|
HSV-2 Ab, IgG SO
|
Facility
|
OP
|
$131.05
|
|
|
Service Code
|
HCPCS 86696
|
| Hospital Charge Code |
9213052
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.55 |
| Max. Negotiated Rate |
$94.36 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7.55
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$19.35
|
| Rate for Payer: Amerigroup Medicare |
$19.35
|
| Rate for Payer: BCBS of TX Blue Advantage |
$39.31
|
| Rate for Payer: BCBS of TX Blue Essentials |
$47.18
|
| Rate for Payer: BCBS of TX Medicare |
$19.35
|
| Rate for Payer: BCBS of TX PPO |
$52.42
|
| Rate for Payer: Cash Price |
$89.11
|
| Rate for Payer: Cash Price |
$89.11
|
| Rate for Payer: Cigna Medicaid |
$94.36
|
| Rate for Payer: Cigna Medicare |
$19.35
|
| Rate for Payer: Employer Direct Commercial |
$19.35
|
| Rate for Payer: Humana Medicare/TRICARE |
$19.35
|
| Rate for Payer: Molina CHIP/Medicaid |
$94.36
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$19.35
|
| Rate for Payer: Molina Medicare |
$19.35
|
| Rate for Payer: Multiplan Auto |
$85.18
|
| Rate for Payer: Multiplan Commercial |
$85.18
|
| Rate for Payer: Multiplan Workers Comp |
$85.18
|
| Rate for Payer: Parkland Medicaid |
$94.36
|
| Rate for Payer: Scott and White EPO/PPO |
$24.19
|
| Rate for Payer: Scott and White Medicare |
$19.35
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$94.36
|
| Rate for Payer: Superior Health Plan EPO |
$19.35
|
| Rate for Payer: Superior Health Plan Medicare |
$19.35
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$19.35
|
| Rate for Payer: Universal American Medicare |
$19.35
|
| Rate for Payer: Wellcare Medicare |
$19.35
|
| Rate for Payer: Wellmed Medicare |
$19.35
|
|
|
HSV Culture Without Typing SO
|
Facility
|
OP
|
$153.00
|
|
|
Service Code
|
HCPCS 87255
|
| Hospital Charge Code |
1740928
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$13.21 |
| Max. Negotiated Rate |
$110.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$13.21
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$33.86
|
| Rate for Payer: Amerigroup Medicare |
$33.86
|
| Rate for Payer: BCBS of TX Blue Advantage |
$45.90
|
| Rate for Payer: BCBS of TX Blue Essentials |
$55.08
|
| Rate for Payer: BCBS of TX Medicare |
$33.86
|
| Rate for Payer: BCBS of TX PPO |
$61.20
|
| Rate for Payer: Cash Price |
$104.04
|
| Rate for Payer: Cash Price |
$104.04
|
| Rate for Payer: Cigna Medicaid |
$110.16
|
| Rate for Payer: Cigna Medicare |
$33.86
|
| Rate for Payer: Employer Direct Commercial |
$33.86
|
| Rate for Payer: Humana Medicare/TRICARE |
$33.86
|
| Rate for Payer: Molina CHIP/Medicaid |
$110.16
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$33.86
|
| Rate for Payer: Molina Medicare |
$33.86
|
| Rate for Payer: Multiplan Auto |
$99.45
|
| Rate for Payer: Multiplan Commercial |
$99.45
|
| Rate for Payer: Multiplan Workers Comp |
$99.45
|
| Rate for Payer: Parkland Medicaid |
$110.16
|
| Rate for Payer: Scott and White EPO/PPO |
$42.33
|
| Rate for Payer: Scott and White Medicare |
$33.86
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$110.16
|
| Rate for Payer: Superior Health Plan EPO |
$33.86
|
| Rate for Payer: Superior Health Plan Medicare |
$33.86
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$33.86
|
| Rate for Payer: Universal American Medicare |
$33.86
|
| Rate for Payer: Wellcare Medicare |
$33.86
|
| Rate for Payer: Wellmed Medicare |
$33.86
|
|
|
HSV Culture Without Typing SO
|
Facility
|
IP
|
$153.00
|
|
|
Service Code
|
HCPCS 87255
|
| Hospital Charge Code |
1740928
|
|
Hospital Revenue Code
|
306
|
| Rate for Payer: Cash Price |
$104.04
|
|
|
HSV, IgM I/II Combination SO
|
Facility
|
OP
|
$133.29
|
|
|
Service Code
|
HCPCS 86694
|
| Hospital Charge Code |
1702943
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$95.97 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.61
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14.39
|
| Rate for Payer: Amerigroup Medicare |
$14.39
|
| Rate for Payer: BCBS of TX Blue Advantage |
$39.99
|
| Rate for Payer: BCBS of TX Blue Essentials |
$47.98
|
