|
Bill Only BB RBC Treat w/Enzymes
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS 86971
|
| Hospital Charge Code |
2403632
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$9.45 |
| Max. Negotiated Rate |
$361.78 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$9.45
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$171.15
|
| Rate for Payer: Amerigroup Medicare |
$171.15
|
| Rate for Payer: BCBS of TX Blue Advantage |
$31.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$37.80
|
| Rate for Payer: BCBS of TX Medicare |
$171.15
|
| Rate for Payer: BCBS of TX PPO |
$42.00
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$361.78
|
| Rate for Payer: Cigna Medicaid |
$75.60
|
| Rate for Payer: Cigna Medicare |
$171.15
|
| Rate for Payer: Employer Direct Commercial |
$171.15
|
| Rate for Payer: Humana Medicare/TRICARE |
$171.15
|
| Rate for Payer: Molina CHIP/Medicaid |
$75.60
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$171.15
|
| Rate for Payer: Molina Medicare |
$171.15
|
| Rate for Payer: Multiplan Auto |
$68.25
|
| Rate for Payer: Multiplan Commercial |
$68.25
|
| Rate for Payer: Multiplan Workers Comp |
$68.25
|
| Rate for Payer: Parkland Medicaid |
$75.60
|
| Rate for Payer: Scott and White EPO/PPO |
$52.50
|
| Rate for Payer: Scott and White Medicare |
$171.15
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$75.60
|
| Rate for Payer: Superior Health Plan EPO |
$171.15
|
| Rate for Payer: Superior Health Plan Medicare |
$171.15
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$171.15
|
| Rate for Payer: Universal American Medicare |
$171.15
|
| Rate for Payer: Wellcare Medicare |
$171.15
|
| Rate for Payer: Wellmed Medicare |
$171.15
|
|
|
Bill Only BB Thaw FFP
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS 86927
|
| Hospital Charge Code |
2400547
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$59.16
|
|
|
Bill Only BB Thaw FFP
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS 86927
|
| Hospital Charge Code |
2400547
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.83 |
| Max. Negotiated Rate |
$361.78 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7.83
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$171.15
|
| Rate for Payer: Amerigroup Medicare |
$171.15
|
| Rate for Payer: BCBS of TX Blue Advantage |
$26.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$31.32
|
| Rate for Payer: BCBS of TX Medicare |
$171.15
|
| Rate for Payer: BCBS of TX PPO |
$34.80
|
| Rate for Payer: Cash Price |
$59.16
|
| Rate for Payer: Cash Price |
$59.16
|
| Rate for Payer: Cash Price |
$59.16
|
| Rate for Payer: Cigna Commercial |
$361.78
|
| Rate for Payer: Cigna Medicaid |
$62.64
|
| Rate for Payer: Cigna Medicare |
$171.15
|
| Rate for Payer: Employer Direct Commercial |
$171.15
|
| Rate for Payer: Humana Medicare/TRICARE |
$171.15
|
| Rate for Payer: Molina CHIP/Medicaid |
$62.64
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$171.15
|
| Rate for Payer: Molina Medicare |
$171.15
|
| Rate for Payer: Multiplan Auto |
$56.55
|
| Rate for Payer: Multiplan Commercial |
$56.55
|
| Rate for Payer: Multiplan Workers Comp |
$56.55
|
| Rate for Payer: Parkland Medicaid |
$62.64
|
| Rate for Payer: Scott and White EPO/PPO |
$43.50
|
| Rate for Payer: Scott and White Medicare |
$171.15
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$62.64
|
| Rate for Payer: Superior Health Plan EPO |
$171.15
|
| Rate for Payer: Superior Health Plan Medicare |
$171.15
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$171.15
|
| Rate for Payer: Universal American Medicare |
$171.15
|
| Rate for Payer: Wellcare Medicare |
$171.15
|
