|
TGR001
|
Facility
|
IP
|
$1,948.66
|
|
| Hospital Charge Code |
991227
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$1,325.09
|
|
|
Theophylline, Serum SO
|
Facility
|
IP
|
$437.00
|
|
|
Service Code
|
HCPCS 80198
|
| Hospital Charge Code |
1602986
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$297.16
|
|
|
Theophylline, Serum SO
|
Facility
|
OP
|
$437.00
|
|
|
Service Code
|
HCPCS 80198
|
| Hospital Charge Code |
1602986
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$314.64 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$5.51
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$14.14
|
| Rate for Payer: Amerigroup Medicare |
$14.14
|
| Rate for Payer: BCBS of TX Blue Advantage |
$131.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$157.32
|
| Rate for Payer: BCBS of TX Medicare |
$14.14
|
| Rate for Payer: BCBS of TX PPO |
$174.80
|
| Rate for Payer: Cash Price |
$297.16
|
| Rate for Payer: Cash Price |
$297.16
|
| Rate for Payer: Cigna Medicaid |
$314.64
|
| Rate for Payer: Cigna Medicare |
$14.14
|
| Rate for Payer: Employer Direct Commercial |
$14.14
|
| Rate for Payer: Humana Medicare/TRICARE |
$14.14
|
| Rate for Payer: Molina CHIP/Medicaid |
$314.64
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$14.14
|
| Rate for Payer: Molina Medicare |
$14.14
|
| Rate for Payer: Multiplan Auto |
$284.05
|
| Rate for Payer: Multiplan Commercial |
$284.05
|
| Rate for Payer: Multiplan Workers Comp |
$284.05
|
| Rate for Payer: Parkland Medicaid |
$314.64
|
| Rate for Payer: Scott and White EPO/PPO |
$17.68
|
| Rate for Payer: Scott and White Medicare |
$14.14
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$314.64
|
| Rate for Payer: Superior Health Plan EPO |
$14.14
|
| Rate for Payer: Superior Health Plan Medicare |
$14.14
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$14.14
|
| Rate for Payer: Universal American Medicare |
$14.14
|
| Rate for Payer: Wellcare Medicare |
$14.14
|
| Rate for Payer: Wellmed Medicare |
$14.14
|
|
|
The Ramp
|
Facility
|
OP
|
$3,763.66
|
|
| Hospital Charge Code |
992633
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$338.73 |
| Max. Negotiated Rate |
$2,709.84 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$338.73
|
| Rate for Payer: BCBS of TX Blue Advantage |
$1,129.10
|
| Rate for Payer: BCBS of TX Blue Essentials |
$1,354.92
|
| Rate for Payer: BCBS of TX PPO |
$1,505.46
|
| Rate for Payer: Cash Price |
$2,559.29
|
| Rate for Payer: Cigna Medicaid |
$2,709.84
|
| Rate for Payer: Molina CHIP/Medicaid |
$2,709.84
|
| Rate for Payer: Multiplan Auto |
$2,446.38
|
| Rate for Payer: Multiplan Commercial |
$2,446.38
|
| Rate for Payer: Multiplan Workers Comp |
$2,446.38
|
| Rate for Payer: Parkland Medicaid |
$2,709.84
|
| Rate for Payer: Scott and White EPO/PPO |
$1,881.83
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$2,709.84
|
| Rate for Payer: Superior Health Plan EPO |
$511.86
|
|
|
The Ramp
|
Facility
|
IP
|
$3,763.66
|
|
| Hospital Charge Code |
992633
|
|
Hospital Revenue Code
|
270
|
| Rate for Payer: Cash Price |
$2,559.29
|
|
|
Therapeutic Multiple Vitamins with Minerals Tab
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77843867
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$5.51 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$0.69
|
| Rate for Payer: BCBS of TX Blue Advantage |
$2.29
|
| Rate for Payer: BCBS of TX Blue Essentials |
$2.75
|
| Rate for Payer: BCBS of TX PPO |
$3.06
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Cigna Medicaid |
$5.51
|
| Rate for Payer: Molina CHIP/Medicaid |
$5.51
|
| Rate for Payer: Multiplan Auto |
$4.97
|
| Rate for Payer: Multiplan Commercial |
$4.97
|
