|
acyclovir 200 mg Cap
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77356308
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.69
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.30
|
| Rate for Payer: BCBS of TX Blue Essentials |
$2.75
|
| Rate for Payer: BCBS of TX PPO |
$3.06
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Multiplan Auto |
$4.97
|
| Rate for Payer: Multiplan Commercial |
$4.97
|
| Rate for Payer: Multiplan Workers Comp |
$4.97
|
| Rate for Payer: Scott and White EPO/PPO |
$3.82
|
| Rate for Payer: Superior Health Plan EPO |
$1.04
|
|
|
acyclovir 200 mg Cap
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77356308
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Cigna Commercial |
$1.91
|
| Rate for Payer: Scott and White EPO/PPO |
$3.82
|
|
|
acyclovir 50 mg/mL IV Soln 20 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
77356795
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.04 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cigna Commercial |
$32.04
|
| Rate for Payer: Scott and White EPO/PPO |
$64.08
|
|
|
acyclovir 50 mg/mL IV Soln 20 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
77356795
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$83.31 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$0.17
|
| Rate for Payer: BCBS of TX Blue Essentials |
$0.21
|
| Rate for Payer: BCBS of TX PPO |
$0.23
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Multiplan Auto |
$83.31
|
| Rate for Payer: Multiplan Commercial |
$83.31
|
| Rate for Payer: Multiplan Workers Comp |
$83.31
|
| Rate for Payer: Scott and White EPO/PPO |
$64.08
|
| Rate for Payer: Superior Health Plan EPO |
$17.43
|
|
|
acyclovir 800 mg Tab
|
Facility
|
OP
|
$18.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77356911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$11.90 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1.65
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5.49
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6.59
|
| Rate for Payer: BCBS of TX PPO |
$7.32
|
| Rate for Payer: Cash Price |
$12.44
|
| Rate for Payer: Multiplan Auto |
$11.90
|
| Rate for Payer: Multiplan Commercial |
$11.90
|
| Rate for Payer: Multiplan Workers Comp |
$11.90
|
| Rate for Payer: Scott and White EPO/PPO |
$9.15
|
| Rate for Payer: Superior Health Plan EPO |
$2.49
|
|
|
acyclovir 800 mg Tab
|
Facility
|
IP
|
$18.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77356911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$9.15 |
| Rate for Payer: Cash Price |
$12.44
|
| Rate for Payer: Cigna Commercial |
$4.58
|
| Rate for Payer: Scott and White EPO/PPO |
$9.15
|
|
|
ADAMTS13 Activity SO
|
Facility
|
OP
|
$149.00
|
|
|
Service Code
|
CPT 85397
|
| Hospital Charge Code |
1709989
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$12.04 |
| Max. Negotiated Rate |
$96.85 |
| Rate for Payer: Aetna Commercial |
$32.41
|
| Rate for Payer: Aetna Medicare |
$46.29
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$12.04
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$30.86
|
| Rate for Payer: Amerigroup Medicare |
$30.86
|
| Rate for Payer: BCBS of TX Blue Advantage |
$50.92
|
| Rate for Payer: BCBS of TX Blue Essentials |
$61.10
|
| Rate for Payer: BCBS of TX Medicare |
$30.86
|
| Rate for Payer: BCBS of TX PPO |
$68.20
|
| Rate for Payer: Cash Price |
$131.12
|
| Rate for Payer: Cash Price |
$131.12
|
| Rate for Payer: Cigna Medicaid |
$30.86
|
| Rate for Payer: Cigna Medicare |
$30.86
|
| Rate for Payer: Employer Direct Commercial |
$30.86
|
| Rate for Payer: Humana Medicare/TRICARE |
$30.86
|
| Rate for Payer: Molina CHIP/Medicaid |
$30.86
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$30.86
|
| Rate for Payer: Molina Medicare |
$30.86
|
| Rate for Payer: Multiplan Auto |
$96.85
|
| Rate for Payer: Multiplan Commercial |
$96.85
|
| Rate for Payer: Multiplan Workers Comp |
$96.85
|
| Rate for Payer: Parkland Medicaid |
$30.86
|
