|
Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial caps
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 19370
|
| Hospital Charge Code |
36019370
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$76.89 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$4,635.00
|
| Rate for Payer: Aetna Medicare |
$5,229.02
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$963.66
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,486.01
|
| Rate for Payer: Amerigroup Medicare |
$3,486.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,059.35
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,059.10
|
| Rate for Payer: BCBS of TX Medicare |
$3,486.01
|
| Rate for Payer: BCBS of TX PPO |
$7,634.47
|
| Rate for Payer: Cigna Commercial |
$7,896.82
|
| Rate for Payer: Cigna Medicaid |
$963.66
|
| Rate for Payer: Cigna Medicare |
$3,486.01
|
| Rate for Payer: Employer Direct Commercial |
$3,486.01
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,486.01
|
| Rate for Payer: Molina CHIP/Medicaid |
$963.66
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,486.01
|
| Rate for Payer: Molina Medicare |
$3,486.01
|
| 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 |
$963.66
|
| Rate for Payer: Scott and White EPO/PPO |
$76.89
|
| Rate for Payer: Scott and White Medicare |
$3,486.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$963.66
|
| Rate for Payer: Superior Health Plan EPO |
$3,486.01
|
| Rate for Payer: Superior Health Plan Medicare |
$3,486.01
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,486.01
|
| Rate for Payer: Universal American Medicare |
$3,486.01
|
| Rate for Payer: Wellcare Medicare |
$3,486.01
|
| Rate for Payer: Wellmed Medicare |
$3,486.01
|
|
|
Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset
|
Facility
|
OP
|
$13,509.82
|
|
|
Service Code
|
CPT 19380
|
| Hospital Charge Code |
36019380
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$131.54 |
| Max. Negotiated Rate |
$13,509.82 |
| Rate for Payer: Aetna Commercial |
$6,077.00
|
| Rate for Payer: Aetna Medicare |
$8,945.76
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,845.21
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5,963.84
|
| Rate for Payer: Amerigroup Medicare |
$5,963.84
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8,746.27
|
| Rate for Payer: BCBS of TX Blue Essentials |
$10,474.58
|
| Rate for Payer: BCBS of TX Medicare |
$5,963.84
|
| Rate for Payer: BCBS of TX PPO |
$13,197.97
|
| Rate for Payer: Cigna Commercial |
$13,509.82
|
| Rate for Payer: Cigna Medicaid |
$1,845.21
|
| Rate for Payer: Cigna Medicare |
$5,963.84
|
| Rate for Payer: Employer Direct Commercial |
$5,963.84
|
| Rate for Payer: Humana Medicare/TRICARE |
$5,963.84
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,845.21
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5,963.84
|
| Rate for Payer: Molina Medicare |
$5,963.84
|
| 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 |
$1,845.21
|
| Rate for Payer: Scott and White EPO/PPO |
$131.54
|
| Rate for Payer: Scott and White Medicare |
$5,963.84
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,845.21
|
| Rate for Payer: Superior Health Plan EPO |
$5,963.84
|
| Rate for Payer: Superior Health Plan Medicare |
$5,963.84
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5,963.84
|
| Rate for Payer: Universal American Medicare |
$5,963.84
|
| Rate for Payer: Wellcare Medicare |
$5,963.84
|
| Rate for Payer: Wellmed Medicare |
$5,963.84
|
|
|
Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 27487
|
| Hospital Charge Code |
36027487
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,053.19 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$8,755.00
|
| Rate for Payer: BCBS of TX Blue Advantage |
$3,053.19
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,656.52
|
| Rate for Payer: BCBS of TX PPO |
