|
Drug test(s)(1) drug per day; 1-7 drug class(es)
|
Facility
|
OP
|
$457.72
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
991141
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$329.56 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$31.98
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$114.43
|
| Rate for Payer: Amerigroup Medicare |
$114.43
|
| Rate for Payer: BCBS of TX Blue Advantage |
$137.32
|
| Rate for Payer: BCBS of TX Blue Essentials |
$164.78
|
| Rate for Payer: BCBS of TX Medicare |
$114.43
|
| Rate for Payer: BCBS of TX PPO |
$183.09
|
| Rate for Payer: Cash Price |
$311.25
|
| Rate for Payer: Cash Price |
$311.25
|
| Rate for Payer: Cigna Medicaid |
$329.56
|
| Rate for Payer: Cigna Medicare |
$114.43
|
| Rate for Payer: Employer Direct Commercial |
$114.43
|
| Rate for Payer: Humana Medicare/TRICARE |
$114.43
|
| Rate for Payer: Molina CHIP/Medicaid |
$329.56
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$114.43
|
| Rate for Payer: Molina Medicare |
$114.43
|
| Rate for Payer: Multiplan Auto |
$297.52
|
| Rate for Payer: Multiplan Commercial |
$297.52
|
| Rate for Payer: Multiplan Workers Comp |
$297.52
|
| Rate for Payer: Parkland Medicaid |
$329.56
|
| Rate for Payer: Scott and White EPO/PPO |
$143.04
|
| Rate for Payer: Scott and White Medicare |
$114.43
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$329.56
|
| Rate for Payer: Superior Health Plan EPO |
$114.43
|
| Rate for Payer: Superior Health Plan Medicare |
$114.43
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$114.43
|
| Rate for Payer: Universal American Medicare |
$114.43
|
| Rate for Payer: Wellcare Medicare |
$114.43
|
| Rate for Payer: Wellmed Medicare |
$114.43
|
|
|
Drug test(s)(1) drug per day; 1-7 drug class(es)
|
Facility
|
IP
|
$457.72
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
991141
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$311.25
|
|
|
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish, per day; 15-21 drug class(es), including metabolite(s) if performed
|
Facility
|
IP
|
$794.96
|
|
|
Service Code
|
HCPCS G0482
|
| Hospital Charge Code |
991143
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$540.57
|
|
|
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish, per day; 15-21 drug class(es), including metabolite(s) if performed
|
Facility
|
OP
|
$794.96
|
|
|
Service Code
|
HCPCS G0482
|
| Hospital Charge Code |
991143
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$572.37 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$31.98
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$198.74
|
| Rate for Payer: Amerigroup Medicare |
$198.74
|
| Rate for Payer: BCBS of TX Blue Advantage |
$238.49
|
| Rate for Payer: BCBS of TX Blue Essentials |
$286.19
|
| Rate for Payer: BCBS of TX Medicare |
$198.74
|
| Rate for Payer: BCBS of TX PPO |
$317.98
|
| Rate for Payer: Cash Price |
$540.57
|
| Rate for Payer: Cash Price |
$540.57
|
| Rate for Payer: Cigna Medicaid |
$572.37
|
| Rate for Payer: Cigna Medicare |
$198.74
|
| Rate for Payer: Employer Direct Commercial |
$198.74
|
| Rate for Payer: Humana Medicare/TRICARE |
$198.74
|
| Rate for Payer: Molina CHIP/Medicaid |
$572.37
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$198.74
|
| Rate for Payer: Molina Medicare |
$198.74
|
| Rate for Payer: Multiplan Auto |
$516.72
|
| Rate for Payer: Multiplan Commercial |
$516.72
|
| Rate for Payer: Multiplan Workers Comp |
$516.72
|
| Rate for Payer: Parkland Medicaid |
$572.37
|
| Rate for Payer: Scott and White EPO/PPO |
$248.43
|
| Rate for Payer: Scott and White Medicare |
$198.74
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$572.37
|
| Rate for Payer: Superior Health Plan EPO |
$198.74
|
| Rate for Payer: Superior Health Plan Medicare |
$198.74
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$198.74
