|
ferrous sulfate (as elemental iron) 15 mg/mL Oral Liquid 5 mL
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
79165028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.90
|
| Rate for Payer: BCBS of TX Blue Advantage |
$3.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3.60
|
| Rate for Payer: BCBS of TX PPO |
$4.00
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Cigna Medicaid |
$7.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$7.20
|
| Rate for Payer: Multiplan Auto |
$6.50
|
| Rate for Payer: Multiplan Commercial |
$6.50
|
| Rate for Payer: Multiplan Workers Comp |
$6.50
|
| Rate for Payer: Parkland Medicaid |
$7.20
|
| Rate for Payer: Scott and White EPO/PPO |
$5.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$7.20
|
| Rate for Payer: Superior Health Plan EPO |
$1.36
|
|
|
Fetal Fibronectin
|
Facility
|
IP
|
$809.00
|
|
|
Service Code
|
HCPCS 82731
|
| Hospital Charge Code |
1709203
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$550.12
|
|
|
Fetal Fibronectin
|
Facility
|
OP
|
$809.00
|
|
|
Service Code
|
HCPCS 82731
|
| Hospital Charge Code |
1709203
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$25.12 |
| Max. Negotiated Rate |
$582.48 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$25.12
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$64.41
|
| Rate for Payer: Amerigroup Medicare |
$64.41
|
| Rate for Payer: BCBS of TX Blue Advantage |
$242.70
|
| Rate for Payer: BCBS of TX Blue Essentials |
$291.24
|
| Rate for Payer: BCBS of TX Medicare |
$64.41
|
| Rate for Payer: BCBS of TX PPO |
$323.60
|
| Rate for Payer: Cash Price |
$550.12
|
| Rate for Payer: Cash Price |
$550.12
|
| Rate for Payer: Cigna Medicaid |
$582.48
|
| Rate for Payer: Cigna Medicare |
$64.41
|
| Rate for Payer: Employer Direct Commercial |
$64.41
|
| Rate for Payer: Humana Medicare/TRICARE |
$64.41
|
| Rate for Payer: Molina CHIP/Medicaid |
$582.48
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$64.41
|
| Rate for Payer: Molina Medicare |
$64.41
|
| Rate for Payer: Multiplan Auto |
$525.85
|
| Rate for Payer: Multiplan Commercial |
$525.85
|
| Rate for Payer: Multiplan Workers Comp |
$525.85
|
| Rate for Payer: Parkland Medicaid |
$582.48
|
| Rate for Payer: Scott and White EPO/PPO |
$80.51
|
| Rate for Payer: Scott and White Medicare |
$64.41
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$582.48
|
| Rate for Payer: Superior Health Plan EPO |
$64.41
|
| Rate for Payer: Superior Health Plan Medicare |
$64.41
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$64.41
|
| Rate for Payer: Universal American Medicare |
$64.41
|
| Rate for Payer: Wellcare Medicare |
$64.41
|
| Rate for Payer: Wellmed Medicare |
$64.41
|
|
|
Fetal Hgb Flow Cyto (Ref Lab)
|
Facility
|
IP
|
$438.00
|
|
|
Service Code
|
HCPCS 88184
|
| Hospital Charge Code |
7108818
|
|
Hospital Revenue Code
|
311
|
| Rate for Payer: Cash Price |
$297.84
|
|
|
Fetal Hgb Flow Cyto (Ref Lab)
|
Facility
|
IP
|
$438.00
|
|
|
Service Code
|
HCPCS 88184
|
| Hospital Charge Code |
1709468
|
|
Hospital Revenue Code
|
311
|
| Rate for Payer: Cash Price |
$297.84
|
|
|
Fetal Hgb Flow Cyto (Ref Lab)
|
Facility
|
OP
|
$438.00
|
|
|
Service Code
|
HCPCS 88184
|
| Hospital Charge Code |
1709468
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$761.14 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$26.60
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$360.08
|
| Rate for Payer: Amerigroup Medicare |
$360.08
|
| Rate for Payer: BCBS of TX Blue Advantage |
$131.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$157.68
|
| Rate for Payer: BCBS of TX Medicare |
$360.08
|
| Rate for Payer: BCBS of TX PPO |
$175.20
|
| Rate for Payer: Cash Price |
$297.84
|
| Rate for Payer: Cash Price |
$297.84
|
| Rate for Payer: Cash Price |
$297.84
|
| Rate for Payer: Cigna Commercial |
$761.14
|
| Rate for Payer: Cigna Medicaid |
