|
Alkaline Phosphatase
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
CPT 84075
|
| Hospital Charge Code |
1601608
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$120.90 |
| Rate for Payer: Aetna Commercial |
$5.44
|
| Rate for Payer: Aetna Medicare |
$7.77
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.02
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5.18
|
| Rate for Payer: Amerigroup Medicare |
$5.18
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8.55
|
| Rate for Payer: BCBS of TX Blue Essentials |
$10.26
|
| Rate for Payer: BCBS of TX Medicare |
$5.18
|
| Rate for Payer: BCBS of TX PPO |
$11.45
|
| Rate for Payer: Cash Price |
$163.68
|
| Rate for Payer: Cash Price |
$163.68
|
| Rate for Payer: Cigna Medicaid |
$5.18
|
| Rate for Payer: Cigna Medicare |
$5.18
|
| Rate for Payer: Employer Direct Commercial |
$5.18
|
| Rate for Payer: Humana Medicare/TRICARE |
$5.18
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.18
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5.18
|
| Rate for Payer: Molina Medicare |
$5.18
|
| Rate for Payer: Multiplan Auto |
$120.90
|
| Rate for Payer: Multiplan Commercial |
$120.90
|
| Rate for Payer: Multiplan Workers Comp |
$120.90
|
| Rate for Payer: Parkland Medicaid |
$5.18
|
| Rate for Payer: Scott and White EPO/PPO |
$6.48
|
| Rate for Payer: Scott and White Medicare |
$5.18
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.18
|
| Rate for Payer: Superior Health Plan EPO |
$5.18
|
| Rate for Payer: Superior Health Plan Medicare |
$5.18
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5.18
|
| Rate for Payer: Universal American Medicare |
$5.18
|
| Rate for Payer: Wellcare Medicare |
$5.18
|
| Rate for Payer: Wellmed Medicare |
$5.18
|
|
|
Alkaline Phosphatase
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
CPT 84075
|
| Hospital Charge Code |
1601608
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$163.68
|
|
|
Alk Phos Isoenzyme SO
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
CPT 84075
|
| Hospital Charge Code |
1601608
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$120.90 |
| Rate for Payer: Aetna Commercial |
$5.44
|
| Rate for Payer: Aetna Medicare |
$7.77
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.02
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5.18
|
| Rate for Payer: Amerigroup Medicare |
$5.18
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8.55
|
| Rate for Payer: BCBS of TX Blue Essentials |
$10.26
|
| Rate for Payer: BCBS of TX Medicare |
$5.18
|
| Rate for Payer: BCBS of TX PPO |
$11.45
|
| Rate for Payer: Cash Price |
$163.68
|
| Rate for Payer: Cash Price |
$163.68
|
| Rate for Payer: Cigna Medicaid |
$5.18
|
| Rate for Payer: Cigna Medicare |
$5.18
|
| Rate for Payer: Employer Direct Commercial |
$5.18
|
| Rate for Payer: Humana Medicare/TRICARE |
$5.18
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.18
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5.18
|
| Rate for Payer: Molina Medicare |
$5.18
|
| Rate for Payer: Multiplan Auto |
$120.90
|
| Rate for Payer: Multiplan Commercial |
$120.90
|
| Rate for Payer: Multiplan Workers Comp |
$120.90
|
| Rate for Payer: Parkland Medicaid |
$5.18
|
| Rate for Payer: Scott and White EPO/PPO |
$6.48
|
| Rate for Payer: Scott and White Medicare |
$5.18
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.18
|
| Rate for Payer: Superior Health Plan EPO |
$5.18
|
| Rate for Payer: Superior Health Plan Medicare |
$5.18