|
| Rate for Payer: Universal American Medicare |
$198.74
|
| Rate for Payer: Wellcare Medicare |
$198.74
|
| Rate for Payer: Wellmed Medicare |
$198.74
|
|
|
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish, per day; 22+ drug class(es), including metabolite(s) if performed
|
Facility
|
IP
|
$987.68
|
|
|
Service Code
|
HCPCS G0483
|
| Hospital Charge Code |
991144
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$671.62
|
|
|
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish, per day; 22+ drug class(es), including metabolite(s) if performed
|
Facility
|
OP
|
$987.68
|
|
|
Service Code
|
HCPCS G0483
|
| Hospital Charge Code |
991144
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$711.13 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$31.98
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$246.92
|
| Rate for Payer: Amerigroup Medicare |
$246.92
|
| Rate for Payer: BCBS of TX Blue Advantage |
$296.30
|
| Rate for Payer: BCBS of TX Blue Essentials |
$355.56
|
| Rate for Payer: BCBS of TX Medicare |
$246.92
|
| Rate for Payer: BCBS of TX PPO |
$395.07
|
| Rate for Payer: Cash Price |
$671.62
|
| Rate for Payer: Cash Price |
$671.62
|
| Rate for Payer: Cigna Medicaid |
$711.13
|
| Rate for Payer: Cigna Medicare |
$246.92
|
| Rate for Payer: Employer Direct Commercial |
$246.92
|
| Rate for Payer: Humana Medicare/TRICARE |
$246.92
|
| Rate for Payer: Molina CHIP/Medicaid |
$711.13
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$246.92
|
| Rate for Payer: Molina Medicare |
$246.92
|
| Rate for Payer: Multiplan Auto |
$641.99
|
| Rate for Payer: Multiplan Commercial |
$641.99
|
| Rate for Payer: Multiplan Workers Comp |
$641.99
|
| Rate for Payer: Parkland Medicaid |
$711.13
|
| Rate for Payer: Scott and White EPO/PPO |
$308.65
|
| Rate for Payer: Scott and White Medicare |
$246.92
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$711.13
|
| Rate for Payer: Superior Health Plan EPO |
$246.92
|
| Rate for Payer: Superior Health Plan Medicare |
$246.92
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$246.92
|
| Rate for Payer: Universal American Medicare |
$246.92
|
| Rate for Payer: Wellcare Medicare |
$246.92
|
| Rate for Payer: Wellmed Medicare |
$246.92
|
|
|
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish per day; 8-14 drug class(es), including metabolite(s) if performed
|
Facility
|
IP
|
$626.36
|
|
|
Service Code
|
HCPCS G0481
|
| Hospital Charge Code |
991142
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$425.92
|
|
|
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish per day; 8-14 drug class(es), including metabolite(s) if performed
|
Facility
|
OP
|
$626.36
|
|
|
Service Code
|
HCPCS G0481
|
| Hospital Charge Code |
991142
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$450.98 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$31.98
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$156.59
|
| Rate for Payer: Amerigroup Medicare |
$156.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$187.91
|
| Rate for Payer: BCBS of TX Blue Essentials |
$225.49
|
| Rate for Payer: BCBS of TX Medicare |
$156.59
|
| Rate for Payer: BCBS of TX PPO |
$250.54
|
| Rate for Payer: Cash Price |
$425.92
|
| Rate for Payer: Cash Price |
$425.92
|
| Rate for Payer: Cigna Medicaid |
$450.98
|
| Rate for Payer: Cigna Medicare |
$156.59
|
| Rate for Payer: Employer Direct Commercial |
$156.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$156.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$450.98
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$156.59
|
| Rate for Payer: Molina Medicare |
$156.59
|
| Rate for Payer: Multiplan Auto |
$407.13
|
| Rate for Payer: Multiplan Commercial |
$407.13
|
| Rate for Payer: Multiplan Workers Comp |
$407.13
|
| Rate for Payer: Parkland Medicaid |
$450.98
|
