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17101 DALLAS PARKWAY, ADDISON, TX, 75001
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| Procedure | Type | Code | Payers | Gross | Cash | Neg min | Neg median | Neg max |
|---|---|---|---|---|---|---|---|---|
| emergency | ||||||||
| ED visit level 1 | CPT | 99281 | 32 | $524 | $314.4 | $82.85 | $88.24 | $366 |
| ED visit level 2 | CPT | 99282 | 32 | $926 | $555.6 | $150.87 | $160.68 | $588 |
| ED visit level 3 | CPT | 99283 | 32 | $1,956 | $1,173.6 | $266.29 | $285.65 | $2,268 |
| ED visit level 4 | CPT | 99284 | 32 | $2,582 | $1,549.2 | $409.52 | $436.63 | $3,660 |
| ED visit level 5 | CPT | 99285 | 32 | $3,549 | $2,129.4 | $585.14 | $623.18 | $5,800 |
| Critical care, first hour | CPT | 99291 | 32 | $4,654 | $2,792.4 | $810.35 | $864.37 | $5,800 |
| imaging | ||||||||
| CT head without contrast | CPT | 70450 | 32 | $3,578 | $2,146.8 | $102.27 | $109.4 | $500 |
| CT head with contrast | CPT | 70460 | 32 | $4,115 | $2,469 | $171.21 | $183.54 | $512.04 |
| CT head with and without contrast | CPT | 70470 | 32 | $4,651 | $2,790.6 | $171.21 | $183.54 | $512.04 |
| CT neck with contrast | CPT | 70491 | 32 | $4,514 | $2,708.4 | $171.21 | $183.54 | $512.04 |
| MRI brain without contrast | CPT | 70551 | 32 | $4,648 | $2,788.8 | $232.47 | $249.68 | $850 |
| MRI brain with contrast | CPT | 70552 | 32 | $5,345 | $3,207 | $342.79 | $365.07 | $1,073 |
| MRI brain with and without contrast | CPT | 70553 | 32 | $6,042 | $3,625.2 | $342.79 | $365.07 | $1,073 |
| Chest X-ray single view | CPT | 71045 | 32 | $601 | $360.6 | $84.68 | $90.64 | $171.01 |
| Chest X-ray 2 views | CPT | 71046 | 32 | $649 | $389.4 | $84.68 | $90.64 | $171.01 |
| Chest X-ray 3 views | CPT | 71047 | 32 | $697 | $418.2 | $84.68 | $90.64 | $171.01 |
| CT chest without contrast | CPT | 71250 | 32 | $3,919 | $2,351.4 | $102.27 | $109.4 | $500 |
| CT chest with contrast | CPT | 71260 | 32 | $4,505 | $2,703 | $171.21 | $183.54 | $512.04 |
| CT chest with and without contrast | CPT | 71270 | 32 | $5,095 | $3,057 | $171.21 | $183.54 | $512.04 |
| MRI chest without contrast | CPT | 71550 | 32 | $4,190 | $2,514 | $232.47 | $249.68 | $850 |
| Lumbosacral spine X-ray | CPT | 72100 | 32 | $746 | $447.6 | $102.27 | $109.4 | $229.76 |
| CT cervical spine without contrast | CPT | 72125 | 32 | $4,225 | $2,535 | $102.27 | $109.4 | $500 |
| CT thoracic spine without contrast | CPT | 72128 | 32 | $4,481 | $2,688.6 | $102.27 | $109.4 | $500 |
| CT lumbar spine without contrast | CPT | 72131 | 32 | $4,526 | $2,715.6 | $102.27 | $109.4 | $500 |
| MRI cervical spine without contrast | CPT | 72141 | 32 | $4,838 | $2,902.8 | $232.47 | $249.68 | $850 |
| MRI thoracic spine without contrast | CPT | 72146 | 32 | $4,614 | $2,768.4 | $232.47 | $249.68 | $850 |
| MRI lumbar spine without contrast | CPT | 72148 | 32 | $4,910 | $2,946 | $232.47 | $249.68 | $850 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 32 | $5,648 | $3,388.8 | $342.79 | $365.07 | $1,073 |
| MRI cervical spine with and without contrast | CPT | 72156 | 32 | $6,292 | $3,775.2 | $342.79 | $365.07 | $1,073 |
| MRI lumbar spine with contrast | CPT | 72158 | 32 | $6,383 | $3,829.8 | $342.79 | $365.07 | $1,073 |
| CT pelvis without contrast | CPT | 72192 | 32 | $3,916 | $2,349.6 | $102.27 | $109.4 | $500 |