$4,607.22
|
| 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
|
|
|
Revision or removal of implanted spinal neurostimulator pulse generator or receiver
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 63688
|
| Hospital Charge Code |
36063688
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$68.64 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$4,635.00
|
| Rate for Payer: Aetna Medicare |
$4,667.66
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2,072.02
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,111.77
|
| Rate for Payer: Amerigroup Medicare |
$3,111.77
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,258.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,297.00
|
| Rate for Payer: BCBS of TX Medicare |
$3,111.77
|
| Rate for Payer: BCBS of TX PPO |
$7,934.22
|
| Rate for Payer: Cigna Commercial |
$7,049.06
|
| Rate for Payer: Cigna Medicaid |
$2,072.02
|
| Rate for Payer: Cigna Medicare |
$3,111.77
|
| Rate for Payer: Employer Direct Commercial |
$3,111.77
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,111.77
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,072.02
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,111.77
|
| Rate for Payer: Molina Medicare |
$3,111.77
|
| 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 |
$2,072.02
|
| Rate for Payer: Scott and White EPO/PPO |
$68.64
|
| Rate for Payer: Scott and White Medicare |
$3,111.77
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,072.02
|
| Rate for Payer: Superior Health Plan EPO |
$3,111.77
|
| Rate for Payer: Superior Health Plan Medicare |
$3,111.77
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,111.77
|
| Rate for Payer: Universal American Medicare |
$3,111.77
|
| Rate for Payer: Wellcare Medicare |
$3,111.77
|
| Rate for Payer: Wellmed Medicare |
$3,111.77
|
|
|
Revision or removal of peripheral neurostimulator electrode array
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64585
|
| Hospital Charge Code |
36064585
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$68.64 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$4,635.00
|
| Rate for Payer: Aetna Medicare |
$4,667.66
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,499.71
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,111.77
|
| Rate for Payer: Amerigroup Medicare |
$3,111.77
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,258.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,297.00
|
| Rate for Payer: BCBS of TX Medicare |
$3,111.77
|
| Rate for Payer: BCBS of TX PPO |
$7,934.22
|
| Rate for Payer: Cigna Commercial |
$7,049.06
|
| Rate for Payer: Cigna Medicaid |
$1,499.71
|
| Rate for Payer: Cigna Medicare |
$3,111.77
|
| Rate for Payer: Employer Direct Commercial |
$3,111.77
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,111.77
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,499.71
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,111.77
|
| Rate for Payer: Molina Medicare |
$3,111.77
|
| 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 |
$1,499.71
|
| Rate for Payer: Scott and White EPO/PPO |
$68.64
|
| Rate for Payer: Scott and White Medicare |
$3,111.77
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,499.71
|
| Rate for Payer: Superior Health Plan EPO |
$3,111.77
|
| Rate for Payer: Superior Health Plan Medicare |
$3,111.77
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,111.77
|
| Rate for Payer: Universal American Medicare |
$3,111.77
|
| Rate for Payer: Wellcare Medicare |
$3,111.77
|
| Rate for Payer: Wellmed Medicare |
$3,111.77
|
|
|
Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64595
|
| Hospital Charge Code |
36064595
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$68.64 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$4,635.00
|
| Rate for Payer: Aetna Medicare |