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5.18
|
| Rate for Payer: Universal American Medicare |
$5.18
|
| Rate for Payer: Wellcare Medicare |
$5.18
|
| Rate for Payer: Wellmed Medicare |
$5.18
|
|
|
Alk Phosphatase, Bone Specific SO
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT 84080
|
| Hospital Charge Code |
1701549
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$46.80 |
| Rate for Payer: Aetna Commercial |
$15.52
|
| Rate for Payer: Aetna Medicare |
$22.17
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.76
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14.78
|
| Rate for Payer: Amerigroup Medicare |
$14.78
|
| Rate for Payer: BCBS of TX Blue Advantage |
$24.39
|
| Rate for Payer: BCBS of TX Blue Essentials |
$29.26
|
| Rate for Payer: BCBS of TX Medicare |
$14.78
|
| Rate for Payer: BCBS of TX PPO |
$32.66
|
| Rate for Payer: Cash Price |
$63.36
|
| Rate for Payer: Cash Price |
$63.36
|
| Rate for Payer: Cigna Medicaid |
$14.78
|
| Rate for Payer: Cigna Medicare |
$14.78
|
| Rate for Payer: Employer Direct Commercial |
$14.78
|
| Rate for Payer: Humana Medicare/TRICARE |
$14.78
|
| Rate for Payer: Molina CHIP/Medicaid |
$14.78
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14.78
|
| Rate for Payer: Molina Medicare |
$14.78
|
| Rate for Payer: Multiplan Auto |
$46.80
|
| Rate for Payer: Multiplan Commercial |
$46.80
|
| Rate for Payer: Multiplan Workers Comp |
$46.80
|
| Rate for Payer: Parkland Medicaid |
$14.78
|
| Rate for Payer: Scott and White EPO/PPO |
$18.48
|
| Rate for Payer: Scott and White Medicare |
$14.78
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$14.78
|
| Rate for Payer: Superior Health Plan EPO |
$14.78
|
| Rate for Payer: Superior Health Plan Medicare |
$14.78
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14.78
|
| Rate for Payer: Universal American Medicare |
$14.78
|
| Rate for Payer: Wellcare Medicare |
$14.78
|
| Rate for Payer: Wellmed Medicare |
$14.78
|
|
|
Alk Phosphatase, Bone Specific SO
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
CPT 84080
|
| Hospital Charge Code |
1701549
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$63.36
|
|
|
ALLERGEN SPECIFIC IGE EACH
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
1701028
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$48.10 |
| Rate for Payer: Aetna Commercial |
$5.48
|
| Rate for Payer: Aetna Medicare |
$7.83
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.04
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5.22
|
| Rate for Payer: Amerigroup Medicare |
$5.22
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8.61
|
| Rate for Payer: BCBS of TX Blue Essentials |
$10.34
|
| Rate for Payer: BCBS of TX Medicare |
$5.22
|
| Rate for Payer: BCBS of TX PPO |
$11.54
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: Cigna Medicaid |
$5.22
|
| Rate for Payer: Cigna Medicare |
$5.22
|
| Rate for Payer: Employer Direct Commercial |
$5.22
|
| Rate for Payer: Humana Medicare/TRICARE |
$5.22
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.22
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5.22
|
| Rate for Payer: Molina Medicare |
$5.22
|
| Rate for Payer: Multiplan Auto |
$48.10
|
| Rate for Payer: Multiplan Commercial |
$48.10
|
| Rate for Payer: Multiplan Workers Comp |
$48.10
|
| Rate for Payer: Parkland Medicaid |
$5.22
|
| Rate for Payer: Scott and White EPO/PPO |
$6.52
|
| Rate for Payer: Scott and White Medicare |
$5.22
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.22
|
