|
.Lyme Western Blot 163601 SO
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT 86617
|
| Hospital Charge Code |
1708866
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.04 |
| Max. Negotiated Rate |
$55.90 |
| Rate for Payer: Aetna Commercial |
$16.26
|
| Rate for Payer: Aetna Medicare |
$23.24
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$6.04
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$15.49
|
| Rate for Payer: Amerigroup Medicare |
$15.49
|
| Rate for Payer: BCBS of TX Blue Advantage |
$25.56
|
| Rate for Payer: BCBS of TX Blue Essentials |
$30.67
|
| Rate for Payer: BCBS of TX Medicare |
$15.49
|
| Rate for Payer: BCBS of TX PPO |
$34.23
|
| Rate for Payer: Cash Price |
$75.68
|
| Rate for Payer: Cash Price |
$75.68
|
| Rate for Payer: Cigna Medicaid |
$15.49
|
| Rate for Payer: Cigna Medicare |
$15.49
|
| Rate for Payer: Employer Direct Commercial |
$15.49
|
| Rate for Payer: Humana Medicare/TRICARE |
$15.49
|
| Rate for Payer: Molina CHIP/Medicaid |
$15.49
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$15.49
|
| Rate for Payer: Molina Medicare |
$15.49
|
| Rate for Payer: Multiplan Auto |
$55.90
|
| Rate for Payer: Multiplan Commercial |
$55.90
|
| Rate for Payer: Multiplan Workers Comp |
$55.90
|
| Rate for Payer: Parkland Medicaid |
$15.49
|
| Rate for Payer: Scott and White EPO/PPO |
$19.36
|
| Rate for Payer: Scott and White Medicare |
$15.49
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$15.49
|
| Rate for Payer: Superior Health Plan EPO |
$15.49
|
| Rate for Payer: Superior Health Plan Medicare |
$15.49
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$15.49
|
| Rate for Payer: Universal American Medicare |
$15.49
|
| Rate for Payer: Wellcare Medicare |
$15.49
|
| Rate for Payer: Wellmed Medicare |
$15.49
|
|
|
.Lyme Western Blot 163601 SO
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT 86617
|
| Hospital Charge Code |
1708866
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$75.68
|
|
|
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC
|
Facility
|
IP
|
$42,409.90
|
|
|
Service Code
|
MSDRG 821
|
| Min. Negotiated Rate |
$18,783.18 |
| Max. Negotiated Rate |
$42,409.90 |
| Rate for Payer: Aetna Commercial |
$25,111.12
|
| Rate for Payer: Aetna Medicare |
$28,174.77
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$18,783.18
|
| Rate for Payer: Amerigroup Medicare |
$18,783.18
|
| Rate for Payer: BCBS of TX Blue Advantage |
$20,045.74
|
| Rate for Payer: BCBS of TX Blue Essentials |
$24,706.78
|
| Rate for Payer: BCBS of TX Medicare |
$18,783.18
|
| Rate for Payer: BCBS of TX PPO |
$27,453.04
|
| Rate for Payer: Cigna Commercial |
$28,749.45
|
| Rate for Payer: Cigna Medicare |
$18,783.18
|
| Rate for Payer: Employer Direct Commercial |
$18,783.18
|
| Rate for Payer: Humana Medicare/TRICARE |
$18,783.18
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$18,783.18
|
| Rate for Payer: Molina Medicare |
$18,783.18
|
| Rate for Payer: Multiplan Auto |
$42,409.90
|
| Rate for Payer: Multiplan Commercial |
$42,409.90
|
| Rate for Payer: Multiplan Workers Comp |
$42,409.90
|
| Rate for Payer: Scott and White EPO/PPO |
$19,530.88
|
| Rate for Payer: Scott and White Medicare |
$18,783.18
|
| Rate for Payer: Superior Health Plan EPO |
$18,783.18
|
| Rate for Payer: Superior Health Plan Medicare |
$18,783.18
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$18,783.18
|
| Rate for Payer: Universal American Medicare |
$18,783.18
|
| Rate for Payer: Wellcare Medicare |
$18,783.18
|
| Rate for Payer: Wellmed Medicare |
$18,783.18
|
|
|
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC
|
Facility
|
IP
|
$114,887.30
|
|
|
