|
Destruction by neurolytic agent pudendal nerve
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64630
|
| Hospital Charge Code |
36064630
|
|
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, trigeminal nerve; second and third division branches at foramen ova
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64610
|
| Hospital Charge Code |
36064610
|
|
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, trigeminal nerve supraorbital, infraorbital, mental, or inferior a
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64600
|
| Hospital Charge Code |
36064600
|
|
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, with or without radiologic monitoring; celiac plexus
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64680
|
| Hospital Charge Code |
36064680
|
|
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, with or without radiologic monitoring; superior hypogastric plexus
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64681
|
| Hospital Charge Code |
36064681
|
|
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
|
|
|
DETECT AGNT MULT DNA AMPLI
|
Facility
|
IP
|
$436.00
|
|
|
Service Code
|
CPT 87801
|
| Hospital Charge Code |
1709732
|
|
Hospital Revenue Code
|
306
|
| Rate for Payer: Cash Price |
$383.68
|
|
|
DETECT AGNT MULT DNA AMPLI
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
CPT 87801
|
| Hospital Charge Code |
1709732
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$27.38 |
| Max. Negotiated Rate |
$283.40 |
| Rate for Payer: Aetna Commercial |
$73.71
|
| Rate for Payer: Aetna Medicare |
$105.30
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$27.38
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$70.20
|
| Rate for Payer: Amerigroup Medicare |
$70.20
|
| Rate for Payer: BCBS of TX Blue Advantage |
$115.83
|
| Rate for Payer: BCBS of TX Blue Essentials |
$139.00
|
| Rate for Payer: BCBS of TX Medicare |
$70.20
|
| Rate for Payer: BCBS of TX PPO |
$155.14
|
| Rate for Payer: Cash Price |
$383.68
|
| Rate for Payer: Cash Price |
$383.68
|
| Rate for Payer: Cigna Medicaid |
$70.20
|
| Rate for Payer: Cigna Medicare |
$70.20
|
| Rate for Payer: Employer Direct Commercial |
$70.20
|
| Rate for Payer: Humana Medicare/TRICARE |
$70.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$70.20
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$70.20
|
| Rate for Payer: Molina Medicare |
$70.20
|
| Rate for Payer: Multiplan Auto |
$283.40
|
| Rate for Payer: Multiplan Commercial |
$283.40
|
| Rate for Payer: Multiplan Workers Comp |
$283.40
|
| Rate for Payer: Parkland Medicaid |
$70.20
|
| Rate for Payer: Scott and White EPO/PPO |
$87.75
|
| Rate for Payer: Scott and White Medicare |
$70.20
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$70.20
|
| Rate for Payer: Superior Health Plan EPO |
$70.20
|
| Rate for Payer: Superior Health Plan Medicare |
$70.20
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$70.20
|
| Rate for Payer: Universal American Medicare |
$70.20
|
| Rate for Payer: Wellcare Medicare |
$70.20
|
| Rate for Payer: Wellmed Medicare |
$70.20
|
|
|
DETR CP CO2 -- DHF
|
Facility
|
OP
|
$46.99
|
|
| Hospital Charge Code |
82022005
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$30.54 |
| Rate for Payer: Aetna Commercial |
$25.84
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$4.23
|
| Rate for Payer: BCBS of TX Blue Advantage |
$14.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$16.92
|
| Rate for Payer: BCBS of TX PPO |
$18.80
|
| Rate for Payer: Cash Price |
$41.35
|
| Rate for Payer: Multiplan Auto |
$30.54
|
| Rate for Payer: Multiplan Commercial |
$30.54
