|
latanoprost ophthalmic 0.005%
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78403923
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$110.16
|
|
|
latch assist nipple everter aid
|
Facility
|
OP
|
$28.01
|
|
| Hospital Charge Code |
8630563
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$18.21 |
| Rate for Payer: Aetna Commercial |
$15.41
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.52
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$10.08
|
| Rate for Payer: BCBS of TX PPO |
$11.20
|
| Rate for Payer: Cash Price |
$24.65
|
| Rate for Payer: Multiplan Auto |
$18.21
|
| Rate for Payer: Multiplan Commercial |
$18.21
|
| Rate for Payer: Multiplan Workers Comp |
$18.21
|
| Rate for Payer: Scott and White EPO/PPO |
$14.01
|
| Rate for Payer: Superior Health Plan EPO |
$3.81
|
|
|
latch assist nipple everter aid
|
Facility
|
IP
|
$28.01
|
|
| Hospital Charge Code |
8630563
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$24.65
|
|
|
LC Skin Sub App Face/Nck/HF ad 100sqcm
|
Facility
|
OP
|
$4,073.00
|
|
|
Service Code
|
HCPCS C5278
|
| Hospital Charge Code |
7150908
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.00 |
| Max. Negotiated Rate |
$2,647.45 |
| Rate for Payer: Aetna Commercial |
$2,240.15
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$366.57
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$45.00
|
| Rate for Payer: BCBS of TX PPO |
$50.00
|
| Rate for Payer: Cash Price |
$3,584.24
|
| Rate for Payer: Cash Price |
$3,584.24
|
| Rate for Payer: Multiplan Auto |
$2,647.45
|
| Rate for Payer: Multiplan Commercial |
$2,647.45
|
| Rate for Payer: Multiplan Workers Comp |
$2,647.45
|
| Rate for Payer: Scott and White EPO/PPO |
$2,036.50
|
| Rate for Payer: Superior Health Plan EPO |
$553.93
|
|
|
LC Skin Sub App Face/Nck/HF ad 25 sqcm
|
Facility
|
OP
|
$1,267.00
|
|
|
Service Code
|
HCPCS C5276
|
| Hospital Charge Code |
7150906
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.00 |
| Max. Negotiated Rate |
$823.55 |
| Rate for Payer: Aetna Commercial |
$696.85
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$114.03
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$45.00
|
| Rate for Payer: BCBS of TX PPO |
$50.00
|
| Rate for Payer: Cash Price |
$1,114.96
|
| Rate for Payer: Cash Price |
$1,114.96
|
| Rate for Payer: Multiplan Auto |
$823.55
|
| Rate for Payer: Multiplan Commercial |
$823.55
|
| Rate for Payer: Multiplan Workers Comp |
$823.55
|
| Rate for Payer: Scott and White EPO/PPO |
$633.50
|
| Rate for Payer: Superior Health Plan EPO |
$172.31
|
|
|
LC Skin Sub App Face/Nck/HF to100sqcm
|
Facility
|
OP
|
$5,030.00
|
|
|
Service Code
|
HCPCS C5277
|
| Hospital Charge Code |
7150907
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$452.70 |
| Max. Negotiated Rate |
$3,269.50 |
| Rate for Payer: Aetna Commercial |
$2,766.50
|
| Rate for Payer: Aetna Medicare |
$861.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$452.70
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$574.38
|
| Rate for Payer: Amerigroup Medicare |
$574.38
|
| Rate for Payer: BCBS of TX Blue Advantage |
$830.02
|
| Rate for Payer: BCBS of TX Blue Essentials |
$994.04
|
| Rate for Payer: BCBS of TX Medicare |
$574.38
|
| Rate for Payer: BCBS of TX PPO |
$1,252.49
|
| Rate for Payer: Cash Price |
$4,426.40
|
| Rate for Payer: Cash Price |
$4,426.40
|
| Rate for Payer: Cash Price |
$4,426.40
|
| Rate for Payer: Cigna Commercial |
$1,301.14
|
| Rate for Payer: Cigna Medicare |
