|
ED REPAIR INTERMEDIATE S A T E 12.6-20.0CM BCE
|
Facility
|
OP
|
$1,248.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
8404451
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$112.32 |
| Max. Negotiated Rate |
$898.56 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$112.32
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Amerigroup Medicare |
$408.37
|
| Rate for Payer: BCBS of TX Blue Advantage |
$533.58
|
| Rate for Payer: BCBS of TX Blue Essentials |
$639.02
|
| Rate for Payer: BCBS of TX Medicare |
$408.37
|
| Rate for Payer: BCBS of TX PPO |
$805.17
|
| Rate for Payer: Cash Price |
$848.64
|
| Rate for Payer: Cash Price |
$848.64
|
| Rate for Payer: Cash Price |
$848.64
|
| Rate for Payer: Cigna Commercial |
$863.21
|
| Rate for Payer: Cigna Medicaid |
$898.56
|
| Rate for Payer: Cigna Medicare |
$408.37
|
| Rate for Payer: Employer Direct Commercial |
$408.37
|
| Rate for Payer: Humana Medicare/TRICARE |
$408.37
|
| Rate for Payer: Molina CHIP/Medicaid |
$898.56
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Molina Medicare |
$408.37
|
| Rate for Payer: Multiplan Auto |
$811.20
|
| Rate for Payer: Multiplan Commercial |
$811.20
|
| Rate for Payer: Multiplan Workers Comp |
$811.20
|
| Rate for Payer: Parkland Medicaid |
$898.56
|
| Rate for Payer: Scott and White EPO/PPO |
$295.62
|
| Rate for Payer: Scott and White Medicare |
$408.37
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$898.56
|
| Rate for Payer: Superior Health Plan EPO |
$408.37
|
| Rate for Payer: Superior Health Plan Medicare |
$408.37
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Universal American Medicare |
$408.37
|
| Rate for Payer: Wellcare Medicare |
$408.37
|
| Rate for Payer: Wellmed Medicare |
$408.37
|
|
|
ED REPAIR INTERMEDIATE WOUNDS S/A/T/E EXCL HAND/FEET 7.6 CM TO 12.5 CM BCE
|
Facility
|
OP
|
$1,082.00
|
|
|
Service Code
|
HCPCS 12034
|
| Hospital Charge Code |
8470466
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$97.38 |
| Max. Negotiated Rate |
$863.21 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$97.38
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Amerigroup Medicare |
$408.37
|
| Rate for Payer: BCBS of TX Blue Advantage |
$533.58
|
| Rate for Payer: BCBS of TX Blue Essentials |
$639.02
|
| Rate for Payer: BCBS of TX Medicare |
$408.37
|
| Rate for Payer: BCBS of TX PPO |
$805.17
|
| Rate for Payer: Cash Price |
$735.76
|
| Rate for Payer: Cash Price |
$735.76
|
| Rate for Payer: Cash Price |
$735.76
|
| Rate for Payer: Cigna Commercial |
$863.21
|
| Rate for Payer: Cigna Medicaid |
$779.04
|
| Rate for Payer: Cigna Medicare |
$408.37
|
| Rate for Payer: Employer Direct Commercial |
$408.37
|
| Rate for Payer: Humana Medicare/TRICARE |
$408.37
|
| Rate for Payer: Molina CHIP/Medicaid |
$779.04
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Molina Medicare |
$408.37
|
| Rate for Payer: Multiplan Auto |
$703.30
|
| Rate for Payer: Multiplan Commercial |
$703.30
|
| Rate for Payer: Multiplan Workers Comp |
$703.30
|
| Rate for Payer: Parkland Medicaid |
$779.04
|
| Rate for Payer: Scott and White EPO/PPO |
$251.84
|
| Rate for Payer: Scott and White Medicare |
$408.37
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$779.04
|
| Rate for Payer: Superior Health Plan EPO |
$408.37
|
| Rate for Payer: Superior Health Plan Medicare |
$408.37
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Universal American Medicare |
$408.37
|
| Rate for Payer: Wellcare Medicare |
$408.37
|
| Rate for Payer: Wellmed Medicare |
$408.37
|
|
|
ED REPAIR INTERMEDIATE WOUNDS S/A/T/E EXCL HAND/FEET 7.6 CM TO 12.5 CM BCE
|
Facility
|
IP
|
$1,082.00
|
|
|
Service Code
|
HCPCS 12034
|
| Hospital Charge Code |
8470466
