|
THERAPEUTIC PHLEBOTOMY
|
Facility
|
IP
|
$265.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
7002603
|
|
Hospital Revenue Code
|
940
|
| Rate for Payer: Cash Price |
$233.20
|
|
|
THERAPEUTIC PHLEBOTOMY
|
Facility
|
OP
|
$265.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
7002603
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$274.76 |
| Rate for Payer: Aetna Commercial |
$145.75
|
| Rate for Payer: Aetna Medicare |
$175.23
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$23.85
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$116.82
|
| Rate for Payer: Amerigroup Medicare |
$116.82
|
| Rate for Payer: BCBS of TX Blue Advantage |
$182.08
|
| Rate for Payer: BCBS of TX Blue Essentials |
$218.06
|
| Rate for Payer: BCBS of TX Medicare |
$116.82
|
| Rate for Payer: BCBS of TX PPO |
$274.76
|
| Rate for Payer: Cash Price |
$233.20
|
| Rate for Payer: Cash Price |
$233.20
|
| Rate for Payer: Cash Price |
$233.20
|
| Rate for Payer: Cigna Commercial |
$264.63
|
| Rate for Payer: Cigna Medicare |
$116.82
|
| Rate for Payer: Employer Direct Commercial |
$116.82
|
| Rate for Payer: Humana Medicare/TRICARE |
$116.82
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$116.82
|
| Rate for Payer: Molina Medicare |
$116.82
|
| Rate for Payer: Multiplan Auto |
$172.25
|
| Rate for Payer: Multiplan Commercial |
$172.25
|
| Rate for Payer: Multiplan Workers Comp |
$172.25
|
| Rate for Payer: Scott and White EPO/PPO |
$2.09
|
| Rate for Payer: Scott and White Medicare |
$116.82
|
| Rate for Payer: Superior Health Plan EPO |
$116.82
|
| Rate for Payer: Superior Health Plan Medicare |
$116.82
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$116.82
|
| Rate for Payer: Universal American Medicare |
$116.82
|
| Rate for Payer: Wellcare Medicare |
$116.82
|
| Rate for Payer: Wellmed Medicare |
$116.82
|
|
|
Therapeutic Phlebotomy 99195
|
Facility
|
IP
|
$265.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
3609195
|
|
Hospital Revenue Code
|
940
|
| Rate for Payer: Cash Price |
$233.20
|
|
|
Therapeutic Phlebotomy 99195
|
Facility
|
OP
|
$265.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
3609195
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$274.76 |
| Rate for Payer: Aetna Commercial |
$145.75
|
| Rate for Payer: Aetna Medicare |
$175.23
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$23.85
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$116.82
|
| Rate for Payer: Amerigroup Medicare |
$116.82
|
| Rate for Payer: BCBS of TX Blue Advantage |
$182.08
|
| Rate for Payer: BCBS of TX Blue Essentials |
$218.06
|
| Rate for Payer: BCBS of TX Medicare |
$116.82
|
| Rate for Payer: BCBS of TX PPO |
$274.76
|
| Rate for Payer: Cash Price |
$233.20
|
| Rate for Payer: Cash Price |
$233.20
|
| Rate for Payer: Cash Price |
$233.20
|
| Rate for Payer: Cigna Commercial |
$264.63
|
| Rate for Payer: Cigna Medicare |
$116.82
|
| Rate for Payer: Employer Direct Commercial |
$116.82
|
| Rate for Payer: Humana Medicare/TRICARE |
$116.82
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$116.82
|
| Rate for Payer: Molina Medicare |
$116.82
|
| Rate for Payer: Multiplan Auto |
$172.25
|
| Rate for Payer: Multiplan Commercial |
$172.25
|
| Rate for Payer: Multiplan Workers Comp |
$172.25
|
| Rate for Payer: Scott and White EPO/PPO |
$2.09
|
| Rate for Payer: Scott and White Medicare |
$116.82
|
| Rate for Payer: Superior Health Plan EPO |
$116.82
|
| Rate for Payer: Superior Health Plan Medicare |
$116.82
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$116.82
|
| Rate for Payer: Universal American Medicare |
$116.82
|
| Rate for Payer: Wellcare Medicare |
$116.82
|
| Rate for Payer: Wellmed Medicare |
$116.82
|
|
|
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
36096372
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Aetna Medicare |
$96.64
