|
ED ID Body Site: Peritonsillar
|
Facility
|
OP
|
$1,336.00
|
|
|
Service Code
|
CPT 42700
|
| Hospital Charge Code |
9250040
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$868.40 |
| Rate for Payer: Aetna Commercial |
$734.80
|
| Rate for Payer: Aetna Medicare |
$335.08
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$120.24
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Amerigroup Medicare |
$223.39
|
| Rate for Payer: BCBS of TX Blue Advantage |
$340.08
|
| Rate for Payer: BCBS of TX Blue Essentials |
$407.28
|
| Rate for Payer: BCBS of TX Medicare |
$223.39
|
| Rate for Payer: BCBS of TX PPO |
$513.17
|
| Rate for Payer: Cash Price |
$1,175.68
|
| Rate for Payer: Cash Price |
$1,175.68
|
| Rate for Payer: Cash Price |
$1,175.68
|
| Rate for Payer: Cigna Commercial |
$506.05
|
| Rate for Payer: Cigna Medicaid |
$87.58
|
| Rate for Payer: Cigna Medicare |
$223.39
|
| Rate for Payer: Employer Direct Commercial |
$223.39
|
| Rate for Payer: Humana Medicare/TRICARE |
$223.39
|
| Rate for Payer: Molina CHIP/Medicaid |
$87.58
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Molina Medicare |
$223.39
|
| Rate for Payer: Multiplan Auto |
$868.40
|
| Rate for Payer: Multiplan Commercial |
$868.40
|
| Rate for Payer: Multiplan Workers Comp |
$868.40
|
| Rate for Payer: Parkland Medicaid |
$87.58
|
| Rate for Payer: Scott and White EPO/PPO |
$4.00
|
| Rate for Payer: Scott and White Medicare |
$223.39
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$87.58
|
| Rate for Payer: Superior Health Plan EPO |
$223.39
|
| Rate for Payer: Superior Health Plan Medicare |
$223.39
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Universal American Medicare |
$223.39
|
| Rate for Payer: Wellcare Medicare |
$223.39
|
| Rate for Payer: Wellmed Medicare |
$223.39
|
|
|
ED ID Body Site: Peritonsillar
|
Facility
|
IP
|
$1,336.00
|
|
|
Service Code
|
CPT 42700
|
| Hospital Charge Code |
9250040
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$1,175.68
|
|
|
ED ID Body Site Peritonsillar BCE
|
Facility
|
OP
|
$1,336.00
|
|
|
Service Code
|
CPT 42700
|
| Hospital Charge Code |
9250040
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$868.40 |
| Rate for Payer: Aetna Commercial |
$734.80
|
| Rate for Payer: Aetna Medicare |
$335.08
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$120.24
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Amerigroup Medicare |
$223.39
|
| Rate for Payer: BCBS of TX Blue Advantage |
$340.08
|
| Rate for Payer: BCBS of TX Blue Essentials |
$407.28
|
| Rate for Payer: BCBS of TX Medicare |
$223.39
|
| Rate for Payer: BCBS of TX PPO |
$513.17
|
| Rate for Payer: Cash Price |
$1,175.68
|
| Rate for Payer: Cash Price |
$1,175.68
|
| Rate for Payer: Cash Price |
$1,175.68
|
| Rate for Payer: Cigna Commercial |
$506.05
|
| Rate for Payer: Cigna Medicaid |
$87.58
|
| Rate for Payer: Cigna Medicare |
$223.39
|
| Rate for Payer: Employer Direct Commercial |
$223.39
|
| Rate for Payer: Humana Medicare/TRICARE |
$223.39
|
| Rate for Payer: Molina CHIP/Medicaid |
$87.58
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Molina Medicare |
$223.39
|
| Rate for Payer: Multiplan Auto |
$868.40
|
| Rate for Payer: Multiplan Commercial |
$868.40
|
| Rate for Payer: Multiplan Workers Comp |
$868.40
|
| Rate for Payer: Parkland Medicaid |
$87.58
|
| Rate for Payer: Scott and White EPO/PPO |
$4.00
|
| Rate for Payer: Scott and White Medicare |
$223.39
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$87.58
|
| Rate for Payer: Superior Health Plan EPO |
$223.39
|
| Rate for Payer: Superior Health Plan Medicare |
