|
DEFIBRILLATOR DYNAGEN CRT-D G151
|
Facility
|
IP
|
$99,759.04
|
|
|
Service Code
|
HCPCS C2621
|
| Hospital Charge Code |
145409
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$24,939.76 |
| Max. Negotiated Rate |
$49,879.52 |
| Rate for Payer: Aetna Commercial |
$29,927.71
|
| Rate for Payer: Cash Price |
$87,787.96
|
| Rate for Payer: Cigna Commercial |
$24,939.76
|
| Rate for Payer: Multiplan Auto |
$49,879.52
|
| Rate for Payer: Multiplan Commercial |
$49,879.52
|
| Rate for Payer: Multiplan Workers Comp |
$49,879.52
|
| Rate for Payer: Scott and White EPO/PPO |
$49,879.52
|
|
|
DEFIBRILLATOR IILLIVIA DR-T, DF1 429529
|
Facility
|
OP
|
$125,302.71
|
|
|
Service Code
|
HCPCS C1882
|
| Hospital Charge Code |
145142
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$11,277.24 |
| Max. Negotiated Rate |
$62,651.36 |
| Rate for Payer: Aetna Commercial |
$37,590.81
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11,277.24
|
| Rate for Payer: BCBS of TX Blue Advantage |
$37,590.81
|
| Rate for Payer: BCBS of TX Blue Essentials |
$45,108.98
|
| Rate for Payer: BCBS of TX PPO |
$50,121.08
|
| Rate for Payer: Cash Price |
$110,266.38
|
| Rate for Payer: Multiplan Auto |
$62,651.36
|
| Rate for Payer: Multiplan Commercial |
$62,651.36
|
| Rate for Payer: Multiplan Workers Comp |
$62,651.36
|
| Rate for Payer: Scott and White EPO/PPO |
$62,651.36
|
| Rate for Payer: Superior Health Plan EPO |
$17,041.17
|
|
|
DEFIBRILLATOR IILLIVIA DR-T, DF1 429529
|
Facility
|
IP
|
$125,302.71
|
|
|
Service Code
|
HCPCS C1882
|
| Hospital Charge Code |
145142
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$31,325.68 |
| Max. Negotiated Rate |
$62,651.36 |
| Rate for Payer: Aetna Commercial |
$37,590.81
|
| Rate for Payer: Cash Price |
$110,266.38
|
| Rate for Payer: Cigna Commercial |
$31,325.68
|
| Rate for Payer: Multiplan Auto |
$62,651.36
|
| Rate for Payer: Multiplan Commercial |
$62,651.36
|
| Rate for Payer: Multiplan Workers Comp |
$62,651.36
|
| Rate for Payer: Scott and White EPO/PPO |
$62,651.36
|
|
|
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC
|
Facility
|
IP
|
$45,486.00
|
|
|
Service Code
|
MSDRG 056
|
| Min. Negotiated Rate |
$15,922.04 |
| Max. Negotiated Rate |
$45,486.00 |
| Rate for Payer: Aetna Commercial |
$26,932.50
|
| Rate for Payer: Aetna Medicare |
$29,907.76
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$19,938.51
|
| Rate for Payer: Amerigroup Medicare |
$19,938.51
|
| Rate for Payer: BCBS of TX Blue Advantage |
$15,922.04
|
| Rate for Payer: BCBS of TX Blue Essentials |
$21,922.72
|
| Rate for Payer: BCBS of TX Medicare |
$19,938.51
|
| Rate for Payer: BCBS of TX PPO |
$24,359.52
|
| Rate for Payer: Cigna Commercial |
$30,834.72
|
| Rate for Payer: Cigna Medicare |
$19,938.51
|
| Rate for Payer: Employer Direct Commercial |
$19,938.51
|
| Rate for Payer: Humana Medicare/TRICARE |
$19,938.51
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$19,938.51
|
| Rate for Payer: Molina Medicare |
$19,938.51
|
| Rate for Payer: Multiplan Auto |
$45,486.00
|
| Rate for Payer: Multiplan Commercial |
$45,486.00
|
| Rate for Payer: Multiplan Workers Comp |
$45,486.00
|
| Rate for Payer: Scott and White EPO/PPO |
$20,947.50
|
| Rate for Payer: Scott and White Medicare |
$19,938.51
|
| Rate for Payer: Superior Health Plan EPO |
$19,938.51
|
| Rate for Payer: Superior Health Plan Medicare |
$19,938.51
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$19,938.51
|
| Rate for Payer: Universal American Medicare |
$19,938.51
|
| Rate for Payer: Wellcare Medicare |
$19,938.51
|
| Rate for Payer: Wellmed Medicare |
$19,938.51
|
|
|
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC
|
Facility
|
IP
|
$25,900.80
|
|
|
Service Code
|
MSDRG 057
|
| Min. Negotiated Rate |
$9,630.28 |
| Max. Negotiated Rate |
$25,900.80 |
| Rate for Payer: Aetna Commercial |
$15,336.00
|
| Rate for Payer: Aetna Medicare |
$18,873.98
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12,582.65
