|
simethicone 40 mg/0.6 mL Oral Liquid 30 mL
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77813459
|
|
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
|
|
|
simethicone 40 mg/0.6 mL Oral Liquid 30 mL
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77813459
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.44
|
|
|
simethicone 80 mg Chew Tab
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77813565
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
simethicone 80 mg Chew Tab
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77813565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.69
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.30
|
| 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: Multiplan Auto |
$4.97
|
| Rate for Payer: Multiplan Commercial |
$4.97
|
| Rate for Payer: Multiplan Workers Comp |
$4.97
|
| Rate for Payer: Scott and White EPO/PPO |
$3.82
|
| Rate for Payer: Superior Health Plan EPO |
$1.04
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH CC
|
Facility
|
IP
|
$15,621.80
|
|
|
Service Code
|
MSDRG 194
|
| Min. Negotiated Rate |
$7,194.25 |
| Max. Negotiated Rate |
$15,621.80 |
| Rate for Payer: Aetna Commercial |
$9,249.75
|
| Rate for Payer: Aetna Medicare |
$13,083.09
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$8,722.06
|
| Rate for Payer: Amerigroup Medicare |
$8,722.06
|
| Rate for Payer: BCBS of TX Blue Advantage |
$8,143.34
|
| Rate for Payer: BCBS of TX Blue Essentials |
$9,289.16
|
| Rate for Payer: BCBS of TX Medicare |
$8,722.06
|
| Rate for Payer: BCBS of TX PPO |
$10,321.69
|
| Rate for Payer: Cigna Commercial |
$10,589.94
|
| Rate for Payer: Cigna Medicare |
$8,722.06
|
| Rate for Payer: Employer Direct Commercial |
$8,722.06
|
| Rate for Payer: Humana Medicare/TRICARE |
$8,722.06
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$8,722.06
|
| Rate for Payer: Molina Medicare |
$8,722.06
|
| Rate for Payer: Multiplan Auto |
$15,621.80
|
| Rate for Payer: Multiplan Commercial |
$15,621.80
|
| Rate for Payer: Multiplan Workers Comp |
$15,621.80
|
| Rate for Payer: Scott and White EPO/PPO |
$7,194.25
|
| Rate for Payer: Scott and White Medicare |
$8,722.06
|
| Rate for Payer: Superior Health Plan EPO |
$8,722.06
|
| Rate for Payer: Superior Health Plan Medicare |
$8,722.06
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$8,722.06
|
| Rate for Payer: Universal American Medicare |
$8,722.06
|
| Rate for Payer: Wellcare Medicare |
$8,722.06
|
| Rate for Payer: Wellmed Medicare |
$8,722.06
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH MCC
|
Facility
|
IP
|
$25,205.40
|
|
|
Service Code
|
MSDRG 193
|
| Min. Negotiated Rate |
$11,607.75 |
| Max. Negotiated Rate |
$25,205.40 |
| Rate for Payer: Aetna Commercial |
$14,924.25
|
| Rate for Payer: Aetna Medicare |
$18,482.20
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12,321.47
|
| Rate for Payer: Amerigroup Medicare |
$12,321.47
|
| Rate for Payer: BCBS of TX Blue Advantage |
$11,919.60
|
| Rate for Payer: BCBS of TX Blue Essentials |
$13,587.03
|
| Rate for Payer: BCBS of TX Medicare |
$12,321.47
|
| Rate for Payer: BCBS of TX PPO |
$15,097.28
|
| Rate for Payer: Cigna Commercial |
$17,086.61
|
| Rate for Payer: Cigna Medicare |
$12,321.47
|
| Rate for Payer: Employer Direct Commercial |
$12,321.47
|
| Rate for Payer: Humana Medicare/TRICARE |
$12,321.47
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12,321.47
|
| Rate for Payer: Molina Medicare |
$12,321.47
|
| Rate for Payer: Multiplan Auto |
$25,205.40
|