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$64.43
|
| Rate for Payer: Amerigroup Medicare |
$64.43
|
| Rate for Payer: BCBS of TX Blue Advantage |
$105.22
|
| Rate for Payer: BCBS of TX Blue Essentials |
$125.78
|
| Rate for Payer: BCBS of TX Medicare |
$64.43
|
| Rate for Payer: BCBS of TX PPO |
$140.29
|
| Rate for Payer: Cigna Commercial |
$145.94
|
| Rate for Payer: Cigna Medicaid |
$11.23
|
| Rate for Payer: Cigna Medicare |
$64.43
|
| Rate for Payer: Employer Direct Commercial |
$64.43
|
| Rate for Payer: Humana Medicare/TRICARE |
$64.43
|
| Rate for Payer: Molina CHIP/Medicaid |
$11.23
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$64.43
|
| Rate for Payer: Molina Medicare |
$64.43
|
| 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 |
$11.23
|
| Rate for Payer: Scott and White EPO/PPO |
$1.15
|
| Rate for Payer: Scott and White Medicare |
$64.43
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$11.23
|
| Rate for Payer: Superior Health Plan EPO |
$64.43
|
| Rate for Payer: Superior Health Plan Medicare |
$64.43
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$64.43
|
| Rate for Payer: Universal American Medicare |
$64.43
|
| Rate for Payer: Wellcare Medicare |
$64.43
|
| Rate for Payer: Wellmed Medicare |
$64.43
|
|
|
Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
7003650
|
|
Hospital Revenue Code
|
260
|
| Rate for Payer: Cash Price |
$290.40
|
|
|
Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
7003650
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$214.50 |
| Rate for Payer: Aetna Commercial |
$181.50
|
| Rate for Payer: Aetna Medicare |
$65.16
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.70
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$43.44
|
| Rate for Payer: Amerigroup Medicare |
$43.44
|
| Rate for Payer: BCBS of TX Blue Advantage |
$29.48
|
| Rate for Payer: BCBS of TX Blue Essentials |
$35.24
|
| Rate for Payer: BCBS of TX Medicare |
$43.44
|
| Rate for Payer: BCBS of TX PPO |
$39.30
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cigna Commercial |
$98.40
|
| Rate for Payer: Cigna Medicare |
$43.44
|
| Rate for Payer: Employer Direct Commercial |
$43.44
|
| Rate for Payer: Humana Medicare/TRICARE |
$43.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$43.44
|
| Rate for Payer: Molina Medicare |
$43.44
|
| Rate for Payer: Multiplan Auto |
$214.50
|
| Rate for Payer: Multiplan Commercial |
$214.50
|
| Rate for Payer: Multiplan Workers Comp |
$214.50
|
| Rate for Payer: Scott and White EPO/PPO |
$0.78
|
| Rate for Payer: Scott and White Medicare |
$43.44
|
| Rate for Payer: Superior Health Plan EPO |
$43.44
|
| Rate for Payer: Superior Health Plan Medicare |
$43.44
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$43.44
|
| Rate for Payer: Universal American Medicare |
$43.44
|
| Rate for Payer: Wellcare Medicare |
$43.44
|
| Rate for Payer: Wellmed Medicare |
$43.44
|
|
|
Therapy, Prophylactic, Diagnostic Injection SQ or IM 96372
|
Facility
|
OP
|
$280.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
1500370
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Aetna Medicare |
$96.64
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$25.20
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$64.43
|
| Rate for Payer: Amerigroup Medicare |
$64.43
|
| Rate for Payer: BCBS of TX Blue Advantage |
$105.22
|
| Rate for Payer: BCBS of TX Blue Essentials |
$125.78
|
| Rate for Payer: BCBS of TX Medicare |
$64.43
|
| Rate for Payer: BCBS of TX PPO |
$140.29
|
| Rate for Payer: Cash Price |
$246.40
|
| Rate for Payer: Cash Price |
$246.40
|
| Rate for Payer: Cash Price |
$246.40
|
| Rate for Payer: Cigna Commercial |
$145.94
|
| Rate for Payer: Cigna Medicaid |
$11.23
|
| Rate for Payer: Cigna Medicare |
$64.43
|
| Rate for Payer: Employer Direct Commercial |
$64.43
|
| Rate for Payer: Humana Medicare/TRICARE |
$64.43
|
