|
XR Small Bowel via Enteroclysis Tube
|
Facility
|
OP
|
$892.00
|
|
|
Service Code
|
HCPCS 74251
|
| Hospital Charge Code |
4904251
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$175.06 |
| Max. Negotiated Rate |
$642.24 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$175.06
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Amerigroup Medicare |
$176.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$300.66
|
| Rate for Payer: BCBS of TX Blue Essentials |
$360.80
|
| Rate for Payer: BCBS of TX Medicare |
$176.20
|
| Rate for Payer: BCBS of TX PPO |
$402.71
|
| Rate for Payer: Cash Price |
$606.56
|
| Rate for Payer: Cash Price |
$606.56
|
| Rate for Payer: Cash Price |
$606.56
|
| Rate for Payer: Cigna Commercial |
$372.46
|
| Rate for Payer: Cigna Medicaid |
$642.24
|
| Rate for Payer: Cigna Medicare |
$176.20
|
| Rate for Payer: Employer Direct Commercial |
$176.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$176.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$642.24
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Molina Medicare |
$176.20
|
| Rate for Payer: Multiplan Auto |
$579.80
|
| Rate for Payer: Multiplan Commercial |
$579.80
|
| Rate for Payer: Multiplan Workers Comp |
$579.80
|
| Rate for Payer: Parkland Medicaid |
$642.24
|
| Rate for Payer: Scott and White EPO/PPO |
$447.85
|
| Rate for Payer: Scott and White Medicare |
$176.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$642.24
|
| Rate for Payer: Superior Health Plan EPO |
$176.20
|
| Rate for Payer: Superior Health Plan Medicare |
$176.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Universal American Medicare |
$176.20
|
| Rate for Payer: Wellcare Medicare |
$176.20
|
| Rate for Payer: Wellmed Medicare |
$176.20
|
|
|
XR Small Bowel w/ Multiple Series
|
Facility
|
OP
|
$685.00
|
|
|
Service Code
|
HCPCS 74250
|
| Hospital Charge Code |
3101136
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$121.96 |
| Max. Negotiated Rate |
$493.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$121.96
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Amerigroup Medicare |
$176.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$300.66
|
| Rate for Payer: BCBS of TX Blue Essentials |
$360.80
|
| Rate for Payer: BCBS of TX Medicare |
$176.20
|
| Rate for Payer: BCBS of TX PPO |
$402.71
|
| Rate for Payer: Cash Price |
$465.80
|
| Rate for Payer: Cash Price |
$465.80
|
| Rate for Payer: Cash Price |
$465.80
|
| Rate for Payer: Cigna Commercial |
$372.46
|
| Rate for Payer: Cigna Medicaid |
$493.20
|
| Rate for Payer: Cigna Medicare |
$176.20
|
| Rate for Payer: Employer Direct Commercial |
$176.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$176.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$493.20
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Molina Medicare |
$176.20
|
| Rate for Payer: Multiplan Auto |
$445.25
|
| Rate for Payer: Multiplan Commercial |
$445.25
|
| Rate for Payer: Multiplan Workers Comp |
$445.25
|
| Rate for Payer: Parkland Medicaid |
$493.20
|
| Rate for Payer: Scott and White EPO/PPO |
$150.31
|
| Rate for Payer: Scott and White Medicare |
$176.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$493.20
|
| Rate for Payer: Superior Health Plan EPO |
$176.20
|
| Rate for Payer: Superior Health Plan Medicare |
$176.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$176.20
|
| Rate for Payer: Universal American Medicare |
$176.20
|
| Rate for Payer: Wellcare Medicare |
$176.20
|
| Rate for Payer: Wellmed Medicare |
$176.20
|
|
|
XR Small Bowel w/ Multiple Series
|
Facility
|
IP
|
$685.00
|
|
|
Service Code
|
HCPCS 74250
|
| Hospital Charge Code |
3101136
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$465.80
|
|
|
XR Speech Evaluation w/ Cine Video
|
Facility
|
IP
|
$719.00
|
|
|
Service Code
|
HCPCS 70371
|
| Hospital Charge Code |
3160413
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$488.92
|
|
|
XR Speech Evaluation w/ Cine Video
|
Facility
|
OP
|
$719.00
|
|
|
Service Code
|
HCPCS 70371
|
| Hospital Charge Code |
3160413
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$109.60 |
| Max. Negotiated Rate |
$517.68 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$109.60
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Amerigroup Medicare |
$239.69
|
| Rate for Payer: BCBS of TX Blue Advantage |
