|
XR UGI & Small Bowel w/ or w/o Air BCE
|
Facility
|
OP
|
$981.00
|
|
|
Service Code
|
CPT 74248 FY
|
| Hospital Charge Code |
3100002
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.53 |
| Max. Negotiated Rate |
$637.65 |
| Rate for Payer: Aetna Commercial |
$59.53
|
| 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
|
|
|
XR UGI & Small Bowel w/ or w/o Air BCE
|
Facility
|
IP
|
$981.00
|
|
|
Service Code
|
CPT 74248 FY
|
| Hospital Charge Code |
3100002
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$863.28
|
|
|
XR Upper Extremity Infant (0-1yr) Left
|
Facility
|
OP
|
$553.00
|
|
|
Service Code
|
CPT 73092 LT,FY
|
| Hospital Charge Code |
3101573
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$27.56 |
| Max. Negotiated Rate |
$359.45 |
| Rate for Payer: Aetna Commercial |
$27.56
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$106.88
|
| 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 PPO |
$247.70
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$106.88
|
| Rate for Payer: Molina CHIP/Medicaid |
$106.88
|
| Rate for Payer: Multiplan Auto |
$359.45
|
| Rate for Payer: Multiplan Commercial |
$359.45
|
| Rate for Payer: Multiplan Workers Comp |
$359.45
|
| Rate for Payer: Parkland Medicaid |
$106.88
|
| Rate for Payer: Scott and White EPO/PPO |
$276.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$106.88
|
| Rate for Payer: Superior Health Plan EPO |
$75.21
|
|
|
XR Upper Extremity Infant (0-1yr) Left BCE
|
Facility
|
OP
|
$553.00
|
|
|
Service Code
|
CPT 73092 LT,FY
|
| Hospital Charge Code |
3101573
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$27.56 |
| Max. Negotiated Rate |
$359.45 |
| Rate for Payer: Aetna Commercial |
$27.56
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$106.88
|
| 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 PPO |
$247.70
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$106.88
|
| Rate for Payer: Molina CHIP/Medicaid |
$106.88
|
| Rate for Payer: Multiplan Auto |
$359.45
|
| Rate for Payer: Multiplan Commercial |
$359.45
|
| Rate for Payer: Multiplan Workers Comp |
$359.45
|
| Rate for Payer: Parkland Medicaid |
$106.88
|
| Rate for Payer: Scott and White EPO/PPO |
$276.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$106.88
|
| Rate for Payer: Superior Health Plan EPO |
$75.21
|
|
|
XR Upper Extremity Infant (0-1yr) Left BCE
|
Facility
|
IP
|
$553.00
|
|
|
Service Code
|
CPT 73092 LT,FY
|
| Hospital Charge Code |
3101573
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$486.64
|
|
|
XR Upper Extremity Infant (0-1yr) Right
|
Facility
|
OP
|
$553.00
|
|
|
Service Code
|
CPT 73092 RT,FY
|
| Hospital Charge Code |
3101680
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$27.56 |
| Max. Negotiated Rate |
$359.45 |
| Rate for Payer: Aetna Commercial |
$27.56
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$106.88
|
| 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 PPO |
$247.70
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$106.88
|
| Rate for Payer: Molina CHIP/Medicaid |
$106.88
|
| Rate for Payer: Multiplan Auto |
$359.45
|
| Rate for Payer: Multiplan Commercial |
$359.45
|
| Rate for Payer: Multiplan Workers Comp |
$359.45
|
| Rate for Payer: Parkland Medicaid |
$106.88
|
| Rate for Payer: Scott and White EPO/PPO |
$276.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$106.88
|
| Rate for Payer: Superior Health Plan EPO |
$75.21
|
|
|
XR Upper Extremity Infant (0-1yr) Right BCE
|
Facility
|
OP
|
$553.00
|
|
|
Service Code
|
CPT 73092 RT,FY
|
| Hospital Charge Code |
3101680
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$27.56 |
