|
US OB Greater Than 14 Weeks
|
Facility
|
IP
|
$1,654.00
|
|
|
Service Code
|
HCPCS 76805
|
| Hospital Charge Code |
3500170
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$1,124.72
|
|
|
US OB Greater Than 14 Weeks
|
Facility
|
OP
|
$1,654.00
|
|
|
Service Code
|
HCPCS 76805
|
| Hospital Charge Code |
3500170
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$104.75 |
| Max. Negotiated Rate |
$1,190.88 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$104.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| Rate for Payer: BCBS of TX Blue Advantage |
$151.04
|
| Rate for Payer: BCBS of TX Blue Essentials |
$181.25
|
| Rate for Payer: BCBS of TX Medicare |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$202.30
|
| Rate for Payer: Cash Price |
$1,124.72
|
| Rate for Payer: Cash Price |
$1,124.72
|
| Rate for Payer: Cash Price |
$1,124.72
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$1,190.88
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,190.88
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$1,075.10
|
| Rate for Payer: Multiplan Commercial |
$1,075.10
|
| Rate for Payer: Multiplan Workers Comp |
$1,075.10
|
| Rate for Payer: Parkland Medicaid |
$1,190.88
|
| Rate for Payer: Scott and White EPO/PPO |
$827.00
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,190.88
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
US OB Growth or Anat f/u w/ BPP & UA Dop
|
Facility
|
OP
|
$761.00
|
|
|
Service Code
|
HCPCS 76816
|
| Hospital Charge Code |
9331024
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$104.75 |
| Max. Negotiated Rate |
$547.92 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$104.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| 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 |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$517.48
|
| Rate for Payer: Cash Price |
$517.48
|
| Rate for Payer: Cash Price |
$517.48
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$547.92
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$547.92
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$494.65
|
| Rate for Payer: Multiplan Commercial |
$494.65
|
| Rate for Payer: Multiplan Workers Comp |
$494.65
|
| Rate for Payer: Parkland Medicaid |
$547.92
|
| Rate for Payer: Scott and White EPO/PPO |
$380.50
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$547.92
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
US OB Growth or Anat f/u w/ BPP & UA Dop
|
Facility
|
IP
|
$761.00
|
|
|
Service Code
|
HCPCS 76816
|
| Hospital Charge Code |
9331024
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$517.48
|
|
|
US OB Growth or Anatomy f/u w/ BPP
|
Facility
|
OP
|
$761.00
|
|
|
Service Code
|
HCPCS 76816
|
| Hospital Charge Code |
9331021
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$104.75 |
| Max. Negotiated Rate |
$547.92 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$104.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| 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 |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$517.48
|
| Rate for Payer: Cash Price |
$517.48
|
| Rate for Payer: Cash Price |
$517.48
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$547.92
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$547.92
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$494.65
|
| Rate for Payer: Multiplan Commercial |
$494.65
|
| Rate for Payer: Multiplan Workers Comp |
$494.65
|
| Rate for Payer: Parkland Medicaid |
$547.92
|
| Rate for Payer: Scott and White EPO/PPO |
$380.50
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$547.92
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
US OB Growth or Anatomy f/u w/ BPP
|
Facility
|
IP
|
$761.00
|
|
|
Service Code
|
HCPCS 76816
|
| Hospital Charge Code |
9331021
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$517.48
|
|
|
US OB Level II
|
Facility
|
IP
|
$1,380.00
|
|
|
Service Code
|
HCPCS 76811
|
| Hospital Charge Code |
5066811
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$938.40
|
|
|
US OB Level II
|
Facility
|
OP
|
$1,380.00
|
|
|
Service Code
|
HCPCS 76811
|
| Hospital Charge Code |
5066811
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$139.74 |
| Max. Negotiated Rate |
$993.60 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$177.76
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Amerigroup Medicare |
$239.69
|
| Rate for Payer: BCBS of TX Blue Advantage |