$223.39
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Universal American Medicare |
$223.39
|
| Rate for Payer: Wellcare Medicare |
$223.39
|
| Rate for Payer: Wellmed Medicare |
$223.39
|
|
|
ED ID Body Site: Pilonidal cyst, multiple
|
Facility
|
IP
|
$1,780.00
|
|
|
Service Code
|
CPT 10081
|
| Hospital Charge Code |
5202537
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$1,566.40
|
|
|
ED ID Body Site: Pilonidal cyst, multiple
|
Facility
|
OP
|
$1,780.00
|
|
|
Service Code
|
CPT 10081
|
| Hospital Charge Code |
5202537
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$1,457.60 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$160.20
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$348.36
|
| Rate for Payer: BCBS of TX Blue Essentials |
$417.20
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$525.67
|
| Rate for Payer: Cash Price |
$1,566.40
|
| Rate for Payer: Cash Price |
$1,566.40
|
| Rate for Payer: Cash Price |
$1,566.40
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$209.30
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$209.30
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| Rate for Payer: Multiplan Auto |
$1,157.00
|
| Rate for Payer: Multiplan Commercial |
$1,157.00
|
| Rate for Payer: Multiplan Workers Comp |
$1,157.00
|
| Rate for Payer: Parkland Medicaid |
$209.30
|
| Rate for Payer: Scott and White EPO/PPO |
$11.51
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$209.30
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
ED ID Body Site Pilonidal cyst, multiple BCE
|
Facility
|
OP
|
$1,780.00
|
|
|
Service Code
|
CPT 10081
|
| Hospital Charge Code |
5202537
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$1,457.60 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$160.20
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$348.36
|
| Rate for Payer: BCBS of TX Blue Essentials |
$417.20
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$525.67
|
| Rate for Payer: Cash Price |
$1,566.40
|
| Rate for Payer: Cash Price |
$1,566.40
|
| Rate for Payer: Cash Price |
$1,566.40
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$209.30
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$209.30
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| Rate for Payer: Multiplan Auto |
$1,157.00
|
| Rate for Payer: Multiplan Commercial |
$1,157.00
|
| Rate for Payer: Multiplan Workers Comp |
$1,157.00
|
| Rate for Payer: Parkland Medicaid |
$209.30
|
| Rate for Payer: Scott and White EPO/PPO |
$11.51
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$209.30
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
ED ID Body Site: Pilonidal cyst, single
|
Facility
|
OP
|
$266.00
|
|
|
Service Code
|
CPT 10080
|
| Hospital Charge Code |
5202536
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$1,457.60 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$23.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$276.03
|
| Rate for Payer: BCBS of TX Blue Essentials |
$330.58
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$416.53
|
| Rate for Payer: Cash Price |
$234.08
|
| Rate for Payer: Cash Price |
$234.08
|
| Rate for Payer: Cash Price |
$234.08
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$174.14
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$174.14
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| Rate for Payer: Multiplan Auto |
$172.90
|
| Rate for Payer: Multiplan Commercial |
$172.90
|
| Rate for Payer: Multiplan Workers Comp |
$172.90
|
| Rate for Payer: Parkland Medicaid |
$174.14
|
| Rate for Payer: Scott and White EPO/PPO |
$11.51