| Rate for Payer: Superior Health Plan EPO |
$5.22
|
| Rate for Payer: Superior Health Plan Medicare |
$5.22
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5.22
|
| Rate for Payer: Universal American Medicare |
$5.22
|
| Rate for Payer: Wellcare Medicare |
$5.22
|
| Rate for Payer: Wellmed Medicare |
$5.22
|
|
|
Allergens w/Total IgE Area 5 SO
|
Facility
|
OP
|
$246.00
|
|
|
Service Code
|
CPT 82785
|
| Hospital Charge Code |
1701408
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$159.90 |
| Rate for Payer: Aetna Commercial |
$17.29
|
| Rate for Payer: Aetna Medicare |
$24.69
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$6.42
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$16.46
|
| Rate for Payer: Amerigroup Medicare |
$16.46
|
| Rate for Payer: BCBS of TX Blue Advantage |
$27.16
|
| Rate for Payer: BCBS of TX Blue Essentials |
$32.59
|
| Rate for Payer: BCBS of TX Medicare |
$16.46
|
| Rate for Payer: BCBS of TX PPO |
$36.38
|
| Rate for Payer: Cash Price |
$216.48
|
| Rate for Payer: Cash Price |
$216.48
|
| Rate for Payer: Cigna Medicaid |
$16.46
|
| Rate for Payer: Cigna Medicare |
$16.46
|
| Rate for Payer: Employer Direct Commercial |
$16.46
|
| Rate for Payer: Humana Medicare/TRICARE |
$16.46
|
| Rate for Payer: Molina CHIP/Medicaid |
$16.46
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$16.46
|
| Rate for Payer: Molina Medicare |
$16.46
|
| Rate for Payer: Multiplan Auto |
$159.90
|
| Rate for Payer: Multiplan Commercial |
$159.90
|
| Rate for Payer: Multiplan Workers Comp |
$159.90
|
| Rate for Payer: Parkland Medicaid |
$16.46
|
| Rate for Payer: Scott and White EPO/PPO |
$20.58
|
| Rate for Payer: Scott and White Medicare |
$16.46
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$16.46
|
| Rate for Payer: Superior Health Plan EPO |
$16.46
|
| Rate for Payer: Superior Health Plan Medicare |
$16.46
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$16.46
|
| Rate for Payer: Universal American Medicare |
$16.46
|
| Rate for Payer: Wellcare Medicare |
$16.46
|
| Rate for Payer: Wellmed Medicare |
$16.46
|
|
|
Allergens w/Total IgE Area 8 SO
|
Facility
|
OP
|
$246.00
|
|
|
Service Code
|
CPT 82785
|
| Hospital Charge Code |
1701408
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$159.90 |
| Rate for Payer: Aetna Commercial |
$17.29
|
| Rate for Payer: Aetna Medicare |
$24.69
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$6.42
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$16.46
|
| Rate for Payer: Amerigroup Medicare |
$16.46
|
| Rate for Payer: BCBS of TX Blue Advantage |
$27.16
|
| Rate for Payer: BCBS of TX Blue Essentials |
$32.59
|
| Rate for Payer: BCBS of TX Medicare |
$16.46
|
| Rate for Payer: BCBS of TX PPO |
$36.38
|
| Rate for Payer: Cash Price |
$216.48
|
| Rate for Payer: Cash Price |
$216.48
|
| Rate for Payer: Cigna Medicaid |
$16.46
|
| Rate for Payer: Cigna Medicare |
$16.46
|
| Rate for Payer: Employer Direct Commercial |
$16.46
|
| Rate for Payer: Humana Medicare/TRICARE |
$16.46
|
| Rate for Payer: Molina CHIP/Medicaid |
$16.46
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$16.46
|
| Rate for Payer: Molina Medicare |
$16.46
|
| Rate for Payer: Multiplan Auto |
$159.90
|
| Rate for Payer: Multiplan Commercial |
$159.90
|
| Rate for Payer: Multiplan Workers Comp |
$159.90
|
| Rate for Payer: Parkland Medicaid |
$16.46
|
| Rate for Payer: Scott and White EPO/PPO |
$20.58
|
| Rate for Payer: Scott and White Medicare |
$16.46
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$16.46