| Rate for Payer: Multiplan Commercial |
$25,205.40
|
| Rate for Payer: Multiplan Workers Comp |
$25,205.40
|
| Rate for Payer: Scott and White EPO/PPO |
$11,607.75
|
| Rate for Payer: Scott and White Medicare |
$12,321.47
|
| Rate for Payer: Superior Health Plan EPO |
$12,321.47
|
| Rate for Payer: Superior Health Plan Medicare |
$12,321.47
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12,321.47
|
| Rate for Payer: Universal American Medicare |
$12,321.47
|
| Rate for Payer: Wellcare Medicare |
$12,321.47
|
| Rate for Payer: Wellmed Medicare |
$12,321.47
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC
|
Facility
|
IP
|
$11,886.40
|
|
|
Service Code
|
MSDRG 195
|
| Min. Negotiated Rate |
$5,474.00 |
| Max. Negotiated Rate |
$11,886.40 |
| Rate for Payer: Aetna Commercial |
$7,038.00
|
| Rate for Payer: Aetna Medicare |
$10,978.65
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7,319.10
|
| Rate for Payer: Amerigroup Medicare |
$7,319.10
|
| Rate for Payer: BCBS of TX Blue Advantage |
$6,044.08
|
| Rate for Payer: BCBS of TX Blue Essentials |
$7,087.09
|
| Rate for Payer: BCBS of TX Medicare |
$7,319.10
|
| Rate for Payer: BCBS of TX PPO |
$7,874.85
|
| Rate for Payer: Cigna Commercial |
$8,057.73
|
| Rate for Payer: Cigna Medicare |
$7,319.10
|
| Rate for Payer: Employer Direct Commercial |
$7,319.10
|
| Rate for Payer: Humana Medicare/TRICARE |
$7,319.10
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7,319.10
|
| Rate for Payer: Molina Medicare |
$7,319.10
|
| Rate for Payer: Multiplan Auto |
$11,886.40
|
| Rate for Payer: Multiplan Commercial |
$11,886.40
|
| Rate for Payer: Multiplan Workers Comp |
$11,886.40
|
| Rate for Payer: Scott and White EPO/PPO |
$5,474.00
|
| Rate for Payer: Scott and White Medicare |
$7,319.10
|
| Rate for Payer: Superior Health Plan EPO |
$7,319.10
|
| Rate for Payer: Superior Health Plan Medicare |
$7,319.10
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7,319.10
|
| Rate for Payer: Universal American Medicare |
$7,319.10
|
| Rate for Payer: Wellcare Medicare |
$7,319.10
|
| Rate for Payer: Wellmed Medicare |
$7,319.10
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT
|
Facility
|
IP
|
$99,972.30
|
|
|
Service Code
|
MSDRG 008
|
| Min. Negotiated Rate |
$40,402.59 |
| Max. Negotiated Rate |
$99,972.30 |
| Rate for Payer: Aetna Commercial |
$59,194.12
|
| Rate for Payer: Aetna Medicare |
$60,603.88
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$40,402.59
|
| Rate for Payer: Amerigroup Medicare |
$40,402.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$47,183.04
|
| Rate for Payer: BCBS of TX Blue Essentials |
$54,164.43
|
| Rate for Payer: BCBS of TX Medicare |
$40,402.59
|
| Rate for Payer: BCBS of TX PPO |
$60,185.03
|
| Rate for Payer: Cigna Commercial |
$67,770.70
|
| Rate for Payer: Cigna Medicare |
$40,402.59
|
| Rate for Payer: Employer Direct Commercial |
$40,402.59
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$40,402.59
|
| Rate for Payer: Molina Medicare |
$40,402.59
|
| Rate for Payer: Multiplan Auto |
$99,972.30
|
| Rate for Payer: Multiplan Commercial |
$99,972.30
|
| Rate for Payer: Multiplan Workers Comp |
$99,972.30
|
| Rate for Payer: Scott and White EPO/PPO |
$46,039.88
|
| Rate for Payer: Scott and White Medicare |
$40,402.59
|
| Rate for Payer: Superior Health Plan EPO |
$40,402.59
|
| Rate for Payer: Superior Health Plan Medicare |
$40,402.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$40,402.59
|
| Rate for Payer: Universal American Medicare |
$40,402.59
|