$139.74
|
| Rate for Payer: BCBS of TX Blue Essentials |
$167.69
|
| Rate for Payer: BCBS of TX Medicare |
$239.69
|
| Rate for Payer: BCBS of TX PPO |
$187.16
|
| Rate for Payer: Cash Price |
$938.40
|
| Rate for Payer: Cash Price |
$938.40
|
| Rate for Payer: Cash Price |
$938.40
|
| Rate for Payer: Cigna Commercial |
$506.65
|
| Rate for Payer: Cigna Medicaid |
$993.60
|
| Rate for Payer: Cigna Medicare |
$239.69
|
| Rate for Payer: Employer Direct Commercial |
$239.69
|
| Rate for Payer: Humana Medicare/TRICARE |
$239.69
|
| Rate for Payer: Molina CHIP/Medicaid |
$993.60
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Molina Medicare |
$239.69
|
| Rate for Payer: Multiplan Auto |
$897.00
|
| Rate for Payer: Multiplan Commercial |
$897.00
|
| Rate for Payer: Multiplan Workers Comp |
$897.00
|
| Rate for Payer: Parkland Medicaid |
$993.60
|
| Rate for Payer: Scott and White EPO/PPO |
$690.00
|
| Rate for Payer: Scott and White Medicare |
$239.69
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$993.60
|
| Rate for Payer: Superior Health Plan EPO |
$239.69
|
| Rate for Payer: Superior Health Plan Medicare |
$239.69
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Universal American Medicare |
$239.69
|
| Rate for Payer: Wellcare Medicare |
$239.69
|
| Rate for Payer: Wellmed Medicare |
$239.69
|
|
|
US OB Limited
|
Facility
|
IP
|
$596.00
|
|
|
Service Code
|
HCPCS 76815
|
| Hospital Charge Code |
3500196
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$405.28
|
|
|
US OB Limited
|
Facility
|
OP
|
$596.00
|
|
|
Service Code
|
HCPCS 76815
|
| Hospital Charge Code |
3500196
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$429.12 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$81.20
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| 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 |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$405.28
|
| Rate for Payer: Cash Price |
$405.28
|
| Rate for Payer: Cash Price |
$405.28
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$429.12
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$429.12
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$387.40
|
| Rate for Payer: Multiplan Commercial |
$387.40
|
| Rate for Payer: Multiplan Workers Comp |
$387.40
|
| Rate for Payer: Parkland Medicaid |
$429.12
|
| Rate for Payer: Scott and White EPO/PPO |
$298.00
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$429.12
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
US OB Transvaginal
|
Facility
|
IP
|
$303.00
|
|
|
Service Code
|
HCPCS 76817
|
| Hospital Charge Code |
3511169
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$206.04
|
|
|
US OB Transvaginal
|
Facility
|
OP
|
$303.00
|
|
|
Service Code
|
HCPCS 76817
|
| Hospital Charge Code |
3511169
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$92.89 |
| Max. Negotiated Rate |
$247.70 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$92.89
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| 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 |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$206.04
|
| Rate for Payer: Cash Price |
$206.04
|
| Rate for Payer: Cash Price |
$206.04
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$218.16
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$218.16
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$196.95
|
| Rate for Payer: Multiplan Commercial |
$196.95
|
| Rate for Payer: Multiplan Workers Comp |
$196.95
|
| Rate for Payer: Parkland Medicaid |
$218.16
|
| Rate for Payer: Scott and White EPO/PPO |
$151.50
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$218.16
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
US Paracentesis
|
Facility
|
OP
|
$1,947.00
|
|
|
Service Code
|
HCPCS 49083
|
| Hospital Charge Code |
3520068
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$334.95 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$334.95
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$911.12
|
| Rate for Payer: Amerigroup Medicare |
$911.12
|
| 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 |
$911.12
|
| Rate for Payer: BCBS of TX PPO |
$1,980.52
|
| Rate for Payer: Cash Price |
$1,323.96
|
| Rate for Payer: Cash Price |
$1,323.96
|
| Rate for Payer: Cash Price |
$1,323.96
|
| Rate for Payer: Cigna Commercial |
$1,925.93
|
| Rate for Payer: Cigna Medicaid |
$1,401.84
|
