|
Admin Immunization Charge - Flu -> L&D - Initial Admin Charge 90471
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
315368
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$84.32
|
|
|
Admin Immunization Charge - Hep B Ped -> IV Therapy/Nursing - Initial Admin Charge 90471
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
1500421
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$152.89 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Amerigroup Medicare |
$72.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$37.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$44.64
|
| Rate for Payer: BCBS of TX Medicare |
$72.33
|
| Rate for Payer: BCBS of TX PPO |
$49.60
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cigna Commercial |
$152.89
|
| Rate for Payer: Cigna Medicaid |
$89.28
|
| Rate for Payer: Cigna Medicare |
$72.33
|
| Rate for Payer: Employer Direct Commercial |
$72.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$72.33
|
| Rate for Payer: Molina CHIP/Medicaid |
$89.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Molina Medicare |
$72.33
|
| Rate for Payer: Multiplan Auto |
$80.60
|
| Rate for Payer: Multiplan Commercial |
$80.60
|
| Rate for Payer: Multiplan Workers Comp |
$80.60
|
| Rate for Payer: Parkland Medicaid |
$89.28
|
| Rate for Payer: Scott and White EPO/PPO |
$25.52
|
| Rate for Payer: Scott and White Medicare |
$72.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$89.28
|
| Rate for Payer: Superior Health Plan EPO |
$72.33
|
| Rate for Payer: Superior Health Plan Medicare |
$72.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Universal American Medicare |
$72.33
|
| Rate for Payer: Wellcare Medicare |
$72.33
|
| Rate for Payer: Wellmed Medicare |
$72.33
|
|
|
Admin Immunization Charge - Hep B Ped -> IV Therapy/Nursing - Initial Admin Charge 90471
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
1500421
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$84.32
|
|
|
Admin Immunization Charge -> IV Therapy/Nursing - Initial Admin Charge 90471
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
1510001
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$84.32
|
|
|
Admin Immunization Charge -> IV Therapy/Nursing - Initial Admin Charge 90471
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
1510001
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$152.89 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Amerigroup Medicare |
$72.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$37.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$44.64
|
| Rate for Payer: BCBS of TX Medicare |
$72.33
|
| Rate for Payer: BCBS of TX PPO |
$49.60
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cigna Commercial |
$152.89
|
| Rate for Payer: Cigna Medicaid |
$89.28
|
| Rate for Payer: Cigna Medicare |
$72.33
|
| Rate for Payer: Employer Direct Commercial |
$72.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$72.33
|
| Rate for Payer: Molina CHIP/Medicaid |
$89.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Molina Medicare |
$72.33
|
| Rate for Payer: Multiplan Auto |
$80.60
|
| Rate for Payer: Multiplan Commercial |
$80.60
|
| Rate for Payer: Multiplan Workers Comp |
$80.60
|
| Rate for Payer: Parkland Medicaid |
$89.28
|
| Rate for Payer: Scott and White EPO/PPO |
$25.52
|
| Rate for Payer: Scott and White Medicare |
$72.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$89.28
|
| Rate for Payer: Superior Health Plan EPO |
$72.33
|
| Rate for Payer: Superior Health Plan Medicare |
$72.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Universal American Medicare |
$72.33
|
| Rate for Payer: Wellcare Medicare |
$72.33
|
| Rate for Payer: Wellmed Medicare |
$72.33
|
|
|
Admin Immunization Charge -> L&D - Initial Admin Charge 90471
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
315367
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$84.32
|
|
|
Admin Immunization Charge -> L&D - Initial Admin Charge 90471
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
315367
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$152.89 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Amerigroup Medicare |
$72.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$37.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$44.64
|
| Rate for Payer: BCBS of TX Medicare |
$72.33
|
| Rate for Payer: BCBS of TX PPO |
$49.60
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cigna Commercial |