| Rate for Payer: Scott and White EPO/PPO |
$195.74
|
| Rate for Payer: Scott and White Medicare |
$156.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$450.98
|
| Rate for Payer: Superior Health Plan EPO |
$156.59
|
| Rate for Payer: Superior Health Plan Medicare |
$156.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$156.59
|
| Rate for Payer: Universal American Medicare |
$156.59
|
| Rate for Payer: Wellcare Medicare |
$156.59
|
| Rate for Payer: Wellmed Medicare |
$156.59
|
|
|
Drug test(s), presumptive, any number of drug classes, any number of dev
|
Facility
|
OP
|
$317.00
|
|
|
Service Code
|
HCPCS 80305
|
| Hospital Charge Code |
994046
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$228.24 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$4.91
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12.60
|
| Rate for Payer: Amerigroup Medicare |
$12.60
|
| Rate for Payer: BCBS of TX Blue Advantage |
$95.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$114.12
|
| Rate for Payer: BCBS of TX Medicare |
$12.60
|
| Rate for Payer: BCBS of TX PPO |
$126.80
|
| Rate for Payer: Cash Price |
$215.56
|
| Rate for Payer: Cash Price |
$215.56
|
| Rate for Payer: Cigna Medicaid |
$228.24
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Employer Direct Commercial |
$12.60
|
| Rate for Payer: Humana Medicare/TRICARE |
$12.60
|
| Rate for Payer: Molina CHIP/Medicaid |
$228.24
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12.60
|
| Rate for Payer: Molina Medicare |
$12.60
|
| Rate for Payer: Multiplan Auto |
$206.05
|
| Rate for Payer: Multiplan Commercial |
$206.05
|
| Rate for Payer: Multiplan Workers Comp |
$206.05
|
| Rate for Payer: Parkland Medicaid |
$228.24
|
| Rate for Payer: Scott and White EPO/PPO |
$15.75
|
| Rate for Payer: Scott and White Medicare |
$12.60
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$228.24
|
| Rate for Payer: Superior Health Plan EPO |
$12.60
|
| Rate for Payer: Superior Health Plan Medicare |
$12.60
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12.60
|
| Rate for Payer: Universal American Medicare |
$12.60
|
| Rate for Payer: Wellcare Medicare |
$12.60
|
| Rate for Payer: Wellmed Medicare |
$12.60
|
|
|
Drug test(s), presumptive, any number of drug classes, any number of dev
|
Facility
|
IP
|
$317.00
|
|
|
Service Code
|
HCPCS 80305
|
| Hospital Charge Code |
994046
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$215.56
|
|
|
DRY DOC CANNULA
|
Facility
|
OP
|
$124.76
|
|
| Hospital Charge Code |
992642
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$89.83 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.23
|
| Rate for Payer: BCBS of TX Blue Advantage |
$37.43
|
| Rate for Payer: BCBS of TX Blue Essentials |
$44.91
|
| Rate for Payer: BCBS of TX PPO |
$49.90
|
| Rate for Payer: Cash Price |
$84.84
|
| Rate for Payer: Cigna Medicaid |
$89.83
|
| Rate for Payer: Molina CHIP/Medicaid |
$89.83
|
| Rate for Payer: Multiplan Auto |
$81.09
|
| Rate for Payer: Multiplan Commercial |
$81.09
|
| Rate for Payer: Multiplan Workers Comp |
$81.09
|
| Rate for Payer: Parkland Medicaid |
$89.83
|
| Rate for Payer: Scott and White EPO/PPO |
$62.38
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$89.83
|
| Rate for Payer: Superior Health Plan EPO |
$16.97
|
|
|
DRY DOC CANNULA
|
Facility
|
IP
|
$124.76
|
|
| Hospital Charge Code |
992642
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$84.84
|
|
|
DS003280
|
Facility
|
IP
|
$3,987.67
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
994017
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$996.92 |
| Max. Negotiated Rate |
$1,993.84 |
| Rate for Payer: Cash Price |
$2,711.62
|
| Rate for Payer: Cigna Commercial |
$996.92
|
| Rate for Payer: Multiplan Auto |
$1,993.84
|
| Rate for Payer: Multiplan Commercial |
$1,993.84
|
| Rate for Payer: Multiplan Workers Comp |