| Rate for Payer: Scott and White EPO/PPO |
$38.58
|
| Rate for Payer: Scott and White Medicare |
$30.86
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$30.86
|
| Rate for Payer: Superior Health Plan EPO |
$30.86
|
| Rate for Payer: Superior Health Plan Medicare |
$30.86
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$30.86
|
| Rate for Payer: Universal American Medicare |
$30.86
|
| Rate for Payer: Wellcare Medicare |
$30.86
|
| Rate for Payer: Wellmed Medicare |
$30.86
|
|
|
ADAMTS13 Activity SO
|
Facility
|
IP
|
$149.00
|
|
|
Service Code
|
CPT 85397
|
| Hospital Charge Code |
1709989
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$131.12
|
|
|
Adenoidectomy, primary age 12 or over
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 42831
|
| Hospital Charge Code |
36042831
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$64.95 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$3,090.00
|
| Rate for Payer: Aetna Medicare |
$4,416.74
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$886.62
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$2,944.49
|
| Rate for Payer: Amerigroup Medicare |
$2,944.49
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,374.21
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,238.58
|
| Rate for Payer: BCBS of TX Medicare |
$2,944.49
|
| Rate for Payer: BCBS of TX PPO |
$6,600.61
|
| Rate for Payer: Cigna Commercial |
$6,670.12
|
| Rate for Payer: Cigna Medicaid |
$886.62
|
| Rate for Payer: Cigna Medicare |
$2,944.49
|
| Rate for Payer: Employer Direct Commercial |
$2,944.49
|
| Rate for Payer: Humana Medicare/TRICARE |
$2,944.49
|
| Rate for Payer: Molina CHIP/Medicaid |
$886.62
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$2,944.49
|
| Rate for Payer: Molina Medicare |
$2,944.49
|
| 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 |
$886.62
|
| Rate for Payer: Scott and White EPO/PPO |
$64.95
|
| Rate for Payer: Scott and White Medicare |
$2,944.49
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$886.62
|
| Rate for Payer: Superior Health Plan EPO |
$2,944.49
|
| Rate for Payer: Superior Health Plan Medicare |
$2,944.49
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$2,944.49
|
| Rate for Payer: Universal American Medicare |
$2,944.49
|
| Rate for Payer: Wellcare Medicare |
$2,944.49
|
| Rate for Payer: Wellmed Medicare |
$2,944.49
|
|
|
adenosine 3 mg/mL IV Soln 2 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
77357431
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$83.31 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1.83
|
| Rate for Payer: BCBS of TX Blue Essentials |
$2.19
|
| Rate for Payer: BCBS of TX PPO |
$2.43
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Multiplan Auto |
$83.31
|
| Rate for Payer: Multiplan Commercial |
$83.31
|
| Rate for Payer: Multiplan Workers Comp |
$83.31
|
| Rate for Payer: Scott and White EPO/PPO |
$64.08
|
| Rate for Payer: Superior Health Plan EPO |
$17.43
|
|
|
adenosine 3 mg/mL IV Soln 2 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
77357431
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.04 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cigna Commercial |
$32.04
|
| Rate for Payer: Scott and White EPO/PPO |
$64.08
|
|
|
adenosine 3 mg/mL IV Soln 4 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
7602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$83.31 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1.83
|
| Rate for Payer: BCBS of TX Blue Essentials |
$2.19
|
| Rate for Payer: BCBS of TX PPO |
$2.43
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Multiplan Auto |
$83.31
|
| Rate for Payer: Multiplan Commercial |
$83.31
|
| Rate for Payer: Multiplan Workers Comp |
$83.31
|
| Rate for Payer: Scott and White EPO/PPO |
$64.08
|
| Rate for Payer: Superior Health Plan EPO |
$17.43
|
|
|
adenosine 3 mg/mL IV Soln 4 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