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$735.76
|
|
|
ED REPAIR LAC 2.5 CM OR LESS FLOOR OF MOUTH AND/OR ANT TWO-THIRDS OF TONGUE BCE
|
Facility
|
OP
|
$536.00
|
|
|
Service Code
|
HCPCS 41250
|
| Hospital Charge Code |
8472467
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$48.24 |
| Max. Negotiated Rate |
$948.59 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$48.24
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$448.76
|
| Rate for Payer: Amerigroup Medicare |
$448.76
|
| Rate for Payer: BCBS of TX Blue Advantage |
$182.08
|
| Rate for Payer: BCBS of TX Blue Essentials |
$218.06
|
| Rate for Payer: BCBS of TX Medicare |
$448.76
|
| Rate for Payer: BCBS of TX PPO |
$274.76
|
| Rate for Payer: Cash Price |
$364.48
|
| Rate for Payer: Cash Price |
$364.48
|
| Rate for Payer: Cash Price |
$364.48
|
| Rate for Payer: Cigna Commercial |
$948.59
|
| Rate for Payer: Cigna Medicaid |
$385.92
|
| Rate for Payer: Cigna Medicare |
$448.76
|
| Rate for Payer: Employer Direct Commercial |
$448.76
|
| Rate for Payer: Humana Medicare/TRICARE |
$448.76
|
| Rate for Payer: Molina CHIP/Medicaid |
$385.92
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$448.76
|
| Rate for Payer: Molina Medicare |
$448.76
|
| Rate for Payer: Multiplan Auto |
$348.40
|
| Rate for Payer: Multiplan Commercial |
$348.40
|
| Rate for Payer: Multiplan Workers Comp |
$348.40
|
| Rate for Payer: Parkland Medicaid |
$385.92
|
| Rate for Payer: Scott and White EPO/PPO |
$189.55
|
| Rate for Payer: Scott and White Medicare |
$448.76
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$385.92
|
| Rate for Payer: Superior Health Plan EPO |
$448.76
|
| Rate for Payer: Superior Health Plan Medicare |
$448.76
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$448.76
|
| Rate for Payer: Universal American Medicare |
$448.76
|
| Rate for Payer: Wellcare Medicare |
$448.76
|
| Rate for Payer: Wellmed Medicare |
$448.76
|
|
|
ED REPAIR LAC 2.5 CM OR LESS FLOOR OF MOUTH AND/OR ANT TWO-THIRDS OF TONGUE BCE
|
Facility
|
IP
|
$536.00
|
|
|
Service Code
|
HCPCS 41250
|
| Hospital Charge Code |
8472467
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$364.48
|
|
|
ED RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP BCE
|
Facility
|
OP
|
$494.00
|
|
|
Service Code
|
HCPCS 65222
|
| Hospital Charge Code |
8726549
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$44.46 |
| Max. Negotiated Rate |
$355.68 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$44.46
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$133.65
|
| Rate for Payer: Amerigroup Medicare |
$133.65
|
| Rate for Payer: BCBS of TX Blue Advantage |
$182.08
|
| Rate for Payer: BCBS of TX Blue Essentials |
$218.06
|
| Rate for Payer: BCBS of TX Medicare |
$133.65
|
| Rate for Payer: BCBS of TX PPO |
$274.76
|
| Rate for Payer: Cash Price |
$335.92
|
| Rate for Payer: Cash Price |
$335.92
|
| Rate for Payer: Cash Price |
$335.92
|
| Rate for Payer: Cigna Commercial |
$282.53
|
| Rate for Payer: Cigna Medicaid |
$355.68
|
| Rate for Payer: Cigna Medicare |
$133.65
|
| Rate for Payer: Employer Direct Commercial |
$133.65
|
| Rate for Payer: Humana Medicare/TRICARE |
$133.65
|
| Rate for Payer: Molina CHIP/Medicaid |
$355.68
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$133.65
|
| Rate for Payer: Molina Medicare |
$133.65
|
| Rate for Payer: Multiplan Auto |
$321.10
|
| Rate for Payer: Multiplan Commercial |
$321.10
|
| Rate for Payer: Multiplan Workers Comp |
$321.10
|
| Rate for Payer: Parkland Medicaid |
$355.68
|
| Rate for Payer: Scott and White EPO/PPO |
$61.29
|
| Rate for Payer: Scott and White Medicare |
$133.65
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$355.68
|
| Rate for Payer: Superior Health Plan EPO |