$315.36
|
| Rate for Payer: Cigna Medicare |
$360.08
|
| Rate for Payer: Employer Direct Commercial |
$360.08
|
| Rate for Payer: Humana Medicare/TRICARE |
$360.08
|
| Rate for Payer: Molina CHIP/Medicaid |
$315.36
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$360.08
|
| Rate for Payer: Molina Medicare |
$360.08
|
| Rate for Payer: Multiplan Auto |
$284.70
|
| Rate for Payer: Multiplan Commercial |
$284.70
|
| Rate for Payer: Multiplan Workers Comp |
$284.70
|
| Rate for Payer: Parkland Medicaid |
$315.36
|
| Rate for Payer: Scott and White EPO/PPO |
$100.94
|
| Rate for Payer: Scott and White Medicare |
$360.08
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$315.36
|
| Rate for Payer: Superior Health Plan EPO |
$360.08
|
| Rate for Payer: Superior Health Plan Medicare |
$360.08
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$360.08
|
| Rate for Payer: Universal American Medicare |
$360.08
|
| Rate for Payer: Wellcare Medicare |
$360.08
|
| Rate for Payer: Wellmed Medicare |
$360.08
|
|
|
Fetal Hgb Flow Cyto (Ref Lab)
|
Facility
|
OP
|
$438.00
|
|
|
Service Code
|
HCPCS 88184
|
| Hospital Charge Code |
7108818
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$761.14 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$26.60
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$360.08
|
| Rate for Payer: Amerigroup Medicare |
$360.08
|
| Rate for Payer: BCBS of TX Blue Advantage |
$131.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$157.68
|
| Rate for Payer: BCBS of TX Medicare |
$360.08
|
| Rate for Payer: BCBS of TX PPO |
$175.20
|
| Rate for Payer: Cash Price |
$297.84
|
| Rate for Payer: Cash Price |
$297.84
|
| Rate for Payer: Cash Price |
$297.84
|
| Rate for Payer: Cigna Commercial |
$761.14
|
| Rate for Payer: Cigna Medicaid |
$315.36
|
| Rate for Payer: Cigna Medicare |
$360.08
|
| Rate for Payer: Employer Direct Commercial |
$360.08
|
| Rate for Payer: Humana Medicare/TRICARE |
$360.08
|
| Rate for Payer: Molina CHIP/Medicaid |
$315.36
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$360.08
|
| Rate for Payer: Molina Medicare |
$360.08
|
| Rate for Payer: Multiplan Auto |
$284.70
|
| Rate for Payer: Multiplan Commercial |
$284.70
|
| Rate for Payer: Multiplan Workers Comp |
$284.70
|
| Rate for Payer: Parkland Medicaid |
$315.36
|
| Rate for Payer: Scott and White EPO/PPO |
$100.94
|
| Rate for Payer: Scott and White Medicare |
$360.08
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$315.36
|
| Rate for Payer: Superior Health Plan EPO |
$360.08
|
| Rate for Payer: Superior Health Plan Medicare |
$360.08
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$360.08
|
| Rate for Payer: Universal American Medicare |
$360.08
|
| Rate for Payer: Wellcare Medicare |
$360.08
|
| Rate for Payer: Wellmed Medicare |
$360.08
|
|
|
Fetal Non-Stress Test (NST)
|
Facility
|
OP
|
$1,004.00
|
|
|
Service Code
|
HCPCS 59025
|
| Hospital Charge Code |
300467
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$90.36 |
| Max. Negotiated Rate |
$722.88 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$90.36
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$203.09
|
| Rate for Payer: Amerigroup Medicare |
$203.09
|
| Rate for Payer: BCBS of TX Blue Advantage |
$301.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$361.44
|
| Rate for Payer: BCBS of TX Medicare |
$203.09
|
| Rate for Payer: BCBS of TX PPO |
$401.60
|
| Rate for Payer: Cash Price |
$682.72
|
| Rate for Payer: Cash Price |
$682.72
|
| Rate for Payer: Cash Price |
$682.72
|
| Rate for Payer: Cigna Commercial |
$429.31
|
| Rate for Payer: Cigna Medicaid |
$722.88
|
| Rate for Payer: Cigna Medicare |
$203.09
|
| Rate for Payer: Employer Direct Commercial |
$203.09
|
| Rate for Payer: Humana Medicare/TRICARE |
$203.09
|
| Rate for Payer: Molina CHIP/Medicaid |
$722.88
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$203.09