$1,993.84
|
| Rate for Payer: Scott and White EPO/PPO |
$1,993.84
|
|
|
DS003280
|
Facility
|
OP
|
$3,987.67
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
994017
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$358.89 |
| Max. Negotiated Rate |
$2,871.12 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$358.89
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,196.30
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,435.56
|
| Rate for Payer: BCBS of TX PPO |
$1,595.07
|
| Rate for Payer: Cash Price |
$2,711.62
|
| Rate for Payer: Cigna Medicaid |
$2,871.12
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,871.12
|
| Rate for Payer: Multiplan Auto |
$1,993.84
|
| Rate for Payer: Multiplan Commercial |
$1,993.84
|
| Rate for Payer: Multiplan Workers Comp |
$1,993.84
|
| Rate for Payer: Parkland Medicaid |
$2,871.12
|
| Rate for Payer: Scott and White EPO/PPO |
$1,993.84
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,871.12
|
| Rate for Payer: Superior Health Plan EPO |
$542.32
|
|
|
DSDS0022
|
Facility
|
OP
|
$1,536.14
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
991173
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$1,106.02 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$138.25
|
| Rate for Payer: BCBS of TX Blue Advantage |
$460.84
|
| Rate for Payer: BCBS of TX Blue Essentials |
$553.01
|
| Rate for Payer: BCBS of TX PPO |
$614.46
|
| Rate for Payer: Cash Price |
$1,044.58
|
| Rate for Payer: Cigna Medicaid |
$1,106.02
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,106.02
|
| Rate for Payer: Multiplan Auto |
$768.07
|
| Rate for Payer: Multiplan Commercial |
$768.07
|
| Rate for Payer: Multiplan Workers Comp |
$768.07
|
| Rate for Payer: Parkland Medicaid |
$1,106.02
|
| Rate for Payer: Scott and White EPO/PPO |
$768.07
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,106.02
|
| Rate for Payer: Superior Health Plan EPO |
$208.92
|
|
|
DSDS0022
|
Facility
|
IP
|
$1,536.14
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
991173
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$384.04 |
| Max. Negotiated Rate |
$768.07 |
| Rate for Payer: Cash Price |
$1,044.58
|
| Rate for Payer: Cigna Commercial |
$384.04
|
| Rate for Payer: Multiplan Auto |
$768.07
|
| Rate for Payer: Multiplan Commercial |
$768.07
|
| Rate for Payer: Multiplan Workers Comp |
$768.07
|
| Rate for Payer: Scott and White EPO/PPO |
$768.07
|
|
|
DSDS1009
|
Facility
|
IP
|
$222.90
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
991161
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$151.57
|
|
|
DSDS1009
|
Facility
|
OP
|
$222.90
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
991161
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.06 |
| Max. Negotiated Rate |
$160.49 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$20.06
|
| Rate for Payer: BCBS of TX Blue Advantage |
$66.87
|
| Rate for Payer: BCBS of TX Blue Essentials |
$80.24
|
| Rate for Payer: BCBS of TX PPO |
$89.16
|
| Rate for Payer: Cash Price |
$151.57
|
| Rate for Payer: Cigna Medicaid |
$160.49
|
| Rate for Payer: Molina CHIP/Medicaid |
$160.49
|
| Rate for Payer: Multiplan Auto |
$144.88
|
| Rate for Payer: Multiplan Commercial |
$144.88
|
| Rate for Payer: Multiplan Workers Comp |
$144.88
|
| Rate for Payer: Parkland Medicaid |
$160.49
|
| Rate for Payer: Scott and White EPO/PPO |
$111.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$160.49
|
| Rate for Payer: Superior Health Plan EPO |
$30.31
|
|
|
DSDS1050
|
Facility
|
OP
|
$1,168.67
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
991174
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.18 |
| Max. Negotiated Rate |
$841.44 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$105.18
|
| Rate for Payer: BCBS of TX Blue Advantage |
$350.60
|
| Rate for Payer: BCBS of TX Blue Essentials |
