|
XR Osseous Survey Complete
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
HCPCS 77075
|
| Hospital Charge Code |
3120078
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$99.90 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$99.90
|
| 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 |
$323.00
|
| Rate for Payer: Cash Price |
$323.00
|
| Rate for Payer: Cash Price |
$323.00
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$342.00
|
| 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 |
$342.00
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$308.75
|
| Rate for Payer: Multiplan Commercial |
$308.75
|
| Rate for Payer: Multiplan Workers Comp |
$308.75
|
| Rate for Payer: Parkland Medicaid |
$342.00
|
| Rate for Payer: Scott and White EPO/PPO |
$123.06
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$342.00
|
| 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
|
|
|
XR Osseous Survey Infant
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
HCPCS 77076
|
| Hospital Charge Code |
3120086
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$339.32
|
|
|
XR Osseous Survey Infant
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
HCPCS 77076
|
| Hospital Charge Code |
3120086
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$104.75 |
| Max. Negotiated Rate |
$359.28 |
| 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 |
$339.32
|
| Rate for Payer: Cash Price |
$339.32
|
| Rate for Payer: Cash Price |
$339.32
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$359.28
|
| 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 |
$359.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$324.35
|
| Rate for Payer: Multiplan Commercial |
$324.35
|
| Rate for Payer: Multiplan Workers Comp |
$324.35
|
| Rate for Payer: Parkland Medicaid |
$359.28
|
| Rate for Payer: Scott and White EPO/PPO |
$132.51
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$359.28
|
| 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
|
|
|
XR Osseous Survey Limited
|
Facility
|
OP
|
$452.00
|
|
|
Service Code
|
HCPCS 77074
|
| Hospital Charge Code |
4906060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$65.49 |
| Max. Negotiated Rate |
$325.44 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$65.49
|
| 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 |
$307.36
|
| Rate for Payer: Cash Price |
$307.36
|
| Rate for Payer: Cash Price |
$307.36
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$325.44
|
| 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 |
$325.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$293.80
|
| Rate for Payer: Multiplan Commercial |
$293.80
|
| Rate for Payer: Multiplan Workers Comp |
$293.80
|
| Rate for Payer: Parkland Medicaid |
$325.44
|
| Rate for Payer: Scott and White EPO/PPO |
$80.70
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$325.44
|
| 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
|
|
|
XR Osseous Survey Limited
|
Facility
|
IP
|
$452.00
|
|
|
Service Code
|
HCPCS 77074
|
| Hospital Charge Code |
4906060
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$307.36
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
|
OP
|
$546.00
|
|
|
Service Code
|
HCPCS 72170
|
| Hospital Charge Code |
3100518
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$28.06 |
| Max. Negotiated Rate |
$393.12 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$28.06
|
| 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 |
$371.28
|
| Rate for Payer: Cash Price |
$371.28
|
| Rate for Payer: Cash Price |
$371.28
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$393.12
|
| 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 |
$393.12
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$354.90
|
| Rate for Payer: Multiplan Commercial |
$354.90
|
| Rate for Payer: Multiplan Workers Comp |
$354.90
|
| Rate for Payer: Parkland Medicaid |
$393.12
|
| Rate for Payer: Scott and White EPO/PPO |
$34.54
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$393.12
|
| 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
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
|
IP
|
$546.00
|
|
|
Service Code
|
HCPCS 72170
|
| Hospital Charge Code |
3100518
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$371.28
|
|
|
XR Pelvis Complete 3+ Views
|
Facility
|
OP
|
$603.00
|
|
|
Service Code
|
HCPCS 72190
|
| Hospital Charge Code |
3160132
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$42.44 |
| Max. Negotiated Rate |
$434.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$42.44
|
| 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 |
$410.04
|
| Rate for Payer: Cash Price |
$410.04
|
| Rate for Payer: Cash Price |
$410.04
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$434.16
|
| 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 |
$434.16
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$391.95
|
| Rate for Payer: Multiplan Commercial |
$391.95
|
| Rate for Payer: Multiplan Workers Comp |
$391.95
|
