|
Revision or removal of implanted spinal neurostimulator pulse generator or receiver
|
Facility
|
IP
|
$25,090.91
|
|
|
Service Code
|
HCPCS 63688
|
| Hospital Charge Code |
9900777
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$17,061.82
|
|
|
Revision or removal of implanted spinal neurostimulator pulse generator or receiver
|
Facility
|
OP
|
$25,090.91
|
|
|
Service Code
|
HCPCS 63688
|
| Hospital Charge Code |
9900777
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,072.02 |
| Max. Negotiated Rate |
$18,065.46 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2,072.02
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Amerigroup Medicare |
$3,512.04
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,257.99
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,297.00
|
| Rate for Payer: BCBS of TX Medicare |
$3,512.04
|
| Rate for Payer: BCBS of TX PPO |
$7,934.22
|
| Rate for Payer: Cash Price |
$17,061.82
|
| Rate for Payer: Cash Price |
$17,061.82
|
| Rate for Payer: Cash Price |
$17,061.82
|
| Rate for Payer: Cigna Commercial |
$7,423.81
|
| Rate for Payer: Cigna Medicaid |
$18,065.46
|
| Rate for Payer: Cigna Medicare |
$3,512.04
|
| Rate for Payer: Employer Direct Commercial |
$3,512.04
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,512.04
|
| Rate for Payer: Molina CHIP/Medicaid |
$18,065.46
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Molina Medicare |
$3,512.04
|
| 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 |
$18,065.46
|
| Rate for Payer: Scott and White EPO/PPO |
$6,497.27
|
| Rate for Payer: Scott and White Medicare |
$3,512.04
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$18,065.46
|
| Rate for Payer: Superior Health Plan EPO |
$3,512.04
|
| Rate for Payer: Superior Health Plan Medicare |
$3,512.04
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Universal American Medicare |
$3,512.04
|
| Rate for Payer: Wellcare Medicare |
$3,512.04
|
| Rate for Payer: Wellmed Medicare |
$3,512.04
|
|
|
Revision or removal of peripheral neurostimulator electrode array
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64585
|
| Hospital Charge Code |
36064585
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,499.71 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,499.71
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Amerigroup Medicare |
$3,512.04
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,257.99
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,297.00
|
| Rate for Payer: BCBS of TX Medicare |
$3,512.04
|
| Rate for Payer: BCBS of TX PPO |
$7,934.22
|
| Rate for Payer: Cigna Commercial |
$7,423.81
|
| Rate for Payer: Cigna Medicare |
$3,512.04
|
| Rate for Payer: Employer Direct Commercial |
$3,512.04
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,512.04
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Molina Medicare |
$3,512.04
|
| 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: Scott and White EPO/PPO |
$6,497.27
|
| Rate for Payer: Scott and White Medicare |
$3,512.04
|
| Rate for Payer: Superior Health Plan EPO |
$3,512.04
|
| Rate for Payer: Superior Health Plan Medicare |
$3,512.04
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Universal American Medicare |
$3,512.04
|
| Rate for Payer: Wellcare Medicare |
$3,512.04
|
| Rate for Payer: Wellmed Medicare |
$3,512.04
|
|
|
Revision or removal of peripheral neurostimulator electrode array
|
Facility
|
OP
|
$20,074.38
|
|
|
Service Code
|
HCPCS 64585
|
| Hospital Charge Code |
9900816
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,499.71 |
| Max. Negotiated Rate |
$14,453.55 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$1,499.71
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Amerigroup Medicare |
$3,512.04
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,257.99
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,297.00
|
| Rate for Payer: BCBS of TX Medicare |
$3,512.04
|
| Rate for Payer: BCBS of TX PPO |
$7,934.22
|
| Rate for Payer: Cash Price |
$13,650.58
|
| Rate for Payer: Cash Price |
$13,650.58
|
| Rate for Payer: Cash Price |
$13,650.58
|
| Rate for Payer: Cigna Commercial |
$7,423.81
|
| Rate for Payer: Cigna Medicaid |
$14,453.55
|
| Rate for Payer: Cigna Medicare |
$3,512.04
|
| Rate for Payer: Employer Direct Commercial |
$3,512.04
