|
nitroglycerin 2% TD Oint 1 g
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77728168
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.44
|
|
|
NITRO IN D5W 100 MG 250 SOL
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
77728060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$11.52
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.09
|
| Rate for Payer: BCBS of TX Blue Essentials |
$2.51
|
| Rate for Payer: BCBS of TX PPO |
$2.78
|
| 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
|
|
|
NITRO IN D5W 100 MG 250 SOL
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
77728060
|
|
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
|
|
|
NIV Mask, nonvent, sfty vlv, Nivairo
|
Facility
|
IP
|
$22.75
|
|
| Hospital Charge Code |
993577
|
|
Hospital Revenue Code
|
270
|
| Rate for Payer: Cash Price |
$15.47
|
|
|
NIV Mask, nonvent, sfty vlv, Nivairo
|
Facility
|
OP
|
$22.75
|
|
| Hospital Charge Code |
993577
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$16.38 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.05
|
| Rate for Payer: BCBS of TX Blue Advantage |
$6.83
|
| Rate for Payer: BCBS of TX Blue Essentials |
$8.19
|
| Rate for Payer: BCBS of TX PPO |
$9.10
|
| Rate for Payer: Cash Price |
$15.47
|
| Rate for Payer: Cigna Medicaid |
$16.38
|
| Rate for Payer: Molina CHIP/Medicaid |
$16.38
|
| Rate for Payer: Multiplan Auto |
$14.79
|
| Rate for Payer: Multiplan Commercial |
$14.79
|
| Rate for Payer: Multiplan Workers Comp |
$14.79
|
| Rate for Payer: Parkland Medicaid |
$16.38
|
| Rate for Payer: Scott and White EPO/PPO |
$11.38
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$16.38
|
| Rate for Payer: Superior Health Plan EPO |
$3.09
|
|
|
NM Bone Imaging Limited Delay 1
|
Facility
|
IP
|
$1,134.00
|
|
|
Service Code
|
HCPCS 78300
|
| Hospital Charge Code |
3402153
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$771.12
|
|
|
NM Bone Imaging Limited Delay 1
|
Facility
|
OP
|
$1,134.00
|
|
|
Service Code
|
HCPCS 78300
|
| Hospital Charge Code |
3402153
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$203.15 |
| Max. Negotiated Rate |
$848.90 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$203.15
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Amerigroup Medicare |
$401.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$341.91
|
| Rate for Payer: BCBS of TX Blue Essentials |
$410.30
|
| Rate for Payer: BCBS of TX Medicare |
$401.59
|
| Rate for Payer: BCBS of TX PPO |
$457.96
|
| Rate for Payer: Cash Price |
$771.12
|
| Rate for Payer: Cash Price |
$771.12
|
| Rate for Payer: Cash Price |
$771.12
|
| Rate for Payer: Cigna Commercial |
$848.90
|
| Rate for Payer: Cigna Medicaid |
$816.48
|
| Rate for Payer: Cigna Medicare |
$401.59
|
| Rate for Payer: Employer Direct Commercial |
$401.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$401.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$816.48
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Molina Medicare |
$401.59
|
| Rate for Payer: Multiplan Auto |
$737.10
|
| Rate for Payer: Multiplan Commercial |
$737.10
|
| Rate for Payer: Multiplan Workers Comp |
$737.10
|
| Rate for Payer: Parkland Medicaid |
$816.48
|
| Rate for Payer: Scott and White EPO/PPO |
$255.32
|
| Rate for Payer: Scott and White Medicare |
$401.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$816.48
|
| Rate for Payer: Superior Health Plan EPO |
$401.59
|
| Rate for Payer: Superior Health Plan Medicare |
$401.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Universal American Medicare |
$401.59
|
| Rate for Payer: Wellcare Medicare |
$401.59
|
| Rate for Payer: Wellmed Medicare |
$401.59
|
|
|
NM Bone Imaging Whole Body Delay 1
|
Facility
|
IP
|
$2,212.00
|
|
|
Service Code
|
HCPCS 78306
|
| Hospital Charge Code |
3400025
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$1,504.16
|
|
|
NM Bone Imaging Whole Body Delay 1
|
Facility
|
OP
|
$2,212.00
|
|
|
Service Code
|
HCPCS 78306
|
| Hospital Charge Code |
3400025
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$264.64 |
| Max. Negotiated Rate |
$1,592.64 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$264.64
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Amerigroup Medicare |
$401.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$446.57