| Rate for Payer: Parkland Medicaid |
$434.16
|
| Rate for Payer: Scott and White EPO/PPO |
$52.27
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$434.16
|
| 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
|
|
|
XR Pelvis Complete 3+ Views
|
Facility
|
IP
|
$603.00
|
|
|
Service Code
|
HCPCS 72190
|
| Hospital Charge Code |
3160132
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$410.04
|
|
|
XR Replace Duodenostomy Tube
|
Facility
|
IP
|
$1,591.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
4906589
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,081.88
|
|
|
XR Replace Duodenostomy Tube
|
Facility
|
OP
|
$1,591.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
4906589
|
|
Hospital Revenue Code
|
360
|
| 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 |
$1,081.88
|
| Rate for Payer: Cash Price |
$1,081.88
|
| Rate for Payer: Cash Price |
$1,081.88
|
| Rate for Payer: Cigna Commercial |
$1,925.93
|
| Rate for Payer: Cigna Medicaid |
$1,145.52
|
| 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 |
$1,145.52
|
| 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 |
$1,145.52
|
| Rate for Payer: Scott and White EPO/PPO |
$1,533.69
|
| Rate for Payer: Scott and White Medicare |
$911.12
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,145.52
|
| 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
|
|
|
XR Ribs 2 Views Left
|
Facility
|
OP
|
$727.00
|
|
|
Service Code
|
HCPCS 71100 LT
|
| Hospital Charge Code |
3100351
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$523.44 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$36.75
|
| 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 PPO |
$176.38
|
| Rate for Payer: Cash Price |
$494.36
|
| Rate for Payer: Cash Price |
$494.36
|
| Rate for Payer: Cash Price |
$494.36
|
| Rate for Payer: Cigna Commercial |
$184.79
|
| Rate for Payer: Cigna Medicaid |
$523.44
|
| Rate for Payer: Molina CHIP/Medicaid |
$523.44
|
| Rate for Payer: Multiplan Auto |
$472.55
|
| Rate for Payer: Multiplan Commercial |
$472.55
|
| Rate for Payer: Multiplan Workers Comp |
$472.55
|
| Rate for Payer: Parkland Medicaid |
$523.44
|
| Rate for Payer: Scott and White EPO/PPO |
$363.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$523.44
|
| Rate for Payer: Superior Health Plan EPO |
$98.87
|
|
|
XR Ribs 2 Views Left
|
Facility
|
IP
|
$727.00
|
|
|
Service Code
|
HCPCS 71100 LT
|
| Hospital Charge Code |
3100351
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$494.36
|
|
|
XR Ribs 2 Views Right
|
Facility
|
IP
|
$727.00
|
|
|
Service Code
|
HCPCS 71100 RT
|
| Hospital Charge Code |
3100369
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$494.36
|
|
|
XR Ribs 2 Views Right
|
Facility
|
OP
|
$727.00
|
|
|
Service Code
|
HCPCS 71100 RT
|
| Hospital Charge Code |
3100369
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$523.44 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$36.75
|
| 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 PPO |
$176.38
|
| Rate for Payer: Cash Price |
$494.36
|
| Rate for Payer: Cash Price |
$494.36
|
| Rate for Payer: Cash Price |
$494.36
|
| Rate for Payer: Cigna Commercial |
$184.79
|
| Rate for Payer: Cigna Medicaid |
$523.44
|
| Rate for Payer: Molina CHIP/Medicaid |
$523.44
|
| Rate for Payer: Multiplan Auto |
$472.55
|
| Rate for Payer: Multiplan Commercial |
$472.55
|
| Rate for Payer: Multiplan Workers Comp |
$472.55
|
| Rate for Payer: Parkland Medicaid |
$523.44
|
| Rate for Payer: Scott and White EPO/PPO |
$363.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$523.44
|
| Rate for Payer: Superior Health Plan EPO |
$98.87
|
|
|
XR Ribs 3 Views Bilateral
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
HCPCS 71110
|
| Hospital Charge Code |
3170015
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$612.00
|
|
|
XR Ribs 3 Views Bilateral
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
HCPCS 71110
|
| Hospital Charge Code |
3170015
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$44.10
|
| 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 |
$612.00
|
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$648.00
|
| 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 |
$648.00
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$585.00
|
| Rate for Payer: Multiplan Commercial |
$585.00
|
| Rate for Payer: Multiplan Workers Comp |
$585.00
|
| Rate for Payer: Parkland Medicaid |
$648.00
|
| Rate for Payer: Scott and White EPO/PPO |
$54.35
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$648.00
|
| 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
|
|
|
XR ribs, unilateral LEFT ; including posteroanterior chest, minimum of 3 views
|
Facility
|
OP
|
$419.00
|
|
|
Service Code
|
HCPCS 71101 LT
|
| Hospital Charge Code |
990926
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$42.44 |
| Max. Negotiated Rate |
$301.68 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$42.44
|
| 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 |
$284.92
|
| Rate for Payer: Cash Price |
$284.92