|
| Rate for Payer: Multiplan Workers Comp |
$30.54
|
| Rate for Payer: Scott and White EPO/PPO |
$23.50
|
| Rate for Payer: Superior Health Plan EPO |
$6.39
|
|
|
DETR CP CO2 -- DHF
|
Facility
|
IP
|
$46.99
|
|
| Hospital Charge Code |
82022005
|
|
Hospital Revenue Code
|
271
|
| Rate for Payer: Cash Price |
$41.35
|
|
|
DEV CLOSR VASC IMP/INSRT -- DHF
|
Facility
|
OP
|
$1,246.99
|
|
|
Service Code
|
HCPCS C1760
|
| Hospital Charge Code |
82401332
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$112.23 |
| Max. Negotiated Rate |
$623.50 |
| Rate for Payer: Aetna Commercial |
$374.10
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$112.23
|
| Rate for Payer: BCBS of TX Blue Advantage |
$374.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$448.92
|
| Rate for Payer: BCBS of TX PPO |
$498.80
|
| Rate for Payer: Cash Price |
$1,097.35
|
| Rate for Payer: Multiplan Auto |
$623.50
|
| Rate for Payer: Multiplan Commercial |
$623.50
|
| Rate for Payer: Multiplan Workers Comp |
$623.50
|
| Rate for Payer: Scott and White EPO/PPO |
$623.50
|
| Rate for Payer: Superior Health Plan EPO |
$169.59
|
|
|
DEV CLOSR VASC IMP/INSRT -- DHF
|
Facility
|
IP
|
$1,246.99
|
|
|
Service Code
|
HCPCS C1760
|
| Hospital Charge Code |
82401332
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$311.75 |
| Max. Negotiated Rate |
$623.50 |
| Rate for Payer: Aetna Commercial |
$374.10
|
| Rate for Payer: Cash Price |
$1,097.35
|
| Rate for Payer: Cigna Commercial |
$311.75
|
| Rate for Payer: Multiplan Auto |
$623.50
|
| Rate for Payer: Multiplan Commercial |
$623.50
|
| Rate for Payer: Multiplan Workers Comp |
$623.50
|
| Rate for Payer: Scott and White EPO/PPO |
$623.50
|
|
|
DEV CLS VASCULAR MVP VASCADE
|
Facility
|
IP
|
$1,415.66
|
|
|
Service Code
|
HCPCS C1760
|
| Hospital Charge Code |
8692542
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$353.92 |
| Max. Negotiated Rate |
$707.83 |
| Rate for Payer: Aetna Commercial |
$424.70
|
| Rate for Payer: Cash Price |
$1,245.78
|
| Rate for Payer: Cigna Commercial |
$353.92
|
| Rate for Payer: Multiplan Auto |
$707.83
|
| Rate for Payer: Multiplan Commercial |
$707.83
|
| Rate for Payer: Multiplan Workers Comp |
$707.83
|
| Rate for Payer: Scott and White EPO/PPO |
$707.83
|
|
|
DEV CLS VASCULAR MVP VASCADE
|
Facility
|
OP
|
$1,415.66
|
|
|
Service Code
|
HCPCS C1760
|
| Hospital Charge Code |
8692542
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.41 |
| Max. Negotiated Rate |
$707.83 |
| Rate for Payer: Aetna Commercial |
$424.70
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$127.41
|
| Rate for Payer: BCBS of TX Blue Advantage |
$424.70
|
| Rate for Payer: BCBS of TX Blue Essentials |
$509.64
|
| Rate for Payer: BCBS of TX PPO |
$566.26
|
| Rate for Payer: Cash Price |
$1,245.78
|
| Rate for Payer: Multiplan Auto |
$707.83
|
| Rate for Payer: Multiplan Commercial |
$707.83
|
| Rate for Payer: Multiplan Workers Comp |
$707.83
|
| Rate for Payer: Scott and White EPO/PPO |
$707.83
|
| Rate for Payer: Superior Health Plan EPO |
$192.53
|
|
|
DEVICE, ASEPTIC DECANTING BAG STERILE -- DHF
|
Facility
|
IP
|
$101.36
|
|
| Hospital Charge Code |
80312259
|
|
Hospital Revenue Code
|
270
|
| Rate for Payer: Cash Price |
$89.20
|
|
|
DEVICE, ASEPTIC DECANTING BAG STERILE -- DHF
|
Facility
|
OP
|
$101.36
|
|
| Hospital Charge Code |
80312259
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$65.88 |
| Rate for Payer: Aetna Commercial |
$55.75
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$9.12
|
| Rate for Payer: BCBS of TX Blue Advantage |
$30.41
|
| Rate for Payer: BCBS of TX Blue Essentials |
$36.49
|