|
| Rate for Payer: BCBS of TX Blue Essentials |
$535.89
|
| Rate for Payer: BCBS of TX Medicare |
$401.59
|
| Rate for Payer: BCBS of TX PPO |
$598.14
|
| Rate for Payer: Cash Price |
$1,504.16
|
| Rate for Payer: Cash Price |
$1,504.16
|
| Rate for Payer: Cash Price |
$1,504.16
|
| Rate for Payer: Cigna Commercial |
$848.90
|
| Rate for Payer: Cigna Medicaid |
$1,592.64
|
| Rate for Payer: Cigna Medicare |
$401.59
|
| Rate for Payer: Employer Direct Commercial |
$401.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$401.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,592.64
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Molina Medicare |
$401.59
|
| Rate for Payer: Multiplan Auto |
$1,437.80
|
| Rate for Payer: Multiplan Commercial |
$1,437.80
|
| Rate for Payer: Multiplan Workers Comp |
$1,437.80
|
| Rate for Payer: Parkland Medicaid |
$1,592.64
|
| Rate for Payer: Scott and White EPO/PPO |
$332.75
|
| Rate for Payer: Scott and White Medicare |
$401.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,592.64
|
| Rate for Payer: Superior Health Plan EPO |
$401.59
|
| Rate for Payer: Superior Health Plan Medicare |
$401.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Universal American Medicare |
$401.59
|
| Rate for Payer: Wellcare Medicare |
$401.59
|
| Rate for Payer: Wellmed Medicare |
$401.59
|
|
|
NM Bone Marrow Imaging Limited
|
Facility
|
OP
|
$1,764.00
|
|
|
Service Code
|
HCPCS 78102
|
| Hospital Charge Code |
5208102
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$159.38 |
| Max. Negotiated Rate |
$1,270.08 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$159.38
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Amerigroup Medicare |
$401.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$246.18
|
| Rate for Payer: BCBS of TX Blue Essentials |
$295.42
|
| Rate for Payer: BCBS of TX Medicare |
$401.59
|
| Rate for Payer: BCBS of TX PPO |
$329.73
|
| Rate for Payer: Cash Price |
$1,199.52
|
| Rate for Payer: Cash Price |
$1,199.52
|
| Rate for Payer: Cash Price |
$1,199.52
|
| Rate for Payer: Cigna Commercial |
$848.90
|
| Rate for Payer: Cigna Medicaid |
$1,270.08
|
| Rate for Payer: Cigna Medicare |
$401.59
|
| Rate for Payer: Employer Direct Commercial |
$401.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$401.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,270.08
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Molina Medicare |
$401.59
|
| Rate for Payer: Multiplan Auto |
$1,146.60
|
| Rate for Payer: Multiplan Commercial |
$1,146.60
|
| Rate for Payer: Multiplan Workers Comp |
$1,146.60
|
| Rate for Payer: Parkland Medicaid |
$1,270.08
|
| Rate for Payer: Scott and White EPO/PPO |
$198.03
|
| Rate for Payer: Scott and White Medicare |
$401.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,270.08
|
| Rate for Payer: Superior Health Plan EPO |
$401.59
|
| Rate for Payer: Superior Health Plan Medicare |
$401.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Universal American Medicare |
$401.59
|
| Rate for Payer: Wellcare Medicare |
$401.59
|
| Rate for Payer: Wellmed Medicare |
$401.59
|
|
|
NM Bone Marrow Imaging Limited
|
Facility
|
IP
|
$1,764.00
|
|
|
Service Code
|
HCPCS 78102
|
| Hospital Charge Code |
5208102
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$1,199.52
|
|
|
NM Bone Marrow Imaging Whole Body
|
Facility
|
IP
|
$1,978.00
|
|
|
Service Code
|
HCPCS 78104
|
| Hospital Charge Code |
5208104
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$1,345.04
|
|
|
NM Bone Marrow Imaging Whole Body
|
Facility
|
OP
|
$1,978.00
|
|
|
Service Code
|
HCPCS 78104
|
| Hospital Charge Code |
5208104
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$225.20 |
| Max. Negotiated Rate |
$1,424.16 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$225.20
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Amerigroup Medicare |
$401.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$359.77
|
| Rate for Payer: BCBS of TX Blue Essentials |
$431.72
|
| Rate for Payer: BCBS of TX Medicare |
$401.59
|
| Rate for Payer: BCBS of TX PPO |
$481.87
|
| Rate for Payer: Cash Price |
$1,345.04
|
| Rate for Payer: Cash Price |
$1,345.04
|
| Rate for Payer: Cash Price |
$1,345.04
|
| Rate for Payer: Cigna Commercial |