$152.89
|
| Rate for Payer: Cigna Medicaid |
$89.28
|
| Rate for Payer: Cigna Medicare |
$72.33
|
| Rate for Payer: Employer Direct Commercial |
$72.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$72.33
|
| Rate for Payer: Molina CHIP/Medicaid |
$89.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Molina Medicare |
$72.33
|
| Rate for Payer: Multiplan Auto |
$80.60
|
| Rate for Payer: Multiplan Commercial |
$80.60
|
| Rate for Payer: Multiplan Workers Comp |
$80.60
|
| Rate for Payer: Parkland Medicaid |
$89.28
|
| Rate for Payer: Scott and White EPO/PPO |
$25.52
|
| Rate for Payer: Scott and White Medicare |
$72.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$89.28
|
| Rate for Payer: Superior Health Plan EPO |
$72.33
|
| Rate for Payer: Superior Health Plan Medicare |
$72.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Universal American Medicare |
$72.33
|
| Rate for Payer: Wellcare Medicare |
$72.33
|
| Rate for Payer: Wellmed Medicare |
$72.33
|
|
|
Admin Immunization Charge - Pneumococcal -> ED - Addl Admin Charge 90472
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
HCPCS 90472
|
| Hospital Charge Code |
5200068
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$59.84
|
|
|
Admin Immunization Charge - Pneumococcal -> ED - Addl Admin Charge 90472
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
HCPCS 90472
|
| Hospital Charge Code |
5200068
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$63.36 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7.92
|
| Rate for Payer: BCBS of TX Blue Advantage |
$26.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$31.68
|
| Rate for Payer: BCBS of TX PPO |
$35.20
|
| Rate for Payer: Cash Price |
$59.84
|
| Rate for Payer: Cash Price |
$59.84
|
| Rate for Payer: Cigna Medicaid |
$63.36
|
| Rate for Payer: Molina CHIP/Medicaid |
$63.36
|
| Rate for Payer: Multiplan Auto |
$57.20
|
| Rate for Payer: Multiplan Commercial |
$57.20
|
| Rate for Payer: Multiplan Workers Comp |
$57.20
|
| Rate for Payer: Parkland Medicaid |
$63.36
|
| Rate for Payer: Scott and White EPO/PPO |
$18.11
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$63.36
|
| Rate for Payer: Superior Health Plan EPO |
$11.97
|
|
|
Admin Immunization Charge - Pneumococcal -> ED - Initial Admin Charge 90471
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
5200050
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$84.32
|
|
|
Admin Immunization Charge - Pneumococcal -> ED - Initial Admin Charge 90471
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
5200050
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$152.89 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Amerigroup Medicare |
$72.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$37.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$44.64
|
| Rate for Payer: BCBS of TX Medicare |
$72.33
|
| Rate for Payer: BCBS of TX PPO |
$49.60
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cigna Commercial |
$152.89
|
| Rate for Payer: Cigna Medicaid |
$89.28
|
| Rate for Payer: Cigna Medicare |
$72.33
|
| Rate for Payer: Employer Direct Commercial |
$72.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$72.33
|
| Rate for Payer: Molina CHIP/Medicaid |
$89.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Molina Medicare |
$72.33
|
| Rate for Payer: Multiplan Auto |
$80.60
|
| Rate for Payer: Multiplan Commercial |
$80.60
|
| Rate for Payer: Multiplan Workers Comp |
$80.60
|
| Rate for Payer: Parkland Medicaid |
$89.28
|
| Rate for Payer: Scott and White EPO/PPO |
$25.52
|
| Rate for Payer: Scott and White Medicare |
$72.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$89.28
|
| Rate for Payer: Superior Health Plan EPO |
$72.33
|
| Rate for Payer: Superior Health Plan Medicare |
$72.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Universal American Medicare |
$72.33
|
| Rate for Payer: Wellcare Medicare |
$72.33
|
| Rate for Payer: Wellmed Medicare |
$72.33
|
|
|
Admin Immunization Charge - Pneumococcal -> IV Therapy/Nursing - Addl Admin Charge 90472
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
HCPCS 90472
|
| Hospital Charge Code |
1500422
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$59.84
|
|
|
Admin Immunization Charge - Pneumococcal -> IV Therapy/Nursing - Addl Admin Charge 90472
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
HCPCS 90472
|
| Hospital Charge Code |