$420.72
|
| Rate for Payer: BCBS of TX PPO |
$467.47
|
| Rate for Payer: Cash Price |
$794.70
|
| Rate for Payer: Cigna Medicaid |
$841.44
|
| Rate for Payer: Molina CHIP/Medicaid |
$841.44
|
| Rate for Payer: Multiplan Auto |
$584.34
|
| Rate for Payer: Multiplan Commercial |
$584.34
|
| Rate for Payer: Multiplan Workers Comp |
$584.34
|
| Rate for Payer: Parkland Medicaid |
$841.44
|
| Rate for Payer: Scott and White EPO/PPO |
$584.34
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$841.44
|
| Rate for Payer: Superior Health Plan EPO |
$158.94
|
|
|
DSDS1050
|
Facility
|
IP
|
$1,168.67
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
991174
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$292.17 |
| Max. Negotiated Rate |
$584.34 |
| Rate for Payer: Cash Price |
$794.70
|
| Rate for Payer: Cigna Commercial |
$292.17
|
| Rate for Payer: Multiplan Auto |
$584.34
|
| Rate for Payer: Multiplan Commercial |
$584.34
|
| Rate for Payer: Multiplan Workers Comp |
$584.34
|
| Rate for Payer: Scott and White EPO/PPO |
$584.34
|
|
|
DUAL CHAMBER IMPL DEFIBRILLATOR ELLIPS
|
Facility
|
IP
|
$108,102.41
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
8394467
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$27,025.60 |
| Max. Negotiated Rate |
$54,051.21 |
| Rate for Payer: Cash Price |
$73,509.64
|
| Rate for Payer: Cigna Commercial |
$27,025.60
|
| Rate for Payer: Multiplan Auto |
$54,051.21
|
| Rate for Payer: Multiplan Commercial |
$54,051.21
|
| Rate for Payer: Multiplan Workers Comp |
$54,051.21
|
| Rate for Payer: Scott and White EPO/PPO |
$54,051.21
|
|
|
DUAL CHAMBER IMPL DEFIBRILLATOR ELLIPS
|
Facility
|
OP
|
$108,102.41
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
8394467
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$9,729.22 |
| Max. Negotiated Rate |
$77,833.74 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$9,729.22
|
| Rate for Payer: BCBS of TX Blue Advantage |
$32,430.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$38,916.87
|
| Rate for Payer: BCBS of TX PPO |
$43,240.96
|
| Rate for Payer: Cash Price |
$73,509.64
|
| Rate for Payer: Cigna Medicaid |
$77,833.74
|
| Rate for Payer: Molina CHIP/Medicaid |
$77,833.74
|
| Rate for Payer: Multiplan Auto |
$54,051.21
|
| Rate for Payer: Multiplan Commercial |
$54,051.21
|
| Rate for Payer: Multiplan Workers Comp |
$54,051.21
|
| Rate for Payer: Parkland Medicaid |
$77,833.74
|
| Rate for Payer: Scott and White EPO/PPO |
$54,051.21
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$77,833.74
|
| Rate for Payer: Superior Health Plan EPO |
$14,701.93
|
|
|
Dual edge shaver blade -40mm
|
Facility
|
OP
|
$623.21
|
|
| Hospital Charge Code |
993582
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.09 |
| Max. Negotiated Rate |
$448.71 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$56.09
|
| Rate for Payer: BCBS of TX Blue Advantage |
$186.96
|
| Rate for Payer: BCBS of TX Blue Essentials |
$224.36
|
| Rate for Payer: BCBS of TX PPO |
$249.28
|
| Rate for Payer: Cash Price |
$423.78
|
| Rate for Payer: Cigna Medicaid |
$448.71
|
| Rate for Payer: Molina CHIP/Medicaid |
$448.71
|
| Rate for Payer: Multiplan Auto |
$405.09
|
| Rate for Payer: Multiplan Commercial |
$405.09
|
| Rate for Payer: Multiplan Workers Comp |
$405.09
|
| Rate for Payer: Parkland Medicaid |
$448.71
|
| Rate for Payer: Scott and White EPO/PPO |
$311.61
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$448.71
|
| Rate for Payer: Superior Health Plan EPO |
$84.76
|
|
|
Dual edge shaver blade -40mm
|
Facility
|
IP
|
$623.21
|
|
| Hospital Charge Code |
993582
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$423.78
|
|
|
DULoxetine 20 mg DR Cap
|
Facility
|
IP
|
$25.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78419952
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$17.34
|
|