$4,667.66
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2,397.68
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,111.77
|
| Rate for Payer: Amerigroup Medicare |
$3,111.77
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,258.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,297.00
|
| Rate for Payer: BCBS of TX Medicare |
$3,111.77
|
| Rate for Payer: BCBS of TX PPO |
$7,934.22
|
| Rate for Payer: Cigna Commercial |
$7,049.06
|
| Rate for Payer: Cigna Medicaid |
$2,397.68
|
| Rate for Payer: Cigna Medicare |
$3,111.77
|
| Rate for Payer: Employer Direct Commercial |
$3,111.77
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,111.77
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,397.68
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,111.77
|
| Rate for Payer: Molina Medicare |
$3,111.77
|
| 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 |
$2,397.68
|
| Rate for Payer: Scott and White EPO/PPO |
$68.64
|
| Rate for Payer: Scott and White Medicare |
$3,111.77
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,397.68
|
| Rate for Payer: Superior Health Plan EPO |
$3,111.77
|
| Rate for Payer: Superior Health Plan Medicare |
$3,111.77
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,111.77
|
| Rate for Payer: Universal American Medicare |
$3,111.77
|
| Rate for Payer: Wellcare Medicare |
$3,111.77
|
| Rate for Payer: Wellmed Medicare |
$3,111.77
|
|
|
Revision or repair of operative wound of anterior segment, any type, early or late, major or minor p
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 66250
|
| Hospital Charge Code |
36066250
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$47.14 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$3,090.00
|
| Rate for Payer: Aetna Medicare |
$3,205.66
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$698.30
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$2,137.11
|
| Rate for Payer: Amerigroup Medicare |
$2,137.11
|
| Rate for Payer: BCBS of TX Blue Advantage |
$3,231.78
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,870.40
|
| Rate for Payer: BCBS of TX Medicare |
$2,137.11
|
| Rate for Payer: BCBS of TX PPO |
$4,876.70
|
| Rate for Payer: Cigna Commercial |
$4,841.18
|
| Rate for Payer: Cigna Medicaid |
$698.30
|
| Rate for Payer: Cigna Medicare |
$2,137.11
|
| Rate for Payer: Employer Direct Commercial |
$2,137.11
|
| Rate for Payer: Humana Medicare/TRICARE |
$2,137.11
|
| Rate for Payer: Molina CHIP/Medicaid |
$698.30
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$2,137.11
|
| Rate for Payer: Molina Medicare |
$2,137.11
|
| 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 |
$698.30
|
| Rate for Payer: Scott and White EPO/PPO |
$47.14
|
| Rate for Payer: Scott and White Medicare |
$2,137.11
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$698.30
|
| Rate for Payer: Superior Health Plan EPO |
$2,137.11
|
| Rate for Payer: Superior Health Plan Medicare |
$2,137.11
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$2,137.11
|
| Rate for Payer: Universal American Medicare |
$2,137.11
|
| Rate for Payer: Wellcare Medicare |
$2,137.11
|
| Rate for Payer: Wellmed Medicare |
$2,137.11
|
|
|
REV SKIN POCKET SNGL/DUAL AICD
|
Facility
|
OP
|
$4,566.00
|
|
|
Service Code
|
CPT 33223
|
| Hospital Charge Code |
2302347
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$29.83 |
| Max. Negotiated Rate |
$4,089.30 |
| Rate for Payer: Aetna Commercial |
$2,200.00
|
| Rate for Payer: Aetna Medicare |
$2,501.68
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$410.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Amerigroup Medicare |
$1,667.79
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,709.98
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,245.48
|
| Rate for Payer: BCBS of TX Medicare |
$1,667.79
|
| Rate for Payer: BCBS of TX PPO |
