|
diphenhydrAMINE 25 mg Cap
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
77518039
|
|
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
|
|
|
diphenhydrAMINE 25 mg Cap
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
77518039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna Commercial |
$4.21
|
| 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
|
|
|
diphenhydrAMINE 50 mg/mL Inj Soln 1 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
77518369
|
|
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
|
|
|
diphenhydrAMINE 50 mg/mL Inj Soln 1 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
77518369
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$83.31 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1.20
|
| Rate for Payer: BCBS of TX PPO |
$1.33
|
| 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
|
|
|
Direct Antiglobulin Test
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
2403103
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$126.71 |
| Rate for Payer: Aetna Commercial |
$5.65
|
| Rate for Payer: Aetna Medicare |
$83.91
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.10
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$55.94
|
| Rate for Payer: Amerigroup Medicare |
$55.94
|
| Rate for Payer: BCBS of TX Blue Advantage |
$55.16
|
| Rate for Payer: BCBS of TX Blue Essentials |
$66.19
|
| Rate for Payer: BCBS of TX Medicare |
$55.94
|
| Rate for Payer: BCBS of TX PPO |
$73.88
|
| Rate for Payer: Cash Price |
$124.96
|
| Rate for Payer: Cash Price |
$124.96
|
| Rate for Payer: Cash Price |
$124.96
|
| Rate for Payer: Cigna Commercial |
$126.71
|
| Rate for Payer: Cigna Medicaid |
$5.39
|
| Rate for Payer: Cigna Medicare |
$55.94
|
| Rate for Payer: Employer Direct Commercial |
$55.94
|
| Rate for Payer: Humana Medicare/TRICARE |
$55.94
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.39
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$55.94
|
| Rate for Payer: Molina Medicare |
$55.94
|
| Rate for Payer: Multiplan Auto |
$92.30
|
| Rate for Payer: Multiplan Commercial |
$92.30
|
| Rate for Payer: Multiplan Workers Comp |
$92.30
|
| Rate for Payer: Parkland Medicaid |
$5.39
|
| Rate for Payer: Scott and White EPO/PPO |
$6.74
|
| Rate for Payer: Scott and White Medicare |
$55.94
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.39
|
| Rate for Payer: Superior Health Plan EPO |
$55.94
|
| Rate for Payer: Superior Health Plan Medicare |
$55.94
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$55.94
|
| Rate for Payer: Universal American Medicare |
$55.94
|
| Rate for Payer: Wellcare Medicare |
$55.94
|
| Rate for Payer: Wellmed Medicare |
$55.94
|
|
|
Discography, lumbar, radiological supervision and interpretation
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 72295
|
| Hospital Charge Code |
36072295
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$31.58 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$83.42
|
| Rate for Payer: Aetna Medicare |
$2,648.68
|
| 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 |
$2,836.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,404.31
|
| Rate for Payer: BCBS of TX Medicare |
$1,765.79
|
| Rate for Payer: BCBS of TX PPO |
$3,799.76
|
| Rate for Payer: Cigna Commercial |
$4,000.01
|
| Rate for Payer: Cigna Medicaid |
$111.26
|
| 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 |
$111.26
|
| 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 |
$111.26
|
| Rate for Payer: Scott and White EPO/PPO |
$31.58
|
| Rate for Payer: Scott and White Medicare |
$1,765.79
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$111.26
|
| 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