$574.38
|
| Rate for Payer: Employer Direct Commercial |
$574.38
|
| Rate for Payer: Humana Medicare/TRICARE |
$574.38
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$574.38
|
| Rate for Payer: Molina Medicare |
$574.38
|
| Rate for Payer: Multiplan Auto |
$3,269.50
|
| Rate for Payer: Multiplan Commercial |
$3,269.50
|
| Rate for Payer: Multiplan Workers Comp |
$3,269.50
|
| Rate for Payer: Scott and White EPO/PPO |
$2,515.00
|
| Rate for Payer: Scott and White Medicare |
$574.38
|
| Rate for Payer: Superior Health Plan EPO |
$574.38
|
| Rate for Payer: Superior Health Plan Medicare |
$574.38
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$574.38
|
| Rate for Payer: Universal American Medicare |
$574.38
|
| Rate for Payer: Wellcare Medicare |
$574.38
|
| Rate for Payer: Wellmed Medicare |
$574.38
|
|
|
LC Skin Sub App Face/Nck/HF to 25 sqcm
|
Facility
|
OP
|
$2,804.00
|
|
|
Service Code
|
HCPCS C5275
|
| Hospital Charge Code |
7150905
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$252.36 |
| Max. Negotiated Rate |
$1,822.60 |
| Rate for Payer: Aetna Commercial |
$1,542.20
|
| Rate for Payer: Aetna Medicare |
$861.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$252.36
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$574.38
|
| Rate for Payer: Amerigroup Medicare |
$574.38
|
| Rate for Payer: BCBS of TX Blue Advantage |
$830.02
|
| Rate for Payer: BCBS of TX Blue Essentials |
$994.04
|
| Rate for Payer: BCBS of TX Medicare |
$574.38
|
| Rate for Payer: BCBS of TX PPO |
$1,252.49
|
| Rate for Payer: Cash Price |
$2,467.52
|
| Rate for Payer: Cash Price |
$2,467.52
|
| Rate for Payer: Cash Price |
$2,467.52
|
| Rate for Payer: Cigna Commercial |
$1,301.14
|
| Rate for Payer: Cigna Medicare |
$574.38
|
| Rate for Payer: Employer Direct Commercial |
$574.38
|
| Rate for Payer: Humana Medicare/TRICARE |
$574.38
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$574.38
|
| Rate for Payer: Molina Medicare |
$574.38
|
| Rate for Payer: Multiplan Auto |
$1,822.60
|
| Rate for Payer: Multiplan Commercial |
$1,822.60
|
| Rate for Payer: Multiplan Workers Comp |
$1,822.60
|
| Rate for Payer: Scott and White EPO/PPO |
$1,402.00
|
| Rate for Payer: Scott and White Medicare |
$574.38
|
| Rate for Payer: Superior Health Plan EPO |
$574.38
|
| Rate for Payer: Superior Health Plan Medicare |
$574.38
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$574.38
|
| Rate for Payer: Universal American Medicare |
$574.38
|
| Rate for Payer: Wellcare Medicare |
$574.38
|
| Rate for Payer: Wellmed Medicare |
$574.38
|
|
|
LC Skin Sub App Trnk/Arm/Leg ad 100sqcm
|
Facility
|
OP
|
$1,623.00
|
|
|
Service Code
|
HCPCS C5274
|
| Hospital Charge Code |
7150904
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.00 |
| Max. Negotiated Rate |
$1,054.95 |
| Rate for Payer: Aetna Commercial |
$892.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$146.07
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$45.00
|
| Rate for Payer: BCBS of TX PPO |
$50.00
|
| Rate for Payer: Cash Price |
$1,428.24
|
| Rate for Payer: Cash Price |
$1,428.24
|
| Rate for Payer: Multiplan Auto |
$1,054.95
|
| Rate for Payer: Multiplan Commercial |
$1,054.95
|
| Rate for Payer: Multiplan Workers Comp |
$1,054.95
|
| Rate for Payer: Scott and White EPO/PPO |
$811.50
|
| Rate for Payer: Superior Health Plan EPO |
$220.73
|
|
|
LC Skin Sub App Trnk/Arm/Leg ad 25 sqcm
|
Facility
|
OP
|
$1,037.00
|
|
|
Service Code
|
HCPCS C5272
|