| Rate for Payer: Multiplan Workers Comp |
$4.97
|
| Rate for Payer: Parkland Medicaid |
$5.51
|
| Rate for Payer: Scott and White EPO/PPO |
$3.83
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$5.51
|
| Rate for Payer: Superior Health Plan EPO |
$1.04
|
|
|
Therapeutic Multiple Vitamins with Minerals Tab
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
77843867
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$5.20
|
|
|
Therapeutic Phlebotomy 99195
|
Facility
|
IP
|
$265.00
|
|
|
Service Code
|
HCPCS 99195
|
| Hospital Charge Code |
7002603
|
|
Hospital Revenue Code
|
940
|
| Rate for Payer: Cash Price |
$180.20
|
|
|
Therapeutic Phlebotomy 99195
|
Facility
|
IP
|
$265.00
|
|
|
Service Code
|
HCPCS 99195
|
| Hospital Charge Code |
3609195
|
|
Hospital Revenue Code
|
940
|
| Rate for Payer: Cash Price |
$180.20
|
|
|
Therapeutic Phlebotomy 99195
|
Facility
|
OP
|
$265.00
|
|
|
Service Code
|
HCPCS 99195
|
| Hospital Charge Code |
7002603
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$23.85 |
| Max. Negotiated Rate |
$282.53 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$23.85
|
| 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 |
$180.20
|
| Rate for Payer: Cash Price |
$180.20
|
| Rate for Payer: Cash Price |
$180.20
|
| Rate for Payer: Cigna Commercial |
$282.53
|
| Rate for Payer: Cigna Medicaid |
$190.80
|
| 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 |
$190.80
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$133.65
|
| Rate for Payer: Molina Medicare |
$133.65
|
| Rate for Payer: Multiplan Auto |
$172.25
|
| Rate for Payer: Multiplan Commercial |
$172.25
|
| Rate for Payer: Multiplan Workers Comp |
$172.25
|
| Rate for Payer: Parkland Medicaid |
$190.80
|
| Rate for Payer: Scott and White EPO/PPO |
$117.97
|
| Rate for Payer: Scott and White Medicare |
$133.65
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$190.80
|
| 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
|
|
|
Therapeutic Phlebotomy 99195
|
Facility
|
OP
|
$265.00
|
|
|
Service Code
|
HCPCS 99195
|
| Hospital Charge Code |
3609195
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$23.85 |
| Max. Negotiated Rate |
$282.53 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$23.85
|
| 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 |
$180.20
|
| Rate for Payer: Cash Price |
$180.20
|
| Rate for Payer: Cash Price |
$180.20
|
| Rate for Payer: Cigna Commercial |
$282.53
|
| Rate for Payer: Cigna Medicaid |
$190.80
|
| 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 |
$190.80
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$133.65
|
| Rate for Payer: Molina Medicare |
$133.65
|
| Rate for Payer: Multiplan Auto |
$172.25
|
| Rate for Payer: Multiplan Commercial |
$172.25
|
| Rate for Payer: Multiplan Workers Comp |
$172.25
|
| Rate for Payer: Parkland Medicaid |
$190.80
|
| Rate for Payer: Scott and White EPO/PPO |
$117.97
|
| Rate for Payer: Scott and White Medicare |
$133.65
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$190.80
|
| 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
|
|
|
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
9900912
|
|
Hospital Revenue Code
|
260
|
| Rate for Payer: Cash Price |
$190.40
|
|
|
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
36096372
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$17.70 |
| Max. Negotiated Rate |
$10,000.00 |
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Amerigroup Medicare |
$72.33
|
| Rate for Payer: BCBS of TX Medicare |
$72.33
|
| Rate for Payer: Cigna Commercial |
$152.89
|
| Rate for Payer: Cigna Medicare |
$72.33
|
| Rate for Payer: Employer Direct Commercial |
