|
XR Tilt Table BCE
|
Facility
|
OP
|
$1,399.00
|
|
|
Service Code
|
CPT 93660 FY
|
| Hospital Charge Code |
3170085
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$1,110.40 |
| Rate for Payer: Aetna Commercial |
$769.45
|
| Rate for Payer: Aetna Medicare |
$735.27
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$125.91
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$490.18
|
| Rate for Payer: Amerigroup Medicare |
$490.18
|
| Rate for Payer: BCBS of TX Blue Advantage |
$115.38
|
| Rate for Payer: BCBS of TX Blue Essentials |
$137.92
|
| Rate for Payer: BCBS of TX Medicare |
$490.18
|
| Rate for Payer: BCBS of TX PPO |
$153.84
|
| Rate for Payer: Cash Price |
$1,231.12
|
| Rate for Payer: Cash Price |
$1,231.12
|
| Rate for Payer: Cash Price |
$1,231.12
|
| Rate for Payer: Cigna Commercial |
$1,110.40
|
| Rate for Payer: Cigna Medicaid |
$56.13
|
| Rate for Payer: Cigna Medicare |
$490.18
|
| Rate for Payer: Employer Direct Commercial |
$490.18
|
| Rate for Payer: Humana Medicare/TRICARE |
$490.18
|
| Rate for Payer: Molina CHIP/Medicaid |
$56.13
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$490.18
|
| Rate for Payer: Molina Medicare |
$490.18
|
| Rate for Payer: Multiplan Auto |
$909.35
|
| Rate for Payer: Multiplan Commercial |
$909.35
|
| Rate for Payer: Multiplan Workers Comp |
$909.35
|
| Rate for Payer: Parkland Medicaid |
$56.13
|
| Rate for Payer: Scott and White EPO/PPO |
$8.77
|
| Rate for Payer: Scott and White Medicare |
$490.18
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$56.13
|
| Rate for Payer: Superior Health Plan EPO |
$490.18
|
| Rate for Payer: Superior Health Plan Medicare |
$490.18
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$490.18
|
| Rate for Payer: Universal American Medicare |
$490.18
|
| Rate for Payer: Wellcare Medicare |
$490.18
|
| Rate for Payer: Wellmed Medicare |
$490.18
|
|
|
XR Tilt Table BCE
|
Facility
|
IP
|
$1,399.00
|
|
|
Service Code
|
CPT 93660 FY
|
| Hospital Charge Code |
3170085
|
|
Hospital Revenue Code
|
480
|
| Rate for Payer: Cash Price |
$1,231.12
|
|
|
XR TMJ Open and Closed Bilateral
|
Facility
|
OP
|
$608.00
|
|
|
Service Code
|
CPT 70330 FY
|
| Hospital Charge Code |
3100237
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$395.20 |
| Rate for Payer: Aetna Commercial |
$48.35
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$53.13
|
| 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 |
$535.04
|
| Rate for Payer: Cash Price |
$535.04
|
| Rate for Payer: Cash Price |
$535.04
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$53.13
|
| 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 |
$53.13
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$395.20
|
| Rate for Payer: Multiplan Commercial |
$395.20
|
| Rate for Payer: Multiplan Workers Comp |
$395.20
|
| Rate for Payer: Parkland Medicaid |
$53.13
|
| 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 |
$53.13
|
| 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 TMJ Open and Closed Bilateral BCE
|
Facility
|
OP
|
$608.00
|
|
|
Service Code
|
CPT 70330 FY
|
| Hospital Charge Code |
3100237
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$395.20 |
| Rate for Payer: Aetna Commercial |
$48.35
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$53.13
|
| 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 |
$535.04
|
| Rate for Payer: Cash Price |
$535.04
|
| Rate for Payer: Cash Price |
$535.04
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$53.13
|
| 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 |
$53.13
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$395.20
|
| Rate for Payer: Multiplan Commercial |
$395.20
|
| Rate for Payer: Multiplan Workers Comp |
$395.20
|
| Rate for Payer: Parkland Medicaid |
$53.13
|
| 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 |
$53.13
|
| 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 TMJ Open and Closed Bilateral BCE
|
Facility
|
IP
|
$608.00
|
|
|
Service Code
|
CPT 70330 FY
|
| Hospital Charge Code |
3100237
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$535.04
|
|
|
XR Toe(1st Digit) 2+ Views Left
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 LT,FY
|
| Hospital Charge Code |
3101052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe(1st Digit) 2+ Views Right
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 RT,FY
|
| Hospital Charge Code |
3101060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe(2nd Digit) 2+ Views Left
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 LT,FY
|
| Hospital Charge Code |
3101052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe(2nd Digit) 2+ Views Right
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 RT,FY