$384.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$461.42
|
| Rate for Payer: BCBS of TX Medicare |
$239.69
|
| Rate for Payer: BCBS of TX PPO |
$515.02
|
| Rate for Payer: Cash Price |
$488.92
|
| Rate for Payer: Cash Price |
$488.92
|
| Rate for Payer: Cash Price |
$488.92
|
| Rate for Payer: Cigna Commercial |
$506.65
|
| Rate for Payer: Cigna Medicaid |
$517.68
|
| 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 |
$517.68
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$239.69
|
| Rate for Payer: Molina Medicare |
$239.69
|
| Rate for Payer: Multiplan Auto |
$467.35
|
| Rate for Payer: Multiplan Commercial |
$467.35
|
| Rate for Payer: Multiplan Workers Comp |
$467.35
|
| Rate for Payer: Parkland Medicaid |
$517.68
|
| Rate for Payer: Scott and White EPO/PPO |
$135.06
|
| Rate for Payer: Scott and White Medicare |
$239.69
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$517.68
|
| 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
|
|
|
XR Spine Cervical 2 or 3 Views
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
HCPCS 72040
|
| Hospital Charge Code |
3100401
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$39.76 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$39.76
|
| 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 |
$387.60
|
| Rate for Payer: Cash Price |
$387.60
|
| Rate for Payer: Cash Price |
$387.60
|
| Rate for Payer: Cigna Commercial |
$184.79
|
| Rate for Payer: Cigna Medicaid |
$410.40
|
| 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 |
$410.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$87.42
|
| Rate for Payer: Molina Medicare |
$87.42
|
| Rate for Payer: Multiplan Auto |
$370.50
|
| Rate for Payer: Multiplan Commercial |
$370.50
|
| Rate for Payer: Multiplan Workers Comp |
$370.50
|
| Rate for Payer: Parkland Medicaid |
$410.40
|
| Rate for Payer: Scott and White EPO/PPO |
$48.98
|
| Rate for Payer: Scott and White Medicare |
$87.42
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$410.40
|
| 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 Spine Cervical 2 or 3 Views
|
Facility
|
IP
|
$570.00
|
|
|
Service Code
|
HCPCS 72040
|
| Hospital Charge Code |
3100401
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$387.60
|
|
|
XR Spine Cervical 4 or 5 Views
|
Facility
|
IP
|
$685.00
|
|
|
Service Code
|
HCPCS 72050
|
| Hospital Charge Code |
3100419
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$465.80
|
|
|
XR Spine Cervical 4 or 5 Views
|
Facility
|
OP
|
$685.00
|
|
|
Service Code
|
HCPCS 72050
|
| Hospital Charge Code |
3100419
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.80 |
| Max. Negotiated Rate |
$493.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$53.80
|
| 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 |
$465.80
|
| Rate for Payer: Cash Price |
$465.80
|
| Rate for Payer: Cash Price |
$465.80
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$493.20
|
| 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 |
$493.20
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$445.25
|
| Rate for Payer: Multiplan Commercial |
$445.25
|
| Rate for Payer: Multiplan Workers Comp |
$445.25
|
| Rate for Payer: Parkland Medicaid |
$493.20
|
| Rate for Payer: Scott and White EPO/PPO |
$66.30
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$493.20
|
| 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 Spine Cervical 6+ Views
|
Facility
|
OP
|
$774.00
|
|
|
Service Code
|
HCPCS 72052
|
| Hospital Charge Code |
3100427
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$62.81 |
| Max. Negotiated Rate |
$557.28 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$62.81
|
| 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 |
$526.32
|
| Rate for Payer: Cash Price |
$526.32
|
| Rate for Payer: Cash Price |
$526.32
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$557.28
|
| 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 |
$557.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$503.10
|
| Rate for Payer: Multiplan Commercial |
$503.10
|
| Rate for Payer: Multiplan Workers Comp |
$503.10
|
| Rate for Payer: Parkland Medicaid |
$557.28
|
| Rate for Payer: Scott and White EPO/PPO |
$77.38
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$557.28
|
| 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 Spine Cervical 6+ Views