| Rate for Payer: Molina CHIP/Medicaid |
$11.23
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$64.43
|
| Rate for Payer: Molina Medicare |
$64.43
|
| Rate for Payer: Multiplan Auto |
$182.00
|
| Rate for Payer: Multiplan Commercial |
$182.00
|
| Rate for Payer: Multiplan Workers Comp |
$182.00
|
| Rate for Payer: Parkland Medicaid |
$11.23
|
| Rate for Payer: Scott and White EPO/PPO |
$1.15
|
| Rate for Payer: Scott and White Medicare |
$64.43
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$11.23
|
| Rate for Payer: Superior Health Plan EPO |
$64.43
|
| Rate for Payer: Superior Health Plan Medicare |
$64.43
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$64.43
|
| Rate for Payer: Universal American Medicare |
$64.43
|
| Rate for Payer: Wellcare Medicare |
$64.43
|
| Rate for Payer: Wellmed Medicare |
$64.43
|
|
|
Therapy, Prophylactic, Diagnostic Injection SQ or IM 96372
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
1500370
|
|
Hospital Revenue Code
|
260
|
| Rate for Payer: Cash Price |
$246.40
|
|
|
Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additi
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64629
|
| Hospital Charge Code |
36064629
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$10,000.00 |
| Max. Negotiated Rate |
$10,000.00 |
| 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
|
|
|
Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 ver
|
Facility
|
OP
|
$31,735.09
|
|
|
Service Code
|
CPT 64628
|
| Hospital Charge Code |
36064628
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$265.49 |
| Max. Negotiated Rate |
$31,735.09 |
| Rate for Payer: Aetna Commercial |
$7,210.00
|
| Rate for Payer: Aetna Medicare |
$18,054.70
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7,534.26
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12,036.47
|
| Rate for Payer: Amerigroup Medicare |
$12,036.47
|
| Rate for Payer: BCBS of TX Blue Advantage |
$21,030.79
|
| Rate for Payer: BCBS of TX Blue Essentials |
$25,186.58
|
| Rate for Payer: BCBS of TX Medicare |
$12,036.47
|
| Rate for Payer: BCBS of TX PPO |
$31,735.09
|
| Rate for Payer: Cigna Commercial |
$27,266.10
|
| Rate for Payer: Cigna Medicaid |
$7,534.26
|
| Rate for Payer: Cigna Medicare |
$12,036.47
|
| Rate for Payer: Employer Direct Commercial |
$12,036.47
|
| Rate for Payer: Humana Medicare/TRICARE |
$12,036.47
|
| Rate for Payer: Molina CHIP/Medicaid |
$7,534.26
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12,036.47
|
| Rate for Payer: Molina Medicare |
$12,036.47
|
| 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 |
$7,534.26
|
| Rate for Payer: Scott and White EPO/PPO |
$265.49
|
| Rate for Payer: Scott and White Medicare |
$12,036.47
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$7,534.26
|
| Rate for Payer: Superior Health Plan EPO |
$12,036.47
|
| Rate for Payer: Superior Health Plan Medicare |
$12,036.47
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12,036.47
|
| Rate for Payer: Universal American Medicare |
$12,036.47
|
| Rate for Payer: Wellcare Medicare |
$12,036.47
|
| Rate for Payer: Wellmed Medicare |
$12,036.47
|
|
|
thiamine 100 mg/mL Inj Soln 2 mL
|
Facility
|
OP
|
$128.17
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
77844018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$83.31 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.54
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4.45
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5.34
|
| Rate for Payer: BCBS of TX PPO |
$5.93
|
| Rate for Payer: Cash Price |
$87.16
|
| Rate for Payer: Cash Price |
$87.16
|
| 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: Scott and White EPO/PPO |
$64.08
|
| Rate for Payer: Superior Health Plan EPO |
$17.43
|
|
|
thiamine 100 mg/mL Inj Soln 2 mL
|
Facility
|
IP
|
$128.17
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
77844018
