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Charge

Type

Setting

Price

magnesium hydroxide 8% Oral Susp 30 mL

Facility

IP

$8.43

Service Code	HCPCS J3490
Hospital Charge Code	77675679
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.73

Magnesium Level SO

Facility

OP

$55.12

Service Code	HCPCS 83735
Hospital Charge Code	1148254
Hospital Revenue Code	301
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$39.69
Rate for Payer: Amerigroup CHIP/Medicaid	$2.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.70
Rate for Payer: Amerigroup Medicare	$6.70
Rate for Payer: BCBS of TX Blue Advantage	$16.54
Rate for Payer: BCBS of TX Blue Essentials	$19.84
Rate for Payer: BCBS of TX Medicare	$6.70
Rate for Payer: BCBS of TX PPO	$22.05
Rate for Payer: Cash Price	$37.48
Rate for Payer: Cash Price	$37.48
Rate for Payer: Cigna Medicaid	$39.69
Rate for Payer: Cigna Medicare	$6.70
Rate for Payer: Employer Direct Commercial	$6.70
Rate for Payer: Humana Medicare/TRICARE	$6.70
Rate for Payer: Molina CHIP/Medicaid	$39.69
Rate for Payer: Molina Dual Medicare/Medicaid	$6.70
Rate for Payer: Molina Medicare	$6.70
Rate for Payer: Multiplan Auto	$35.83
Rate for Payer: Multiplan Commercial	$35.83
Rate for Payer: Multiplan Workers Comp	$35.83
Rate for Payer: Parkland Medicaid	$39.69
Rate for Payer: Scott and White EPO/PPO	$8.38
Rate for Payer: Scott and White Medicare	$6.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.69
Rate for Payer: Superior Health Plan EPO	$6.70
Rate for Payer: Superior Health Plan Medicare	$6.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.70
Rate for Payer: Universal American Medicare	$6.70
Rate for Payer: Wellcare Medicare	$6.70
Rate for Payer: Wellmed Medicare	$6.70

Magnesium Level SO

Facility

IP

$55.12

Service Code	HCPCS 83735
Hospital Charge Code	1148254
Hospital Revenue Code	301
Rate for Payer: Cash Price	$37.48

magnesium oxide 400 mg (241.3 mg elemental magnesium) Tab

Facility

IP

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77676264
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

magnesium oxide 400 mg (241.3 mg elemental magnesium) Tab

Facility

OP

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77676264
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

magnesium sulfate 50% Inj Soln 2 mL

Facility

OP

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	77676782
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.10
Rate for Payer: BCBS of TX Blue Essentials	$0.12
Rate for Payer: BCBS of TX PPO	$0.14
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

magnesium sulfate 50% Inj Soln 2 mL

Facility

IP

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	77677593
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

magnesium sulfate 50% Inj Soln 2 mL

Facility

OP

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	78740463
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.10
Rate for Payer: BCBS of TX Blue Essentials	$0.12
Rate for Payer: BCBS of TX PPO	$0.14
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

magnesium sulfate 50% Inj Soln 2 mL

Facility

IP

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	78740463
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

magnesium sulfate 50% Inj Soln 2 mL

Facility

IP

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	77676782
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

magnesium sulfate 50% Inj Soln 2 mL

Facility

OP

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	77677593
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.10
Rate for Payer: BCBS of TX Blue Essentials	$0.12
Rate for Payer: BCBS of TX PPO	$0.14
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

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)

Facility

IP

$1,766.28

Service Code	HCPCS 72149
Hospital Charge Code	991166
Hospital Revenue Code	612
Rate for Payer: Cash Price	$1,201.07

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)

Facility

OP

$1,766.28

Service Code	HCPCS 72149
Hospital Charge Code	991166
Hospital Revenue Code	612
Min. Negotiated Rate	$279.00
Max. Negotiated Rate	$1,271.72
Rate for Payer: Amerigroup CHIP/Medicaid	$279.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX Medicare	$350.46
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$1,201.07
Rate for Payer: Cash Price	$1,201.07
Rate for Payer: Cash Price	$1,201.07
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$1,271.72
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$1,271.72
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$1,148.08
Rate for Payer: Multiplan Commercial	$1,148.08
Rate for Payer: Multiplan Workers Comp	$1,148.08
Rate for Payer: Parkland Medicaid	$1,271.72
Rate for Payer: Scott and White EPO/PPO	$343.76
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,271.72
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

MAJ-2318 OER 0.2M INTERNAL H20 46A

Facility

IP

$3,337.81

Hospital Charge Code	993949
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2,269.71

MAJ-2318 OER 0.2M INTERNAL H20 46A

Facility

OP

$3,337.81

Hospital Charge Code	993949
Hospital Revenue Code	270
Min. Negotiated Rate	$300.40
Max. Negotiated Rate	$2,403.22
Rate for Payer: Amerigroup CHIP/Medicaid	$300.40
Rate for Payer: BCBS of TX Blue Advantage	$1,001.34
Rate for Payer: BCBS of TX Blue Essentials	$1,201.61
Rate for Payer: BCBS of TX PPO	$1,335.12
Rate for Payer: Cash Price	$2,269.71
Rate for Payer: Cigna Medicaid	$2,403.22
Rate for Payer: Molina CHIP/Medicaid	$2,403.22
Rate for Payer: Multiplan Auto	$2,169.58
Rate for Payer: Multiplan Commercial	$2,169.58
Rate for Payer: Multiplan Workers Comp	$2,169.58
Rate for Payer: Parkland Medicaid	$2,403.22
Rate for Payer: Scott and White EPO/PPO	$1,668.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,403.22
Rate for Payer: Superior Health Plan EPO	$453.94