|
| Rate for Payer: Amerigroup Medicare |
$12,582.65
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9,630.28
|
| Rate for Payer: BCBS of TX Blue Essentials |
$12,474.64
|
| Rate for Payer: BCBS of TX Medicare |
$12,582.65
|
| Rate for Payer: BCBS of TX PPO |
$13,861.25
|
| Rate for Payer: Cigna Commercial |
$17,558.02
|
| Rate for Payer: Cigna Medicare |
$12,582.65
|
| Rate for Payer: Employer Direct Commercial |
$12,582.65
|
| Rate for Payer: Humana Medicare/TRICARE |
$12,582.65
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12,582.65
|
| Rate for Payer: Molina Medicare |
$12,582.65
|
| Rate for Payer: Multiplan Auto |
$25,900.80
|
| Rate for Payer: Multiplan Commercial |
$25,900.80
|
| Rate for Payer: Multiplan Workers Comp |
$25,900.80
|
| Rate for Payer: Scott and White EPO/PPO |
$11,928.00
|
| Rate for Payer: Scott and White Medicare |
$12,582.65
|
| Rate for Payer: Superior Health Plan EPO |
$12,582.65
|
| Rate for Payer: Superior Health Plan Medicare |
$12,582.65
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12,582.65
|
| Rate for Payer: Universal American Medicare |
$12,582.65
|
| Rate for Payer: Wellcare Medicare |
$12,582.65
|
| Rate for Payer: Wellmed Medicare |
$12,582.65
|
|
|
Delay of flap or sectioning of flap (division and inset) at eyelids, nose, ears, or lips
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 15630
|
| Hospital Charge Code |
36015630
|
|
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
|
|
|
Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae,
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 15620
|
| Hospital Charge Code |
36015620
|
|
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
|
|
|
Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 15610
|
| Hospital Charge Code |
36015610
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$36.79 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$3,090.00
|
| 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
|
|
|
DENTAL AND ORAL DISEASES WITH CC
|
Facility
|
IP
|
$17,831.50
|
|
|
Service Code
|
MSDRG 158
|
| Min. Negotiated Rate |
$7,285.06 |
| Max. Negotiated Rate |
$17,831.50 |
| Rate for Payer: Aetna Commercial |
$10,558.12
|
| Rate for Payer: Aetna Medicare |
$14,327.96
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$9,551.97
|
| Rate for Payer: Amerigroup Medicare |
$9,551.97
|
| Rate for Payer: BCBS of TX Blue Advantage |
$7,285.06
|
| Rate for Payer: BCBS of TX Blue Essentials |
$9,187.01
|
| Rate for Payer: BCBS of TX Medicare |
$9,551.97
|
| Rate for Payer: BCBS of TX PPO |
$10,208.18
|
| Rate for Payer: Cigna Commercial |
$12,087.88
|
| Rate for Payer: Cigna Medicare |
$9,551.97
|
| Rate for Payer: Employer Direct Commercial |
$9,551.97
|
| Rate for Payer: Humana Medicare/TRICARE |
$9,551.97
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$9,551.97
|
| Rate for Payer: Molina Medicare |
$9,551.97
|
| Rate for Payer: Multiplan Auto |
$17,831.50
|
| Rate for Payer: Multiplan Commercial |
$17,831.50
|
| Rate for Payer: Multiplan Workers Comp |
$17,831.50
|
| Rate for Payer: Scott and White EPO/PPO |
$8,211.88
|
| Rate for Payer: Scott and White Medicare |
$9,551.97
|
| Rate for Payer: Superior Health Plan EPO |
$9,551.97
|
| Rate for Payer: Superior Health Plan Medicare |
$9,551.97
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$9,551.97
|
| Rate for Payer: Universal American Medicare |
$9,551.97
|
| Rate for Payer: Wellcare Medicare |
$9,551.97
|
| Rate for Payer: Wellmed Medicare |
$9,551.97
|
|
|
DENTAL AND ORAL DISEASES WITH MCC
|
Facility
|
IP
|
$32,433.00
|
|
|
Service Code
|
MSDRG 157
|
| Min. Negotiated Rate |
$13,250.02 |
| Max. Negotiated Rate |
$32,433.00 |
| Rate for Payer: Aetna Commercial |
$19,203.75
|
| Rate for Payer: Aetna Medicare |
$22,554.04
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$15,036.03
|
| Rate for Payer: Amerigroup Medicare |
$15,036.03
|
| Rate for Payer: BCBS of TX Blue Advantage |