| Rate for Payer: Wellmed Medicare |
$171.15
|
|
|
Bill Only Cell Count without Differential
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS 89050
|
| Hospital Charge Code |
1620061
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$77.52
|
|
|
Bill Only Cell Count without Differential
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS 89050
|
| Hospital Charge Code |
1620061
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$82.08 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1.84
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$4.72
|
| Rate for Payer: Amerigroup Medicare |
$4.72
|
| Rate for Payer: BCBS of TX Blue Advantage |
$34.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$41.04
|
| Rate for Payer: BCBS of TX Medicare |
$4.72
|
| Rate for Payer: BCBS of TX PPO |
$45.60
|
| Rate for Payer: Cash Price |
$77.52
|
| Rate for Payer: Cash Price |
$77.52
|
| Rate for Payer: Cigna Medicaid |
$82.08
|
| Rate for Payer: Cigna Medicare |
$4.72
|
| Rate for Payer: Employer Direct Commercial |
$4.72
|
| Rate for Payer: Humana Medicare/TRICARE |
$4.72
|
| Rate for Payer: Molina CHIP/Medicaid |
$82.08
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$4.72
|
| Rate for Payer: Molina Medicare |
$4.72
|
| Rate for Payer: Multiplan Auto |
$74.10
|
| Rate for Payer: Multiplan Commercial |
$74.10
|
| Rate for Payer: Multiplan Workers Comp |
$74.10
|
| Rate for Payer: Parkland Medicaid |
$82.08
|
| Rate for Payer: Scott and White EPO/PPO |
$5.90
|
| Rate for Payer: Scott and White Medicare |
$4.72
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$82.08
|
| Rate for Payer: Superior Health Plan EPO |
$4.72
|
| Rate for Payer: Superior Health Plan Medicare |
$4.72
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$4.72
|
| Rate for Payer: Universal American Medicare |
$4.72
|
| Rate for Payer: Wellcare Medicare |
$4.72
|
| Rate for Payer: Wellmed Medicare |
$4.72
|
|
|
Bill Only GTT 1st 3 Specimens
|
Facility
|
IP
|
$379.00
|
|
|
Service Code
|
HCPCS 82951 QW
|
| Hospital Charge Code |
1602853
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$257.72
|
|
|
Bill Only GTT 1st 3 Specimens
|
Facility
|
OP
|
$379.00
|
|
|
Service Code
|
HCPCS 82951 QW
|
| Hospital Charge Code |
1602853
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.02 |
| Max. Negotiated Rate |
$272.88 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.02
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12.87
|
| Rate for Payer: Amerigroup Medicare |
$12.87
|
| Rate for Payer: BCBS of TX Blue Advantage |
$113.70
|
| Rate for Payer: BCBS of TX Blue Essentials |
$136.44
|
| Rate for Payer: BCBS of TX Medicare |
$12.87
|
| Rate for Payer: BCBS of TX PPO |
$151.60
|
| Rate for Payer: Cash Price |
$257.72
|
| Rate for Payer: Cash Price |
$257.72
|
| Rate for Payer: Cigna Medicaid |
$272.88
|
| Rate for Payer: Cigna Medicare |
$12.87
|
| Rate for Payer: Employer Direct Commercial |
$12.87
|
| Rate for Payer: Humana Medicare/TRICARE |
$12.87
|
| Rate for Payer: Molina CHIP/Medicaid |
$272.88
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12.87
|
| Rate for Payer: Molina Medicare |
$12.87
|
| Rate for Payer: Multiplan Auto |
$246.35
|
| Rate for Payer: Multiplan Commercial |
$246.35
|
| Rate for Payer: Multiplan Workers Comp |
$246.35
|
| Rate for Payer: Parkland Medicaid |
$272.88
|
| Rate for Payer: Scott and White EPO/PPO |
$16.09
|
| Rate for Payer: Scott and White Medicare |
$12.87
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$272.88
|
| Rate for Payer: Superior Health Plan EPO |
$12.87
|
| Rate for Payer: Superior Health Plan Medicare |
$12.87
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12.87
