|
Ligamentous reconstruction (augmentation), knee; extra-articular
|
Facility
|
OP
|
$15,074.51
|
|
|
Service Code
|
CPT 27427
|
| Hospital Charge Code |
36027427
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$144.31 |
| Max. Negotiated Rate |
$15,074.51 |
| Rate for Payer: Aetna Commercial |
$7,210.00
|
| Rate for Payer: Aetna Medicare |
$9,814.08
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3,170.89
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$6,542.72
|
| Rate for Payer: Amerigroup Medicare |
$6,542.72
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9,989.86
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11,963.90
|
| Rate for Payer: BCBS of TX Medicare |
$6,542.72
|
| Rate for Payer: BCBS of TX PPO |
$15,074.51
|
| Rate for Payer: Cigna Commercial |
$14,821.16
|
| Rate for Payer: Cigna Medicaid |
$3,170.89
|
| Rate for Payer: Cigna Medicare |
$6,542.72
|
| Rate for Payer: Employer Direct Commercial |
$6,542.72
|
| Rate for Payer: Humana Medicare/TRICARE |
$6,542.72
|
| Rate for Payer: Molina CHIP/Medicaid |
$3,170.89
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$6,542.72
|
| Rate for Payer: Molina Medicare |
$6,542.72
|
| 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: Parkland Medicaid |
$3,170.89
|
| Rate for Payer: Scott and White EPO/PPO |
$144.31
|
| Rate for Payer: Scott and White Medicare |
$6,542.72
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$3,170.89
|
| Rate for Payer: Superior Health Plan EPO |
$6,542.72
|
| Rate for Payer: Superior Health Plan Medicare |
$6,542.72
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$6,542.72
|
| Rate for Payer: Universal American Medicare |
$6,542.72
|
| Rate for Payer: Wellcare Medicare |
$6,542.72
|
| Rate for Payer: Wellmed Medicare |
$6,542.72
|
|
|
Ligation and division and complete stripping of long or short saphenous veins with radical excision
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 37735
|
| Hospital Charge Code |
36037735
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$64.30 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$4,635.00
|
| Rate for Payer: Aetna Medicare |
$4,372.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,118.22
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$2,915.10
|
| Rate for Payer: Amerigroup Medicare |
$2,915.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,628.04
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,542.56
|
| Rate for Payer: BCBS of TX Medicare |
$2,915.10
|
| Rate for Payer: BCBS of TX PPO |
$6,983.63
|
| Rate for Payer: Cigna Commercial |
$6,603.56
|
| Rate for Payer: Cigna Medicaid |
$1,118.22
|
| Rate for Payer: Cigna Medicare |
$2,915.10
|
| Rate for Payer: Employer Direct Commercial |
$2,915.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$2,915.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,118.22
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$2,915.10
|
| Rate for Payer: Molina Medicare |
$2,915.10
|
| 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: Parkland Medicaid |
$1,118.22
|
| Rate for Payer: Scott and White EPO/PPO |
$64.30
|
| Rate for Payer: Scott and White Medicare |
$2,915.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,118.22
|
| Rate for Payer: Superior Health Plan EPO |
$2,915.10
|
| Rate for Payer: Superior Health Plan Medicare |
$2,915.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$2,915.10
|
| Rate for Payer: Universal American Medicare |
$2,915.10
|
| Rate for Payer: Wellcare Medicare |
$2,915.10
|
| Rate for Payer: Wellmed Medicare |
$2,915.10
|
|
|
LIGATION INF VENACAVA
|
Facility
|
IP
|
$19,220.00
|
|
|
Service Code
|
CPT 37619
|
| Hospital Charge Code |
4617619
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$16,913.60
|
|
|
LIGATION INF VENACAVA
|
Facility
|
OP
|
$19,220.00