$13,250.02
|
| Rate for Payer: BCBS of TX Blue Essentials |
$17,263.69
|
| Rate for Payer: BCBS of TX Medicare |
$15,036.03
|
| Rate for Payer: BCBS of TX PPO |
$19,182.62
|
| Rate for Payer: Cigna Commercial |
$21,986.16
|
| Rate for Payer: Cigna Medicare |
$15,036.03
|
| Rate for Payer: Employer Direct Commercial |
$15,036.03
|
| Rate for Payer: Humana Medicare/TRICARE |
$15,036.03
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$15,036.03
|
| Rate for Payer: Molina Medicare |
$15,036.03
|
| Rate for Payer: Multiplan Auto |
$32,433.00
|
| Rate for Payer: Multiplan Commercial |
$32,433.00
|
| Rate for Payer: Multiplan Workers Comp |
$32,433.00
|
| Rate for Payer: Scott and White EPO/PPO |
$14,936.25
|
| Rate for Payer: Scott and White Medicare |
$15,036.03
|
| Rate for Payer: Superior Health Plan EPO |
$15,036.03
|
| Rate for Payer: Superior Health Plan Medicare |
$15,036.03
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$15,036.03
|
| Rate for Payer: Universal American Medicare |
$15,036.03
|
| Rate for Payer: Wellcare Medicare |
$15,036.03
|
| Rate for Payer: Wellmed Medicare |
$15,036.03
|
|
|
DENTAL AND ORAL DISEASES WITHOUT CC/MCC
|
Facility
|
IP
|
$12,828.80
|
|
|
Service Code
|
MSDRG 159
|
| Min. Negotiated Rate |
$5,332.86 |
| Max. Negotiated Rate |
$12,828.80 |
| Rate for Payer: Aetna Commercial |
$7,596.00
|
| Rate for Payer: Aetna Medicare |
$11,509.58
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7,673.05
|
| Rate for Payer: Amerigroup Medicare |
$7,673.05
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,332.86
|
| Rate for Payer: BCBS of TX Blue Essentials |
$7,000.41
|
| Rate for Payer: BCBS of TX Medicare |
$7,673.05
|
| Rate for Payer: BCBS of TX PPO |
$7,778.53
|
| Rate for Payer: Cigna Commercial |
$8,696.58
|
| Rate for Payer: Cigna Medicare |
$7,673.05
|
| Rate for Payer: Employer Direct Commercial |
$7,673.05
|
| Rate for Payer: Humana Medicare/TRICARE |
$7,673.05
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7,673.05
|
| Rate for Payer: Molina Medicare |
$7,673.05
|
| Rate for Payer: Multiplan Auto |
$12,828.80
|
| Rate for Payer: Multiplan Commercial |
$12,828.80
|
| Rate for Payer: Multiplan Workers Comp |
$12,828.80
|
| Rate for Payer: Scott and White EPO/PPO |
$5,908.00
|
| Rate for Payer: Scott and White Medicare |
$7,673.05
|
| Rate for Payer: Superior Health Plan EPO |
$7,673.05
|
| Rate for Payer: Superior Health Plan Medicare |
$7,673.05
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7,673.05
|
| Rate for Payer: Universal American Medicare |
$7,673.05
|
| Rate for Payer: Wellcare Medicare |
$7,673.05
|
| Rate for Payer: Wellmed Medicare |
$7,673.05
|
|
|
DEPRESSIVE NEUROSES
|
Facility
|
IP
|
$17,223.50
|
|
|
Service Code
|
MSDRG 881
|
| Min. Negotiated Rate |
$5,742.22 |
| Max. Negotiated Rate |
$17,223.50 |
| Rate for Payer: Aetna Commercial |
$10,198.12
|
| Rate for Payer: Aetna Medicare |
$13,985.42
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$9,323.61
|
| Rate for Payer: Amerigroup Medicare |
$9,323.61
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,742.22
|
| Rate for Payer: BCBS of TX Blue Essentials |
$7,826.96
|
| Rate for Payer: BCBS of TX Medicare |
$9,323.61
|
| Rate for Payer: BCBS of TX PPO |
$8,696.96
|
| Rate for Payer: Cigna Commercial |
$11,675.72
|
| Rate for Payer: Cigna Medicare |
$9,323.61
|
| Rate for Payer: Employer Direct Commercial |
$9,323.61
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$9,323.61
|
| Rate for Payer: Molina Medicare |
$9,323.61
|
| Rate for Payer: Multiplan Auto |
$17,223.50
|
| Rate for Payer: Multiplan Commercial |
$17,223.50
|
| Rate for Payer: Multiplan Workers Comp |
$17,223.50
|
| Rate for Payer: Scott and White EPO/PPO |
$7,931.88
|
| Rate for Payer: Scott and White Medicare |
$9,323.61
|
| Rate for Payer: Superior Health Plan EPO |
$9,323.61
|
| Rate for Payer: Superior Health Plan Medicare |
$9,323.61
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$9,323.61