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC
|
Facility
|
IP
|
$18,078.50
|
|
|
Service Code
|
MSDRG 442
|
| Min. Negotiated Rate |
$7,845.78 |
| Max. Negotiated Rate |
$18,078.50 |
| Rate for Payer: Aetna Commercial |
$10,704.38
|
| Rate for Payer: Aetna Medicare |
$14,467.11
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$9,644.74
|
| Rate for Payer: Amerigroup Medicare |
$9,644.74
|
| Rate for Payer: BCBS of TX Blue Advantage |
$7,845.78
|
| Rate for Payer: BCBS of TX Blue Essentials |
$9,688.51
|
| Rate for Payer: BCBS of TX Medicare |
$9,644.74
|
| Rate for Payer: BCBS of TX PPO |
$10,765.43
|
| Rate for Payer: Cigna Commercial |
$12,255.32
|
| Rate for Payer: Cigna Medicare |
$9,644.74
|
| Rate for Payer: Employer Direct Commercial |
$9,644.74
|
| Rate for Payer: Humana Medicare/TRICARE |
$9,644.74
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$9,644.74
|
| Rate for Payer: Molina Medicare |
$9,644.74
|
| Rate for Payer: Multiplan Auto |
$18,078.50
|
| Rate for Payer: Multiplan Commercial |
$18,078.50
|
| Rate for Payer: Multiplan Workers Comp |
$18,078.50
|
| Rate for Payer: Scott and White EPO/PPO |
$8,325.62
|
| Rate for Payer: Scott and White Medicare |
$9,644.74
|
| Rate for Payer: Superior Health Plan EPO |
$9,644.74
|
| Rate for Payer: Superior Health Plan Medicare |
$9,644.74
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$9,644.74
|
| Rate for Payer: Universal American Medicare |
$9,644.74
|
| Rate for Payer: Wellcare Medicare |
$9,644.74
|
| Rate for Payer: Wellmed Medicare |
$9,644.74
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC
|
Facility
|
IP
|
$34,735.80
|
|
|
Service Code
|
MSDRG 441
|
| Min. Negotiated Rate |
$15,900.92 |
| Max. Negotiated Rate |
$34,735.80 |
| Rate for Payer: Aetna Commercial |
$20,567.25
|
| Rate for Payer: Aetna Medicare |
$23,851.38
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$15,900.92
|
| Rate for Payer: Amerigroup Medicare |
$15,900.92
|
| Rate for Payer: BCBS of TX Blue Advantage |
$16,262.60
|
| Rate for Payer: BCBS of TX Blue Essentials |
$19,164.45
|
| Rate for Payer: BCBS of TX Medicare |
$15,900.92
|
| Rate for Payer: BCBS of TX PPO |
$21,294.66
|
| Rate for Payer: Cigna Commercial |
$23,547.22
|
| Rate for Payer: Cigna Medicare |
$15,900.92
|
| Rate for Payer: Employer Direct Commercial |
$15,900.92
|
| Rate for Payer: Humana Medicare/TRICARE |
$15,900.92
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$15,900.92
|
| Rate for Payer: Molina Medicare |
$15,900.92
|
| Rate for Payer: Multiplan Auto |
$34,735.80
|
| Rate for Payer: Multiplan Commercial |
$34,735.80
|
| Rate for Payer: Multiplan Workers Comp |
$34,735.80
|
| Rate for Payer: Scott and White EPO/PPO |
$15,996.75
|
| Rate for Payer: Scott and White Medicare |
$15,900.92
|
| Rate for Payer: Superior Health Plan EPO |
$15,900.92
|
| Rate for Payer: Superior Health Plan Medicare |
$15,900.92
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$15,900.92
|
| Rate for Payer: Universal American Medicare |
$15,900.92
|
| Rate for Payer: Wellcare Medicare |
$15,900.92
|
| Rate for Payer: Wellmed Medicare |
$15,900.92
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$13,579.30
|
|
|
Service Code
|
MSDRG 443
|
| Min. Negotiated Rate |
$5,713.84 |
| Max. Negotiated Rate |
$13,579.30 |
| Rate for Payer: Aetna Commercial |
$8,040.38
|
| Rate for Payer: Aetna Medicare |
$11,932.38
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7,954.92
|
| Rate for Payer: Amerigroup Medicare |
$7,954.92
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,713.84
|
| Rate for Payer: BCBS of TX Blue Essentials |
$7,179.96
|
| Rate for Payer: BCBS of TX Medicare |