| Rate for Payer: BCBS of TX Medicare |
$14.39
|
| Rate for Payer: BCBS of TX PPO |
$53.32
|
| Rate for Payer: Cash Price |
$90.64
|
| Rate for Payer: Cash Price |
$90.64
|
| Rate for Payer: Cigna Medicaid |
$95.97
|
| Rate for Payer: Cigna Medicare |
$14.39
|
| Rate for Payer: Employer Direct Commercial |
$14.39
|
| Rate for Payer: Humana Medicare/TRICARE |
$14.39
|
| Rate for Payer: Molina CHIP/Medicaid |
$95.97
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14.39
|
| Rate for Payer: Molina Medicare |
$14.39
|
| Rate for Payer: Multiplan Auto |
$86.64
|
| Rate for Payer: Multiplan Commercial |
$86.64
|
| Rate for Payer: Multiplan Workers Comp |
$86.64
|
| Rate for Payer: Parkland Medicaid |
$95.97
|
| Rate for Payer: Scott and White EPO/PPO |
$17.99
|
| Rate for Payer: Scott and White Medicare |
$14.39
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$95.97
|
| Rate for Payer: Superior Health Plan EPO |
$14.39
|
| Rate for Payer: Superior Health Plan Medicare |
$14.39
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14.39
|
| Rate for Payer: Universal American Medicare |
$14.39
|
| Rate for Payer: Wellcare Medicare |
$14.39
|
| Rate for Payer: Wellmed Medicare |
$14.39
|
|
|
HSV, IgM I/II Combination SO
|
Facility
|
IP
|
$133.29
|
|
|
Service Code
|
HCPCS 86694
|
| Hospital Charge Code |
1702943
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$90.64
|
|
|
HTLV-I/II Antibodies, Qual. SO
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS 86790
|
| Hospital Charge Code |
1703651
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$110.84
|
|
|
HTLV-I/II Antibodies, Qual. SO
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS 86790
|
| Hospital Charge Code |
1703651
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.02 |
| Max. Negotiated Rate |
$117.36 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.02
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12.88
|
| Rate for Payer: Amerigroup Medicare |
$12.88
|
| Rate for Payer: BCBS of TX Blue Advantage |
$48.90
|
| Rate for Payer: BCBS of TX Blue Essentials |
$58.68
|
| Rate for Payer: BCBS of TX Medicare |
$12.88
|
| Rate for Payer: BCBS of TX PPO |
$65.20
|
| Rate for Payer: Cash Price |
$110.84
|
| Rate for Payer: Cash Price |
$110.84
|
| Rate for Payer: Cigna Medicaid |
$117.36
|
| Rate for Payer: Cigna Medicare |
$12.88
|
| Rate for Payer: Employer Direct Commercial |
$12.88
|
| Rate for Payer: Humana Medicare/TRICARE |
$12.88
|
| Rate for Payer: Molina CHIP/Medicaid |
$117.36
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12.88
|
| Rate for Payer: Molina Medicare |
$12.88
|
| Rate for Payer: Multiplan Auto |
$105.95
|
| Rate for Payer: Multiplan Commercial |
$105.95
|
| Rate for Payer: Multiplan Workers Comp |
$105.95
|
| Rate for Payer: Parkland Medicaid |
$117.36
|
| Rate for Payer: Scott and White EPO/PPO |
$16.10
|
| Rate for Payer: Scott and White Medicare |
$12.88
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$117.36
|
| Rate for Payer: Superior Health Plan EPO |
$12.88
|
| Rate for Payer: Superior Health Plan Medicare |
$12.88
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12.88
|
| Rate for Payer: Universal American Medicare |
$12.88
|
| Rate for Payer: Wellcare Medicare |
$12.88
|
| Rate for Payer: Wellmed Medicare |
$12.88
|
|
|
.HTLV-I/II Immunoblot 164133 SO
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS 86688
|
| Hospital Charge Code |
1700036
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$65.28
|
|
|
.HTLV-I/II Immunoblot 164133 SO
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
HCPCS 86688
|
| Hospital Charge Code |
1700036
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.46
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14.00
|
| Rate for Payer: Amerigroup Medicare |
$14.00
|
| Rate for Payer: BCBS of TX Blue Advantage |
$28.80
|
| Rate for Payer: BCBS of TX Blue Essentials |
$34.56
|
| Rate for Payer: BCBS of TX Medicare |
$14.00
|
| Rate for Payer: BCBS of TX PPO |
$38.40
|
| Rate for Payer: Cash Price |
$65.28
|
| Rate for Payer: Cash Price |
$65.28
|
| Rate for Payer: Cigna Medicaid |