|
| Rate for Payer: Universal American Medicare |
$9,323.61
|
| Rate for Payer: Wellcare Medicare |
$9,323.61
|
| Rate for Payer: Wellmed Medicare |
$9,323.61
|
|
|
DERMACARRIER -- DHF
|
Facility
|
OP
|
$546.91
|
|
| Hospital Charge Code |
81740102
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.22 |
| Max. Negotiated Rate |
$355.49 |
| Rate for Payer: Aetna Commercial |
$300.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$49.22
|
| Rate for Payer: BCBS of TX Blue Advantage |
$164.07
|
| Rate for Payer: BCBS of TX Blue Essentials |
$196.89
|
| Rate for Payer: BCBS of TX PPO |
$218.76
|
| Rate for Payer: Cash Price |
$481.28
|
| Rate for Payer: Multiplan Auto |
$355.49
|
| Rate for Payer: Multiplan Commercial |
$355.49
|
| Rate for Payer: Multiplan Workers Comp |
$355.49
|
| Rate for Payer: Scott and White EPO/PPO |
$273.46
|
| Rate for Payer: Superior Health Plan EPO |
$74.38
|
|
|
DERMACARRIER -- DHF
|
Facility
|
IP
|
$546.91
|
|
| Hospital Charge Code |
81740102
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$481.28
|
|
|
DERMAGRAFT PER SQ CM
|
Facility
|
OP
|
$280.08
|
|
|
Service Code
|
HCPCS Q4106
|
| Hospital Charge Code |
82461260
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25.21 |
| Max. Negotiated Rate |
$140.04 |
| Rate for Payer: Aetna Commercial |
$84.02
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$25.21
|
| Rate for Payer: BCBS of TX Blue Advantage |
$84.02
|
| Rate for Payer: BCBS of TX Blue Essentials |
$100.83
|
| Rate for Payer: BCBS of TX PPO |
$112.03
|
| Rate for Payer: Cash Price |
$246.47
|
| Rate for Payer: Multiplan Auto |
$140.04
|
| Rate for Payer: Multiplan Commercial |
$140.04
|
| Rate for Payer: Multiplan Workers Comp |
$140.04
|
| Rate for Payer: Scott and White EPO/PPO |
$140.04
|
| Rate for Payer: Superior Health Plan EPO |
$38.09
|
|
|
DERMAGRAFT PER SQ CM
|
Facility
|
IP
|
$280.08
|
|
|
Service Code
|
HCPCS Q4106
|
| Hospital Charge Code |
82461260
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$70.02 |
| Max. Negotiated Rate |
$140.04 |
| Rate for Payer: Aetna Commercial |
$84.02
|
| Rate for Payer: Cash Price |
$246.47
|
| Rate for Payer: Cigna Commercial |
$70.02
|
| Rate for Payer: Multiplan Auto |
$140.04
|
| Rate for Payer: Multiplan Commercial |
$140.04
|
| Rate for Payer: Multiplan Workers Comp |
$140.04
|
| Rate for Payer: Scott and White EPO/PPO |
$140.04
|
|
|
desflurane Inh Liquid 240 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77495057
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$83.31 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38.45
|
| Rate for Payer: BCBS of TX Blue Essentials |
$46.14
|
| Rate for Payer: BCBS of TX PPO |
$51.27
|
| 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
|
|
|
desflurane Inh Liquid 240 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77495057
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$87.16
|
|
|
Destroy lumb/sac facet jnt
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64635
|
| Hospital Charge Code |
36064635
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$38.95 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$3,090.00
|
| Rate for Payer: Aetna Medicare |
$2,648.68
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$659.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,765.79
|
| Rate for Payer: Amerigroup Medicare |
$1,765.79
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,871.31
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,438.70
|
| Rate for Payer: BCBS of TX Medicare |
$1,765.79
|
| Rate for Payer: BCBS of TX PPO |
$4,332.76
|
| Rate for Payer: Cigna Commercial |
$4,000.01
|
| Rate for Payer: Cigna Medicaid |
$659.94
|
| Rate for Payer: Cigna Medicare |
$1,765.79
|
| Rate for Payer: Employer Direct Commercial |
$1,765.79
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,765.79
|
| Rate for Payer: Molina CHIP/Medicaid |
$659.94
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,765.79
