|
GRAFT CV 80CMX6MM 60CM REM RNG PRPTN
|
Facility
|
IP
|
$17,108.43
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
992349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,277.11 |
| Max. Negotiated Rate |
$8,554.22 |
| Rate for Payer: Cash Price |
$11,633.73
|
| Rate for Payer: Cigna Commercial |
$4,277.11
|
| Rate for Payer: Multiplan Auto |
$8,554.22
|
| Rate for Payer: Multiplan Commercial |
$8,554.22
|
| Rate for Payer: Multiplan Workers Comp |
$8,554.22
|
| Rate for Payer: Scott and White EPO/PPO |
$8,554.22
|
|
|
Graft derma-fat-fascia
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 15770
|
| Hospital Charge Code |
36015770
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,457.62 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,457.62
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Amerigroup Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,972.07
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,954.58
|
| Rate for Payer: BCBS of TX Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX PPO |
$7,502.77
|
| Rate for Payer: Cigna Commercial |
$7,524.93
|
| Rate for Payer: Cigna Medicare |
$3,559.87
|
| Rate for Payer: Employer Direct Commercial |
$3,559.87
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,559.87
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Molina Medicare |
$3,559.87
|
| 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 |
$6,069.94
|
| Rate for Payer: Scott and White Medicare |
$3,559.87
|
| Rate for Payer: Superior Health Plan EPO |
$3,559.87
|
| Rate for Payer: Superior Health Plan Medicare |
$3,559.87
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Universal American Medicare |
$3,559.87
|
| Rate for Payer: Wellcare Medicare |
$3,559.87
|
| Rate for Payer: Wellmed Medicare |
$3,559.87
|
|
|
Graft derma-fat-fascia
|
Facility
|
IP
|
$10,992.01
|
|
|
Service Code
|
HCPCS 15770
|
| Hospital Charge Code |
9900136
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$7,474.57
|
|
|
Graft derma-fat-fascia
|
Facility
|
OP
|
$10,992.01
|
|
|
Service Code
|
HCPCS 15770
|
| Hospital Charge Code |
9900136
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,457.62 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,457.62
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Amerigroup Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,972.07
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,954.58
|
| Rate for Payer: BCBS of TX Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX PPO |
$7,502.77
|
| Rate for Payer: Cash Price |
$7,474.57
|
| Rate for Payer: Cash Price |
$7,474.57
|
| Rate for Payer: Cash Price |
$7,474.57
|
| Rate for Payer: Cigna Commercial |
$7,524.93
|
| Rate for Payer: Cigna Medicaid |
$7,914.25
|
| Rate for Payer: Cigna Medicare |
$3,559.87
|
| Rate for Payer: Employer Direct Commercial |
$3,559.87
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,559.87
|
| Rate for Payer: Molina CHIP/Medicaid |
$7,914.25
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Molina Medicare |
$3,559.87
|
| 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 |
$7,914.25
|
| Rate for Payer: Scott and White EPO/PPO |
$6,069.94
|
| Rate for Payer: Scott and White Medicare |
$3,559.87
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$7,914.25
|
| Rate for Payer: Superior Health Plan EPO |
$3,559.87
|
| Rate for Payer: Superior Health Plan Medicare |
$3,559.87
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Universal American Medicare |
$3,559.87
|
| Rate for Payer: Wellcare Medicare |
$3,559.87
|
| Rate for Payer: Wellmed Medicare |
$3,559.87
|
|
|
GRAFT DURAL DURAGEN 2IN X 2IN REGENERATION SUTURABLE ABSORBA
|
Facility
|
IP
|
$2,934.88
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
992338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$733.72 |
| Max. Negotiated Rate |
$1,467.44 |
| Rate for Payer: Cash Price |
$1,995.72
|
| Rate for Payer: Cigna Commercial |
$733.72
|
| Rate for Payer: Multiplan Auto |
$1,467.44
|
| Rate for Payer: Multiplan Commercial |
$1,467.44
|
| Rate for Payer: Multiplan Workers Comp |
$1,467.44
|
| Rate for Payer: Scott and White EPO/PPO |
$1,467.44
|
|
|
GRAFT DURAL DURAGEN 2IN X 2IN REGENERATION SUTURABLE ABSORBA
|
Facility
|
OP
|
$2,934.88
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