| Hospital Charge Code |
7150902
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.00 |
| Max. Negotiated Rate |
$674.05 |
| Rate for Payer: Aetna Commercial |
$570.35
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$93.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$45.00
|
| Rate for Payer: BCBS of TX PPO |
$50.00
|
| Rate for Payer: Cash Price |
$912.56
|
| Rate for Payer: Cash Price |
$912.56
|
| Rate for Payer: Multiplan Auto |
$674.05
|
| Rate for Payer: Multiplan Commercial |
$674.05
|
| Rate for Payer: Multiplan Workers Comp |
$674.05
|
| Rate for Payer: Scott and White EPO/PPO |
$518.50
|
| Rate for Payer: Superior Health Plan EPO |
$141.03
|
|
|
LC Skin Sub App Trnk/Arm/Leg to 25 sqcm
|
Facility
|
OP
|
$1,845.00
|
|
|
Service Code
|
HCPCS C5271
|
| Hospital Charge Code |
7150901
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$166.05 |
| Max. Negotiated Rate |
$1,301.14 |
| Rate for Payer: Aetna Commercial |
$1,014.75
|
| Rate for Payer: Aetna Medicare |
$861.57
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$166.05
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$574.38
|
| Rate for Payer: Amerigroup Medicare |
$574.38
|
| Rate for Payer: BCBS of TX Blue Advantage |
$830.02
|
| Rate for Payer: BCBS of TX Blue Essentials |
$994.04
|
| Rate for Payer: BCBS of TX Medicare |
$574.38
|
| Rate for Payer: BCBS of TX PPO |
$1,252.49
|
| Rate for Payer: Cash Price |
$1,623.60
|
| Rate for Payer: Cash Price |
$1,623.60
|
| Rate for Payer: Cash Price |
$1,623.60
|
| Rate for Payer: Cigna Commercial |
$1,301.14
|
| Rate for Payer: Cigna Medicare |
$574.38
|
| Rate for Payer: Employer Direct Commercial |
$574.38
|
| Rate for Payer: Humana Medicare/TRICARE |
$574.38
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$574.38
|
| Rate for Payer: Molina Medicare |
$574.38
|
| Rate for Payer: Multiplan Auto |
$1,199.25
|
| Rate for Payer: Multiplan Commercial |
$1,199.25
|
| Rate for Payer: Multiplan Workers Comp |
$1,199.25
|
| Rate for Payer: Scott and White EPO/PPO |
$922.50
|
| Rate for Payer: Scott and White Medicare |
$574.38
|
| Rate for Payer: Superior Health Plan EPO |
$574.38
|
| Rate for Payer: Superior Health Plan Medicare |
$574.38
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$574.38
|
| Rate for Payer: Universal American Medicare |
$574.38
|
| Rate for Payer: Wellcare Medicare |
$574.38
|
| Rate for Payer: Wellmed Medicare |
$574.38
|
|
|
LC Skin Sub App Trnk/Arm/Leg up 100sqcm
|
Facility
|
OP
|
$3,676.00
|
|
|
Service Code
|
HCPCS C5273
|
| Hospital Charge Code |
7150903
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$330.84 |
| Max. Negotiated Rate |
$4,089.30 |
| Rate for Payer: Aetna Commercial |
$2,200.00
|
| Rate for Payer: Aetna Medicare |
$2,501.68
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$330.84
|
| 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: Cash Price |
$3,234.88
|
| Rate for Payer: Cash Price |
$3,234.88
|
| Rate for Payer: Cash Price |
$3,234.88
|
| Rate for Payer: Cigna Commercial |
$3,778.02
|
| 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 Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Molina Medicare |
$1,667.79
|
| Rate for Payer: Multiplan Auto |
$2,389.40
|
| Rate for Payer: Multiplan Commercial |
$2,389.40
|
| Rate for Payer: Multiplan Workers Comp |
$2,389.40
|
| Rate for Payer: Scott and White EPO/PPO |
$1,838.00
|
| Rate for Payer: Scott and White Medicare |
$1,667.79
|
| 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
