|
HSV Culture Without Typing SO
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 87255
|
| Hospital Charge Code |
1740928
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$13.21 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$35.56
|
| Rate for Payer: Aetna Medicare |
$50.79
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$13.21
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$33.86
|
| Rate for Payer: Amerigroup Medicare |
$33.86
|
| Rate for Payer: BCBS of TX Blue Advantage |
$55.87
|
| Rate for Payer: BCBS of TX Blue Essentials |
$67.04
|
| Rate for Payer: BCBS of TX Medicare |
$33.86
|
| Rate for Payer: BCBS of TX PPO |
$74.83
|
| Rate for Payer: Cash Price |
$105.60
|
| Rate for Payer: Cash Price |
$105.60
|
| Rate for Payer: Cigna Medicaid |
$33.86
|
| Rate for Payer: Cigna Medicare |
$33.86
|
| Rate for Payer: Employer Direct Commercial |
$33.86
|
| Rate for Payer: Humana Medicare/TRICARE |
$33.86
|
| Rate for Payer: Molina CHIP/Medicaid |
$33.86
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$33.86
|
| Rate for Payer: Molina Medicare |
$33.86
|
| Rate for Payer: Multiplan Auto |
$78.00
|
| Rate for Payer: Multiplan Commercial |
$78.00
|
| Rate for Payer: Multiplan Workers Comp |
$78.00
|
| Rate for Payer: Parkland Medicaid |
$33.86
|
| Rate for Payer: Scott and White EPO/PPO |
$42.32
|
| Rate for Payer: Scott and White Medicare |
$33.86
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$33.86
|
| Rate for Payer: Superior Health Plan EPO |
$33.86
|
| Rate for Payer: Superior Health Plan Medicare |
$33.86
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$33.86
|
| Rate for Payer: Universal American Medicare |
$33.86
|
| Rate for Payer: Wellcare Medicare |
$33.86
|
| Rate for Payer: Wellmed Medicare |
$33.86
|
|
|
HSV, IgM I/II Combination SO
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
CPT 86694
|
| Hospital Charge Code |
1702943
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$31.80 |
| Rate for Payer: Aetna Commercial |
$15.10
|
| Rate for Payer: Aetna Medicare |
$21.58
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.61
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14.39
|
| Rate for Payer: Amerigroup Medicare |
$14.39
|
| Rate for Payer: BCBS of TX Blue Advantage |
$23.74
|
| Rate for Payer: BCBS of TX Blue Essentials |
$28.49
|
| Rate for Payer: BCBS of TX Medicare |
$14.39
|
| Rate for Payer: BCBS of TX PPO |
$31.80
|
| Rate for Payer: Cash Price |
$32.56
|
| Rate for Payer: Cash Price |
$32.56
|
| Rate for Payer: Cigna Medicaid |
$14.39
|
| Rate for Payer: Cigna Medicare |
$14.39
|
| Rate for Payer: Employer Direct Commercial |
$14.39
|
| Rate for Payer: Humana Medicare/TRICARE |
$14.39
|
| Rate for Payer: Molina CHIP/Medicaid |
$14.39
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14.39
|
| Rate for Payer: Molina Medicare |
$14.39
|
| Rate for Payer: Multiplan Auto |
$24.05
|
| Rate for Payer: Multiplan Commercial |
$24.05
|
| Rate for Payer: Multiplan Workers Comp |
$24.05
|
| Rate for Payer: Parkland Medicaid |
$14.39
|
| Rate for Payer: Scott and White EPO/PPO |
$17.99
|
| Rate for Payer: Scott and White Medicare |
$14.39
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$14.39
|
| Rate for Payer: Superior Health Plan EPO |
$14.39
|
| Rate for Payer: Superior Health Plan Medicare |
$14.39
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14.39
|
| Rate for Payer: Universal American Medicare |
$14.39
|
| Rate for Payer: Wellcare Medicare |
$14.39
|
| Rate for Payer: Wellmed Medicare |
$14.39
|
|
|
HTLV-I/II Antibodies, Qual. SO
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 86790
|
| Hospital Charge Code |
1703651
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.02 |
| Max. Negotiated Rate |
$105.95 |
| Rate for Payer: Aetna Commercial |
$13.53
|
| Rate for Payer: Aetna Medicare |
$19.32
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.02
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12.88
|
| Rate for Payer: Amerigroup Medicare |
$12.88
|
| Rate for Payer: BCBS of TX Blue Advantage |
$21.25
|
| Rate for Payer: BCBS of TX Blue Essentials |
$25.50
|
| Rate for Payer: BCBS of TX Medicare |
$12.88
|
| Rate for Payer: BCBS of TX PPO |
$28.46
|
| Rate for Payer: Cash Price |
$143.44
|
| Rate for Payer: Cash Price |
$143.44
|
| Rate for Payer: Cigna Medicaid |
$12.88
|
| Rate for Payer: Cigna Medicare |
$12.88
|
| Rate for Payer: Employer Direct Commercial |
$12.88
|
| Rate for Payer: Humana Medicare/TRICARE |