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,512.04
|
| Rate for Payer: Molina CHIP/Medicaid |
$14,453.55
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Molina Medicare |
$3,512.04
|
| 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 |
$14,453.55
|
| Rate for Payer: Scott and White EPO/PPO |
$6,497.27
|
| Rate for Payer: Scott and White Medicare |
$3,512.04
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$14,453.55
|
| Rate for Payer: Superior Health Plan EPO |
$3,512.04
|
| Rate for Payer: Superior Health Plan Medicare |
$3,512.04
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Universal American Medicare |
$3,512.04
|
| Rate for Payer: Wellcare Medicare |
$3,512.04
|
| Rate for Payer: Wellmed Medicare |
$3,512.04
|
|
|
Revision or removal of peripheral neurostimulator electrode array
|
Facility
|
IP
|
$20,074.38
|
|
|
Service Code
|
HCPCS 64585
|
| Hospital Charge Code |
9900816
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$13,650.58
|
|
|
Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64595
|
| Hospital Charge Code |
36064595
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,397.68 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2,397.68
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Amerigroup Medicare |
$3,512.04
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,257.99
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,297.00
|
| Rate for Payer: BCBS of TX Medicare |
$3,512.04
|
| Rate for Payer: BCBS of TX PPO |
$7,934.22
|
| Rate for Payer: Cigna Commercial |
$7,423.81
|
| Rate for Payer: Cigna Medicare |
$3,512.04
|
| Rate for Payer: Employer Direct Commercial |
$3,512.04
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,512.04
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Molina Medicare |
$3,512.04
|
| 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: Scott and White EPO/PPO |
$6,497.27
|
| Rate for Payer: Scott and White Medicare |
$3,512.04
|
| Rate for Payer: Superior Health Plan EPO |
$3,512.04
|
| Rate for Payer: Superior Health Plan Medicare |
$3,512.04
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Universal American Medicare |
$3,512.04
|
| Rate for Payer: Wellcare Medicare |
$3,512.04
|
| Rate for Payer: Wellmed Medicare |
$3,512.04
|
|
|
Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
|
Facility
|
IP
|
$20,074.38
|
|
|
Service Code
|
HCPCS 64595
|
| Hospital Charge Code |
9900818
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$13,650.58
|
|
|
Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
|
Facility
|
OP
|
$20,074.38
|
|
|
Service Code
|
HCPCS 64595
|
| Hospital Charge Code |
9900818
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,397.68 |
| Max. Negotiated Rate |
$14,453.55 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2,397.68
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Amerigroup Medicare |
$3,512.04
|
| Rate for Payer: BCBS of TX Blue Advantage |
$5,257.99
|
| Rate for Payer: BCBS of TX Blue Essentials |
$6,297.00
|
| Rate for Payer: BCBS of TX Medicare |
$3,512.04
|
| Rate for Payer: BCBS of TX PPO |
$7,934.22
|
| Rate for Payer: Cash Price |
$13,650.58
|
| Rate for Payer: Cash Price |
$13,650.58
|
| Rate for Payer: Cash Price |
$13,650.58
|
| Rate for Payer: Cigna Commercial |
$7,423.81
|
| Rate for Payer: Cigna Medicaid |
$14,453.55
|
| Rate for Payer: Cigna Medicare |
$3,512.04
|
| Rate for Payer: Employer Direct Commercial |
$3,512.04
|
| Rate for Payer: Humana Medicare/TRICARE |
$3,512.04
|
| Rate for Payer: Molina CHIP/Medicaid |
$14,453.55
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Molina Medicare |
$3,512.04
|
| 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 |
$14,453.55
|
| Rate for Payer: Scott and White EPO/PPO |
$6,497.27
|
| Rate for Payer: Scott and White Medicare |
$3,512.04
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$14,453.55
|
| Rate for Payer: Superior Health Plan EPO |
$3,512.04
|
| Rate for Payer: Superior Health Plan Medicare |
$3,512.04
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$3,512.04
|
| Rate for Payer: Universal American Medicare |
$3,512.04
|
| Rate for Payer: Wellcare Medicare |
$3,512.04
|
| Rate for Payer: Wellmed Medicare |
$3,512.04
|
|
|
Revision or repair of operative wound of anterior segment, any type, early or late, major or minor p