| Rate for Payer: Cigna Medicare |
$911.12
|
| Rate for Payer: Employer Direct Commercial |
$911.12
|
| Rate for Payer: Humana Medicare/TRICARE |
$911.12
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,401.84
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$911.12
|
| Rate for Payer: Molina Medicare |
$911.12
|
| 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 |
$1,401.84
|
| Rate for Payer: Scott and White EPO/PPO |
$1,685.57
|
| Rate for Payer: Scott and White Medicare |
$911.12
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,401.84
|
| Rate for Payer: Superior Health Plan EPO |
$911.12
|
| Rate for Payer: Superior Health Plan Medicare |
$911.12
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$911.12
|
| Rate for Payer: Universal American Medicare |
$911.12
|
| Rate for Payer: Wellcare Medicare |
$911.12
|
| Rate for Payer: Wellmed Medicare |
$911.12
|
|
|
US Paracentesis
|
Facility
|
IP
|
$1,947.00
|
|
|
Service Code
|
HCPCS 49083
|
| Hospital Charge Code |
3520068
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,323.96
|
|
|
US Pelvis Complete Non-OB
|
Facility
|
OP
|
$1,483.00
|
|
|
Service Code
|
HCPCS 76856
|
| Hospital Charge Code |
3500089
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$96.28 |
| Max. Negotiated Rate |
$1,067.76 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$96.28
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| 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 |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$1,008.44
|
| Rate for Payer: Cash Price |
$1,008.44
|
| Rate for Payer: Cash Price |
$1,008.44
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$1,067.76
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,067.76
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$963.95
|
| Rate for Payer: Multiplan Commercial |
$963.95
|
| Rate for Payer: Multiplan Workers Comp |
$963.95
|
| Rate for Payer: Parkland Medicaid |
$1,067.76
|
| Rate for Payer: Scott and White EPO/PPO |
$741.50
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,067.76
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
US Pelvis Complete Non-OB
|
Facility
|
IP
|
$1,483.00
|
|
|
Service Code
|
HCPCS 76856
|
| Hospital Charge Code |
3500089
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$1,008.44
|
|
|
US Pelvis Limited Non-OB
|
Facility
|
OP
|
$613.00
|
|
|
Service Code
|
HCPCS 76857
|
| Hospital Charge Code |
3500535
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$50.79 |
| Max. Negotiated Rate |
$441.36 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$50.79
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| 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 |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$416.84
|
| Rate for Payer: Cash Price |
$416.84
|
| Rate for Payer: Cash Price |
$416.84
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$441.36
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$441.36
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$398.45
|
| Rate for Payer: Multiplan Commercial |
$398.45
|
| Rate for Payer: Multiplan Workers Comp |
$398.45
|
| Rate for Payer: Parkland Medicaid |
$441.36
|
| Rate for Payer: Scott and White EPO/PPO |
$306.50
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$441.36
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
US Pelvis Limited Non-OB
|
Facility
|
IP
|
$613.00
|
|
|
Service Code
|
HCPCS 76857
|
| Hospital Charge Code |
3500535
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$416.84
|
|
|
US Pelvis Non-OB Limited TA
|
Facility
|
IP
|
$613.00
|
|
|
Service Code
|
HCPCS 76857
|
| Hospital Charge Code |
9341008
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$416.84
|
|
|
US Pelvis Non-OB Limited TA
|
Facility
|
OP
|
$613.00
|
|
|
Service Code
|
HCPCS 76857
|
| Hospital Charge Code |
9341008
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$50.79 |
| Max. Negotiated Rate |
$441.36 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$50.79
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| 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 |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$416.84
|
| Rate for Payer: Cash Price |
$416.84
|
| Rate for Payer: Cash Price |
$416.84
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$441.36
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$441.36
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$398.45
|
