|
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$21,679.00
|
|
|
Service Code
|
MSDRG 039
|
| Min. Negotiated Rate |
$9,303.48 |
| Max. Negotiated Rate |
$21,679.00 |
| Rate for Payer: Aetna Commercial |
$12,836.25
|
| Rate for Payer: Aetna Medicare |
$16,495.53
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$10,997.02
|
| Rate for Payer: Amerigroup Medicare |
$10,997.02
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9,303.48
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11,685.24
|
| Rate for Payer: BCBS of TX Medicare |
$10,997.02
|
| Rate for Payer: BCBS of TX PPO |
$12,984.10
|
| Rate for Payer: Cigna Commercial |
$14,696.08
|
| Rate for Payer: Cigna Medicare |
$10,997.02
|
| Rate for Payer: Employer Direct Commercial |
$10,997.02
|
| Rate for Payer: Humana Medicare/TRICARE |
$10,997.02
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$10,997.02
|
| Rate for Payer: Molina Medicare |
$10,997.02
|
| Rate for Payer: Multiplan Auto |
$21,679.00
|
| Rate for Payer: Multiplan Commercial |
$21,679.00
|
| Rate for Payer: Multiplan Workers Comp |
$21,679.00
|
| Rate for Payer: Scott and White EPO/PPO |
$9,983.75
|
| Rate for Payer: Scott and White Medicare |
$10,997.02
|
| Rate for Payer: Superior Health Plan EPO |
$10,997.02
|
| Rate for Payer: Superior Health Plan Medicare |
$10,997.02
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$10,997.02
|
| Rate for Payer: Universal American Medicare |
$10,997.02
|
| Rate for Payer: Wellcare Medicare |
$10,997.02
|
| Rate for Payer: Wellmed Medicare |
$10,997.02
|
|
|
EXTRACTABLE NUCL ANTIGN, AB TO, AM
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
1701143
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.99 |
| Max. Negotiated Rate |
$149.50 |
| Rate for Payer: Aetna Commercial |
$18.83
|
| Rate for Payer: Aetna Medicare |
$26.90
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$6.99
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$17.93
|
| Rate for Payer: Amerigroup Medicare |
$17.93
|
| Rate for Payer: BCBS of TX Blue Advantage |
$29.58
|
| Rate for Payer: BCBS of TX Blue Essentials |
$35.50
|
| Rate for Payer: BCBS of TX Medicare |
$17.93
|
| Rate for Payer: BCBS of TX PPO |
$39.63
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Cigna Medicaid |
$17.93
|
| Rate for Payer: Cigna Medicare |
$17.93
|
| Rate for Payer: Employer Direct Commercial |
$17.93
|
| Rate for Payer: Humana Medicare/TRICARE |
$17.93
|
| Rate for Payer: Molina CHIP/Medicaid |
$17.93
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$17.93
|
| Rate for Payer: Molina Medicare |
$17.93
|
| Rate for Payer: Multiplan Auto |
$149.50
|
| Rate for Payer: Multiplan Commercial |
$149.50
|
| Rate for Payer: Multiplan Workers Comp |
$149.50
|
| Rate for Payer: Parkland Medicaid |
$17.93
|
| Rate for Payer: Scott and White EPO/PPO |
$22.41
|
| Rate for Payer: Scott and White Medicare |
$17.93
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$17.93
|
| Rate for Payer: Superior Health Plan EPO |
$17.93
|
| Rate for Payer: Superior Health Plan Medicare |
$17.93
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$17.93
|
| Rate for Payer: Universal American Medicare |
$17.93
|
| Rate for Payer: Wellcare Medicare |
$17.93
|
| Rate for Payer: Wellmed Medicare |
$17.93
|
|
|
EXTRAOCULAR PROCEDURES EXCEPT ORBIT
|
Facility
|
IP
|
$29,723.60
|
|
|
Service Code
|
MSDRG 115
|
| Min. Negotiated Rate |
$11,843.06 |
| Max. Negotiated Rate |
$29,723.60 |
| Rate for Payer: Aetna Commercial |
$17,599.50
|
| Rate for Payer: Aetna Medicare |
$21,027.63
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14,018.42
|
| Rate for Payer: Amerigroup Medicare |
$14,018.42
|
| Rate for Payer: BCBS of TX Blue Advantage |
$11,843.06
|
| Rate for Payer: BCBS of TX Blue Essentials |
$14,055.51
|