$69.12
|
| Rate for Payer: Cigna Medicare |
$14.00
|
| Rate for Payer: Employer Direct Commercial |
$14.00
|
| Rate for Payer: Humana Medicare/TRICARE |
$14.00
|
| Rate for Payer: Molina CHIP/Medicaid |
$69.12
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14.00
|
| Rate for Payer: Molina Medicare |
$14.00
|
| Rate for Payer: Multiplan Auto |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: Multiplan Workers Comp |
$62.40
|
| Rate for Payer: Parkland Medicaid |
$69.12
|
| Rate for Payer: Scott and White EPO/PPO |
$17.50
|
| Rate for Payer: Scott and White Medicare |
$14.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$69.12
|
| Rate for Payer: Superior Health Plan EPO |
$14.00
|
| Rate for Payer: Superior Health Plan Medicare |
$14.00
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14.00
|
| Rate for Payer: Universal American Medicare |
$14.00
|
| Rate for Payer: Wellcare Medicare |
$14.00
|
| Rate for Payer: Wellmed Medicare |
$14.00
|
|
|
HUMAN DONOR MILK HDM PLUS
|
Facility
|
OP
|
$118.04
|
|
| Hospital Charge Code |
8484495
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$10.62 |
| Max. Negotiated Rate |
$84.99 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$10.62
|
| Rate for Payer: BCBS of TX Blue Advantage |
$35.41
|
| Rate for Payer: BCBS of TX Blue Essentials |
$42.49
|
| Rate for Payer: BCBS of TX PPO |
$47.22
|
| Rate for Payer: Cash Price |
$80.27
|
| Rate for Payer: Cigna Medicaid |
$84.99
|
| Rate for Payer: Molina CHIP/Medicaid |
$84.99
|
| Rate for Payer: Multiplan Auto |
$76.73
|
| Rate for Payer: Multiplan Commercial |
$76.73
|
| Rate for Payer: Multiplan Workers Comp |
$76.73
|
| Rate for Payer: Parkland Medicaid |
$84.99
|
| Rate for Payer: Scott and White EPO/PPO |
$59.02
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$84.99
|
| Rate for Payer: Superior Health Plan EPO |
$16.05
|
|
|
HUMAN DONOR MILK HDM PLUS
|
Facility
|
IP
|
$118.04
|
|
| Hospital Charge Code |
8484495
|
|
Hospital Revenue Code
|
271
|
| Rate for Payer: Cash Price |
$80.27
|
|
|
HUMIDIFIER PREFILLED STRL WATER W/ADAPTER 500ML
|
Facility
|
OP
|
$14.76
|
|
| Hospital Charge Code |
993304
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$10.63 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4.43
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5.31
|
| Rate for Payer: BCBS of TX PPO |
$5.90
|
| Rate for Payer: Cash Price |
$10.04
|
| Rate for Payer: Cigna Medicaid |
$10.63
|
| Rate for Payer: Molina CHIP/Medicaid |
$10.63
|
| Rate for Payer: Multiplan Auto |
$9.59
|
| Rate for Payer: Multiplan Commercial |
$9.59
|
| Rate for Payer: Multiplan Workers Comp |
$9.59
|
| Rate for Payer: Parkland Medicaid |
$10.63
|
| Rate for Payer: Scott and White EPO/PPO |
$7.38
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$10.63
|
| Rate for Payer: Superior Health Plan EPO |
$2.01
|
|
|
HUMIDIFIER PREFILLED STRL WATER W/ADAPTER 500ML
|
Facility
|
IP
|
$14.76
|
|
| Hospital Charge Code |
993304
|
|
Hospital Revenue Code
|
270
|
| Rate for Payer: Cash Price |
$10.04
|
|
|
Hyaluronan or derivative, HYMOVIS, for intra-articular injection, 1 mg
|
Facility
|
IP
|
$87.09
|
|
|
Service Code
|
HCPCS J7322
|
| Hospital Charge Code |
9900920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.77 |
| Max. Negotiated Rate |
$43.55 |
| Rate for Payer: Cash Price |
$59.22
|
| Rate for Payer: Cigna Commercial |
$21.77
|
| Rate for Payer: Scott and White EPO/PPO |
$43.55
|
|
|
Hyaluronan or derivative, HYMOVIS, for intra-articular injection, 1 mg
|
Facility
|
OP
|
$87.09
|
|
|
Service Code
|
HCPCS J7322
|
| Hospital Charge Code |
9900920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7.84
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$18.13
|
| Rate for Payer: Amerigroup Medicare |
$18.13
|
| Rate for Payer: BCBS of TX Blue Advantage |
$20.79
|
| Rate for Payer: BCBS of TX Blue Essentials |
$24.95
|
| Rate for Payer: BCBS of TX Medicare |
$18.13
|
| Rate for Payer: BCBS of TX PPO |
$27.68
|
| Rate for Payer: Cash Price |
$59.22
|
| Rate for Payer: Cash Price |
$59.22
|
| Rate for Payer: Cigna Medicaid |