$4,089.30
|
| Rate for Payer: Cash Price |
$4,018.08
|
| Rate for Payer: Cash Price |
$4,018.08
|
| Rate for Payer: Cash Price |
$4,018.08
|
| Rate for Payer: Cigna Commercial |
$3,778.02
|
| Rate for Payer: Cigna Medicaid |
$709.01
|
| Rate for Payer: Cigna Medicare |
$1,667.79
|
| Rate for Payer: Employer Direct Commercial |
$1,667.79
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,667.79
|
| Rate for Payer: Molina CHIP/Medicaid |
$709.01
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Molina Medicare |
$1,667.79
|
| Rate for Payer: Multiplan Auto |
$2,967.90
|
| Rate for Payer: Multiplan Commercial |
$2,967.90
|
| Rate for Payer: Multiplan Workers Comp |
$2,967.90
|
| Rate for Payer: Parkland Medicaid |
$709.01
|
| Rate for Payer: Scott and White EPO/PPO |
$29.83
|
| Rate for Payer: Scott and White Medicare |
$1,667.79
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$709.01
|
| Rate for Payer: Superior Health Plan EPO |
$1,667.79
|
| Rate for Payer: Superior Health Plan Medicare |
$1,667.79
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,667.79
|
| Rate for Payer: Universal American Medicare |
$1,667.79
|
| Rate for Payer: Wellcare Medicare |
$1,667.79
|
| Rate for Payer: Wellmed Medicare |
$1,667.79
|
|
|
REV SKIN POCKET SNGL/DUAL AICD
|
Facility
|
IP
|
$4,566.00
|
|
|
Service Code
|
CPT 33223
|
| Hospital Charge Code |
2302347
|
|
Hospital Revenue Code
|
481
|
| Rate for Payer: Cash Price |
$4,018.08
|
|
|
Rheumatoid Factor
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
CPT 86431
|
| Hospital Charge Code |
1603398
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$199.76
|
|
|
Rheumatoid Factor
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
CPT 86431
|
| Hospital Charge Code |
1603398
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$147.55 |
| Rate for Payer: Aetna Commercial |
$5.95
|
| Rate for Payer: Aetna Medicare |
$8.50
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.21
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5.67
|
| Rate for Payer: Amerigroup Medicare |
$5.67
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9.36
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11.23
|
| Rate for Payer: BCBS of TX Medicare |
$5.67
|
| Rate for Payer: BCBS of TX PPO |
$12.53
|
| Rate for Payer: Cash Price |
$199.76
|
| Rate for Payer: Cash Price |
$199.76
|
| Rate for Payer: Cigna Medicaid |
$5.67
|
| Rate for Payer: Cigna Medicare |
$5.67
|
| Rate for Payer: Employer Direct Commercial |
$5.67
|
| Rate for Payer: Humana Medicare/TRICARE |
$5.67
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.67
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5.67
|
| Rate for Payer: Molina Medicare |
$5.67
|
| Rate for Payer: Multiplan Auto |
$147.55
|
| Rate for Payer: Multiplan Commercial |
$147.55
|
| Rate for Payer: Multiplan Workers Comp |
$147.55
|
| Rate for Payer: Parkland Medicaid |
$5.67
|
| Rate for Payer: Scott and White EPO/PPO |
$7.09
|
| Rate for Payer: Scott and White Medicare |
$5.67
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.67
|
| Rate for Payer: Superior Health Plan EPO |
$5.67
|
| Rate for Payer: Superior Health Plan Medicare |
$5.67
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5.67
|
| Rate for Payer: Universal American Medicare |
$5.67
|
| Rate for Payer: Wellcare Medicare |
$5.67
|
| Rate for Payer: Wellmed Medicare |
$5.67
|
|
|
Rh Typing
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
2400414
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$99.44
|
|
|
Rh Typing
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
2400414
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$83.09 |
| Rate for Payer: Aetna Commercial |
$3.13
|
| Rate for Payer: Aetna Medicare |
$55.02
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1.17
