|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$8,284.96
|
|
|
Service Code
|
APR-DRG 8114
|
| Min. Negotiated Rate |
$7,811.35 |
| Max. Negotiated Rate |
$8,284.96 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7,811.35
|
| Rate for Payer: Cigna Medicaid |
$7,811.35
|
| Rate for Payer: Molina CHIP/Medicaid |
$7,811.35
|
| Rate for Payer: Parkland Medicaid |
$7,811.35
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$8,284.96
|
|
|
ALLERGIC REACTIONS WITH MCC
|
Facility
|
IP
|
$34,581.90
|
|
|
Service Code
|
MSDRG 915
|
| Min. Negotiated Rate |
$14,421.34 |
| Max. Negotiated Rate |
$34,581.90 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$17,084.56
|
| Rate for Payer: Amerigroup Medicare |
$17,084.56
|
| Rate for Payer: BCBS of TX Medicare |
$17,084.56
|
| Rate for Payer: Cigna Commercial |
$21,659.01
|
| Rate for Payer: Cigna Medicare |
$17,084.56
|
| Rate for Payer: Employer Direct Commercial |
$17,084.56
|
| Rate for Payer: Humana Medicare/TRICARE |
$17,084.56
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$17,084.56
|
| Rate for Payer: Molina Medicare |
$17,084.56
|
| Rate for Payer: Multiplan Auto |
$34,581.90
|
| Rate for Payer: Multiplan Commercial |
$34,581.90
|
| Rate for Payer: Multiplan Workers Comp |
$34,581.90
|
| Rate for Payer: Scott and White EPO/PPO |
$15,925.88
|
| Rate for Payer: Scott and White Medicare |
$17,084.56
|
| Rate for Payer: Superior Health Plan EPO |
$17,084.56
|
| Rate for Payer: Superior Health Plan Medicare |
$17,084.56
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$17,084.56
|
| Rate for Payer: Universal American Medicare |
$17,084.56
|
| Rate for Payer: Wellcare Medicare |
$17,084.56
|
| Rate for Payer: Wellmed Medicare |
$17,084.56
|
|
|
ALLERGIC REACTIONS WITHOUT MCC
|
Facility
|
IP
|
$12,619.80
|
|
|
Service Code
|
MSDRG 916
|
| Min. Negotiated Rate |
$5,463.58 |
| Max. Negotiated Rate |
$12,619.80 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$9,643.41
|
| Rate for Payer: Amerigroup Medicare |
$9,643.41
|
| Rate for Payer: BCBS of TX Medicare |
$9,643.41
|
| Rate for Payer: Cigna Commercial |
$8,581.94
|
| Rate for Payer: Cigna Medicare |
$9,643.41
|
| Rate for Payer: Employer Direct Commercial |
$9,643.41
|
| Rate for Payer: Humana Medicare/TRICARE |
$9,643.41
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$9,643.41
|
| Rate for Payer: Molina Medicare |
$9,643.41
|
| Rate for Payer: Multiplan Auto |
$12,619.80
|
| Rate for Payer: Multiplan Commercial |
$12,619.80
|
| Rate for Payer: Multiplan Workers Comp |
$12,619.80
|
| Rate for Payer: Scott and White EPO/PPO |
$5,811.75
|
| Rate for Payer: Scott and White Medicare |
$9,643.41
|
| Rate for Payer: Superior Health Plan EPO |
$9,643.41
|
| Rate for Payer: Superior Health Plan Medicare |
$9,643.41
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$9,643.41
|
| Rate for Payer: Universal American Medicare |
$9,643.41
|
| Rate for Payer: Wellcare Medicare |
$9,643.41
|
| Rate for Payer: Wellmed Medicare |
$9,643.41
|
|
|
ALLERGIC REACTIONS W MCC
|
Facility
|
IP
|
$34,581.90
|
|
|
Service Code
|
MSDRG 915
|
| Min. Negotiated Rate |
$14,421.34 |
| Max. Negotiated Rate |
$34,581.90 |
| Rate for Payer: BCBS of TX Blue Advantage |
$14,421.34
|
| Rate for Payer: BCBS of TX Blue Essentials |
$17,303.93
|
| Rate for Payer: BCBS of TX PPO |
$19,227.34
|
|
|
ALLERGIC REACTIONS W/O MCC
|
Facility
|
IP
|
$12,619.80
|
|
|
Service Code
|
MSDRG 916
|
| Min. Negotiated Rate |
$5,463.58 |
| Max. Negotiated Rate |
$12,619.80 |
| Rate for Payer: BCBS of TX Blue Advantage |
$5,463.58
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,555.66
|
| Rate for Payer: BCBS of TX PPO |
$7,284.35
|
|
|
ALLODERM PER SQ CM (IMPLANT) -- DHF
|
Facility
|
IP
|
$153.00
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
40204869
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$38.25 |
| Max. Negotiated Rate |
$76.50 |
| Rate for Payer: Cash Price |
$104.04
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: Multiplan Auto |
$76.50
|
| Rate for Payer: Multiplan Commercial |
$76.50
|
| Rate for Payer: Multiplan Workers Comp |