|
| Rate for Payer: Molina Medicare |
$203.09
|
| Rate for Payer: Multiplan Auto |
$652.60
|
| Rate for Payer: Multiplan Commercial |
$652.60
|
| Rate for Payer: Multiplan Workers Comp |
$652.60
|
| Rate for Payer: Parkland Medicaid |
$722.88
|
| Rate for Payer: Scott and White EPO/PPO |
$502.00
|
| Rate for Payer: Scott and White Medicare |
$203.09
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$722.88
|
| Rate for Payer: Superior Health Plan EPO |
$203.09
|
| Rate for Payer: Superior Health Plan Medicare |
$203.09
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$203.09
|
| Rate for Payer: Universal American Medicare |
$203.09
|
| Rate for Payer: Wellcare Medicare |
$203.09
|
| Rate for Payer: Wellmed Medicare |
$203.09
|
|
|
Fetal Non-Stress Test (NST)
|
Facility
|
IP
|
$1,004.00
|
|
|
Service Code
|
HCPCS 59025
|
| Hospital Charge Code |
300467
|
|
Hospital Revenue Code
|
920
|
| Rate for Payer: Cash Price |
$682.72
|
|
|
Fetal Screen
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS 83033
|
| Hospital Charge Code |
1708932
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$21.08
|
|
|
Fetal Screen
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS 83033
|
| Hospital Charge Code |
1708932
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$22.32 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.12
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$8.00
|
| Rate for Payer: Amerigroup Medicare |
$8.00
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9.30
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11.16
|
| Rate for Payer: BCBS of TX Medicare |
$8.00
|
| Rate for Payer: BCBS of TX PPO |
$12.40
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cigna Medicaid |
$22.32
|
| Rate for Payer: Cigna Medicare |
$8.00
|
| Rate for Payer: Employer Direct Commercial |
$8.00
|
| Rate for Payer: Humana Medicare/TRICARE |
$8.00
|
| Rate for Payer: Molina CHIP/Medicaid |
$22.32
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$8.00
|
| Rate for Payer: Molina Medicare |
$8.00
|
| Rate for Payer: Multiplan Auto |
$20.15
|
| Rate for Payer: Multiplan Commercial |
$20.15
|
| Rate for Payer: Multiplan Workers Comp |
$20.15
|
| Rate for Payer: Parkland Medicaid |
$22.32
|
| Rate for Payer: Scott and White EPO/PPO |
$10.00
|
| Rate for Payer: Scott and White Medicare |
$8.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$22.32
|
| Rate for Payer: Superior Health Plan EPO |
$8.00
|
| Rate for Payer: Superior Health Plan Medicare |
$8.00
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$8.00
|
| Rate for Payer: Universal American Medicare |
$8.00
|
| Rate for Payer: Wellcare Medicare |
$8.00
|
| Rate for Payer: Wellmed Medicare |
$8.00
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$16,866.30
|
|
|
Service Code
|
MSDRG 864
|
| Min. Negotiated Rate |
$7,432.98 |
| Max. Negotiated Rate |
$16,866.30 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$11,266.06
|
| Rate for Payer: Amerigroup Medicare |
$11,266.06
|
| Rate for Payer: BCBS of TX Blue Advantage |
$7,432.98
|
| Rate for Payer: BCBS of TX Blue Essentials |
$8,918.71
|
| Rate for Payer: BCBS of TX Medicare |
$11,266.06
|
| Rate for Payer: BCBS of TX PPO |
$9,910.06
|
| Rate for Payer: Cigna Commercial |
$11,433.58
|
| Rate for Payer: Cigna Medicare |
$11,266.06
|
| Rate for Payer: Employer Direct Commercial |
$11,266.06
|
| Rate for Payer: Humana Medicare/TRICARE |
$11,266.06
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$11,266.06
|
| Rate for Payer: Molina Medicare |
$11,266.06
|
| Rate for Payer: Multiplan Auto |
$16,866.30
|
| Rate for Payer: Multiplan Commercial |
$16,866.30
|
| Rate for Payer: Multiplan Workers Comp |
$16,866.30
|
| Rate for Payer: Scott and White EPO/PPO |
$7,767.38
|
| Rate for Payer: Scott and White Medicare |
$11,266.06
|
| Rate for Payer: Superior Health Plan EPO |