|
|
|
L&D - Addl Admin Charge 90472
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
315387
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$57.20 |
| Rate for Payer: Aetna Commercial |
$48.40
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7.92
|
| Rate for Payer: BCBS of TX Blue Advantage |
$22.57
|
| Rate for Payer: BCBS of TX Blue Essentials |
$26.98
|
| Rate for Payer: BCBS of TX PPO |
$30.09
|
| Rate for Payer: Cash Price |
$77.44
|
| Rate for Payer: Cash Price |
$77.44
|
| Rate for Payer: Multiplan Auto |
$57.20
|
| Rate for Payer: Multiplan Commercial |
$57.20
|
| Rate for Payer: Multiplan Workers Comp |
$57.20
|
| Rate for Payer: Scott and White EPO/PPO |
$18.11
|
| Rate for Payer: Superior Health Plan EPO |
$11.97
|
|
|
L&D - Addl Admin Charge 90472
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
315387
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$77.44
|
|
|
L&D Addl Admin Charge 90472 BCE
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
315387
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$57.20 |
| Rate for Payer: Aetna Commercial |
$48.40
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7.92
|
| Rate for Payer: BCBS of TX Blue Advantage |
$22.57
|
| Rate for Payer: BCBS of TX Blue Essentials |
$26.98
|
| Rate for Payer: BCBS of TX PPO |
$30.09
|
| Rate for Payer: Cash Price |
$77.44
|
| Rate for Payer: Cash Price |
$77.44
|
| Rate for Payer: Multiplan Auto |
$57.20
|
| Rate for Payer: Multiplan Commercial |
$57.20
|
| Rate for Payer: Multiplan Workers Comp |
$57.20
|
| Rate for Payer: Scott and White EPO/PPO |
$18.11
|
| Rate for Payer: Superior Health Plan EPO |
$11.97
|
|
|
LD ATTAIN PERFORMA 4298 -- DHF
|
Facility
|
OP
|
$13,158.08
|
|
|
Service Code
|
HCPCS C1900
|
| Hospital Charge Code |
40003683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,184.23 |
| Max. Negotiated Rate |
$6,579.04 |
| Rate for Payer: Aetna Commercial |
$3,947.42
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,184.23
|
| Rate for Payer: BCBS of TX Blue Advantage |
$3,947.42
|
| Rate for Payer: BCBS of TX Blue Essentials |
$4,736.91
|
| Rate for Payer: BCBS of TX PPO |
$5,263.23
|
| Rate for Payer: Cash Price |
$11,579.11
|
| Rate for Payer: Multiplan Auto |
$6,579.04
|
| Rate for Payer: Multiplan Commercial |
$6,579.04
|
| Rate for Payer: Multiplan Workers Comp |
$6,579.04
|
| Rate for Payer: Scott and White EPO/PPO |
$6,579.04
|
| Rate for Payer: Superior Health Plan EPO |
$1,789.50
|
|
|
LD ATTAIN PERFORMA 4298 -- DHF
|
Facility
|
IP
|
$13,158.08
|
|
|
Service Code
|
HCPCS C1900
|
| Hospital Charge Code |
40003683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,289.52 |
| Max. Negotiated Rate |
$6,579.04 |
| Rate for Payer: Aetna Commercial |
$3,947.42
|
| Rate for Payer: Cash Price |
$11,579.11
|
| Rate for Payer: Cigna Commercial |
$3,289.52
|
| Rate for Payer: Multiplan Auto |
$6,579.04
|
| Rate for Payer: Multiplan Commercial |
$6,579.04
|
| Rate for Payer: Multiplan Workers Comp |
$6,579.04
|
| Rate for Payer: Scott and White EPO/PPO |
$6,579.04
|
|
|
LD ATTAIN PERFORMA 4598 -- DHF
|
Facility
|
IP
|
$15,289.25
|
|
|
Service Code
|
HCPCS C1900
|
| Hospital Charge Code |
40085680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,822.31 |
| Max. Negotiated Rate |
$7,644.62 |
| Rate for Payer: Aetna Commercial |
$4,586.77
|
| Rate for Payer: Cash Price |
$13,454.54
|
| Rate for Payer: Cigna Commercial |
$3,822.31
|
| Rate for Payer: Multiplan Auto |