992338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.14 |
| Max. Negotiated Rate |
$2,113.11 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$264.14
|
| Rate for Payer: BCBS of TX Blue Advantage |
$880.46
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,056.56
|
| Rate for Payer: BCBS of TX PPO |
$1,173.95
|
| Rate for Payer: Cash Price |
$1,995.72
|
| Rate for Payer: Cigna Medicaid |
$2,113.11
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,113.11
|
| Rate for Payer: Multiplan Auto |
$1,467.44
|
| Rate for Payer: Multiplan Commercial |
$1,467.44
|
| Rate for Payer: Multiplan Workers Comp |
$1,467.44
|
| Rate for Payer: Parkland Medicaid |
$2,113.11
|
| Rate for Payer: Scott and White EPO/PPO |
$1,467.44
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,113.11
|
| Rate for Payer: Superior Health Plan EPO |
$399.14
|
|
|
Graft ear cartilage, autogenous, to nose or ear (includes obtaining graft)
|
Facility
|
OP
|
$12,570.48
|
|
|
Service Code
|
CPT 21235
|
| Hospital Charge Code |
36021235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,954.22 |
| Max. Negotiated Rate |
$12,570.48 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,954.22
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Amerigroup Medicare |
$5,946.81
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8,100.39
|
| Rate for Payer: BCBS of TX Blue Essentials |
$9,701.06
|
| Rate for Payer: BCBS of TX Medicare |
$5,946.81
|
| Rate for Payer: BCBS of TX PPO |
$12,223.34
|
| Rate for Payer: Cigna Commercial |
$12,570.48
|
| Rate for Payer: Cigna Medicare |
$5,946.81
|
| Rate for Payer: Employer Direct Commercial |
$5,946.81
|
| Rate for Payer: Humana Medicare/TRICARE |
$5,946.81
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Molina Medicare |
$5,946.81
|
| 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 |
$9,908.12
|
| Rate for Payer: Scott and White Medicare |
$5,946.81
|
| Rate for Payer: Superior Health Plan EPO |
$5,946.81
|
| Rate for Payer: Superior Health Plan Medicare |
$5,946.81
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Universal American Medicare |
$5,946.81
|
| Rate for Payer: Wellcare Medicare |
$5,946.81
|
| Rate for Payer: Wellmed Medicare |
$5,946.81
|
|
|
Graft ear cartilage, autogenous, to nose or ear (includes obtaining graft)
|
Facility
|
OP
|
$12,715.13
|
|
|
Service Code
|
HCPCS 21235
|
| Hospital Charge Code |
9900192
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,954.22 |
| Max. Negotiated Rate |
$12,570.48 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,954.22
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Amerigroup Medicare |
$5,946.81
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8,100.39
|
| Rate for Payer: BCBS of TX Blue Essentials |
$9,701.06
|
| Rate for Payer: BCBS of TX Medicare |
$5,946.81
|
| Rate for Payer: BCBS of TX PPO |
$12,223.34
|
| Rate for Payer: Cash Price |
$8,646.29
|
| Rate for Payer: Cash Price |
$8,646.29
|
| Rate for Payer: Cash Price |
$8,646.29
|
| Rate for Payer: Cigna Commercial |
$12,570.48
|
| Rate for Payer: Cigna Medicaid |
$9,154.89
|
| Rate for Payer: Cigna Medicare |
$5,946.81
|
| Rate for Payer: Employer Direct Commercial |
$5,946.81
|
| Rate for Payer: Humana Medicare/TRICARE |
$5,946.81
|
| Rate for Payer: Molina CHIP/Medicaid |
$9,154.89
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Molina Medicare |
$5,946.81
|
| 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 |
$9,154.89
|
| Rate for Payer: Scott and White EPO/PPO |
$9,908.12
|
| Rate for Payer: Scott and White Medicare |
$5,946.81
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$9,154.89
|
| Rate for Payer: Superior Health Plan EPO |
$5,946.81
|
| Rate for Payer: Superior Health Plan Medicare |
$5,946.81
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Universal American Medicare |
$5,946.81
|
| Rate for Payer: Wellcare Medicare |
$5,946.81
|
| Rate for Payer: Wellmed Medicare |
$5,946.81
|
|
|
Graft ear cartilage, autogenous, to nose or ear (includes obtaining graft)
|
Facility
|
IP
|
$12,715.13
|
|
|
Service Code
|
HCPCS 21235
|
| Hospital Charge Code |
9900192
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$8,646.29
|
|
|
Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 15771
