|
kerecis omega 3 3x3.5 50200s01b0d per sq cm
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8640519
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$103.75 |
| Max. Negotiated Rate |
$207.50 |
| Rate for Payer: Cash Price |
$282.20
|
| Rate for Payer: Cigna Commercial |
$103.75
|
| Rate for Payer: Multiplan Auto |
$207.50
|
| Rate for Payer: Multiplan Commercial |
$207.50
|
| Rate for Payer: Multiplan Workers Comp |
$207.50
|
| Rate for Payer: Scott and White EPO/PPO |
$207.50
|
|
|
kerecis omega3 3x3.5cm-50200s01b2d
|
Facility
|
OP
|
$256.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8630553
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$23.04
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$76.80
|
| Rate for Payer: BCBS of TX Blue Essentials |
$92.16
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$102.40
|
| Rate for Payer: Cash Price |
$174.08
|
| Rate for Payer: Cash Price |
$174.08
|
| Rate for Payer: Cash Price |
$174.08
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$184.32
|
| 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 |
$184.32
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$128.00
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: Multiplan Workers Comp |
$128.00
|
| Rate for Payer: Parkland Medicaid |
$184.32
|
| Rate for Payer: Scott and White EPO/PPO |
$128.00
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$184.32
|
| 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
|
|
|
kerecis omega3 3x3.5cm-50200s01b2d
|
Facility
|
IP
|
$256.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8630553
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$64.00 |
| Max. Negotiated Rate |
$128.00 |
| Rate for Payer: Cash Price |
$174.08
|
| Rate for Payer: Cigna Commercial |
$64.00
|
| Rate for Payer: Multiplan Auto |
$128.00
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: Multiplan Workers Comp |
$128.00
|
| Rate for Payer: Scott and White EPO/PPO |
$128.00
|
|
|
kerecis omega 3 3x7cm 50200s02b2d per sq cm
|
Facility
|
OP
|
$252.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
40299018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22.68 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$22.68
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$75.60
|
| Rate for Payer: BCBS of TX Blue Essentials |
$90.72
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$100.80
|
| Rate for Payer: Cash Price |
$171.36
|
| Rate for Payer: Cash Price |
$171.36
|
| Rate for Payer: Cash Price |
$171.36
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$181.44
|
| 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 |
$181.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$126.00
|
| Rate for Payer: Multiplan Commercial |
$126.00
|
| Rate for Payer: Multiplan Workers Comp |
$126.00
|
| Rate for Payer: Parkland Medicaid |
$181.44
|
| Rate for Payer: Scott and White EPO/PPO |
$126.00
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$181.44
|
| 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
|
|
|
kerecis omega 3 3x7cm 50200s02b2d per sq cm
|
Facility
|
IP
|
$252.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
40299018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Cash Price |
$171.36
|
| Rate for Payer: Cigna Commercial |
$63.00
|
| Rate for Payer: Multiplan Auto |
$126.00
|
| Rate for Payer: Multiplan Commercial |
$126.00
|
| Rate for Payer: Multiplan Workers Comp |
$126.00
|
| Rate for Payer: Scott and White EPO/PPO |
$126.00
|
|
|
kerecis omega3 3x7cm(ea) 50200s02b0d sq cm
|
Facility
|
OP
|
$347.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8640520
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$31.23 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$31.23
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$104.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$124.92
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$138.80
|
| Rate for Payer: Cash Price |
$235.96
|
| Rate for Payer: Cash Price |
$235.96
|
| Rate for Payer: Cash Price |
$235.96
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$249.84
|
| 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 |
$249.84
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$173.50
|
| Rate for Payer: Multiplan Commercial |
$173.50
|
| Rate for Payer: Multiplan Workers Comp |
$173.50
|
| Rate for Payer: Parkland Medicaid |
$249.84
|
| Rate for Payer: Scott and White EPO/PPO |
$173.50
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$249.84
|
| 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
|
|
|
kerecis omega3 3x7cm(ea) 50200s02b0d sq cm
|
Facility
|
IP
|
$347.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8640520