| Max. Negotiated Rate |
$359.45 |
| Rate for Payer: Aetna Commercial |
$27.56
|
| Rate for Payer: Aetna Medicare |
$150.82
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$106.88
|
| 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 PPO |
$247.70
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cash Price |
$486.64
|
| Rate for Payer: Cigna Commercial |
$227.77
|
| Rate for Payer: Cigna Medicaid |
$106.88
|
| Rate for Payer: Molina CHIP/Medicaid |
$106.88
|
| Rate for Payer: Multiplan Auto |
$359.45
|
| Rate for Payer: Multiplan Commercial |
$359.45
|
| Rate for Payer: Multiplan Workers Comp |
$359.45
|
| Rate for Payer: Parkland Medicaid |
$106.88
|
| Rate for Payer: Scott and White EPO/PPO |
$276.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$106.88
|
| Rate for Payer: Superior Health Plan EPO |
$75.21
|
|
|
XR Upper Extremity Infant (0-1yr) Right BCE
|
Facility
|
IP
|
$553.00
|
|
|
Service Code
|
CPT 73092 RT,FY
|
| Hospital Charge Code |
3101680
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$486.64
|
|
|
XR Upper GI
|
Facility
|
OP
|
$981.00
|
|
|
Service Code
|
CPT 74240 FY
|
| Hospital Charge Code |
3160181
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$101.52 |
| Max. Negotiated Rate |
$637.65 |
| Rate for Payer: Aetna Commercial |
$101.52
|
| Rate for Payer: Aetna Medicare |
$252.04
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$124.96
|
| 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 PPO |
$402.71
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cigna Commercial |
$380.65
|
| Rate for Payer: Cigna Medicaid |
$124.96
|
| Rate for Payer: Molina CHIP/Medicaid |
$124.96
|
| 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 |
$124.96
|
| Rate for Payer: Scott and White EPO/PPO |
$490.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$124.96
|
| Rate for Payer: Superior Health Plan EPO |
$133.42
|
|
|
XR Upper GI BCE
|
Facility
|
IP
|
$981.00
|
|
|
Service Code
|
CPT 74240 FY
|
| Hospital Charge Code |
3160181
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$863.28
|
|
|
XR Upper GI BCE
|
Facility
|
OP
|
$981.00
|
|
|
Service Code
|
CPT 74240 FY
|
| Hospital Charge Code |
3160181
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$101.52 |
| Max. Negotiated Rate |
$637.65 |
| Rate for Payer: Aetna Commercial |
$101.52
|
| Rate for Payer: Aetna Medicare |
$252.04
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$124.96
|
| 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 PPO |
$402.71
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cigna Commercial |
$380.65
|
| Rate for Payer: Cigna Medicaid |
$124.96
|
| Rate for Payer: Molina CHIP/Medicaid |
$124.96
|
| 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 |
$124.96
|
| Rate for Payer: Scott and White EPO/PPO |
$490.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$124.96
|
| Rate for Payer: Superior Health Plan EPO |
$133.42
|
|
|
XR Upper GI + KUB
|
Facility
|
OP
|
$981.00
|
|
|
Service Code
|
CPT 74240 FY
|
| Hospital Charge Code |
3160181
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$101.52 |
| Max. Negotiated Rate |
$637.65 |
| Rate for Payer: Aetna Commercial |
$101.52
|
| Rate for Payer: Aetna Medicare |
$252.04
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$124.96
|
| 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 PPO |
$402.71
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cigna Commercial |
$380.65
|
| Rate for Payer: Cigna Medicaid |
$124.96
|
| Rate for Payer: Molina CHIP/Medicaid |
$124.96
|
| 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 |