| Rate for Payer: BCBS of TX Medicare |
$14,018.42
|
| Rate for Payer: BCBS of TX PPO |
$15,617.84
|
| Rate for Payer: Cigna Commercial |
$20,149.47
|
| Rate for Payer: Cigna Medicare |
$14,018.42
|
| Rate for Payer: Employer Direct Commercial |
$14,018.42
|
| Rate for Payer: Humana Medicare/TRICARE |
$14,018.42
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14,018.42
|
| Rate for Payer: Molina Medicare |
$14,018.42
|
| Rate for Payer: Multiplan Auto |
$29,723.60
|
| Rate for Payer: Multiplan Commercial |
$29,723.60
|
| Rate for Payer: Multiplan Workers Comp |
$29,723.60
|
| Rate for Payer: Scott and White EPO/PPO |
$13,688.50
|
| Rate for Payer: Scott and White Medicare |
$14,018.42
|
| Rate for Payer: Superior Health Plan EPO |
$14,018.42
|
| Rate for Payer: Superior Health Plan Medicare |
$14,018.42
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14,018.42
|
| Rate for Payer: Universal American Medicare |
$14,018.42
|
| Rate for Payer: Wellcare Medicare |
$14,018.42
|
| Rate for Payer: Wellmed Medicare |
$14,018.42
|
|
|
EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE
|
Facility
|
IP
|
$114,001.90
|
|
|
Service Code
|
MSDRG 790
|
| Min. Negotiated Rate |
$45,315.12 |
| Max. Negotiated Rate |
$114,001.90 |
| Rate for Payer: Aetna Commercial |
$67,501.12
|
| Rate for Payer: Aetna Medicare |
$68,507.78
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$45,671.85
|
| Rate for Payer: Amerigroup Medicare |
$45,671.85
|
| Rate for Payer: BCBS of TX Blue Advantage |
$45,315.12
|
| Rate for Payer: BCBS of TX Blue Essentials |
$56,613.13
|
| Rate for Payer: BCBS of TX Medicare |
$45,671.85
|
| Rate for Payer: BCBS of TX PPO |
$62,905.92
|
| Rate for Payer: Cigna Commercial |
$77,281.29
|
| Rate for Payer: Cigna Medicare |
$45,671.85
|
| Rate for Payer: Employer Direct Commercial |
$45,671.85
|
| Rate for Payer: Humana Medicare/TRICARE |
$45,671.85
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$45,671.85
|
| Rate for Payer: Molina Medicare |
$45,671.85
|
| Rate for Payer: Multiplan Auto |
$114,001.90
|
| Rate for Payer: Multiplan Commercial |
$114,001.90
|
| Rate for Payer: Multiplan Workers Comp |
$114,001.90
|
| Rate for Payer: Scott and White EPO/PPO |
$52,500.88
|
| Rate for Payer: Scott and White Medicare |
$45,671.85
|
| Rate for Payer: Superior Health Plan EPO |
$45,671.85
|
| Rate for Payer: Superior Health Plan Medicare |
$45,671.85
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$45,671.85
|
| Rate for Payer: Universal American Medicare |
$45,671.85
|
| Rate for Payer: Wellcare Medicare |
$45,671.85
|
| Rate for Payer: Wellmed Medicare |
$45,671.85
|
|
|
Extremity Study Bilateral 1-2 Levels
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
CPT 93922
|
| Hospital Charge Code |
7150844
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$468.00 |
| Rate for Payer: Aetna Commercial |
$141.36
|
| Rate for Payer: Aetna Medicare |
$175.23
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$64.80
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$116.82
|
| Rate for Payer: Amerigroup Medicare |
$116.82
|
| Rate for Payer: BCBS of TX Blue Advantage |
$189.71
|
| Rate for Payer: BCBS of TX Blue Essentials |
$226.78
|
| Rate for Payer: BCBS of TX Medicare |
$116.82
|
| Rate for Payer: BCBS of TX PPO |
$252.95
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cigna Commercial |
$264.63
|
| Rate for Payer: Cigna Medicare |
$116.82
|
| Rate for Payer: Employer Direct Commercial |
$116.82
|
| Rate for Payer: Humana Medicare/TRICARE |
$116.82
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$116.82
|
| Rate for Payer: Molina Medicare |
$116.82
|
| Rate for Payer: Multiplan Auto |
$468.00
|
| Rate for Payer: Multiplan Commercial |
$468.00
|
| Rate for Payer: Multiplan Workers Comp |
$468.00
|
