|
Application of a modality to 1 or more areas; infrared
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
HCPCS 97026 GP
|
| Hospital Charge Code |
9385000
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3.69
|
| Rate for Payer: BCBS of TX Blue Advantage |
$12.30
|
| Rate for Payer: BCBS of TX Blue Essentials |
$14.76
|
| Rate for Payer: BCBS of TX PPO |
$16.40
|
| Rate for Payer: Cash Price |
$27.88
|
| Rate for Payer: Cash Price |
$27.88
|
| Rate for Payer: Cash Price |
$27.88
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$29.52
|
| Rate for Payer: Molina CHIP/Medicaid |
$29.52
|
| Rate for Payer: Multiplan Auto |
$26.65
|
| Rate for Payer: Multiplan Commercial |
$26.65
|
| Rate for Payer: Multiplan Workers Comp |
$26.65
|
| Rate for Payer: Parkland Medicaid |
$29.52
|
| Rate for Payer: Scott and White EPO/PPO |
$180.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$29.52
|
| Rate for Payer: Superior Health Plan EPO |
$5.58
|
|
|
Application of a modality to 1 or more areas; vasopneumatic devices
|
Facility
|
IP
|
$50.00
|
|
| Hospital Charge Code |
9385001
|
|
Hospital Revenue Code
|
420
|
| Rate for Payer: Cash Price |
$34.00
|
|
|
Application of a modality to 1 or more areas; vasopneumatic devices
|
Facility
|
OP
|
$50.00
|
|
| Hospital Charge Code |
9385001
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$4.50
|
| Rate for Payer: BCBS of TX Blue Advantage |
$15.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$18.00
|
| Rate for Payer: BCBS of TX PPO |
$20.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Cigna Medicaid |
$36.00
|
| Rate for Payer: Molina CHIP/Medicaid |
$36.00
|
| Rate for Payer: Multiplan Auto |
$32.50
|
| Rate for Payer: Multiplan Commercial |
$32.50
|
| Rate for Payer: Multiplan Workers Comp |
$32.50
|
| Rate for Payer: Parkland Medicaid |
$36.00
|
| Rate for Payer: Scott and White EPO/PPO |
$180.00
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$36.00
|
| Rate for Payer: Superior Health Plan EPO |
$6.80
|
|
|
Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation syst
|
Facility
|
OP
|
$73,888.56
|
|
|
Service Code
|
HCPCS 20692
|
| Hospital Charge Code |
9900182
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,448.53 |
| Max. Negotiated Rate |
$53,199.76 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7,448.53
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12,897.19
|
| Rate for Payer: Amerigroup Medicare |
$12,897.19
|
| Rate for Payer: BCBS of TX Blue Advantage |
$19,874.19
|
| Rate for Payer: BCBS of TX Blue Essentials |
$23,801.42
|
| Rate for Payer: BCBS of TX Medicare |
$12,897.19
|
| Rate for Payer: BCBS of TX PPO |
$29,989.79
|
| Rate for Payer: Cash Price |
$50,244.22
|
| Rate for Payer: Cash Price |
$50,244.22
|
| Rate for Payer: Cash Price |
$50,244.22
|
| Rate for Payer: Cigna Commercial |
$27,262.32
|
| Rate for Payer: Cigna Medicaid |
$53,199.76
|
| Rate for Payer: Cigna Medicare |
$12,897.19
|
| Rate for Payer: Employer Direct Commercial |
$12,897.19
|
| Rate for Payer: Humana Medicare/TRICARE |
$12,897.19
|
| Rate for Payer: Molina CHIP/Medicaid |
$53,199.76
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12,897.19
|
| Rate for Payer: Molina Medicare |
$12,897.19
|
| 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 |
$53,199.76
|
| Rate for Payer: Scott and White EPO/PPO |
$23,859.80
|
| Rate for Payer: Scott and White Medicare |
$12,897.19
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$53,199.76
|
| Rate for Payer: Superior Health Plan EPO |
$12,897.19
|
| Rate for Payer: Superior Health Plan Medicare |
$12,897.19
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12,897.19
|
| Rate for Payer: Universal American Medicare |
$12,897.19
|
| Rate for Payer: Wellcare Medicare |