|
| Rate for Payer: Superior Health Plan EPO |
$16.46
|
| Rate for Payer: Superior Health Plan Medicare |
$16.46
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$16.46
|
| Rate for Payer: Universal American Medicare |
$16.46
|
| Rate for Payer: Wellcare Medicare |
$16.46
|
| Rate for Payer: Wellmed Medicare |
$16.46
|
|
|
ALLERGIC REACTIONS WITH MCC
|
Facility
|
IP
|
$33,706.00
|
|
|
Service Code
|
MSDRG 915
|
| Min. Negotiated Rate |
$13,760.86 |
| Max. Negotiated Rate |
$33,706.00 |
| Rate for Payer: Aetna Commercial |
$19,957.50
|
| Rate for Payer: Aetna Medicare |
$23,271.21
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$15,514.14
|
| Rate for Payer: Amerigroup Medicare |
$15,514.14
|
| Rate for Payer: BCBS of TX Blue Advantage |
$13,760.86
|
| Rate for Payer: BCBS of TX Blue Essentials |
$17,303.93
|
| Rate for Payer: BCBS of TX Medicare |
$15,514.14
|
| Rate for Payer: BCBS of TX PPO |
$19,227.34
|
| Rate for Payer: Cigna Commercial |
$22,849.12
|
| Rate for Payer: Cigna Medicare |
$15,514.14
|
| Rate for Payer: Employer Direct Commercial |
$15,514.14
|
| Rate for Payer: Humana Medicare/TRICARE |
$15,514.14
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$15,514.14
|
| Rate for Payer: Molina Medicare |
$15,514.14
|
| Rate for Payer: Multiplan Auto |
$33,706.00
|
| Rate for Payer: Multiplan Commercial |
$33,706.00
|
| Rate for Payer: Multiplan Workers Comp |
$33,706.00
|
| Rate for Payer: Scott and White EPO/PPO |
$15,522.50
|
| Rate for Payer: Scott and White Medicare |
$15,514.14
|
| Rate for Payer: Superior Health Plan EPO |
$15,514.14
|
| Rate for Payer: Superior Health Plan Medicare |
$15,514.14
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$15,514.14
|
| Rate for Payer: Universal American Medicare |
$15,514.14
|
| Rate for Payer: Wellcare Medicare |
$15,514.14
|
| Rate for Payer: Wellmed Medicare |
$15,514.14
|
|
|
ALLERGIC REACTIONS WITHOUT MCC
|
Facility
|
IP
|
$12,517.20
|
|
|
Service Code
|
MSDRG 916
|
| Min. Negotiated Rate |
$5,121.30 |
| Max. Negotiated Rate |
$12,517.20 |
| Rate for Payer: Aetna Commercial |
$7,411.50
|
| Rate for Payer: Aetna Medicare |
$11,334.02
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7,556.01
|
| Rate for Payer: Amerigroup Medicare |
$7,556.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,121.30
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,555.66
|
| Rate for Payer: BCBS of TX Medicare |
$7,556.01
|
| Rate for Payer: BCBS of TX PPO |
$7,284.35
|
| Rate for Payer: Cigna Commercial |
$8,485.34
|
| Rate for Payer: Cigna Medicare |
$7,556.01
|
| Rate for Payer: Employer Direct Commercial |
$7,556.01
|
| Rate for Payer: Humana Medicare/TRICARE |
$7,556.01
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7,556.01
|
| Rate for Payer: Molina Medicare |
$7,556.01
|
| Rate for Payer: Multiplan Auto |
$12,517.20
|
| Rate for Payer: Multiplan Commercial |
$12,517.20
|
| Rate for Payer: Multiplan Workers Comp |
$12,517.20
|
| Rate for Payer: Scott and White EPO/PPO |
$5,764.50
|
| Rate for Payer: Scott and White Medicare |
$7,556.01
|
| Rate for Payer: Superior Health Plan EPO |
$7,556.01
|
| Rate for Payer: Superior Health Plan Medicare |
$7,556.01
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7,556.01
|
| Rate for Payer: Universal American Medicare |
$7,556.01
|
| Rate for Payer: Wellcare Medicare |
$7,556.01
|
| Rate for Payer: Wellmed Medicare |
$7,556.01
|
|
|
Allergy/Immunology
|
Facility
|
IP
|
$16,775.30