| CT pelvis with contrast | CPT | 72193 | 32 | $4,503 | $2,701.8 | $171.21 | $183.54 | $512.04 |
| Shoulder X-ray | CPT | 73030 | 32 | $679 | $407.4 | $84.68 | $90.64 | $171.01 |
| Humerus X-ray | CPT | 73060 | 32 | $567 | $340.2 | $84.68 | $90.64 | $171.01 |
| Hand X-ray 3 views | CPT | 73130 | 32 | $567 | $340.2 | $84.68 | $90.64 | $171.01 |
| MRI upper extremity joint without contrast | CPT | 73221 | 32 | $4,784 | $2,870.4 | $232.47 | $249.68 | $850 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 32 | $6,220 | $3,732 | $342.79 | $365.07 | $1,073 |
| Knee X-ray 1-2 views | CPT | 73560 | 32 | $270 | $162 | $84.68 | $90.64 | $171.01 |
| Ankle X-ray 3 views | CPT | 73610 | 32 | $755 | $453 | $84.68 | $90.64 | $171.01 |
| MRI lower extremity joint without contrast | CPT | 73721 | 32 | $4,878 | $2,926.8 | $232.47 | $249.68 | $850 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 32 | $6,343 | $3,805.8 | $342.79 | $365.07 | $1,073 |
| CT abdomen without contrast | CPT | 74150 | 32 | $3,954 | $2,372.4 | $102.27 | $109.4 | $500 |
| CT abdomen with contrast | CPT | 74160 | 32 | $4,546 | $2,727.6 | $171.21 | $183.54 | $512.04 |
| CT abdomen with and without contrast | CPT | 74170 | 32 | $5,138 | $3,082.8 | $171.21 | $183.54 | $512.04 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 32 | $7,539 | $4,523.4 | $232.47 | $249.68 | $654.84 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 32 | $8,670 | $5,202 | $342.79 | $365.07 | $1,073 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 32 | $10,012 | $6,007.2 | $342.79 | $365.07 | $1,073 |
| MRI abdomen without contrast | CPT | 74181 | 32 | $4,565 | $2,739 | $232.47 | $249.68 | $850 |
| MRI abdomen with and without contrast | CPT | 74183 | 32 | $5,934 | $3,560.4 | $342.79 | $365.07 | $1,073 |
| Abdominal ultrasound complete | CPT | 76700 | 32 | $1,566 | $939.6 | $102.27 | $109.4 | $229.76 |
| Abdominal ultrasound limited | CPT | 76705 | 32 | $1,013 | $607.8 | $102.27 | $109.4 | $229.76 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 32 | $1,416 | $849.6 | $102.27 | $109.4 | $229.76 |
| Obstetric ultrasound first trimester | CPT | 76801 | 32 | $1,063 | $637.8 | $79.4 | $108.88 | $205.44 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 32 | $1,134 | $680.4 | $98.86 | $108.88 | $205.44 |
| Transvaginal ultrasound | CPT | 76830 | 32 | $1,323 | $793.8 | $95.36 | $108.88 | $205.44 |
| Pelvic ultrasound complete | CPT | 76856 | 32 | $1,259 | $755.4 | $102.27 | $109.4 | $229.76 |
| Scrotal ultrasound | CPT | 76870 | 32 | $1,147 | $688.2 | $102.27 | $109.4 | $229.76 |
| EKG tracing only | CPT | 93005 | 32 | $631 | $378.6 | $24.53 | $61.15 | $115.93 |
| inpatient | ||||||||
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 34 | $132,305 | $79,383 | $2.97 | $14,365 | $33,563 |
| lab | ||||||||
| Basic metabolic panel (BMP) | CPT | 80048 | 28 | $626 | $375.6 | $5.5 | $9.05 | $16.92 |
| Electrolyte panel | CPT | 80051 | 28 | $494 | $296.4 | $4.56 | $7.5 | $14.02 |
| Comprehensive metabolic panel | CPT | 80053 | 28 | $723 | $433.8 | $6.86 | $11.3 | $21.12 |
| Lipid panel | CPT | 80061 | 28 | $441 | $264.6 | $8.7 | $14.33 | $26.78 |
| Renal function panel | CPT | 80069 | 28 | $774 | $464.4 | $5.64 | $9.29 | $17.36 |
| Hepatic function panel | CPT | 80076 | 28 | $576 | $345.6 | $5.31 | $8.74 | $16.34 |