$12,897.19
|
| Rate for Payer: Wellmed Medicare |
$12,897.19
|
|
|
Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation syst
|
Facility
|
OP
|
$29,989.79
|
|
|
Service Code
|
CPT 20692
|
| Hospital Charge Code |
36020692
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,448.53 |
| Max. Negotiated Rate |
$29,989.79 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7,448.53
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$12,897.19
|
| Rate for Payer: Amerigroup Medicare |
$12,897.19
|
| Rate for Payer: BCBS of TX Blue Advantage |
$19,874.19
|
| Rate for Payer: BCBS of TX Blue Essentials |
$23,801.42
|
| Rate for Payer: BCBS of TX Medicare |
$12,897.19
|
| Rate for Payer: BCBS of TX PPO |
$29,989.79
|
| Rate for Payer: Cigna Commercial |
$27,262.32
|
| Rate for Payer: Cigna Medicare |
$12,897.19
|
| Rate for Payer: Employer Direct Commercial |
$12,897.19
|
| Rate for Payer: Humana Medicare/TRICARE |
$12,897.19
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$12,897.19
|
| Rate for Payer: Molina Medicare |
$12,897.19
|
| 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 |
$23,859.80
|
| Rate for Payer: Scott and White Medicare |
$12,897.19
|
| Rate for Payer: Superior Health Plan EPO |
$12,897.19
|
| Rate for Payer: Superior Health Plan Medicare |
$12,897.19
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$12,897.19
|
| Rate for Payer: Universal American Medicare |
$12,897.19
|
| Rate for Payer: Wellcare Medicare |
$12,897.19
|
| Rate for Payer: Wellmed Medicare |
$12,897.19
|
|
|
Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation syst
|
Facility
|
IP
|
$73,888.56
|
|
|
Service Code
|
HCPCS 20692
|
| Hospital Charge Code |
9900182
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$50,244.22
|
|
|
Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system
|
Facility
|
IP
|
$15,662.38
|
|
|
Service Code
|
HCPCS 20690
|
| Hospital Charge Code |
9900181
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$10,650.42
|
|
|
Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system
|
Facility
|
OP
|
$15,662.38
|
|
|
Service Code
|
HCPCS 20690
|
| Hospital Charge Code |
9900181
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,422.19 |
| Max. Negotiated Rate |
$15,408.22 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3,422.19
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Amerigroup Medicare |
$7,289.28
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9,989.86
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11,963.90
|
| Rate for Payer: BCBS of TX Medicare |
$7,289.28
|
| Rate for Payer: BCBS of TX PPO |
$15,074.51
|
| Rate for Payer: Cash Price |
$10,650.42
|
| Rate for Payer: Cash Price |
$10,650.42
|
| Rate for Payer: Cash Price |
$10,650.42
|
| Rate for Payer: Cigna Commercial |
$15,408.22
|
| Rate for Payer: Cigna Medicaid |
$11,276.91
|
| Rate for Payer: Cigna Medicare |
$7,289.28
|
| Rate for Payer: Employer Direct Commercial |
$7,289.28
|
| Rate for Payer: Humana Medicare/TRICARE |
$7,289.28
|
| Rate for Payer: Molina CHIP/Medicaid |
$11,276.91
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Molina Medicare |
$7,289.28
|
| 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 |
$11,276.91
|
| Rate for Payer: Scott and White EPO/PPO |
$13,485.17
|
| Rate for Payer: Scott and White Medicare |
$7,289.28
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$11,276.91
|
| Rate for Payer: Superior Health Plan EPO |
$7,289.28
|
| Rate for Payer: Superior Health Plan Medicare |
$7,289.28
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Universal American Medicare |
$7,289.28
|
| Rate for Payer: Wellcare Medicare |
$7,289.28
|
| Rate for Payer: Wellmed Medicare |
$7,289.28
|
|
|
Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system