$133.65
|
| Rate for Payer: Superior Health Plan Medicare |
$133.65
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$133.65
|
| Rate for Payer: Universal American Medicare |
$133.65
|
| Rate for Payer: Wellcare Medicare |
$133.65
|
| Rate for Payer: Wellmed Medicare |
$133.65
|
|
|
ED RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP BCE
|
Facility
|
IP
|
$494.00
|
|
|
Service Code
|
HCPCS 65222
|
| Hospital Charge Code |
8726549
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$335.92
|
|
|
ED RMVL NON-BIODEGRADABLE DRUG DELIV IMPLT BCE
|
Facility
|
IP
|
$5,620.00
|
|
|
Service Code
|
HCPCS 11982
|
| Hospital Charge Code |
8724546
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$3,821.60
|
|
|
ED RMVL NON-BIODEGRADABLE DRUG DELIV IMPLT BCE
|
Facility
|
OP
|
$5,620.00
|
|
|
Service Code
|
HCPCS 11982
|
| Hospital Charge Code |
8724546
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$88.80 |
| Max. Negotiated Rate |
$4,046.40 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$505.80
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$448.76
|
| Rate for Payer: Amerigroup Medicare |
$448.76
|
| Rate for Payer: BCBS of TX Blue Advantage |
$607.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$727.18
|
| Rate for Payer: BCBS of TX Medicare |
$448.76
|
| Rate for Payer: BCBS of TX PPO |
$916.25
|
| Rate for Payer: Cash Price |
$3,821.60
|
| Rate for Payer: Cash Price |
$3,821.60
|
| Rate for Payer: Cash Price |
$3,821.60
|
| Rate for Payer: Cigna Commercial |
$948.59
|
| Rate for Payer: Cigna Medicaid |
$4,046.40
|
| Rate for Payer: Cigna Medicare |
$448.76
|
| Rate for Payer: Employer Direct Commercial |
$448.76
|
| Rate for Payer: Humana Medicare/TRICARE |
$448.76
|
| Rate for Payer: Molina CHIP/Medicaid |
$4,046.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$448.76
|
| Rate for Payer: Molina Medicare |
$448.76
|
| Rate for Payer: Multiplan Auto |
$3,653.00
|
| Rate for Payer: Multiplan Commercial |
$3,653.00
|
| Rate for Payer: Multiplan Workers Comp |
$3,653.00
|
| Rate for Payer: Parkland Medicaid |
$4,046.40
|
| Rate for Payer: Scott and White EPO/PPO |
$88.80
|
| Rate for Payer: Scott and White Medicare |
$448.76
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$4,046.40
|
| Rate for Payer: Superior Health Plan EPO |
$448.76
|
| Rate for Payer: Superior Health Plan Medicare |
$448.76
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$448.76
|
| Rate for Payer: Universal American Medicare |
$448.76
|
| Rate for Payer: Wellcare Medicare |
$448.76
|
| Rate for Payer: Wellmed Medicare |
$448.76
|
|
|
ED RPLC GASTRO/CECOSTOMY TUBE PERC W/GUIDE CNTRST IMG BCE
|
Facility
|
OP
|
$1,573.00
|
|
|
Service Code
|
HCPCS 49450
|
| Hospital Charge Code |
8424452
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$78.15 |
| Max. Negotiated Rate |
$1,980.52 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$141.57
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$911.12
|
| Rate for Payer: Amerigroup Medicare |
$911.12
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,312.49
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,571.84
|
| Rate for Payer: BCBS of TX Medicare |
$911.12
|
| Rate for Payer: BCBS of TX PPO |
$1,980.52
|
| Rate for Payer: Cash Price |
$1,069.64
|
| Rate for Payer: Cash Price |
$1,069.64
|
| Rate for Payer: Cash Price |
$1,069.64
|
| Rate for Payer: Cigna Commercial |
$1,925.93
|
| Rate for Payer: Cigna Medicaid |
$1,132.56
|
| Rate for Payer: Cigna Medicare |
$911.12
|
| Rate for Payer: Employer Direct Commercial |
$911.12
|
| Rate for Payer: Humana Medicare/TRICARE |
$911.12
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,132.56
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$911.12