| Rate for Payer: Scott and White EPO/PPO |
$2.09
|
| Rate for Payer: Scott and White Medicare |
$116.82
|
| Rate for Payer: Superior Health Plan EPO |
$116.82
|
| Rate for Payer: Superior Health Plan Medicare |
$116.82
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$116.82
|
| Rate for Payer: Universal American Medicare |
$116.82
|
| Rate for Payer: Wellcare Medicare |
$116.82
|
| Rate for Payer: Wellmed Medicare |
$116.82
|
|
|
Extremity Study Bilateral 3+ Levels
|
Facility
|
OP
|
$1,579.00
|
|
|
Service Code
|
CPT 93923
|
| Hospital Charge Code |
6620804
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$1,026.35 |
| Rate for Payer: Aetna Commercial |
$215.61
|
| Rate for Payer: Aetna Medicare |
$214.29
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$142.11
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$142.86
|
| Rate for Payer: Amerigroup Medicare |
$142.86
|
| Rate for Payer: BCBS of TX Blue Advantage |
$197.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$236.12
|
| Rate for Payer: BCBS of TX Medicare |
$142.86
|
| Rate for Payer: BCBS of TX PPO |
$263.37
|
| Rate for Payer: Cash Price |
$1,389.52
|
| Rate for Payer: Cash Price |
$1,389.52
|
| Rate for Payer: Cash Price |
$1,389.52
|
| Rate for Payer: Cigna Commercial |
$323.61
|
| Rate for Payer: Cigna Medicaid |
$128.31
|
| Rate for Payer: Cigna Medicare |
$142.86
|
| Rate for Payer: Employer Direct Commercial |
$142.86
|
| Rate for Payer: Humana Medicare/TRICARE |
$142.86
|
| Rate for Payer: Molina CHIP/Medicaid |
$128.31
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$142.86
|
| Rate for Payer: Molina Medicare |
$142.86
|
| Rate for Payer: Multiplan Auto |
$1,026.35
|
| Rate for Payer: Multiplan Commercial |
$1,026.35
|
| Rate for Payer: Multiplan Workers Comp |
$1,026.35
|
| Rate for Payer: Parkland Medicaid |
$128.31
|
| Rate for Payer: Scott and White EPO/PPO |
$2.55
|
| Rate for Payer: Scott and White Medicare |
$142.86
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$128.31
|
| Rate for Payer: Superior Health Plan EPO |
$142.86
|
| Rate for Payer: Superior Health Plan Medicare |
$142.86
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$142.86
|
| Rate for Payer: Universal American Medicare |
$142.86
|
| Rate for Payer: Wellcare Medicare |
$142.86
|
| Rate for Payer: Wellmed Medicare |
$142.86
|
|
|
EXTR RETRV BALLOON -- DHF
|
Facility
|
IP
|
$809.66
|
|
| Hospital Charge Code |
80322191
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$712.50
|
|
|
EXTR RETRV BALLOON -- DHF
|
Facility
|
OP
|
$809.66
|
|
| Hospital Charge Code |
80322191
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$72.87 |
| Max. Negotiated Rate |
$526.28 |
| Rate for Payer: Aetna Commercial |
$445.31
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$72.87
|
| Rate for Payer: BCBS of TX Blue Advantage |
$242.90
|
| Rate for Payer: BCBS of TX Blue Essentials |
$291.48
|
| Rate for Payer: BCBS of TX PPO |
$323.86
|
| Rate for Payer: Cash Price |
$712.50
|
| Rate for Payer: Multiplan Auto |
$526.28
|
| Rate for Payer: Multiplan Commercial |
$526.28
|
| Rate for Payer: Multiplan Workers Comp |
$526.28
|
| Rate for Payer: Scott and White EPO/PPO |
$404.83
|
| Rate for Payer: Superior Health Plan EPO |
$110.11
|
|
|
Eye Culture
|
Facility
|
IP
|
$309.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
4107073
|
|
Hospital Revenue Code
|
306
|
| Rate for Payer: Cash Price |
$271.92
|
|
|
Eye Culture
|
Facility
|
OP
|
$309.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
4107073
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$200.85 |
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: Aetna Medicare |
$12.93
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.36
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$8.62
|
| Rate for Payer: Amerigroup Medicare |