Service Code
|
MSDRG 820
|
| Min. Negotiated Rate |
$46,004.40 |
| Max. Negotiated Rate |
$114,887.30 |
| Rate for Payer: Aetna Commercial |
$68,025.38
|
| Rate for Payer: Aetna Medicare |
$69,006.60
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$46,004.40
|
| Rate for Payer: Amerigroup Medicare |
$46,004.40
|
| Rate for Payer: BCBS of TX Blue Advantage |
$50,862.12
|
| Rate for Payer: BCBS of TX Blue Essentials |
$56,173.54
|
| Rate for Payer: BCBS of TX Medicare |
$46,004.40
|
| Rate for Payer: BCBS of TX PPO |
$62,417.46
|
| Rate for Payer: Cigna Commercial |
$77,881.50
|
| Rate for Payer: Cigna Medicare |
$46,004.40
|
| Rate for Payer: Employer Direct Commercial |
$46,004.40
|
| Rate for Payer: Humana Medicare/TRICARE |
$46,004.40
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$46,004.40
|
| Rate for Payer: Molina Medicare |
$46,004.40
|
| Rate for Payer: Multiplan Auto |
$114,887.30
|
| Rate for Payer: Multiplan Commercial |
$114,887.30
|
| Rate for Payer: Multiplan Workers Comp |
$114,887.30
|
| Rate for Payer: Scott and White EPO/PPO |
$52,908.62
|
| Rate for Payer: Scott and White Medicare |
$46,004.40
|
| Rate for Payer: Superior Health Plan EPO |
$46,004.40
|
| Rate for Payer: Superior Health Plan Medicare |
$46,004.40
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$46,004.40
|
| Rate for Payer: Universal American Medicare |
$46,004.40
|
| Rate for Payer: Wellcare Medicare |
$46,004.40
|
| Rate for Payer: Wellmed Medicare |
$46,004.40
|
|
|
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$23,537.20
|
|
|
Service Code
|
MSDRG 822
|
| Min. Negotiated Rate |
$10,435.24 |
| Max. Negotiated Rate |
$23,537.20 |
| Rate for Payer: Aetna Commercial |
$13,936.50
|
| Rate for Payer: Aetna Medicare |
$17,542.38
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$11,694.92
|
| Rate for Payer: Amerigroup Medicare |
$11,694.92
|
| Rate for Payer: BCBS of TX Blue Advantage |
$10,435.24
|
| Rate for Payer: BCBS of TX Blue Essentials |
$12,483.93
|
| Rate for Payer: BCBS of TX Medicare |
$11,694.92
|
| Rate for Payer: BCBS of TX PPO |
$13,871.57
|
| Rate for Payer: Cigna Commercial |
$15,955.74
|
| Rate for Payer: Cigna Medicare |
$11,694.92
|
| Rate for Payer: Employer Direct Commercial |
$11,694.92
|
| Rate for Payer: Humana Medicare/TRICARE |
$11,694.92
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$11,694.92
|
| Rate for Payer: Molina Medicare |
$11,694.92
|
| Rate for Payer: Multiplan Auto |
$23,537.20
|
| Rate for Payer: Multiplan Commercial |
$23,537.20
|
| Rate for Payer: Multiplan Workers Comp |
$23,537.20
|
| Rate for Payer: Scott and White EPO/PPO |
$10,839.50
|
| Rate for Payer: Scott and White Medicare |
$11,694.92
|
| Rate for Payer: Superior Health Plan EPO |
$11,694.92
|
| Rate for Payer: Superior Health Plan Medicare |
$11,694.92
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$11,694.92
|
| Rate for Payer: Universal American Medicare |
$11,694.92
|
| Rate for Payer: Wellcare Medicare |
$11,694.92
|
| Rate for Payer: Wellmed Medicare |
$11,694.92
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC
|
Facility
|
IP
|
$29,896.50
|
|
|
Service Code
|
MSDRG 841
|
| Min. Negotiated Rate |
$13,768.12 |
| Max. Negotiated Rate |
$29,896.50 |
| Rate for Payer: Aetna Commercial |
$17,701.88
|
| Rate for Payer: Aetna Medicare |
$21,125.07
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14,083.38
|
| Rate for Payer: Amerigroup Medicare |
$14,083.38
|
| Rate for Payer: BCBS of TX Blue Advantage |
$14,560.66
|
| Rate for Payer: BCBS of TX Blue Essentials |
$16,869.50
|
| Rate for Payer: BCBS of TX Medicare |
$14,083.38
|
| Rate for Payer: BCBS of TX PPO |
$18,744.62