|
| Hospital Charge Code |
36015771
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,457.62 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,457.62
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Amerigroup Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,972.07
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,954.58
|
| Rate for Payer: BCBS of TX Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX PPO |
$7,502.77
|
| Rate for Payer: Cigna Commercial |
$7,524.93
|
| Rate for Payer: Cigna Medicare |
$3,559.87
|
| Rate for Payer: Employer Direct Commercial |
$3,559.87
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,559.87
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Molina Medicare |
$3,559.87
|
| 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 |
$6,069.94
|
| Rate for Payer: Scott and White Medicare |
$3,559.87
|
| Rate for Payer: Superior Health Plan EPO |
$3,559.87
|
| Rate for Payer: Superior Health Plan Medicare |
$3,559.87
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Universal American Medicare |
$3,559.87
|
| Rate for Payer: Wellcare Medicare |
$3,559.87
|
| Rate for Payer: Wellmed Medicare |
$3,559.87
|
|
|
Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or
|
Facility
|
IP
|
$21,132.90
|
|
|
Service Code
|
HCPCS 15771
|
| Hospital Charge Code |
9900137
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$14,370.37
|
|
|
Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or
|
Facility
|
OP
|
$21,132.90
|
|
|
Service Code
|
HCPCS 15771
|
| Hospital Charge Code |
9900137
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,457.62 |
| Max. Negotiated Rate |
$15,215.69 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,457.62
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Amerigroup Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,972.07
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,954.58
|
| Rate for Payer: BCBS of TX Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX PPO |
$7,502.77
|
| Rate for Payer: Cash Price |
$14,370.37
|
| Rate for Payer: Cash Price |
$14,370.37
|
| Rate for Payer: Cash Price |
$14,370.37
|
| Rate for Payer: Cigna Commercial |
$7,524.93
|
| Rate for Payer: Cigna Medicaid |
$15,215.69
|
| Rate for Payer: Cigna Medicare |
$3,559.87
|
| Rate for Payer: Employer Direct Commercial |
$3,559.87
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,559.87
|
| Rate for Payer: Molina CHIP/Medicaid |
$15,215.69
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Molina Medicare |
$3,559.87
|
| 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 |
$15,215.69
|
| Rate for Payer: Scott and White EPO/PPO |
$6,069.94
|
| Rate for Payer: Scott and White Medicare |
$3,559.87
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$15,215.69
|
| Rate for Payer: Superior Health Plan EPO |
$3,559.87
|
| Rate for Payer: Superior Health Plan Medicare |
$3,559.87
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Universal American Medicare |
$3,559.87
|
| Rate for Payer: Wellcare Medicare |
$3,559.87
|
| Rate for Payer: Wellmed Medicare |
$3,559.87
|
|
|
Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 15769
|
| Hospital Charge Code |
36015769
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,457.62 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,457.62
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Amerigroup Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,972.07
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,954.58
|
| Rate for Payer: BCBS of TX Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX PPO |
$7,502.77
|
| Rate for Payer: Cigna Commercial |
$7,524.93
|
| Rate for Payer: Cigna Medicare |
$3,559.87
|
| Rate for Payer: Employer Direct Commercial |
$3,559.87
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,559.87
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Molina Medicare |
$3,559.87
|
| 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 |
$6,069.94
|
| Rate for Payer: Scott and White Medicare |
$3,559.87
|
| Rate for Payer: Superior Health Plan EPO |
$3,559.87
|
| Rate for Payer: Superior Health Plan Medicare |
$3,559.87
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Universal American Medicare |
$3,559.87
|
| Rate for Payer: Wellcare Medicare |