$76.50
|
| Rate for Payer: Scott and White EPO/PPO |
$76.50
|
|
|
ALLODERM PER SQ CM (IMPLANT) -- DHF
|
Facility
|
OP
|
$153.00
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
40204869
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13.77 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$13.77
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$45.90
|
| Rate for Payer: BCBS of TX Blue Essentials |
$55.08
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$61.20
|
| Rate for Payer: Cash Price |
$104.04
|
| Rate for Payer: Cash Price |
$104.04
|
| Rate for Payer: Cash Price |
$104.04
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$110.16
|
| Rate for Payer: Cigna Medicare |
$125.01
|
| Rate for Payer: Employer Direct Commercial |
$125.01
|
| Rate for Payer: Humana Medicare/TRICARE |
$125.01
|
| Rate for Payer: Molina CHIP/Medicaid |
$110.16
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$76.50
|
| Rate for Payer: Multiplan Commercial |
$76.50
|
| Rate for Payer: Multiplan Workers Comp |
$76.50
|
| Rate for Payer: Parkland Medicaid |
$110.16
|
| Rate for Payer: Scott and White EPO/PPO |
$76.50
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$110.16
|
| Rate for Payer: Superior Health Plan EPO |
$125.01
|
| Rate for Payer: Superior Health Plan Medicare |
$125.01
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Universal American Medicare |
$125.01
|
| Rate for Payer: Wellcare Medicare |
$125.01
|
| Rate for Payer: Wellmed Medicare |
$125.01
|
|
|
AlloDerm SELECT%E2%84%A2 Regenerative Tissue Matrix Perf. Re
|
Facility
|
OP
|
$66,692.60
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
146352
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.01 |
| Max. Negotiated Rate |
$48,018.67 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$6,002.33
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$20,007.78
|
| Rate for Payer: BCBS of TX Blue Essentials |
$24,009.34
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$26,677.04
|
| Rate for Payer: Cash Price |
$45,350.97
|
| Rate for Payer: Cash Price |
$45,350.97
|
| Rate for Payer: Cash Price |
$45,350.97
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$48,018.67
|
| Rate for Payer: Cigna Medicare |
$125.01
|
| Rate for Payer: Employer Direct Commercial |
$125.01
|
| Rate for Payer: Humana Medicare/TRICARE |
$125.01
|
| Rate for Payer: Molina CHIP/Medicaid |
$48,018.67
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$33,346.30
|
| Rate for Payer: Multiplan Commercial |
$33,346.30
|
| Rate for Payer: Multiplan Workers Comp |
$33,346.30
|
| Rate for Payer: Parkland Medicaid |
$48,018.67
|
| Rate for Payer: Scott and White EPO/PPO |
$33,346.30
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$48,018.67
|
| Rate for Payer: Superior Health Plan EPO |
$125.01
|
| Rate for Payer: Superior Health Plan Medicare |
$125.01
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Universal American Medicare |
$125.01
|
| Rate for Payer: Wellcare Medicare |
$125.01
|
| Rate for Payer: Wellmed Medicare |
$125.01
|
|
|
AlloDerm SELECT%E2%84%A2 Regenerative Tissue Matrix Perf. Re
|
Facility
|
OP
|
$66,692.60
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
993848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.01 |
| Max. Negotiated Rate |
$48,018.67 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$6,002.33
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$20,007.78
|
| Rate for Payer: BCBS of TX Blue Essentials |
$24,009.34
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$26,677.04
|
| Rate for Payer: Cash Price |
$45,350.97
|
| Rate for Payer: Cash Price |
$45,350.97
|
| Rate for Payer: Cash Price |
$45,350.97
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$48,018.67
|
| Rate for Payer: Cigna Medicare |
$125.01
|
| Rate for Payer: Employer Direct Commercial |
$125.01
|
| Rate for Payer: Humana Medicare/TRICARE |
$125.01
|
| Rate for Payer: Molina CHIP/Medicaid |
$48,018.67
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$33,346.30
|
| Rate for Payer: Multiplan Commercial |
$33,346.30
|
| Rate for Payer: Multiplan Workers Comp |