|
| Rate for Payer: Cigna Commercial |
$20,266.68
|
| Rate for Payer: Cigna Medicare |
$14,083.38
|
| Rate for Payer: Employer Direct Commercial |
$14,083.38
|
| Rate for Payer: Humana Medicare/TRICARE |
$14,083.38
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14,083.38
|
| Rate for Payer: Molina Medicare |
$14,083.38
|
| Rate for Payer: Multiplan Auto |
$29,896.50
|
| Rate for Payer: Multiplan Commercial |
$29,896.50
|
| Rate for Payer: Multiplan Workers Comp |
$29,896.50
|
| Rate for Payer: Scott and White EPO/PPO |
$13,768.12
|
| Rate for Payer: Scott and White Medicare |
$14,083.38
|
| Rate for Payer: Superior Health Plan EPO |
$14,083.38
|
| Rate for Payer: Superior Health Plan Medicare |
$14,083.38
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14,083.38
|
| Rate for Payer: Universal American Medicare |
$14,083.38
|
| Rate for Payer: Wellcare Medicare |
$14,083.38
|
| Rate for Payer: Wellmed Medicare |
$14,083.38
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC
|
Facility
|
IP
|
$59,378.80
|
|
|
Service Code
|
MSDRG 840
|
| Min. Negotiated Rate |
$25,156.39 |
| Max. Negotiated Rate |
$59,378.80 |
| Rate for Payer: Aetna Commercial |
$35,158.50
|
| Rate for Payer: Aetna Medicare |
$37,734.58
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$25,156.39
|
| Rate for Payer: Amerigroup Medicare |
$25,156.39
|
| Rate for Payer: BCBS of TX Blue Advantage |
$26,845.76
|
| Rate for Payer: BCBS of TX Blue Essentials |
$33,979.44
|
| Rate for Payer: BCBS of TX Medicare |
$25,156.39
|
| Rate for Payer: BCBS of TX PPO |
$37,756.39
|
| Rate for Payer: Cigna Commercial |
$40,252.58
|
| Rate for Payer: Cigna Medicare |
$25,156.39
|
| Rate for Payer: Employer Direct Commercial |
$25,156.39
|
| Rate for Payer: Humana Medicare/TRICARE |
$25,156.39
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$25,156.39
|
| Rate for Payer: Molina Medicare |
$25,156.39
|
| Rate for Payer: Multiplan Auto |
$59,378.80
|
| Rate for Payer: Multiplan Commercial |
$59,378.80
|
| Rate for Payer: Multiplan Workers Comp |
$59,378.80
|
| Rate for Payer: Scott and White EPO/PPO |
$27,345.50
|
| Rate for Payer: Scott and White Medicare |
$25,156.39
|
| Rate for Payer: Superior Health Plan EPO |
$25,156.39
|
| Rate for Payer: Superior Health Plan Medicare |
$25,156.39
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$25,156.39
|
| Rate for Payer: Universal American Medicare |
$25,156.39
|
| Rate for Payer: Wellcare Medicare |
$25,156.39
|
| Rate for Payer: Wellmed Medicare |
$25,156.39
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC
|
Facility
|
IP
|
$42,425.10
|
|
|
Service Code
|
MSDRG 824
|
| Min. Negotiated Rate |
$18,788.89 |
| Max. Negotiated Rate |
$42,425.10 |
| Rate for Payer: Aetna Commercial |
$25,120.12
|
| Rate for Payer: Aetna Medicare |
$28,183.34
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$18,788.89
|
| Rate for Payer: Amerigroup Medicare |
$18,788.89
|
| Rate for Payer: BCBS of TX Blue Advantage |
$19,405.04
|
| Rate for Payer: BCBS of TX Blue Essentials |
$22,644.01
|
| Rate for Payer: BCBS of TX Medicare |
$18,788.89
|
| Rate for Payer: BCBS of TX PPO |
$25,160.99
|
| Rate for Payer: Cigna Commercial |
$28,759.75
|
| Rate for Payer: Cigna Medicare |
$18,788.89
|
| Rate for Payer: Employer Direct Commercial |
$18,788.89
|
| Rate for Payer: Humana Medicare/TRICARE |
$18,788.89
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$18,788.89
|
| Rate for Payer: Molina Medicare |
$18,788.89
|
| Rate for Payer: Multiplan Auto |
$42,425.10
|
| Rate for Payer: Multiplan Commercial |
$42,425.10
|
| Rate for Payer: Multiplan Workers Comp |
$42,425.10
|
| Rate for Payer: Scott and White EPO/PPO |