|
| Rate for Payer: Universal American Medicare |
$12.87
|
| Rate for Payer: Wellcare Medicare |
$12.87
|
| Rate for Payer: Wellmed Medicare |
$12.87
|
|
|
Bill Only Specimen Processing
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS 99001
|
| Hospital Charge Code |
1605815
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$93.84
|
|
|
Bill Only Specimen Processing
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS 99001
|
| Hospital Charge Code |
1605815
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.42 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$12.42
|
| Rate for Payer: BCBS of TX Blue Advantage |
$41.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$49.68
|
| Rate for Payer: BCBS of TX PPO |
$55.20
|
| Rate for Payer: Cash Price |
$93.84
|
| Rate for Payer: Cigna Medicaid |
$99.36
|
| Rate for Payer: Molina CHIP/Medicaid |
$99.36
|
| Rate for Payer: Multiplan Auto |
$89.70
|
| Rate for Payer: Multiplan Commercial |
$89.70
|
| Rate for Payer: Multiplan Workers Comp |
$89.70
|
| Rate for Payer: Parkland Medicaid |
$99.36
|
| Rate for Payer: Scott and White EPO/PPO |
$69.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$99.36
|
| Rate for Payer: Superior Health Plan EPO |
$18.77
|
|
|
BIOBRACE 5 X 250MM
|
Facility
|
IP
|
$15,895.00
|
|
|
Service Code
|
HCPCS C1734
|
| Hospital Charge Code |
145855
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,973.75 |
| Max. Negotiated Rate |
$7,947.50 |
| Rate for Payer: Cash Price |
$10,808.60
|
| Rate for Payer: Cigna Commercial |
$3,973.75
|
| Rate for Payer: Multiplan Auto |
$7,947.50
|
| Rate for Payer: Multiplan Commercial |
$7,947.50
|
| Rate for Payer: Multiplan Workers Comp |
$7,947.50
|
| Rate for Payer: Scott and White EPO/PPO |
$7,947.50
|
|
|
BIOBRACE 5 X 250MM
|
Facility
|
OP
|
$15,895.00
|
|
|
Service Code
|
HCPCS C1734
|
| Hospital Charge Code |
145855
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,430.55 |
| Max. Negotiated Rate |
$11,444.40 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,430.55
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,768.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,722.20
|
| Rate for Payer: BCBS of TX PPO |
$6,358.00
|
| Rate for Payer: Cash Price |
$10,808.60
|
| Rate for Payer: Cigna Medicaid |
$11,444.40
|
| Rate for Payer: Molina CHIP/Medicaid |
$11,444.40
|
| Rate for Payer: Multiplan Auto |
$7,947.50
|
| Rate for Payer: Multiplan Commercial |
$7,947.50
|
| Rate for Payer: Multiplan Workers Comp |
$7,947.50
|
| Rate for Payer: Parkland Medicaid |
$11,444.40
|
| Rate for Payer: Scott and White EPO/PPO |
$7,947.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$11,444.40
|
| Rate for Payer: Superior Health Plan EPO |
$2,161.72
|
|
|
BIO-COMP-TENOD SCRW W/DISP DRV 5.5 X 15MM
|
Facility
|
OP
|
$4,066.27
|
|
|
Service Code
|
HCPCS C1734
|
| Hospital Charge Code |
992392
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$365.96 |
| Max. Negotiated Rate |
$2,927.71 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$365.96
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,219.88
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,463.86
|
| Rate for Payer: BCBS of TX PPO |
$1,626.51
|
| Rate for Payer: Cash Price |
$2,765.06
|
| Rate for Payer: Cigna Medicaid |
$2,927.71
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,927.71
|
| Rate for Payer: Multiplan Auto |
$2,033.13
|
| Rate for Payer: Multiplan Commercial |
$2,033.13
|
| Rate for Payer: Multiplan Workers Comp |
$2,033.13
|
| Rate for Payer: Parkland Medicaid |
$2,927.71
|
| Rate for Payer: Scott and White EPO/PPO |
$2,033.13
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,927.71