|
| Hospital Charge Code |
3101060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe 2+ Views Left BCE
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 LT,FY
|
| Hospital Charge Code |
3101052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe 2+ Views Right BCE
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 RT,FY
|
| Hospital Charge Code |
3101060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe(3rd Digit) 2+ Views Left
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 LT,FY
|
| Hospital Charge Code |
3101052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe(3rd Digit) 2+ Views Right
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 RT,FY
|
| Hospital Charge Code |
3101060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe(4th Digit) 2+ Views Left
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 LT,FY
|
| Hospital Charge Code |
3101052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe(4th Digit) 2+ Views Right
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 RT,FY
|
| Hospital Charge Code |
3101060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe(5th Digit) 2+ Views Left
|
Facility
|
IP
|
$506.00
|
|
|
Service Code
|
CPT 73660 LT,FY
|
| Hospital Charge Code |
3101052
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$445.28
|
|
|
XR Toe(5th Digit) 2+ Views Left
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 LT,FY
|
| Hospital Charge Code |
3101052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe(5th Digit) 2+ Views Right
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
CPT 73660 RT,FY
|
| Hospital Charge Code |
3101060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$328.90 |
| Rate for Payer: Aetna Commercial |
$26.02
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.40
|
| 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 |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cash Price |
$445.28
|
| Rate for Payer: Cigna Commercial |
$188.25
|
| Rate for Payer: Cigna Medicaid |
$29.40
|
| 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 |
$29.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$83.10
|
| Rate for Payer: Molina Medicare |
$83.10
|
| Rate for Payer: Multiplan Auto |
$328.90
|
| Rate for Payer: Multiplan Commercial |
$328.90
|
| Rate for Payer: Multiplan Workers Comp |
$328.90
|
| Rate for Payer: Parkland Medicaid |
$29.40
|
| 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 |
$29.40
|
| 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 Toe(5th Digit) 2+ Views Right
|
Facility
|
IP
|
$506.00
|
|
|
Service Code
|
CPT 73660 RT,FY
|
| Hospital Charge Code |
3101060
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$445.28
|
|
|
XR Tube Replace G or J w/ Fluoro w/ Cnt
|
Facility
|
OP
|
$1,591.00
|
|
|
Service Code
|
CPT 49451 FY
|
| Hospital Charge Code |
4909452
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$2,200.00
|
| Rate for Payer: Aetna Medicare |
$1,243.53
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$334.95
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Amerigroup Medicare |
$829.02
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,312.49
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,571.84
|
| Rate for Payer: BCBS of TX Medicare |
$829.02
|
| Rate for Payer: BCBS of TX PPO |
$1,980.52
|
| Rate for Payer: Cash Price |
$1,400.08
|
| Rate for Payer: Cash Price |
$1,400.08
|
| Rate for Payer: Cigna Commercial |
$1,877.98
|
| Rate for Payer: Cigna Medicaid |
$334.95
|
| Rate for Payer: Cigna Medicare |
$829.02
|
| Rate for Payer: Employer Direct Commercial |
$829.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$829.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$334.95
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Molina Medicare |
$829.02
|
| Rate for Payer: Multiplan Auto |
$10,000.00
|
| Rate for Payer: Multiplan Commercial |
$10,000.00
|
| Rate for Payer: Multiplan Workers Comp |
$10,000.00
|
| Rate for Payer: Parkland Medicaid |
$334.95
|
| Rate for Payer: Scott and White EPO/PPO |
$18.29
|
| Rate for Payer: Scott and White Medicare |
$829.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$334.95
|
| Rate for Payer: Superior Health Plan EPO |
$829.02
|
| Rate for Payer: Superior Health Plan Medicare |
$829.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Universal American Medicare |
$829.02
|
| Rate for Payer: Wellcare Medicare |
$829.02
|
| Rate for Payer: Wellmed Medicare |
$829.02
|
|
|
XR Tube Replace G or J w/ Fluoro w/ Cnt BCE
|
Facility
|
IP
|
$1,591.00
|
|
|
Service Code
|
CPT 49451 FY
|
| Hospital Charge Code |
4909452
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,400.08
|
|
|
XR Tube Replace G or J w/ Fluoro w/ Cnt BCE