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.75 |
| Max. Negotiated Rate |
$173.50 |
| Rate for Payer: Cash Price |
$235.96
|
| Rate for Payer: Cigna Commercial |
$86.75
|
| Rate for Payer: Multiplan Auto |
$173.50
|
| Rate for Payer: Multiplan Commercial |
$173.50
|
| Rate for Payer: Multiplan Workers Comp |
$173.50
|
| Rate for Payer: Scott and White EPO/PPO |
$173.50
|
|
|
kerecis omega 3 7x10 50200s03bod per sq cm
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8638508
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$68.75 |
| Max. Negotiated Rate |
$137.50 |
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cigna Commercial |
$68.75
|
| Rate for Payer: Multiplan Auto |
$137.50
|
| Rate for Payer: Multiplan Commercial |
$137.50
|
| Rate for Payer: Multiplan Workers Comp |
$137.50
|
| Rate for Payer: Scott and White EPO/PPO |
$137.50
|
|
|
kerecis omega 3 7x10 50200s03bod per sq cm
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8638508
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$24.75
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$82.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$99.00
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$110.00
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$198.00
|
| 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 |
$198.00
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$137.50
|
| Rate for Payer: Multiplan Commercial |
$137.50
|
| Rate for Payer: Multiplan Workers Comp |
$137.50
|
| Rate for Payer: Parkland Medicaid |
$198.00
|
| Rate for Payer: Scott and White EPO/PPO |
$137.50
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$198.00
|
| 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
|
|
|
kerecis omega3 7x20 (ea) per sq cm
|
Facility
|
OP
|
$323.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8630552
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$29.07 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.07
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$96.90
|
| Rate for Payer: BCBS of TX Blue Essentials |
$116.28
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$129.20
|
| Rate for Payer: Cash Price |
$219.64
|
| Rate for Payer: Cash Price |
$219.64
|
| Rate for Payer: Cash Price |
$219.64
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$232.56
|
| 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 |
$232.56
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$161.50
|
| Rate for Payer: Multiplan Commercial |
$161.50
|
| Rate for Payer: Multiplan Workers Comp |
$161.50
|
| Rate for Payer: Parkland Medicaid |
$232.56
|
| Rate for Payer: Scott and White EPO/PPO |
$161.50
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$232.56
|
| 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
|
|
|
kerecis omega3 7x20 (ea) per sq cm
|
Facility
|
IP
|
$323.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8630552
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$80.75 |
| Max. Negotiated Rate |
$161.50 |
| Rate for Payer: Cash Price |
$219.64
|
| Rate for Payer: Cigna Commercial |
$80.75
|
| Rate for Payer: Multiplan Auto |
$161.50
|
| Rate for Payer: Multiplan Commercial |
$161.50
|
| Rate for Payer: Multiplan Workers Comp |
$161.50
|
| Rate for Payer: Scott and White EPO/PPO |
$161.50
|
|
|
kerecis omega3 7x7cm 50200s04b0d sq cm
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8638507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$50.50 |
| Max. Negotiated Rate |
$101.00 |
| Rate for Payer: Cash Price |
$137.36
|
| Rate for Payer: Cigna Commercial |
$50.50
|
| Rate for Payer: Multiplan Auto |
$101.00
|
| Rate for Payer: Multiplan Commercial |
$101.00
|
| Rate for Payer: Multiplan Workers Comp |
$101.00
|
| Rate for Payer: Scott and White EPO/PPO |
$101.00
|
|
|
kerecis omega3 7x7cm 50200s04b0d sq cm
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
8638507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$18.18 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$18.18
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$60.60
|
| Rate for Payer: BCBS of TX Blue Essentials |
$72.72
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$80.80
|
| Rate for Payer: Cash Price |
$137.36
|
| Rate for Payer: Cash Price |
$137.36
|
| Rate for Payer: Cash Price |
$137.36
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$145.44
|
| 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 |
$145.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$101.00
|
| Rate for Payer: Multiplan Commercial |
$101.00
|
| Rate for Payer: Multiplan Workers Comp |
$101.00
|
| Rate for Payer: Parkland Medicaid |
$145.44
|
| Rate for Payer: Scott and White EPO/PPO |
$101.00