$8.62
|
| Rate for Payer: BCBS of TX Blue Advantage |
$14.22
|
| Rate for Payer: BCBS of TX Blue Essentials |
$17.07
|
| Rate for Payer: BCBS of TX Medicare |
$8.62
|
| Rate for Payer: BCBS of TX PPO |
$19.05
|
| Rate for Payer: Cash Price |
$271.92
|
| Rate for Payer: Cash Price |
$271.92
|
| Rate for Payer: Cigna Medicaid |
$8.62
|
| Rate for Payer: Cigna Medicare |
$8.62
|
| Rate for Payer: Employer Direct Commercial |
$8.62
|
| Rate for Payer: Humana Medicare/TRICARE |
$8.62
|
| Rate for Payer: Molina CHIP/Medicaid |
$8.62
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$8.62
|
| Rate for Payer: Molina Medicare |
$8.62
|
| Rate for Payer: Multiplan Auto |
$200.85
|
| Rate for Payer: Multiplan Commercial |
$200.85
|
| Rate for Payer: Multiplan Workers Comp |
$200.85
|
| Rate for Payer: Parkland Medicaid |
$8.62
|
| Rate for Payer: Scott and White EPO/PPO |
$10.78
|
| Rate for Payer: Scott and White Medicare |
$8.62
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$8.62
|
| Rate for Payer: Superior Health Plan EPO |
$8.62
|
| Rate for Payer: Superior Health Plan Medicare |
$8.62
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$8.62
|
| Rate for Payer: Universal American Medicare |
$8.62
|
| Rate for Payer: Wellcare Medicare |
$8.62
|
| Rate for Payer: Wellmed Medicare |
$8.62
|
|
|
ezetimibe 10 mg Tab
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77560850
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$5.85 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.81
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.70
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3.24
|
| Rate for Payer: BCBS of TX PPO |
$3.60
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Multiplan Auto |
$5.85
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: Multiplan Workers Comp |
$5.85
|
| Rate for Payer: Scott and White EPO/PPO |
$4.50
|
| Rate for Payer: Superior Health Plan EPO |
$1.22
|
|
|
ezetimibe 10 mg Tab
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77560850
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$6.12
|
|
|
F017-IgE Hazelnut (Filbert) SO
|
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
|
|
|
Facility Eval, New Patient Level 2 99202
|
Facility
|
OP
|
$272.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
7003106
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.48 |
| Max. Negotiated Rate |
$176.80 |
| Rate for Payer: Aetna Commercial |
$149.60
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$24.48
|
| Rate for Payer: BCBS of TX Blue Advantage |
$89.68
|
| Rate for Payer: BCBS of TX Blue Essentials |
$107.20
|
| Rate for Payer: BCBS of TX PPO |
$119.57
|
| Rate for Payer: Cash Price |
$239.36
|
| Rate for Payer: Cash Price |
$239.36
|
| Rate for Payer: Cigna Medicaid |
$37.80
|
| Rate for Payer: Molina CHIP/Medicaid |
$37.80
|
| Rate for Payer: Multiplan Auto |
$176.80
|
| Rate for Payer: Multiplan Commercial |
$176.80
|
| Rate for Payer: Multiplan Workers Comp |
$176.80
|
| Rate for Payer: Parkland Medicaid |
$37.80
|
| Rate for Payer: Scott and White EPO/PPO |
$136.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$37.80
|
|
|
Facility Eval, New Patient Level 2 99202
|
Facility
|
IP
|
$272.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
7003106
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$239.36
|
|
|
Facility Eval, New Patient Level 4 99204
|
Facility
|
OP
|
$488.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
7003114
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.92 |
| Max. Negotiated Rate |
$317.20 |
| Rate for Payer: Aetna Commercial |
$268.40
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$43.92
|
| Rate for Payer: BCBS of TX Blue Advantage |
$228.25
|
| Rate for Payer: BCBS of TX Blue Essentials |
$272.85
|