$7,644.62
|
| Rate for Payer: Multiplan Commercial |
$7,644.62
|
| Rate for Payer: Multiplan Workers Comp |
$7,644.62
|
| Rate for Payer: Scott and White EPO/PPO |
$7,644.62
|
|
|
LD ATTAIN PERFORMA 4598 -- DHF
|
Facility
|
OP
|
$15,289.25
|
|
|
Service Code
|
HCPCS C1900
|
| Hospital Charge Code |
40085680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,376.03 |
| Max. Negotiated Rate |
$7,644.62 |
| Rate for Payer: Aetna Commercial |
$4,586.77
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,376.03
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,586.77
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,504.13
|
| Rate for Payer: BCBS of TX PPO |
$6,115.70
|
| Rate for Payer: Cash Price |
$13,454.54
|
| Rate for Payer: Multiplan Auto |
$7,644.62
|
| Rate for Payer: Multiplan Commercial |
$7,644.62
|
| Rate for Payer: Multiplan Workers Comp |
$7,644.62
|
| Rate for Payer: Scott and White EPO/PPO |
$7,644.62
|
| Rate for Payer: Superior Health Plan EPO |
$2,079.34
|
|
|
LD, Body Fluid SO
|
Facility
|
OP
|
$254.00
|
|
|
Service Code
|
CPT 83615
|
| Hospital Charge Code |
1602093
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$165.10 |
| Rate for Payer: Aetna Commercial |
$6.33
|
| Rate for Payer: Aetna Medicare |
$9.06
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.36
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$6.04
|
| Rate for Payer: Amerigroup Medicare |
$6.04
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9.97
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11.96
|
| Rate for Payer: BCBS of TX Medicare |
$6.04
|
| Rate for Payer: BCBS of TX PPO |
$13.35
|
| Rate for Payer: Cash Price |
$223.52
|
| Rate for Payer: Cash Price |
$223.52
|
| Rate for Payer: Cigna Medicaid |
$6.04
|
| Rate for Payer: Cigna Medicare |
$6.04
|
| Rate for Payer: Employer Direct Commercial |
$6.04
|
| Rate for Payer: Humana Medicare/TRICARE |
$6.04
|
| Rate for Payer: Molina CHIP/Medicaid |
$6.04
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$6.04
|
| Rate for Payer: Molina Medicare |
$6.04
|
| Rate for Payer: Multiplan Auto |
$165.10
|
| Rate for Payer: Multiplan Commercial |
$165.10
|
| Rate for Payer: Multiplan Workers Comp |
$165.10
|
| Rate for Payer: Parkland Medicaid |
$6.04
|
| Rate for Payer: Scott and White EPO/PPO |
$7.55
|
| Rate for Payer: Scott and White Medicare |
$6.04
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$6.04
|
| Rate for Payer: Superior Health Plan EPO |
$6.04
|
| Rate for Payer: Superior Health Plan Medicare |
$6.04
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$6.04
|
| Rate for Payer: Universal American Medicare |
$6.04
|
| Rate for Payer: Wellcare Medicare |
$6.04
|
| Rate for Payer: Wellmed Medicare |
$6.04
|
|
|
LD DFB SPRINT SECR 6935M -- DHF
|
Facility
|
IP
|
$24,469.88
|
|
|
Service Code
|
HCPCS C1777
|
| Hospital Charge Code |
40085789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,117.47 |
| Max. Negotiated Rate |
$12,234.94 |
| Rate for Payer: Aetna Commercial |
$7,340.96
|
| Rate for Payer: Cash Price |
$21,533.49
|
| Rate for Payer: Cigna Commercial |
$6,117.47
|
| Rate for Payer: Multiplan Auto |
$12,234.94
|
| Rate for Payer: Multiplan Commercial |
$12,234.94
|
| Rate for Payer: Multiplan Workers Comp |
$12,234.94
|
| Rate for Payer: Scott and White EPO/PPO |
$12,234.94
|
|
|
LD DFB SPRINT SECR 6935M -- DHF
|
Facility
|
OP
|
$24,469.88
|
|
|
Service Code
|
HCPCS C1777
|
| Hospital Charge Code |
