|
FULL TERM NEONATE WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$79,976.70
|
|
|
Service Code
|
MSDRG 793
|
| Min. Negotiated Rate |
$31,791.62 |
| Max. Negotiated Rate |
$79,976.70 |
| Rate for Payer: Aetna Commercial |
$47,354.62
|
| Rate for Payer: Aetna Medicare |
$49,338.92
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$32,892.61
|
| Rate for Payer: Amerigroup Medicare |
$32,892.61
|
| Rate for Payer: BCBS of TX Blue Advantage |
$31,791.62
|
| Rate for Payer: BCBS of TX Blue Essentials |
$39,716.80
|
| Rate for Payer: BCBS of TX Medicare |
$32,892.61
|
| Rate for Payer: BCBS of TX PPO |
$44,131.49
|
| Rate for Payer: Cigna Commercial |
$54,215.78
|
| Rate for Payer: Cigna Medicare |
$32,892.61
|
| Rate for Payer: Employer Direct Commercial |
$32,892.61
|
| Rate for Payer: Humana Medicare/TRICARE |
$32,892.61
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$32,892.61
|
| Rate for Payer: Molina Medicare |
$32,892.61
|
| Rate for Payer: Multiplan Auto |
$79,976.70
|
| Rate for Payer: Multiplan Commercial |
$79,976.70
|
| Rate for Payer: Multiplan Workers Comp |
$79,976.70
|
| Rate for Payer: Scott and White EPO/PPO |
$36,831.38
|
| Rate for Payer: Scott and White Medicare |
$32,892.61
|
| Rate for Payer: Superior Health Plan EPO |
$32,892.61
|
| Rate for Payer: Superior Health Plan Medicare |
$32,892.61
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$32,892.61
|
| Rate for Payer: Universal American Medicare |
$32,892.61
|
| Rate for Payer: Wellcare Medicare |
$32,892.61
|
| Rate for Payer: Wellmed Medicare |
$32,892.61
|
|
|
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY
|
Facility
|
IP
|
$39,757.50
|
|
|
Service Code
|
MSDRG 934
|
| Min. Negotiated Rate |
$14,254.50 |
| Max. Negotiated Rate |
$39,757.50 |
| Rate for Payer: Aetna Commercial |
$23,540.62
|
| Rate for Payer: Aetna Medicare |
$26,680.47
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$17,786.98
|
| Rate for Payer: Amerigroup Medicare |
$17,786.98
|
| Rate for Payer: BCBS of TX Blue Advantage |
$14,254.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$18,919.89
|
| Rate for Payer: BCBS of TX Medicare |
$17,786.98
|
| Rate for Payer: BCBS of TX PPO |
$21,022.91
|
| Rate for Payer: Cigna Commercial |
$26,951.40
|
| Rate for Payer: Cigna Medicare |
$17,786.98
|
| Rate for Payer: Employer Direct Commercial |
$17,786.98
|
| Rate for Payer: Humana Medicare/TRICARE |
$17,786.98
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$17,786.98
|
| Rate for Payer: Molina Medicare |
$17,786.98
|
| Rate for Payer: Multiplan Auto |
$39,757.50
|
| Rate for Payer: Multiplan Commercial |
$39,757.50
|
| Rate for Payer: Multiplan Workers Comp |
$39,757.50
|
| Rate for Payer: Scott and White EPO/PPO |
$18,309.38
|
| Rate for Payer: Scott and White Medicare |
$17,786.98
|
| Rate for Payer: Superior Health Plan EPO |
$17,786.98
|
| Rate for Payer: Superior Health Plan Medicare |
$17,786.98
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$17,786.98
|
| Rate for Payer: Universal American Medicare |
$17,786.98
|
| Rate for Payer: Wellcare Medicare |
$17,786.98
|
| Rate for Payer: Wellmed Medicare |
$17,786.98
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC
|
Facility
|
IP
|
$131,474.30
|
|
|
Service Code
|
MSDRG 928
|
| Min. Negotiated Rate |
$44,674.42 |
| Max. Negotiated Rate |
$131,474.30 |
| Rate for Payer: Aetna Commercial |
$77,846.62
|
| Rate for Payer: Aetna Medicare |
$78,351.27
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$52,234.18
|
| Rate for Payer: Amerigroup Medicare |
$52,234.18
|
| Rate for Payer: BCBS of TX Blue Advantage |
$44,674.42
|
| Rate for Payer: BCBS of TX Blue Essentials |
$60,630.32
|
| Rate for Payer: BCBS of TX Medicare |
$52,234.18
|
| Rate for Payer: BCBS of TX PPO |
$67,369.63
|
| Rate for Payer: Cigna Commercial |
$89,125.74
|
| Rate for Payer: Cigna Medicare |
$52,234.18
|
| Rate for Payer: Employer Direct Commercial |
$52,234.18
|
| Rate for Payer: Humana Medicare/TRICARE |
$52,234.18
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$52,234.18
|
| Rate for Payer: Molina Medicare |
$52,234.18
|
| Rate for Payer: Multiplan Auto |
$131,474.30
|
| Rate for Payer: Multiplan Commercial |