|
|
|
Service Code
|
CPT 37619
|
| Hospital Charge Code |
4617619
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$110.85 |
| Max. Negotiated Rate |
$11,582.40 |
| Rate for Payer: Aetna Commercial |
$7,210.00
|
| Rate for Payer: Aetna Medicare |
$7,538.62
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,729.80
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5,025.75
|
| Rate for Payer: Amerigroup Medicare |
$5,025.75
|
| Rate for Payer: BCBS of TX Blue Advantage |
$7,675.64
|
| Rate for Payer: BCBS of TX Blue Essentials |
$9,192.38
|
| Rate for Payer: BCBS of TX Medicare |
$5,025.75
|
| Rate for Payer: BCBS of TX PPO |
$11,582.40
|
| Rate for Payer: Cash Price |
$16,913.60
|
| Rate for Payer: Cash Price |
$16,913.60
|
| Rate for Payer: Cash Price |
$16,913.60
|
| Rate for Payer: Cigna Commercial |
$11,384.78
|
| Rate for Payer: Cigna Medicare |
$5,025.75
|
| Rate for Payer: Employer Direct Commercial |
$5,025.75
|
| Rate for Payer: Humana Medicare/TRICARE |
$5,025.75
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5,025.75
|
| Rate for Payer: Molina Medicare |
$5,025.75
|
| 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 EPO/PPO |
$110.85
|
| Rate for Payer: Scott and White Medicare |
$5,025.75
|
| Rate for Payer: Superior Health Plan EPO |
$5,025.75
|
| Rate for Payer: Superior Health Plan Medicare |
$5,025.75
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5,025.75
|
| Rate for Payer: Universal American Medicare |
$5,025.75
|
| Rate for Payer: Wellcare Medicare |
$5,025.75
|
| Rate for Payer: Wellmed Medicare |
$5,025.75
|
|
|
Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 l
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 37761
|
| Hospital Charge Code |
36037761
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$64.30 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$4,372.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,118.22
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$2,915.10
|
| Rate for Payer: Amerigroup Medicare |
$2,915.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$968.45
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,159.82
|
| Rate for Payer: BCBS of TX Medicare |
$2,915.10
|
| Rate for Payer: BCBS of TX PPO |
$1,461.37
|
| Rate for Payer: Cigna Commercial |
$6,603.56
|
| Rate for Payer: Cigna Medicaid |
$1,118.22
|
| Rate for Payer: Cigna Medicare |
$2,915.10
|
| Rate for Payer: Employer Direct Commercial |
$2,915.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$2,915.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,118.22
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$2,915.10
|
| Rate for Payer: Molina Medicare |
$2,915.10
|
| 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: Parkland Medicaid |
$1,118.22
|
| Rate for Payer: Scott and White EPO/PPO |
$64.30
|
| Rate for Payer: Scott and White Medicare |
$2,915.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,118.22
|
| Rate for Payer: Superior Health Plan EPO |
$2,915.10
|
| Rate for Payer: Superior Health Plan Medicare |
$2,915.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$2,915.10
|
| Rate for Payer: Universal American Medicare |
$2,915.10
|
| Rate for Payer: Wellcare Medicare |
$2,915.10
|
| Rate for Payer: Wellmed Medicare |
$2,915.10
|
|
|
LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$73,685.80
|
|
|
Service Code
|
MSDRG 956
|
| Min. Negotiated Rate |
$30,529.85 |
| Max. Negotiated Rate |
$73,685.80 |
| Rate for Payer: Aetna Commercial |
$43,629.75
|
| Rate for Payer: Aetna Medicare |
$45,794.78
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$30,529.85
|
| Rate for Payer: Amerigroup Medicare |
$30,529.85
|
| Rate for Payer: BCBS of TX Blue Advantage |
$32,840.82
|
| Rate for Payer: BCBS of TX Blue Essentials |
$39,045.03
|