|
Facility
|
OP
|
$15,408.22
|
|
|
Service Code
|
CPT 20690
|
| Hospital Charge Code |
36020690
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,422.19 |
| Max. Negotiated Rate |
$15,408.22 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$3,422.19
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Amerigroup Medicare |
$7,289.28
|
| Rate for Payer: BCBS of TX Blue Advantage |
$9,989.86
|
| Rate for Payer: BCBS of TX Blue Essentials |
$11,963.90
|
| Rate for Payer: BCBS of TX Medicare |
$7,289.28
|
| Rate for Payer: BCBS of TX PPO |
$15,074.51
|
| Rate for Payer: Cigna Commercial |
$15,408.22
|
| Rate for Payer: Cigna Medicare |
$7,289.28
|
| Rate for Payer: Employer Direct Commercial |
$7,289.28
|
| Rate for Payer: Humana Medicare/TRICARE |
$7,289.28
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Molina Medicare |
$7,289.28
|
| 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 |
$13,485.17
|
| Rate for Payer: Scott and White Medicare |
$7,289.28
|
| Rate for Payer: Superior Health Plan EPO |
$7,289.28
|
| Rate for Payer: Superior Health Plan Medicare |
$7,289.28
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$7,289.28
|
| Rate for Payer: Universal American Medicare |
$7,289.28
|
| Rate for Payer: Wellcare Medicare |
$7,289.28
|
| Rate for Payer: Wellmed Medicare |
$7,289.28
|
|
|
Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
|
Facility
|
OP
|
$5,812.02
|
|
|
Service Code
|
HCPCS 21110
|
| Hospital Charge Code |
990962
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$420.64 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$420.64
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$1,558.65
|
| Rate for Payer: Amerigroup Medicare |
$1,558.65
|
| Rate for Payer: BCBS of TX Blue Advantage |
$896.12
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,073.20
|
| Rate for Payer: BCBS of TX Medicare |
$1,558.65
|
| Rate for Payer: BCBS of TX PPO |
$1,352.23
|
| Rate for Payer: Cash Price |
$3,952.17
|
| Rate for Payer: Cash Price |
$3,952.17
|
| Rate for Payer: Cash Price |
$3,952.17
|
| Rate for Payer: Cigna Commercial |
$3,294.71
|
| Rate for Payer: Cigna Medicaid |
$4,184.65
|
| Rate for Payer: Cigna Medicare |
$1,558.65
|
| Rate for Payer: Employer Direct Commercial |
$1,558.65
|
| Rate for Payer: Humana Medicare/TRICARE |
$1,558.65
|
| Rate for Payer: Molina CHIP/Medicaid |
$4,184.65
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$1,558.65
|
| Rate for Payer: Molina Medicare |
$1,558.65
|
| 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 |
$4,184.65
|
| Rate for Payer: Scott and White EPO/PPO |
$2,883.50
|
| Rate for Payer: Scott and White Medicare |
$1,558.65
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$4,184.65
|
| Rate for Payer: Superior Health Plan EPO |
$1,558.65
|
| Rate for Payer: Superior Health Plan Medicare |
$1,558.65
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$1,558.65
|
| Rate for Payer: Universal American Medicare |
$1,558.65
|
| Rate for Payer: Wellcare Medicare |
$1,558.65
|
| Rate for Payer: Wellmed Medicare |
$1,558.65
|
|
|
Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
|
Facility
|
IP
|
$5,812.02
|
|
|
Service Code
|
HCPCS 21110
|
| Hospital Charge Code |
990962
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$3,952.17
|
|
|
Application of short arm splint (forearm to hand) static
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS 29125
|
| Hospital Charge Code |
9900538
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$775.20
|
|
|
Application of short arm splint (forearm to hand) static
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 29125
|
| Hospital Charge Code |
36029125
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$133.65 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$133.65
