|
Methylmalonic Acid, Serum SO
|
Facility
|
IP
|
$349.00
|
|
|
Service Code
|
HCPCS 83921
|
| Hospital Charge Code |
1709112
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$237.32
|
|
|
Methylmalonic Acid, Serum SO
|
Facility
|
OP
|
$349.00
|
|
|
Service Code
|
HCPCS 83921
|
| Hospital Charge Code |
1709112
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$251.28 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$8.27
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$21.21
|
| Rate for Payer: Amerigroup Medicare |
$21.21
|
| Rate for Payer: BCBS of TX Blue Advantage |
$104.70
|
| Rate for Payer: BCBS of TX Blue Essentials |
$125.64
|
| Rate for Payer: BCBS of TX Medicare |
$21.21
|
| Rate for Payer: BCBS of TX PPO |
$139.60
|
| Rate for Payer: Cash Price |
$237.32
|
| Rate for Payer: Cash Price |
$237.32
|
| Rate for Payer: Cigna Medicaid |
$251.28
|
| Rate for Payer: Cigna Medicare |
$21.21
|
| Rate for Payer: Employer Direct Commercial |
$21.21
|
| Rate for Payer: Humana Medicare/TRICARE |
$21.21
|
| Rate for Payer: Molina CHIP/Medicaid |
$251.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$21.21
|
| Rate for Payer: Molina Medicare |
$21.21
|
| Rate for Payer: Multiplan Auto |
$226.85
|
| Rate for Payer: Multiplan Commercial |
$226.85
|
| Rate for Payer: Multiplan Workers Comp |
$226.85
|
| Rate for Payer: Parkland Medicaid |
$251.28
|
| Rate for Payer: Scott and White EPO/PPO |
$26.51
|
| Rate for Payer: Scott and White Medicare |
$21.21
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$251.28
|
| Rate for Payer: Superior Health Plan EPO |
$21.21
|
| Rate for Payer: Superior Health Plan Medicare |
$21.21
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$21.21
|
| Rate for Payer: Universal American Medicare |
$21.21
|
| Rate for Payer: Wellcare Medicare |
$21.21
|
| Rate for Payer: Wellmed Medicare |
$21.21
|
|
|
methylPREDNISolone 125. mg Powder-Inj
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
78418466
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Commercial |
$32.00
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
|
|
methylPREDNISolone 125. mg Powder-Inj
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
78418466
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.52
|
| Rate for Payer: BCBS of TX Blue Advantage |
$0.45
|
| Rate for Payer: BCBS of TX Blue Essentials |
$0.54
|
| Rate for Payer: BCBS of TX PPO |
$0.60
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Medicaid |
$92.16
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.16
|
| Rate for Payer: Multiplan Auto |
$83.20
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Multiplan Workers Comp |
$83.20
|
| Rate for Payer: Parkland Medicaid |
$92.16
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.16
|
| Rate for Payer: Superior Health Plan EPO |
$17.41
|
|
|
methylPREDNISolone acetate 40 mg/mL inj Susp 1 mL
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS J1030
|
| Hospital Charge Code |
77697422
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Commercial |
$32.00
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
|
|
methylPREDNISolone acetate 40 mg/mL inj Susp 1 mL
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS J1030
|
| Hospital Charge Code |
77697422
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.52
|
| Rate for Payer: BCBS of TX Blue Advantage |
$7.16
|
| Rate for Payer: BCBS of TX Blue Essentials |
$8.60
|
| Rate for Payer: BCBS of TX PPO |
$9.53
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Medicaid |
$92.16
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.16
|
| Rate for Payer: Multiplan Auto |
$83.20
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Multiplan Workers Comp |
$83.20
|
| Rate for Payer: Parkland Medicaid |
$92.16
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.16
|
| Rate for Payer: Superior Health Plan EPO |
$17.41
|
|
|
methylPREDNISolone sodium succ 40 mg Inj
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
78411206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.52
|
| Rate for Payer: BCBS of TX Blue Advantage |
$0.45
|
| Rate for Payer: BCBS of TX Blue Essentials |
$0.54
|
| Rate for Payer: BCBS of TX PPO |
$0.60
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Medicaid |
$92.16
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.16
|
| Rate for Payer: Multiplan Auto |
$83.20
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Multiplan Workers Comp |
$83.20
|
| Rate for Payer: Parkland Medicaid |
$92.16
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.16
|
| Rate for Payer: Superior Health Plan EPO |
$17.41
|
|
|
methylPREDNISolone sodium succ 40 mg Inj
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
78411206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Commercial |
$32.00
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
|
|
methylPREDNISolone sodium succ 40 mg PF Inj
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
77697369
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Commercial |
$32.00
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
|
|
methylPREDNISolone sodium succ 40 mg PF Inj
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
77697369
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.52
|
| Rate for Payer: BCBS of TX Blue Advantage |
$0.45
|
| Rate for Payer: BCBS of TX Blue Essentials |
$0.54
|
| Rate for Payer: BCBS of TX PPO |
$0.60
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Medicaid |
$92.16
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.16
|
| Rate for Payer: Multiplan Auto |
$83.20
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Multiplan Workers Comp |
$83.20
|
| Rate for Payer: Parkland Medicaid |
$92.16
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.16
|
| Rate for Payer: Superior Health Plan EPO |
$17.41
|
|
|
metoclopramide 10 mg Tab
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