| Rate for Payer: BCBS of TX Medicare |
$30,529.85
|
| Rate for Payer: BCBS of TX PPO |
$43,385.05
|
| Rate for Payer: Cigna Commercial |
$49,951.22
|
| Rate for Payer: Cigna Medicare |
$30,529.85
|
| Rate for Payer: Employer Direct Commercial |
$30,529.85
|
| Rate for Payer: Humana Medicare/TRICARE |
$30,529.85
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$30,529.85
|
| Rate for Payer: Molina Medicare |
$30,529.85
|
| Rate for Payer: Multiplan Auto |
$73,685.80
|
| Rate for Payer: Multiplan Commercial |
$73,685.80
|
| Rate for Payer: Multiplan Workers Comp |
$73,685.80
|
| Rate for Payer: Scott and White EPO/PPO |
$33,934.25
|
| Rate for Payer: Scott and White Medicare |
$30,529.85
|
| Rate for Payer: Superior Health Plan EPO |
$30,529.85
|
| Rate for Payer: Superior Health Plan Medicare |
$30,529.85
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$30,529.85
|
| Rate for Payer: Universal American Medicare |
$30,529.85
|
| Rate for Payer: Wellcare Medicare |
$30,529.85
|
| Rate for Payer: Wellmed Medicare |
$30,529.85
|
|
|
linezolid 2 mg/mL IV Soln 300 mL
|
Facility
|
IP
|
$253.70
|
|
|
Service Code
|
HCPCS J2020
|
| Hospital Charge Code |
78438885
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.42 |
| Max. Negotiated Rate |
$126.85 |
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cigna Commercial |
$63.42
|
| Rate for Payer: Scott and White EPO/PPO |
$126.85
|
|
|
linezolid 2 mg/mL IV Soln 300 mL
|
Facility
|
OP
|
$253.70
|
|
|
Service Code
|
HCPCS J2020
|
| Hospital Charge Code |
78438885
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.88 |
| Max. Negotiated Rate |
$164.90 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$22.83
|
| Rate for Payer: BCBS of TX Blue Advantage |
$20.88
|
| Rate for Payer: BCBS of TX Blue Essentials |
$25.06
|
| Rate for Payer: BCBS of TX PPO |
$27.79
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Multiplan Auto |
$164.90
|
| Rate for Payer: Multiplan Commercial |
$164.90
|
| Rate for Payer: Multiplan Workers Comp |
$164.90
|
| Rate for Payer: Scott and White EPO/PPO |
$126.85
|
| Rate for Payer: Superior Health Plan EPO |
$34.50
|
|
|
linezolid 600 mg Tab
|
Facility
|
OP
|
$314.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78430404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.26 |
| Max. Negotiated Rate |
$204.10 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$28.26
|
| Rate for Payer: BCBS of TX Blue Advantage |
$94.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$113.04
|
| Rate for Payer: BCBS of TX PPO |
$125.60
|
| Rate for Payer: Cash Price |
$213.52
|
| Rate for Payer: Multiplan Auto |
$204.10
|
| Rate for Payer: Multiplan Commercial |
$204.10
|
| Rate for Payer: Multiplan Workers Comp |
$204.10
|
| Rate for Payer: Scott and White EPO/PPO |
$157.00
|
| Rate for Payer: Superior Health Plan EPO |
$42.70
|
|
|
linezolid 600 mg Tab
|
Facility
|
IP
|
$314.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78430404
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$213.52
|
|
|
Lipase Level
|
Facility
|
IP
|
$274.00
|
|
|
Service Code
|
CPT 83690
|
| Hospital Charge Code |
1602127
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$241.12
|
|
|
Lipase Level
|
Facility
|
OP
|
$274.00
|
|
|
Service Code
|
CPT 83690
|
| Hospital Charge Code |
1602127
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$178.10 |
| Rate for Payer: Aetna Commercial |
$7.23
|
| Rate for Payer: Aetna Medicare |
$10.34
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.69
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$6.89
|
| Rate for Payer: Amerigroup Medicare |
$6.89
|
| Rate for Payer: BCBS of TX Blue Advantage |
$11.37
|
| Rate for Payer: BCBS of TX Blue Essentials |
$13.64
|
| Rate for Payer: BCBS of TX Medicare |
$6.89
|
| Rate for Payer: BCBS of TX PPO |
$15.23
|