| Rate for Payer: Wellcare Medicare |
$40,402.59
|
| Rate for Payer: Wellmed Medicare |
$40,402.59
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS
|
Facility
|
IP
|
$151,876.50
|
|
|
Service Code
|
MSDRG 019
|
| Min. Negotiated Rate |
$59,896.88 |
| Max. Negotiated Rate |
$151,876.50 |
| Rate for Payer: Aetna Commercial |
$89,926.88
|
| Rate for Payer: Aetna Medicare |
$89,845.32
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$59,896.88
|
| Rate for Payer: Amerigroup Medicare |
$59,896.88
|
| Rate for Payer: BCBS of TX Medicare |
$59,896.88
|
| Rate for Payer: Cigna Commercial |
$102,956.28
|
| Rate for Payer: Cigna Medicare |
$59,896.88
|
| Rate for Payer: Employer Direct Commercial |
$59,896.88
|
| Rate for Payer: Humana Medicare/TRICARE |
$59,896.88
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$59,896.88
|
| Rate for Payer: Molina Medicare |
$59,896.88
|
| Rate for Payer: Multiplan Auto |
$151,876.50
|
| Rate for Payer: Multiplan Commercial |
$151,876.50
|
| Rate for Payer: Multiplan Workers Comp |
$151,876.50
|
| Rate for Payer: Scott and White EPO/PPO |
$69,943.12
|
| Rate for Payer: Scott and White Medicare |
$59,896.88
|
| Rate for Payer: Superior Health Plan EPO |
$59,896.88
|
| Rate for Payer: Superior Health Plan Medicare |
$59,896.88
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$59,896.88
|
| Rate for Payer: Universal American Medicare |
$59,896.88
|
| Rate for Payer: Wellcare Medicare |
$59,896.88
|
| Rate for Payer: Wellmed Medicare |
$59,896.88
|
|
|
SINUS AND MASTOID PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$50,389.90
|
|
|
Service Code
|
MSDRG 135
|
| Min. Negotiated Rate |
$17,322.12 |
| Max. Negotiated Rate |
$50,389.90 |
| Rate for Payer: Aetna Commercial |
$29,836.12
|
| Rate for Payer: Aetna Medicare |
$32,670.48
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$21,780.32
|
| Rate for Payer: Amerigroup Medicare |
$21,780.32
|
| Rate for Payer: BCBS of TX Blue Advantage |
$17,322.12
|
| Rate for Payer: BCBS of TX Blue Essentials |
$23,715.13
|
| Rate for Payer: BCBS of TX Medicare |
$21,780.32
|
| Rate for Payer: BCBS of TX PPO |
$26,351.16
|
| Rate for Payer: Cigna Commercial |
$34,159.05
|
| Rate for Payer: Cigna Medicare |
$21,780.32
|
| Rate for Payer: Employer Direct Commercial |
$21,780.32
|
| Rate for Payer: Humana Medicare/TRICARE |
$21,780.32
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$21,780.32
|
| Rate for Payer: Molina Medicare |
$21,780.32
|
| Rate for Payer: Multiplan Auto |
$50,389.90
|
| Rate for Payer: Multiplan Commercial |
$50,389.90
|
| Rate for Payer: Multiplan Workers Comp |
$50,389.90
|
| Rate for Payer: Scott and White EPO/PPO |
$23,205.88
|
| Rate for Payer: Scott and White Medicare |
$21,780.32
|
| Rate for Payer: Superior Health Plan EPO |
$21,780.32
|
| Rate for Payer: Superior Health Plan Medicare |
$21,780.32
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$21,780.32
|
| Rate for Payer: Universal American Medicare |
$21,780.32
|
| Rate for Payer: Wellcare Medicare |
$21,780.32
|
| Rate for Payer: Wellmed Medicare |
$21,780.32
|
|
|
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$17,842.90
|
|
|
Service Code
|
MSDRG 136
|
| Min. Negotiated Rate |
$8,217.12 |
| Max. Negotiated Rate |
$17,842.90 |
| Rate for Payer: Aetna Commercial |
$10,564.88
|
| Rate for Payer: Aetna Medicare |
$15,460.47
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$10,306.98
|
| Rate for Payer: Amerigroup Medicare |
$10,306.98
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9,529.66
|