|
| Rate for Payer: Superior Health Plan EPO |
$553.01
|
|
|
BIO-COMP-TENOD SCRW W/DISP DRV 5.5 X 15MM
|
Facility
|
IP
|
$4,066.27
|
|
|
Service Code
|
HCPCS C1734
|
| Hospital Charge Code |
992392
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,016.57 |
| Max. Negotiated Rate |
$2,033.13 |
| Rate for Payer: Cash Price |
$2,765.06
|
| Rate for Payer: Cigna Commercial |
$1,016.57
|
| Rate for Payer: Multiplan Auto |
$2,033.13
|
| Rate for Payer: Multiplan Commercial |
$2,033.13
|
| Rate for Payer: Multiplan Workers Comp |
$2,033.13
|
| Rate for Payer: Scott and White EPO/PPO |
$2,033.13
|
|
|
BIOFOAM COTTON WEDGE 16 X 14 X 10 X 4.5 STERILE
|
Facility
|
OP
|
$27,289.16
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
992393
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,456.02 |
| Max. Negotiated Rate |
$19,648.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2,456.02
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8,186.75
|
| Rate for Payer: BCBS of TX Blue Essentials |
$9,824.10
|
| Rate for Payer: BCBS of TX PPO |
$10,915.66
|
| Rate for Payer: Cash Price |
$18,556.63
|
| Rate for Payer: Cigna Medicaid |
$19,648.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$19,648.20
|
| Rate for Payer: Multiplan Auto |
$13,644.58
|
| Rate for Payer: Multiplan Commercial |
$13,644.58
|
| Rate for Payer: Multiplan Workers Comp |
$13,644.58
|
| Rate for Payer: Parkland Medicaid |
$19,648.20
|
| Rate for Payer: Scott and White EPO/PPO |
$13,644.58
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$19,648.20
|
| Rate for Payer: Superior Health Plan EPO |
$3,711.33
|
|
|
BIOFOAM COTTON WEDGE 16 X 14 X 10 X 4.5 STERILE
|
Facility
|
IP
|
$27,289.16
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
992393
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,822.29 |
| Max. Negotiated Rate |
$13,644.58 |
| Rate for Payer: Cash Price |
$18,556.63
|
| Rate for Payer: Cigna Commercial |
$6,822.29
|
| Rate for Payer: Multiplan Auto |
$13,644.58
|
| Rate for Payer: Multiplan Commercial |
$13,644.58
|
| Rate for Payer: Multiplan Workers Comp |
$13,644.58
|
| Rate for Payer: Scott and White EPO/PPO |
$13,644.58
|
|
|
Biofoam Evans wdge 18X18X08mm
|
Facility
|
OP
|
$13,388.46
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
993398
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,204.96 |
| Max. Negotiated Rate |
$9,639.69 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,204.96
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,016.54
|
| Rate for Payer: BCBS of TX Blue Essentials |
$4,819.85
|
| Rate for Payer: BCBS of TX PPO |
$5,355.38
|
| Rate for Payer: Cash Price |
$9,104.15
|
| Rate for Payer: Cigna Medicaid |
$9,639.69
|
| Rate for Payer: Molina CHIP/Medicaid |
$9,639.69
|
| Rate for Payer: Multiplan Auto |
$6,694.23
|
| Rate for Payer: Multiplan Commercial |
$6,694.23
|
| Rate for Payer: Multiplan Workers Comp |
$6,694.23
|
| Rate for Payer: Parkland Medicaid |
$9,639.69
|
| Rate for Payer: Scott and White EPO/PPO |
$6,694.23
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$9,639.69
|
| Rate for Payer: Superior Health Plan EPO |
$1,820.83
|
|
|
Biofoam Evans wdge 18X18X08mm
|
Facility
|
IP
|
$13,388.46
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
993398
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,347.11 |
| Max. Negotiated Rate |
$6,694.23 |
| Rate for Payer: Cash Price |
$9,104.15
|
| Rate for Payer: Cigna Commercial |
$3,347.11
|
| Rate for Payer: Multiplan Auto |
$6,694.23
|
| Rate for Payer: Multiplan Commercial |
$6,694.23
|
| Rate for Payer: Multiplan Workers Comp |
$6,694.23
|
| Rate for Payer: Scott and White EPO/PPO |