MAJ-822 OER-PRO CHARCOAL GAS V

Facility

OP

$152.09

Hospital Charge Code	993943
Hospital Revenue Code	270
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$109.50
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: BCBS of TX Blue Advantage	$45.63
Rate for Payer: BCBS of TX Blue Essentials	$54.75
Rate for Payer: BCBS of TX PPO	$60.84
Rate for Payer: Cash Price	$103.42
Rate for Payer: Cigna Medicaid	$109.50
Rate for Payer: Molina CHIP/Medicaid	$109.50
Rate for Payer: Multiplan Auto	$98.86
Rate for Payer: Multiplan Commercial	$98.86
Rate for Payer: Multiplan Workers Comp	$98.86
Rate for Payer: Parkland Medicaid	$109.50
Rate for Payer: Scott and White EPO/PPO	$76.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.50
Rate for Payer: Superior Health Plan EPO	$20.68

MAJ-822 OER-PRO CHARCOAL GAS V

Facility

IP

$152.09

Hospital Charge Code	993943
Hospital Revenue Code	270
Rate for Payer: Cash Price	$103.42

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

IP

$13,830.39

Service Code	APR-DRG 1692
Min. Negotiated Rate	$13,039.78
Max. Negotiated Rate	$13,830.39
Rate for Payer: Amerigroup CHIP/Medicaid	$13,039.78
Rate for Payer: Cigna Medicaid	$13,039.78
Rate for Payer: Molina CHIP/Medicaid	$13,039.78
Rate for Payer: Parkland Medicaid	$13,039.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,830.39

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

IP

$13,818.70

Service Code	APR-DRG 1691
Min. Negotiated Rate	$13,028.75
Max. Negotiated Rate	$13,818.70
Rate for Payer: Amerigroup CHIP/Medicaid	$13,028.75
Rate for Payer: Cigna Medicaid	$13,028.75
Rate for Payer: Molina CHIP/Medicaid	$13,028.75
Rate for Payer: Parkland Medicaid	$13,028.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,818.70

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

IP

$19,611.94

Service Code	APR-DRG 1693
Min. Negotiated Rate	$18,490.83
Max. Negotiated Rate	$19,611.94
Rate for Payer: Amerigroup CHIP/Medicaid	$18,490.83
Rate for Payer: Cigna Medicaid	$18,490.83
Rate for Payer: Molina CHIP/Medicaid	$18,490.83
Rate for Payer: Parkland Medicaid	$18,490.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,611.94

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

IP

$38,070.06

Service Code	APR-DRG 1694
Min. Negotiated Rate	$35,893.79
Max. Negotiated Rate	$38,070.06
Rate for Payer: Amerigroup CHIP/Medicaid	$35,893.79
Rate for Payer: Cigna Medicaid	$35,893.79
Rate for Payer: Molina CHIP/Medicaid	$35,893.79
Rate for Payer: Parkland Medicaid	$35,893.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38,070.06

MAJOR BILIARY TRACT PROCEDURES

Facility

IP

$20,801.60

Service Code	APR-DRG 2613
Min. Negotiated Rate	$19,612.47
Max. Negotiated Rate	$20,801.60
Rate for Payer: Amerigroup CHIP/Medicaid	$19,612.47
Rate for Payer: Cigna Medicaid	$19,612.47
Rate for Payer: Molina CHIP/Medicaid	$19,612.47
Rate for Payer: Parkland Medicaid	$19,612.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,801.60

MAJOR BILIARY TRACT PROCEDURES

Facility

IP

$10,314.99

Service Code	APR-DRG 2612
Min. Negotiated Rate	$9,725.33
Max. Negotiated Rate	$10,314.99
Rate for Payer: Amerigroup CHIP/Medicaid	$9,725.33
Rate for Payer: Cigna Medicaid	$9,725.33
Rate for Payer: Molina CHIP/Medicaid	$9,725.33
Rate for Payer: Parkland Medicaid	$9,725.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,314.99

MAJOR BILIARY TRACT PROCEDURES

Facility

IP

$31,470.01

Service Code	APR-DRG 2614
Min. Negotiated Rate	$29,671.03
Max. Negotiated Rate	$31,470.01
Rate for Payer: Amerigroup CHIP/Medicaid	$29,671.03
Rate for Payer: Cigna Medicaid	$29,671.03
Rate for Payer: Molina CHIP/Medicaid	$29,671.03
Rate for Payer: Parkland Medicaid	$29,671.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31,470.01

MAJOR BILIARY TRACT PROCEDURES

Facility

IP

$7,064.37

Service Code	APR-DRG 2611
Min. Negotiated Rate	$6,660.54
Max. Negotiated Rate	$7,064.37
Rate for Payer: Amerigroup CHIP/Medicaid	$6,660.54
Rate for Payer: Cigna Medicaid	$6,660.54
Rate for Payer: Molina CHIP/Medicaid	$6,660.54
Rate for Payer: Parkland Medicaid	$6,660.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,064.37

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