$124.96
|
| Rate for Payer: Scott and White EPO/PPO |
$490.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$124.96
|
| Rate for Payer: Superior Health Plan EPO |
$133.42
|
|
|
XR Upper GI w/ Air Contrast
|
Facility
|
OP
|
$1,359.00
|
|
|
Service Code
|
CPT 74246 FY
|
| Hospital Charge Code |
3101110
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$116.94 |
| Max. Negotiated Rate |
$883.35 |
| Rate for Payer: Aetna Commercial |
$116.94
|
| Rate for Payer: Aetna Medicare |
$252.04
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$141.68
|
| 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 PPO |
$402.71
|
| Rate for Payer: Cash Price |
$1,195.92
|
| Rate for Payer: Cash Price |
$1,195.92
|
| Rate for Payer: Cash Price |
$1,195.92
|
| Rate for Payer: Cigna Commercial |
$380.65
|
| Rate for Payer: Cigna Medicaid |
$141.68
|
| Rate for Payer: Molina CHIP/Medicaid |
$141.68
|
| Rate for Payer: Multiplan Auto |
$883.35
|
| Rate for Payer: Multiplan Commercial |
$883.35
|
| Rate for Payer: Multiplan Workers Comp |
$883.35
|
| Rate for Payer: Parkland Medicaid |
$141.68
|
| Rate for Payer: Scott and White EPO/PPO |
$679.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$141.68
|
| Rate for Payer: Superior Health Plan EPO |
$184.82
|
|
|
XR Upper GI w/ Air Contrast BCE
|
Facility
|
OP
|
$1,359.00
|
|
|
Service Code
|
CPT 74246 FY
|
| Hospital Charge Code |
3101110
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$116.94 |
| Max. Negotiated Rate |
$883.35 |
| Rate for Payer: Aetna Commercial |
$116.94
|
| Rate for Payer: Aetna Medicare |
$252.04
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$141.68
|
| 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 PPO |
$402.71
|
| Rate for Payer: Cash Price |
$1,195.92
|
| Rate for Payer: Cash Price |
$1,195.92
|
| Rate for Payer: Cash Price |
$1,195.92
|
| Rate for Payer: Cigna Commercial |
$380.65
|
| Rate for Payer: Cigna Medicaid |
$141.68
|
| Rate for Payer: Molina CHIP/Medicaid |
$141.68
|
| Rate for Payer: Multiplan Auto |
$883.35
|
| Rate for Payer: Multiplan Commercial |
$883.35
|
| Rate for Payer: Multiplan Workers Comp |
$883.35
|
| Rate for Payer: Parkland Medicaid |
$141.68
|
| Rate for Payer: Scott and White EPO/PPO |
$679.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$141.68
|
| Rate for Payer: Superior Health Plan EPO |
$184.82
|
|
|
XR Upper GI w/ Air Contrast BCE
|
Facility
|
IP
|
$1,359.00
|
|
|
Service Code
|
CPT 74246 FY
|
| Hospital Charge Code |
3101110
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$1,195.92
|
|
|
XR Upper GI w/ Small Bowel
|
Facility
|
OP
|
$981.00
|
|
|
Service Code
|
CPT 74240 FY
|
| Hospital Charge Code |
3160181
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$101.52 |
| Max. Negotiated Rate |
$637.65 |
| Rate for Payer: Aetna Commercial |
$101.52
|
| Rate for Payer: Aetna Medicare |
$252.04
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$124.96
|
| 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 PPO |
$402.71
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cash Price |
$863.28
|
| Rate for Payer: Cigna Commercial |
$380.65
|
| Rate for Payer: Cigna Medicaid |
$124.96
|
| Rate for Payer: Molina CHIP/Medicaid |
$124.96
|
| 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 |
$124.96
|
| Rate for Payer: Scott and White EPO/PPO |
$490.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$124.96
|
| Rate for Payer: Superior Health Plan EPO |
$133.42
|
|
|
XR Urethrocystography Retrograde
|
Facility
|
OP
|
$1,057.00
|
|
|
Service Code
|
CPT 74450 FY
|
| Hospital Charge Code |