|
| Rate for Payer: Cash Price |
$284.92
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$301.68
|
| Rate for Payer: Molina CHIP/Medicaid |
$301.68
|
| Rate for Payer: Multiplan Auto |
$272.35
|
| Rate for Payer: Multiplan Commercial |
$272.35
|
| Rate for Payer: Multiplan Workers Comp |
$272.35
|
| Rate for Payer: Parkland Medicaid |
$301.68
|
| Rate for Payer: Scott and White EPO/PPO |
$209.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$301.68
|
| Rate for Payer: Superior Health Plan EPO |
$56.98
|
|
|
XR ribs, unilateral LEFT ; including posteroanterior chest, minimum of 3 views
|
Facility
|
IP
|
$419.00
|
|
|
Service Code
|
HCPCS 71101 LT
|
| Hospital Charge Code |
990926
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$284.92
|
|
|
XR ribs, unilateral RIGHT ; including posteroanterior chest, minimum of 3 views
|
Facility
|
OP
|
$419.00
|
|
|
Service Code
|
HCPCS 71101 RT
|
| Hospital Charge Code |
994112
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$42.44 |
| Max. Negotiated Rate |
$301.68 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$42.44
|
| 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 |
$284.92
|
| Rate for Payer: Cash Price |
$284.92
|
| Rate for Payer: Cash Price |
$284.92
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$301.68
|
| Rate for Payer: Molina CHIP/Medicaid |
$301.68
|
| Rate for Payer: Multiplan Auto |
$272.35
|
| Rate for Payer: Multiplan Commercial |
$272.35
|
| Rate for Payer: Multiplan Workers Comp |
$272.35
|
| Rate for Payer: Parkland Medicaid |
$301.68
|
| Rate for Payer: Scott and White EPO/PPO |
$209.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$301.68
|
| Rate for Payer: Superior Health Plan EPO |
$56.98
|
|
|
XR ribs, unilateral RIGHT ; including posteroanterior chest, minimum of 3 views
|
Facility
|
IP
|
$419.00
|
|
|
Service Code
|
HCPCS 71101 RT
|
| Hospital Charge Code |
994112
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$284.92
|
|
|
XR Sacroiliac Joints 3+ Views
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
HCPCS 72202
|
| Hospital Charge Code |
3100534
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$163.88
|
|
|
XR Sacroiliac Joints 3+ Views
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
HCPCS 72202
|
| Hospital Charge Code |
3100534
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$39.43 |
| Max. Negotiated Rate |
$247.70 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$39.43
|
| 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 |
$163.88
|
| Rate for Payer: Cash Price |
$163.88
|
| Rate for Payer: Cash Price |
$163.88
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$173.52
|
| 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 |
$173.52
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$156.65
|
| Rate for Payer: Multiplan Commercial |
$156.65
|
| Rate for Payer: Multiplan Workers Comp |
$156.65
|
| Rate for Payer: Parkland Medicaid |
$173.52
|
| Rate for Payer: Scott and White EPO/PPO |
$48.56
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$173.52
|
| 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
|
|
|
XR Sacrum/Coccyx 2+ Views
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
HCPCS 72220
|
| Hospital Charge Code |
3100542
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.75 |
| Max. Negotiated Rate |
$247.68 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$32.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$87.42
|
| Rate for Payer: Amerigroup Medicare |
$87.42
|
| 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 |
$87.42
|
| Rate for Payer: BCBS of TX PPO |
$176.38
|
| Rate for Payer: Cash Price |
$233.92
|
| Rate for Payer: Cash Price |
$233.92
|
| Rate for Payer: Cash Price |
$233.92
|
| Rate for Payer: Cigna Commercial |
$184.79
|
| Rate for Payer: Cigna Medicaid |
$247.68
|
| Rate for Payer: Cigna Medicare |
$87.42
|
| Rate for Payer: Employer Direct Commercial |
$87.42
|
| Rate for Payer: Humana Medicare/TRICARE |
$87.42
|
| Rate for Payer: Molina CHIP/Medicaid |
$247.68
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$87.42
|
| Rate for Payer: Molina Medicare |
$87.42
|
| Rate for Payer: Multiplan Auto |
$223.60
|
| Rate for Payer: Multiplan Commercial |
$223.60
|
| Rate for Payer: Multiplan Workers Comp |
$223.60
|
| Rate for Payer: Parkland Medicaid |
$247.68
|
| Rate for Payer: Scott and White EPO/PPO |
$40.31
|
| Rate for Payer: Scott and White Medicare |
$87.42
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$247.68
|
| Rate for Payer: Superior Health Plan EPO |
$87.42
|
| Rate for Payer: Superior Health Plan Medicare |
$87.42
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$87.42
|
| Rate for Payer: Universal American Medicare |
$87.42
|
| Rate for Payer: Wellcare Medicare |
$87.42
|
| Rate for Payer: Wellmed Medicare |
$87.42
|
|
|
XR Sacrum/Coccyx 2+ Views
|
Facility
|
IP
|
$344.00
|
|
|
Service Code
|
HCPCS 72220
|
| Hospital Charge Code |
3100542
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$233.92
|
|