7602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.04 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cigna Commercial |
$32.04
|
| Rate for Payer: Scott and White EPO/PPO |
$64.08
|
|
|
Adenosine Deaminase,Pleural Fl SO
|
Facility
|
OP
|
$334.00
|
|
|
Service Code
|
CPT 84311
|
| Hospital Charge Code |
1708650
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$217.10 |
| Rate for Payer: Aetna Commercial |
$8.50
|
| Rate for Payer: Aetna Medicare |
$12.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$8.10
|
| Rate for Payer: Amerigroup Medicare |
$8.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$13.36
|
| Rate for Payer: BCBS of TX Blue Essentials |
$16.04
|
| Rate for Payer: BCBS of TX Medicare |
$8.10
|
| Rate for Payer: BCBS of TX PPO |
$17.90
|
| Rate for Payer: Cash Price |
$293.92
|
| Rate for Payer: Cash Price |
$293.92
|
| Rate for Payer: Cigna Medicaid |
$8.10
|
| Rate for Payer: Cigna Medicare |
$8.10
|
| Rate for Payer: Employer Direct Commercial |
$8.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$8.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$8.10
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$8.10
|
| Rate for Payer: Molina Medicare |
$8.10
|
| Rate for Payer: Multiplan Auto |
$217.10
|
| Rate for Payer: Multiplan Commercial |
$217.10
|
| Rate for Payer: Multiplan Workers Comp |
$217.10
|
| Rate for Payer: Parkland Medicaid |
$8.10
|
| Rate for Payer: Scott and White EPO/PPO |
$10.12
|
| Rate for Payer: Scott and White Medicare |
$8.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$8.10
|
| Rate for Payer: Superior Health Plan EPO |
$8.10
|
| Rate for Payer: Superior Health Plan Medicare |
$8.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$8.10
|
| Rate for Payer: Universal American Medicare |
$8.10
|
| Rate for Payer: Wellcare Medicare |
$8.10
|
| Rate for Payer: Wellmed Medicare |
$8.10
|
|
|
ADHESIVE, SKIN LIQUID TOPICAL DERMABOND -- DHF
|
Facility
|
OP
|
$289.78
|
|
| Hospital Charge Code |
80220205
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$188.36 |
| Rate for Payer: Aetna Commercial |
$159.38
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$26.08
|
| Rate for Payer: BCBS of TX Blue Advantage |
$86.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$104.32
|
| Rate for Payer: BCBS of TX PPO |
$115.91
|
| Rate for Payer: Cash Price |
$255.01
|
| Rate for Payer: Multiplan Auto |
$188.36
|
| Rate for Payer: Multiplan Commercial |
$188.36
|
| Rate for Payer: Multiplan Workers Comp |
$188.36
|
| Rate for Payer: Scott and White EPO/PPO |
$144.89
|
| Rate for Payer: Superior Health Plan EPO |
$39.41
|
|
|
ADHESIVE, SKIN LIQUID TOPICAL PRINEO 22CM -- DHF
|
Facility
|
OP
|
$289.78
|
|
| Hospital Charge Code |
80220205
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$188.36 |
| Rate for Payer: Aetna Commercial |
$159.38
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$26.08
|
| Rate for Payer: BCBS of TX Blue Advantage |
$86.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$104.32
|
| Rate for Payer: BCBS of TX PPO |
$115.91
|
| Rate for Payer: Cash Price |
$255.01
|
| Rate for Payer: Multiplan Auto |
$188.36
|
| Rate for Payer: Multiplan Commercial |
$188.36
|
| Rate for Payer: Multiplan Workers Comp |
$188.36
|
| Rate for Payer: Scott and White EPO/PPO |
$144.89
|
| Rate for Payer: Superior Health Plan EPO |
$39.41
|
|
|
ADHESIVE, SKIN TOPICAL ADVANCED DERMABOND 0.7ML -- DHF
|
Facility
|
OP
|
$289.78
|
|
| Hospital Charge Code |
80220205
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$188.36 |
| Rate for Payer: Aetna Commercial |
$159.38
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$26.08
|
| Rate for Payer: BCBS of TX Blue Advantage |
$86.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$104.32
|
| Rate for Payer: BCBS of TX PPO |
$115.91
|
| Rate for Payer: Cash Price |
$255.01
|
| Rate for Payer: Multiplan Auto |
$188.36
|
| Rate for Payer: Multiplan Commercial |
$188.36
|
| Rate for Payer: Multiplan Workers Comp |
$188.36
|
| Rate for Payer: Scott and White EPO/PPO |