3170070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.38 |
| Max. Negotiated Rate |
$687.05 |
| Rate for Payer: Aetna Commercial |
$261.40
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$81.38
|
| 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 PPO |
$515.02
|
| Rate for Payer: Cash Price |
$930.16
|
| Rate for Payer: Cash Price |
$930.16
|
| Rate for Payer: Cash Price |
$930.16
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$81.38
|
| Rate for Payer: Molina CHIP/Medicaid |
$81.38
|
| Rate for Payer: Multiplan Auto |
$687.05
|
| Rate for Payer: Multiplan Commercial |
$687.05
|
| Rate for Payer: Multiplan Workers Comp |
$687.05
|
| Rate for Payer: Parkland Medicaid |
$81.38
|
| Rate for Payer: Scott and White EPO/PPO |
$528.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$81.38
|
| Rate for Payer: Superior Health Plan EPO |
$143.75
|
|
|
XR Urethrocystography Retrograde BCE
|
Facility
|
IP
|
$1,057.00
|
|
|
Service Code
|
CPT 74450 FY
|
| Hospital Charge Code |
3170070
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$930.16
|
|
|
XR Urethrocystography Retrograde BCE
|
Facility
|
OP
|
$1,057.00
|
|
|
Service Code
|
CPT 74450 FY
|
| Hospital Charge Code |
3170070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.38 |
| Max. Negotiated Rate |
$687.05 |
| Rate for Payer: Aetna Commercial |
$261.40
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$81.38
|
| 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 PPO |
$515.02
|
| Rate for Payer: Cash Price |
$930.16
|
| Rate for Payer: Cash Price |
$930.16
|
| Rate for Payer: Cash Price |
$930.16
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$81.38
|
| Rate for Payer: Molina CHIP/Medicaid |
$81.38
|
| Rate for Payer: Multiplan Auto |
$687.05
|
| Rate for Payer: Multiplan Commercial |
$687.05
|
| Rate for Payer: Multiplan Workers Comp |
$687.05
|
| Rate for Payer: Parkland Medicaid |
$81.38
|
| Rate for Payer: Scott and White EPO/PPO |
$528.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$81.38
|
| Rate for Payer: Superior Health Plan EPO |
$143.75
|
|
|
XR Urography Retrograde Left
|
Facility
|
OP
|
$814.00
|
|
|
Service Code
|
CPT 74420 LT,FY
|
| Hospital Charge Code |
3101235
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$60.30 |
| Max. Negotiated Rate |
$796.73 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$77.19
|
| Rate for Payer: BCBS of TX Blue Advantage |
$76.71
|
| Rate for Payer: BCBS of TX Blue Essentials |
$92.05
|
| Rate for Payer: BCBS of TX PPO |
$102.74
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$77.19
|
| Rate for Payer: Molina CHIP/Medicaid |
$77.19
|
| Rate for Payer: Multiplan Auto |
$529.10
|
| Rate for Payer: Multiplan Commercial |
$529.10
|
| Rate for Payer: Multiplan Workers Comp |
$529.10
|
| Rate for Payer: Parkland Medicaid |
$77.19
|
| Rate for Payer: Scott and White EPO/PPO |
$407.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$77.19
|
| Rate for Payer: Superior Health Plan EPO |
$110.70
|
|
|
XR Urography Retrograde Left BCE
|
Facility
|
OP
|
$814.00
|
|
|
Service Code
|
CPT 74420 LT,FY
|
| Hospital Charge Code |
3101235
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$60.30 |
| Max. Negotiated Rate |
$796.73 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$77.19
|
| Rate for Payer: BCBS of TX Blue Advantage |
$76.71
|
| Rate for Payer: BCBS of TX Blue Essentials |
$92.05
|
| Rate for Payer: BCBS of TX PPO |
$102.74
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$77.19
|
| Rate for Payer: Molina CHIP/Medicaid |
$77.19
|
| Rate for Payer: Multiplan Auto |
$529.10
|