$3,559.87
|
| Rate for Payer: Wellmed Medicare |
$3,559.87
|
|
|
Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
|
Facility
|
IP
|
$14,088.60
|
|
|
Service Code
|
HCPCS 15769
|
| Hospital Charge Code |
9900135
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$9,580.25
|
|
|
Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
|
Facility
|
OP
|
$14,088.60
|
|
|
Service Code
|
HCPCS 15769
|
| Hospital Charge Code |
9900135
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,457.62 |
| Max. Negotiated Rate |
$10,143.79 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,457.62
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Amerigroup Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,972.07
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,954.58
|
| Rate for Payer: BCBS of TX Medicare |
$3,559.87
|
| Rate for Payer: BCBS of TX PPO |
$7,502.77
|
| Rate for Payer: Cash Price |
$9,580.25
|
| Rate for Payer: Cash Price |
$9,580.25
|
| Rate for Payer: Cash Price |
$9,580.25
|
| Rate for Payer: Cigna Commercial |
$7,524.93
|
| Rate for Payer: Cigna Medicaid |
$10,143.79
|
| Rate for Payer: Cigna Medicare |
$3,559.87
|
| Rate for Payer: Employer Direct Commercial |
$3,559.87
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,559.87
|
| Rate for Payer: Molina CHIP/Medicaid |
$10,143.79
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Molina Medicare |
$3,559.87
|
| 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 |
$10,143.79
|
| Rate for Payer: Scott and White EPO/PPO |
$6,069.94
|
| Rate for Payer: Scott and White Medicare |
$3,559.87
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$10,143.79
|
| Rate for Payer: Superior Health Plan EPO |
$3,559.87
|
| Rate for Payer: Superior Health Plan Medicare |
$3,559.87
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,559.87
|
| Rate for Payer: Universal American Medicare |
$3,559.87
|
| Rate for Payer: Wellcare Medicare |
$3,559.87
|
| Rate for Payer: Wellmed Medicare |
$3,559.87
|
|
|
graft kerecis micro omega 3 38cm ea
|
Facility
|
IP
|
$288.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8738541
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$72.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Cash Price |
$195.84
|
| Rate for Payer: Cigna Commercial |
$72.00
|
| Rate for Payer: Multiplan Auto |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$144.00
|
| Rate for Payer: Multiplan Workers Comp |
$144.00
|
| Rate for Payer: Scott and White EPO/PPO |
$144.00
|
|
|
graft kerecis micro omega 3 38cm ea
|
Facility
|
OP
|
$288.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8688548
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25.92 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$25.92
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$86.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$103.68
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$115.20
|
| Rate for Payer: Cash Price |
$195.84
|
| Rate for Payer: Cash Price |
$195.84
|
| Rate for Payer: Cash Price |
$195.84
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$207.36
|
| Rate for Payer: Cigna Medicare |
$125.01
|
| Rate for Payer: Employer Direct Commercial |
$125.01
|
| Rate for Payer: Humana Medicare/TRICARE |
$125.01
|
| Rate for Payer: Molina CHIP/Medicaid |
$207.36
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$144.00
|
| Rate for Payer: Multiplan Workers Comp |
$144.00
|
| Rate for Payer: Parkland Medicaid |
$207.36
|
| Rate for Payer: Scott and White EPO/PPO |
$144.00
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$207.36
|
| Rate for Payer: Superior Health Plan EPO |
$125.01
|
| Rate for Payer: Superior Health Plan Medicare |
$125.01
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Universal American Medicare |
$125.01
|
| Rate for Payer: Wellcare Medicare |
$125.01
|
| Rate for Payer: Wellmed Medicare |
$125.01
|
|
|
graft kerecis micro omega 3 38cm ea
|
Facility
|
OP
|
$288.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8738541
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25.92 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$25.92
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$86.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$103.68