$62.70
|
| Rate for Payer: Cigna Medicare |
$18.13
|
| Rate for Payer: Employer Direct Commercial |
$18.13
|
| Rate for Payer: Humana Medicare/TRICARE |
$18.13
|
| Rate for Payer: Molina CHIP/Medicaid |
$62.70
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$18.13
|
| Rate for Payer: Molina Medicare |
$18.13
|
| Rate for Payer: Multiplan Auto |
$56.61
|
| Rate for Payer: Multiplan Commercial |
$56.61
|
| Rate for Payer: Multiplan Workers Comp |
$56.61
|
| Rate for Payer: Parkland Medicaid |
$62.70
|
| Rate for Payer: Scott and White EPO/PPO |
$43.55
|
| Rate for Payer: Scott and White Medicare |
$18.13
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$62.70
|
| Rate for Payer: Superior Health Plan EPO |
$18.13
|
| Rate for Payer: Superior Health Plan Medicare |
$18.13
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$18.13
|
| Rate for Payer: Universal American Medicare |
$18.13
|
| Rate for Payer: Wellcare Medicare |
$18.13
|
| Rate for Payer: Wellmed Medicare |
$18.13
|
|
|
Hyaluronan or derivative, HYMOVIS, for intra-articular injection, 1 mg
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT J7322
|
| Hospital Charge Code |
360J7322
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$18.13
|
| Rate for Payer: Amerigroup Medicare |
$18.13
|
| Rate for Payer: BCBS of TX Medicare |
$18.13
|
| Rate for Payer: Cigna Medicare |
$18.13
|
| Rate for Payer: Employer Direct Commercial |
$18.13
|
| Rate for Payer: Humana Medicare/TRICARE |
$18.13
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$18.13
|
| Rate for Payer: Molina Medicare |
$18.13
|
| 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 Medicare |
$18.13
|
| Rate for Payer: Superior Health Plan EPO |
$18.13
|
| Rate for Payer: Superior Health Plan Medicare |
$18.13
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$18.13
|
| Rate for Payer: Universal American Medicare |
$18.13
|
| Rate for Payer: Wellcare Medicare |
$18.13
|
| Rate for Payer: Wellmed Medicare |
$18.13
|
|
|
Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT J7324
|
| Hospital Charge Code |
360J7324
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$100.33 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$100.33
|
| Rate for Payer: Amerigroup Medicare |
$100.33
|
| Rate for Payer: BCBS of TX Medicare |
$100.33
|
| Rate for Payer: Cigna Medicare |
$100.33
|
| Rate for Payer: Employer Direct Commercial |
$100.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$100.33
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.33
|
| Rate for Payer: Molina Medicare |
$100.33
|
| 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 Medicare |
$100.33
|
| Rate for Payer: Superior Health Plan EPO |
$100.33
|
| Rate for Payer: Superior Health Plan Medicare |
$100.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$100.33
|
| Rate for Payer: Universal American Medicare |
$100.33
|
| Rate for Payer: Wellcare Medicare |
$100.33
|
| Rate for Payer: Wellmed Medicare |
$100.33
|
|
|
Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
|
Facility
|
OP
|
$353.12
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
9900921
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.78 |
| Max. Negotiated Rate |
$287.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$31.78
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$100.33
|
| Rate for Payer: Amerigroup Medicare |
$100.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$215.77
|
| Rate for Payer: BCBS of TX Blue Essentials |
$258.93
|
| Rate for Payer: BCBS of TX Medicare |
$100.33
|
| Rate for Payer: BCBS of TX PPO |
$287.20
|
| Rate for Payer: Cash Price |
$240.12
|
| Rate for Payer: Cash Price |
$240.12
|
| Rate for Payer: Cigna Medicaid |
$254.25
|
| Rate for Payer: Cigna Medicare |
$100.33
|
| Rate for Payer: Employer Direct Commercial |
$100.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$100.33
|
| Rate for Payer: Molina CHIP/Medicaid |
$254.25
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$100.33
|
| Rate for Payer: Molina Medicare |
$100.33
|
| Rate for Payer: Multiplan Auto |
