1400 8TH AVENUE, FORT WORTH, TX, 450137
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| Procedure | Type | Code | Payers | Gross | Cash | Neg min | Neg median | Neg max |
|---|---|---|---|---|---|---|---|---|
| behavioral | ||||||||
| Psychoses | MS-DRG | 885 | 18 | — | — | $1,458 | $12,440 | $30,024 |
| imaging | ||||||||
| EKG tracing only | CPT | 93005 | 14 | — | — | $53.31 | $58.93 | $892 |
| inpatient | ||||||||
| Intracranial hemorrhage/CVA w MCC | MS-DRG | 064 | 18 | — | — | $2,778 | $18,692 | $42,370 |
| Intracranial hemorrhage/CVA w CC | MS-DRG | 065 | 18 | — | — | $2,778 | $9,773.7 | $21,660 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG | 066 | 18 | — | — | $2,778 | $6,681.63 | $14,661 |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 18 | — | — | $2,778 | $15,433 | $34,431 |
| COPD w MCC | MS-DRG | 190 | 18 | — | — | $2,778 | $10,597 | $23,920 |
| COPD w CC | MS-DRG | 191 | 18 | — | — | $2,778 | $8,163.98 | $18,299 |
| COPD w/o CC/MCC | MS-DRG | 192 | 18 | — | — | $2,778 | $6,353.55 | $13,785 |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 18 | — | — | $2,778 | $7,906.28 | $17,466 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG | 195 | 18 | — | — | $2,778 | $6,157.99 | $13,264 |
| AMI discharged alive w MCC | MS-DRG | 280 | 19 | — | — | $12,261 | $16,240 | $34,962 |
| AMI discharged alive w CC | MS-DRG | 281 | 19 | — | — | $6,885.67 | $9,326.48 | $26,466 |
| AMI discharged alive w/o CC/MCC | MS-DRG | 282 | 19 | — | — | $5,416.36 | $7,403.97 | $19,849 |
| Heart failure & shock w MCC | MS-DRG | 291 | 18 | — | — | $2,778 | $12,346 | $27,792 |
| Heart failure & shock w CC | MS-DRG | 292 | 18 | — | — | $2,778 | $8,236.1 | $18,344 |
| Heart failure & shock w/o CC/MCC | MS-DRG | 293 | 18 | — | — | $2,778 | $5,567.25 | $11,983 |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 18 | — | — | $2,778 | $11,560 | $25,686 |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 18 | — | — | $2,778 | $7,161.04 | $15,747 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG | 310 | 18 | — | — | $2,778 | $5,653.44 | $12,168 |
| GI hemorrhage w CC | MS-DRG | 378 | 18 | — | — | $2,778 | $9,460.22 | $21,000 |
| GI hemorrhage w/o CC/MCC | MS-DRG | 379 | 18 | — | — | $2,778 | $6,269.73 | $13,562 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 18 | — | — | $2,778 | $7,554.33 | $16,620 |
| Fractures of femur w/o MCC | MS-DRG | 533 | 18 | — | — | $2,778 | $14,632 | $32,480 |
| Kidney/UTI w MCC | MS-DRG | 689 | 18 | — | — | $2,778 | $11,293 | $24,927 |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 18 | — | — | $2,778 | $7,759.15 | $17,095 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 18 | — | — | $2,778 | $18,455 | $41,793 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 18 | — | — | $2,778 | $9,903.52 | $21,960 |
| lab | ||||||||
| Comprehensive metabolic panel | CPT | 80053 | 14 | — | — | $10.03 | $11.09 | $51.64 |
| Complete blood count with automated differential | CPT | 85025 | 14 | — | — | $7.38 | $8.16 | $38 |
| Tissue exam by pathologist level IV | CPT | 88305 | 14 | — | — | $47.23 | $52.21 | $241.91 |
| maternity | ||||||||
| C-section delivery only | CPT | 59514 | 2 | — | — | $1,518.26 | $3,046 | $7,702 |
| preventive | ||||||||
| Upper GI endoscopy diagnostic | CPT | 43235 | 17 | — | — | $334.95 | $956.41 | $4,042 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 17 | — | — | $334.95 | $956.41 | $5,016 |
| Sigmoidoscopy diagnostic | CPT | 45330 | 16 | — | — | $130.67 | $879.44 | $4,042 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 16 | — | — | $328.5 | $922.38 | $4,042 |
| Colonoscopy diagnostic | CPT | 45378 | 17 | — | — | $328.5 | $964.3 | $5,016 |
| Colonoscopy with biopsy | CPT | 45380 | 17 | — | — | $429.26 | $1,245.07 | $5,016 |
| Colonoscopy with polyp removal | CPT | 45385 | 17 | — | — | $429.26 | $1,245.07 | $5,016 |
| surgery | ||||||||
| Total shoulder arthroplasty | CPT | 23472 | 15 | — | — | $2,417.79 | $17,098 | $35,393 |