$12.88
|
| Rate for Payer: Molina CHIP/Medicaid |
$12.88
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12.88
|
| Rate for Payer: Molina Medicare |
$12.88
|
| Rate for Payer: Multiplan Auto |
$105.95
|
| Rate for Payer: Multiplan Commercial |
$105.95
|
| Rate for Payer: Multiplan Workers Comp |
$105.95
|
| Rate for Payer: Parkland Medicaid |
$12.88
|
| Rate for Payer: Scott and White EPO/PPO |
$16.10
|
| Rate for Payer: Scott and White Medicare |
$12.88
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$12.88
|
| Rate for Payer: Superior Health Plan EPO |
$12.88
|
| Rate for Payer: Superior Health Plan Medicare |
$12.88
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12.88
|
| Rate for Payer: Universal American Medicare |
$12.88
|
| Rate for Payer: Wellcare Medicare |
$12.88
|
| Rate for Payer: Wellmed Medicare |
$12.88
|
|
|
.HTLV-I/II Immunoblot 164133 SO
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
CPT 86688
|
| Hospital Charge Code |
1700036
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$84.48
|
|
|
.HTLV-I/II Immunoblot 164133 SO
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
CPT 86688
|
| Hospital Charge Code |
1700036
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$14.70
|
| Rate for Payer: Aetna Medicare |
$21.00
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.46
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14.00
|
| Rate for Payer: Amerigroup Medicare |
$14.00
|
| Rate for Payer: BCBS of TX Blue Advantage |
$23.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$27.72
|
| Rate for Payer: BCBS of TX Medicare |
$14.00
|
| Rate for Payer: BCBS of TX PPO |
$30.94
|
| Rate for Payer: Cash Price |
$84.48
|
| Rate for Payer: Cash Price |
$84.48
|
| Rate for Payer: Cigna Medicaid |
$14.00
|
| Rate for Payer: Cigna Medicare |
$14.00
|
| Rate for Payer: Employer Direct Commercial |
$14.00
|
| Rate for Payer: Humana Medicare/TRICARE |
$14.00
|
| Rate for Payer: Molina CHIP/Medicaid |
$14.00
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14.00
|
| Rate for Payer: Molina Medicare |
$14.00
|
| Rate for Payer: Multiplan Auto |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: Multiplan Workers Comp |
$62.40
|
| Rate for Payer: Parkland Medicaid |
$14.00
|
| Rate for Payer: Scott and White EPO/PPO |
$17.50
|
| Rate for Payer: Scott and White Medicare |
$14.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$14.00
|
| Rate for Payer: Superior Health Plan EPO |
$14.00
|
| Rate for Payer: Superior Health Plan Medicare |
$14.00
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14.00
|
| Rate for Payer: Universal American Medicare |
$14.00
|
| Rate for Payer: Wellcare Medicare |
$14.00
|
| Rate for Payer: Wellmed Medicare |
$14.00
|
|
|
HUMAN DONOR MILK HDM PLUS
|
Facility
|
IP
|
$118.04
|
|
| Hospital Charge Code |
8484495
|
|
Hospital Revenue Code
|
271
|
| Rate for Payer: Cash Price |
$103.88
|
|
|
HUMAN DONOR MILK HDM PLUS
|
Facility
|
OP
|
$118.04
|
|
| Hospital Charge Code |
8484495
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$10.62 |
| Max. Negotiated Rate |
$76.73 |
| Rate for Payer: Aetna Commercial |
$64.92
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$10.62
|
| Rate for Payer: BCBS of TX Blue Advantage |
$35.41
|
| Rate for Payer: BCBS of TX Blue Essentials |
$42.49
|
| Rate for Payer: BCBS of TX PPO |
$47.22
|
| Rate for Payer: Cash Price |
$103.88
|
| Rate for Payer: Multiplan Auto |
$76.73
|
| Rate for Payer: Multiplan Commercial |
$76.73
|
| Rate for Payer: Multiplan Workers Comp |
$76.73
|
| Rate for Payer: Scott and White EPO/PPO |
$59.02
|
| Rate for Payer: Superior Health Plan EPO |
$16.05
|
|
|
Hyaluronan or derivative, HYMOVIS, for intra-articular injection, 1 mg
|
Facility
|
IP
|
$87.09
|
|
|
Service Code
|
HCPCS J7322
|
| Hospital Charge Code |
9900920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.77 |
| Max. Negotiated Rate |
$43.54 |
| Rate for Payer: Cash Price |
$59.22
|
| Rate for Payer: Cigna Commercial |
$21.77
|
| Rate for Payer: Scott and White EPO/PPO |
$43.54
|
|
|
Hyaluronan or derivative, HYMOVIS, for intra-articular injection, 1 mg
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT J7322
|
| Hospital Charge Code |
360J7322
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$17.26 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Medicare |
$25.90
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$17.26
|
| Rate for Payer: Amerigroup Medicare |
$17.26
|