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$174.14
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
ED ID Body Site: Pilonidal cyst, single
|
Facility
|
IP
|
$266.00
|
|
|
Service Code
|
CPT 10080
|
| Hospital Charge Code |
5202536
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$234.08
|
|
|
ED ID Body Site Pilonidal cyst, single BCE
|
Facility
|
OP
|
$266.00
|
|
|
Service Code
|
CPT 10080
|
| Hospital Charge Code |
5202536
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$1,457.60 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$23.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$276.03
|
| Rate for Payer: BCBS of TX Blue Essentials |
$330.58
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$416.53
|
| Rate for Payer: Cash Price |
$234.08
|
| Rate for Payer: Cash Price |
$234.08
|
| Rate for Payer: Cash Price |
$234.08
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$174.14
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$174.14
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| Rate for Payer: Multiplan Auto |
$172.90
|
| Rate for Payer: Multiplan Commercial |
$172.90
|
| Rate for Payer: Multiplan Workers Comp |
$172.90
|
| Rate for Payer: Parkland Medicaid |
$174.14
|
| Rate for Payer: Scott and White EPO/PPO |
$11.51
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$174.14
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
ED ID Body Site: Scrotal Space
|
Facility
|
IP
|
$7,660.00
|
|
|
Service Code
|
CPT 54700
|
| Hospital Charge Code |
5202542
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$6,740.80
|
|
|
ED ID Body Site: Scrotal Space
|
Facility
|
OP
|
$7,660.00
|
|
|
Service Code
|
CPT 54700
|
| Hospital Charge Code |
5202542
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$33.31 |
| Max. Negotiated Rate |
$4,979.00 |
| Rate for Payer: Aetna Commercial |
$3,090.00
|
| Rate for Payer: Aetna Medicare |
$2,794.14
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$689.40
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,862.76
|
| Rate for Payer: Amerigroup Medicare |
$1,862.76
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,958.49
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,543.10
|
| Rate for Payer: BCBS of TX Medicare |
$1,862.76
|
| Rate for Payer: BCBS of TX PPO |
$4,464.31
|
| Rate for Payer: Cash Price |
$6,740.80
|
| Rate for Payer: Cash Price |
$6,740.80
|
| Rate for Payer: Cash Price |
$6,740.80
|
| Rate for Payer: Cigna Commercial |
$4,219.69
|
| Rate for Payer: Cigna Medicaid |
$652.80
|
| Rate for Payer: Cigna Medicare |
$1,862.76
|
| Rate for Payer: Employer Direct Commercial |
$1,862.76
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,862.76
|
| Rate for Payer: Molina CHIP/Medicaid |
$652.80
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,862.76
|
| Rate for Payer: Molina Medicare |
$1,862.76
|
| Rate for Payer: Multiplan Auto |
$4,979.00
|
| Rate for Payer: Multiplan Commercial |
$4,979.00
|
| Rate for Payer: Multiplan Workers Comp |
$4,979.00
|
| Rate for Payer: Parkland Medicaid |
$652.80
|
| Rate for Payer: Scott and White EPO/PPO |
$33.31
|
| Rate for Payer: Scott and White Medicare |
$1,862.76
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$652.80
|
| Rate for Payer: Superior Health Plan EPO |
$1,862.76
|
| Rate for Payer: Superior Health Plan Medicare |
$1,862.76
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,862.76
|
| Rate for Payer: Universal American Medicare |
$1,862.76
|
| Rate for Payer: Wellcare Medicare |
$1,862.76
|
| Rate for Payer: Wellmed Medicare |
$1,862.76
|
|
|
ED ID Body Site Scrotal Space BCE
