |
$262.86
|
| Rate for Payer: Cigna Medicare |
$632.45
|
| Rate for Payer: Employer Direct Commercial |
$632.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$632.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$262.86
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$632.45
|
| Rate for Payer: Molina Medicare |
$632.45
|
| 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 |
$262.86
|
| Rate for Payer: Scott and White EPO/PPO |
$13.95
|
| Rate for Payer: Scott and White Medicare |
$632.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$262.86
|
| Rate for Payer: Superior Health Plan EPO |
$632.45
|
| Rate for Payer: Superior Health Plan Medicare |
$632.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$632.45
|
| Rate for Payer: Universal American Medicare |
$632.45
|
| Rate for Payer: Wellcare Medicare |
$632.45
|
| Rate for Payer: Wellmed Medicare |
$632.45
|
|
|
XR Spinal Puncture Therapeutic BCE
|
Facility
|
IP
|
$1,519.00
|
|
|
Service Code
|
CPT 62272 FY
|
| Hospital Charge Code |
2161020
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,336.72
|
|
|
XR Spinal Puncture Therapeutic BCE
|
Facility
|
OP
|
$1,519.00
|
|
|
Service Code
|
CPT 62272 FY
|
| Hospital Charge Code |
2161020
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$13.95 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$948.68
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$262.86
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$632.45
|
| Rate for Payer: Amerigroup Medicare |
$632.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,043.83
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,250.10
|
| Rate for Payer: BCBS of TX Medicare |
$632.45
|
| Rate for Payer: BCBS of TX PPO |
$1,575.13
|
| Rate for Payer: Cash Price |
$1,336.72
|
| Rate for Payer: Cash Price |
$1,336.72
|
| Rate for Payer: Cigna Commercial |
$1,432.68
|
| Rate for Payer: Cigna Medicaid |
$262.86
|
| Rate for Payer: Cigna Medicare |
$632.45
|
| Rate for Payer: Employer Direct Commercial |
$632.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$632.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$262.86
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$632.45
|
| Rate for Payer: Molina Medicare |
$632.45
|
| 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 |
$262.86
|
| Rate for Payer: Scott and White EPO/PPO |
$13.95
|
| Rate for Payer: Scott and White Medicare |
$632.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$262.86
|
| Rate for Payer: Superior Health Plan EPO |
$632.45
|
| Rate for Payer: Superior Health Plan Medicare |
$632.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$632.45
|
| Rate for Payer: Universal American Medicare |
$632.45
|
| Rate for Payer: Wellcare Medicare |
$632.45
|
| Rate for Payer: Wellmed Medicare |
$632.45
|
|
|
XR Spine Cervical 1 View
|
Facility
|
OP
|
$364.00
|
|
|
Service Code
|
CPT 72020 FY
|
| Hospital Charge Code |
3100377
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$236.60 |
| Rate for Payer: Aetna Commercial |
$19.08
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$24.73
|
| 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 |
$320.32
|
| Rate for Payer: Cash Price |
$320.32
|
| Rate for Payer: Cash Price |
$320.32
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$24.73
|
| 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 |
$24.73
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$236.60
|
| Rate for Payer: Multiplan Commercial |
$236.60
|
| Rate for Payer: Multiplan Workers Comp |
$236.60
|
| Rate for Payer: Parkland Medicaid |
$24.73
|
| 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 |
$24.73
|
| 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 Spine Cervical 1 View BCE
|
Facility
|
OP
|
$364.00
|
|
|
Service Code
|
CPT 72020 FY
|
| Hospital Charge Code |
3100377
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$236.60 |
| Rate for Payer: Aetna Commercial |
$19.08
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$24.73
|
| 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 |
$320.32
|
| Rate for Payer: Cash Price |
$320.32
|
| Rate for Payer: Cash Price |
$320.32
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$24.73
|
| 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 |
$24.73
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$236.60
|
| Rate for Payer: Multiplan Commercial |
$236.60
|
| Rate for Payer: Multiplan Workers Comp |
$236.60
|
| Rate for Payer: Parkland Medicaid |
$24.73
|
| 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 |
$24.73
|
| 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 Spine Cervical 2 or 3 Views
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
CPT 72040 FY
|
| Hospital Charge Code |
3100401
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$370.50 |
| Rate for Payer: Aetna Commercial |
$32.95
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$39.76
|
| 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 |
$501.60
|
| Rate for Payer: Cash Price |
$501.60
|
| Rate for Payer: Cash Price |
$501.60
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$39.76
|
| 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 |