1500422
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$63.36 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7.92
|
| Rate for Payer: BCBS of TX Blue Advantage |
$26.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$31.68
|
| Rate for Payer: BCBS of TX PPO |
$35.20
|
| Rate for Payer: Cash Price |
$59.84
|
| Rate for Payer: Cash Price |
$59.84
|
| Rate for Payer: Cigna Medicaid |
$63.36
|
| Rate for Payer: Molina CHIP/Medicaid |
$63.36
|
| Rate for Payer: Multiplan Auto |
$57.20
|
| Rate for Payer: Multiplan Commercial |
$57.20
|
| Rate for Payer: Multiplan Workers Comp |
$57.20
|
| Rate for Payer: Parkland Medicaid |
$63.36
|
| Rate for Payer: Scott and White EPO/PPO |
$18.11
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$63.36
|
| Rate for Payer: Superior Health Plan EPO |
$11.97
|
|
|
Admin Immunization Charge - Pneumococcal -> IV Therapy/Nursing - Initial Admin Charge 90471
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
1500297
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$152.89 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Amerigroup Medicare |
$72.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$37.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$44.64
|
| Rate for Payer: BCBS of TX Medicare |
$72.33
|
| Rate for Payer: BCBS of TX PPO |
$49.60
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cash Price |
$84.32
|
| Rate for Payer: Cigna Commercial |
$152.89
|
| Rate for Payer: Cigna Medicaid |
$89.28
|
| Rate for Payer: Cigna Medicare |
$72.33
|
| Rate for Payer: Employer Direct Commercial |
$72.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$72.33
|
| Rate for Payer: Molina CHIP/Medicaid |
$89.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Molina Medicare |
$72.33
|
| Rate for Payer: Multiplan Auto |
$80.60
|
| Rate for Payer: Multiplan Commercial |
$80.60
|
| Rate for Payer: Multiplan Workers Comp |
$80.60
|
| Rate for Payer: Parkland Medicaid |
$89.28
|
| Rate for Payer: Scott and White EPO/PPO |
$25.52
|
| Rate for Payer: Scott and White Medicare |
$72.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$89.28
|
| Rate for Payer: Superior Health Plan EPO |
$72.33
|
| Rate for Payer: Superior Health Plan Medicare |
$72.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Universal American Medicare |
$72.33
|
| Rate for Payer: Wellcare Medicare |
$72.33
|
| Rate for Payer: Wellmed Medicare |
$72.33
|
|
|
Admin Immunization Charge - Pneumococcal -> IV Therapy/Nursing - Initial Admin Charge 90471
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
1500297
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$84.32
|
|
|
Admin Infusion Fee Casirivimab/Imdevimab -> Infusion & Monitoring M0243
|
Facility
|
IP
|
$675.00
|
|
|
Service Code
|
HCPCS M0243
|
| Hospital Charge Code |
8686554
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$459.00
|
|
|
Admin Infusion Fee Casirivimab/Imdevimab -> Infusion & Monitoring M0243
|
Facility
|
OP
|
$675.00
|
|
|
Service Code
|
HCPCS M0243
|
| Hospital Charge Code |
8686554
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$60.75 |
| Max. Negotiated Rate |
$486.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$60.75
|
| Rate for Payer: BCBS of TX Blue Advantage |
$202.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$243.00
|
| Rate for Payer: BCBS of TX PPO |
$270.00
|
| Rate for Payer: Cash Price |
$459.00
|
| Rate for Payer: Cigna Medicaid |
$486.00
|
| Rate for Payer: Molina CHIP/Medicaid |
$486.00
|
| Rate for Payer: Multiplan Auto |
$438.75
|
| Rate for Payer: Multiplan Commercial |
$438.75
|
| Rate for Payer: Multiplan Workers Comp |
$438.75
|
| Rate for Payer: Parkland Medicaid |
$486.00
|
| Rate for Payer: Scott and White EPO/PPO |
$337.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$486.00
|
| Rate for Payer: Superior Health Plan EPO |
$91.80
|
|
|
Administration Set Needleless 104' 15 Drops / ml Priming Volume 20ml 50 / Ca
|
Facility
|
IP
|
$18.33
|
|
| Hospital Charge Code |
993560
|
|
Hospital Revenue Code
|
270
|
| Rate for Payer: Cash Price |
$12.46
|
|
|
Administration Set Needleless 104' 15 Drops / ml Priming Volume 20ml 50 / Ca
|
Facility
|
OP
|
$18.33
|
|
| Hospital Charge Code |
993560
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$13.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1.65
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6.60
|
| Rate for Payer: BCBS of TX PPO |
$7.33