$19,537.88
|
| Rate for Payer: Scott and White Medicare |
$18,788.89
|
| Rate for Payer: Superior Health Plan EPO |
$18,788.89
|
| Rate for Payer: Superior Health Plan Medicare |
$18,788.89
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$18,788.89
|
| Rate for Payer: Universal American Medicare |
$18,788.89
|
| Rate for Payer: Wellcare Medicare |
$18,788.89
|
| Rate for Payer: Wellmed Medicare |
$18,788.89
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC
|
Facility
|
IP
|
$85,536.10
|
|
|
Service Code
|
MSDRG 823
|
| Min. Negotiated Rate |
$34,980.61 |
| Max. Negotiated Rate |
$85,536.10 |
| Rate for Payer: Aetna Commercial |
$50,646.38
|
| Rate for Payer: Aetna Medicare |
$52,470.92
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$34,980.61
|
| Rate for Payer: Amerigroup Medicare |
$34,980.61
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38,101.44
|
| Rate for Payer: BCBS of TX Blue Essentials |
$46,689.35
|
| Rate for Payer: BCBS of TX Medicare |
$34,980.61
|
| Rate for Payer: BCBS of TX PPO |
$51,879.06
|
| Rate for Payer: Cigna Commercial |
$57,984.47
|
| Rate for Payer: Cigna Medicare |
$34,980.61
|
| Rate for Payer: Employer Direct Commercial |
$34,980.61
|
| Rate for Payer: Humana Medicare/TRICARE |
$34,980.61
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$34,980.61
|
| Rate for Payer: Molina Medicare |
$34,980.61
|
| Rate for Payer: Multiplan Auto |
$85,536.10
|
| Rate for Payer: Multiplan Commercial |
$85,536.10
|
| Rate for Payer: Multiplan Workers Comp |
$85,536.10
|
| Rate for Payer: Scott and White EPO/PPO |
$39,391.62
|
| Rate for Payer: Scott and White Medicare |
$34,980.61
|
| Rate for Payer: Superior Health Plan EPO |
$34,980.61
|
| Rate for Payer: Superior Health Plan Medicare |
$34,980.61
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$34,980.61
|
| Rate for Payer: Universal American Medicare |
$34,980.61
|
| Rate for Payer: Wellcare Medicare |
$34,980.61
|
| Rate for Payer: Wellmed Medicare |
$34,980.61
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$24,536.60
|
|
|
Service Code
|
MSDRG 825
|
| Min. Negotiated Rate |
$11,299.75 |
| Max. Negotiated Rate |
$24,536.60 |
| Rate for Payer: Aetna Commercial |
$14,528.25
|
| Rate for Payer: Aetna Medicare |
$18,105.42
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12,070.28
|
| Rate for Payer: Amerigroup Medicare |
$12,070.28
|
| Rate for Payer: BCBS of TX Blue Advantage |
$11,662.46
|
| Rate for Payer: BCBS of TX Blue Essentials |
$14,023.52
|
| Rate for Payer: BCBS of TX Medicare |
$12,070.28
|
| Rate for Payer: BCBS of TX PPO |
$15,582.29
|
| Rate for Payer: Cigna Commercial |
$16,633.23
|
| Rate for Payer: Cigna Medicare |
$12,070.28
|
| Rate for Payer: Employer Direct Commercial |
$12,070.28
|
| Rate for Payer: Humana Medicare/TRICARE |
$12,070.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12,070.28
|
| Rate for Payer: Molina Medicare |
$12,070.28
|
| Rate for Payer: Multiplan Auto |
$24,536.60
|
| Rate for Payer: Multiplan Commercial |
$24,536.60
|
| Rate for Payer: Multiplan Workers Comp |
$24,536.60
|
| Rate for Payer: Scott and White EPO/PPO |
$11,299.75
|
| Rate for Payer: Scott and White Medicare |
$12,070.28
|
| Rate for Payer: Superior Health Plan EPO |
$12,070.28
|
| Rate for Payer: Superior Health Plan Medicare |
$12,070.28
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12,070.28
|
| Rate for Payer: Universal American Medicare |
$12,070.28
|
| Rate for Payer: Wellcare Medicare |
$12,070.28
|
| Rate for Payer: Wellmed Medicare |
$12,070.28
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC
|
Facility
|
IP
|
$20,261.60
|
|
|
Service Code
|