$131,474.30
|
| Rate for Payer: Multiplan Workers Comp |
$131,474.30
|
| Rate for Payer: Scott and White EPO/PPO |
$60,547.38
|
| Rate for Payer: Scott and White Medicare |
$52,234.18
|
| Rate for Payer: Superior Health Plan EPO |
$52,234.18
|
| Rate for Payer: Superior Health Plan Medicare |
$52,234.18
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$52,234.18
|
| Rate for Payer: Universal American Medicare |
$52,234.18
|
| Rate for Payer: Wellcare Medicare |
$52,234.18
|
| Rate for Payer: Wellmed Medicare |
$52,234.18
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC
|
Facility
|
IP
|
$61,094.50
|
|
|
Service Code
|
MSDRG 929
|
| Min. Negotiated Rate |
$22,004.82 |
| Max. Negotiated Rate |
$61,094.50 |
| Rate for Payer: Aetna Commercial |
$36,174.38
|
| Rate for Payer: Aetna Medicare |
$38,701.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$25,800.77
|
| Rate for Payer: Amerigroup Medicare |
$25,800.77
|
| Rate for Payer: BCBS of TX Blue Advantage |
$22,004.82
|
| Rate for Payer: BCBS of TX Blue Essentials |
$30,670.13
|
| Rate for Payer: BCBS of TX Medicare |
$25,800.77
|
| Rate for Payer: BCBS of TX PPO |
$34,079.25
|
| Rate for Payer: Cigna Commercial |
$41,415.64
|
| Rate for Payer: Cigna Medicare |
$25,800.77
|
| Rate for Payer: Employer Direct Commercial |
$25,800.77
|
| Rate for Payer: Humana Medicare/TRICARE |
$25,800.77
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$25,800.77
|
| Rate for Payer: Molina Medicare |
$25,800.77
|
| Rate for Payer: Multiplan Auto |
$61,094.50
|
| Rate for Payer: Multiplan Commercial |
$61,094.50
|
| Rate for Payer: Multiplan Workers Comp |
$61,094.50
|
| Rate for Payer: Scott and White EPO/PPO |
$28,135.62
|
| Rate for Payer: Scott and White Medicare |
$25,800.77
|
| Rate for Payer: Superior Health Plan EPO |
$25,800.77
|
| Rate for Payer: Superior Health Plan Medicare |
$25,800.77
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$25,800.77
|
| Rate for Payer: Universal American Medicare |
$25,800.77
|
| Rate for Payer: Wellcare Medicare |
$25,800.77
|
| Rate for Payer: Wellmed Medicare |
$25,800.77
|
|
|
Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth,
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 15240
|
| Hospital Charge Code |
36015240
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$36.79 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$2,200.00
|
| Rate for Payer: Aetna Medicare |
$2,501.68
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$709.01
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Amerigroup Medicare |
$1,667.79
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,709.98
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,245.48
|
| Rate for Payer: BCBS of TX Medicare |
$1,667.79
|
| Rate for Payer: BCBS of TX PPO |
$4,089.30
|
| Rate for Payer: Cigna Commercial |
$3,778.02
|
| Rate for Payer: Cigna Medicaid |
$709.01
|
| Rate for Payer: Cigna Medicare |
$1,667.79
|
| Rate for Payer: Employer Direct Commercial |
$1,667.79
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,667.79
|
| Rate for Payer: Molina CHIP/Medicaid |
$709.01
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Molina Medicare |
$1,667.79
|
| 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 |
$709.01
|
| Rate for Payer: Scott and White EPO/PPO |
$36.79
|
| Rate for Payer: Scott and White Medicare |
$1,667.79
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$709.01
|
| Rate for Payer: Superior Health Plan EPO |
$1,667.79
|
| Rate for Payer: Superior Health Plan Medicare |
$1,667.79
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Universal American Medicare |
$1,667.79
|
| Rate for Payer: Wellcare Medicare |
$1,667.79
|
| Rate for Payer: Wellmed Medicare |
$1,667.79
|
|
|
Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 15220
|
| Hospital Charge Code |
36015220
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$36.79 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$2,200.00
|
| Rate for Payer: Aetna Medicare |
$2,501.68
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$709.01
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Amerigroup Medicare |
$1,667.79
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,709.98