|
| Rate for Payer: Molina Medicare |
$911.12
|
| Rate for Payer: Multiplan Auto |
$1,022.45
|
| Rate for Payer: Multiplan Commercial |
$1,022.45
|
| Rate for Payer: Multiplan Workers Comp |
$1,022.45
|
| Rate for Payer: Parkland Medicaid |
$1,132.56
|
| Rate for Payer: Scott and White EPO/PPO |
$78.15
|
| Rate for Payer: Scott and White Medicare |
$911.12
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,132.56
|
| Rate for Payer: Superior Health Plan EPO |
$911.12
|
| Rate for Payer: Superior Health Plan Medicare |
$911.12
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$911.12
|
| Rate for Payer: Universal American Medicare |
$911.12
|
| Rate for Payer: Wellcare Medicare |
$911.12
|
| Rate for Payer: Wellmed Medicare |
$911.12
|
|
|
ED RPLC GASTRO/CECOSTOMY TUBE PERC W/GUIDE CNTRST IMG BCE
|
Facility
|
IP
|
$1,573.00
|
|
|
Service Code
|
HCPCS 49450
|
| Hospital Charge Code |
8424452
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$1,069.64
|
|
|
ED Sedation - Different Physician -> Each Addl 15 mins
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
HCPCS 99157
|
| Hospital Charge Code |
2161303
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$232.56
|
|
|
ED Sedation - Different Physician -> Each Addl 15 mins
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
HCPCS 99157
|
| Hospital Charge Code |
2161303
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$30.78 |
| Max. Negotiated Rate |
$3,520.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$30.78
|
| Rate for Payer: BCBS of TX Blue Advantage |
$102.60
|
| Rate for Payer: BCBS of TX Blue Essentials |
$123.12
|
| Rate for Payer: BCBS of TX PPO |
$3,520.00
|
| Rate for Payer: Cash Price |
$232.56
|
| Rate for Payer: Cash Price |
$232.56
|
| Rate for Payer: Cash Price |
$232.56
|
| Rate for Payer: Cigna Medicaid |
$246.24
|
| Rate for Payer: Molina CHIP/Medicaid |
$246.24
|
| Rate for Payer: Multiplan Auto |
$222.30
|
| Rate for Payer: Multiplan Commercial |
$222.30
|
| Rate for Payer: Multiplan Workers Comp |
$222.30
|
| Rate for Payer: Parkland Medicaid |
$246.24
|
| Rate for Payer: Scott and White EPO/PPO |
$72.16
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$246.24
|
| Rate for Payer: Superior Health Plan EPO |
$46.51
|
|
|
ED Sedation - Different Physician -> First 15 mins >= 5 years
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
HCPCS 99156
|
| Hospital Charge Code |
2161302
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$325.72
|
|
|
ED Sedation - Different Physician -> First 15 mins >= 5 years
|
Facility
|
OP
|
$479.00
|
|
|
Service Code
|
HCPCS 99156
|
| Hospital Charge Code |
2161302
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$43.11 |
| Max. Negotiated Rate |
$3,520.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$43.11
|
| Rate for Payer: BCBS of TX Blue Advantage |
$143.70
|
| Rate for Payer: BCBS of TX Blue Essentials |
$172.44
|
| Rate for Payer: BCBS of TX PPO |
$3,520.00
|
| Rate for Payer: Cash Price |
$325.72
|
| Rate for Payer: Cash Price |
$325.72
|
| Rate for Payer: Cash Price |
$325.72
|
| Rate for Payer: Cigna Medicaid |
$344.88
|
| Rate for Payer: Molina CHIP/Medicaid |
$344.88
|
| Rate for Payer: Multiplan Auto |
$311.35
|
| Rate for Payer: Multiplan Commercial |
$311.35
|
| Rate for Payer: Multiplan Workers Comp |
$311.35
|
| Rate for Payer: Parkland Medicaid |
$344.88
|
| Rate for Payer: Scott and White EPO/PPO |
$90.86
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$344.88
|
| Rate for Payer: Superior Health Plan EPO |
$65.14
|
|
|
ED Sedation - Same Physician -> Each Addl 15 mins
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
HCPCS 99153
|
| Hospital Charge Code |
6100408