|
|
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
|
|
|
thiamine 100 mg Tab
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78436046
|
|
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
|
|
|
thiamine 100 mg Tab
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
78436046
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
Third Dose Moderna 0013A
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 0031A
|
| Hospital Charge Code |
8686559
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$52.80
|
|
|
Third Dose Moderna 0013A
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 0031A
|
| Hospital Charge Code |
8686559
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Aetna Commercial |
$33.00
|
| 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 |
$52.80
|
| 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: Scott and White EPO/PPO |
$30.00
|
| Rate for Payer: Superior Health Plan EPO |
$8.16
|
|
|
Third Dose Pfizer 0003A
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 0003A
|
| Hospital Charge Code |
8684535
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Aetna Commercial |
$33.00
|
| 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 |
$52.80
|
| 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: Scott and White EPO/PPO |
$30.00
|
| Rate for Payer: Superior Health Plan EPO |
$8.16
|
|
|
Third Dose Pfizer 0003A
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 0003A
|
| Hospital Charge Code |
8684535
|
|
Hospital Revenue Code
|
771
|
| Rate for Payer: Cash Price |
$52.80
|
|
|
Throat Culture
|
Facility
|
OP
|
$309.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
4107043
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$200.85 |
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: Aetna Medicare |
$12.93
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.36
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$8.62
|
| Rate for Payer: Amerigroup Medicare |
$8.62
|
| Rate for Payer: BCBS of TX Blue Advantage |
$14.22
|
| Rate for Payer: BCBS of TX Blue Essentials |
$17.07
|
| Rate for Payer: BCBS of TX Medicare |
$8.62
|
| Rate for Payer: BCBS of TX PPO |
$19.05
|
| Rate for Payer: Cash Price |
$271.92
|
| Rate for Payer: Cash Price |
$271.92
|
| Rate for Payer: Cigna Medicaid |
$8.62
|
| Rate for Payer: Cigna Medicare |
$8.62
|
| Rate for Payer: Employer Direct Commercial |
$8.62
|
| Rate for Payer: Humana Medicare/TRICARE |
$8.62
|
| Rate for Payer: Molina CHIP/Medicaid |
$8.62
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$8.62
|
| Rate for Payer: Molina Medicare |
$8.62
|
| Rate for Payer: Multiplan Auto |
$200.85
|
| Rate for Payer: Multiplan Commercial |
$200.85
|
| Rate for Payer: Multiplan Workers Comp |
$200.85
|
| Rate for Payer: Parkland Medicaid |
$8.62
|
| Rate for Payer: Scott and White EPO/PPO |
$10.78
|
| Rate for Payer: Scott and White Medicare |
$8.62
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$8.62
|
| Rate for Payer: Superior Health Plan EPO |
$8.62
|
| Rate for Payer: Superior Health Plan Medicare |
$8.62
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$8.62
|
| Rate for Payer: Universal American Medicare |
$8.62
|
| Rate for Payer: Wellcare Medicare |
$8.62
|
| Rate for Payer: Wellmed Medicare |
$8.62
|
|
|
Throat Culture
|
Facility
|
IP
|
$309.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
4107043
|
|
Hospital Revenue Code
|
306
|
| Rate for Payer: Cash Price |
$271.92
|
|
|
thrombin bovine 5000 intl units Topical Powder-Recon
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77845021
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$102.00
|
|
|
thrombin bovine 5000 intl units Topical Powder-Recon
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77845021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$97.50 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$13.50