MSDRG 842
|
| Min. Negotiated Rate |
$9,331.00 |
| Max. Negotiated Rate |
$20,261.60 |
| Rate for Payer: Aetna Commercial |
$11,997.00
|
| Rate for Payer: Aetna Medicare |
$15,697.02
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$10,464.68
|
| Rate for Payer: Amerigroup Medicare |
$10,464.68
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9,773.90
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11,568.63
|
| Rate for Payer: BCBS of TX Medicare |
$10,464.68
|
| Rate for Payer: BCBS of TX PPO |
$12,854.53
|
| Rate for Payer: Cigna Commercial |
$13,735.23
|
| Rate for Payer: Cigna Medicare |
$10,464.68
|
| Rate for Payer: Employer Direct Commercial |
$10,464.68
|
| Rate for Payer: Humana Medicare/TRICARE |
$10,464.68
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$10,464.68
|
| Rate for Payer: Molina Medicare |
$10,464.68
|
| Rate for Payer: Multiplan Auto |
$20,261.60
|
| Rate for Payer: Multiplan Commercial |
$20,261.60
|
| Rate for Payer: Multiplan Workers Comp |
$20,261.60
|
| Rate for Payer: Scott and White EPO/PPO |
$9,331.00
|
| Rate for Payer: Scott and White Medicare |
$10,464.68
|
| Rate for Payer: Superior Health Plan EPO |
$10,464.68
|
| Rate for Payer: Superior Health Plan Medicare |
$10,464.68
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$10,464.68
|
| Rate for Payer: Universal American Medicare |
$10,464.68
|
| Rate for Payer: Wellcare Medicare |
$10,464.68
|
| Rate for Payer: Wellmed Medicare |
$10,464.68
|
|
|
Lysozyme, Serum SO
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
CPT 85549
|
| Hospital Charge Code |
1740018
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$85.36
|
|
|
Lysozyme, Serum SO
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
CPT 85549
|
| Hospital Charge Code |
1740018
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$63.05 |
| Rate for Payer: Aetna Commercial |
$19.69
|
| Rate for Payer: Aetna Medicare |
$28.12
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7.31
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$18.75
|
| Rate for Payer: Amerigroup Medicare |
$18.75
|
| Rate for Payer: BCBS of TX Blue Advantage |
$30.94
|
| Rate for Payer: BCBS of TX Blue Essentials |
$37.12
|
| Rate for Payer: BCBS of TX Medicare |
$18.75
|
| Rate for Payer: BCBS of TX PPO |
$41.44
|
| Rate for Payer: Cash Price |
$85.36
|
| Rate for Payer: Cash Price |
$85.36
|
| Rate for Payer: Cigna Medicaid |
$18.75
|
| Rate for Payer: Cigna Medicare |
$18.75
|
| Rate for Payer: Employer Direct Commercial |
$18.75
|
| Rate for Payer: Humana Medicare/TRICARE |
$18.75
|
| Rate for Payer: Molina CHIP/Medicaid |
$18.75
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$18.75
|
| Rate for Payer: Molina Medicare |
$18.75
|
| Rate for Payer: Multiplan Auto |
$63.05
|
| Rate for Payer: Multiplan Commercial |
$63.05
|
| Rate for Payer: Multiplan Workers Comp |
$63.05
|
| Rate for Payer: Parkland Medicaid |
$18.75
|
| Rate for Payer: Scott and White EPO/PPO |
$23.44
|
| Rate for Payer: Scott and White Medicare |
$18.75
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$18.75
|
| Rate for Payer: Superior Health Plan EPO |
$18.75
|
| Rate for Payer: Superior Health Plan Medicare |
$18.75
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$18.75
|
| Rate for Payer: Universal American Medicare |
$18.75
|
| Rate for Payer: Wellcare Medicare |
$18.75
|
| Rate for Payer: Wellmed Medicare |
$18.75
|
|
|
M003-IgE Aspergillus fumigatus SO
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
1701028
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$48.10 |
| Rate for Payer: Aetna Commercial |
$5.48
|
| Rate for Payer: Aetna Medicare |
$7.83