$7,954.92
|
| Rate for Payer: BCBS of TX PPO |
$7,978.04
|
| Rate for Payer: Cigna Commercial |
$9,205.34
|
| Rate for Payer: Cigna Medicare |
$7,954.92
|
| Rate for Payer: Employer Direct Commercial |
$7,954.92
|
| Rate for Payer: Humana Medicare/TRICARE |
$7,954.92
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7,954.92
|
| Rate for Payer: Molina Medicare |
$7,954.92
|
| Rate for Payer: Multiplan Auto |
$13,579.30
|
| Rate for Payer: Multiplan Commercial |
$13,579.30
|
| Rate for Payer: Multiplan Workers Comp |
$13,579.30
|
| Rate for Payer: Scott and White EPO/PPO |
$6,253.62
|
| Rate for Payer: Scott and White Medicare |
$7,954.92
|
| Rate for Payer: Superior Health Plan EPO |
$7,954.92
|
| Rate for Payer: Superior Health Plan Medicare |
$7,954.92
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7,954.92
|
| Rate for Payer: Universal American Medicare |
$7,954.92
|
| Rate for Payer: Wellcare Medicare |
$7,954.92
|
| Rate for Payer: Wellmed Medicare |
$7,954.92
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC
|
Facility
|
IP
|
$16,248.80
|
|
|
Service Code
|
MSDRG 439
|
| Min. Negotiated Rate |
$7,483.00 |
| Max. Negotiated Rate |
$16,248.80 |
| Rate for Payer: Aetna Commercial |
$9,621.00
|
| Rate for Payer: Aetna Medicare |
$13,436.28
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$8,957.52
|
| Rate for Payer: Amerigroup Medicare |
$8,957.52
|
| Rate for Payer: BCBS of TX Blue Advantage |
$7,484.58
|
| Rate for Payer: BCBS of TX Blue Essentials |
$8,898.07
|
| Rate for Payer: BCBS of TX Medicare |
$8,957.52
|
| Rate for Payer: BCBS of TX PPO |
$9,887.13
|
| Rate for Payer: Cigna Commercial |
$11,014.98
|
| Rate for Payer: Cigna Medicare |
$8,957.52
|
| Rate for Payer: Employer Direct Commercial |
$8,957.52
|
| Rate for Payer: Humana Medicare/TRICARE |
$8,957.52
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$8,957.52
|
| Rate for Payer: Molina Medicare |
$8,957.52
|
| Rate for Payer: Multiplan Auto |
$16,248.80
|
| Rate for Payer: Multiplan Commercial |
$16,248.80
|
| Rate for Payer: Multiplan Workers Comp |
$16,248.80
|
| Rate for Payer: Scott and White EPO/PPO |
$7,483.00
|
| Rate for Payer: Scott and White Medicare |
$8,957.52
|
| Rate for Payer: Superior Health Plan EPO |
$8,957.52
|
| Rate for Payer: Superior Health Plan Medicare |
$8,957.52
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$8,957.52
|
| Rate for Payer: Universal American Medicare |
$8,957.52
|
| Rate for Payer: Wellcare Medicare |
$8,957.52
|
| Rate for Payer: Wellmed Medicare |
$8,957.52
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC
|
Facility
|
IP
|
$31,707.20
|
|
|
Service Code
|
MSDRG 438
|
| Min. Negotiated Rate |
$14,262.24 |
| Max. Negotiated Rate |
$31,707.20 |
| Rate for Payer: Aetna Commercial |
$18,774.00
|
| Rate for Payer: Aetna Medicare |
$22,145.13
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14,763.42
|
| Rate for Payer: Amerigroup Medicare |
$14,763.42
|
| Rate for Payer: BCBS of TX Blue Advantage |
$14,262.24
|
| Rate for Payer: BCBS of TX Blue Essentials |
$16,904.59
|
| Rate for Payer: BCBS of TX Medicare |
$14,763.42
|
| Rate for Payer: BCBS of TX PPO |
$18,783.60
|
| Rate for Payer: Cigna Commercial |
$21,494.14
|
| Rate for Payer: Cigna Medicare |
$14,763.42
|
| Rate for Payer: Employer Direct Commercial |
$14,763.42
|
| Rate for Payer: Humana Medicare/TRICARE |
$14,763.42
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14,763.42
|
| Rate for Payer: Molina Medicare |
$14,763.42
|
| Rate for Payer: Multiplan Auto |
$31,707.20
|
| Rate for Payer: Multiplan Commercial |
$31,707.20
|
| Rate for Payer: Multiplan Workers Comp |
$31,707.20
|