| Rate for Payer: Cash Price |
$241.12
|
| Rate for Payer: Cash Price |
$241.12
|
| Rate for Payer: Cigna Medicaid |
$6.89
|
| Rate for Payer: Cigna Medicare |
$6.89
|
| Rate for Payer: Employer Direct Commercial |
$6.89
|
| Rate for Payer: Humana Medicare/TRICARE |
$6.89
|
| Rate for Payer: Molina CHIP/Medicaid |
$6.89
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$6.89
|
| Rate for Payer: Molina Medicare |
$6.89
|
| Rate for Payer: Multiplan Auto |
$178.10
|
| Rate for Payer: Multiplan Commercial |
$178.10
|
| Rate for Payer: Multiplan Workers Comp |
$178.10
|
| Rate for Payer: Parkland Medicaid |
$6.89
|
| Rate for Payer: Scott and White EPO/PPO |
$8.61
|
| Rate for Payer: Scott and White Medicare |
$6.89
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$6.89
|
| Rate for Payer: Superior Health Plan EPO |
$6.89
|
| Rate for Payer: Superior Health Plan Medicare |
$6.89
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$6.89
|
| Rate for Payer: Universal American Medicare |
$6.89
|
| Rate for Payer: Wellcare Medicare |
$6.89
|
| Rate for Payer: Wellmed Medicare |
$6.89
|
|
|
Lipid Panel
|
Facility
|
OP
|
$438.00
|
|
|
Service Code
|
CPT 80061
|
| Hospital Charge Code |
1601004
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$284.70 |
| Rate for Payer: Aetna Commercial |
$14.05
|
| Rate for Payer: Aetna Medicare |
$20.08
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.22
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$13.39
|
| Rate for Payer: Amerigroup Medicare |
$13.39
|
| Rate for Payer: BCBS of TX Blue Advantage |
$22.09
|
| Rate for Payer: BCBS of TX Blue Essentials |
$26.51
|
| Rate for Payer: BCBS of TX Medicare |
$13.39
|
| Rate for Payer: BCBS of TX PPO |
$29.59
|
| Rate for Payer: Cash Price |
$385.44
|
| Rate for Payer: Cash Price |
$385.44
|
| Rate for Payer: Cigna Medicaid |
$13.39
|
| Rate for Payer: Cigna Medicare |
$13.39
|
| Rate for Payer: Employer Direct Commercial |
$13.39
|
| Rate for Payer: Humana Medicare/TRICARE |
$13.39
|
| Rate for Payer: Molina CHIP/Medicaid |
$13.39
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$13.39
|
| Rate for Payer: Molina Medicare |
$13.39
|
| 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 |
$13.39
|
| Rate for Payer: Scott and White EPO/PPO |
$16.74
|
| Rate for Payer: Scott and White Medicare |
$13.39
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$13.39
|
| Rate for Payer: Superior Health Plan EPO |
$13.39
|
| Rate for Payer: Superior Health Plan Medicare |
$13.39
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$13.39
|
| Rate for Payer: Universal American Medicare |
$13.39
|
| Rate for Payer: Wellcare Medicare |
$13.39
|
| Rate for Payer: Wellmed Medicare |
$13.39
|
|
|
Lipid Panel
|
Facility
|
IP
|
$438.00
|
|
|
Service Code
|
CPT 80061
|
| Hospital Charge Code |
1601004
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$385.44
|
|
|
Lipoprotein (a) SO
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 83695
|
| Hospital Charge Code |
1740299
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$132.00
|
|
|
Lipoprotein (a) SO
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 83695
|
| Hospital Charge Code |
1740299
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$97.50 |
| Rate for Payer: Aetna Commercial |
$15.03
|
| Rate for Payer: Aetna Medicare |
$21.48
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.58
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14.32
|
| Rate for Payer: Amerigroup Medicare |
$14.32
|
| Rate for Payer: BCBS of TX Blue Advantage |
$23.63
|
| Rate for Payer: BCBS of TX Blue Essentials |
$28.35
|
| Rate for Payer: BCBS of TX Medicare |
$14.32
|
| Rate for Payer: BCBS of TX PPO |
$31.65
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Medicaid |
$14.32
|
| Rate for Payer: Cigna Medicare |