$848.90
|
| Rate for Payer: Cigna Medicaid |
$1,424.16
|
| Rate for Payer: Cigna Medicare |
$401.59
|
| Rate for Payer: Employer Direct Commercial |
$401.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$401.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,424.16
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Molina Medicare |
$401.59
|
| Rate for Payer: Multiplan Auto |
$1,285.70
|
| Rate for Payer: Multiplan Commercial |
$1,285.70
|
| Rate for Payer: Multiplan Workers Comp |
$1,285.70
|
| Rate for Payer: Parkland Medicaid |
$1,424.16
|
| Rate for Payer: Scott and White EPO/PPO |
$283.69
|
| Rate for Payer: Scott and White Medicare |
$401.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,424.16
|
| Rate for Payer: Superior Health Plan EPO |
$401.59
|
| Rate for Payer: Superior Health Plan Medicare |
$401.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Universal American Medicare |
$401.59
|
| Rate for Payer: Wellcare Medicare |
$401.59
|
| Rate for Payer: Wellmed Medicare |
$401.59
|
|
|
NM Bone Three Phase Study Injection/Scan
|
Facility
|
OP
|
$2,852.00
|
|
|
Service Code
|
HCPCS 78315
|
| Hospital Charge Code |
3400389
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$310.74 |
| Max. Negotiated Rate |
$2,053.44 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$310.74
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Amerigroup Medicare |
$401.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$509.01
|
| Rate for Payer: BCBS of TX Blue Essentials |
$610.81
|
| Rate for Payer: BCBS of TX Medicare |
$401.59
|
| Rate for Payer: BCBS of TX PPO |
$681.76
|
| Rate for Payer: Cash Price |
$1,939.36
|
| Rate for Payer: Cash Price |
$1,939.36
|
| Rate for Payer: Cash Price |
$1,939.36
|
| Rate for Payer: Cigna Commercial |
$848.90
|
| Rate for Payer: Cigna Medicaid |
$2,053.44
|
| Rate for Payer: Cigna Medicare |
$401.59
|
| Rate for Payer: Employer Direct Commercial |
$401.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$401.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,053.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Molina Medicare |
$401.59
|
| Rate for Payer: Multiplan Auto |
$1,853.80
|
| Rate for Payer: Multiplan Commercial |
$1,853.80
|
| Rate for Payer: Multiplan Workers Comp |
$1,853.80
|
| Rate for Payer: Parkland Medicaid |
$2,053.44
|
| Rate for Payer: Scott and White EPO/PPO |
$391.14
|
| Rate for Payer: Scott and White Medicare |
$401.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,053.44
|
| Rate for Payer: Superior Health Plan EPO |
$401.59
|
| Rate for Payer: Superior Health Plan Medicare |
$401.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Universal American Medicare |
$401.59
|
| Rate for Payer: Wellcare Medicare |
$401.59
|
| Rate for Payer: Wellmed Medicare |
$401.59
|
|
|
NM Bone Three Phase Study Injection/Scan
|
Facility
|
IP
|
$2,852.00
|
|
|
Service Code
|
HCPCS 78315
|
| Hospital Charge Code |
3400389
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$1,939.36
|
|
|
NM Brain Imaging <4 Delay 1
|
Facility
|
OP
|
$1,118.00
|
|
|
Service Code
|
HCPCS 78600
|
| Hospital Charge Code |
5208600
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$166.74 |
| Max. Negotiated Rate |
$848.90 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$166.74
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Amerigroup Medicare |
$401.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$278.88
|
| Rate for Payer: BCBS of TX Blue Essentials |
$334.66
|
| Rate for Payer: BCBS of TX Medicare |
$401.59
|
| Rate for Payer: BCBS of TX PPO |
$373.53
|
| Rate for Payer: Cash Price |
$760.24
|
| Rate for Payer: Cash Price |
$760.24
|
| Rate for Payer: Cash Price |
$760.24
|
| Rate for Payer: Cigna Commercial |
$848.90
|
| Rate for Payer: Cigna Medicaid |
$804.96
|
| Rate for Payer: Cigna Medicare |
$401.59
|
| Rate for Payer: Employer Direct Commercial |
$401.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$401.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$804.96
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Molina Medicare |
$401.59
|
| Rate for Payer: Multiplan Auto |
$726.70
|
| Rate for Payer: Multiplan Commercial |
$726.70
|
| Rate for Payer: Multiplan Workers Comp |
$726.70
|
| Rate for Payer: Parkland Medicaid |