77698186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$5.76 |
| 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: Cigna Medicaid |
$5.76
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.76
|
| 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: Parkland Medicaid |
$5.76
|
| Rate for Payer: Scott and White EPO/PPO |
$4.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.76
|
| Rate for Payer: Superior Health Plan EPO |
$1.09
|
|
|
metoclopramide 10 mg Tab
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
77698186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Cigna Commercial |
$2.00
|
| Rate for Payer: Scott and White EPO/PPO |
$4.00
|
|
|
metoclopramide 5 mg/mL Sol
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
78398727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Commercial |
$32.00
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
|
|
metoclopramide 5 mg/mL Sol
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
78398727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.52
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.20
|
| Rate for Payer: BCBS of TX Blue Essentials |
$2.64
|
| Rate for Payer: BCBS of TX PPO |
$2.93
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Medicaid |
$92.16
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.16
|
| Rate for Payer: Multiplan Auto |
$83.20
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Multiplan Workers Comp |
$83.20
|
| Rate for Payer: Parkland Medicaid |
$92.16
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.16
|
| Rate for Payer: Superior Health Plan EPO |
$17.41
|
|
|
metOLazone 2.5 mg Tab
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77698891
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$5.76 |
| 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: Cigna Medicaid |
$5.76
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.76
|
| 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: Parkland Medicaid |
$5.76
|
| Rate for Payer: Scott and White EPO/PPO |
$4.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.76
|
| Rate for Payer: Superior Health Plan EPO |
$1.09
|
|
|
metOLazone 2.5 mg Tab
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77698891
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.44
|
|
|
metoprolol 1 mg/mL Inj Soln 5 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78425888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$92.28 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38.45
|
| Rate for Payer: BCBS of TX Blue Essentials |
$46.14
|
| Rate for Payer: BCBS of TX PPO |
$51.27
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cigna Medicaid |
$92.28
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.28
|
| Rate for Payer: Multiplan Auto |
$83.31
|
| Rate for Payer: Multiplan Commercial |
$83.31
|
| Rate for Payer: Multiplan Workers Comp |
$83.31
|
| Rate for Payer: Parkland Medicaid |
$92.28
|
| Rate for Payer: Scott and White EPO/PPO |
$64.08
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.28
|
| Rate for Payer: Superior Health Plan EPO |
$17.43
|
|
|
metoprolol 1 mg/mL Inj Soln 5 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78425888
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$87.16
|
|
|
metoprolol 1 mg/mL Inj Soln 5 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
5888
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$87.16
|
|
|
metoprolol 1 mg/mL Inj Soln 5 mL
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
1.33878E+11
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.52
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$46.08
|
| Rate for Payer: BCBS of TX PPO |
$51.20
|
| Rate for Payer: Cash Price |
$87.04
|
| Rate for Payer: Cigna Medicaid |
$92.16
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.16
|
| Rate for Payer: Multiplan Auto |
$83.20
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Multiplan Workers Comp |
$83.20
|
| Rate for Payer: Parkland Medicaid |
$92.16
|
| Rate for Payer: Scott and White EPO/PPO |
$64.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.16
|
| Rate for Payer: Superior Health Plan EPO |
$17.41
|
|
|
metoprolol 1 mg/mL Inj Soln 5 mL
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
1.33878E+11
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$87.04
|
|
|
metoprolol 1 mg/mL Inj Soln 5 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
5888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$92.28 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$38.45
|
| Rate for Payer: BCBS of TX Blue Essentials |
$46.14
|
| Rate for Payer: BCBS of TX PPO |
$51.27
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cigna Medicaid |
$92.28
|
| Rate for Payer: Molina CHIP/Medicaid |
$92.28
|
| Rate for Payer: Multiplan Auto |
$83.31
|
| Rate for Payer: Multiplan Commercial |
$83.31
|
| Rate for Payer: Multiplan Workers Comp |
$83.31
|
| Rate for Payer: Parkland Medicaid |
$92.28
|
| Rate for Payer: Scott and White EPO/PPO |
$64.08
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$92.28
|
| Rate for Payer: Superior Health Plan EPO |
$17.43
|
|
|
metoprolol 25mg Tab
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
1.33978E+11
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$5.76 |
| 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: Cigna Medicaid |
$5.76
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.76
|
| 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: Parkland Medicaid |
$5.76
|
| Rate for Payer: Scott and White EPO/PPO |
$4.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.76
|
| Rate for Payer: Superior Health Plan EPO |
$1.09
|
|
|
metoprolol 25mg Tab
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
1.33978E+11
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.44
|
|
|
metoprolol 25mg Tab
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78437123
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.44
|
|