| Rate for Payer: BCBS of TX Medicare |
$17.26
|
| Rate for Payer: Cigna Medicare |
$17.26
|
| Rate for Payer: Employer Direct Commercial |
$17.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$17.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$17.26
|
| Rate for Payer: Molina Medicare |
$17.26
|
| 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: Scott and White Medicare |
$17.26
|
| Rate for Payer: Superior Health Plan EPO |
$17.26
|
| Rate for Payer: Superior Health Plan Medicare |
$17.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$17.26
|
| Rate for Payer: Universal American Medicare |
$17.26
|
| Rate for Payer: Wellcare Medicare |
$17.26
|
| Rate for Payer: Wellmed Medicare |
$17.26
|
|
|
Hyaluronan or derivative, HYMOVIS, for intra-articular injection, 1 mg
|
Facility
|
OP
|
$87.09
|
|
|
Service Code
|
HCPCS J7322
|
| Hospital Charge Code |
9900920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$56.61 |
| Rate for Payer: Aetna Medicare |
$25.90
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7.84
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$17.26
|
| Rate for Payer: Amerigroup Medicare |
$17.26
|
| Rate for Payer: BCBS of TX Blue Advantage |
$20.79
|
| Rate for Payer: BCBS of TX Blue Essentials |
$24.95
|
| Rate for Payer: BCBS of TX Medicare |
$17.26
|
| Rate for Payer: BCBS of TX PPO |
$27.68
|
| Rate for Payer: Cash Price |
$59.22
|
| Rate for Payer: Cash Price |
$59.22
|
| Rate for Payer: Cigna Medicare |
$17.26
|
| Rate for Payer: Employer Direct Commercial |
$17.26
|
| Rate for Payer: Humana Medicare/TRICARE |
$17.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$17.26
|
| Rate for Payer: Molina Medicare |
$17.26
|
| Rate for Payer: Multiplan Auto |
$56.61
|
| Rate for Payer: Multiplan Commercial |
$56.61
|
| Rate for Payer: Multiplan Workers Comp |
$56.61
|
| Rate for Payer: Scott and White EPO/PPO |
$43.54
|
| Rate for Payer: Scott and White Medicare |
$17.26
|
| Rate for Payer: Superior Health Plan EPO |
$17.26
|
| Rate for Payer: Superior Health Plan Medicare |
$17.26
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$17.26
|
| Rate for Payer: Universal American Medicare |
$17.26
|
| Rate for Payer: Wellcare Medicare |
$17.26
|
| Rate for Payer: Wellmed Medicare |
$17.26
|
|
|
Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
|
Facility
|
OP
|
$353.12
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
9900921
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.78 |
| Max. Negotiated Rate |
$287.20 |
| Rate for Payer: Aetna Medicare |
$195.96
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$31.78
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$130.64
|
| Rate for Payer: Amerigroup Medicare |
$130.64
|
| Rate for Payer: BCBS of TX Blue Advantage |
$215.77
|
| Rate for Payer: BCBS of TX Blue Essentials |
$258.93
|
| Rate for Payer: BCBS of TX Medicare |
$130.64
|
| Rate for Payer: BCBS of TX PPO |
$287.20
|
| Rate for Payer: Cash Price |
$240.12
|
| Rate for Payer: Cash Price |
$240.12
|
| Rate for Payer: Cigna Medicare |
$130.64
|
| Rate for Payer: Employer Direct Commercial |
$130.64
|
| Rate for Payer: Humana Medicare/TRICARE |
$130.64
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$130.64
|
| Rate for Payer: Molina Medicare |
$130.64
|
| Rate for Payer: Multiplan Auto |
$229.53
|
| Rate for Payer: Multiplan Commercial |
$229.53
|
| Rate for Payer: Multiplan Workers Comp |
$229.53
|
| Rate for Payer: Scott and White EPO/PPO |
$176.56
|
| Rate for Payer: Scott and White Medicare |
$130.64
|
| Rate for Payer: Superior Health Plan EPO |
$130.64
|
| Rate for Payer: Superior Health Plan Medicare |
$130.64
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$130.64
|
| Rate for Payer: Universal American Medicare |
$130.64
|
| Rate for Payer: Wellcare Medicare |
$130.64
|
| Rate for Payer: Wellmed Medicare |
$130.64
|
|
|
Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT J7324
|
| Hospital Charge Code |
360J7324
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$130.64 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Medicare |
$195.96
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$130.64
|
| Rate for Payer: Amerigroup Medicare |
$130.64
|
| Rate for Payer: BCBS of TX Medicare |
$130.64
|
| Rate for Payer: Cigna Medicare |
$130.64
|
| Rate for Payer: Employer Direct Commercial |
$130.64
|
| Rate for Payer: Humana Medicare/TRICARE |
$130.64
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$130.64
|