$804.96
|
| Rate for Payer: Scott and White EPO/PPO |
$207.90
|
| Rate for Payer: Scott and White Medicare |
$401.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$804.96
|
| Rate for Payer: Superior Health Plan EPO |
$401.59
|
| Rate for Payer: Superior Health Plan Medicare |
$401.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Universal American Medicare |
$401.59
|
| Rate for Payer: Wellcare Medicare |
$401.59
|
| Rate for Payer: Wellmed Medicare |
$401.59
|
|
|
NM Brain Imaging <4 Delay 1
|
Facility
|
IP
|
$1,118.00
|
|
|
Service Code
|
HCPCS 78600
|
| Hospital Charge Code |
5208600
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$760.24
|
|
|
NM Cardiac MUGA
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS 78472
|
| Hospital Charge Code |
3400033
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$206.83 |
| Max. Negotiated Rate |
$1,260.72 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$206.83
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Amerigroup Medicare |
$401.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$310.40
|
| Rate for Payer: BCBS of TX Blue Essentials |
$372.48
|
| Rate for Payer: BCBS of TX Medicare |
$401.59
|
| Rate for Payer: BCBS of TX PPO |
$415.75
|
| Rate for Payer: Cash Price |
$1,190.68
|
| Rate for Payer: Cash Price |
$1,190.68
|
| Rate for Payer: Cash Price |
$1,190.68
|
| Rate for Payer: Cigna Commercial |
$848.90
|
| Rate for Payer: Cigna Medicaid |
$1,260.72
|
| Rate for Payer: Cigna Medicare |
$401.59
|
| Rate for Payer: Employer Direct Commercial |
$401.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$401.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,260.72
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Molina Medicare |
$401.59
|
| Rate for Payer: Multiplan Auto |
$1,138.15
|
| Rate for Payer: Multiplan Commercial |
$1,138.15
|
| Rate for Payer: Multiplan Workers Comp |
$1,138.15
|
| Rate for Payer: Parkland Medicaid |
$1,260.72
|
| Rate for Payer: Scott and White EPO/PPO |
$259.81
|
| Rate for Payer: Scott and White Medicare |
$401.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,260.72
|
| Rate for Payer: Superior Health Plan EPO |
$401.59
|
| Rate for Payer: Superior Health Plan Medicare |
$401.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Universal American Medicare |
$401.59
|
| Rate for Payer: Wellcare Medicare |
$401.59
|
| Rate for Payer: Wellmed Medicare |
$401.59
|
|
|
NM Cardiac MUGA
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS 78472
|
| Hospital Charge Code |
3400033
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$1,190.68
|
|
|
NM Cisternography Delay 1
|
Facility
|
IP
|
$1,254.00
|
|
|
Service Code
|
HCPCS 78630
|
| Hospital Charge Code |
5218630
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$852.72
|
|
|
NM Cisternography Delay 1
|
Facility
|
OP
|
$1,254.00
|
|
|
Service Code
|
HCPCS 78630
|
| Hospital Charge Code |
5218630
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$302.05 |
| Max. Negotiated Rate |
$1,152.98 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$302.05
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$545.44
|
| Rate for Payer: Amerigroup Medicare |
$545.44
|
| Rate for Payer: BCBS of TX Blue Advantage |
$522.09
|
| Rate for Payer: BCBS of TX Blue Essentials |
$626.51
|
| Rate for Payer: BCBS of TX Medicare |
$545.44
|
| Rate for Payer: BCBS of TX PPO |
$699.29
|
| Rate for Payer: Cash Price |
$852.72
|
| Rate for Payer: Cash Price |
$852.72
|
| Rate for Payer: Cash Price |
$852.72
|
| Rate for Payer: Cigna Commercial |
$1,152.98
|
| Rate for Payer: Cigna Medicaid |
$902.88
|
| Rate for Payer: Cigna Medicare |
$545.44
|
| Rate for Payer: Employer Direct Commercial |
$545.44
|
| Rate for Payer: Humana Medicare/TRICARE |
$545.44
|
| Rate for Payer: Molina CHIP/Medicaid |
$902.88
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$545.44
|
| Rate for Payer: Molina Medicare |
$545.44
|
| Rate for Payer: Multiplan Auto |
$815.10
|
| Rate for Payer: Multiplan Commercial |
$815.10
|
| Rate for Payer: Multiplan Workers Comp |
$815.10
|
| Rate for Payer: Parkland Medicaid |
$902.88
|
| Rate for Payer: Scott and White EPO/PPO |
$380.06
|
| Rate for Payer: Scott and White Medicare |
$545.44