|
Facility
|
IP
|
$774.00
|
|
|
Service Code
|
HCPCS 72052
|
| Hospital Charge Code |
3100427
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$526.32
|
|
|
XR Spine Lumbar 1 View
|
Facility
|
OP
|
$364.00
|
|
|
Service Code
|
HCPCS 72020
|
| Hospital Charge Code |
3100385
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$24.39 |
| Max. Negotiated Rate |
$262.08 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$24.39
|
| 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 |
$247.52
|
| Rate for Payer: Cash Price |
$247.52
|
| Rate for Payer: Cash Price |
$247.52
|
| Rate for Payer: Cigna Commercial |
$184.79
|
| Rate for Payer: Cigna Medicaid |
$262.08
|
| 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 |
$262.08
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$87.42
|
| Rate for Payer: Molina Medicare |
$87.42
|
| Rate for Payer: Multiplan Auto |
$236.60
|
| Rate for Payer: Multiplan Commercial |
$236.60
|
| Rate for Payer: Multiplan Workers Comp |
$236.60
|
| Rate for Payer: Parkland Medicaid |
$262.08
|
| Rate for Payer: Scott and White EPO/PPO |
$30.01
|
| Rate for Payer: Scott and White Medicare |
$87.42
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$262.08
|
| 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 Spine Lumbar 1 View
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
HCPCS 72020
|
| Hospital Charge Code |
3100385
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$247.52
|
|
|
XR Spine Lumbosacral 2 or 3 Views
|
Facility
|
IP
|
$890.00
|
|
|
Service Code
|
HCPCS 72100
|
| Hospital Charge Code |
3100476
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$605.20
|
|
|
XR Spine Lumbosacral 2 or 3 Views
|
Facility
|
OP
|
$890.00
|
|
|
Service Code
|
HCPCS 72100
|
| Hospital Charge Code |
3100476
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$40.10 |
| Max. Negotiated Rate |
$640.80 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$40.10
|
| 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 |
$605.20
|
| Rate for Payer: Cash Price |
$605.20
|
| Rate for Payer: Cash Price |
$605.20
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$640.80
|
| 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 |
$640.80
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$578.50
|
| Rate for Payer: Multiplan Commercial |
$578.50
|
| Rate for Payer: Multiplan Workers Comp |
$578.50
|
| Rate for Payer: Parkland Medicaid |
$640.80
|
| Rate for Payer: Scott and White EPO/PPO |
$49.39
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$640.80
|
| 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 Spine Lumbosacral 4+ Views
|
Facility
|
IP
|
$1,077.00
|
|
|
Service Code
|
HCPCS 72110
|
| Hospital Charge Code |
3100484
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$732.36
|
|
|
XR Spine Lumbosacral 4+ Views
|
Facility
|
OP
|
$1,077.00
|
|
|
Service Code
|
HCPCS 72110
|
| Hospital Charge Code |
3100484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$52.13 |
| Max. Negotiated Rate |
$775.44 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$52.13
|
| 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 |
$732.36
|
| Rate for Payer: Cash Price |
$732.36
|
| Rate for Payer: Cash Price |
$732.36
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$775.44
|
| 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 |
$775.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$700.05
|
| Rate for Payer: Multiplan Commercial |
$700.05
|
| Rate for Payer: Multiplan Workers Comp |
$700.05
|
| Rate for Payer: Parkland Medicaid |
$775.44
|
| Rate for Payer: Scott and White EPO/PPO |
$64.24
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$775.44
|
| 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 Spine Lumbosacral Bending 2-3 Views
|
Facility
|
IP
|
$678.00
|
|
|
Service Code
|
HCPCS 72120
|
| Hospital Charge Code |
3100500
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$461.04
|
|
|
XR Spine Lumbosacral Bending 2-3 Views
|
Facility
|
OP
|
$678.00
|
|
|
Service Code
|
HCPCS 72120
|
| Hospital Charge Code |
3100500
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$40.76 |
| Max. Negotiated Rate |
$488.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$40.76
|
| 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 |
$461.04
|
| Rate for Payer: Cash Price |