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,245.48
|
| Rate for Payer: BCBS of TX Medicare |
$1,667.79
|
| Rate for Payer: BCBS of TX PPO |
$4,089.30
|
| Rate for Payer: Cigna Commercial |
$3,778.02
|
| Rate for Payer: Cigna Medicaid |
$709.01
|
| Rate for Payer: Cigna Medicare |
$1,667.79
|
| Rate for Payer: Employer Direct Commercial |
$1,667.79
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,667.79
|
| Rate for Payer: Molina CHIP/Medicaid |
$709.01
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Molina Medicare |
$1,667.79
|
| 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 |
$709.01
|
| Rate for Payer: Scott and White EPO/PPO |
$36.79
|
| Rate for Payer: Scott and White Medicare |
$1,667.79
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$709.01
|
| Rate for Payer: Superior Health Plan EPO |
$1,667.79
|
| Rate for Payer: Superior Health Plan Medicare |
$1,667.79
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Universal American Medicare |
$1,667.79
|
| Rate for Payer: Wellcare Medicare |
$1,667.79
|
| Rate for Payer: Wellmed Medicare |
$1,667.79
|
|
|
Fungal Antibodies, DID SO
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
CPT 86612
|
| Hospital Charge Code |
1705839
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$96.20 |
| Rate for Payer: Aetna Commercial |
$13.54
|
| Rate for Payer: Aetna Medicare |
$19.35
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.03
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12.90
|
| Rate for Payer: Amerigroup Medicare |
$12.90
|
| Rate for Payer: BCBS of TX Blue Advantage |
$21.28
|
| Rate for Payer: BCBS of TX Blue Essentials |
$25.54
|
| Rate for Payer: BCBS of TX Medicare |
$12.90
|
| Rate for Payer: BCBS of TX PPO |
$28.51
|
| Rate for Payer: Cash Price |
$130.24
|
| Rate for Payer: Cash Price |
$130.24
|
| Rate for Payer: Cigna Medicaid |
$12.90
|
| Rate for Payer: Cigna Medicare |
$12.90
|
| Rate for Payer: Employer Direct Commercial |
$12.90
|
| Rate for Payer: Humana Medicare/TRICARE |
$12.90
|
| Rate for Payer: Molina CHIP/Medicaid |
$12.90
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12.90
|
| Rate for Payer: Molina Medicare |
$12.90
|
| Rate for Payer: Multiplan Auto |
$96.20
|
| Rate for Payer: Multiplan Commercial |
$96.20
|
| Rate for Payer: Multiplan Workers Comp |
$96.20
|
| Rate for Payer: Parkland Medicaid |
$12.90
|
| Rate for Payer: Scott and White EPO/PPO |
$16.12
|
| Rate for Payer: Scott and White Medicare |
$12.90
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$12.90
|
| Rate for Payer: Superior Health Plan EPO |
$12.90
|
| Rate for Payer: Superior Health Plan Medicare |
$12.90
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12.90
|
| Rate for Payer: Universal American Medicare |
$12.90
|
| Rate for Payer: Wellcare Medicare |
$12.90
|
| Rate for Payer: Wellmed Medicare |
$12.90
|
|
|
Fungal Antibodies, DID SO
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
CPT 86612
|
| Hospital Charge Code |
1705839
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$130.24
|
|
|
FUNGUS ANTIBODY
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
1709757
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$55.25 |
| Rate for Payer: Aetna Commercial |
$12.86
|
| Rate for Payer: Aetna Medicare |
$18.38
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$4.78
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12.25
|
| Rate for Payer: Amerigroup Medicare |
$12.25
|
| Rate for Payer: BCBS of TX Blue Advantage |
$20.21
|
| Rate for Payer: BCBS of TX Blue Essentials |
$24.26
|
| Rate for Payer: BCBS of TX Medicare |
$12.25
|
| Rate for Payer: BCBS of TX PPO |
$27.07
|
| Rate for Payer: Cash Price |
$74.80
|
| Rate for Payer: Cash Price |
$74.80
|
| Rate for Payer: Cigna Medicaid |
$12.25
|
| Rate for Payer: Cigna Medicare |
$12.25
|
| Rate for Payer: Employer Direct Commercial |
$12.25
|
| Rate for Payer: Humana Medicare/TRICARE |
$12.25
|
| Rate for Payer: Molina CHIP/Medicaid |
$12.25
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12.25
|
| Rate for Payer: Molina Medicare |
$12.25
|
| Rate for Payer: Multiplan Auto |
$55.25
|
| Rate for Payer: Multiplan Commercial |
$55.25
|