$33,346.30
|
| Rate for Payer: Parkland Medicaid |
$48,018.67
|
| Rate for Payer: Scott and White EPO/PPO |
$33,346.30
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$48,018.67
|
| Rate for Payer: Superior Health Plan EPO |
$125.01
|
| Rate for Payer: Superior Health Plan Medicare |
$125.01
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Universal American Medicare |
$125.01
|
| Rate for Payer: Wellcare Medicare |
$125.01
|
| Rate for Payer: Wellmed Medicare |
$125.01
|
|
|
AlloDerm SELECT%E2%84%A2 Regenerative Tissue Matrix Perf. Re
|
Facility
|
IP
|
$66,692.60
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
993848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,673.15 |
| Max. Negotiated Rate |
$33,346.30 |
| Rate for Payer: Cash Price |
$45,350.97
|
| Rate for Payer: Cigna Commercial |
$16,673.15
|
| Rate for Payer: Multiplan Auto |
$33,346.30
|
| Rate for Payer: Multiplan Commercial |
$33,346.30
|
| Rate for Payer: Multiplan Workers Comp |
$33,346.30
|
| Rate for Payer: Scott and White EPO/PPO |
$33,346.30
|
|
|
AlloDerm SELECT%E2%84%A2 Regenerative Tissue Matrix Perf. Re
|
Facility
|
IP
|
$66,692.60
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
146352
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,673.15 |
| Max. Negotiated Rate |
$33,346.30 |
| Rate for Payer: Cash Price |
$45,350.97
|
| Rate for Payer: Cigna Commercial |
$16,673.15
|
| Rate for Payer: Multiplan Auto |
$33,346.30
|
| Rate for Payer: Multiplan Commercial |
$33,346.30
|
| Rate for Payer: Multiplan Workers Comp |
$33,346.30
|
| Rate for Payer: Scott and White EPO/PPO |
$33,346.30
|
|
|
ALLODERM SELECT PER SQ CM
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
8478525
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$15.12
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$50.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$60.48
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$67.20
|
| Rate for Payer: Cash Price |
$114.24
|
| Rate for Payer: Cash Price |
$114.24
|
| Rate for Payer: Cash Price |
$114.24
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$120.96
|
| Rate for Payer: Cigna Medicare |
$125.01
|
| Rate for Payer: Employer Direct Commercial |
$125.01
|
| Rate for Payer: Humana Medicare/TRICARE |
$125.01
|
| Rate for Payer: Molina CHIP/Medicaid |
$120.96
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$84.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Multiplan Workers Comp |
$84.00
|
| Rate for Payer: Parkland Medicaid |
$120.96
|
| Rate for Payer: Scott and White EPO/PPO |
$84.00
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$120.96
|
| Rate for Payer: Superior Health Plan EPO |
$125.01
|
| Rate for Payer: Superior Health Plan Medicare |
$125.01
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Universal American Medicare |
$125.01
|
| Rate for Payer: Wellcare Medicare |
$125.01
|
| Rate for Payer: Wellmed Medicare |
$125.01
|
|
|
ALLODERM SELECT PER SQ CM
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
8478525
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Cash Price |
$114.24
|
| Rate for Payer: Cigna Commercial |
$42.00
|
| Rate for Payer: Multiplan Auto |
$84.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Multiplan Workers Comp |
$84.00
|
| Rate for Payer: Scott and White EPO/PPO |
$84.00
|
|
|
alloderm select rtm rectangle per sq cm
|
Facility
|
OP
|
$343.00
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
8698569
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$30.87 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$30.87
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Amerigroup Medicare |
$125.01
|
| Rate for Payer: BCBS of TX Blue Advantage |
$102.90
|
| Rate for Payer: BCBS of TX Blue Essentials |
$123.48
|
| Rate for Payer: BCBS of TX Medicare |
$125.01
|
| Rate for Payer: BCBS of TX PPO |
$137.20
|
| Rate for Payer: Cash Price |
$233.24
|
| Rate for Payer: Cash Price |
$233.24
|
| Rate for Payer: Cash Price |
$233.24
|
| Rate for Payer: Cigna Commercial |
$264.25
|
| Rate for Payer: Cigna Medicaid |
$246.96