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$145.44
|
| 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
|
|
|
ketamine 50 mg/ml Inj Soln 10 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
79732735
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$87.16
|
|
|
ketamine 50 mg/ml Inj Soln 10 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
79732735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$92.28 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38.45
|
| Rate for Payer: BCBS of TX Blue Essentials |
$46.14
|
| Rate for Payer: BCBS of TX PPO |
$51.27
|
| 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
|
|
|
ketoconazole 2% Cream 15 g
|
Facility
|
OP
|
$51.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78435133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$36.94 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$4.62
|
| Rate for Payer: BCBS of TX Blue Advantage |
$15.39
|
| Rate for Payer: BCBS of TX Blue Essentials |
$18.47
|
| Rate for Payer: BCBS of TX PPO |
$20.52
|
| Rate for Payer: Cash Price |
$34.88
|
| Rate for Payer: Cigna Medicaid |
$36.94
|
| Rate for Payer: Molina CHIP/Medicaid |
$36.94
|
| Rate for Payer: Multiplan Auto |
$33.34
|
| Rate for Payer: Multiplan Commercial |
$33.34
|
| Rate for Payer: Multiplan Workers Comp |
$33.34
|
| Rate for Payer: Parkland Medicaid |
$36.94
|
| Rate for Payer: Scott and White EPO/PPO |
$25.65
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$36.94
|
| Rate for Payer: Superior Health Plan EPO |
$6.98
|
|
|
ketoconazole 2% Cream 15 g
|
Facility
|
IP
|
$51.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78435133
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$34.88
|
|
|
Ketone body(s) (eg, acetone, acetoacetic acid, beta-hydroxybutyrate); quantitative
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
HCPCS 82010
|
| Hospital Charge Code |
1708809
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$125.28 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.19
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$8.17
|
| Rate for Payer: Amerigroup Medicare |
$8.17
|
| Rate for Payer: BCBS of TX Blue Advantage |
$52.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$62.64
|
| Rate for Payer: BCBS of TX Medicare |
$8.17
|
| Rate for Payer: BCBS of TX PPO |
$69.60
|
| Rate for Payer: Cash Price |
$118.32
|
| Rate for Payer: Cash Price |
$118.32
|
| Rate for Payer: Cigna Medicaid |
$125.28
|
| Rate for Payer: Cigna Medicare |
$8.17
|
| Rate for Payer: Employer Direct Commercial |
$8.17
|
| Rate for Payer: Humana Medicare/TRICARE |
$8.17
|
| Rate for Payer: Molina CHIP/Medicaid |
$125.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$8.17
|
| Rate for Payer: Molina Medicare |
$8.17
|
| Rate for Payer: Multiplan Auto |
$113.10
|
| Rate for Payer: Multiplan Commercial |
$113.10
|
| Rate for Payer: Multiplan Workers Comp |
$113.10
|
| Rate for Payer: Parkland Medicaid |
$125.28
|
| Rate for Payer: Scott and White EPO/PPO |
$10.21
|
| Rate for Payer: Scott and White Medicare |
$8.17
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$125.28
|
| Rate for Payer: Superior Health Plan EPO |
$8.17
|
| Rate for Payer: Superior Health Plan Medicare |
$8.17
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$8.17
|
| Rate for Payer: Universal American Medicare |
$8.17
|
| Rate for Payer: Wellcare Medicare |
$8.17
|
| Rate for Payer: Wellmed Medicare |
$8.17
|
|
|
Ketone body(s) (eg, acetone, acetoacetic acid, beta-hydroxybutyrate); quantitative
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
HCPCS 82010
|
| Hospital Charge Code |
1708809
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$118.32
|
|
|
ketorolac 15 mg/mL Inj Soln 1 mL
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
78411482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Commercial |
$32.00
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
|
|
ketorolac 15 mg/mL Inj Soln 1 mL
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
78411482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.52
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$0.33
|
| Rate for Payer: Amerigroup Medicare |
$0.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$0.26
|
| Rate for Payer: BCBS of TX Blue Essentials |
$0.31
|
| Rate for Payer: BCBS of TX Medicare |
$0.33
|
| Rate for Payer: BCBS of TX PPO |
$0.35
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Medicaid |
$92.16
|
| Rate for Payer: Cigna Medicare |
$0.33
|
| Rate for Payer: Employer Direct Commercial |
$0.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$0.33
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.16
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$0.33
|
| Rate for Payer: Molina Medicare |