$144.89
|
| Rate for Payer: Superior Health Plan EPO |
$39.41
|
|
|
ADHESIVE, SKIN TOPICAL ADVANCED DERMABOND 0.7ML -- DHF
|
Facility
|
IP
|
$289.78
|
|
| Hospital Charge Code |
80220205
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$255.01
|
|
|
ADHESIVE, SKIN TOPICAL HI VICOSITY PEN X-LARGE -- DHF
|
Facility
|
OP
|
$213.43
|
|
| Hospital Charge Code |
80220007
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.21 |
| Max. Negotiated Rate |
$138.73 |
| Rate for Payer: Aetna Commercial |
$117.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$19.21
|
| Rate for Payer: BCBS of TX Blue Advantage |
$64.03
|
| Rate for Payer: BCBS of TX Blue Essentials |
$76.83
|
| Rate for Payer: BCBS of TX PPO |
$85.37
|
| Rate for Payer: Cash Price |
$187.82
|
| Rate for Payer: Multiplan Auto |
$138.73
|
| Rate for Payer: Multiplan Commercial |
$138.73
|
| Rate for Payer: Multiplan Workers Comp |
$138.73
|
| Rate for Payer: Scott and White EPO/PPO |
$106.72
|
| Rate for Payer: Superior Health Plan EPO |
$29.03
|
|
|
ADHESIVE, SKIN TOPICAL HI VICOSITY PEN X-LARGE -- DHF
|
Facility
|
IP
|
$213.43
|
|
| Hospital Charge Code |
80220007
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$187.82
|
|
|
ADHES TOPICAL SKN 2 -- DHF
|
Facility
|
OP
|
$774.71
|
|
| Hospital Charge Code |
80220213
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.72 |
| Max. Negotiated Rate |
$503.56 |
| Rate for Payer: Aetna Commercial |
$426.09
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$69.72
|
| Rate for Payer: BCBS of TX Blue Advantage |
$232.41
|
| Rate for Payer: BCBS of TX Blue Essentials |
$278.90
|
| Rate for Payer: BCBS of TX PPO |
$309.88
|
| Rate for Payer: Cash Price |
$681.74
|
| Rate for Payer: Multiplan Auto |
$503.56
|
| Rate for Payer: Multiplan Commercial |
$503.56
|
| Rate for Payer: Multiplan Workers Comp |
$503.56
|
| Rate for Payer: Scott and White EPO/PPO |
$387.36
|
| Rate for Payer: Superior Health Plan EPO |
$105.36
|
|
|
ADHES TOPICAL SKN 2 -- DHF
|
Facility
|
IP
|
$774.71
|
|
| Hospital Charge Code |
80220213
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$681.74
|
|
|
Adjacent tissue transfer or rearrangement, any area defect 30.1 sq cm to 60.0 sq cm
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 14301
|
| Hospital Charge Code |
36014301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$72.37 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$4,635.00
|
| Rate for Payer: Aetna Medicare |
$4,921.58
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,457.62
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,281.05
|
| Rate for Payer: Amerigroup Medicare |
$3,281.05
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,972.07
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,954.58
|
| Rate for Payer: BCBS of TX Medicare |
$3,281.05
|
| Rate for Payer: BCBS of TX PPO |
$7,502.77
|
| Rate for Payer: Cigna Commercial |
$7,432.53
|
| Rate for Payer: Cigna Medicaid |
$1,457.62
|
| Rate for Payer: Cigna Medicare |
$3,281.05
|
| Rate for Payer: Employer Direct Commercial |
$3,281.05
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,281.05
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,457.62
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,281.05
|
| Rate for Payer: Molina Medicare |
$3,281.05
|
| 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 |
$1,457.62
|
| Rate for Payer: Scott and White EPO/PPO |
$72.37
|
| Rate for Payer: Scott and White Medicare |
$3,281.05
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,457.62
|
| Rate for Payer: Superior Health Plan EPO |
$3,281.05
|
| Rate for Payer: Superior Health Plan Medicare |
$3,281.05
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,281.05
|
| Rate for Payer: Universal American Medicare |
$3,281.05
|
| Rate for Payer: Wellcare Medicare |
$3,281.05
|
| Rate for Payer: Wellmed Medicare |
$3,281.05
|
|
|
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips defect 10.1 sq cm to 30.