| Rate for Payer: BCBS of TX PPO |
$304.34
|
| Rate for Payer: Cash Price |
$429.44
|
| Rate for Payer: Cash Price |
$429.44
|
| Rate for Payer: Cigna Medicaid |
$74.74
|
| Rate for Payer: Molina CHIP/Medicaid |
$74.74
|
| Rate for Payer: Multiplan Auto |
$317.20
|
| Rate for Payer: Multiplan Commercial |
$317.20
|
| Rate for Payer: Multiplan Workers Comp |
$317.20
|
| Rate for Payer: Parkland Medicaid |
$74.74
|
| Rate for Payer: Scott and White EPO/PPO |
$244.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$74.74
|
|
|
Facility Eval, New Patient Level 4 99204
|
Facility
|
IP
|
$488.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
7003114
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$429.44
|
|
|
Facility Eval, New Patient Level 5 99205
|
Facility
|
IP
|
$596.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
7000029
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$524.48
|
|
|
Facility Eval, New Patient Level 5 99205
|
Facility
|
OP
|
$596.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
7000029
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.64 |
| Max. Negotiated Rate |
$397.16 |
| Rate for Payer: Aetna Commercial |
$327.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$53.64
|
| Rate for Payer: BCBS of TX Blue Advantage |
$297.87
|
| Rate for Payer: BCBS of TX Blue Essentials |
$356.08
|
| Rate for Payer: BCBS of TX PPO |
$397.16
|
| Rate for Payer: Cash Price |
$524.48
|
| Rate for Payer: Cash Price |
$524.48
|
| Rate for Payer: Cigna Medicaid |
$92.92
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.92
|
| Rate for Payer: Multiplan Auto |
$387.40
|
| Rate for Payer: Multiplan Commercial |
$387.40
|
| Rate for Payer: Multiplan Workers Comp |
$387.40
|
| Rate for Payer: Parkland Medicaid |
$92.92
|
| Rate for Payer: Scott and White EPO/PPO |
$298.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.92
|
|
|
FACILTY EST PATIENT E/M LEVEL 2 Units
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
6039212
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.66 |
| Max. Negotiated Rate |
$113.10 |
| Rate for Payer: Aetna Commercial |
$95.70
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$15.66
|
| Rate for Payer: BCBS of TX Blue Advantage |
$45.15
|
| Rate for Payer: BCBS of TX Blue Essentials |
$53.98
|
| Rate for Payer: BCBS of TX PPO |
$60.20
|
| Rate for Payer: Cash Price |
$153.12
|
| Rate for Payer: Cash Price |
$153.12
|
| Rate for Payer: Cigna Medicaid |
$20.78
|
| Rate for Payer: Molina CHIP/Medicaid |
$20.78
|
| Rate for Payer: Multiplan Auto |
$113.10
|
| Rate for Payer: Multiplan Commercial |
$113.10
|
| Rate for Payer: Multiplan Workers Comp |
$113.10
|
| Rate for Payer: Parkland Medicaid |
$20.78
|
| Rate for Payer: Scott and White EPO/PPO |
$87.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$20.78
|
|
|
FACILTY EST PATIENT E/M LEVEL 3 Units
|
Facility
|
OP
|
$211.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
6039213
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$18.99 |
| Max. Negotiated Rate |
$137.15 |
| Rate for Payer: Aetna Commercial |
$116.05
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$18.99
|
| Rate for Payer: BCBS of TX Blue Advantage |
$90.31
|
| Rate for Payer: BCBS of TX Blue Essentials |
$107.95
|
| Rate for Payer: BCBS of TX PPO |
$120.41
|
| Rate for Payer: Cash Price |
$185.68
|
| Rate for Payer: Cash Price |
$185.68
|
| Rate for Payer: Cigna Medicaid |
$31.23
|
| Rate for Payer: Molina CHIP/Medicaid |
$31.23
|
| Rate for Payer: Multiplan Auto |
$137.15
|
| Rate for Payer: Multiplan Commercial |
$137.15
|
| Rate for Payer: Multiplan Workers Comp |
$137.15
|
| Rate for Payer: Parkland Medicaid |
$31.23
|
| Rate for Payer: Scott and White EPO/PPO |
$105.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$31.23
|
|
|
FACILTY EST PATIENT E/M LEVEL 4 Units