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$115.20
|
| Rate for Payer: Cash Price |
$195.84
|
| Rate for Payer: Cash Price |
$195.84
|
| Rate for Payer: Cash Price |
$195.84
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$207.36
|
| Rate for Payer: Cigna Medicare |
$125.01
|
| Rate for Payer: Employer Direct Commercial |
$125.01
|
| Rate for Payer: Humana Medicare/TRICARE |
$125.01
|
| Rate for Payer: Molina CHIP/Medicaid |
$207.36
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$144.00
|
| Rate for Payer: Multiplan Workers Comp |
$144.00
|
| Rate for Payer: Parkland Medicaid |
$207.36
|
| Rate for Payer: Scott and White EPO/PPO |
$144.00
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$207.36
|
| Rate for Payer: Superior Health Plan EPO |
$125.01
|
| Rate for Payer: Superior Health Plan Medicare |
$125.01
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Universal American Medicare |
$125.01
|
| Rate for Payer: Wellcare Medicare |
$125.01
|
| Rate for Payer: Wellmed Medicare |
$125.01
|
|
|
graft kerecis micro omega 3 38cm ea
|
Facility
|
IP
|
$288.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8688548
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$72.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Cash Price |
$195.84
|
| Rate for Payer: Cigna Commercial |
$72.00
|
| Rate for Payer: Multiplan Auto |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$144.00
|
| Rate for Payer: Multiplan Workers Comp |
$144.00
|
| Rate for Payer: Scott and White EPO/PPO |
$144.00
|
|
|
graft nushield membrane mnts 4x6cm
|
Facility
|
IP
|
$439.00
|
|
|
Service Code
|
HCPCS Q4205
|
| Hospital Charge Code |
8672534
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$109.75 |
| Max. Negotiated Rate |
$219.50 |
| Rate for Payer: Cash Price |
$298.52
|
| Rate for Payer: Cigna Commercial |
$109.75
|
| Rate for Payer: Multiplan Auto |
$219.50
|
| Rate for Payer: Multiplan Commercial |
$219.50
|
| Rate for Payer: Multiplan Workers Comp |
$219.50
|
| Rate for Payer: Scott and White EPO/PPO |
$219.50
|
|
|
graft nushield membrane mnts 4x6cm
|
Facility
|
OP
|
$439.00
|
|
|
Service Code
|
HCPCS Q4205
|
| Hospital Charge Code |
145974
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$316.08 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$39.51
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$14.83
|
| Rate for Payer: BCBS of TX Blue Essentials |
$17.80
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$19.74
|
| Rate for Payer: Cash Price |
$298.52
|
| Rate for Payer: Cash Price |
$298.52
|
| Rate for Payer: Cash Price |
$298.52
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$316.08
|
| Rate for Payer: Cigna Medicare |
$125.01
|
| Rate for Payer: Employer Direct Commercial |
$125.01
|
| Rate for Payer: Humana Medicare/TRICARE |
$125.01
|
| Rate for Payer: Molina CHIP/Medicaid |
$316.08
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$219.50
|
| Rate for Payer: Multiplan Commercial |
$219.50
|
| Rate for Payer: Multiplan Workers Comp |
$219.50
|
| Rate for Payer: Parkland Medicaid |
$316.08
|
| Rate for Payer: Scott and White EPO/PPO |
$219.50
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$316.08
|
| Rate for Payer: Superior Health Plan EPO |
$125.01
|
| Rate for Payer: Superior Health Plan Medicare |
$125.01
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Universal American Medicare |
$125.01
|
| Rate for Payer: Wellcare Medicare |
$125.01
|
| Rate for Payer: Wellmed Medicare |
$125.01
|
|
|
graft nushield membrane mnts 4x6cm
|
Facility
|
OP
|
$439.00
|
|
|
Service Code
|
HCPCS Q4205
|
| Hospital Charge Code |
8672534
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$316.08 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$39.51
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$14.83
|
| Rate for Payer: BCBS of TX Blue Essentials |
$17.80
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$19.74
|
| Rate for Payer: Cash Price |
$298.52
|
| Rate for Payer: Cash Price |
$298.52
|
| Rate for Payer: Cash Price |
$298.52
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$316.08
|
| Rate for Payer: Cigna Medicare |
$125.01
|
| Rate for Payer: Employer Direct Commercial |
$125.01
|
| Rate for Payer: Humana Medicare/TRICARE |
$125.01
|
| Rate for Payer: Molina CHIP/Medicaid |