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$902.88
|
| Rate for Payer: Superior Health Plan EPO |
$545.44
|
| Rate for Payer: Superior Health Plan Medicare |
$545.44
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$545.44
|
| Rate for Payer: Universal American Medicare |
$545.44
|
| Rate for Payer: Wellcare Medicare |
$545.44
|
| Rate for Payer: Wellmed Medicare |
$545.44
|
|
|
NM Gastric Emptying Study
|
Facility
|
IP
|
$2,237.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
3400579
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$1,521.16
|
|
|
NM Gastric Emptying Study
|
Facility
|
OP
|
$2,237.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
3400579
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$296.71 |
| Max. Negotiated Rate |
$1,610.64 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$296.71
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Amerigroup Medicare |
$401.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$508.41
|
| Rate for Payer: BCBS of TX Blue Essentials |
$610.10
|
| Rate for Payer: BCBS of TX Medicare |
$401.59
|
| Rate for Payer: BCBS of TX PPO |
$680.97
|
| Rate for Payer: Cash Price |
$1,521.16
|
| Rate for Payer: Cash Price |
$1,521.16
|
| Rate for Payer: Cash Price |
$1,521.16
|
| Rate for Payer: Cigna Commercial |
$848.90
|
| Rate for Payer: Cigna Medicaid |
$1,610.64
|
| Rate for Payer: Cigna Medicare |
$401.59
|
| Rate for Payer: Employer Direct Commercial |
$401.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$401.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$1,610.64
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Molina Medicare |
$401.59
|
| Rate for Payer: Multiplan Auto |
$1,454.05
|
| Rate for Payer: Multiplan Commercial |
$1,454.05
|
| Rate for Payer: Multiplan Workers Comp |
$1,454.05
|
| Rate for Payer: Parkland Medicaid |
$1,610.64
|
| Rate for Payer: Scott and White EPO/PPO |
$373.02
|
| Rate for Payer: Scott and White Medicare |
$401.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$1,610.64
|
| Rate for Payer: Superior Health Plan EPO |
$401.59
|
| Rate for Payer: Superior Health Plan Medicare |
$401.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Universal American Medicare |
$401.59
|
| Rate for Payer: Wellcare Medicare |
$401.59
|
| Rate for Payer: Wellmed Medicare |
$401.59
|
|
|
NM GI Blood Loss 24 hour delay
|
Facility
|
OP
|
$1,075.00
|
|
|
Service Code
|
HCPCS 78278
|
| Hospital Charge Code |
3400066
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$313.08 |
| Max. Negotiated Rate |
$848.90 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$313.08
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Amerigroup Medicare |
$401.59
|
| Rate for Payer: BCBS of TX Blue Advantage |
$515.56
|
| Rate for Payer: BCBS of TX Blue Essentials |
$618.67
|
| Rate for Payer: BCBS of TX Medicare |
$401.59
|
| Rate for Payer: BCBS of TX PPO |
$690.54
|
| Rate for Payer: Cash Price |
$731.00
|
| Rate for Payer: Cash Price |
$731.00
|
| Rate for Payer: Cash Price |
$731.00
|
| Rate for Payer: Cigna Commercial |
$848.90
|
| Rate for Payer: Cigna Medicaid |
$774.00
|
| Rate for Payer: Cigna Medicare |
$401.59
|
| Rate for Payer: Employer Direct Commercial |
$401.59
|
| Rate for Payer: Humana Medicare/TRICARE |
$401.59
|
| Rate for Payer: Molina CHIP/Medicaid |
$774.00
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Molina Medicare |
$401.59
|
| Rate for Payer: Multiplan Auto |
$698.75
|
| Rate for Payer: Multiplan Commercial |
$698.75
|
| Rate for Payer: Multiplan Workers Comp |
$698.75
|
| Rate for Payer: Parkland Medicaid |
$774.00
|
| Rate for Payer: Scott and White EPO/PPO |
$393.61
|
| Rate for Payer: Scott and White Medicare |
$401.59
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$774.00
|
| Rate for Payer: Superior Health Plan EPO |
$401.59
|
| Rate for Payer: Superior Health Plan Medicare |
$401.59
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$401.59
|
| Rate for Payer: Universal American Medicare |
$401.59
|
| Rate for Payer: Wellcare Medicare |
$401.59
|
| Rate for Payer: Wellmed Medicare |
$401.59
|
|
|
NM GI Blood Loss 24 hour delay
|
Facility
|
IP
|
$1,075.00
|
|
|
Service Code
|
HCPCS 78278
|
| Hospital Charge Code |
3400066
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$731.00
|
|