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
6039214
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$253.50 |
| Rate for Payer: Aetna Commercial |
$214.50
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$35.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$139.22
|
| Rate for Payer: BCBS of TX Blue Essentials |
$166.42
|
| Rate for Payer: BCBS of TX PPO |
$185.62
|
| Rate for Payer: Cash Price |
$343.20
|
| Rate for Payer: Cash Price |
$343.20
|
| Rate for Payer: Cigna Medicaid |
$43.87
|
| Rate for Payer: Molina CHIP/Medicaid |
$43.87
|
| Rate for Payer: Multiplan Auto |
$253.50
|
| Rate for Payer: Multiplan Commercial |
$253.50
|
| Rate for Payer: Multiplan Workers Comp |
$253.50
|
| Rate for Payer: Parkland Medicaid |
$43.87
|
| Rate for Payer: Scott and White EPO/PPO |
$195.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$43.87
|
|
|
FACILTY EST PATIENT E/M LEVEL 5 Units
|
Facility
|
OP
|
$426.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
6039215
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$38.34 |
| Max. Negotiated Rate |
$276.90 |
| Rate for Payer: Aetna Commercial |
$234.30
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$38.34
|
| Rate for Payer: BCBS of TX Blue Advantage |
$196.27
|
| Rate for Payer: BCBS of TX Blue Essentials |
$234.62
|
| Rate for Payer: BCBS of TX PPO |
$261.70
|
| Rate for Payer: Cash Price |
$374.88
|
| Rate for Payer: Cash Price |
$374.88
|
| Rate for Payer: Cigna Medicaid |
$67.53
|
| Rate for Payer: Molina CHIP/Medicaid |
$67.53
|
| Rate for Payer: Multiplan Auto |
$276.90
|
| Rate for Payer: Multiplan Commercial |
$276.90
|
| Rate for Payer: Multiplan Workers Comp |
$276.90
|
| Rate for Payer: Parkland Medicaid |
$67.53
|
| Rate for Payer: Scott and White EPO/PPO |
$213.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$67.53
|
|
|
FACILTY NEW PATIENT E/M LEVEL 4 Units
|
Facility
|
OP
|
$488.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
6039204
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.92 |
| Max. Negotiated Rate |
$317.20 |
| Rate for Payer: Aetna Commercial |
$268.40
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$43.92
|
| Rate for Payer: BCBS of TX Blue Advantage |
$228.25
|
| Rate for Payer: BCBS of TX Blue Essentials |
$272.85
|
| Rate for Payer: BCBS of TX PPO |
$304.34
|
| Rate for Payer: Cash Price |
$429.44
|
| Rate for Payer: Cash Price |
$429.44
|
| Rate for Payer: Cigna Medicaid |
$74.74
|
| Rate for Payer: Molina CHIP/Medicaid |
$74.74
|
| Rate for Payer: Multiplan Auto |
$317.20
|
| Rate for Payer: Multiplan Commercial |
$317.20
|
| Rate for Payer: Multiplan Workers Comp |
$317.20
|
| Rate for Payer: Parkland Medicaid |
$74.74
|
| Rate for Payer: Scott and White EPO/PPO |
$244.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$74.74
|
|
|
FACILTY NEW PATIENT E/M LEVEL 5 Units
|
Facility
|
OP
|
$596.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
6039205
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.64 |
| Max. Negotiated Rate |
$397.16 |
| Rate for Payer: Aetna Commercial |
$327.80
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$53.64
|
| Rate for Payer: BCBS of TX Blue Advantage |
$297.87
|
| Rate for Payer: BCBS of TX Blue Essentials |
$356.08
|
| Rate for Payer: BCBS of TX PPO |
$397.16
|
| Rate for Payer: Cash Price |
$524.48
|
| Rate for Payer: Cash Price |
$524.48
|
| Rate for Payer: Cigna Medicaid |
$92.92
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.92
|
| Rate for Payer: Multiplan Auto |
$387.40
|
| Rate for Payer: Multiplan Commercial |
$387.40
|
| Rate for Payer: Multiplan Workers Comp |
$387.40
|
| Rate for Payer: Parkland Medicaid |
$92.92
|
| Rate for Payer: Scott and White EPO/PPO |
$298.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.92
|
|