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 14061
|
| Hospital Charge Code |
36014061
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$36.79 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$2,200.00
|
| Rate for Payer: Aetna Medicare |
$2,501.68
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$709.01
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Amerigroup Medicare |
$1,667.79
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,709.98
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,245.48
|
| Rate for Payer: BCBS of TX Medicare |
$1,667.79
|
| Rate for Payer: BCBS of TX PPO |
$4,089.30
|
| Rate for Payer: Cigna Commercial |
$3,778.02
|
| Rate for Payer: Cigna Medicaid |
$709.01
|
| Rate for Payer: Cigna Medicare |
$1,667.79
|
| Rate for Payer: Employer Direct Commercial |
$1,667.79
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,667.79
|
| Rate for Payer: Molina CHIP/Medicaid |
$709.01
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Molina Medicare |
$1,667.79
|
| 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 |
$709.01
|
| Rate for Payer: Scott and White EPO/PPO |
$36.79
|
| Rate for Payer: Scott and White Medicare |
$1,667.79
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$709.01
|
| Rate for Payer: Superior Health Plan EPO |
$1,667.79
|
| Rate for Payer: Superior Health Plan Medicare |
$1,667.79
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Universal American Medicare |
$1,667.79
|
| Rate for Payer: Wellcare Medicare |
$1,667.79
|
| Rate for Payer: Wellmed Medicare |
$1,667.79
|
|
|
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia,
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
36014040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$36.79 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$2,200.00
|
| Rate for Payer: Aetna Medicare |
$2,501.68
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$709.01
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Amerigroup Medicare |
$1,667.79
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,709.98
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,245.48
|
| Rate for Payer: BCBS of TX Medicare |
$1,667.79
|
| Rate for Payer: BCBS of TX PPO |
$4,089.30
|
| Rate for Payer: Cigna Commercial |
$3,778.02
|
| Rate for Payer: Cigna Medicaid |
$709.01
|
| Rate for Payer: Cigna Medicare |
$1,667.79
|
| Rate for Payer: Employer Direct Commercial |
$1,667.79
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,667.79
|
| Rate for Payer: Molina CHIP/Medicaid |
$709.01
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Molina Medicare |
$1,667.79
|
| 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 |
$709.01
|
| Rate for Payer: Scott and White EPO/PPO |
$36.79
|
| Rate for Payer: Scott and White Medicare |
$1,667.79
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$709.01
|
| Rate for Payer: Superior Health Plan EPO |
$1,667.79
|
| Rate for Payer: Superior Health Plan Medicare |
$1,667.79
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Universal American Medicare |
$1,667.79
|
| Rate for Payer: Wellcare Medicare |
$1,667.79
|
| Rate for Payer: Wellmed Medicare |
$1,667.79
|
|