$72.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$72.33
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Molina Medicare |
$72.33
|
| 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 |
$17.70
|
| Rate for Payer: Scott and White Medicare |
$72.33
|
| Rate for Payer: Superior Health Plan EPO |
$72.33
|
| Rate for Payer: Superior Health Plan Medicare |
$72.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Universal American Medicare |
$72.33
|
| Rate for Payer: Wellcare Medicare |
$72.33
|
| Rate for Payer: Wellmed Medicare |
$72.33
|
|
|
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr
|
Facility
|
OP
|
$280.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
9900912
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$17.70 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$25.20
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Amerigroup Medicare |
$72.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$84.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$100.80
|
| Rate for Payer: BCBS of TX Medicare |
$72.33
|
| Rate for Payer: BCBS of TX PPO |
$112.00
|
| Rate for Payer: Cash Price |
$190.40
|
| Rate for Payer: Cash Price |
$190.40
|
| Rate for Payer: Cash Price |
$190.40
|
| Rate for Payer: Cigna Commercial |
$152.89
|
| Rate for Payer: Cigna Medicaid |
$201.60
|
| Rate for Payer: Cigna Medicare |
$72.33
|
| Rate for Payer: Employer Direct Commercial |
$72.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$72.33
|
| Rate for Payer: Molina CHIP/Medicaid |
$201.60
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Molina Medicare |
$72.33
|
| Rate for Payer: Multiplan Auto |
$182.00
|
| Rate for Payer: Multiplan Commercial |
$182.00
|
| Rate for Payer: Multiplan Workers Comp |
$182.00
|
| Rate for Payer: Parkland Medicaid |
$201.60
|
| Rate for Payer: Scott and White EPO/PPO |
$17.70
|
| Rate for Payer: Scott and White Medicare |
$72.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$201.60
|
| Rate for Payer: Superior Health Plan EPO |
$72.33
|
| Rate for Payer: Superior Health Plan Medicare |
$72.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Universal American Medicare |
$72.33
|
| Rate for Payer: Wellcare Medicare |
$72.33
|
| Rate for Payer: Wellmed Medicare |
$72.33
|
|
|
Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
7003650
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$18.93 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.70
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$47.04
|
| Rate for Payer: Amerigroup Medicare |
$47.04
|
| Rate for Payer: BCBS of TX Blue Advantage |
$99.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$118.80
|
| Rate for Payer: BCBS of TX Medicare |
$47.04
|
| Rate for Payer: BCBS of TX PPO |
$132.00
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$99.43
|
| Rate for Payer: Cigna Medicaid |
$237.60
|
| Rate for Payer: Cigna Medicare |
$47.04
|
| Rate for Payer: Employer Direct Commercial |
$47.04
|
| Rate for Payer: Humana Medicare/TRICARE |
$47.04
|
| Rate for Payer: Molina CHIP/Medicaid |
$237.60
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$47.04
|
| Rate for Payer: Molina Medicare |
$47.04
|
| Rate for Payer: Multiplan Auto |
$214.50
|
| Rate for Payer: Multiplan Commercial |
$214.50
|
| Rate for Payer: Multiplan Workers Comp |
$214.50
|
| Rate for Payer: Parkland Medicaid |
$237.60
|
| Rate for Payer: Scott and White EPO/PPO |
$18.93
|
| Rate for Payer: Scott and White Medicare |
$47.04
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$237.60
|
| Rate for Payer: Superior Health Plan EPO |
$47.04
|
| Rate for Payer: Superior Health Plan Medicare |
$47.04
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$47.04
|