$11,266.06
|
| Rate for Payer: Superior Health Plan Medicare |
$11,266.06
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$11,266.06
|
| Rate for Payer: Universal American Medicare |
$11,266.06
|
| Rate for Payer: Wellcare Medicare |
$11,266.06
|
| Rate for Payer: Wellmed Medicare |
$11,266.06
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$4,881.20
|
|
|
Service Code
|
APR-DRG 7224
|
| Min. Negotiated Rate |
$4,602.17 |
| Max. Negotiated Rate |
$4,881.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$4,602.17
|
| Rate for Payer: Cigna Medicaid |
$4,602.17
|
| Rate for Payer: Molina CHIP/Medicaid |
$4,602.17
|
| Rate for Payer: Parkland Medicaid |
$4,602.17
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$4,881.20
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$3,832.24
|
|
|
Service Code
|
APR-DRG 7223
|
| Min. Negotiated Rate |
$3,613.17 |
| Max. Negotiated Rate |
$3,832.24 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3,613.17
|
| Rate for Payer: Cigna Medicaid |
$3,613.17
|
| Rate for Payer: Molina CHIP/Medicaid |
$3,613.17
|
| Rate for Payer: Parkland Medicaid |
$3,613.17
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$3,832.24
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$1,471.04
|
|
|
Service Code
|
APR-DRG 7221
|
| Min. Negotiated Rate |
$1,386.95 |
| Max. Negotiated Rate |
$1,471.04 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,386.95
|
| Rate for Payer: Cigna Medicaid |
$1,386.95
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,386.95
|
| Rate for Payer: Parkland Medicaid |
$1,386.95
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,471.04
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$2,180.15
|
|
|
Service Code
|
APR-DRG 7222
|
| Min. Negotiated Rate |
$2,055.52 |
| Max. Negotiated Rate |
$2,180.15 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2,055.52
|
| Rate for Payer: Cigna Medicaid |
$2,055.52
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,055.52
|
| Rate for Payer: Parkland Medicaid |
$2,055.52
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,180.15
|
|
|
FFS22020
|
Facility
|
IP
|
$15,234.34
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
991132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,808.59 |
| Max. Negotiated Rate |
$7,617.17 |
| Rate for Payer: Cash Price |
$10,359.35
|
| Rate for Payer: Cigna Commercial |
$3,808.59
|
| Rate for Payer: Multiplan Auto |
$7,617.17
|
| Rate for Payer: Multiplan Commercial |
$7,617.17
|
| Rate for Payer: Multiplan Workers Comp |
$7,617.17
|
| Rate for Payer: Scott and White EPO/PPO |
$7,617.17
|
|
|
FFS22020
|
Facility
|
OP
|
$15,234.34
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
991132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,371.09 |
| Max. Negotiated Rate |
$10,968.72 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,371.09
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,570.30
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,484.36
|
| Rate for Payer: BCBS of TX PPO |
$6,093.74
|
| Rate for Payer: Cash Price |
$10,359.35
|
| Rate for Payer: Cigna Medicaid |
$10,968.72
|
| Rate for Payer: Molina CHIP/Medicaid |
$10,968.72
|
| Rate for Payer: Multiplan Auto |
$7,617.17
|
| Rate for Payer: Multiplan Commercial |
$7,617.17
|
| Rate for Payer: Multiplan Workers Comp |
$7,617.17
|
| Rate for Payer: Parkland Medicaid |
$10,968.72
|
| Rate for Payer: Scott and White EPO/PPO |
$7,617.17
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$10,968.72
|
| Rate for Payer: Superior Health Plan EPO |
$2,071.87
|
|
|
FFSP1530
|
Facility
|
IP
|
$2,704.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
991131
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$676.21 |
| Max. Negotiated Rate |
$1,352.41 |
| Rate for Payer: Cash Price |
$1,839.28
|
| Rate for Payer: Cigna Commercial |
$676.21
|
| Rate for Payer: Multiplan Auto |