| Rate for Payer: BCBS of TX Blue Essentials |
$12,511.79
|
| Rate for Payer: BCBS of TX Medicare |
$10,306.98
|
| Rate for Payer: BCBS of TX PPO |
$13,902.52
|
| Rate for Payer: Cigna Commercial |
$12,095.61
|
| Rate for Payer: Cigna Medicare |
$10,306.98
|
| Rate for Payer: Employer Direct Commercial |
$10,306.98
|
| Rate for Payer: Humana Medicare/TRICARE |
$10,306.98
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$10,306.98
|
| Rate for Payer: Molina Medicare |
$10,306.98
|
| Rate for Payer: Multiplan Auto |
$17,842.90
|
| Rate for Payer: Multiplan Commercial |
$17,842.90
|
| Rate for Payer: Multiplan Workers Comp |
$17,842.90
|
| Rate for Payer: Scott and White EPO/PPO |
$8,217.12
|
| Rate for Payer: Scott and White Medicare |
$10,306.98
|
| Rate for Payer: Superior Health Plan EPO |
$10,306.98
|
| Rate for Payer: Superior Health Plan Medicare |
$10,306.98
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$10,306.98
|
| Rate for Payer: Universal American Medicare |
$10,306.98
|
| Rate for Payer: Wellcare Medicare |
$10,306.98
|
| Rate for Payer: Wellmed Medicare |
$10,306.98
|
|
|
SIZER BREAST IMPLANT
|
Facility
|
IP
|
$1,265.06
|
|
| Hospital Charge Code |
8592512
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$316.26 |
| Max. Negotiated Rate |
$632.53 |
| Rate for Payer: Aetna Commercial |
$379.52
|
| Rate for Payer: Cash Price |
$1,113.25
|
| Rate for Payer: Cigna Commercial |
$316.26
|
| Rate for Payer: Multiplan Auto |
$632.53
|
| Rate for Payer: Multiplan Commercial |
$632.53
|
| Rate for Payer: Multiplan Workers Comp |
$632.53
|
| Rate for Payer: Scott and White EPO/PPO |
$632.53
|
|
|
SIZER BREAST IMPLANT
|
Facility
|
OP
|
$1,265.06
|
|
| Hospital Charge Code |
8592512
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$113.86 |
| Max. Negotiated Rate |
$632.53 |
| Rate for Payer: Aetna Commercial |
$379.52
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$113.86
|
| Rate for Payer: BCBS of TX Blue Advantage |
$379.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$455.42
|
| Rate for Payer: BCBS of TX PPO |
$506.02
|
| Rate for Payer: Cash Price |
$1,113.25
|
| Rate for Payer: Multiplan Auto |
$632.53
|
| Rate for Payer: Multiplan Commercial |
$632.53
|
| Rate for Payer: Multiplan Workers Comp |
$632.53
|
| Rate for Payer: Scott and White EPO/PPO |
$632.53
|
| Rate for Payer: Superior Health Plan EPO |
$172.05
|
|
|
Sjogren's Anti-SS-A SO
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
1701143
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.99 |
| Max. Negotiated Rate |
$149.50 |
| Rate for Payer: Aetna Commercial |
$18.83
|
| Rate for Payer: Aetna Medicare |
$26.90
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$6.99
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$17.93
|
| Rate for Payer: Amerigroup Medicare |
$17.93
|
| Rate for Payer: BCBS of TX Blue Advantage |
$29.58
|
| Rate for Payer: BCBS of TX Blue Essentials |
$35.50
|
| Rate for Payer: BCBS of TX Medicare |
$17.93
|
| Rate for Payer: BCBS of TX PPO |
$39.63
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Cigna Medicaid |
$17.93
|
| Rate for Payer: Cigna Medicare |
$17.93
|
| Rate for Payer: Employer Direct Commercial |
$17.93
|
| Rate for Payer: Humana Medicare/TRICARE |
$17.93
|
| Rate for Payer: Molina CHIP/Medicaid |
$17.93
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$17.93
|
| Rate for Payer: Molina Medicare |
$17.93
|
| Rate for Payer: Multiplan Auto |
$149.50
|
| Rate for Payer: Multiplan Commercial |
$149.50
|
| Rate for Payer: Multiplan Workers Comp |