$14.32
|
| Rate for Payer: Employer Direct Commercial |
$14.32
|
| Rate for Payer: Humana Medicare/TRICARE |
$14.32
|
| Rate for Payer: Molina CHIP/Medicaid |
$14.32
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14.32
|
| Rate for Payer: Molina Medicare |
$14.32
|
| Rate for Payer: Multiplan Auto |
$97.50
|
| Rate for Payer: Multiplan Commercial |
$97.50
|
| Rate for Payer: Multiplan Workers Comp |
$97.50
|
| Rate for Payer: Parkland Medicaid |
$14.32
|
| Rate for Payer: Scott and White EPO/PPO |
$17.90
|
| Rate for Payer: Scott and White Medicare |
$14.32
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$14.32
|
| Rate for Payer: Superior Health Plan EPO |
$14.32
|
| Rate for Payer: Superior Health Plan Medicare |
$14.32
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14.32
|
| Rate for Payer: Universal American Medicare |
$14.32
|
| Rate for Payer: Wellcare Medicare |
$14.32
|
| Rate for Payer: Wellmed Medicare |
$14.32
|
|
|
lisinopril 10 mg Tab
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77668489
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
lisinopril 10 mg Tab
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77668489
|
|
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
|
|
|
lisinopril 20 mg Tab
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77668597
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
lisinopril 20 mg Tab
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77668597
|
|
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
|
|
|
lisinopril 5 mg Tab
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77668762
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
lisinopril 5 mg Tab
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77668762
|
|
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
|
|
|
lithium 150 mg Cap
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77668815
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
lithium 150 mg Cap
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77668815
|
|
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
|
|
|
Lithium Level
|
Facility
|
OP
|
$334.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
1602820
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$217.10 |
| Rate for Payer: Aetna Commercial |
$6.95
|
| Rate for Payer: Aetna Medicare |
$9.92
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.58
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$6.61
|
| Rate for Payer: Amerigroup Medicare |
$6.61
|
| Rate for Payer: BCBS of TX Blue Advantage |
$10.91
|
| Rate for Payer: BCBS of TX Blue Essentials |
$13.09
|
| Rate for Payer: BCBS of TX Medicare |
$6.61
|
| Rate for Payer: BCBS of TX PPO |
$14.61
|
| Rate for Payer: Cash Price |
$293.92
|
| Rate for Payer: Cash Price |
$293.92
|
| Rate for Payer: Cigna Medicaid |
$6.61
|
| Rate for Payer: Cigna Medicare |
$6.61
|
| Rate for Payer: Employer Direct Commercial |
$6.61
|
| Rate for Payer: Humana Medicare/TRICARE |
$6.61
|
| Rate for Payer: Molina CHIP/Medicaid |
$6.61
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$6.61
|
| Rate for Payer: Molina Medicare |
$6.61
|
| Rate for Payer: Multiplan Auto |
$217.10
|
| Rate for Payer: Multiplan Commercial |
$217.10
|
| Rate for Payer: Multiplan Workers Comp |
$217.10
|
| Rate for Payer: Parkland Medicaid |
$6.61
|
| Rate for Payer: Scott and White EPO/PPO |
$8.26
|
| Rate for Payer: Scott and White Medicare |
$6.61
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$6.61
|
| Rate for Payer: Superior Health Plan EPO |
$6.61
|
| Rate for Payer: Superior Health Plan Medicare |
$6.61
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$6.61
|
| Rate for Payer: Universal American Medicare |
$6.61
|
| Rate for Payer: Wellcare Medicare |
$6.61
|
| Rate for Payer: Wellmed Medicare |
$6.61
|
|