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$36.68
|
| Rate for Payer: Amerigroup Medicare |
$36.68
|
| Rate for Payer: BCBS of TX Blue Advantage |
$55.16
|
| Rate for Payer: BCBS of TX Blue Essentials |
$66.19
|
| Rate for Payer: BCBS of TX Medicare |
$36.68
|
| Rate for Payer: BCBS of TX PPO |
$73.88
|
| Rate for Payer: Cash Price |
$99.44
|
| Rate for Payer: Cash Price |
$99.44
|
| Rate for Payer: Cash Price |
$99.44
|
| Rate for Payer: Cigna Commercial |
$83.09
|
| Rate for Payer: Cigna Medicaid |
$2.99
|
| Rate for Payer: Cigna Medicare |
$36.68
|
| Rate for Payer: Employer Direct Commercial |
$36.68
|
| Rate for Payer: Humana Medicare/TRICARE |
$36.68
|
| Rate for Payer: Molina CHIP/Medicaid |
$2.99
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$36.68
|
| Rate for Payer: Molina Medicare |
$36.68
|
| Rate for Payer: Multiplan Auto |
$73.45
|
| Rate for Payer: Multiplan Commercial |
$73.45
|
| Rate for Payer: Multiplan Workers Comp |
$73.45
|
| Rate for Payer: Parkland Medicaid |
$2.99
|
| Rate for Payer: Scott and White EPO/PPO |
$3.74
|
| Rate for Payer: Scott and White Medicare |
$36.68
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2.99
|
| Rate for Payer: Superior Health Plan EPO |
$36.68
|
| Rate for Payer: Superior Health Plan Medicare |
$36.68
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$36.68
|
| Rate for Payer: Universal American Medicare |
$36.68
|
| Rate for Payer: Wellcare Medicare |
$36.68
|
| Rate for Payer: Wellmed Medicare |
$36.68
|
|
|
Rhythm ECG 1-3 leads tracing only
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
CPT 93041
|
| Hospital Charge Code |
5367567
|
|
Hospital Revenue Code
|
730
|
| Rate for Payer: Cash Price |
$212.96
|
|
|
Rhythm ECG 1-3 leads tracing only
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
CPT 93041
|
| Hospital Charge Code |
5367567
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$157.30 |
| Rate for Payer: Aetna Commercial |
$9.55
|
| Rate for Payer: Aetna Medicare |
$83.91
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$21.78
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$55.94
|
| Rate for Payer: Amerigroup Medicare |
$55.94
|
| Rate for Payer: BCBS of TX Blue Advantage |
$95.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$114.42
|
| Rate for Payer: BCBS of TX Medicare |
$55.94
|
| Rate for Payer: BCBS of TX PPO |
$127.62
|
| Rate for Payer: Cash Price |
$212.96
|
| Rate for Payer: Cash Price |
$212.96
|
| Rate for Payer: Cash Price |
$212.96
|
| Rate for Payer: Cigna Commercial |
$126.71
|
| Rate for Payer: Cigna Medicare |
$55.94
|
| Rate for Payer: Employer Direct Commercial |
$55.94
|
| Rate for Payer: Humana Medicare/TRICARE |
$55.94
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$55.94
|
| Rate for Payer: Molina Medicare |
$55.94
|
| Rate for Payer: Multiplan Auto |
$157.30
|
| Rate for Payer: Multiplan Commercial |
$157.30
|
| Rate for Payer: Multiplan Workers Comp |
$157.30
|
| Rate for Payer: Scott and White EPO/PPO |
$1.00
|
| Rate for Payer: Scott and White Medicare |
$55.94
|
| Rate for Payer: Superior Health Plan EPO |
$55.94
|
| Rate for Payer: Superior Health Plan Medicare |
$55.94
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$55.94
|
| Rate for Payer: Universal American Medicare |
$55.94
|
| Rate for Payer: Wellcare Medicare |
$55.94
|
| Rate for Payer: Wellmed Medicare |
$55.94
|
|
|
rigid loop cortical fix implant
|
Facility
|
IP
|
$3,283.13
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8612546
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$820.78 |
| Max. Negotiated Rate |
$1,641.56 |
| Rate for Payer: Aetna Commercial |
$984.94
|
| Rate for Payer: Cash Price |
$2,889.15
|
| Rate for Payer: Cigna Commercial |
$820.78
|
| Rate for Payer: Multiplan Auto |
$1,641.56
|
| Rate for Payer: Multiplan Commercial |
$1,641.56
|