| Rate for Payer: Universal American Medicare |
$47.04
|
| Rate for Payer: Wellcare Medicare |
$47.04
|
| Rate for Payer: Wellmed Medicare |
$47.04
|
|
|
Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
7003650
|
|
Hospital Revenue Code
|
260
|
| Rate for Payer: Cash Price |
$224.40
|
|
|
Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
8932543
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$18.93 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$29.70
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$47.04
|
| Rate for Payer: Amerigroup Medicare |
$47.04
|
| Rate for Payer: BCBS of TX Blue Advantage |
$99.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$118.80
|
| Rate for Payer: BCBS of TX Medicare |
$47.04
|
| Rate for Payer: BCBS of TX PPO |
$132.00
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$99.43
|
| Rate for Payer: Cigna Medicaid |
$237.60
|
| Rate for Payer: Cigna Medicare |
$47.04
|
| Rate for Payer: Employer Direct Commercial |
$47.04
|
| Rate for Payer: Humana Medicare/TRICARE |
$47.04
|
| Rate for Payer: Molina CHIP/Medicaid |
$237.60
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$47.04
|
| Rate for Payer: Molina Medicare |
$47.04
|
| Rate for Payer: Multiplan Auto |
$214.50
|
| Rate for Payer: Multiplan Commercial |
$214.50
|
| Rate for Payer: Multiplan Workers Comp |
$214.50
|
| Rate for Payer: Parkland Medicaid |
$237.60
|
| Rate for Payer: Scott and White EPO/PPO |
$18.93
|
| Rate for Payer: Scott and White Medicare |
$47.04
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$237.60
|
| Rate for Payer: Superior Health Plan EPO |
$47.04
|
| Rate for Payer: Superior Health Plan Medicare |
$47.04
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$47.04
|
| Rate for Payer: Universal American Medicare |
$47.04
|
| Rate for Payer: Wellcare Medicare |
$47.04
|
| Rate for Payer: Wellmed Medicare |
$47.04
|
|
|
Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
8932543
|
|
Hospital Revenue Code
|
260
|
| Rate for Payer: Cash Price |
$224.40
|
|
|
Therapy, Prophylactic, Diagnostic Injection SQ or IM 96372
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
1500370
|
|
Hospital Revenue Code
|
260
|
| Rate for Payer: Cash Price |
$190.40
|
|
|
Therapy, Prophylactic, Diagnostic Injection SQ or IM 96372
|
Facility
|
OP
|
$280.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
1500370
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$17.70 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$25.20
|
| Rate for Payer: Amerigroup Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Amerigroup Medicare |
$72.33
|
| Rate for Payer: BCBS of TX Blue Advantage |
$84.00
|
| Rate for Payer: BCBS of TX Blue Essentials |
$100.80
|
| Rate for Payer: BCBS of TX Medicare |
$72.33
|
| Rate for Payer: BCBS of TX PPO |
$112.00
|
| Rate for Payer: Cash Price |
$190.40
|
| Rate for Payer: Cash Price |
$190.40
|
| Rate for Payer: Cash Price |
$190.40
|
| Rate for Payer: Cigna Commercial |
$152.89
|
| Rate for Payer: Cigna Medicaid |
$201.60
|
| Rate for Payer: Cigna Medicare |
$72.33
|
| Rate for Payer: Employer Direct Commercial |
$72.33
|
| Rate for Payer: Humana Medicare/TRICARE |
$72.33
|
| Rate for Payer: Molina CHIP/Medicaid |
$201.60
|
| Rate for Payer: Molina Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Molina Medicare |
$72.33
|
| Rate for Payer: Multiplan Auto |
$182.00
|
| Rate for Payer: Multiplan Commercial |
$182.00
|
| Rate for Payer: Multiplan Workers Comp |
$182.00
|
| Rate for Payer: Parkland Medicaid |
$201.60
|
| Rate for Payer: Scott and White EPO/PPO |
$17.70
|
| Rate for Payer: Scott and White Medicare |
$72.33
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$201.60