|
| Rate for Payer: Cigna Medicare |
$125.01
|
| Rate for Payer: Employer Direct Commercial |
$125.01
|
| Rate for Payer: Humana Medicare/TRICARE |
$125.01
|
| Rate for Payer: Molina CHIP/Medicaid |
$246.96
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Molina Medicare |
$125.01
|
| Rate for Payer: Multiplan Auto |
$171.50
|
| Rate for Payer: Multiplan Commercial |
$171.50
|
| Rate for Payer: Multiplan Workers Comp |
$171.50
|
| Rate for Payer: Parkland Medicaid |
$246.96
|
| Rate for Payer: Scott and White EPO/PPO |
$171.50
|
| Rate for Payer: Scott and White Medicare |
$125.01
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$246.96
|
| Rate for Payer: Superior Health Plan EPO |
$125.01
|
| Rate for Payer: Superior Health Plan Medicare |
$125.01
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$125.01
|
| Rate for Payer: Universal American Medicare |
$125.01
|
| Rate for Payer: Wellcare Medicare |
$125.01
|
| Rate for Payer: Wellmed Medicare |
$125.01
|
|
|
alloderm select rtm rectangle per sq cm
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
8698569
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$85.75 |
| Max. Negotiated Rate |
$171.50 |
| Rate for Payer: Cash Price |
$233.24
|
| Rate for Payer: Cigna Commercial |
$85.75
|
| Rate for Payer: Multiplan Auto |
$171.50
|
| Rate for Payer: Multiplan Commercial |
$171.50
|
| Rate for Payer: Multiplan Workers Comp |
$171.50
|
| Rate for Payer: Scott and White EPO/PPO |
$171.50
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$98,338.08
|
|
|
Service Code
|
APR-DRG 0073
|
| Min. Negotiated Rate |
$92,716.58 |
| Max. Negotiated Rate |
$98,338.08 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$92,716.58
|
| Rate for Payer: Cigna Medicaid |
$92,716.58
|
| Rate for Payer: Molina CHIP/Medicaid |
$92,716.58
|
| Rate for Payer: Parkland Medicaid |
$92,716.58
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$98,338.08
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$212,667.00
|
|
|
Service Code
|
MSDRG 014
|
| Min. Negotiated Rate |
$92,839.58 |
| Max. Negotiated Rate |
$212,667.00 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$92,839.58
|
| Rate for Payer: Amerigroup Medicare |
$92,839.58
|
| Rate for Payer: BCBS of TX Blue Advantage |
$102,772.58
|
| Rate for Payer: BCBS of TX Blue Essentials |
$123,315.15
|
| Rate for Payer: BCBS of TX Medicare |
$92,839.58
|
| Rate for Payer: BCBS of TX PPO |
$137,022.14
|
| Rate for Payer: Cigna Commercial |
$154,790.55
|
| Rate for Payer: Cigna Medicare |
$92,839.58
|
| Rate for Payer: Employer Direct Commercial |
$92,839.58
|
| Rate for Payer: Humana Medicare/TRICARE |
$92,839.58
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$92,839.58
|
| Rate for Payer: Molina Medicare |
$92,839.58
|
| Rate for Payer: Multiplan Auto |
$212,667.00
|
| Rate for Payer: Multiplan Commercial |
$212,667.00
|
| Rate for Payer: Multiplan Workers Comp |
$212,667.00
|
| Rate for Payer: Scott and White EPO/PPO |
$97,938.75
|
| Rate for Payer: Scott and White Medicare |
$92,839.58
|
| Rate for Payer: Superior Health Plan EPO |
$92,839.58
|
| Rate for Payer: Superior Health Plan Medicare |
$92,839.58
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$92,839.58
|
| Rate for Payer: Universal American Medicare |
$92,839.58
|
| Rate for Payer: Wellcare Medicare |
$92,839.58
|
| Rate for Payer: Wellmed Medicare |
$92,839.58
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$278,687.22
|
|
|
Service Code
|
APR-DRG 0074
|
| Min. Negotiated Rate |
$262,756.08 |
| Max. Negotiated Rate |
$278,687.22 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$262,756.08
|
| Rate for Payer: Cigna Medicaid |
$262,756.08
|
| Rate for Payer: Molina CHIP/Medicaid |
$262,756.08
|
| Rate for Payer: Parkland Medicaid |
$262,756.08
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$278,687.22
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$66,072.20
|
|
|
Service Code
|
APR-DRG 0072
|
| Min. Negotiated Rate |
$62,295.18 |
| Max. Negotiated Rate |
$66,072.20 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$62,295.18
|