| Rate for Payer: Scott and White EPO/PPO |
$14,602.00
|
| Rate for Payer: Scott and White Medicare |
$14,763.42
|
| Rate for Payer: Superior Health Plan EPO |
$14,763.42
|
| Rate for Payer: Superior Health Plan Medicare |
$14,763.42
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14,763.42
|
| Rate for Payer: Universal American Medicare |
$14,763.42
|
| Rate for Payer: Wellcare Medicare |
$14,763.42
|
| Rate for Payer: Wellmed Medicare |
$14,763.42
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$11,696.40
|
|
|
Service Code
|
MSDRG 440
|
| Min. Negotiated Rate |
$5,386.50 |
| Max. Negotiated Rate |
$11,696.40 |
| Rate for Payer: Aetna Commercial |
$6,925.50
|
| Rate for Payer: Aetna Medicare |
$10,871.60
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7,247.73
|
| Rate for Payer: Amerigroup Medicare |
$7,247.73
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,400.80
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,411.19
|
| Rate for Payer: BCBS of TX Medicare |
$7,247.73
|
| Rate for Payer: BCBS of TX PPO |
$7,123.83
|
| Rate for Payer: Cigna Commercial |
$7,928.93
|
| Rate for Payer: Cigna Medicare |
$7,247.73
|
| Rate for Payer: Employer Direct Commercial |
$7,247.73
|
| Rate for Payer: Humana Medicare/TRICARE |
$7,247.73
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7,247.73
|
| Rate for Payer: Molina Medicare |
$7,247.73
|
| Rate for Payer: Multiplan Auto |
$11,696.40
|
| Rate for Payer: Multiplan Commercial |
$11,696.40
|
| Rate for Payer: Multiplan Workers Comp |
$11,696.40
|
| Rate for Payer: Scott and White EPO/PPO |
$5,386.50
|
| Rate for Payer: Scott and White Medicare |
$7,247.73
|
| Rate for Payer: Superior Health Plan EPO |
$7,247.73
|
| Rate for Payer: Superior Health Plan Medicare |
$7,247.73
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7,247.73
|
| Rate for Payer: Universal American Medicare |
$7,247.73
|
| Rate for Payer: Wellcare Medicare |
$7,247.73
|
| Rate for Payer: Wellmed Medicare |
$7,247.73
|
|
|
DISORDERS OF PERSONALITY AND IMPULSE CONTROL
|
Facility
|
IP
|
$35,632.60
|
|
|
Service Code
|
MSDRG 883
|
| Min. Negotiated Rate |
$11,051.86 |
| Max. Negotiated Rate |
$35,632.60 |
| Rate for Payer: Aetna Commercial |
$21,098.25
|
| Rate for Payer: Aetna Medicare |
$24,356.62
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$16,237.75
|
| Rate for Payer: Amerigroup Medicare |
$16,237.75
|
| Rate for Payer: BCBS of TX Blue Advantage |
$11,051.86
|
| Rate for Payer: BCBS of TX Blue Essentials |
$13,620.05
|
| Rate for Payer: BCBS of TX Medicare |
$16,237.75
|
| Rate for Payer: BCBS of TX PPO |
$15,133.97
|
| Rate for Payer: Cigna Commercial |
$24,155.15
|
| Rate for Payer: Cigna Medicare |
$16,237.75
|
| Rate for Payer: Employer Direct Commercial |
$16,237.75
|
| Rate for Payer: Humana Medicare/TRICARE |
$16,237.75
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$16,237.75
|
| Rate for Payer: Molina Medicare |
$16,237.75
|
| Rate for Payer: Multiplan Auto |
$35,632.60
|
| Rate for Payer: Multiplan Commercial |
$35,632.60
|
| Rate for Payer: Multiplan Workers Comp |
$35,632.60
|
| Rate for Payer: Scott and White EPO/PPO |
$16,409.75
|
| Rate for Payer: Scott and White Medicare |
$16,237.75
|
| Rate for Payer: Superior Health Plan EPO |
$16,237.75
|
| Rate for Payer: Superior Health Plan Medicare |
$16,237.75
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$16,237.75
|
| Rate for Payer: Universal American Medicare |
$16,237.75
|
| Rate for Payer: Wellcare Medicare |
$16,237.75
|
| Rate for Payer: Wellmed Medicare |
$16,237.75
|
|
|
DISORDERS OF THE BILIARY TRACT WITH CC
|
Facility
|
IP
|
$20,649.20
|
|
|
Service Code
|
MSDRG 445
|
| Min. Negotiated Rate |
$8,877.78 |