$149.50
|
| Rate for Payer: Parkland Medicaid |
$17.93
|
| Rate for Payer: Scott and White EPO/PPO |
$22.41
|
| Rate for Payer: Scott and White Medicare |
$17.93
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$17.93
|
| Rate for Payer: Superior Health Plan EPO |
$17.93
|
| Rate for Payer: Superior Health Plan Medicare |
$17.93
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$17.93
|
| Rate for Payer: Universal American Medicare |
$17.93
|
| Rate for Payer: Wellcare Medicare |
$17.93
|
| Rate for Payer: Wellmed Medicare |
$17.93
|
|
|
Sjogren's Anti-SS-B SO
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
1701143
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$202.40
|
|
|
Sjogren's Anti-SS-B SO
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
1701143
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.99 |
| Max. Negotiated Rate |
$149.50 |
| Rate for Payer: Aetna Commercial |
$18.83
|
| Rate for Payer: Aetna Medicare |
$26.90
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$6.99
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$17.93
|
| Rate for Payer: Amerigroup Medicare |
$17.93
|
| Rate for Payer: BCBS of TX Blue Advantage |
$29.58
|
| Rate for Payer: BCBS of TX Blue Essentials |
$35.50
|
| Rate for Payer: BCBS of TX Medicare |
$17.93
|
| Rate for Payer: BCBS of TX PPO |
$39.63
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Cigna Medicaid |
$17.93
|
| Rate for Payer: Cigna Medicare |
$17.93
|
| Rate for Payer: Employer Direct Commercial |
$17.93
|
| Rate for Payer: Humana Medicare/TRICARE |
$17.93
|
| Rate for Payer: Molina CHIP/Medicaid |
$17.93
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$17.93
|
| Rate for Payer: Molina Medicare |
$17.93
|
| Rate for Payer: Multiplan Auto |
$149.50
|
| Rate for Payer: Multiplan Commercial |
$149.50
|
| Rate for Payer: Multiplan Workers Comp |
$149.50
|
| Rate for Payer: Parkland Medicaid |
$17.93
|
| Rate for Payer: Scott and White EPO/PPO |
$22.41
|
| Rate for Payer: Scott and White Medicare |
$17.93
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$17.93
|
| Rate for Payer: Superior Health Plan EPO |
$17.93
|
| Rate for Payer: Superior Health Plan Medicare |
$17.93
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$17.93
|
| Rate for Payer: Universal American Medicare |
$17.93
|
| Rate for Payer: Wellcare Medicare |
$17.93
|
| Rate for Payer: Wellmed Medicare |
$17.93
|
|
|
SKIN CLOS 1/4 -- DHF
|
Facility
|
IP
|
$55.15
|
|
| Hospital Charge Code |
81850653
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$48.53
|
|
|
SKIN CLOS 1/4 -- DHF
|
Facility
|
OP
|
$55.15
|
|
| Hospital Charge Code |
81850653
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$35.85 |
| Rate for Payer: Aetna Commercial |
$30.33
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$4.96
|
| Rate for Payer: BCBS of TX Blue Advantage |
$16.54
|
| Rate for Payer: BCBS of TX Blue Essentials |
$19.85
|
| Rate for Payer: BCBS of TX PPO |
$22.06
|
| Rate for Payer: Cash Price |
$48.53
|
| Rate for Payer: Multiplan Auto |
$35.85
|
| Rate for Payer: Multiplan Commercial |
$35.85
|
| Rate for Payer: Multiplan Workers Comp |
$35.85
|
| Rate for Payer: Scott and White EPO/PPO |
$27.58
|
| Rate for Payer: Superior Health Plan EPO |
$7.50
|
|
|
SKIN DEBRIDEMENT WITH CC
|
Facility
|
IP
|
$32,146.10
|
|
|
Service Code
|
MSDRG 571
|
| Min. Negotiated Rate |
$12,376.26 |
| Max. Negotiated Rate |
$32,146.10 |
| Rate for Payer: Aetna Commercial |
$19,033.88
|
| Rate for Payer: Aetna Medicare |
$22,392.42