$1,352.41
|
| Rate for Payer: Multiplan Commercial |
$1,352.41
|
| Rate for Payer: Multiplan Workers Comp |
$1,352.41
|
| Rate for Payer: Scott and White EPO/PPO |
$1,352.41
|
|
|
FFSP1530
|
Facility
|
OP
|
$2,704.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
991131
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$243.43 |
| Max. Negotiated Rate |
$1,947.47 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$243.43
|
| Rate for Payer: BCBS of TX Blue Advantage |
$811.45
|
| Rate for Payer: BCBS of TX Blue Essentials |
$973.74
|
| Rate for Payer: BCBS of TX PPO |
$1,081.93
|
| Rate for Payer: Cash Price |
$1,839.28
|
| Rate for Payer: Cigna Medicaid |
$1,947.47
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,947.47
|
| Rate for Payer: Multiplan Auto |
$1,352.41
|
| Rate for Payer: Multiplan Commercial |
$1,352.41
|
| Rate for Payer: Multiplan Workers Comp |
$1,352.41
|
| Rate for Payer: Parkland Medicaid |
$1,947.47
|
| Rate for Payer: Scott and White EPO/PPO |
$1,352.41
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,947.47
|
| Rate for Payer: Superior Health Plan EPO |
$367.86
|
|
|
FIBER LASER GREEN LIGHT
|
Facility
|
OP
|
$4,994.00
|
|
| Hospital Charge Code |
8492482
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$449.46 |
| Max. Negotiated Rate |
$3,595.68 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$449.46
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,498.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,797.84
|
| Rate for Payer: BCBS of TX PPO |
$1,997.60
|
| Rate for Payer: Cash Price |
$3,395.92
|
| Rate for Payer: Cigna Medicaid |
$3,595.68
|
| Rate for Payer: Molina CHIP/Medicaid |
$3,595.68
|
| Rate for Payer: Multiplan Auto |
$3,246.10
|
| Rate for Payer: Multiplan Commercial |
$3,246.10
|
| Rate for Payer: Multiplan Workers Comp |
$3,246.10
|
| Rate for Payer: Parkland Medicaid |
$3,595.68
|
| Rate for Payer: Scott and White EPO/PPO |
$2,497.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$3,595.68
|
| Rate for Payer: Superior Health Plan EPO |
$679.18
|
|
|
FIBER LASER GREEN LIGHT
|
Facility
|
IP
|
$4,994.00
|
|
| Hospital Charge Code |
8492482
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$3,395.92
|
|
|
FIBER LASER HOLMIUM AGILITI
|
Facility
|
OP
|
$2,174.66
|
|
| Hospital Charge Code |
146143
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$195.72 |
| Max. Negotiated Rate |
$1,565.76 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$195.72
|
| Rate for Payer: BCBS of TX Blue Advantage |
$652.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$782.88
|
| Rate for Payer: BCBS of TX PPO |
$869.86
|
| Rate for Payer: Cash Price |
$1,478.77
|
| Rate for Payer: Cigna Medicaid |
$1,565.76
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,565.76
|
| Rate for Payer: Multiplan Auto |
$1,413.53
|
| Rate for Payer: Multiplan Commercial |
$1,413.53
|
| Rate for Payer: Multiplan Workers Comp |
$1,413.53
|
| Rate for Payer: Parkland Medicaid |
$1,565.76
|
| Rate for Payer: Scott and White EPO/PPO |
$1,087.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,565.76
|
| Rate for Payer: Superior Health Plan EPO |
$295.75
|
|
|
FIBER LASER HOLMIUM AGILITI
|
Facility
|
IP
|
$2,174.66
|
|
| Hospital Charge Code |
146143
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$1,478.77
|
|
|
FIBERTAPE CERCLAGE 2MM W/ TIGERLINK SHUTTLE SUTURE
|
Facility
|
IP
|
$4,889.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
146431
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,222.25 |
| Max. Negotiated Rate |
$2,444.50 |
| Rate for Payer: Cash Price |
$3,324.52
|
| Rate for Payer: Cigna Commercial |
$1,222.25
|
| Rate for Payer: Multiplan Auto |
$2,444.50
|
| Rate for Payer: Multiplan Commercial |
$2,444.50
|
| Rate for Payer: Multiplan Workers Comp |
$2,444.50
|
| Rate for Payer: Scott and White EPO/PPO |
$2,444.50
|
|