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$104.72
|
|
|
ED Sedation - Same Physician -> Each Addl 15 mins
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
HCPCS 99153
|
| Hospital Charge Code |
6100408
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$3,520.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$13.86
|
| Rate for Payer: BCBS of TX Blue Advantage |
$46.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$55.44
|
| Rate for Payer: BCBS of TX PPO |
$3,520.00
|
| Rate for Payer: Cash Price |
$104.72
|
| Rate for Payer: Cash Price |
$104.72
|
| Rate for Payer: Cash Price |
$104.72
|
| Rate for Payer: Cigna Medicaid |
$110.88
|
| Rate for Payer: Molina CHIP/Medicaid |
$110.88
|
| 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 |
$110.88
|
| Rate for Payer: Scott and White EPO/PPO |
$14.32
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$110.88
|
| Rate for Payer: Superior Health Plan EPO |
$20.94
|
|
|
ED Sedation - Same Physician -> First 15 mins < 5 years
|
Facility
|
OP
|
$427.00
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
5210309
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$29.19 |
| Max. Negotiated Rate |
$3,520.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$38.43
|
| Rate for Payer: BCBS of TX Blue Advantage |
$128.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$153.72
|
| Rate for Payer: BCBS of TX PPO |
$3,520.00
|
| Rate for Payer: Cash Price |
$290.36
|
| Rate for Payer: Cash Price |
$290.36
|
| Rate for Payer: Cash Price |
$290.36
|
| Rate for Payer: Cigna Medicaid |
$307.44
|
| Rate for Payer: Molina CHIP/Medicaid |
$307.44
|
| Rate for Payer: Multiplan Auto |
$277.55
|
| Rate for Payer: Multiplan Commercial |
$277.55
|
| Rate for Payer: Multiplan Workers Comp |
$277.55
|
| Rate for Payer: Parkland Medicaid |
$307.44
|
| Rate for Payer: Scott and White EPO/PPO |
$29.19
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$307.44
|
| Rate for Payer: Superior Health Plan EPO |
$58.07
|
|
|
ED Sedation - Same Physician -> First 15 mins < 5 years
|
Facility
|
IP
|
$427.00
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
5210309
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$290.36
|
|
|
ED Sedation - Same Physician -> First 15 mins >= 5 years
|
Facility
|
OP
|
$247.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
6100390
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$3,520.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$22.23
|
| Rate for Payer: BCBS of TX Blue Advantage |
$74.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$88.92
|
| Rate for Payer: BCBS of TX PPO |
$3,520.00
|
| Rate for Payer: Cash Price |
$167.96
|
| Rate for Payer: Cash Price |
$167.96
|
| Rate for Payer: Cash Price |
$167.96
|
| Rate for Payer: Cigna Medicaid |
$177.84
|
| Rate for Payer: Molina CHIP/Medicaid |
$177.84
|
| Rate for Payer: Multiplan Auto |
$160.55
|
| Rate for Payer: Multiplan Commercial |
$160.55
|
| Rate for Payer: Multiplan Workers Comp |
$160.55
|
| Rate for Payer: Parkland Medicaid |
$177.84
|
| Rate for Payer: Scott and White EPO/PPO |
$14.72
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$177.84
|
| Rate for Payer: Superior Health Plan EPO |
$33.59
|
|
|
ED Sedation - Same Physician -> First 15 mins >= 5 years
|
Facility
|
IP
|
$247.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
6100390
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$167.96
|
|
|
ED SMPL RPR WND FACE/EAR/EYELID/NOSE/LIP 7.6 TO 12.5 CM BCE
|
Facility
|
OP
|
$987.00
|
|
|
Service Code
|
HCPCS 12015
|
| Hospital Charge Code |
8422451
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$88.83 |
| Max. Negotiated Rate |
$710.64 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$88.83