|
| Rate for Payer: Amerigroup Medicare |
$133.65
|
| 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 |
$133.65
|
| Rate for Payer: BCBS of TX PPO |
$274.76
|
| Rate for Payer: Cigna Commercial |
$282.53
|
| Rate for Payer: Cigna Medicare |
$133.65
|
| Rate for Payer: Employer Direct Commercial |
$133.65
|
| Rate for Payer: Humana Medicare/TRICARE |
$133.65
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$133.65
|
| Rate for Payer: Molina Medicare |
$133.65
|
| 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 |
$247.25
|
| Rate for Payer: Scott and White Medicare |
$133.65
|
| Rate for Payer: Superior Health Plan EPO |
$133.65
|
| Rate for Payer: Superior Health Plan Medicare |
$133.65
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$133.65
|
| Rate for Payer: Universal American Medicare |
$133.65
|
| Rate for Payer: Wellcare Medicare |
$133.65
|
| Rate for Payer: Wellmed Medicare |
$133.65
|
|
|
Application of short arm splint (forearm to hand) static
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS 29125
|
| Hospital Charge Code |
9900538
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$102.60 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$102.60
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$133.65
|
| Rate for Payer: Amerigroup Medicare |
$133.65
|
| 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 |
$133.65
|
| Rate for Payer: BCBS of TX PPO |
$274.76
|
| Rate for Payer: Cash Price |
$775.20
|
| Rate for Payer: Cash Price |
$775.20
|
| Rate for Payer: Cash Price |
$775.20
|
| Rate for Payer: Cigna Commercial |
$282.53
|
| Rate for Payer: Cigna Medicaid |
$820.80
|
| Rate for Payer: Cigna Medicare |
$133.65
|
| Rate for Payer: Employer Direct Commercial |
$133.65
|
| Rate for Payer: Humana Medicare/TRICARE |
$133.65
|
| Rate for Payer: Molina CHIP/Medicaid |
$820.80
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$133.65
|
| Rate for Payer: Molina Medicare |
$133.65
|
| 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 |
$820.80
|
| Rate for Payer: Scott and White EPO/PPO |
$247.25
|
| Rate for Payer: Scott and White Medicare |
$133.65
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$820.80
|
| Rate for Payer: Superior Health Plan EPO |
$133.65
|
| Rate for Payer: Superior Health Plan Medicare |
$133.65
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$133.65
|
| Rate for Payer: Universal American Medicare |
$133.65
|
| Rate for Payer: Wellcare Medicare |
$133.65
|
| Rate for Payer: Wellmed Medicare |
$133.65
|
|
|
Application of short leg cast (below knee to toes); walking or ambulatory type
|
Facility
|
OP
|
$739.14
|
|
|
Service Code
|
HCPCS 29425
|
| Hospital Charge Code |
9900539
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$35.99 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$35.99
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$280.97
|
| Rate for Payer: Amerigroup Medicare |
$280.97
|
| Rate for Payer: BCBS of TX Blue Advantage |
$75.93
|
| Rate for Payer: BCBS of TX Blue Essentials |
$90.94
|
| Rate for Payer: BCBS of TX Medicare |
$280.97
|
| Rate for Payer: BCBS of TX PPO |
$114.58
|
| Rate for Payer: Cash Price |
$502.62
|
| Rate for Payer: Cash Price |
$502.62
|
| Rate for Payer: Cash Price |
$502.62
|
| Rate for Payer: Cigna Commercial |
$593.92
|
| Rate for Payer: Cigna Medicaid |
$532.18
|
| Rate for Payer: Cigna Medicare |
$280.97
|
| Rate for Payer: Employer Direct Commercial |
$280.97
|
| Rate for Payer: Humana Medicare/TRICARE |
$280.97
|
| Rate for Payer: Molina CHIP/Medicaid |
$532.18
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$280.97
|
| Rate for Payer: Molina Medicare |
$280.97
|
| 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 |
$532.18
|