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 66250
|
| Hospital Charge Code |
36066250
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$698.30 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$698.30
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$2,388.32
|
| Rate for Payer: Amerigroup Medicare |
$2,388.32
|
| Rate for Payer: BCBS of TX Blue Advantage |
$3,231.78
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,870.40
|
| Rate for Payer: BCBS of TX Medicare |
$2,388.32
|
| Rate for Payer: BCBS of TX PPO |
$4,876.70
|
| Rate for Payer: Cigna Commercial |
$5,048.47
|
| Rate for Payer: Cigna Medicare |
$2,388.32
|
| Rate for Payer: Employer Direct Commercial |
$2,388.32
|
| Rate for Payer: Humana Medicare/TRICARE |
$2,388.32
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$2,388.32
|
| Rate for Payer: Molina Medicare |
$2,388.32
|
| 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: Scott and White EPO/PPO |
$4,418.39
|
| Rate for Payer: Scott and White Medicare |
$2,388.32
|
| Rate for Payer: Superior Health Plan EPO |
$2,388.32
|
| Rate for Payer: Superior Health Plan Medicare |
$2,388.32
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$2,388.32
|
| Rate for Payer: Universal American Medicare |
$2,388.32
|
| Rate for Payer: Wellcare Medicare |
$2,388.32
|
| Rate for Payer: Wellmed Medicare |
$2,388.32
|
|
|
Revision or repair of operative wound of anterior segment, any type, early or late, major or minor p
|
Facility
|
OP
|
$8,174.80
|
|
|
Service Code
|
HCPCS 66250
|
| Hospital Charge Code |
9900865
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$698.30 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$698.30
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$2,388.32
|
| Rate for Payer: Amerigroup Medicare |
$2,388.32
|
| Rate for Payer: BCBS of TX Blue Advantage |
$3,231.78
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,870.40
|
| Rate for Payer: BCBS of TX Medicare |
$2,388.32
|
| Rate for Payer: BCBS of TX PPO |
$4,876.70
|
| Rate for Payer: Cash Price |
$5,558.86
|
| Rate for Payer: Cash Price |
$5,558.86
|
| Rate for Payer: Cash Price |
$5,558.86
|
| Rate for Payer: Cigna Commercial |
$5,048.47
|
| Rate for Payer: Cigna Medicaid |
$5,885.86
|
| Rate for Payer: Cigna Medicare |
$2,388.32
|
| Rate for Payer: Employer Direct Commercial |
$2,388.32
|
| Rate for Payer: Humana Medicare/TRICARE |
$2,388.32
|
| Rate for Payer: Molina CHIP/Medicaid |
$5,885.86
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$2,388.32
|
| Rate for Payer: Molina Medicare |
$2,388.32
|
| 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 |
$5,885.86
|
| Rate for Payer: Scott and White EPO/PPO |
$4,418.39
|
| Rate for Payer: Scott and White Medicare |
$2,388.32
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5,885.86
|
| Rate for Payer: Superior Health Plan EPO |
$2,388.32
|
| Rate for Payer: Superior Health Plan Medicare |
$2,388.32
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$2,388.32
|
| Rate for Payer: Universal American Medicare |
$2,388.32
|
| Rate for Payer: Wellcare Medicare |
$2,388.32
|
| Rate for Payer: Wellmed Medicare |
$2,388.32
|
|
|
Revision or repair of operative wound of anterior segment, any type, early or late, major or minor p
|
Facility
|
IP
|
$8,174.80
|
|
|
Service Code
|
HCPCS 66250
|
| Hospital Charge Code |
9900865
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$5,558.86
|
|
|
REV SKIN POCKET SNGL/DUAL AICD
|
Facility
|
OP
|
$4,566.00
|
|
|
Service Code
|
HCPCS 33223
|
| Hospital Charge Code |
2302347
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$410.94 |
| Max. Negotiated Rate |
$4,381.27 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$410.94
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$2,072.68
|
| Rate for Payer: Amerigroup Medicare |
$2,072.68
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2,709.98
|
| Rate for Payer: BCBS of TX Blue Essentials |
$3,245.48
|
| Rate for Payer: BCBS of TX Medicare |
$2,072.68
|
| Rate for Payer: BCBS of TX PPO |
$4,089.30
|
| Rate for Payer: Cash Price |
$3,104.88
|
| Rate for Payer: Cash Price |
$3,104.88
|
| Rate for Payer: Cash Price |
$3,104.88
|
| Rate for Payer: Cigna Commercial |
$4,381.27
|
| Rate for Payer: Cigna Medicaid |
$3,287.52
|
| Rate for Payer: Cigna Medicare |