|
| Rate for Payer: Molina Medicare |
$1,765.79
|
| 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 |
$659.94
|
| Rate for Payer: Scott and White EPO/PPO |
$38.95
|
| Rate for Payer: Scott and White Medicare |
$1,765.79
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$659.94
|
| Rate for Payer: Superior Health Plan EPO |
$1,765.79
|
| Rate for Payer: Superior Health Plan Medicare |
$1,765.79
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,765.79
|
| Rate for Payer: Universal American Medicare |
$1,765.79
|
| Rate for Payer: Wellcare Medicare |
$1,765.79
|
| Rate for Payer: Wellmed Medicare |
$1,765.79
|
|
|
Destroy lumb/sac facet jnt addl lvl
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64636
|
| Hospital Charge Code |
36064636
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$10,000.00 |
| Max. Negotiated Rate |
$10,000.00 |
| 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
|
|
|
Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64624
|
| Hospital Charge Code |
36064624
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$38.95 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$3,090.00
|
| Rate for Payer: Aetna Medicare |
$2,648.68
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$659.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,765.79
|
| Rate for Payer: Amerigroup Medicare |
$1,765.79
|
| Rate for Payer: BCBS of TX Blue Advantage |
$532.18
|
| Rate for Payer: BCBS of TX Blue Essentials |
$637.34
|
| Rate for Payer: BCBS of TX Medicare |
$1,765.79
|
| Rate for Payer: BCBS of TX PPO |
$803.05
|
| Rate for Payer: Cigna Commercial |
$4,000.01
|
| Rate for Payer: Cigna Medicaid |
$659.94
|
| Rate for Payer: Cigna Medicare |
$1,765.79
|
| Rate for Payer: Employer Direct Commercial |
$1,765.79
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,765.79
|
| Rate for Payer: Molina CHIP/Medicaid |
$659.94
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,765.79
|
| Rate for Payer: Molina Medicare |
$1,765.79
|
| 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 |
$659.94
|
| Rate for Payer: Scott and White EPO/PPO |
$38.95
|
| Rate for Payer: Scott and White Medicare |
$1,765.79
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$659.94
|
| Rate for Payer: Superior Health Plan EPO |
$1,765.79
|
| Rate for Payer: Superior Health Plan Medicare |
$1,765.79
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,765.79
|
| Rate for Payer: Universal American Medicare |
$1,765.79
|
| Rate for Payer: Wellcare Medicare |
$1,765.79
|
| Rate for Payer: Wellmed Medicare |
$1,765.79
|
|
|
Destruction by neurolytic agent, intercostal nerve
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64620
|
| Hospital Charge Code |
36064620
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$18.39 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$1,250.38
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$340.77
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$833.59
|
| Rate for Payer: Amerigroup Medicare |
$833.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,356.12
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,624.10
|
| Rate for Payer: BCBS of TX Medicare |
$833.59
|
| Rate for Payer: BCBS of TX PPO |
$2,046.37
|
| Rate for Payer: Cigna Commercial |
$1,888.32
|
| Rate for Payer: Cigna Medicaid |
$340.77
|
| Rate for Payer: Cigna Medicare |
$833.59
|
| Rate for Payer: Employer Direct Commercial |
$833.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$833.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$340.77
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$833.59
|
| Rate for Payer: Molina Medicare |
$833.59
|
| 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 |
$340.77
|
| Rate for Payer: Scott and White EPO/PPO |
$18.39
|
| Rate for Payer: Scott and White Medicare |
$833.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$340.77
|
| Rate for Payer: Superior Health Plan EPO |
$833.59