$39.76
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$370.50
|
| Rate for Payer: Multiplan Commercial |
$370.50
|
| Rate for Payer: Multiplan Workers Comp |
$370.50
|
| Rate for Payer: Parkland Medicaid |
$39.76
|
| 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 |
$39.76
|
| 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 Spine Cervical 2 or 3 Views BCE
|
Facility
|
IP
|
$570.00
|
|
|
Service Code
|
CPT 72040 FY
|
| Hospital Charge Code |
3100401
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$501.60
|
|
|
XR Spine Cervical 2 or 3 Views BCE
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
CPT 72040 FY
|
| Hospital Charge Code |
3100401
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$370.50 |
| Rate for Payer: Aetna Commercial |
$32.95
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$39.76
|
| 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 |
$501.60
|
| Rate for Payer: Cash Price |
$501.60
|
| Rate for Payer: Cash Price |
$501.60
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$39.76
|
| 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 |
$39.76
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$370.50
|
| Rate for Payer: Multiplan Commercial |
$370.50
|
| Rate for Payer: Multiplan Workers Comp |
$370.50
|
| Rate for Payer: Parkland Medicaid |
$39.76
|
| 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 |
$39.76
|
| 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 Spine Cervical 4 or 5 Views
|
Facility
|
OP
|
$685.00
|
|
|
Service Code
|
CPT 72050 FY
|
| Hospital Charge Code |
3100419
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$445.25 |
| Rate for Payer: Aetna Commercial |
$46.04
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$53.46
|
| 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 |
$602.80
|
| Rate for Payer: Cash Price |
$602.80
|
| Rate for Payer: Cash Price |
$602.80
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$53.46
|
| 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 |
$53.46
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| 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 |
$53.46
|
| 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 |
$53.46
|
| 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 Spine Cervical 4 or 5 Views BCE
|
Facility
|
IP
|
$685.00
|
|
|
Service Code
|
CPT 72050 FY
|
| Hospital Charge Code |
3100419
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$602.80
|
|
|
XR Spine Cervical 4 or 5 Views BCE
|
Facility
|
OP
|
$685.00
|
|
|
Service Code
|
CPT 72050 FY
|
| Hospital Charge Code |
3100419
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$445.25 |
| Rate for Payer: Aetna Commercial |
$46.04
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$53.46
|
| 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 |
$602.80
|
| Rate for Payer: Cash Price |
$602.80
|
| Rate for Payer: Cash Price |
$602.80
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$53.46
|
| 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 |
$53.46
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| 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 |
$53.46
|
| 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 |
$53.46
|
| 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 Spine Cervical 6+ Views
|
Facility
|
OP
|
$774.00
|
|
|
Service Code
|
CPT 72052 FY
|
| Hospital Charge Code |
3100427
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$503.10 |
| Rate for Payer: Aetna Commercial |
$54.92
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$62.49
|
| 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 |
$681.12
|
| Rate for Payer: Cash Price |
$681.12
|
| Rate for Payer: Cash Price |
$681.12
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$62.49
|
| 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 |
$62.49
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$503.10
|
| Rate for Payer: Multiplan Commercial |
$503.10
|
| Rate for Payer: Multiplan Workers Comp |
$503.10
|
| Rate for Payer: Parkland Medicaid |
$62.49
|
| 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 |
$62.49
|
| 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 Spine Cervical 6+ Views BCE
|
Facility
|
OP
|
$774.00
|
|
|
Service Code
|
CPT 72052 FY
|
| Hospital Charge Code |
3100427
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$503.10 |
| Rate for Payer: Aetna Commercial |
$54.92
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$62.49
|
| 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 |
$681.12
|
| Rate for Payer: Cash Price |
$681.12
|
| Rate for Payer: Cash Price |
$681.12
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$62.49
|
| 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 |
$62.49
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$503.10
|
| Rate for Payer: Multiplan Commercial |
$503.10
|
| Rate for Payer: Multiplan Workers Comp |
$503.10
|
| Rate for Payer: Parkland Medicaid |
$62.49
|
| 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 |
$62.49
|
| 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 Spine Cervical 6+ Views BCE
|
Facility
|
IP