$2,072.68
|
| Rate for Payer: Employer Direct Commercial |
$2,072.68
|
| Rate for Payer: Humana Medicare/TRICARE |
$2,072.68
|
| Rate for Payer: Molina CHIP/Medicaid |
$3,287.52
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$2,072.68
|
| Rate for Payer: Molina Medicare |
$2,072.68
|
| Rate for Payer: Multiplan Auto |
$2,967.90
|
| Rate for Payer: Multiplan Commercial |
$2,967.90
|
| Rate for Payer: Multiplan Workers Comp |
$2,967.90
|
| Rate for Payer: Parkland Medicaid |
$3,287.52
|
| Rate for Payer: Scott and White EPO/PPO |
$2,283.00
|
| Rate for Payer: Scott and White Medicare |
$2,072.68
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$3,287.52
|
| Rate for Payer: Superior Health Plan EPO |
$2,072.68
|
| Rate for Payer: Superior Health Plan Medicare |
$2,072.68
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$2,072.68
|
| Rate for Payer: Universal American Medicare |
$2,072.68
|
| Rate for Payer: Wellcare Medicare |
$2,072.68
|
| Rate for Payer: Wellmed Medicare |
$2,072.68
|
|
|
REV SKIN POCKET SNGL/DUAL AICD
|
Facility
|
IP
|
$4,566.00
|
|
|
Service Code
|
HCPCS 33223
|
| Hospital Charge Code |
2302347
|
|
Hospital Revenue Code
|
481
|
| Rate for Payer: Cash Price |
$3,104.88
|
|
|
RFE356
|
Facility
|
OP
|
$1,325.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
991008
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$119.25 |
| Max. Negotiated Rate |
$954.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$119.25
|
| Rate for Payer: BCBS of TX Blue Advantage |
$397.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$477.00
|
| Rate for Payer: BCBS of TX PPO |
$530.00
|
| Rate for Payer: Cash Price |
$901.00
|
| Rate for Payer: Cigna Medicaid |
$954.00
|
| Rate for Payer: Molina CHIP/Medicaid |
$954.00
|
| Rate for Payer: Multiplan Auto |
$662.50
|
| Rate for Payer: Multiplan Commercial |
$662.50
|
| Rate for Payer: Multiplan Workers Comp |
$662.50
|
| Rate for Payer: Parkland Medicaid |
$954.00
|
| Rate for Payer: Scott and White EPO/PPO |
$662.50
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$954.00
|
| Rate for Payer: Superior Health Plan EPO |
$180.20
|
|
|
RFE356
|
Facility
|
IP
|
$1,325.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
991008
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$331.25 |
| Max. Negotiated Rate |
$662.50 |
| Rate for Payer: Cash Price |
$901.00
|
| Rate for Payer: Cigna Commercial |
$331.25
|
| Rate for Payer: Multiplan Auto |
$662.50
|
| Rate for Payer: Multiplan Commercial |
$662.50
|
| Rate for Payer: Multiplan Workers Comp |
$662.50
|
| Rate for Payer: Scott and White EPO/PPO |
$662.50
|
|
|
Rheumatoid Factor
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
HCPCS 86431
|
| Hospital Charge Code |
1603398
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$163.44 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$2.21
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$5.67
|
| Rate for Payer: Amerigroup Medicare |
$5.67
|
| Rate for Payer: BCBS of TX Blue Advantage |
$68.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$81.72
|
| Rate for Payer: BCBS of TX Medicare |
$5.67
|
| Rate for Payer: BCBS of TX PPO |
$90.80
|
| Rate for Payer: Cash Price |
$154.36
|
| Rate for Payer: Cash Price |
$154.36
|
| Rate for Payer: Cigna Medicaid |
$163.44
|
| Rate for Payer: Cigna Medicare |
$5.67
|
| Rate for Payer: Employer Direct Commercial |
$5.67
|
| Rate for Payer: Humana Medicare/TRICARE |
$5.67
|
| Rate for Payer: Molina CHIP/Medicaid |
$163.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$5.67
|
| Rate for Payer: Molina Medicare |
$5.67
|
| Rate for Payer: Multiplan Auto |
$147.55
|
| Rate for Payer: Multiplan Commercial |
$147.55
|
| Rate for Payer: Multiplan Workers Comp |
$147.55
|
| Rate for Payer: Parkland Medicaid |
$163.44
|
| Rate for Payer: Scott and White EPO/PPO |
$7.09
|
| Rate for Payer: Scott and White Medicare |
$5.67
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$163.44
|
| Rate for Payer: Superior Health Plan EPO |
$5.67
|
| Rate for Payer: Superior Health Plan Medicare |
$5.67
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$5.67
|
| Rate for Payer: Universal American Medicare |
$5.67
|
| Rate for Payer: Wellcare Medicare |
$5.67
|
| Rate for Payer: Wellmed Medicare |
$5.67
|
|
|
Rheumatoid Factor