|
Facility
|
OP
|
$7,660.00
|
|
|
Service Code
|
CPT 54700
|
| Hospital Charge Code |
5202542
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$33.31 |
| Max. Negotiated Rate |
$4,979.00 |
| Rate for Payer: Aetna Commercial |
$3,090.00
|
| Rate for Payer: Aetna Medicare |
$2,794.14
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$689.40
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,862.76
|
| Rate for Payer: Amerigroup Medicare |
$1,862.76
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,958.49
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,543.10
|
| Rate for Payer: BCBS of TX Medicare |
$1,862.76
|
| Rate for Payer: BCBS of TX PPO |
$4,464.31
|
| Rate for Payer: Cash Price |
$6,740.80
|
| Rate for Payer: Cash Price |
$6,740.80
|
| Rate for Payer: Cash Price |
$6,740.80
|
| Rate for Payer: Cigna Commercial |
$4,219.69
|
| Rate for Payer: Cigna Medicaid |
$652.80
|
| Rate for Payer: Cigna Medicare |
$1,862.76
|
| Rate for Payer: Employer Direct Commercial |
$1,862.76
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,862.76
|
| Rate for Payer: Molina CHIP/Medicaid |
$652.80
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,862.76
|
| Rate for Payer: Molina Medicare |
$1,862.76
|
| Rate for Payer: Multiplan Auto |
$4,979.00
|
| Rate for Payer: Multiplan Commercial |
$4,979.00
|
| Rate for Payer: Multiplan Workers Comp |
$4,979.00
|
| Rate for Payer: Parkland Medicaid |
$652.80
|
| Rate for Payer: Scott and White EPO/PPO |
$33.31
|
| Rate for Payer: Scott and White Medicare |
$1,862.76
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$652.80
|
| Rate for Payer: Superior Health Plan EPO |
$1,862.76
|
| Rate for Payer: Superior Health Plan Medicare |
$1,862.76
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,862.76
|
| Rate for Payer: Universal American Medicare |
$1,862.76
|
| Rate for Payer: Wellcare Medicare |
$1,862.76
|
| Rate for Payer: Wellmed Medicare |
$1,862.76
|
|
|
ED ID Body Site: Vestibule of Mouth, Complex
|
Facility
|
OP
|
$4,221.00
|
|
|
Service Code
|
CPT 40801
|
| Hospital Charge Code |
5202540
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$2,743.65 |
| Rate for Payer: Aetna Commercial |
$2,321.55
|
| Rate for Payer: Aetna Medicare |
$754.78
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$379.89
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$503.19
|
| Rate for Payer: Amerigroup Medicare |
$503.19
|
| Rate for Payer: BCBS of TX Blue Advantage |
$737.67
|
| Rate for Payer: BCBS of TX Blue Essentials |
$883.44
|
| Rate for Payer: BCBS of TX Medicare |
$503.19
|
| Rate for Payer: BCBS of TX PPO |
$1,113.13
|
| Rate for Payer: Cash Price |
$3,714.48
|
| Rate for Payer: Cash Price |
$3,714.48
|
| Rate for Payer: Cash Price |
$3,714.48
|
| Rate for Payer: Cigna Commercial |
$1,139.87
|
| Rate for Payer: Cigna Medicaid |
$187.22
|
| Rate for Payer: Cigna Medicare |
$503.19
|
| Rate for Payer: Employer Direct Commercial |
$503.19
|
| Rate for Payer: Humana Medicare/TRICARE |
$503.19
|
| Rate for Payer: Molina CHIP/Medicaid |
$187.22
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$503.19
|
| Rate for Payer: Molina Medicare |
$503.19
|
| Rate for Payer: Multiplan Auto |
$2,743.65
|
| Rate for Payer: Multiplan Commercial |
$2,743.65
|
| Rate for Payer: Multiplan Workers Comp |
$2,743.65
|
| Rate for Payer: Parkland Medicaid |
$187.22
|
| Rate for Payer: Scott and White EPO/PPO |
$9.00
|
| Rate for Payer: Scott and White Medicare |
$503.19
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$187.22
|
| Rate for Payer: Superior Health Plan EPO |
$503.19
|