| Rate for Payer: Molina Medicare |
$130.64
|
| 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: Scott and White Medicare |
$130.64
|
| Rate for Payer: Superior Health Plan EPO |
$130.64
|
| Rate for Payer: Superior Health Plan Medicare |
$130.64
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$130.64
|
| Rate for Payer: Universal American Medicare |
$130.64
|
| Rate for Payer: Wellcare Medicare |
$130.64
|
| Rate for Payer: Wellmed Medicare |
$130.64
|
|
|
Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
|
Facility
|
IP
|
$353.12
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
9900921
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.28 |
| Max. Negotiated Rate |
$176.56 |
| Rate for Payer: Cash Price |
$240.12
|
| Rate for Payer: Cigna Commercial |
$88.28
|
| Rate for Payer: Scott and White EPO/PPO |
$176.56
|
|
|
hydrALAZINE 10 mg Tab
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77607802
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.84
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.79
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3.35
|
| Rate for Payer: BCBS of TX PPO |
$3.72
|
| Rate for Payer: Cash Price |
$6.32
|
| Rate for Payer: Multiplan Auto |
$6.04
|
| Rate for Payer: Multiplan Commercial |
$6.04
|
| Rate for Payer: Multiplan Workers Comp |
$6.04
|
| Rate for Payer: Scott and White EPO/PPO |
$4.65
|
| Rate for Payer: Superior Health Plan EPO |
$1.26
|
|
|
hydrALAZINE 10 mg Tab
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77607802
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$6.32
|
|
|
hydrALAZINE 20 mg/mL Inj Soln 1 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
77607908
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.40 |
| Max. Negotiated Rate |
$83.31 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11.28
|
| Rate for Payer: BCBS of TX PPO |
$12.51
|
| 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
|
|
|
hydrALAZINE 20 mg/mL Inj Soln 1 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
77607908
|
|
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
|
|
|
hydrALAZINE 25 mg Tab
|
Facility
|
IP
|
$8.85
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77607965
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$6.02
|
|
|
hydrALAZINE 25 mg Tab
|
Facility
|
OP
|
$8.85
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77607965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$5.75 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.80
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.66
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3.19
|
| Rate for Payer: BCBS of TX PPO |
$3.54
|
| Rate for Payer: Cash Price |
$6.02
|
| Rate for Payer: Multiplan Auto |
$5.75
|
| Rate for Payer: Multiplan Commercial |
$5.75
|
| Rate for Payer: Multiplan Workers Comp |
$5.75
|
| Rate for Payer: Scott and White EPO/PPO |
$4.42
|
| Rate for Payer: Superior Health Plan EPO |
$1.20
|
|
|
HYDRATOME RX 44 SPHINCTEROTOME
|
Facility
|
OP
|
$177.06
|
|
| Hospital Charge Code |
144810
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.94 |
| Max. Negotiated Rate |
$115.09 |
| Rate for Payer: Aetna Commercial |
$97.38
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$15.94
|
| Rate for Payer: BCBS of TX Blue Advantage |
$53.12
|
| Rate for Payer: BCBS of TX Blue Essentials |
$63.74
|
| Rate for Payer: BCBS of TX PPO |
$70.82
|
| Rate for Payer: Cash Price |
$155.81
|
| Rate for Payer: Multiplan Auto |
$115.09
|
| Rate for Payer: Multiplan Commercial |
$115.09
|
| Rate for Payer: Multiplan Workers Comp |
$115.09
|
| Rate for Payer: Scott and White EPO/PPO |
$88.53
|
| Rate for Payer: Superior Health Plan EPO |
$24.08
|
|
|
HYDRATOME RX 44 SPHINCTEROTOME
|
Facility
|
IP
|
$177.06
|
|
| Hospital Charge Code |
144810
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$155.81
|
|
|
hydroCHLOROthiazide 25 mg Tab
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77608222
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
hydroCHLOROthiazide 25 mg Tab
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77608222
|
|
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
|
|
|
HYDROcodone-acetaminophen 7.5 mg 15 ml solution
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78432557
|
|
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
|
|
|
HYDROcodone-acetaminophen 7.5 mg 15 ml solution
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78432557
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