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
HCPCS 86431
|
| Hospital Charge Code |
1603398
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$154.36
|
|
|
RHo (D) immune globulin 1500 intl units IM Soln
|
Facility
|
IP
|
$141.93
|
|
|
Service Code
|
HCPCS J2790
|
| Hospital Charge Code |
77793734
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$70.97 |
| Rate for Payer: Cash Price |
$96.51
|
| Rate for Payer: Cigna Commercial |
$35.48
|
| Rate for Payer: Scott and White EPO/PPO |
$70.97
|
|
|
RHo (D) immune globulin 1500 intl units IM Soln
|
Facility
|
OP
|
$141.93
|
|
|
Service Code
|
HCPCS J2790
|
| Hospital Charge Code |
77793734
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$145.75 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$12.77
|
| Rate for Payer: BCBS of TX Blue Advantage |
$109.50
|
| Rate for Payer: BCBS of TX Blue Essentials |
$131.40
|
| Rate for Payer: BCBS of TX PPO |
$145.75
|
| Rate for Payer: Cash Price |
$96.51
|
| Rate for Payer: Cash Price |
$96.51
|
| Rate for Payer: Cigna Medicaid |
$102.19
|
| Rate for Payer: Molina CHIP/Medicaid |
$102.19
|
| Rate for Payer: Multiplan Auto |
$92.25
|
| Rate for Payer: Multiplan Commercial |
$92.25
|
| Rate for Payer: Multiplan Workers Comp |
$92.25
|
| Rate for Payer: Parkland Medicaid |
$102.19
|
| Rate for Payer: Scott and White EPO/PPO |
$70.97
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$102.19
|
| Rate for Payer: Superior Health Plan EPO |
$19.30
|
|
|
rifAXIMin 550 mg Tab
|
Facility
|
OP
|
$118.44
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77795169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.66 |
| Max. Negotiated Rate |
$85.28 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$10.66
|
| Rate for Payer: BCBS of TX Blue Advantage |
$35.53
|
| Rate for Payer: BCBS of TX Blue Essentials |
$42.64
|
| Rate for Payer: BCBS of TX PPO |
$47.38
|
| Rate for Payer: Cash Price |
$80.54
|
| Rate for Payer: Cigna Medicaid |
$85.28
|
| Rate for Payer: Molina CHIP/Medicaid |
$85.28
|
| Rate for Payer: Multiplan Auto |
$76.99
|
| Rate for Payer: Multiplan Commercial |
$76.99
|
| Rate for Payer: Multiplan Workers Comp |
$76.99
|
| Rate for Payer: Parkland Medicaid |
$85.28
|
| Rate for Payer: Scott and White EPO/PPO |
$59.22
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$85.28
|
| Rate for Payer: Superior Health Plan EPO |
$16.11
|
|
|
rifAXIMin 550 mg Tab
|
Facility
|
IP
|
$118.44
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77795169
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$80.54
|
|
|
Rigidfix ST Kit
|
Facility
|
IP
|
$2,832.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
992671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$708.24 |
| Max. Negotiated Rate |
$1,416.48 |
| Rate for Payer: Cash Price |
$1,926.41
|
| Rate for Payer: Cigna Commercial |
$708.24
|
| Rate for Payer: Multiplan Auto |
$1,416.48
|
| Rate for Payer: Multiplan Commercial |
$1,416.48
|
| Rate for Payer: Multiplan Workers Comp |
$1,416.48
|
| Rate for Payer: Scott and White EPO/PPO |
$1,416.48
|
|
|
Rigidfix ST Kit
|
Facility
|
OP
|
$2,832.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
992671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$254.97 |
| Max. Negotiated Rate |
$2,039.73 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$254.97
|
| Rate for Payer: BCBS of TX Blue Advantage |
$849.89
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,019.87
|
| Rate for Payer: BCBS of TX PPO |
$1,133.18
|
| Rate for Payer: Cash Price |
$1,926.41
|
| Rate for Payer: Cigna Medicaid |
$2,039.73
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,039.73
|
| Rate for Payer: Multiplan Auto |
$1,416.48
|
| Rate for Payer: Multiplan Commercial |
$1,416.48
|
| Rate for Payer: Multiplan Workers Comp |
$1,416.48
|
| Rate for Payer: Parkland Medicaid |
$2,039.73
|
| Rate for Payer: Scott and White EPO/PPO |
$1,416.48
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,039.73
|
| Rate for Payer: Superior Health Plan EPO |
$385.28
|
|
|
risperiDONE 1 mg Tab
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77796415
|
|
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
|
|
|
risperiDONE 1 mg Tab
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77796415
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.44
|
|