| Rate for Payer: Superior Health Plan Medicare |
$503.19
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$503.19
|
| Rate for Payer: Universal American Medicare |
$503.19
|
| Rate for Payer: Wellcare Medicare |
$503.19
|
| Rate for Payer: Wellmed Medicare |
$503.19
|
|
|
ED ID Body Site: Vestibule of Mouth, Complex
|
Facility
|
IP
|
$4,221.00
|
|
|
Service Code
|
CPT 40801
|
| Hospital Charge Code |
5202540
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$3,714.48
|
|
|
ED ID Body Site Vestibule of Mouth, Complex BCE
|
Facility
|
OP
|
$4,221.00
|
|
|
Service Code
|
CPT 40801
|
| Hospital Charge Code |
5202540
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$2,743.65 |
| Rate for Payer: Aetna Commercial |
$2,321.55
|
| Rate for Payer: Aetna Medicare |
$754.78
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$379.89
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$503.19
|
| Rate for Payer: Amerigroup Medicare |
$503.19
|
| Rate for Payer: BCBS of TX Blue Advantage |
$737.67
|
| Rate for Payer: BCBS of TX Blue Essentials |
$883.44
|
| Rate for Payer: BCBS of TX Medicare |
$503.19
|
| Rate for Payer: BCBS of TX PPO |
$1,113.13
|
| Rate for Payer: Cash Price |
$3,714.48
|
| Rate for Payer: Cash Price |
$3,714.48
|
| Rate for Payer: Cash Price |
$3,714.48
|
| Rate for Payer: Cigna Commercial |
$1,139.87
|
| Rate for Payer: Cigna Medicaid |
$187.22
|
| Rate for Payer: Cigna Medicare |
$503.19
|
| Rate for Payer: Employer Direct Commercial |
$503.19
|
| Rate for Payer: Humana Medicare/TRICARE |
$503.19
|
| Rate for Payer: Molina CHIP/Medicaid |
$187.22
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$503.19
|
| Rate for Payer: Molina Medicare |
$503.19
|
| Rate for Payer: Multiplan Auto |
$2,743.65
|
| Rate for Payer: Multiplan Commercial |
$2,743.65
|
| Rate for Payer: Multiplan Workers Comp |
$2,743.65
|
| Rate for Payer: Parkland Medicaid |
$187.22
|
| Rate for Payer: Scott and White EPO/PPO |
$9.00
|
| Rate for Payer: Scott and White Medicare |
$503.19
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$187.22
|
| Rate for Payer: Superior Health Plan EPO |
$503.19
|
| Rate for Payer: Superior Health Plan Medicare |
$503.19
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$503.19
|
| Rate for Payer: Universal American Medicare |
$503.19
|
| Rate for Payer: Wellcare Medicare |
$503.19
|
| Rate for Payer: Wellmed Medicare |
$503.19
|
|
|
ED ID Body Site: Vestibule of Mouth, Simple
|
Facility
|
IP
|
$1,175.00
|
|
|
Service Code
|
CPT 40800
|
| Hospital Charge Code |
5202539
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$1,034.00
|
|
|
ED ID Body Site: Vestibule of Mouth, Simple
|
Facility
|
OP
|
$1,175.00
|
|
|
Service Code
|
CPT 40800
|
| Hospital Charge Code |
5202539
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$1,457.60 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$105.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$277.84
|
| Rate for Payer: BCBS of TX Blue Essentials |
$332.74
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$419.25
|
| Rate for Payer: Cash Price |
$1,034.00
|
| Rate for Payer: Cash Price |
$1,034.00
|
| Rate for Payer: Cash Price |
$1,034.00
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$131.78
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$131.78
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| Rate for Payer: Multiplan Auto |
$763.75
|
| Rate for Payer: Multiplan Commercial |
$763.75
|
| Rate for Payer: Multiplan Workers Comp |
$763.75
|
| Rate for Payer: Parkland Medicaid |
$131.78
|
| Rate for Payer: Scott and White EPO/PPO |
$11.51