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
144466
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$14,762.26
|
|
|
Allergy/Immunology
|
Facility
|
OP
|
$16,775.30
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
144466
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,509.78 |
| Max. Negotiated Rate |
$10,903.94 |
| Rate for Payer: Aetna Commercial |
$9,226.42
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,509.78
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,032.59
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,039.11
|
| Rate for Payer: BCBS of TX PPO |
$6,710.12
|
| Rate for Payer: Cash Price |
$14,762.26
|
| Rate for Payer: Multiplan Auto |
$10,903.94
|
| Rate for Payer: Multiplan Commercial |
$10,903.94
|
| Rate for Payer: Multiplan Workers Comp |
$10,903.94
|
| Rate for Payer: Scott and White EPO/PPO |
$8,387.65
|
| Rate for Payer: Superior Health Plan EPO |
$2,281.44
|
|
|
ALLODERM PER SQ CM (IMPLANT) -- DHF
|
Facility
|
IP
|
$153.49
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
40204869
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$38.37 |
| Max. Negotiated Rate |
$76.74 |
| Rate for Payer: Aetna Commercial |
$46.05
|
| Rate for Payer: Cash Price |
$135.07
|
| Rate for Payer: Cigna Commercial |
$38.37
|
| Rate for Payer: Multiplan Auto |
$76.74
|
| Rate for Payer: Multiplan Commercial |
$76.74
|
| Rate for Payer: Multiplan Workers Comp |
$76.74
|
| Rate for Payer: Scott and White EPO/PPO |
$76.74
|
|
|
ALLODERM PER SQ CM (IMPLANT) -- DHF
|
Facility
|
OP
|
$153.49
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
40204869
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13.81 |
| Max. Negotiated Rate |
$76.74 |
| Rate for Payer: Aetna Commercial |
$46.05
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$13.81
|
| Rate for Payer: BCBS of TX Blue Advantage |
$46.05
|
| Rate for Payer: BCBS of TX Blue Essentials |
$55.26
|
| Rate for Payer: BCBS of TX PPO |
$61.40
|
| Rate for Payer: Cash Price |
$135.07
|
| Rate for Payer: Multiplan Auto |
$76.74
|
| Rate for Payer: Multiplan Commercial |
$76.74
|
| Rate for Payer: Multiplan Workers Comp |
$76.74
|
| Rate for Payer: Scott and White EPO/PPO |
$76.74
|
| Rate for Payer: Superior Health Plan EPO |
$20.87
|
|
|
ALLODERM SELECT PER SQ CM
|
Facility
|
IP
|
$167.98
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
8478525
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$83.99 |
| Rate for Payer: Aetna Commercial |
$50.39
|
| Rate for Payer: Cash Price |
$147.82
|
| Rate for Payer: Cigna Commercial |
$42.00
|
| Rate for Payer: Multiplan Auto |
$83.99
|
| Rate for Payer: Multiplan Commercial |
$83.99
|
| Rate for Payer: Multiplan Workers Comp |
$83.99
|
| Rate for Payer: Scott and White EPO/PPO |
$83.99
|
|
|
ALLODERM SELECT PER SQ CM
|
Facility
|
OP
|
$167.98
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
8478525
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$83.99 |
| Rate for Payer: Aetna Commercial |
$50.39
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$15.12
|
| Rate for Payer: BCBS of TX Blue Advantage |
$50.39
|
| Rate for Payer: BCBS of TX Blue Essentials |
$60.47
|
| Rate for Payer: BCBS of TX PPO |
$67.19
|
| Rate for Payer: Cash Price |
$147.82
|
| Rate for Payer: Multiplan Auto |
$83.99
|
| Rate for Payer: Multiplan Commercial |
$83.99
|
| Rate for Payer: Multiplan Workers Comp |
$83.99
|
| Rate for Payer: Scott and White EPO/PPO |
$83.99
|
| Rate for Payer: Superior Health Plan EPO |
$22.85
|
|
|