| Rate for Payer: Multiplan Workers Comp |
$1,641.56
|
| Rate for Payer: Scott and White EPO/PPO |
$1,641.56
|
|
|
rigid loop cortical fix implant
|
Facility
|
OP
|
$3,283.13
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8612546
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$295.48 |
| Max. Negotiated Rate |
$1,641.56 |
| Rate for Payer: Aetna Commercial |
$984.94
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$295.48
|
| Rate for Payer: BCBS of TX Blue Advantage |
$984.94
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,181.93
|
| Rate for Payer: BCBS of TX PPO |
$1,313.25
|
| Rate for Payer: Cash Price |
$2,889.15
|
| Rate for Payer: Multiplan Auto |
$1,641.56
|
| Rate for Payer: Multiplan Commercial |
$1,641.56
|
| Rate for Payer: Multiplan Workers Comp |
$1,641.56
|
| Rate for Payer: Scott and White EPO/PPO |
$1,641.56
|
| Rate for Payer: Superior Health Plan EPO |
$446.51
|
|
|
risperiDONE 1 mg Tab
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77796415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$5.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.72
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$2.88
|
| Rate for Payer: BCBS of TX PPO |
$3.20
|
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Multiplan Auto |
$5.20
|
| Rate for Payer: Multiplan Commercial |
$5.20
|
| Rate for Payer: Multiplan Workers Comp |
$5.20
|
| Rate for Payer: Scott and White EPO/PPO |
$4.00
|
| Rate for Payer: Superior Health Plan EPO |
$1.09
|
|
|
risperiDONE 1 mg Tab
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77796415
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.44
|
|
|
RMVL SUBQ CAR RHYTHM MNTR
|
Facility
|
OP
|
$3,534.00
|
|
|
Service Code
|
CPT 33286
|
| Hospital Charge Code |
2300090
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$2,297.10 |
| Rate for Payer: Aetna Commercial |
$1,400.00
|
| Rate for Payer: Aetna Medicare |
$965.18
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$318.06
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Amerigroup Medicare |
$643.45
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,018.72
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,220.02
|
| Rate for Payer: BCBS of TX Medicare |
$643.45
|
| Rate for Payer: BCBS of TX PPO |
$1,537.23
|
| Rate for Payer: Cash Price |
$3,109.92
|
| Rate for Payer: Cash Price |
$3,109.92
|
| Rate for Payer: Cash Price |
$3,109.92
|
| Rate for Payer: Cigna Commercial |
$1,457.60
|
| Rate for Payer: Cigna Medicaid |
$257.60
|
| Rate for Payer: Cigna Medicare |
$643.45
|
| Rate for Payer: Employer Direct Commercial |
$643.45
|
| Rate for Payer: Humana Medicare/TRICARE |
$643.45
|
| Rate for Payer: Molina CHIP/Medicaid |
$257.60
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Molina Medicare |
$643.45
|
| Rate for Payer: Multiplan Auto |
$2,297.10
|
| Rate for Payer: Multiplan Commercial |
$2,297.10
|
| Rate for Payer: Multiplan Workers Comp |
$2,297.10
|
| Rate for Payer: Parkland Medicaid |
$257.60
|
| Rate for Payer: Scott and White EPO/PPO |
$11.51
|
| Rate for Payer: Scott and White Medicare |
$643.45
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$257.60
|
| Rate for Payer: Superior Health Plan EPO |
$643.45
|
| Rate for Payer: Superior Health Plan Medicare |
$643.45
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$643.45
|
| Rate for Payer: Universal American Medicare |
$643.45
|
| Rate for Payer: Wellcare Medicare |
$643.45
|
| Rate for Payer: Wellmed Medicare |
$643.45
|
|
|
RMVL SUBQ CAR RHYTHM MNTR
|
Facility
|
IP
|
$3,534.00
|
|
|
Service Code
|
CPT 33286
|
| Hospital Charge Code |
2300090
|
|
Hospital Revenue Code
|
481
|
| Rate for Payer: Cash Price |
$3,109.92
|
|
|
RMV TUNLD CVAD W SQ PORT
|
Facility
|
IP
|
$2,334.00
|
|
|
Service Code
|
CPT 36590
|
| Hospital Charge Code |
4616590