|
| Rate for Payer: Superior Health Plan EPO |
$72.33
|
| Rate for Payer: Superior Health Plan Medicare |
$72.33
|
| Rate for Payer: Universal American Dual Medicare/Medicaid |
$72.33
|
| Rate for Payer: Universal American Medicare |
$72.33
|
| Rate for Payer: Wellcare Medicare |
$72.33
|
| Rate for Payer: Wellmed Medicare |
$72.33
|
|
|
Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additi
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
CPT 64629
|
| Hospital Charge Code |
36064629
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$239.07 |
| 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
|
| Rate for Payer: Scott and White EPO/PPO |
$239.07
|
|
|
Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additi
|
Facility
|
IP
|
$78,288.48
|
|
|
Service Code
|
HCPCS 64629
|
| Hospital Charge Code |
9900826
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$53,236.17
|
|
|
Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additi
|
Facility
|
OP
|
$78,288.48
|
|
|
Service Code
|
HCPCS 64629
|
| Hospital Charge Code |
9900826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,045.96 |
| Max. Negotiated Rate |
$56,367.71 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7,045.96
|
| Rate for Payer: BCBS of TX Blue Advantage |
$23,486.54
|
| Rate for Payer: BCBS of TX Blue Essentials |
$28,183.85
|
| Rate for Payer: BCBS of TX PPO |
$31,315.39
|
| Rate for Payer: Cash Price |
$53,236.17
|
| Rate for Payer: Cash Price |
$53,236.17
|
| Rate for Payer: Cigna Medicaid |
$56,367.71
|
| Rate for Payer: Molina CHIP/Medicaid |
$56,367.71
|
| 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 |
$56,367.71
|
| Rate for Payer: Scott and White EPO/PPO |
$39,144.24
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$56,367.71
|
| Rate for Payer: Superior Health Plan EPO |
$10,647.23
|
|
|
Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 ver
|
Facility
|
OP
|
$31,735.09
|
|
|
Service Code
|
CPT 64628
|
| Hospital Charge Code |
36064628
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,534.26 |
| Max. Negotiated Rate |
$31,735.09 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7,534.26
|
| 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 |
$21,030.79
|
| Rate for Payer: BCBS of TX Blue Essentials |
$25,186.58
|
| Rate for Payer: BCBS of TX Medicare |
$12,897.19
|
| Rate for Payer: BCBS of TX PPO |
$31,735.09
|
| 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 |
$22,267.47
|
| 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
|
|
|
Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 ver
|
Facility
|
OP
|
$78,288.48
|
|
|
Service Code
|
HCPCS 64628
|
| Hospital Charge Code |
9900825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,534.26 |
| Max. Negotiated Rate |
$56,367.71 |
| Rate for Payer: Amerigroup CHIP/Medicaid |
$7,534.26
|
| 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 |
$21,030.79
|
| Rate for Payer: BCBS of TX Blue Essentials |
$25,186.58
|
| Rate for Payer: BCBS of TX Medicare |
$12,897.19
|
| Rate for Payer: BCBS of TX PPO |
$31,735.09
|
| Rate for Payer: Cash Price |
$53,236.17
|
| Rate for Payer: Cash Price |
$53,236.17
|
| Rate for Payer: Cash Price |
$53,236.17
|
| Rate for Payer: Cigna Commercial |
$27,262.32
|
| Rate for Payer: Cigna Medicaid |
$56,367.71
|
| 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 |
$56,367.71
|
| 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 |
$56,367.71
|
| Rate for Payer: Scott and White EPO/PPO |
$22,267.47
|
| Rate for Payer: Scott and White Medicare |
$12,897.19
|
| Rate for Payer: Superior Health Plan CHIP/Medicaid |
$56,367.71
|
| 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
|
|