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$131.78
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
ED ID Body Site Vestibule of Mouth, Simple BCE
|
Facility
|
OP
|
$1,175.00
|
|
|
Service Code
|
CPT 40800
|
| Hospital Charge Code |
5202539
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$1,457.60 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$105.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$277.84
|
| Rate for Payer: BCBS of TX Blue Essentials |
$332.74
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$419.25
|
| Rate for Payer: Cash Price |
$1,034.00
|
| Rate for Payer: Cash Price |
$1,034.00
|
| Rate for Payer: Cash Price |
$1,034.00
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$131.78
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$131.78
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| Rate for Payer: Multiplan Auto |
$763.75
|
| Rate for Payer: Multiplan Commercial |
$763.75
|
| Rate for Payer: Multiplan Workers Comp |
$763.75
|
| Rate for Payer: Parkland Medicaid |
$131.78
|
| Rate for Payer: Scott and White EPO/PPO |
$11.51
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$131.78
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
ED ID Drainage: Eyelid
|
Facility
|
IP
|
$4,866.00
|
|
|
Service Code
|
CPT 67700
|
| Hospital Charge Code |
5202546
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$4,282.08
|
|
|
ED ID Drainage: Eyelid
|
Facility
|
OP
|
$4,866.00
|
|
|
Service Code
|
CPT 67700
|
| Hospital Charge Code |
5202546
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$3,162.90 |
| Rate for Payer: Aetna Commercial |
$2,676.30
|
| Rate for Payer: Aetna Medicare |
$399.63
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$437.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$266.42
|
| Rate for Payer: Amerigroup Medicare |
$266.42
|
| Rate for Payer: BCBS of TX Blue Advantage |
$228.26
|
| Rate for Payer: BCBS of TX Blue Essentials |
$273.36
|
| Rate for Payer: BCBS of TX Medicare |
$266.42
|
| Rate for Payer: BCBS of TX PPO |
$344.43
|
| Rate for Payer: Cash Price |
$4,282.08
|
| Rate for Payer: Cash Price |
$4,282.08
|
| Rate for Payer: Cash Price |
$4,282.08
|
| Rate for Payer: Cigna Commercial |
$603.52
|
| Rate for Payer: Cigna Medicaid |
$108.29
|
| Rate for Payer: Cigna Medicare |
$266.42
|
| Rate for Payer: Employer Direct Commercial |
$266.42
|
| Rate for Payer: Humana Medicare/TRICARE |
$266.42
|
| Rate for Payer: Molina CHIP/Medicaid |
$108.29
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$266.42
|
| Rate for Payer: Molina Medicare |
$266.42
|
| Rate for Payer: Multiplan Auto |
$3,162.90
|
| Rate for Payer: Multiplan Commercial |
$3,162.90
|
| Rate for Payer: Multiplan Workers Comp |
$3,162.90
|
| Rate for Payer: Parkland Medicaid |
$108.29
|
| Rate for Payer: Scott and White EPO/PPO |
$4.76
|
| Rate for Payer: Scott and White Medicare |
$266.42
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$108.29
|
| Rate for Payer: Superior Health Plan EPO |
$266.42
|
| Rate for Payer: Superior Health Plan Medicare |
$266.42
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$266.42
|
| Rate for Payer: Universal American Medicare |
$266.42
|
| Rate for Payer: Wellcare Medicare |
$266.42
|
| Rate for Payer: Wellmed Medicare |
$266.42
|
|
|
ED ID Drainage Eyelid BCE
|
Facility
|
OP
|
$4,866.00
|
|
|
Service Code
|
CPT 67700
|
| Hospital Charge Code |
5202546
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$3,162.90 |
| Rate for Payer: Aetna Commercial |
$2,676.30
|
| Rate for Payer: Aetna Medicare |
$399.63