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.04
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5.22
|
| Rate for Payer: Amerigroup Medicare |
$5.22
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8.61
|
| Rate for Payer: BCBS of TX Blue Essentials |
$10.34
|
| Rate for Payer: BCBS of TX Medicare |
$5.22
|
| Rate for Payer: BCBS of TX PPO |
$11.54
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: Cigna Medicaid |
$5.22
|
| Rate for Payer: Cigna Medicare |
$5.22
|
| Rate for Payer: Employer Direct Commercial |
$5.22
|
| Rate for Payer: Humana Medicare/TRICARE |
$5.22
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.22
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5.22
|
| Rate for Payer: Molina Medicare |
$5.22
|
| Rate for Payer: Multiplan Auto |
$48.10
|
| Rate for Payer: Multiplan Commercial |
$48.10
|
| Rate for Payer: Multiplan Workers Comp |
$48.10
|
| Rate for Payer: Parkland Medicaid |
$5.22
|
| Rate for Payer: Scott and White EPO/PPO |
$6.52
|
| Rate for Payer: Scott and White Medicare |
$5.22
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.22
|
| Rate for Payer: Superior Health Plan EPO |
$5.22
|
| Rate for Payer: Superior Health Plan Medicare |
$5.22
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5.22
|
| Rate for Payer: Universal American Medicare |
$5.22
|
| Rate for Payer: Wellcare Medicare |
$5.22
|
| Rate for Payer: Wellmed Medicare |
$5.22
|
|
|
M003-IgE Aspergillus fumigatus SO
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
1701028
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$65.12
|
|
|
.MAC Susceptibility Broth 182835 SO
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
1604610
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$3.37 |
| Max. Negotiated Rate |
$163.15 |
| Rate for Payer: Aetna Commercial |
$9.08
|
| Rate for Payer: Aetna Medicare |
$12.98
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.37
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$8.65
|
| Rate for Payer: Amerigroup Medicare |
$8.65
|
| Rate for Payer: BCBS of TX Blue Advantage |
$14.27
|
| Rate for Payer: BCBS of TX Blue Essentials |
$17.13
|
| Rate for Payer: BCBS of TX Medicare |
$8.65
|
| Rate for Payer: BCBS of TX PPO |
$19.12
|
| Rate for Payer: Cash Price |
$220.88
|
| Rate for Payer: Cash Price |
$220.88
|
| Rate for Payer: Cigna Medicaid |
$8.65
|
| Rate for Payer: Cigna Medicare |
$8.65
|
| Rate for Payer: Employer Direct Commercial |
$8.65
|
| Rate for Payer: Humana Medicare/TRICARE |
$8.65
|
| Rate for Payer: Molina CHIP/Medicaid |
$8.65
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$8.65
|
| Rate for Payer: Molina Medicare |
$8.65
|
| Rate for Payer: Multiplan Auto |
$163.15
|
| Rate for Payer: Multiplan Commercial |
$163.15
|
| Rate for Payer: Multiplan Workers Comp |
$163.15
|
| Rate for Payer: Parkland Medicaid |
$8.65
|
| Rate for Payer: Scott and White EPO/PPO |
$10.81
|
| Rate for Payer: Scott and White Medicare |
$8.65
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$8.65
|
| Rate for Payer: Superior Health Plan EPO |
$8.65
|
| Rate for Payer: Superior Health Plan Medicare |
$8.65
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$8.65
|
| Rate for Payer: Universal American Medicare |
$8.65
|
| Rate for Payer: Wellcare Medicare |
$8.65
|
| Rate for Payer: Wellmed Medicare |
$8.65
|
|
|
Magic Mouthwash
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
79096582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$19.50 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.70
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$10.80
|
| Rate for Payer: BCBS of TX PPO |
$12.00