40085789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,202.29 |
| Max. Negotiated Rate |
$12,234.94 |
| Rate for Payer: Aetna Commercial |
$7,340.96
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2,202.29
|
| Rate for Payer: BCBS of TX Blue Advantage |
$7,340.96
|
| Rate for Payer: BCBS of TX Blue Essentials |
$8,809.16
|
| Rate for Payer: BCBS of TX PPO |
$9,787.95
|
| Rate for Payer: Cash Price |
$21,533.49
|
| Rate for Payer: Multiplan Auto |
$12,234.94
|
| Rate for Payer: Multiplan Commercial |
$12,234.94
|
| Rate for Payer: Multiplan Workers Comp |
$12,234.94
|
| Rate for Payer: Scott and White EPO/PPO |
$12,234.94
|
| Rate for Payer: Superior Health Plan EPO |
$3,327.90
|
|
|
LD DFB SPRNT QUATR 6947M -- DHF
|
Facility
|
OP
|
$21,084.34
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
40086225
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,897.59 |
| Max. Negotiated Rate |
$10,542.17 |
| Rate for Payer: Aetna Commercial |
$6,325.30
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,897.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$6,325.30
|
| Rate for Payer: BCBS of TX Blue Essentials |
$7,590.36
|
| Rate for Payer: BCBS of TX PPO |
$8,433.74
|
| Rate for Payer: Cash Price |
$18,554.22
|
| Rate for Payer: Multiplan Auto |
$10,542.17
|
| Rate for Payer: Multiplan Commercial |
$10,542.17
|
| Rate for Payer: Multiplan Workers Comp |
$10,542.17
|
| Rate for Payer: Scott and White EPO/PPO |
$10,542.17
|
| Rate for Payer: Superior Health Plan EPO |
$2,867.47
|
|
|
LD DFB SPRNT QUATR 6947M -- DHF
|
Facility
|
IP
|
$21,084.34
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
40086225
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,271.09 |
| Max. Negotiated Rate |
$10,542.17 |
| Rate for Payer: Aetna Commercial |
$6,325.30
|
| Rate for Payer: Cash Price |
$18,554.22
|
| Rate for Payer: Cigna Commercial |
$5,271.09
|
| Rate for Payer: Multiplan Auto |
$10,542.17
|
| Rate for Payer: Multiplan Commercial |
$10,542.17
|
| Rate for Payer: Multiplan Workers Comp |
$10,542.17
|
| Rate for Payer: Scott and White EPO/PPO |
$10,542.17
|
|
|
LD DFIB DURATA 7120Q SJ4 -- DHF
|
Facility
|
OP
|
$24,096.39
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
40085904
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,168.68 |
| Max. Negotiated Rate |
$12,048.19 |
| Rate for Payer: Aetna Commercial |
$7,228.92
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2,168.68
|
| Rate for Payer: BCBS of TX Blue Advantage |
$7,228.92
|
| Rate for Payer: BCBS of TX Blue Essentials |
$8,674.70
|
| Rate for Payer: BCBS of TX PPO |
$9,638.56
|
| Rate for Payer: Cash Price |
$21,204.82
|
| Rate for Payer: Multiplan Auto |
$12,048.19
|
| Rate for Payer: Multiplan Commercial |
$12,048.19
|
| Rate for Payer: Multiplan Workers Comp |
$12,048.19
|
| Rate for Payer: Scott and White EPO/PPO |
$12,048.19
|
| Rate for Payer: Superior Health Plan EPO |
$3,277.11
|
|
|
LD DFIB DURATA 7120Q SJ4 -- DHF
|
Facility
|
IP
|
$24,096.39
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
40085904
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,024.10 |
| Max. Negotiated Rate |
$12,048.19 |
| Rate for Payer: Aetna Commercial |
$7,228.92
|
| Rate for Payer: Cash Price |
$21,204.82
|
| Rate for Payer: Cigna Commercial |
$6,024.10
|
| Rate for Payer: Multiplan Auto |
$12,048.19
|
| Rate for Payer: Multiplan Commercial |
$12,048.19
|
| Rate for Payer: Multiplan Workers Comp |
$12,048.19
|
| Rate for Payer: Scott and White EPO/PPO |
$12,048.19
|
|