alloderm select rtm rectangle per sq cm
|
Facility
|
OP
|
$342.77
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
8698569
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$30.85 |
| Max. Negotiated Rate |
$171.38 |
| Rate for Payer: Aetna Commercial |
$102.83
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$30.85
|
| Rate for Payer: BCBS of TX Blue Advantage |
$102.83
|
| Rate for Payer: BCBS of TX Blue Essentials |
$123.40
|
| Rate for Payer: BCBS of TX PPO |
$137.11
|
| Rate for Payer: Cash Price |
$301.64
|
| Rate for Payer: Multiplan Auto |
$171.38
|
| Rate for Payer: Multiplan Commercial |
$171.38
|
| Rate for Payer: Multiplan Workers Comp |
$171.38
|
| Rate for Payer: Scott and White EPO/PPO |
$171.38
|
| Rate for Payer: Superior Health Plan EPO |
$46.62
|
|
|
alloderm select rtm rectangle per sq cm
|
Facility
|
IP
|
$342.77
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
8698569
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$85.69 |
| Max. Negotiated Rate |
$171.38 |
| Rate for Payer: Aetna Commercial |
$102.83
|
| Rate for Payer: Cash Price |
$301.64
|
| Rate for Payer: Cigna Commercial |
$85.69
|
| Rate for Payer: Multiplan Auto |
$171.38
|
| Rate for Payer: Multiplan Commercial |
$171.38
|
| Rate for Payer: Multiplan Workers Comp |
$171.38
|
| Rate for Payer: Scott and White EPO/PPO |
$171.38
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$217,757.10
|
|
|
Service Code
|
MSDRG 014
|
| Min. Negotiated Rate |
$84,640.44 |
| Max. Negotiated Rate |
$217,757.10 |
| Rate for Payer: Aetna Commercial |
$128,935.12
|
| Rate for Payer: Aetna Medicare |
$126,960.66
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$84,640.44
|
| Rate for Payer: Amerigroup Medicare |
$84,640.44
|
| Rate for Payer: BCBS of TX Blue Advantage |
$100,110.02
|
| Rate for Payer: BCBS of TX Blue Essentials |
$123,315.15
|
| Rate for Payer: BCBS of TX Medicare |
$84,640.44
|
| Rate for Payer: BCBS of TX PPO |
$137,022.14
|
| Rate for Payer: Cigna Commercial |
$147,616.39
|
| Rate for Payer: Cigna Medicare |
$84,640.44
|
| Rate for Payer: Employer Direct Commercial |
$84,640.44
|
| Rate for Payer: Humana Medicare/TRICARE |
$84,640.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$84,640.44
|
| Rate for Payer: Molina Medicare |
$84,640.44
|
| Rate for Payer: Multiplan Auto |
$217,757.10
|
| Rate for Payer: Multiplan Commercial |
$217,757.10
|
| Rate for Payer: Multiplan Workers Comp |
$217,757.10
|
| Rate for Payer: Scott and White EPO/PPO |
$100,282.88
|
| Rate for Payer: Scott and White Medicare |
$84,640.44
|
| Rate for Payer: Superior Health Plan EPO |
$84,640.44
|
| Rate for Payer: Superior Health Plan Medicare |
$84,640.44
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$84,640.44
|
| Rate for Payer: Universal American Medicare |
$84,640.44
|
| Rate for Payer: Wellcare Medicare |
$84,640.44
|
| Rate for Payer: Wellmed Medicare |
$84,640.44
|
|
|
ALLOGRAFT ALLOPATCH
|
Facility
|
IP
|
$451.80
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
8502476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$112.95 |
| Max. Negotiated Rate |
$225.90 |
| Rate for Payer: Aetna Commercial |
$135.54
|
| Rate for Payer: Cash Price |
$397.58
|
| Rate for Payer: Cigna Commercial |
$112.95
|
| Rate for Payer: Multiplan Auto |
$225.90
|
| Rate for Payer: Multiplan Commercial |
$225.90
|
| Rate for Payer: Multiplan Workers Comp |
$225.90
|
| Rate for Payer: Scott and White EPO/PPO |
$225.90
|
|
|
ALLOGRAFT ALLOPATCH
|
Facility
|
OP
|