$6,694.23
|
|
|
Biofoam wedge 16mm X 4.5mm
|
Facility
|
IP
|
$12,998.02
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
993397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,249.51 |
| Max. Negotiated Rate |
$6,499.01 |
| Rate for Payer: Cash Price |
$8,838.65
|
| Rate for Payer: Cigna Commercial |
$3,249.51
|
| Rate for Payer: Multiplan Auto |
$6,499.01
|
| Rate for Payer: Multiplan Commercial |
$6,499.01
|
| Rate for Payer: Multiplan Workers Comp |
$6,499.01
|
| Rate for Payer: Scott and White EPO/PPO |
$6,499.01
|
|
|
Biofoam wedge 16mm X 4.5mm
|
Facility
|
OP
|
$12,998.02
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
993397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,169.82 |
| Max. Negotiated Rate |
$9,358.57 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,169.82
|
| Rate for Payer: BCBS of TX Blue Advantage |
$3,899.41
|
| Rate for Payer: BCBS of TX Blue Essentials |
$4,679.29
|
| Rate for Payer: BCBS of TX PPO |
$5,199.21
|
| Rate for Payer: Cash Price |
$8,838.65
|
| Rate for Payer: Cigna Medicaid |
$9,358.57
|
| Rate for Payer: Molina CHIP/Medicaid |
$9,358.57
|
| Rate for Payer: Multiplan Auto |
$6,499.01
|
| Rate for Payer: Multiplan Commercial |
$6,499.01
|
| Rate for Payer: Multiplan Workers Comp |
$6,499.01
|
| Rate for Payer: Parkland Medicaid |
$9,358.57
|
| Rate for Payer: Scott and White EPO/PPO |
$6,499.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$9,358.57
|
| Rate for Payer: Superior Health Plan EPO |
$1,767.73
|
|
|
BIOFOAM WEDGE 20MM X 5.5MM
|
Facility
|
OP
|
$28,246.99
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
993138
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.23 |
| Max. Negotiated Rate |
$20,337.83 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2,542.23
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8,474.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$10,168.92
|
| Rate for Payer: BCBS of TX PPO |
$11,298.80
|
| Rate for Payer: Cash Price |
$19,207.95
|
| Rate for Payer: Cigna Medicaid |
$20,337.83
|
| Rate for Payer: Molina CHIP/Medicaid |
$20,337.83
|
| Rate for Payer: Multiplan Auto |
$14,123.50
|
| Rate for Payer: Multiplan Commercial |
$14,123.50
|
| Rate for Payer: Multiplan Workers Comp |
$14,123.50
|
| Rate for Payer: Parkland Medicaid |
$20,337.83
|
| Rate for Payer: Scott and White EPO/PPO |
$14,123.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$20,337.83
|
| Rate for Payer: Superior Health Plan EPO |
$3,841.59
|
|
|
BIOFOAM WEDGE 20MM X 5.5MM
|
Facility
|
IP
|
$28,246.99
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
993138
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,061.75 |
| Max. Negotiated Rate |
$14,123.50 |
| Rate for Payer: Cash Price |
$19,207.95
|
| Rate for Payer: Cigna Commercial |
$7,061.75
|
| Rate for Payer: Multiplan Auto |
$14,123.50
|
| Rate for Payer: Multiplan Commercial |
$14,123.50
|
| Rate for Payer: Multiplan Workers Comp |
$14,123.50
|
| Rate for Payer: Scott and White EPO/PPO |
$14,123.50
|
|
|
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC
|
Facility
|
IP
|
$46,724.80
|
|
|
Service Code
|
MSDRG 478
|
| Min. Negotiated Rate |
$19,601.12 |
| Max. Negotiated Rate |
$46,724.80 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$22,783.63
|
| Rate for Payer: Amerigroup Medicare |
$22,783.63
|
| Rate for Payer: BCBS of TX Medicare |
$22,783.63
|
| Rate for Payer: Cigna Commercial |
$31,674.50
|
| Rate for Payer: Cigna Medicare |
$22,783.63
|
| Rate for Payer: Employer Direct Commercial |
$22,783.63
|
| Rate for Payer: Humana Medicare/TRICARE |
$22,783.63
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$22,783.63
|