$316.08
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$219.50
|
| Rate for Payer: Multiplan Commercial |
$219.50
|
| Rate for Payer: Multiplan Workers Comp |
$219.50
|
| Rate for Payer: Parkland Medicaid |
$316.08
|
| Rate for Payer: Scott and White EPO/PPO |
$219.50
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$316.08
|
| Rate for Payer: Superior Health Plan EPO |
$125.01
|
| Rate for Payer: Superior Health Plan Medicare |
$125.01
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Universal American Medicare |
$125.01
|
| Rate for Payer: Wellcare Medicare |
$125.01
|
| Rate for Payer: Wellmed Medicare |
$125.01
|
|
|
graft nushield membrane mnts 4x6cm
|
Facility
|
IP
|
$439.00
|
|
|
Service Code
|
HCPCS Q4205
|
| Hospital Charge Code |
145974
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$109.75 |
| Max. Negotiated Rate |
$219.50 |
| Rate for Payer: Cash Price |
$298.52
|
| Rate for Payer: Cigna Commercial |
$109.75
|
| Rate for Payer: Multiplan Auto |
$219.50
|
| Rate for Payer: Multiplan Commercial |
$219.50
|
| Rate for Payer: Multiplan Workers Comp |
$219.50
|
| Rate for Payer: Scott and White EPO/PPO |
$219.50
|
|
|
Graft rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)
|
Facility
|
OP
|
$12,715.13
|
|
|
Service Code
|
HCPCS 21230
|
| Hospital Charge Code |
9900191
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,954.22 |
| Max. Negotiated Rate |
$12,570.48 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,954.22
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Amerigroup Medicare |
$5,946.81
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8,100.39
|
| Rate for Payer: BCBS of TX Blue Essentials |
$9,701.06
|
| Rate for Payer: BCBS of TX Medicare |
$5,946.81
|
| Rate for Payer: BCBS of TX PPO |
$12,223.34
|
| Rate for Payer: Cash Price |
$8,646.29
|
| Rate for Payer: Cash Price |
$8,646.29
|
| Rate for Payer: Cash Price |
$8,646.29
|
| Rate for Payer: Cigna Commercial |
$12,570.48
|
| Rate for Payer: Cigna Medicaid |
$9,154.89
|
| Rate for Payer: Cigna Medicare |
$5,946.81
|
| Rate for Payer: Employer Direct Commercial |
$5,946.81
|
| Rate for Payer: Humana Medicare/TRICARE |
$5,946.81
|
| Rate for Payer: Molina CHIP/Medicaid |
$9,154.89
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Molina Medicare |
$5,946.81
|
| 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 |
$9,154.89
|
| Rate for Payer: Scott and White EPO/PPO |
$9,908.12
|
| Rate for Payer: Scott and White Medicare |
$5,946.81
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$9,154.89
|
| Rate for Payer: Superior Health Plan EPO |
$5,946.81
|
| Rate for Payer: Superior Health Plan Medicare |
$5,946.81
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Universal American Medicare |
$5,946.81
|
| Rate for Payer: Wellcare Medicare |
$5,946.81
|
| Rate for Payer: Wellmed Medicare |
$5,946.81
|
|
|
Graft rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)
|
Facility
|
OP
|
$12,570.48
|
|
|
Service Code
|
CPT 21230
|
| Hospital Charge Code |
36021230
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,954.22 |
| Max. Negotiated Rate |
$12,570.48 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,954.22
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Amerigroup Medicare |
$5,946.81
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8,100.39
|
| Rate for Payer: BCBS of TX Blue Essentials |
$9,701.06
|
| Rate for Payer: BCBS of TX Medicare |
$5,946.81
|
| Rate for Payer: BCBS of TX PPO |
$12,223.34
|
| Rate for Payer: Cigna Commercial |
$12,570.48
|
| Rate for Payer: Cigna Medicare |
$5,946.81
|
| Rate for Payer: Employer Direct Commercial |
$5,946.81
|
| Rate for Payer: Humana Medicare/TRICARE |
$5,946.81
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Molina Medicare |
$5,946.81
|
| 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 |
$9,908.12
|
| Rate for Payer: Scott and White Medicare |
$5,946.81
|
| Rate for Payer: Superior Health Plan EPO |
$5,946.81
|
| Rate for Payer: Superior Health Plan Medicare |
$5,946.81
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5,946.81
|
| Rate for Payer: Universal American Medicare |
$5,946.81
|
| Rate for Payer: Wellcare Medicare |
$5,946.81
|
| Rate for Payer: Wellmed Medicare |
$5,946.81
|
|