$451.80
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
8502476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$40.66 |
| Max. Negotiated Rate |
$225.90 |
| Rate for Payer: Aetna Commercial |
$135.54
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$40.66
|
| Rate for Payer: BCBS of TX Blue Advantage |
$135.54
|
| Rate for Payer: BCBS of TX Blue Essentials |
$162.65
|
| Rate for Payer: BCBS of TX PPO |
$180.72
|
| Rate for Payer: Cash Price |
$397.58
|
| Rate for Payer: Multiplan Auto |
$225.90
|
| Rate for Payer: Multiplan Commercial |
$225.90
|
| Rate for Payer: Multiplan Workers Comp |
$225.90
|
| Rate for Payer: Scott and White EPO/PPO |
$225.90
|
| Rate for Payer: Superior Health Plan EPO |
$61.44
|
|
|
ALLOGRAFT AMNIOCORD 3X5 -AC-5350
|
Facility
|
IP
|
$10,843.37
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
120839
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,710.84 |
| Max. Negotiated Rate |
$5,421.68 |
| Rate for Payer: Aetna Commercial |
$3,253.01
|
| Rate for Payer: Cash Price |
$9,542.17
|
| Rate for Payer: Cigna Commercial |
$2,710.84
|
| Rate for Payer: Multiplan Auto |
$5,421.68
|
| Rate for Payer: Multiplan Commercial |
$5,421.68
|
| Rate for Payer: Multiplan Workers Comp |
$5,421.68
|
| Rate for Payer: Scott and White EPO/PPO |
$5,421.68
|
|
|
ALLOGRAFT AMNIOCORD 3X5 -AC-5350
|
Facility
|
OP
|
$10,843.37
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
120839
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$975.90 |
| Max. Negotiated Rate |
$5,421.68 |
| Rate for Payer: Aetna Commercial |
$3,253.01
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$975.90
|
| Rate for Payer: BCBS of TX Blue Advantage |
$3,253.01
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,903.61
|
| Rate for Payer: BCBS of TX PPO |
$4,337.35
|
| Rate for Payer: Cash Price |
$9,542.17
|
| Rate for Payer: Multiplan Auto |
$5,421.68
|
| Rate for Payer: Multiplan Commercial |
$5,421.68
|
| Rate for Payer: Multiplan Workers Comp |
$5,421.68
|
| Rate for Payer: Scott and White EPO/PPO |
$5,421.68
|
| Rate for Payer: Superior Health Plan EPO |
$1,474.70
|
|
|
ALLOGRAFT AMNIOFIX 2X12 APS-5212
|
Facility
|
OP
|
$5,990.97
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
145327
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$539.19 |
| Max. Negotiated Rate |
$2,995.48 |
| Rate for Payer: Aetna Commercial |
$1,797.29
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$539.19
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,797.29
|
| Rate for Payer: BCBS of TX Blue Essentials |
$2,156.75
|
| Rate for Payer: BCBS of TX PPO |
$2,396.39
|
| Rate for Payer: Cash Price |
$5,272.05
|
| Rate for Payer: Multiplan Auto |
$2,995.48
|
| Rate for Payer: Multiplan Commercial |
$2,995.48
|
| Rate for Payer: Multiplan Workers Comp |
$2,995.48
|
| Rate for Payer: Scott and White EPO/PPO |
$2,995.48
|
| Rate for Payer: Superior Health Plan EPO |
$814.77
|
|
|
ALLOGRAFT AMNIOFIX 2X12 APS-5212
|
Facility
|
IP
|
$5,990.97
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
145327
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.74 |
| Max. Negotiated Rate |
$2,995.48 |
| Rate for Payer: Aetna Commercial |
$1,797.29
|
| Rate for Payer: Cash Price |
$5,272.05
|
| Rate for Payer: Cigna Commercial |
$1,497.74
|
| Rate for Payer: Multiplan Auto |
$2,995.48
|
| Rate for Payer: Multiplan Commercial |
$2,995.48
|
| Rate for Payer: Multiplan Workers Comp |
$2,995.48
|
| Rate for Payer: Scott and White EPO/PPO |
$2,995.48
|
|