| Rate for Payer: BCBS of TX PPO |
$40.54
|
| Rate for Payer: Cash Price |
$89.20
|
| Rate for Payer: Multiplan Auto |
$65.88
|
| Rate for Payer: Multiplan Commercial |
$65.88
|
| Rate for Payer: Multiplan Workers Comp |
$65.88
|
| Rate for Payer: Scott and White EPO/PPO |
$50.68
|
| Rate for Payer: Superior Health Plan EPO |
$13.78
|
|
|
DEVICE, CLOSURE SKIN UP TO 24CM LENGTH ZIPLINE -- DHF
|
Facility
|
IP
|
$617.08
|
|
| Hospital Charge Code |
81920258
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$543.03
|
|
|
DEVICE, CLOSURE SKIN UP TO 24CM LENGTH ZIPLINE -- DHF
|
Facility
|
OP
|
$617.08
|
|
| Hospital Charge Code |
81920258
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.54 |
| Max. Negotiated Rate |
$401.10 |
| Rate for Payer: Aetna Commercial |
$339.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$55.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$185.12
|
| Rate for Payer: BCBS of TX Blue Essentials |
$222.15
|
| Rate for Payer: BCBS of TX PPO |
$246.83
|
| Rate for Payer: Cash Price |
$543.03
|
| Rate for Payer: Multiplan Auto |
$401.10
|
| Rate for Payer: Multiplan Commercial |
$401.10
|
| Rate for Payer: Multiplan Workers Comp |
$401.10
|
| Rate for Payer: Scott and White EPO/PPO |
$308.54
|
| Rate for Payer: Superior Health Plan EPO |
$83.92
|
|
|
DEVICE, CLOSURE WOUND NONABSORB V-20 NDL 3-0 9'''' -- DHF
|
Facility
|
OP
|
$250.52
|
|
| Hospital Charge Code |
81943458
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.55 |
| Max. Negotiated Rate |
$162.84 |
| Rate for Payer: Aetna Commercial |
$137.79
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$22.55
|
| Rate for Payer: BCBS of TX Blue Advantage |
$75.16
|
| Rate for Payer: BCBS of TX Blue Essentials |
$90.19
|
| Rate for Payer: BCBS of TX PPO |
$100.21
|
| Rate for Payer: Cash Price |
$220.46
|
| Rate for Payer: Multiplan Auto |
$162.84
|
| Rate for Payer: Multiplan Commercial |
$162.84
|
| Rate for Payer: Multiplan Workers Comp |
$162.84
|
| Rate for Payer: Scott and White EPO/PPO |
$125.26
|
| Rate for Payer: Superior Health Plan EPO |
$34.07
|
|
|
Device (each 30 days) 99454
|
Facility
|
OP
|
$183.00
|
|
|
Service Code
|
CPT 99454
|
| Hospital Charge Code |
6019907
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$118.95 |
| Rate for Payer: Aetna Commercial |
$100.65
|
| Rate for Payer: Aetna Medicare |
$51.74
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$16.47
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$34.49
|
| Rate for Payer: Amerigroup Medicare |
$34.49
|
| Rate for Payer: BCBS of TX Blue Advantage |
$63.08
|
| Rate for Payer: BCBS of TX Blue Essentials |
$75.40
|
| Rate for Payer: BCBS of TX Medicare |
$34.49
|
| Rate for Payer: BCBS of TX PPO |
$84.10
|
| Rate for Payer: Cash Price |
$161.04
|
| Rate for Payer: Cash Price |
$161.04
|
| Rate for Payer: Cash Price |
$161.04
|
| Rate for Payer: Cigna Commercial |
$78.13
|
| Rate for Payer: Cigna Medicare |
$34.49
|
| Rate for Payer: Employer Direct Commercial |
$34.49
|
| Rate for Payer: Humana Medicare/TRICARE |
$34.49
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$34.49
|
| Rate for Payer: Molina Medicare |
$34.49
|
| Rate for Payer: Multiplan Auto |
$118.95
|
| Rate for Payer: Multiplan Commercial |
$118.95
|
| Rate for Payer: Multiplan Workers Comp |
$118.95
|
| Rate for Payer: Scott and White EPO/PPO |
$0.62
|
| Rate for Payer: Scott and White Medicare |
$34.49
|
| Rate for Payer: Superior Health Plan EPO |
$34.49
|
| Rate for Payer: Superior Health Plan Medicare |
$34.49
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$34.49
|
| Rate for Payer: Universal American Medicare |
$34.49
|