| Rate for Payer: Scott and White EPO/PPO |
$519.79
|
| Rate for Payer: Scott and White Medicare |
$280.97
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$532.18
|
| Rate for Payer: Superior Health Plan EPO |
$280.97
|
| Rate for Payer: Superior Health Plan Medicare |
$280.97
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$280.97
|
| Rate for Payer: Universal American Medicare |
$280.97
|
| Rate for Payer: Wellcare Medicare |
$280.97
|
| Rate for Payer: Wellmed Medicare |
$280.97
|
|
|
Application of short leg cast (below knee to toes); walking or ambulatory type
|
Facility
|
IP
|
$739.14
|
|
|
Service Code
|
HCPCS 29425
|
| Hospital Charge Code |
9900539
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$502.62
|
|
|
Application of short leg splint (calf to foot)
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 29515
|
| Hospital Charge Code |
36029515
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$34.33 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$34.33
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$163.24
|
| Rate for Payer: Amerigroup Medicare |
$163.24
|
| Rate for Payer: BCBS of TX Blue Advantage |
$70.51
|
| Rate for Payer: BCBS of TX Blue Essentials |
$84.44
|
| Rate for Payer: BCBS of TX Medicare |
$163.24
|
| Rate for Payer: BCBS of TX PPO |
$106.39
|
| Rate for Payer: Cigna Commercial |
$345.06
|
| Rate for Payer: Cigna Medicare |
$163.24
|
| Rate for Payer: Employer Direct Commercial |
$163.24
|
| Rate for Payer: Humana Medicare/TRICARE |
$163.24
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$163.24
|
| Rate for Payer: Molina Medicare |
$163.24
|
| 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 |
$301.99
|
| Rate for Payer: Scott and White Medicare |
$163.24
|
| Rate for Payer: Superior Health Plan EPO |
$163.24
|
| Rate for Payer: Superior Health Plan Medicare |
$163.24
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$163.24
|
| Rate for Payer: Universal American Medicare |
$163.24
|
| Rate for Payer: Wellcare Medicare |
$163.24
|
| Rate for Payer: Wellmed Medicare |
$163.24
|
|
|
Application of short leg splint (calf to foot)
|
Facility
|
OP
|
$635.31
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
9900541
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$34.33 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$34.33
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$163.24
|
| Rate for Payer: Amerigroup Medicare |
$163.24
|
| Rate for Payer: BCBS of TX Blue Advantage |
$70.51
|
| Rate for Payer: BCBS of TX Blue Essentials |
$84.44
|
| Rate for Payer: BCBS of TX Medicare |
$163.24
|
| Rate for Payer: BCBS of TX PPO |
$106.39
|
| Rate for Payer: Cash Price |
$432.01
|
| Rate for Payer: Cash Price |
$432.01
|
| Rate for Payer: Cash Price |
$432.01
|
| Rate for Payer: Cigna Commercial |
$345.06
|
| Rate for Payer: Cigna Medicaid |
$457.42
|
| Rate for Payer: Cigna Medicare |
$163.24
|
| Rate for Payer: Employer Direct Commercial |
$163.24
|
| Rate for Payer: Humana Medicare/TRICARE |
$163.24
|
| Rate for Payer: Molina CHIP/Medicaid |
$457.42
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$163.24
|
| Rate for Payer: Molina Medicare |
$163.24
|
| 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 |
$457.42
|
| Rate for Payer: Scott and White EPO/PPO |
$301.99
|
| Rate for Payer: Scott and White Medicare |
$163.24
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$457.42
|
| Rate for Payer: Superior Health Plan EPO |
$163.24
|
| Rate for Payer: Superior Health Plan Medicare |
$163.24
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$163.24
|
| Rate for Payer: Universal American Medicare |
$163.24
|
| Rate for Payer: Wellcare Medicare |
$163.24
|
| Rate for Payer: Wellmed Medicare |
$163.24
|
|
|