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$437.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$266.42
|
| Rate for Payer: Amerigroup Medicare |
$266.42
|
| Rate for Payer: BCBS of TX Blue Advantage |
$228.26
|
| Rate for Payer: BCBS of TX Blue Essentials |
$273.36
|
| Rate for Payer: BCBS of TX Medicare |
$266.42
|
| Rate for Payer: BCBS of TX PPO |
$344.43
|
| Rate for Payer: Cash Price |
$4,282.08
|
| Rate for Payer: Cash Price |
$4,282.08
|
| Rate for Payer: Cash Price |
$4,282.08
|
| Rate for Payer: Cigna Commercial |
$603.52
|
| Rate for Payer: Cigna Medicaid |
$108.29
|
| Rate for Payer: Cigna Medicare |
$266.42
|
| Rate for Payer: Employer Direct Commercial |
$266.42
|
| Rate for Payer: Humana Medicare/TRICARE |
$266.42
|
| Rate for Payer: Molina CHIP/Medicaid |
$108.29
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$266.42
|
| Rate for Payer: Molina Medicare |
$266.42
|
| Rate for Payer: Multiplan Auto |
$3,162.90
|
| Rate for Payer: Multiplan Commercial |
$3,162.90
|
| Rate for Payer: Multiplan Workers Comp |
$3,162.90
|
| Rate for Payer: Parkland Medicaid |
$108.29
|
| Rate for Payer: Scott and White EPO/PPO |
$4.76
|
| Rate for Payer: Scott and White Medicare |
$266.42
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$108.29
|
| Rate for Payer: Superior Health Plan EPO |
$266.42
|
| Rate for Payer: Superior Health Plan Medicare |
$266.42
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$266.42
|
| Rate for Payer: Universal American Medicare |
$266.42
|
| Rate for Payer: Wellcare Medicare |
$266.42
|
| Rate for Payer: Wellmed Medicare |
$266.42
|
|
|
ED ID Drainage: Nose, Internal
|
Facility
|
OP
|
$1,990.00
|
|
|
Service Code
|
CPT 30000
|
| Hospital Charge Code |
5202543
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$1,293.50 |
| Rate for Payer: Aetna Commercial |
$1,094.50
|
| Rate for Payer: Aetna Medicare |
$335.08
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$179.10
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Amerigroup Medicare |
$223.39
|
| Rate for Payer: BCBS of TX Blue Advantage |
$171.83
|
| Rate for Payer: BCBS of TX Blue Essentials |
$205.78
|
| Rate for Payer: BCBS of TX Medicare |
$223.39
|
| Rate for Payer: BCBS of TX PPO |
$259.28
|
| Rate for Payer: Cash Price |
$1,751.20
|
| Rate for Payer: Cash Price |
$1,751.20
|
| Rate for Payer: Cash Price |
$1,751.20
|
| Rate for Payer: Cigna Commercial |
$506.05
|
| Rate for Payer: Cigna Medicaid |
$87.58
|
| Rate for Payer: Cigna Medicare |
$223.39
|
| Rate for Payer: Employer Direct Commercial |
$223.39
|
| Rate for Payer: Humana Medicare/TRICARE |
$223.39
|
| Rate for Payer: Molina CHIP/Medicaid |
$87.58
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Molina Medicare |
$223.39
|
| Rate for Payer: Multiplan Auto |
$1,293.50
|
| Rate for Payer: Multiplan Commercial |
$1,293.50
|
| Rate for Payer: Multiplan Workers Comp |
$1,293.50
|
| Rate for Payer: Parkland Medicaid |
$87.58
|
| Rate for Payer: Scott and White EPO/PPO |
$4.00
|
| Rate for Payer: Scott and White Medicare |
$223.39
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$87.58
|
| Rate for Payer: Superior Health Plan EPO |
$223.39
|
| Rate for Payer: Superior Health Plan Medicare |
$223.39
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Universal American Medicare |
$223.39
|
| Rate for Payer: Wellcare Medicare |
$223.39
|
| Rate for Payer: Wellmed Medicare |
$223.39
|
|
|
ED ID Drainage: Nose, Internal
|
Facility
|
IP
|
$1,990.00
|
|
|
Service Code
|
CPT 30000
|
| Hospital Charge Code |
5202543
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$1,751.20
|
|
|
ED ID Drainage Nose, Internal BCE