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14,928.28
|
| Rate for Payer: Amerigroup Medicare |
$14,928.28
|
| Rate for Payer: BCBS of TX Blue Advantage |
$12,376.26
|
| Rate for Payer: BCBS of TX Blue Essentials |
$17,572.23
|
| Rate for Payer: BCBS of TX Medicare |
$14,928.28
|
| Rate for Payer: BCBS of TX PPO |
$19,525.45
|
| Rate for Payer: Cigna Commercial |
$21,791.67
|
| Rate for Payer: Cigna Medicare |
$14,928.28
|
| Rate for Payer: Employer Direct Commercial |
$14,928.28
|
| Rate for Payer: Humana Medicare/TRICARE |
$14,928.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14,928.28
|
| Rate for Payer: Molina Medicare |
$14,928.28
|
| Rate for Payer: Multiplan Auto |
$32,146.10
|
| Rate for Payer: Multiplan Commercial |
$32,146.10
|
| Rate for Payer: Multiplan Workers Comp |
$32,146.10
|
| Rate for Payer: Scott and White EPO/PPO |
$14,804.12
|
| Rate for Payer: Scott and White Medicare |
$14,928.28
|
| Rate for Payer: Superior Health Plan EPO |
$14,928.28
|
| Rate for Payer: Superior Health Plan Medicare |
$14,928.28
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14,928.28
|
| Rate for Payer: Universal American Medicare |
$14,928.28
|
| Rate for Payer: Wellcare Medicare |
$14,928.28
|
| Rate for Payer: Wellmed Medicare |
$14,928.28
|
|
|
SKIN DEBRIDEMENT WITH MCC
|
Facility
|
IP
|
$55,521.80
|
|
|
Service Code
|
MSDRG 570
|
| Min. Negotiated Rate |
$20,391.46 |
| Max. Negotiated Rate |
$55,521.80 |
| Rate for Payer: Aetna Commercial |
$32,874.75
|
| Rate for Payer: Aetna Medicare |
$35,561.67
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$23,707.78
|
| Rate for Payer: Amerigroup Medicare |
$23,707.78
|
| Rate for Payer: BCBS of TX Blue Advantage |
$20,391.46
|
| Rate for Payer: BCBS of TX Blue Essentials |
$31,315.07
|
| Rate for Payer: BCBS of TX Medicare |
$23,707.78
|
| Rate for Payer: BCBS of TX PPO |
$34,795.87
|
| Rate for Payer: Cigna Commercial |
$37,637.94
|
| Rate for Payer: Cigna Medicare |
$23,707.78
|
| Rate for Payer: Employer Direct Commercial |
$23,707.78
|
| Rate for Payer: Humana Medicare/TRICARE |
$23,707.78
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$23,707.78
|
| Rate for Payer: Molina Medicare |
$23,707.78
|
| Rate for Payer: Multiplan Auto |
$55,521.80
|
| Rate for Payer: Multiplan Commercial |
$55,521.80
|
| Rate for Payer: Multiplan Workers Comp |
$55,521.80
|
| Rate for Payer: Scott and White EPO/PPO |
$25,569.25
|
| Rate for Payer: Scott and White Medicare |
$23,707.78
|
| Rate for Payer: Superior Health Plan EPO |
$23,707.78
|
| Rate for Payer: Superior Health Plan Medicare |
$23,707.78
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$23,707.78
|
| Rate for Payer: Universal American Medicare |
$23,707.78
|
| Rate for Payer: Wellcare Medicare |
$23,707.78
|
| Rate for Payer: Wellmed Medicare |
$23,707.78
|
|
|
SKIN DEBRIDEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$21,652.40
|
|
|
Service Code
|
MSDRG 572
|
| Min. Negotiated Rate |
$9,024.84 |
| Max. Negotiated Rate |
$21,652.40 |
| Rate for Payer: Aetna Commercial |
$12,820.50
|
| Rate for Payer: Aetna Medicare |
$16,480.56
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$10,987.04
|
| Rate for Payer: Amerigroup Medicare |
$10,987.04
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9,024.84
|
| Rate for Payer: BCBS of TX Blue Essentials |
$12,161.97
|
| Rate for Payer: BCBS of TX Medicare |
$10,987.04
|
| Rate for Payer: BCBS of TX PPO |
$13,513.83
|
| Rate for Payer: Cigna Commercial |
$14,678.05
|
| Rate for Payer: Cigna Medicare |