$461.04
|
| Rate for Payer: Cash Price |
$461.04
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$488.16
|
| 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 |
$488.16
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$440.70
|
| Rate for Payer: Multiplan Commercial |
$440.70
|
| Rate for Payer: Multiplan Workers Comp |
$440.70
|
| Rate for Payer: Parkland Medicaid |
$488.16
|
| Rate for Payer: Scott and White EPO/PPO |
$50.21
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$488.16
|
| 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 Spine Lumbosacral w/ Bending 6+ Views
|
Facility
|
IP
|
$1,131.00
|
|
|
Service Code
|
HCPCS 72114
|
| Hospital Charge Code |
3100492
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$769.08
|
|
|
XR Spine Lumbosacral w/ Bending 6+ Views
|
Facility
|
OP
|
$1,131.00
|
|
|
Service Code
|
HCPCS 72114
|
| Hospital Charge Code |
3100492
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$61.48 |
| Max. Negotiated Rate |
$814.32 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$61.48
|
| 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 |
$769.08
|
| Rate for Payer: Cash Price |
$769.08
|
| Rate for Payer: Cash Price |
$769.08
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$814.32
|
| 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 |
$814.32
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$735.15
|
| Rate for Payer: Multiplan Commercial |
$735.15
|
| Rate for Payer: Multiplan Workers Comp |
$735.15
|
| Rate for Payer: Parkland Medicaid |
$814.32
|
| Rate for Payer: Scott and White EPO/PPO |
$75.72
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$814.32
|
| 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 Spine Scoliosis 1 View
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
HCPCS 72081
|
| Hospital Charge Code |
3181200
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$42.78 |
| Max. Negotiated Rate |
$219.60 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$42.78
|
| 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 |
$207.40
|
| Rate for Payer: Cash Price |
$207.40
|
| Rate for Payer: Cash Price |
$207.40
|
| Rate for Payer: Cigna Commercial |
$184.79
|
| Rate for Payer: Cigna Medicaid |
$219.60
|
| 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 |
$219.60
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$87.42
|
| Rate for Payer: Molina Medicare |
$87.42
|
| Rate for Payer: Multiplan Auto |
$198.25
|
| Rate for Payer: Multiplan Commercial |
$198.25
|
| Rate for Payer: Multiplan Workers Comp |
$198.25
|
| Rate for Payer: Parkland Medicaid |
$219.60
|
| Rate for Payer: Scott and White EPO/PPO |
$52.69
|
| Rate for Payer: Scott and White Medicare |
$87.42
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$219.60
|
| 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 Spine Scoliosis 1 View
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
HCPCS 72081
|
| Hospital Charge Code |
3181200
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$207.40
|
|
|
XR Spine Scoliosis 2-3 Views
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
HCPCS 72082
|
| Hospital Charge Code |
3181201
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$70.50 |
| Max. Negotiated Rate |
$385.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$70.50
|
| 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 |
$363.80
|
| Rate for Payer: Cash Price |
$363.80
|
| Rate for Payer: Cash Price |
$363.80
|
| Rate for Payer: Cigna Commercial |
$222.00
|
| Rate for Payer: Cigna Medicaid |
$385.20
|
| 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 |
$385.20
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$105.02
|
| Rate for Payer: Molina Medicare |
$105.02
|
| Rate for Payer: Multiplan Auto |
$347.75
|
| Rate for Payer: Multiplan Commercial |
$347.75
|
| Rate for Payer: Multiplan Workers Comp |
$347.75
|
| Rate for Payer: Parkland Medicaid |
$385.20
|
| Rate for Payer: Scott and White EPO/PPO |
$86.86
|
| Rate for Payer: Scott and White Medicare |
$105.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$385.20
|
| 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 Spine Scoliosis 2-3 Views
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
HCPCS 72082
|
| Hospital Charge Code |
3181201
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$363.80
|
|