|
| Rate for Payer: Superior Health Plan Medicare |
$833.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$833.59
|
| Rate for Payer: Universal American Medicare |
$833.59
|
| Rate for Payer: Wellcare Medicare |
$833.59
|
| Rate for Payer: Wellmed Medicare |
$833.59
|
|
|
Destruction by neurolytic agent other peripheral nerve or branch
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64640
|
| Hospital Charge Code |
36064640
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$18.39 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$1,250.38
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$145.34
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$833.59
|
| Rate for Payer: Amerigroup Medicare |
$833.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$294.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$352.96
|
| Rate for Payer: BCBS of TX Medicare |
$833.59
|
| Rate for Payer: BCBS of TX PPO |
$444.73
|
| Rate for Payer: Cigna Commercial |
$1,888.32
|
| Rate for Payer: Cigna Medicaid |
$145.34
|
| Rate for Payer: Cigna Medicare |
$833.59
|
| Rate for Payer: Employer Direct Commercial |
$833.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$833.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$145.34
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$833.59
|
| Rate for Payer: Molina Medicare |
$833.59
|
| 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 |
$145.34
|
| Rate for Payer: Scott and White EPO/PPO |
$18.39
|
| Rate for Payer: Scott and White Medicare |
$833.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$145.34
|
| Rate for Payer: Superior Health Plan EPO |
$833.59
|
| Rate for Payer: Superior Health Plan Medicare |
$833.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$833.59
|
| Rate for Payer: Universal American Medicare |
$833.59
|
| Rate for Payer: Wellcare Medicare |
$833.59
|
| Rate for Payer: Wellmed Medicare |
$833.59
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluorosc
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64633
|
| Hospital Charge Code |
36064633
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$38.95 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$3,090.00
|
| Rate for Payer: Aetna Medicare |
$2,648.68
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$659.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,765.79
|
| Rate for Payer: Amerigroup Medicare |
$1,765.79
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,871.31
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,438.70
|
| Rate for Payer: BCBS of TX Medicare |
$1,765.79
|
| Rate for Payer: BCBS of TX PPO |
$4,332.76
|
| Rate for Payer: Cigna Commercial |
$4,000.01
|
| Rate for Payer: Cigna Medicaid |
$659.94
|
| Rate for Payer: Cigna Medicare |
$1,765.79
|
| Rate for Payer: Employer Direct Commercial |
$1,765.79
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,765.79
|
| Rate for Payer: Molina CHIP/Medicaid |
$659.94
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,765.79
|
| Rate for Payer: Molina Medicare |
$1,765.79
|
| 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 |
$659.94
|
| Rate for Payer: Scott and White EPO/PPO |
$38.95
|
| Rate for Payer: Scott and White Medicare |
$1,765.79
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$659.94
|
| Rate for Payer: Superior Health Plan EPO |
$1,765.79
|
| Rate for Payer: Superior Health Plan Medicare |
$1,765.79
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,765.79
|
| Rate for Payer: Universal American Medicare |
$1,765.79
|
| Rate for Payer: Wellcare Medicare |
$1,765.79
|
| Rate for Payer: Wellmed Medicare |
$1,765.79
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluorosc
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64634
|
| Hospital Charge Code |
36064634
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$10,000.00 |
| Max. Negotiated Rate |
$10,000.00 |
| 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
|
|