| Rate for Payer: Cigna Medicaid |
$62,295.18
|
| Rate for Payer: Molina CHIP/Medicaid |
$62,295.18
|
| Rate for Payer: Parkland Medicaid |
$62,295.18
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$66,072.20
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$43,385.41
|
|
|
Service Code
|
APR-DRG 0071
|
| Min. Negotiated Rate |
$40,905.28 |
| Max. Negotiated Rate |
$43,385.41 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$40,905.28
|
| Rate for Payer: Cigna Medicaid |
$40,905.28
|
| Rate for Payer: Molina CHIP/Medicaid |
$40,905.28
|
| Rate for Payer: Parkland Medicaid |
$40,905.28
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$43,385.41
|
|
|
ALLOGRAFT ACHILLES TENDON W/10MM BB
|
Facility
|
OP
|
$16,277.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
145098
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,464.93 |
| Max. Negotiated Rate |
$11,719.44 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,464.93
|
| Rate for Payer: BCBS of TX Blue Advantage |
$4,883.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$5,859.72
|
| Rate for Payer: BCBS of TX PPO |
$6,510.80
|
| Rate for Payer: Cash Price |
$11,068.36
|
| Rate for Payer: Cigna Medicaid |
$11,719.44
|
| Rate for Payer: Molina CHIP/Medicaid |
$11,719.44
|
| Rate for Payer: Multiplan Auto |
$8,138.50
|
| Rate for Payer: Multiplan Commercial |
$8,138.50
|
| Rate for Payer: Multiplan Workers Comp |
$8,138.50
|
| Rate for Payer: Parkland Medicaid |
$11,719.44
|
| Rate for Payer: Scott and White EPO/PPO |
$8,138.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$11,719.44
|
| Rate for Payer: Superior Health Plan EPO |
$2,213.67
|
|
|
ALLOGRAFT ACHILLES TENDON W/10MM BB
|
Facility
|
IP
|
$16,277.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
145098
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,069.25 |
| Max. Negotiated Rate |
$8,138.50 |
| Rate for Payer: Cash Price |
$11,068.36
|
| Rate for Payer: Cigna Commercial |
$4,069.25
|
| Rate for Payer: Multiplan Auto |
$8,138.50
|
| Rate for Payer: Multiplan Commercial |
$8,138.50
|
| Rate for Payer: Multiplan Workers Comp |
$8,138.50
|
| Rate for Payer: Scott and White EPO/PPO |
$8,138.50
|
|
|
ALLOGRAFT ALLOPATCH
|
Facility
|
IP
|
$452.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
8502476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$113.00 |
| Max. Negotiated Rate |
$226.00 |
| Rate for Payer: Cash Price |
$307.36
|
| Rate for Payer: Cigna Commercial |
$113.00
|
| Rate for Payer: Multiplan Auto |
$226.00
|
| Rate for Payer: Multiplan Commercial |
$226.00
|
| Rate for Payer: Multiplan Workers Comp |
$226.00
|
| Rate for Payer: Scott and White EPO/PPO |
$226.00
|
|
|
ALLOGRAFT ALLOPATCH
|
Facility
|
OP
|
$452.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
8502476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$40.68 |
| Max. Negotiated Rate |
$325.44 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$40.68
|
| Rate for Payer: BCBS of TX Blue Advantage |
$135.60
|
| Rate for Payer: BCBS of TX Blue Essentials |
$162.72
|
| Rate for Payer: BCBS of TX PPO |
$180.80
|
| Rate for Payer: Cash Price |
$307.36
|
| Rate for Payer: Cigna Medicaid |
$325.44
|
| Rate for Payer: Molina CHIP/Medicaid |
$325.44
|
| Rate for Payer: Multiplan Auto |
$226.00
|
| Rate for Payer: Multiplan Commercial |
$226.00
|
| Rate for Payer: Multiplan Workers Comp |
$226.00
|
| Rate for Payer: Parkland Medicaid |
$325.44
|
| Rate for Payer: Scott and White EPO/PPO |
$226.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$325.44
|
| Rate for Payer: Superior Health Plan EPO |
$61.47
|
|
|
ALLOGRAFT AMNIOFIX 2X12 APS-5212
|
Facility
|
IP
|
$5,991.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
145327
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.75 |
| Max. Negotiated Rate |
$2,995.50 |
| Rate for Payer: Cash Price |
$4,073.88
|
| Rate for Payer: Cigna Commercial |
$1,497.75
|
| Rate for Payer: Multiplan Auto |
$2,995.50
|
| Rate for Payer: Multiplan Commercial |
$2,995.50
|
| Rate for Payer: Multiplan Workers Comp |
$2,995.50
|
| Rate for Payer: Scott and White EPO/PPO |
$2,995.50
|
|