| Max. Negotiated Rate |
$20,649.20 |
| Rate for Payer: Aetna Commercial |
$12,226.50
|
| Rate for Payer: Aetna Medicare |
$15,915.38
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$10,610.25
|
| Rate for Payer: Amerigroup Medicare |
$10,610.25
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8,877.78
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11,016.56
|
| Rate for Payer: BCBS of TX Medicare |
$10,610.25
|
| Rate for Payer: BCBS of TX PPO |
$12,241.10
|
| Rate for Payer: Cigna Commercial |
$13,997.98
|
| Rate for Payer: Cigna Medicare |
$10,610.25
|
| Rate for Payer: Employer Direct Commercial |
$10,610.25
|
| Rate for Payer: Humana Medicare/TRICARE |
$10,610.25
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$10,610.25
|
| Rate for Payer: Molina Medicare |
$10,610.25
|
| Rate for Payer: Multiplan Auto |
$20,649.20
|
| Rate for Payer: Multiplan Commercial |
$20,649.20
|
| Rate for Payer: Multiplan Workers Comp |
$20,649.20
|
| Rate for Payer: Scott and White EPO/PPO |
$9,509.50
|
| Rate for Payer: Scott and White Medicare |
$10,610.25
|
| Rate for Payer: Superior Health Plan EPO |
$10,610.25
|
| Rate for Payer: Superior Health Plan Medicare |
$10,610.25
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$10,610.25
|
| Rate for Payer: Universal American Medicare |
$10,610.25
|
| Rate for Payer: Wellcare Medicare |
$10,610.25
|
| Rate for Payer: Wellmed Medicare |
$10,610.25
|
|
|
DISORDERS OF THE BILIARY TRACT WITH MCC
|
Facility
|
IP
|
$31,030.80
|
|
|
Service Code
|
MSDRG 444
|
| Min. Negotiated Rate |
$13,737.64 |
| Max. Negotiated Rate |
$31,030.80 |
| Rate for Payer: Aetna Commercial |
$18,373.50
|
| Rate for Payer: Aetna Medicare |
$21,764.08
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14,509.39
|
| Rate for Payer: Amerigroup Medicare |
$14,509.39
|
| Rate for Payer: BCBS of TX Blue Advantage |
$13,737.64
|
| Rate for Payer: BCBS of TX Blue Essentials |
$16,622.88
|
| Rate for Payer: BCBS of TX Medicare |
$14,509.39
|
| Rate for Payer: BCBS of TX PPO |
$18,470.58
|
| Rate for Payer: Cigna Commercial |
$21,035.62
|
| Rate for Payer: Cigna Medicare |
$14,509.39
|
| Rate for Payer: Employer Direct Commercial |
$14,509.39
|
| Rate for Payer: Humana Medicare/TRICARE |
$14,509.39
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14,509.39
|
| Rate for Payer: Molina Medicare |
$14,509.39
|
| Rate for Payer: Multiplan Auto |
$31,030.80
|
| Rate for Payer: Multiplan Commercial |
$31,030.80
|
| Rate for Payer: Multiplan Workers Comp |
$31,030.80
|
| Rate for Payer: Scott and White EPO/PPO |
$14,290.50
|
| Rate for Payer: Scott and White Medicare |
$14,509.39
|
| Rate for Payer: Superior Health Plan EPO |
$14,509.39
|
| Rate for Payer: Superior Health Plan Medicare |
$14,509.39
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14,509.39
|
| Rate for Payer: Universal American Medicare |
$14,509.39
|
| Rate for Payer: Wellcare Medicare |
$14,509.39
|
| Rate for Payer: Wellmed Medicare |
$14,509.39
|
|
|
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC
|
Facility
|
IP
|
$15,228.50
|
|
|
Service Code
|
MSDRG 446
|
| Min. Negotiated Rate |
$6,571.26 |
| Max. Negotiated Rate |
$15,228.50 |
| Rate for Payer: Aetna Commercial |
$9,016.88
|
| Rate for Payer: Aetna Medicare |
$12,861.50
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$8,574.33
|
| Rate for Payer: Amerigroup Medicare |
$8,574.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$6,571.26
|
| Rate for Payer: BCBS of TX Blue Essentials |
$8,203.60
|
| Rate for Payer: BCBS of TX Medicare |
$8,574.33
|
| Rate for Payer: BCBS of TX PPO |
$9,115.47
|
| Rate for Payer: Cigna Commercial |
$10,323.32
|