$10,987.04
|
| Rate for Payer: Employer Direct Commercial |
$10,987.04
|
| Rate for Payer: Humana Medicare/TRICARE |
$10,987.04
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$10,987.04
|
| Rate for Payer: Molina Medicare |
$10,987.04
|
| Rate for Payer: Multiplan Auto |
$21,652.40
|
| Rate for Payer: Multiplan Commercial |
$21,652.40
|
| Rate for Payer: Multiplan Workers Comp |
$21,652.40
|
| Rate for Payer: Scott and White EPO/PPO |
$9,971.50
|
| Rate for Payer: Scott and White Medicare |
$10,987.04
|
| Rate for Payer: Superior Health Plan EPO |
$10,987.04
|
| Rate for Payer: Superior Health Plan Medicare |
$10,987.04
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$10,987.04
|
| Rate for Payer: Universal American Medicare |
$10,987.04
|
| Rate for Payer: Wellcare Medicare |
$10,987.04
|
| Rate for Payer: Wellmed Medicare |
$10,987.04
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$50,332.90
|
|
|
Service Code
|
MSDRG 577
|
| Min. Negotiated Rate |
$19,684.54 |
| Max. Negotiated Rate |
$50,332.90 |
| Rate for Payer: Aetna Commercial |
$29,802.38
|
| Rate for Payer: Aetna Medicare |
$32,638.36
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$21,758.91
|
| Rate for Payer: Amerigroup Medicare |
$21,758.91
|
| Rate for Payer: BCBS of TX Blue Advantage |
$19,684.54
|
| Rate for Payer: BCBS of TX Blue Essentials |
$25,892.43
|
| Rate for Payer: BCBS of TX Medicare |
$21,758.91
|
| Rate for Payer: BCBS of TX PPO |
$28,770.49
|
| Rate for Payer: Cigna Commercial |
$34,120.41
|
| Rate for Payer: Cigna Medicare |
$21,758.91
|
| Rate for Payer: Employer Direct Commercial |
$21,758.91
|
| Rate for Payer: Humana Medicare/TRICARE |
$21,758.91
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$21,758.91
|
| Rate for Payer: Molina Medicare |
$21,758.91
|
| Rate for Payer: Multiplan Auto |
$50,332.90
|
| Rate for Payer: Multiplan Commercial |
$50,332.90
|
| Rate for Payer: Multiplan Workers Comp |
$50,332.90
|
| Rate for Payer: Scott and White EPO/PPO |
$23,179.62
|
| Rate for Payer: Scott and White Medicare |
$21,758.91
|
| Rate for Payer: Superior Health Plan EPO |
$21,758.91
|
| Rate for Payer: Superior Health Plan Medicare |
$21,758.91
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$21,758.91
|
| Rate for Payer: Universal American Medicare |
$21,758.91
|
| Rate for Payer: Wellcare Medicare |
$21,758.91
|
| Rate for Payer: Wellmed Medicare |
$21,758.91
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$107,978.90
|
|
|
Service Code
|
MSDRG 576
|
| Min. Negotiated Rate |
$37,149.42 |
| Max. Negotiated Rate |
$107,978.90 |
| Rate for Payer: Aetna Commercial |
$63,934.88
|
| Rate for Payer: Aetna Medicare |
$65,114.60
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$43,409.73
|
| Rate for Payer: Amerigroup Medicare |
$43,409.73
|
| Rate for Payer: BCBS of TX Blue Advantage |
$37,149.42
|
| Rate for Payer: BCBS of TX Blue Essentials |
$50,363.94
|
| Rate for Payer: BCBS of TX Medicare |
$43,409.73
|
| Rate for Payer: BCBS of TX PPO |
$55,962.11
|
| Rate for Payer: Cigna Commercial |
$73,198.33
|
| Rate for Payer: Cigna Medicare |
$43,409.73
|
| Rate for Payer: Employer Direct Commercial |
$43,409.73
|
| Rate for Payer: Humana Medicare/TRICARE |
$43,409.73
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$43,409.73
|
| Rate for Payer: Molina Medicare |
$43,409.73
|
| Rate for Payer: Multiplan Auto |
$107,978.90
|
| Rate for Payer: Multiplan Commercial |
$107,978.90
|
| Rate for Payer: Multiplan Workers Comp |
$107,978.90
|
| Rate for Payer: Scott and White EPO/PPO |