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Cigna Medicaid |
$13.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$13.20
|
| Rate for Payer: Multiplan Auto |
$11.91
|
| Rate for Payer: Multiplan Commercial |
$11.91
|
| Rate for Payer: Multiplan Workers Comp |
$11.91
|
| Rate for Payer: Parkland Medicaid |
$13.20
|
| Rate for Payer: Scott and White EPO/PPO |
$9.16
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$13.20
|
| Rate for Payer: Superior Health Plan EPO |
$2.49
|
|
|
Admin Vaccine Charge ? Covid-19 Janssen -> Booster Dose Janssen 0034A
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS 0034A
|
| Hospital Charge Code |
8740575
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$40.80
|
|
|
Admin Vaccine Charge ? Covid-19 Janssen -> Booster Dose Janssen 0034A
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS 0034A
|
| Hospital Charge Code |
8740575
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.40
|
| Rate for Payer: BCBS of TX Blue Advantage |
$18.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$21.60
|
| Rate for Payer: BCBS of TX PPO |
$24.00
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Medicaid |
$43.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$43.20
|
| Rate for Payer: Multiplan Auto |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$39.00
|
| Rate for Payer: Multiplan Workers Comp |
$39.00
|
| Rate for Payer: Parkland Medicaid |
$43.20
|
| Rate for Payer: Scott and White EPO/PPO |
$30.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$43.20
|
| Rate for Payer: Superior Health Plan EPO |
$8.16
|
|
|
Admin Vaccine Charge ? Covid-19 Janssen -> First Dose Janssen 0031A
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS 0031A
|
| Hospital Charge Code |
8686556
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$40.80
|
|
|
Admin Vaccine Charge ? Covid-19 Janssen -> First Dose Janssen 0031A
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS 0031A
|
| Hospital Charge Code |
8686556
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.40
|
| Rate for Payer: BCBS of TX Blue Advantage |
$18.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$21.60
|
| Rate for Payer: BCBS of TX PPO |
$24.00
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Medicaid |
$43.20
|
| Rate for Payer: Molina CHIP/Medicaid |
$43.20
|
| Rate for Payer: Multiplan Auto |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$39.00
|
| Rate for Payer: Multiplan Workers Comp |
$39.00
|
| Rate for Payer: Parkland Medicaid |
$43.20
|
| Rate for Payer: Scott and White EPO/PPO |
$30.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$43.20
|
| Rate for Payer: Superior Health Plan EPO |
$8.16
|
|
|
Admin Vaccine Charge - Covid-19 Moderna -> Booster Dose 2 Moderna 0064A
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS 0064A
|
| Hospital Charge Code |
8734592
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.60
|
| Rate for Payer: BCBS of TX Blue Advantage |
$12.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$14.40
|
| Rate for Payer: BCBS of TX PPO |
$16.00
|
| Rate for Payer: Cash Price |
$27.20
|
| Rate for Payer: Cigna Medicaid |
$28.80
|
| Rate for Payer: Molina CHIP/Medicaid |
$28.80
|
| Rate for Payer: Multiplan Auto |
$26.00
|
| Rate for Payer: Multiplan Commercial |
$26.00
|
| Rate for Payer: Multiplan Workers Comp |
$26.00
|
| Rate for Payer: Parkland Medicaid |
$28.80
|
| Rate for Payer: Scott and White EPO/PPO |
$20.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$28.80
|
| Rate for Payer: Superior Health Plan EPO |
$5.44
|
|
|
Admin Vaccine Charge - Covid-19 Moderna -> Booster Dose 2 Moderna 0064A
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS 0064A
|
| Hospital Charge Code |
8812543
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.60
|
| Rate for Payer: BCBS of TX Blue Advantage |
$12.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$14.40
|
| Rate for Payer: BCBS of TX PPO |
$16.00
|
| Rate for Payer: Cash Price |
$27.20
|
| Rate for Payer: Cigna Medicaid |
$28.80
|
| Rate for Payer: Molina CHIP/Medicaid |
$28.80
|
| Rate for Payer: Multiplan Auto |
$26.00
|
| Rate for Payer: Multiplan Commercial |
$26.00
|
| Rate for Payer: Multiplan Workers Comp |
$26.00
|
| Rate for Payer: Parkland Medicaid |
$28.80
|
| Rate for Payer: Scott and White EPO/PPO |
$20.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$28.80
|
| Rate for Payer: Superior Health Plan EPO |
$5.44
|
|