| Rate for Payer: Multiplan Workers Comp |
$55.25
|
| Rate for Payer: Parkland Medicaid |
$12.25
|
| Rate for Payer: Scott and White EPO/PPO |
$15.31
|
| Rate for Payer: Scott and White Medicare |
$12.25
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$12.25
|
| Rate for Payer: Superior Health Plan EPO |
$12.25
|
| Rate for Payer: Superior Health Plan Medicare |
$12.25
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12.25
|
| Rate for Payer: Universal American Medicare |
$12.25
|
| Rate for Payer: Wellcare Medicare |
$12.25
|
| Rate for Payer: Wellmed Medicare |
$12.25
|
|
|
Fungus Cult W/Stain SO
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
1604362
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$100.10 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Medicare |
$11.56
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.01
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7.71
|
| Rate for Payer: Amerigroup Medicare |
$7.71
|
| Rate for Payer: BCBS of TX Blue Advantage |
$12.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$15.27
|
| Rate for Payer: BCBS of TX Medicare |
$7.71
|
| Rate for Payer: BCBS of TX PPO |
$17.04
|
| Rate for Payer: Cash Price |
$135.52
|
| Rate for Payer: Cash Price |
$135.52
|
| Rate for Payer: Cigna Medicaid |
$7.71
|
| Rate for Payer: Cigna Medicare |
$7.71
|
| Rate for Payer: Employer Direct Commercial |
$7.71
|
| Rate for Payer: Humana Medicare/TRICARE |
$7.71
|
| Rate for Payer: Molina CHIP/Medicaid |
$7.71
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7.71
|
| Rate for Payer: Molina Medicare |
$7.71
|
| Rate for Payer: Multiplan Auto |
$100.10
|
| Rate for Payer: Multiplan Commercial |
$100.10
|
| Rate for Payer: Multiplan Workers Comp |
$100.10
|
| Rate for Payer: Parkland Medicaid |
$7.71
|
| Rate for Payer: Scott and White EPO/PPO |
$9.64
|
| Rate for Payer: Scott and White Medicare |
$7.71
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$7.71
|
| Rate for Payer: Superior Health Plan EPO |
$7.71
|
| Rate for Payer: Superior Health Plan Medicare |
$7.71
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7.71
|
| Rate for Payer: Universal American Medicare |
$7.71
|
| Rate for Payer: Wellcare Medicare |
$7.71
|
| Rate for Payer: Wellmed Medicare |
$7.71
|
|
|
Fungus Cult W/Stain SO
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
1604362
|
|
Hospital Revenue Code
|
306
|
| Rate for Payer: Cash Price |
$135.52
|
|
|
Fungus (Mycology) Culture SO
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
1604362
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$100.10 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Medicare |
$11.56
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.01
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7.71
|
| Rate for Payer: Amerigroup Medicare |
$7.71
|
| Rate for Payer: BCBS of TX Blue Advantage |
$12.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$15.27
|
| Rate for Payer: BCBS of TX Medicare |
$7.71
|
| Rate for Payer: BCBS of TX PPO |
$17.04
|
| Rate for Payer: Cash Price |
$135.52
|
| Rate for Payer: Cash Price |
$135.52
|
| Rate for Payer: Cigna Medicaid |
$7.71
|
| Rate for Payer: Cigna Medicare |
$7.71
|
| Rate for Payer: Employer Direct Commercial |
$7.71
|
| Rate for Payer: Humana Medicare/TRICARE |
$7.71
|
| Rate for Payer: Molina CHIP/Medicaid |
$7.71
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7.71
|
| Rate for Payer: Molina Medicare |
$7.71
|
| Rate for Payer: Multiplan Auto |
$100.10
|
| Rate for Payer: Multiplan Commercial |
$100.10
|
| Rate for Payer: Multiplan Workers Comp |
$100.10
|
| Rate for Payer: Parkland Medicaid |
$7.71
|
| Rate for Payer: Scott and White EPO/PPO |
$9.64
|
| Rate for Payer: Scott and White Medicare |
$7.71
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$7.71
|
| Rate for Payer: Superior Health Plan EPO |
$7.71
|
| Rate for Payer: Superior Health Plan Medicare |
$7.71
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7.71
|
| Rate for Payer: Universal American Medicare |
$7.71
|
| Rate for Payer: Wellcare Medicare |
$7.71
|
| Rate for Payer: Wellmed Medicare |
$7.71
|
|
|
furosemide 10 mg/mL Inj Soln 10 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