$49,727.12
|
| Rate for Payer: Scott and White Medicare |
$43,409.73
|
| Rate for Payer: Superior Health Plan EPO |
$43,409.73
|
| Rate for Payer: Superior Health Plan Medicare |
$43,409.73
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$43,409.73
|
| Rate for Payer: Universal American Medicare |
$43,409.73
|
| Rate for Payer: Wellcare Medicare |
$43,409.73
|
| Rate for Payer: Wellmed Medicare |
$43,409.73
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$30,599.50
|
|
|
Service Code
|
MSDRG 578
|
| Min. Negotiated Rate |
$11,896.38 |
| Max. Negotiated Rate |
$30,599.50 |
| Rate for Payer: Aetna Commercial |
$18,118.12
|
| Rate for Payer: Aetna Medicare |
$21,521.12
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14,347.41
|
| Rate for Payer: Amerigroup Medicare |
$14,347.41
|
| Rate for Payer: BCBS of TX Blue Advantage |
$11,896.38
|
| Rate for Payer: BCBS of TX Blue Essentials |
$15,784.97
|
| Rate for Payer: BCBS of TX Medicare |
$14,347.41
|
| Rate for Payer: BCBS of TX PPO |
$17,539.54
|
| Rate for Payer: Cigna Commercial |
$20,743.24
|
| Rate for Payer: Cigna Medicare |
$14,347.41
|
| Rate for Payer: Employer Direct Commercial |
$14,347.41
|
| Rate for Payer: Humana Medicare/TRICARE |
$14,347.41
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14,347.41
|
| Rate for Payer: Molina Medicare |
$14,347.41
|
| Rate for Payer: Multiplan Auto |
$30,599.50
|
| Rate for Payer: Multiplan Commercial |
$30,599.50
|
| Rate for Payer: Multiplan Workers Comp |
$30,599.50
|
| Rate for Payer: Scott and White EPO/PPO |
$14,091.88
|
| Rate for Payer: Scott and White Medicare |
$14,347.41
|
| Rate for Payer: Superior Health Plan EPO |
$14,347.41
|
| Rate for Payer: Superior Health Plan Medicare |
$14,347.41
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14,347.41
|
| Rate for Payer: Universal American Medicare |
$14,347.41
|
| Rate for Payer: Wellcare Medicare |
$14,347.41
|
| Rate for Payer: Wellmed Medicare |
$14,347.41
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$64,710.20
|
|
|
Service Code
|
MSDRG 574
|
| Min. Negotiated Rate |
$24,569.34 |
| Max. Negotiated Rate |
$64,710.20 |
| Rate for Payer: Aetna Commercial |
$38,315.25
|
| Rate for Payer: Aetna Medicare |
$40,738.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$27,158.77
|
| Rate for Payer: Amerigroup Medicare |
$27,158.77
|
| Rate for Payer: BCBS of TX Blue Advantage |
$24,569.34
|
| Rate for Payer: BCBS of TX Blue Essentials |
$31,430.64
|
| Rate for Payer: BCBS of TX Medicare |
$27,158.77
|
| Rate for Payer: BCBS of TX PPO |
$34,924.29
|
| Rate for Payer: Cigna Commercial |
$43,866.70
|
| Rate for Payer: Cigna Medicare |
$27,158.77
|
| Rate for Payer: Employer Direct Commercial |
$27,158.77
|
| Rate for Payer: Humana Medicare/TRICARE |
$27,158.77
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$27,158.77
|
| Rate for Payer: Molina Medicare |
$27,158.77
|
| Rate for Payer: Multiplan Auto |
$64,710.20
|
| Rate for Payer: Multiplan Commercial |
$64,710.20
|
| Rate for Payer: Multiplan Workers Comp |
$64,710.20
|
| Rate for Payer: Scott and White EPO/PPO |
$29,800.75
|
| Rate for Payer: Scott and White Medicare |
$27,158.77
|
| Rate for Payer: Superior Health Plan EPO |
$27,158.77
|
| Rate for Payer: Superior Health Plan Medicare |
$27,158.77
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$27,158.77
|
| Rate for Payer: Universal American Medicare |
$27,158.77
|
| Rate for Payer: Wellcare Medicare |
$27,158.77
|
| Rate for Payer: Wellmed Medicare |
$27,158.77
|
|