|
| Rate for Payer: BCBS of TX Blue Advantage |
$45.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$54.00
|
| Rate for Payer: BCBS of TX PPO |
$60.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Multiplan Auto |
$97.50
|
| Rate for Payer: Multiplan Commercial |
$97.50
|
| Rate for Payer: Multiplan Workers Comp |
$97.50
|
| Rate for Payer: Scott and White EPO/PPO |
$75.00
|
| Rate for Payer: Superior Health Plan EPO |
$20.40
|
|
|
THROMBIN TIME PLASMA
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT 85670
|
| Hospital Charge Code |
1600659
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$31.20 |
| Rate for Payer: Aetna Commercial |
$6.06
|
| Rate for Payer: Aetna Medicare |
$8.66
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.25
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5.77
|
| Rate for Payer: Amerigroup Medicare |
$5.77
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11.42
|
| Rate for Payer: BCBS of TX Medicare |
$5.77
|
| Rate for Payer: BCBS of TX PPO |
$12.75
|
| Rate for Payer: Cash Price |
$42.24
|
| Rate for Payer: Cash Price |
$42.24
|
| Rate for Payer: Cigna Medicaid |
$5.77
|
| Rate for Payer: Cigna Medicare |
$5.77
|
| Rate for Payer: Employer Direct Commercial |
$5.77
|
| Rate for Payer: Humana Medicare/TRICARE |
$5.77
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.77
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5.77
|
| Rate for Payer: Molina Medicare |
$5.77
|
| Rate for Payer: Multiplan Auto |
$31.20
|
| Rate for Payer: Multiplan Commercial |
$31.20
|
| Rate for Payer: Multiplan Workers Comp |
$31.20
|
| Rate for Payer: Parkland Medicaid |
$5.77
|
| Rate for Payer: Scott and White EPO/PPO |
$7.21
|
| Rate for Payer: Scott and White Medicare |
$5.77
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.77
|
| Rate for Payer: Superior Health Plan EPO |
$5.77
|
| Rate for Payer: Superior Health Plan Medicare |
$5.77
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5.77
|
| Rate for Payer: Universal American Medicare |
$5.77
|
| Rate for Payer: Wellcare Medicare |
$5.77
|
| Rate for Payer: Wellmed Medicare |
$5.77
|
|
|
Thrombin Time SO
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT 85670
|
| Hospital Charge Code |
1600659
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$31.20 |
| Rate for Payer: Aetna Commercial |
$6.06
|
| Rate for Payer: Aetna Medicare |
$8.66
|
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.25
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5.77
|
| Rate for Payer: Amerigroup Medicare |
$5.77
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9.52
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11.42
|
| Rate for Payer: BCBS of TX Medicare |
$5.77
|
| Rate for Payer: BCBS of TX PPO |
$12.75
|
| Rate for Payer: Cash Price |
$42.24
|
| Rate for Payer: Cash Price |
$42.24
|
| Rate for Payer: Cigna Medicaid |
$5.77
|
| Rate for Payer: Cigna Medicare |
$5.77
|
| Rate for Payer: Employer Direct Commercial |
$5.77
|
| Rate for Payer: Humana Medicare/TRICARE |
$5.77
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.77
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5.77
|
| Rate for Payer: Molina Medicare |
$5.77
|
| Rate for Payer: Multiplan Auto |
$31.20
|
| Rate for Payer: Multiplan Commercial |
$31.20
|
| Rate for Payer: Multiplan Workers Comp |
$31.20
|
| Rate for Payer: Parkland Medicaid |
$5.77
|
| Rate for Payer: Scott and White EPO/PPO |
$7.21
|
| Rate for Payer: Scott and White Medicare |
$5.77
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.77
|
| Rate for Payer: Superior Health Plan EPO |
$5.77
|
| Rate for Payer: Superior Health Plan Medicare |
$5.77
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5.77
|
| Rate for Payer: Universal American Medicare |
$5.77
|
| Rate for Payer: Wellcare Medicare |
$5.77
|
| Rate for Payer: Wellmed Medicare |
$5.77
|
|