|
Facility
|
OP
|
$1,591.00
|
|
|
Service Code
|
CPT 49451 FY
|
| Hospital Charge Code |
4909452
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$2,200.00
|
| Rate for Payer: Aetna Medicare |
$1,243.53
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$334.95
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Amerigroup Medicare |
$829.02
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,312.49
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,571.84
|
| Rate for Payer: BCBS of TX Medicare |
$829.02
|
| Rate for Payer: BCBS of TX PPO |
$1,980.52
|
| Rate for Payer: Cash Price |
$1,400.08
|
| Rate for Payer: Cash Price |
$1,400.08
|
| Rate for Payer: Cigna Commercial |
$1,877.98
|
| Rate for Payer: Cigna Medicaid |
$334.95
|
| Rate for Payer: Cigna Medicare |
$829.02
|
| Rate for Payer: Employer Direct Commercial |
$829.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$829.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$334.95
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Molina Medicare |
$829.02
|
| Rate for Payer: Multiplan Auto |
$10,000.00
|
| Rate for Payer: Multiplan Commercial |
$10,000.00
|
| Rate for Payer: Multiplan Workers Comp |
$10,000.00
|
| Rate for Payer: Parkland Medicaid |
$334.95
|
| Rate for Payer: Scott and White EPO/PPO |
$18.29
|
| Rate for Payer: Scott and White Medicare |
$829.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$334.95
|
| Rate for Payer: Superior Health Plan EPO |
$829.02
|
| Rate for Payer: Superior Health Plan Medicare |
$829.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$829.02
|
| Rate for Payer: Universal American Medicare |
$829.02
|
| Rate for Payer: Wellcare Medicare |
$829.02
|
| Rate for Payer: Wellmed Medicare |
$829.02
|
|
|
XR Tube Reposition Gastric
|
Facility
|
IP
|
$2,417.00
|
|
|
Service Code
|
CPT 43761
|
| Hospital Charge Code |
2425638
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$2,126.96
|
|
|
XR Tube Reposition Gastric
|
Facility
|
OP
|
$2,417.00
|
|
|
Service Code
|
CPT 43761
|
| Hospital Charge Code |
2425638
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$4.99 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,329.35
|
| Rate for Payer: Aetna Medicare |
$339.04
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$110.15
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$226.03
|
| Rate for Payer: Amerigroup Medicare |
$226.03
|
| Rate for Payer: BCBS of TX Blue Advantage |
$392.28
|
| Rate for Payer: BCBS of TX Blue Essentials |
$469.80
|
| Rate for Payer: BCBS of TX Medicare |
$226.03
|
| Rate for Payer: BCBS of TX PPO |
$591.95
|
| Rate for Payer: Cash Price |
$2,126.96
|
| Rate for Payer: Cash Price |
$2,126.96
|
| Rate for Payer: Cash Price |
$2,126.96
|
| Rate for Payer: Cigna Commercial |
$512.01
|
| Rate for Payer: Cigna Medicaid |
$110.15
|
| Rate for Payer: Cigna Medicare |
$226.03
|
| Rate for Payer: Employer Direct Commercial |
$226.03
|
| Rate for Payer: Humana Medicare/TRICARE |
$226.03
|
| Rate for Payer: Molina CHIP/Medicaid |
$110.15
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$226.03
|
| Rate for Payer: Molina Medicare |
$226.03
|
| 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 |
$110.15
|
| Rate for Payer: Scott and White EPO/PPO |
$4.99
|
| Rate for Payer: Scott and White Medicare |
$226.03
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$110.15
|
| Rate for Payer: Superior Health Plan EPO |
$226.03
|
| Rate for Payer: Superior Health Plan Medicare |
$226.03
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$226.03
|
| Rate for Payer: Universal American Medicare |
$226.03
|
| Rate for Payer: Wellcare Medicare |
$226.03
|
| Rate for Payer: Wellmed Medicare |
$226.03
|
|
|
XR UGI & Small Bowel w/ or w/o Air
|
Facility
|
OP
|
$981.00
|
|
|
Service Code
|
CPT 74248 FY
|
| Hospital Charge Code |
3100002
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.54 |
| Max. Negotiated Rate |
$637.65 |
| Rate for Payer: Aetna Commercial |
$59.54
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$83.86
|
| Rate for Payer: BCBS of TX Blue Advantage |
$79.08
|
| Rate for Payer: BCBS of TX Blue Essentials |
$94.90
|
| Rate for Payer: BCBS of TX PPO |
$105.93
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cigna Medicaid |
$83.86
|
| Rate for Payer: Molina CHIP/Medicaid |
$83.86
|
| Rate for Payer: Multiplan Auto |
$637.65
|
| Rate for Payer: Multiplan Commercial |
$637.65
|
| Rate for Payer: Multiplan Workers Comp |
$637.65
|
| Rate for Payer: Parkland Medicaid |
$83.86
|
| Rate for Payer: Scott and White EPO/PPO |
$490.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$83.86
|
| Rate for Payer: Superior Health Plan EPO |
$133.42
|
|