| Rate for Payer: Wellcare Medicare |
$34.49
|
| Rate for Payer: Wellmed Medicare |
$34.49
|
|
|
DEVICE ENDO CLOSE TROCAR SITE CLOSURE 173022
|
Facility
|
IP
|
$348.04
|
|
| Hospital Charge Code |
80819188
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$306.28
|
|
|
DEVICE ENDO CLOSE TROCAR SITE CLOSURE 173022
|
Facility
|
OP
|
$348.04
|
|
| Hospital Charge Code |
80819188
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.32 |
| Max. Negotiated Rate |
$226.23 |
| Rate for Payer: Aetna Commercial |
$191.42
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$31.32
|
| Rate for Payer: BCBS of TX Blue Advantage |
$104.41
|
| Rate for Payer: BCBS of TX Blue Essentials |
$125.29
|
| Rate for Payer: BCBS of TX PPO |
$139.22
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Multiplan Auto |
$226.23
|
| Rate for Payer: Multiplan Commercial |
$226.23
|
| Rate for Payer: Multiplan Workers Comp |
$226.23
|
| Rate for Payer: Scott and White EPO/PPO |
$174.02
|
| Rate for Payer: Superior Health Plan EPO |
$47.33
|
|
|
DEVICE, ENSEAL CRVD RND TIP 35MM-SHFT 3X5MM DISP--DHF
|
Facility
|
OP
|
$2,457.37
|
|
| Hospital Charge Code |
80811300
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.16 |
| Max. Negotiated Rate |
$1,597.29 |
| Rate for Payer: Aetna Commercial |
$1,351.55
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$221.16
|
| Rate for Payer: BCBS of TX Blue Advantage |
$737.21
|
| Rate for Payer: BCBS of TX Blue Essentials |
$884.65
|
| Rate for Payer: BCBS of TX PPO |
$982.95
|
| Rate for Payer: Cash Price |
$2,162.49
|
| Rate for Payer: Multiplan Auto |
$1,597.29
|
| Rate for Payer: Multiplan Commercial |
$1,597.29
|
| Rate for Payer: Multiplan Workers Comp |
$1,597.29
|
| Rate for Payer: Scott and White EPO/PPO |
$1,228.68
|
| Rate for Payer: Superior Health Plan EPO |
$334.20
|
|
|
DEVICE, LAPAROSCOPIC SEALER/DIVIDER MARYLAND 44CM -- DHF
|
Facility
|
OP
|
$3,109.81
|
|
| Hospital Charge Code |
81740052
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$279.88 |
| Max. Negotiated Rate |
$2,021.38 |
| Rate for Payer: Aetna Commercial |
$1,710.40
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$279.88
|
| Rate for Payer: BCBS of TX Blue Advantage |
$932.94
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,119.53
|
| Rate for Payer: BCBS of TX PPO |
$1,243.92
|
| Rate for Payer: Cash Price |
$2,736.63
|
| Rate for Payer: Multiplan Auto |
$2,021.38
|
| Rate for Payer: Multiplan Commercial |
$2,021.38
|
| Rate for Payer: Multiplan Workers Comp |
$2,021.38
|
| Rate for Payer: Scott and White EPO/PPO |
$1,554.90
|
| Rate for Payer: Superior Health Plan EPO |
$422.93
|
|
|
DEVICE, LAPAROSCOPIC SEALING/CUTTING 5MM X 56CM -- DHF
|
Facility
|
OP
|
$3,109.81
|
|
| Hospital Charge Code |
81740052
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$279.88 |
| Max. Negotiated Rate |
$2,021.38 |
| Rate for Payer: Aetna Commercial |
$1,710.40
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$279.88
|
| Rate for Payer: BCBS of TX Blue Advantage |
$932.94
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,119.53
|
| Rate for Payer: BCBS of TX PPO |
$1,243.92
|
| Rate for Payer: Cash Price |
$2,736.63
|
| Rate for Payer: Multiplan Auto |
$2,021.38
|
| Rate for Payer: Multiplan Commercial |
$2,021.38
|
| Rate for Payer: Multiplan Workers Comp |
$2,021.38
|
| Rate for Payer: Scott and White EPO/PPO |
$1,554.90
|
| Rate for Payer: Superior Health Plan EPO |
$422.93
|
|
|
DEVICE, LAPAROSCOPIC SEALING/CUTTING 5MM X 56CM -- DHF
|
Facility
|
IP
|
$3,109.81
|
|
| Hospital Charge Code |
81740052
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$2,736.63
|
|