| Rate for Payer: Molina Medicare |
$22,783.63
|
| Rate for Payer: Multiplan Auto |
$46,724.80
|
| Rate for Payer: Multiplan Commercial |
$46,724.80
|
| Rate for Payer: Multiplan Workers Comp |
$46,724.80
|
| Rate for Payer: Scott and White EPO/PPO |
$21,518.00
|
| Rate for Payer: Scott and White Medicare |
$22,783.63
|
| Rate for Payer: Superior Health Plan EPO |
$22,783.63
|
| Rate for Payer: Superior Health Plan Medicare |
$22,783.63
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$22,783.63
|
| Rate for Payer: Universal American Medicare |
$22,783.63
|
| Rate for Payer: Wellcare Medicare |
$22,783.63
|
| Rate for Payer: Wellmed Medicare |
$22,783.63
|
|
|
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC
|
Facility
|
IP
|
$65,637.40
|
|
|
Service Code
|
MSDRG 477
|
| Min. Negotiated Rate |
$26,990.24 |
| Max. Negotiated Rate |
$65,637.40 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$30,078.94
|
| Rate for Payer: Amerigroup Medicare |
$30,078.94
|
| Rate for Payer: BCBS of TX Medicare |
$30,078.94
|
| Rate for Payer: Cigna Commercial |
$44,495.25
|
| Rate for Payer: Cigna Medicare |
$30,078.94
|
| Rate for Payer: Employer Direct Commercial |
$30,078.94
|
| Rate for Payer: Humana Medicare/TRICARE |
$30,078.94
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$30,078.94
|
| Rate for Payer: Molina Medicare |
$30,078.94
|
| Rate for Payer: Multiplan Auto |
$65,637.40
|
| Rate for Payer: Multiplan Commercial |
$65,637.40
|
| Rate for Payer: Multiplan Workers Comp |
$65,637.40
|
| Rate for Payer: Scott and White EPO/PPO |
$30,227.75
|
| Rate for Payer: Scott and White Medicare |
$30,078.94
|
| Rate for Payer: Superior Health Plan EPO |
$30,078.94
|
| Rate for Payer: Superior Health Plan Medicare |
$30,078.94
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$30,078.94
|
| Rate for Payer: Universal American Medicare |
$30,078.94
|
| Rate for Payer: Wellcare Medicare |
$30,078.94
|
| Rate for Payer: Wellmed Medicare |
$30,078.94
|
|
|
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC
|
Facility
|
IP
|
$35,319.10
|
|
|
Service Code
|
MSDRG 479
|
| Min. Negotiated Rate |
$15,462.80 |
| Max. Negotiated Rate |
$35,319.10 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$18,384.00
|
| Rate for Payer: Amerigroup Medicare |
$18,384.00
|
| Rate for Payer: BCBS of TX Medicare |
$18,384.00
|
| Rate for Payer: Cigna Commercial |
$23,942.63
|
| Rate for Payer: Cigna Medicare |
$18,384.00
|
| Rate for Payer: Employer Direct Commercial |
$18,384.00
|
| Rate for Payer: Humana Medicare/TRICARE |
$18,384.00
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$18,384.00
|
| Rate for Payer: Molina Medicare |
$18,384.00
|
| Rate for Payer: Multiplan Auto |
$35,319.10
|
| Rate for Payer: Multiplan Commercial |
$35,319.10
|
| Rate for Payer: Multiplan Workers Comp |
$35,319.10
|
| Rate for Payer: Scott and White EPO/PPO |
$16,265.38
|
| Rate for Payer: Scott and White Medicare |
$18,384.00
|
| Rate for Payer: Superior Health Plan EPO |
$18,384.00
|
| Rate for Payer: Superior Health Plan Medicare |
$18,384.00
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$18,384.00
|
| Rate for Payer: Universal American Medicare |
$18,384.00
|
| Rate for Payer: Wellcare Medicare |
$18,384.00
|
| Rate for Payer: Wellmed Medicare |
$18,384.00
|
|
|
BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC
|
Facility
|
IP
|
$46,724.80
|
|
|
Service Code
|
MSDRG 478
|
| Min. Negotiated Rate |
$19,601.12 |
| Max. Negotiated Rate |
$46,724.80 |
| Rate for Payer: BCBS of TX Blue Advantage |
$19,601.12
|
| Rate for Payer: BCBS of TX Blue Essentials |
$23,519.06
|
| Rate for Payer: BCBS of TX PPO |
$26,133.31
|
|