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Amerigroup Medicare |
$201.55
|
| Rate for Payer: BCBS of TX Blue Advantage |
$291.80
|
| Rate for Payer: BCBS of TX Blue Essentials |
$349.46
|
| Rate for Payer: BCBS of TX Medicare |
$201.55
|
| Rate for Payer: BCBS of TX PPO |
$440.32
|
| Rate for Payer: Cash Price |
$671.16
|
| Rate for Payer: Cash Price |
$671.16
|
| Rate for Payer: Cash Price |
$671.16
|
| Rate for Payer: Cigna Commercial |
$426.04
|
| Rate for Payer: Cigna Medicaid |
$710.64
|
| Rate for Payer: Cigna Medicare |
$201.55
|
| Rate for Payer: Employer Direct Commercial |
$201.55
|
| Rate for Payer: Humana Medicare/TRICARE |
$201.55
|
| Rate for Payer: Molina CHIP/Medicaid |
$710.64
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Molina Medicare |
$201.55
|
| Rate for Payer: Multiplan Auto |
$641.55
|
| Rate for Payer: Multiplan Commercial |
$641.55
|
| Rate for Payer: Multiplan Workers Comp |
$641.55
|
| Rate for Payer: Parkland Medicaid |
$710.64
|
| Rate for Payer: Scott and White EPO/PPO |
$114.01
|
| Rate for Payer: Scott and White Medicare |
$201.55
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$710.64
|
| Rate for Payer: Superior Health Plan EPO |
$201.55
|
| Rate for Payer: Superior Health Plan Medicare |
$201.55
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$201.55
|
| Rate for Payer: Universal American Medicare |
$201.55
|
| Rate for Payer: Wellcare Medicare |
$201.55
|
| Rate for Payer: Wellmed Medicare |
$201.55
|
|
|
ED SMPL RPR WND FACE/EAR/EYELID/NOSE/LIP 7.6 TO 12.5 CM BCE
|
Facility
|
IP
|
$987.00
|
|
|
Service Code
|
HCPCS 12015
|
| Hospital Charge Code |
8422451
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$671.16
|
|
|
ED SMPL RPR WND S/N/A/GEN/TRNK 20.1 TO 30.0 CM BCE
|
Facility
|
OP
|
$1,251.00
|
|
|
Service Code
|
HCPCS 12006
|
| Hospital Charge Code |
8912657
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$112.59 |
| Max. Negotiated Rate |
$900.72 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$112.59
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Amerigroup Medicare |
$408.37
|
| Rate for Payer: BCBS of TX Blue Advantage |
$533.58
|
| Rate for Payer: BCBS of TX Blue Essentials |
$639.02
|
| Rate for Payer: BCBS of TX Medicare |
$408.37
|
| Rate for Payer: BCBS of TX PPO |
$805.17
|
| Rate for Payer: Cash Price |
$850.68
|
| Rate for Payer: Cash Price |
$850.68
|
| Rate for Payer: Cash Price |
$850.68
|
| Rate for Payer: Cigna Commercial |
$863.21
|
| Rate for Payer: Cigna Medicaid |
$900.72
|
| Rate for Payer: Cigna Medicare |
$408.37
|
| Rate for Payer: Employer Direct Commercial |
$408.37
|
| Rate for Payer: Humana Medicare/TRICARE |
$408.37
|
| Rate for Payer: Molina CHIP/Medicaid |
$900.72
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Molina Medicare |
$408.37
|
| Rate for Payer: Multiplan Auto |
$813.15
|
| Rate for Payer: Multiplan Commercial |
$813.15
|
| Rate for Payer: Multiplan Workers Comp |
$813.15
|
| Rate for Payer: Parkland Medicaid |
$900.72
|
| Rate for Payer: Scott and White EPO/PPO |
$140.50
|
| Rate for Payer: Scott and White Medicare |
$408.37
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$900.72
|
| Rate for Payer: Superior Health Plan EPO |
$408.37
|
| Rate for Payer: Superior Health Plan Medicare |
$408.37
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$408.37
|
| Rate for Payer: Universal American Medicare |
$408.37
|
| Rate for Payer: Wellcare Medicare |
$408.37
|
| Rate for Payer: Wellmed Medicare |
$408.37
|
|
|
ED SMPL RPR WND S/N/A/GEN/TRNK 20.1 TO 30.0 CM BCE
|
Facility
|
IP
|
$1,251.00
|
|
|
Service Code
|
HCPCS 12006
|
| Hospital Charge Code |
8912657
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$850.68
|
|