| Rate for Payer: Multiplan Commercial |
$398.45
|
| Rate for Payer: Multiplan Workers Comp |
$398.45
|
| Rate for Payer: Parkland Medicaid |
$441.36
|
| Rate for Payer: Scott and White EPO/PPO |
$306.50
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$441.36
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
US Prostate Transrectal
|
Facility
|
OP
|
$469.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
3500105
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$104.75 |
| Max. Negotiated Rate |
$337.68 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$104.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| Rate for Payer: BCBS of TX Blue Advantage |
$158.76
|
| Rate for Payer: BCBS of TX Blue Essentials |
$190.52
|
| Rate for Payer: BCBS of TX Medicare |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$212.65
|
| Rate for Payer: Cash Price |
$318.92
|
| Rate for Payer: Cash Price |
$318.92
|
| Rate for Payer: Cash Price |
$318.92
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$337.68
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$337.68
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$304.85
|
| Rate for Payer: Multiplan Commercial |
$304.85
|
| Rate for Payer: Multiplan Workers Comp |
$304.85
|
| Rate for Payer: Parkland Medicaid |
$337.68
|
| Rate for Payer: Scott and White EPO/PPO |
$234.50
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$337.68
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
US Prostate Transrectal
|
Facility
|
IP
|
$469.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
3500105
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$318.92
|
|
|
US Retroperitoneal Complete
|
Facility
|
IP
|
$1,551.00
|
|
|
Service Code
|
HCPCS 76770
|
| Hospital Charge Code |
3501103
|
|
Hospital Revenue Code
|
402
|
| Rate for Payer: Cash Price |
$1,054.68
|
|
|
US Retroperitoneal Complete
|
Facility
|
OP
|
$1,551.00
|
|
|
Service Code
|
HCPCS 76770
|
| Hospital Charge Code |
3501103
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$104.75 |
| Max. Negotiated Rate |
$1,116.72 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$104.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| 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 |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$1,054.68
|
| Rate for Payer: Cash Price |
$1,054.68
|
| Rate for Payer: Cash Price |
$1,054.68
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$1,116.72
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,116.72
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$1,008.15
|
| Rate for Payer: Multiplan Commercial |
$1,008.15
|
| Rate for Payer: Multiplan Workers Comp |
$1,008.15
|
| Rate for Payer: Parkland Medicaid |
$1,116.72
|
| Rate for Payer: Scott and White EPO/PPO |
$775.50
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,116.72
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
|
US Scrotum (Contents) w/ Doppler if ind
|
Facility
|
OP
|
$1,241.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
3500121
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$100.24 |
| Max. Negotiated Rate |
$893.52 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$100.24
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Amerigroup Medicare |
$105.02
|
| 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 |
$105.02
|
| Rate for Payer: BCBS of TX PPO |
$247.70
|
| Rate for Payer: Cash Price |
$843.88
|
| Rate for Payer: Cash Price |
$843.88
|
| Rate for Payer: Cash Price |
$843.88
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$893.52
|
| Rate for Payer: Cigna Medicare |
$105.02
|
| Rate for Payer: Employer Direct Commercial |
$105.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$105.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$893.52
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$806.65
|
| Rate for Payer: Multiplan Commercial |
$806.65
|
| Rate for Payer: Multiplan Workers Comp |
$806.65
|
| Rate for Payer: Parkland Medicaid |
$893.52
|
| Rate for Payer: Scott and White EPO/PPO |
$620.50
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$893.52
|
| Rate for Payer: Superior Health Plan EPO |
$105.02
|
| Rate for Payer: Superior Health Plan Medicare |
$105.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Universal American Medicare |
$105.02
|
| Rate for Payer: Wellcare Medicare |
$105.02
|
| Rate for Payer: Wellmed Medicare |
$105.02
|
|