$229.53
|
| Rate for Payer: Multiplan Commercial |
$229.53
|
| Rate for Payer: Multiplan Workers Comp |
$229.53
|
| Rate for Payer: Parkland Medicaid |
$254.25
|
| Rate for Payer: Scott and White EPO/PPO |
$176.56
|
| Rate for Payer: Scott and White Medicare |
$100.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$254.25
|
| Rate for Payer: Superior Health Plan EPO |
$100.33
|
| Rate for Payer: Superior Health Plan Medicare |
$100.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$100.33
|
| Rate for Payer: Universal American Medicare |
$100.33
|
| Rate for Payer: Wellcare Medicare |
$100.33
|
| Rate for Payer: Wellmed Medicare |
$100.33
|
|
|
Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
|
Facility
|
IP
|
$353.12
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
9900921
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.28 |
| Max. Negotiated Rate |
$176.56 |
| Rate for Payer: Cash Price |
$240.12
|
| Rate for Payer: Cigna Commercial |
$88.28
|
| Rate for Payer: Scott and White EPO/PPO |
$176.56
|
|
|
hydrALAZINE 10 mg Tab
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77607802
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.84
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.79
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3.35
|
| Rate for Payer: BCBS of TX PPO |
$3.72
|
| Rate for Payer: Cash Price |
$6.32
|
| Rate for Payer: Cigna Medicaid |
$6.70
|
| Rate for Payer: Molina CHIP/Medicaid |
$6.70
|
| Rate for Payer: Multiplan Auto |
$6.04
|
| Rate for Payer: Multiplan Commercial |
$6.04
|
| Rate for Payer: Multiplan Workers Comp |
$6.04
|
| Rate for Payer: Parkland Medicaid |
$6.70
|
| Rate for Payer: Scott and White EPO/PPO |
$4.65
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$6.70
|
| Rate for Payer: Superior Health Plan EPO |
$1.26
|
|
|
hydrALAZINE 10 mg Tab
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77607802
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$6.32
|
|
|
hydrALAZINE 20 mg/mL Inj Soln 1 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
77607908
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.40 |
| Max. Negotiated Rate |
$92.28 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11.28
|
| Rate for Payer: BCBS of TX PPO |
$12.51
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cigna Medicaid |
$92.28
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.28
|
| Rate for Payer: Multiplan Auto |
$83.31
|
| Rate for Payer: Multiplan Commercial |
$83.31
|
| Rate for Payer: Multiplan Workers Comp |
$83.31
|
| Rate for Payer: Parkland Medicaid |
$92.28
|
| Rate for Payer: Scott and White EPO/PPO |
$64.08
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.28
|
| Rate for Payer: Superior Health Plan EPO |
$17.43
|
|
|
hydrALAZINE 20 mg/mL Inj Soln 1 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
77607908
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.04 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cigna Commercial |
$32.04
|
| Rate for Payer: Scott and White EPO/PPO |
$64.08
|
|
|
hydrALAZINE 25 mg Tab
|
Facility
|
IP
|
$8.85
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77607965
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$6.02
|
|
|
hydrALAZINE 25 mg Tab
|
Facility
|
OP
|
$8.85
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77607965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$6.37 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.80
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.65
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3.19
|
| Rate for Payer: BCBS of TX PPO |
$3.54
|
| Rate for Payer: Cash Price |
$6.02
|
| Rate for Payer: Cigna Medicaid |
$6.37
|
| Rate for Payer: Molina CHIP/Medicaid |
$6.37
|
| Rate for Payer: Multiplan Auto |
$5.75
|
| Rate for Payer: Multiplan Commercial |
$5.75
|
| Rate for Payer: Multiplan Workers Comp |
$5.75
|
| Rate for Payer: Parkland Medicaid |
$6.37
|
| Rate for Payer: Scott and White EPO/PPO |
$4.42
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$6.37
|
| Rate for Payer: Superior Health Plan EPO |
$1.20
|
|