$0.33
|
| Rate for Payer: Multiplan Auto |
$83.20
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Multiplan Workers Comp |
$83.20
|
| Rate for Payer: Parkland Medicaid |
$92.16
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
| Rate for Payer: Scott and White Medicare |
$0.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.16
|
| Rate for Payer: Superior Health Plan EPO |
$0.33
|
| Rate for Payer: Superior Health Plan Medicare |
$0.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$0.33
|
| Rate for Payer: Universal American Medicare |
$0.33
|
| Rate for Payer: Wellcare Medicare |
$0.33
|
| Rate for Payer: Wellmed Medicare |
$0.33
|
|
|
ketorolac 30 mg/mL Inj Soln 1 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
78470543
|
|
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
|
|
|
ketorolac 30 mg/mL Inj Soln 1 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
78470543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$92.28 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$0.33
|
| Rate for Payer: Amerigroup Medicare |
$0.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$0.26
|
| Rate for Payer: BCBS of TX Blue Essentials |
$0.31
|
| Rate for Payer: BCBS of TX Medicare |
$0.33
|
| Rate for Payer: BCBS of TX PPO |
$0.35
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cigna Medicaid |
$92.28
|
| Rate for Payer: Cigna Medicare |
$0.33
|
| Rate for Payer: Employer Direct Commercial |
$0.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$0.33
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$0.33
|
| Rate for Payer: Molina Medicare |
$0.33
|
| 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: Scott and White Medicare |
$0.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.28
|
| Rate for Payer: Superior Health Plan EPO |
$0.33
|
| Rate for Payer: Superior Health Plan Medicare |
$0.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$0.33
|
| Rate for Payer: Universal American Medicare |
$0.33
|
| Rate for Payer: Wellcare Medicare |
$0.33
|
| Rate for Payer: Wellmed Medicare |
$0.33
|
|
|
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC
|
Facility
|
IP
|
$35,682.00
|
|
|
Service Code
|
MSDRG 657
|
| Min. Negotiated Rate |
$16,432.50 |
| Max. Negotiated Rate |
$35,682.00 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$18,172.19
|
| Rate for Payer: Amerigroup Medicare |
$18,172.19
|
| Rate for Payer: BCBS of TX Medicare |
$18,172.19
|
| Rate for Payer: Cigna Commercial |
$23,570.40
|
| Rate for Payer: Cigna Medicare |
$18,172.19
|
| Rate for Payer: Employer Direct Commercial |
$18,172.19
|
| Rate for Payer: Humana Medicare/TRICARE |
$18,172.19
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$18,172.19
|
| Rate for Payer: Molina Medicare |
$18,172.19
|
| Rate for Payer: Multiplan Auto |
$35,682.00
|
| Rate for Payer: Multiplan Commercial |
$35,682.00
|
| Rate for Payer: Multiplan Workers Comp |
$35,682.00
|
| Rate for Payer: Scott and White EPO/PPO |
$16,432.50
|
| Rate for Payer: Scott and White Medicare |
$18,172.19
|
| Rate for Payer: Superior Health Plan EPO |
$18,172.19
|
| Rate for Payer: Superior Health Plan Medicare |
$18,172.19
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$18,172.19
|
| Rate for Payer: Universal American Medicare |
$18,172.19
|
| Rate for Payer: Wellcare Medicare |
$18,172.19
|
| Rate for Payer: Wellmed Medicare |
$18,172.19
|
|
|
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC
|
Facility
|
IP
|
$62,800.70
|
|
|
Service Code
|
MSDRG 656
|
| Min. Negotiated Rate |
$28,094.23 |
| Max. Negotiated Rate |
$62,800.70 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$28,094.23
|
| Rate for Payer: Amerigroup Medicare |
$28,094.23
|
| Rate for Payer: BCBS of TX Medicare |
$28,094.23
|
| Rate for Payer: Cigna Commercial |
$41,007.34
|
| Rate for Payer: Cigna Medicare |
$28,094.23
|
| Rate for Payer: Employer Direct Commercial |
$28,094.23
|
| Rate for Payer: Humana Medicare/TRICARE |
$28,094.23
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$28,094.23
|
| Rate for Payer: Molina Medicare |
$28,094.23
|
| Rate for Payer: Multiplan Auto |
$62,800.70
|
| Rate for Payer: Multiplan Commercial |
$62,800.70
|
| Rate for Payer: Multiplan Workers Comp |
$62,800.70
|
| Rate for Payer: Scott and White EPO/PPO |
$28,921.38
|
| Rate for Payer: Scott and White Medicare |
$28,094.23
|
| Rate for Payer: Superior Health Plan EPO |
$28,094.23
|
| Rate for Payer: Superior Health Plan Medicare |
$28,094.23
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$28,094.23
|
| Rate for Payer: Universal American Medicare |
$28,094.23
|
| Rate for Payer: Wellcare Medicare |
$28,094.23
|
| Rate for Payer: Wellmed Medicare |
$28,094.23
|
|