| Rate for Payer: Cigna Medicare |
$8,574.33
|
| Rate for Payer: Employer Direct Commercial |
$8,574.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$8,574.33
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$8,574.33
|
| Rate for Payer: Molina Medicare |
$8,574.33
|
| Rate for Payer: Multiplan Auto |
$15,228.50
|
| Rate for Payer: Multiplan Commercial |
$15,228.50
|
| Rate for Payer: Multiplan Workers Comp |
$15,228.50
|
| Rate for Payer: Scott and White EPO/PPO |
$7,013.12
|
| Rate for Payer: Scott and White Medicare |
$8,574.33
|
| Rate for Payer: Superior Health Plan EPO |
$8,574.33
|
| Rate for Payer: Superior Health Plan Medicare |
$8,574.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$8,574.33
|
| Rate for Payer: Universal American Medicare |
$8,574.33
|
| Rate for Payer: Wellcare Medicare |
$8,574.33
|
| Rate for Payer: Wellmed Medicare |
$8,574.33
|
|
|
DISTAL REPAIR KIT
|
Facility
|
OP
|
$5,120.48
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8420457
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$460.84 |
| Max. Negotiated Rate |
$2,560.24 |
| Rate for Payer: Aetna Commercial |
$1,536.14
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$460.84
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,536.14
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,843.37
|
| Rate for Payer: BCBS of TX PPO |
$2,048.19
|
| Rate for Payer: Cash Price |
$4,506.02
|
| Rate for Payer: Multiplan Auto |
$2,560.24
|
| Rate for Payer: Multiplan Commercial |
$2,560.24
|
| Rate for Payer: Multiplan Workers Comp |
$2,560.24
|
| Rate for Payer: Scott and White EPO/PPO |
$2,560.24
|
| Rate for Payer: Superior Health Plan EPO |
$696.39
|
|
|
DISTAL REPAIR KIT
|
Facility
|
IP
|
$5,120.48
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8420457
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,280.12 |
| Max. Negotiated Rate |
$2,560.24 |
| Rate for Payer: Aetna Commercial |
$1,536.14
|
| Rate for Payer: Cash Price |
$4,506.02
|
| Rate for Payer: Cigna Commercial |
$1,280.12
|
| Rate for Payer: Multiplan Auto |
$2,560.24
|
| Rate for Payer: Multiplan Commercial |
$2,560.24
|
| Rate for Payer: Multiplan Workers Comp |
$2,560.24
|
| Rate for Payer: Scott and White EPO/PPO |
$2,560.24
|
|
|
DISTRACTOR LINEAR TELESCOPIC
|
Facility
|
IP
|
$2,275.31
|
|
| Hospital Charge Code |
138444
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$2,002.27
|
|
|
DISTRACTOR LINEAR TELESCOPIC
|
Facility
|
OP
|
$2,275.31
|
|
| Hospital Charge Code |
138444
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.78 |
| Max. Negotiated Rate |
$1,478.95 |
| Rate for Payer: Aetna Commercial |
$1,251.42
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$204.78
|
| Rate for Payer: BCBS of TX Blue Advantage |
$682.59
|
| Rate for Payer: BCBS of TX Blue Essentials |
$819.11
|
| Rate for Payer: BCBS of TX PPO |
$910.12
|
| Rate for Payer: Cash Price |
$2,002.27
|
| Rate for Payer: Multiplan Auto |
$1,478.95
|
| Rate for Payer: Multiplan Commercial |
$1,478.95
|
| Rate for Payer: Multiplan Workers Comp |
$1,478.95
|
| Rate for Payer: Scott and White EPO/PPO |
$1,137.66
|
| Rate for Payer: Superior Health Plan EPO |
$309.44
|
|
|
divalproex sodium 250 mg DR Tab
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77520916
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
divalproex sodium 250 mg DR Tab
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77520916
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
Diverticulectomy of hypopharynx or esophagus, with or without myotomy cervical approach
|
Facility
|
OP
|
$12,223.34
|
|
|
Service Code
|
CPT 43130
|
| Hospital Charge Code |
36043130
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$118.13 |