|
$774.00
|
|
|
Service Code
|
CPT 72052 FY
|
| Hospital Charge Code |
3100427
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$681.12
|
|
|
XR Spine Lumbar 1 View
|
Facility
|
OP
|
$364.00
|
|
|
Service Code
|
CPT 72020 FY
|
| Hospital Charge Code |
3100385
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$236.60 |
| Rate for Payer: Aetna Commercial |
$19.08
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$24.73
|
| 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 |
$320.32
|
| Rate for Payer: Cash Price |
$320.32
|
| Rate for Payer: Cash Price |
$320.32
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$24.73
|
| 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 |
$24.73
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$236.60
|
| Rate for Payer: Multiplan Commercial |
$236.60
|
| Rate for Payer: Multiplan Workers Comp |
$236.60
|
| Rate for Payer: Parkland Medicaid |
$24.73
|
| 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 |
$24.73
|
| 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 Spine Lumbar 1 View BCE
|
Facility
|
OP
|
$364.00
|
|
|
Service Code
|
CPT 72020 FY
|
| Hospital Charge Code |
3100385
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$236.60 |
| Rate for Payer: Aetna Commercial |
$19.08
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$24.73
|
| 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 |
$320.32
|
| Rate for Payer: Cash Price |
$320.32
|
| Rate for Payer: Cash Price |
$320.32
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$24.73
|
| 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 |
$24.73
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$236.60
|
| Rate for Payer: Multiplan Commercial |
$236.60
|
| Rate for Payer: Multiplan Workers Comp |
$236.60
|
| Rate for Payer: Parkland Medicaid |
$24.73
|
| 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 |
$24.73
|
| 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 Spine Lumbar 1 View BCE
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
CPT 72020 FY
|
| Hospital Charge Code |
3100385
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$320.32
|
|
|
XR Spine Lumbosacral 2 or 3 Views
|
Facility
|
OP
|
$890.00
|
|
|
Service Code
|
CPT 72100 FY
|
| Hospital Charge Code |
3100476
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$578.50 |
| Rate for Payer: Aetna Commercial |
$33.34
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$40.10
|
| 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 |
$783.20
|
| Rate for Payer: Cash Price |
$783.20
|
| Rate for Payer: Cash Price |
$783.20
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$40.10
|
| 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 |
$40.10
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$578.50
|
| Rate for Payer: Multiplan Commercial |
$578.50
|
| Rate for Payer: Multiplan Workers Comp |
$578.50
|
| Rate for Payer: Parkland Medicaid |
$40.10
|
| 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 |
$40.10
|
| 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 Spine Lumbosacral 2 or 3 Views BCE
|
Facility
|
IP
|
$890.00
|
|
|
Service Code
|
CPT 72100 FY
|
| Hospital Charge Code |
3100476
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$783.20
|
|
|
XR Spine Lumbosacral 2 or 3 Views BCE
|
Facility
|
OP
|
$890.00
|
|
|
Service Code
|
CPT 72100 FY
|
| Hospital Charge Code |
3100476
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$578.50 |
| Rate for Payer: Aetna Commercial |
$33.34
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$40.10
|
| 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 |
$783.20
|
| Rate for Payer: Cash Price |
$783.20
|
| Rate for Payer: Cash Price |
$783.20
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$40.10
|
| 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 |
$40.10
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$578.50
|
| Rate for Payer: Multiplan Commercial |
$578.50
|
| Rate for Payer: Multiplan Workers Comp |
$578.50
|
| Rate for Payer: Parkland Medicaid |
$40.10
|
| 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 |
$40.10
|
| 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 Spine Lumbosacral 4+ Views
|
Facility
|
OP
|
$1,077.00
|
|
|
Service Code
|
CPT 72110 FY
|
| Hospital Charge Code |
3100484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$700.05 |
| Rate for Payer: Aetna Commercial |
$44.50
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$51.45
|
| 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 |
$947.76
|
| Rate for Payer: Cash Price |
$947.76
|
| Rate for Payer: Cash Price |
$947.76
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$51.45
|
| 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 |
$51.45
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.55
|
| Rate for Payer: Molina Medicare |
$100.55
|
| Rate for Payer: Multiplan Auto |
$700.05
|
| Rate for Payer: Multiplan Commercial |
$700.05
|
| Rate for Payer: Multiplan Workers Comp |
$700.05
|
| Rate for Payer: Parkland Medicaid |
$51.45
|
| 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 |
$51.45
|
| 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
|
|