| Urinalysis automated | CPT | 81003 | 28 | $94 | $56.4 | $1.46 | $2.41 | $4.5 |
| Glucose quantitative | CPT | 82947 | 28 | $212 | $127.2 | $2.55 | $4.21 | $7.86 |
| Hemoglobin A1c | CPT | 83036 | 28 | $158 | $94.8 | $6.31 | $10.39 | $19.42 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 28 | $690 | $414 | $10.92 | $17.98 | $33.6 |
| Complete blood count with automated differential | CPT | 85025 | 28 | $313 | $187.8 | $5.05 | $8.31 | $15.54 |
| Urine culture bacterial | CPT | 87086 | 28 | $402 | $241.2 | $5.25 | $8.63 | $16.14 |
| Tissue exam by pathologist level IV | CPT | 88305 | 32 | $370 | $222 | $32.16 | $54.27 | $102.4 |
| office | ||||||||
| Office visit, new patient, 15-29 min | CPT | 99202 | 32 | $390 | $234 | $43.87 | $130.81 | $141.28 |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 32 | $422 | $253.2 | $76.13 | $130.81 | $142.3 |
| Office visit, new patient, 45-59 min | CPT | 99204 | 32 | $642 | $385.2 | $123.94 | $137.35 | $232.92 |
| Office visit, new patient, 60-74 min | CPT | 99205 | 32 | $735 | $441 | $123.94 | $138.66 | $319.08 |
| Office visit, established patient, 5 min | CPT | 99211 | 32 | $369 | $221.4 | $8.22 | $130.81 | $141.28 |
| Office visit, established patient, 10-19 min | CPT | 99212 | 32 | $390 | $234 | $33.14 | $130.81 | $141.28 |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 32 | $422 | $253.2 | $61.39 | $130.81 | $141.28 |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 32 | $642 | $385.2 | $90.25 | $137.35 | $168.7 |
| Office visit, established patient, 40-54 min | CPT | 99215 | 32 | $735 | $441 | $123.94 | $137.35 | $250.66 |
| surgery | ||||||||
| Spinal fusion (non-cervical) w MCC | MS-DRG | 459 | 1 | $128,955 | $64,478 | $99,044 | $153,070 | $170,077 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG | 460 | 1 | $105,894 | $52,947 | $56,234 | $86,908 | $96,564 |
| Major joint replacement w MCC | MS-DRG | 469 | 34 | $141,311 | $84,787 | $4.64 | $22,431 | $52,408 |
| Major joint replacement w/o MCC | MS-DRG | 470 | 34 | $55,980 | $33,588 | $2.95 | $14,264 | $33,328 |
| Payer | Codes covered | Median rate |
|---|---|---|
| Blue Cross Blue Shield | 85 | $229.76 |
| Aetna | 83 | $130.81 |
| allied national [2031] | 83 | $169.49 |
| alternative service concepts [8005] | 83 | $128.4 |
| Ambetter | 83 | $175.65 |
| american health advantage of texas [7099] | 83 | $137.35 |
| Bright Health | 83 | $143.81 |
| 90 degree benefit [3057] | 83 | $169.49 |
| southwestern health resources swhr [7015] | 83 | $138.66 |
| UnitedHealthcare | 83 | $130.81 |
| ust health proof [1005] | 83 | $130.81 |
| velocity [3070] | 83 | $205.44 |
| WellCare | 83 | $130.81 |
| wellpoint marketplace exchange [3071] | 83 | $159.22 |
| Cigna | 83 | $137.35 |
| entrust/90 degree [2058] | 83 | $169.49 |
| evry health [1013] | 83 | $205.44 |
| friday health plan [2061] | 83 | $271.22 |
| globalhealth [1003] | 83 | $137.35 |
| Humana | 83 | $138.66 |
| imperial insurance companies [2032] | 83 | $109.91 |
| imperial insurance companies [3045] | 83 | $109.91 |
| Medicare | 83 | $130.81 |
| Molina | 83 | $148.95 |
| Oscar Health | 83 | $133.54 |
| procare advantage [7018] | 83 | $137.35 |
| provider partners health plan [7025] | 83 | $141.28 |
| sana benefits [3069] | 83 | $205.44 |
| CHAMPVA | 71 | $123.94 |
| VA Health | 71 | $123.94 |