| Max. Negotiated Rate |
$12,223.34 |
| Rate for Payer: Aetna Commercial |
$6,077.00
|
| Rate for Payer: Aetna Medicare |
$8,033.61
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,954.22
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5,355.74
|
| Rate for Payer: Amerigroup Medicare |
$5,355.74
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8,100.39
|
| Rate for Payer: BCBS of TX Blue Essentials |
$9,701.06
|
| Rate for Payer: BCBS of TX Medicare |
$5,355.74
|
| Rate for Payer: BCBS of TX PPO |
$12,223.34
|
| Rate for Payer: Cigna Commercial |
$12,132.30
|
| Rate for Payer: Cigna Medicaid |
$1,954.22
|
| Rate for Payer: Cigna Medicare |
$5,355.74
|
| Rate for Payer: Employer Direct Commercial |
$5,355.74
|
| Rate for Payer: Humana Medicare/TRICARE |
$5,355.74
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,954.22
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5,355.74
|
| Rate for Payer: Molina Medicare |
$5,355.74
|
| 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 |
$1,954.22
|
| Rate for Payer: Scott and White EPO/PPO |
$118.13
|
| Rate for Payer: Scott and White Medicare |
$5,355.74
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,954.22
|
| Rate for Payer: Superior Health Plan EPO |
$5,355.74
|
| Rate for Payer: Superior Health Plan Medicare |
$5,355.74
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5,355.74
|
| Rate for Payer: Universal American Medicare |
$5,355.74
|
| Rate for Payer: Wellcare Medicare |
$5,355.74
|
| Rate for Payer: Wellmed Medicare |
$5,355.74
|
|
|
Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure)
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 28250
|
| Hospital Charge Code |
36028250
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$65.29 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$3,090.00
|
| Rate for Payer: Aetna Medicare |
$4,440.36
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,088.27
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$2,960.24
|
| Rate for Payer: Amerigroup Medicare |
$2,960.24
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,571.54
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,474.90
|
| Rate for Payer: BCBS of TX Medicare |
$2,960.24
|
| Rate for Payer: BCBS of TX PPO |
$6,898.37
|
| Rate for Payer: Cigna Commercial |
$6,705.80
|
| Rate for Payer: Cigna Medicaid |
$1,088.27
|
| Rate for Payer: Cigna Medicare |
$2,960.24
|
| Rate for Payer: Employer Direct Commercial |
$2,960.24
|
| Rate for Payer: Humana Medicare/TRICARE |
$2,960.24
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,088.27
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$2,960.24
|
| Rate for Payer: Molina Medicare |
$2,960.24
|
| 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 |
$1,088.27
|
| Rate for Payer: Scott and White EPO/PPO |
$65.29
|
| Rate for Payer: Scott and White Medicare |
$2,960.24
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,088.27
|
| Rate for Payer: Superior Health Plan EPO |
$2,960.24
|
| Rate for Payer: Superior Health Plan Medicare |
$2,960.24
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$2,960.24
|
| Rate for Payer: Universal American Medicare |
$2,960.24
|
| Rate for Payer: Wellcare Medicare |
$2,960.24
|
| Rate for Payer: Wellmed Medicare |
$2,960.24
|
|
|
DOBUTamine 250 mg/250 mL-D5W
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
77521130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$83.31 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4.13
|
| Rate for Payer: BCBS of TX Blue Essentials |
$4.96
|
| Rate for Payer: BCBS of TX PPO |
$5.50
|
| 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
|
|