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$2,053.92
|
|
|
RMV TUNLD CVAD W SQ PORT
|
Facility
|
OP
|
$2,334.00
|
|
|
Service Code
|
CPT 36590
|
| Hospital Charge Code |
4616590
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$32.31 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Commercial |
$2,200.00
|
| Rate for Payer: Aetna Medicare |
$2,197.02
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$446.27
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,464.68
|
| Rate for Payer: Amerigroup Medicare |
$1,464.68
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,052.95
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,261.02
|
| Rate for Payer: BCBS of TX Medicare |
$1,464.68
|
| Rate for Payer: BCBS of TX PPO |
$1,588.89
|
| Rate for Payer: Cash Price |
$2,053.92
|
| Rate for Payer: Cash Price |
$2,053.92
|
| Rate for Payer: Cigna Commercial |
$3,317.93
|
| Rate for Payer: Cigna Medicaid |
$446.27
|
| Rate for Payer: Cigna Medicare |
$1,464.68
|
| Rate for Payer: Employer Direct Commercial |
$1,464.68
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,464.68
|
| Rate for Payer: Molina CHIP/Medicaid |
$446.27
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,464.68
|
| Rate for Payer: Molina Medicare |
$1,464.68
|
| 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 |
$446.27
|
| Rate for Payer: Scott and White EPO/PPO |
$32.31
|
| Rate for Payer: Scott and White Medicare |
$1,464.68
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$446.27
|
| Rate for Payer: Superior Health Plan EPO |
$1,464.68
|
| Rate for Payer: Superior Health Plan Medicare |
$1,464.68
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,464.68
|
| Rate for Payer: Universal American Medicare |
$1,464.68
|
| Rate for Payer: Wellcare Medicare |
$1,464.68
|
| Rate for Payer: Wellmed Medicare |
$1,464.68
|
|
|
RNA, Real Time PCR (Non-Graph) SO
|
Facility
|
IP
|
$441.00
|
|
|
Service Code
|
CPT 87536
|
| Hospital Charge Code |
1701069
|
|
Hospital Revenue Code
|
306
|
| Rate for Payer: Cash Price |
$388.08
|
|
|
RNA, Real Time PCR (Non-Graph) SO
|
Facility
|
OP
|
$441.00
|
|
|
Service Code
|
CPT 87536
|
| Hospital Charge Code |
1701069
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$33.19 |
| Max. Negotiated Rate |
$286.65 |
| Rate for Payer: Aetna Commercial |
$89.36
|
| Rate for Payer: Aetna Medicare |
$127.65
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$33.19
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$85.10
|
| Rate for Payer: Amerigroup Medicare |
$85.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$140.42
|
| Rate for Payer: BCBS of TX Blue Essentials |
$168.50
|
| Rate for Payer: BCBS of TX Medicare |
$85.10
|
| Rate for Payer: BCBS of TX PPO |
$188.07
|
| Rate for Payer: Cash Price |
$388.08
|
| Rate for Payer: Cash Price |
$388.08
|
| Rate for Payer: Cigna Medicaid |
$85.10
|
| Rate for Payer: Cigna Medicare |
$85.10
|
| Rate for Payer: Employer Direct Commercial |
$85.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$85.10
|
| Rate for Payer: Molina CHIP/Medicaid |
$85.10
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$85.10
|
| Rate for Payer: Molina Medicare |
$85.10
|
| Rate for Payer: Multiplan Auto |
$286.65
|
| Rate for Payer: Multiplan Commercial |
$286.65
|
| Rate for Payer: Multiplan Workers Comp |
$286.65
|
| Rate for Payer: Parkland Medicaid |
$85.10
|
| Rate for Payer: Scott and White EPO/PPO |
$106.38
|
| Rate for Payer: Scott and White Medicare |
$85.10
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$85.10
|
| Rate for Payer: Superior Health Plan EPO |
$85.10
|
| Rate for Payer: Superior Health Plan Medicare |
$85.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$85.10
|
| Rate for Payer: Universal American Medicare |
$85.10
|
| Rate for Payer: Wellcare Medicare |
$85.10
|
| Rate for Payer: Wellmed Medicare |
$85.10
|
|