77585132
|
|
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
|
|
|
furosemide 10 mg/mL Inj Soln 10 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
77585132
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$83.31 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$2.52
|
| Rate for Payer: BCBS of TX PPO |
$2.80
|
| 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
|
|
|
furosemide 10 mg/mL Inj Soln 2 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
77585191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$83.31 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$2.52
|
| Rate for Payer: BCBS of TX PPO |
$2.80
|
| 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
|
|
|
furosemide 10 mg/mL Inj Soln 2 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
77585191
|
|
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
|
|
|
furosemide 10 mg/mL Inj Soln 4 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
77585248
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$83.31 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$2.52
|
| Rate for Payer: BCBS of TX PPO |
$2.80
|
| 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
|
|
|
furosemide 10 mg/mL Inj Soln 4 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
77585248
|
|
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
|
|
|
furosemide 20 mg Tab
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77585407
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
furosemide 20 mg Tab
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77585407
|
|
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
|
|
|
furosemide 40 mg Tab
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77585462
|
|
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
|
|
|
furosemide 40 mg Tab
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77585462
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
Fusion/Graft of Finger Joint
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 26862
|
| Hospital Charge Code |
36026862
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$65.29 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$4,635.00
|
| 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
|
|
|
G-6-PD, Quant, Blood and RBC SO
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 82955
|
| Hospital Charge Code |
1701390
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.78 |
| Max. Negotiated Rate |
$44.85 |
| Rate for Payer: Aetna Commercial |
$10.18
|
| Rate for Payer: Aetna Medicare |
$14.55
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.78
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$9.70
|
| Rate for Payer: Amerigroup Medicare |
$9.70
|
| Rate for Payer: BCBS of TX Blue Advantage |
$16.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$19.21
|
| Rate for Payer: BCBS of TX Medicare |
$9.70
|
| Rate for Payer: BCBS of TX PPO |
$21.44
|
| Rate for Payer: Cash Price |
$60.72
|
| Rate for Payer: Cash Price |
$60.72
|
| Rate for Payer: Cigna Medicaid |
$9.70
|
| Rate for Payer: Cigna Medicare |
$9.70
|
| Rate for Payer: Employer Direct Commercial |
$9.70
|
| Rate for Payer: Humana Medicare/TRICARE |
$9.70
|
| Rate for Payer: Molina CHIP/Medicaid |
$9.70
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$9.70
|
| Rate for Payer: Molina Medicare |
$9.70
|
| Rate for Payer: Multiplan Auto |
$44.85
|
| Rate for Payer: Multiplan Commercial |
$44.85
|
| Rate for Payer: Multiplan Workers Comp |
$44.85
|
| Rate for Payer: Parkland Medicaid |
$9.70
|
| Rate for Payer: Scott and White EPO/PPO |
$12.12
|
| Rate for Payer: Scott and White Medicare |
$9.70
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$9.70
|
| Rate for Payer: Superior Health Plan EPO |
$9.70
|
| Rate for Payer: Superior Health Plan Medicare |
$9.70
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$9.70
|
| Rate for Payer: Universal American Medicare |
$9.70
|
| Rate for Payer: Wellcare Medicare |
$9.70
|
| Rate for Payer: Wellmed Medicare |
$9.70
|
|
|
G-6-PD, Quant, Blood and RBC SO
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 82955
|
| Hospital Charge Code |
1701390
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$60.72
|
|