Application of short leg splint (calf to foot)
|
Facility
|
IP
|
$635.31
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
9900541
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$432.01
|
|
|
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,
|
Facility
|
OP
|
$7,316.92
|
|
|
Service Code
|
HCPCS 15275
|
| Hospital Charge Code |
9900127
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$71.16 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$71.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$742.44
|
| Rate for Payer: Amerigroup Medicare |
$742.44
|
| 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 |
$742.44
|
| Rate for Payer: BCBS of TX PPO |
$4,089.30
|
| Rate for Payer: Cash Price |
$4,975.51
|
| Rate for Payer: Cash Price |
$4,975.51
|
| Rate for Payer: Cash Price |
$4,975.51
|
| Rate for Payer: Cigna Commercial |
$1,569.38
|
| Rate for Payer: Cigna Medicaid |
$5,268.18
|
| Rate for Payer: Cigna Medicare |
$742.44
|
| Rate for Payer: Employer Direct Commercial |
$742.44
|
| Rate for Payer: Humana Medicare/TRICARE |
$742.44
|
| Rate for Payer: Molina CHIP/Medicaid |
$5,268.18
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$742.44
|
| Rate for Payer: Molina Medicare |
$742.44
|
| 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 |
$5,268.18
|
| Rate for Payer: Scott and White EPO/PPO |
$1,373.51
|
| Rate for Payer: Scott and White Medicare |
$742.44
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5,268.18
|
| Rate for Payer: Superior Health Plan EPO |
$742.44
|
| Rate for Payer: Superior Health Plan Medicare |
$742.44
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$742.44
|
| Rate for Payer: Universal American Medicare |
$742.44
|
| Rate for Payer: Wellcare Medicare |
$742.44
|
| Rate for Payer: Wellmed Medicare |
$742.44
|
|
|
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,
|
Facility
|
IP
|
$10,292.16
|
|
|
Service Code
|
HCPCS 15276
|
| Hospital Charge Code |
9900128
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$6,998.67
|
|
|
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,
|
Facility
|
IP
|
$10,292.16
|
|
|
Service Code
|
HCPCS 15276
|
| Hospital Charge Code |
7150815
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$6,998.67
|
|
|
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,
|
Facility
|
IP
|
$7,316.92
|
|
|
Service Code
|
HCPCS 15275
|
| Hospital Charge Code |
9900127
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$4,975.51
|
|
|
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
36015276
|
|
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
|
|
|
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
36015275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$71.16 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$71.16
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$742.44
|
| Rate for Payer: Amerigroup Medicare |
$742.44
|
| 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 |
$742.44
|
| Rate for Payer: BCBS of TX PPO |
$4,089.30
|
| Rate for Payer: Cigna Commercial |
$1,569.38
|
| Rate for Payer: Cigna Medicare |
$742.44
|
| Rate for Payer: Employer Direct Commercial |
$742.44
|
| Rate for Payer: Humana Medicare/TRICARE |
$742.44
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$742.44
|
| Rate for Payer: Molina Medicare |
$742.44
|
| 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 |
$1,373.51
|
| Rate for Payer: Scott and White Medicare |
$742.44
|
| Rate for Payer: Superior Health Plan EPO |
$742.44
|
| Rate for Payer: Superior Health Plan Medicare |
$742.44
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$742.44
|
| Rate for Payer: Universal American Medicare |
$742.44
|
| Rate for Payer: Wellcare Medicare |
$742.44
|
| Rate for Payer: Wellmed Medicare |
$742.44
|
|