|
Facility
|
OP
|
$1,990.00
|
|
|
Service Code
|
CPT 30000
|
| Hospital Charge Code |
5202543
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$1,293.50 |
| Rate for Payer: Aetna Commercial |
$1,094.50
|
| Rate for Payer: Aetna Medicare |
$335.08
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$179.10
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Amerigroup Medicare |
$223.39
|
| Rate for Payer: BCBS of TX Blue Advantage |
$171.83
|
| Rate for Payer: BCBS of TX Blue Essentials |
$205.78
|
| Rate for Payer: BCBS of TX Medicare |
$223.39
|
| Rate for Payer: BCBS of TX PPO |
$259.28
|
| Rate for Payer: Cash Price |
$1,751.20
|
| Rate for Payer: Cash Price |
$1,751.20
|
| Rate for Payer: Cash Price |
$1,751.20
|
| Rate for Payer: Cigna Commercial |
$506.05
|
| Rate for Payer: Cigna Medicaid |
$87.58
|
| Rate for Payer: Cigna Medicare |
$223.39
|
| Rate for Payer: Employer Direct Commercial |
$223.39
|
| Rate for Payer: Humana Medicare/TRICARE |
$223.39
|
| Rate for Payer: Molina CHIP/Medicaid |
$87.58
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Molina Medicare |
$223.39
|
| Rate for Payer: Multiplan Auto |
$1,293.50
|
| Rate for Payer: Multiplan Commercial |
$1,293.50
|
| Rate for Payer: Multiplan Workers Comp |
$1,293.50
|
| Rate for Payer: Parkland Medicaid |
$87.58
|
| Rate for Payer: Scott and White EPO/PPO |
$4.00
|
| Rate for Payer: Scott and White Medicare |
$223.39
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$87.58
|
| Rate for Payer: Superior Health Plan EPO |
$223.39
|
| Rate for Payer: Superior Health Plan Medicare |
$223.39
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Universal American Medicare |
$223.39
|
| Rate for Payer: Wellcare Medicare |
$223.39
|
| Rate for Payer: Wellmed Medicare |
$223.39
|
|
|
ED ID Drainage: Roof of Mouth
|
Facility
|
OP
|
$838.00
|
|
|
Service Code
|
CPT 42000
|
| Hospital Charge Code |
5202544
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$544.70 |
| Rate for Payer: Aetna Commercial |
$460.90
|
| Rate for Payer: Aetna Medicare |
$335.08
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$75.42
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Amerigroup Medicare |
$223.39
|
| Rate for Payer: BCBS of TX Blue Advantage |
$340.08
|
| Rate for Payer: BCBS of TX Blue Essentials |
$407.28
|
| Rate for Payer: BCBS of TX Medicare |
$223.39
|
| Rate for Payer: BCBS of TX PPO |
$513.17
|
| Rate for Payer: Cash Price |
$737.44
|
| Rate for Payer: Cash Price |
$737.44
|
| Rate for Payer: Cash Price |
$737.44
|
| Rate for Payer: Cigna Commercial |
$506.05
|
| Rate for Payer: Cigna Medicaid |
$87.58
|
| Rate for Payer: Cigna Medicare |
$223.39
|
| Rate for Payer: Employer Direct Commercial |
$223.39
|
| Rate for Payer: Humana Medicare/TRICARE |
$223.39
|
| Rate for Payer: Molina CHIP/Medicaid |
$87.58
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Molina Medicare |
$223.39
|
| Rate for Payer: Multiplan Auto |
$544.70
|
| Rate for Payer: Multiplan Commercial |
$544.70
|
| Rate for Payer: Multiplan Workers Comp |
$544.70
|
| Rate for Payer: Parkland Medicaid |
$87.58
|
| Rate for Payer: Scott and White EPO/PPO |
$4.00
|
| Rate for Payer: Scott and White Medicare |
$223.39
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$87.58
|
| Rate for Payer: Superior Health Plan EPO |
$223.39
|
| Rate for Payer: Superior Health Plan Medicare |
$223.39
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$223.39
|
| Rate for Payer: Universal American Medicare |
$223.39
|
| Rate for Payer: Wellcare Medicare |
$223.39
|
| Rate for Payer: Wellmed Medicare |
$223.39
|
|