| Rate for Payer: Multiplan Commercial |
$529.10
|
| Rate for Payer: Multiplan Workers Comp |
$529.10
|
| Rate for Payer: Parkland Medicaid |
$77.19
|
| Rate for Payer: Scott and White EPO/PPO |
$407.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$77.19
|
| Rate for Payer: Superior Health Plan EPO |
$110.70
|
|
|
XR Urography Retrograde Right
|
Facility
|
OP
|
$814.00
|
|
|
Service Code
|
CPT 74420 RT,FY
|
| Hospital Charge Code |
3101235
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$60.30 |
| Max. Negotiated Rate |
$796.73 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$77.19
|
| Rate for Payer: BCBS of TX Blue Advantage |
$76.71
|
| Rate for Payer: BCBS of TX Blue Essentials |
$92.05
|
| Rate for Payer: BCBS of TX PPO |
$102.74
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$77.19
|
| Rate for Payer: Molina CHIP/Medicaid |
$77.19
|
| Rate for Payer: Multiplan Auto |
$529.10
|
| Rate for Payer: Multiplan Commercial |
$529.10
|
| Rate for Payer: Multiplan Workers Comp |
$529.10
|
| Rate for Payer: Parkland Medicaid |
$77.19
|
| Rate for Payer: Scott and White EPO/PPO |
$407.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$77.19
|
| Rate for Payer: Superior Health Plan EPO |
$110.70
|
|
|
XR Urography Retrograde Right BCE
|
Facility
|
OP
|
$814.00
|
|
|
Service Code
|
CPT 74420 RT,FY
|
| Hospital Charge Code |
3101235
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$60.30 |
| Max. Negotiated Rate |
$796.73 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Medicare |
$527.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$77.19
|
| Rate for Payer: BCBS of TX Blue Advantage |
$76.71
|
| Rate for Payer: BCBS of TX Blue Essentials |
$92.05
|
| Rate for Payer: BCBS of TX PPO |
$102.74
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cash Price |
$716.32
|
| Rate for Payer: Cigna Commercial |
$796.73
|
| Rate for Payer: Cigna Medicaid |
$77.19
|
| Rate for Payer: Molina CHIP/Medicaid |
$77.19
|
| Rate for Payer: Multiplan Auto |
$529.10
|
| Rate for Payer: Multiplan Commercial |
$529.10
|
| Rate for Payer: Multiplan Workers Comp |
$529.10
|
| Rate for Payer: Parkland Medicaid |
$77.19
|
| Rate for Payer: Scott and White EPO/PPO |
$407.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$77.19
|
| Rate for Payer: Superior Health Plan EPO |
$110.70
|
|
|
XR Urography Retrograde Right BCE
|
Facility
|
IP
|
$814.00
|
|
|
Service Code
|
CPT 74420 RT,FY
|
| Hospital Charge Code |
3101235
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$716.32
|
|
|
XR Voiding Urethrocystography
|
Facility
|
OP
|
$686.00
|
|
|
Service Code
|
CPT 74455 FY
|
| Hospital Charge Code |
3101250
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$93.30 |
| Max. Negotiated Rate |
$515.02 |
| Rate for Payer: Aetna Commercial |
$104.98
|
| Rate for Payer: Aetna Medicare |
$336.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$105.25
|
| 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 PPO |
$515.02
|
| Rate for Payer: Cash Price |
$603.68
|
| Rate for Payer: Cash Price |
$603.68
|
| Rate for Payer: Cash Price |
$603.68
|
| Rate for Payer: Cigna Commercial |
$507.64
|
| Rate for Payer: Cigna Medicaid |
$105.25
|
| Rate for Payer: Molina CHIP/Medicaid |
$105.25
|
| Rate for Payer: Multiplan Auto |
$445.90
|
| Rate for Payer: Multiplan Commercial |
$445.90
|
| Rate for Payer: Multiplan Workers Comp |
$445.90
|
| Rate for Payer: Parkland Medicaid |
$105.25
|
| Rate for Payer: Scott and White EPO/PPO |
$343.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$105.25
|
| Rate for Payer: Superior Health Plan EPO |
$93.30
|
|