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Multiplan Auto |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$19.50
|
| Rate for Payer: Multiplan Workers Comp |
$19.50
|
| Rate for Payer: Scott and White EPO/PPO |
$15.00
|
| Rate for Payer: Superior Health Plan EPO |
$4.08
|
|
|
Magic Mouthwash
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
79096582
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$20.40
|
|
|
magnesium citrate 1.745 g/30 mL Oral Liquid 300 mL
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77675114
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
magnesium citrate 1.745 g/30 mL Oral Liquid 300 mL
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77675114
|
|
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
|
|
|
magnesium hydroxide 8% Oral Susp 30 mL
|
Facility
|
IP
|
$8.43
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77675679
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.73
|
|
|
magnesium hydroxide 8% Oral Susp 30 mL
|
Facility
|
OP
|
$8.43
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77675679
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$5.48 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.76
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.53
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3.03
|
| Rate for Payer: BCBS of TX PPO |
$3.37
|
| Rate for Payer: Cash Price |
$5.73
|
| Rate for Payer: Multiplan Auto |
$5.48
|
| Rate for Payer: Multiplan Commercial |
$5.48
|
| Rate for Payer: Multiplan Workers Comp |
$5.48
|
| Rate for Payer: Scott and White EPO/PPO |
$4.22
|
| Rate for Payer: Superior Health Plan EPO |
$1.15
|
|
|
Magnesium Level
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
1602143
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$152.10 |
| Rate for Payer: Aetna Commercial |
$7.04
|
| Rate for Payer: Aetna Medicare |
$10.05
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.61
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$6.70
|
| Rate for Payer: Amerigroup Medicare |
$6.70
|
| Rate for Payer: BCBS of TX Blue Advantage |
$11.06
|
| Rate for Payer: BCBS of TX Blue Essentials |
$13.27
|
| Rate for Payer: BCBS of TX Medicare |
$6.70
|
| Rate for Payer: BCBS of TX PPO |
$14.81
|
| Rate for Payer: Cash Price |
$205.92
|
| Rate for Payer: Cash Price |
$205.92
|
| Rate for Payer: Cigna Medicaid |
$6.70
|
| Rate for Payer: Cigna Medicare |
$6.70
|
| Rate for Payer: Employer Direct Commercial |
$6.70
|
| Rate for Payer: Humana Medicare/TRICARE |
$6.70
|
| Rate for Payer: Molina CHIP/Medicaid |
$6.70
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$6.70
|
| Rate for Payer: Molina Medicare |
$6.70
|
| Rate for Payer: Multiplan Auto |
$152.10
|
| Rate for Payer: Multiplan Commercial |
$152.10
|
| Rate for Payer: Multiplan Workers Comp |
$152.10
|
| Rate for Payer: Parkland Medicaid |
$6.70
|
| Rate for Payer: Scott and White EPO/PPO |
$8.38
|
| Rate for Payer: Scott and White Medicare |
$6.70
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$6.70
|
| Rate for Payer: Superior Health Plan EPO |
$6.70
|
| Rate for Payer: Superior Health Plan Medicare |
$6.70
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$6.70
|
| Rate for Payer: Universal American Medicare |
$6.70
|
| Rate for Payer: Wellcare Medicare |
$6.70
|
| Rate for Payer: Wellmed Medicare |
$6.70
|
|
|
Magnesium Level
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
1602143
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$205.92
|
|
|
magnesium oxide 400 mg (241.3 mg elemental magnesium) Tab
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77676264
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