| Hip hemiarthroplasty | CPT | 27125 | 4 | — | — | $1,886.14 | $6,546 | $16,721 |
| Total hip replacement | CPT | 27130 | 15 | — | — | $6,546 | $13,282 | $40,224 |
| Total knee replacement | CPT | 27447 | 15 | — | — | $6,546 | $13,282 | $40,224 |
| Knee revision arthroplasty single component | CPT | 27486 | 4 | — | — | $2,337.65 | $6,546 | $16,721 |
| Knee revision arthroplasty all components | CPT | 27487 | 4 | — | — | $2,925.22 | $6,546 | $16,721 |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 17 | — | — | $2,398.52 | $6,891.76 | $20,219 |
| Major small/large bowel procedures w MCC | MS-DRG | 329 | 18 | — | — | $6,182 | $41,447 | $97,807 |
| Major small/large bowel procedures w CC | MS-DRG | 330 | 18 | — | — | $6,182 | $21,966 | $50,347 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 18 | — | — | $6,182 | $15,735 | $35,166 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG | 418 | 18 | — | — | $6,182 | $15,719 | $35,324 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG | 419 | 18 | — | — | $6,182 | $12,628 | $28,065 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG | 420 | 18 | — | — | $6,182 | $31,017 | $75,178 |
| Laparoscopic appendectomy | CPT | 44970 | 15 | — | — | $5,029.05 | $6,293.75 | $16,338 |
| Spinal fusion (non-cervical) w MCC | MS-DRG | 459 | 6 | — | — | $35,308 | $68,382 | $103,364 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG | 460 | 6 | — | — | $35,174 | $37,715 | $57,008 |
| Major joint replacement w MCC | MS-DRG | 469 | 19 | — | — | $24,417 | $32,313 | $69,623 |
| Major joint replacement w/o MCC | MS-DRG | 470 | 19 | — | — | $14,084 | $18,984 | $40,161 |
| Laparoscopic cholecystectomy | CPT | 47562 | 16 | — | — | $1,888.85 | $5,823.12 | $16,338 |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 16 | — | — | $1,888.85 | $5,823.12 | $16,338 |
| Hip & femur procedures except major joint w MCC | MS-DRG | 480 | 19 | — | — | $9,144 | $26,430 | $62,643 |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 19 | — | — | $9,144 | $18,838 | $44,195 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG | 482 | 19 | — | — | $9,144 | $14,556 | $33,790 |
| Lap inguinal hernia repair | CPT | 49650 | 17 | — | — | $1,888.85 | $6,087.8 | $16,338 |
| Total abdominal hysterectomy | CPT | 58150 | 4 | — | — | $1,677.98 | $5,369 | $16,163 |
| Vaginal hysterectomy | CPT | 58260 | 16 | — | — | $1,526.99 | $5,019.71 | $15,605 |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 17 | — | — | $1,888.85 | $6,087.8 | $16,721 |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 16 | — | — | $3,110.01 | $9,904.96 | $28,436 |
| Lap salpingo-oophorectomy | CPT | 58661 | 17 | — | — | $1,888.85 | $6,087.8 | $16,338 |
| OR procedure for obesity w MCC | MS-DRG | 619 | 19 | — | — | $6,182 | $25,685 | $58,074 |
| OR procedure for obesity w CC | MS-DRG | 620 | 19 | — | — | $6,182 | $15,763 | $34,016 |
| OR procedure for obesity w/o CC/MCC | MS-DRG | 621 | 19 | — | — | $6,182 | $14,595 | $31,136 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 18 | — | — | $6,182 | $11,174 | $25,532 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG | 744 | 18 | — | — | $6,182 | $18,101 | $41,620 |
| Payer | Codes covered | Median rate |
|---|---|---|
| Blue Cross Blue Shield | 73 | $11,909 |
| Aetna | 72 | $11,161 |
| UnitedHealthcare | 70 | $15,011 |
| Humana | 68 | $6,182 |
| Cigna | 67 | $10,042 |
| healthspring | 66 | $8,801.48 |
| wellpoint (fka amerigroup) | 66 | $6,842.57 |
| Ambetter | 66 | $18,944 |
| american health plan | 66 | $8,801.48 |
| baylor scott & white health plan | 66 | $10,594 |
| corvel | 66 | $8,781.36 |
| prime health services | 66 | $8,781.36 |
| procare advantage | 66 | $8,801.48 |
| superior health plan | 66 | $6,975.43 |
| triwest | 66 | $8,382.36 |
| healthsmart | 54 | $9,655.73 |
| employers health network | 45 | $13,367 |
| university of mary hardin-baylor | 43 | $11,228 |
| cook children's health plan | 15 | $1,526.99 |
| private health care system | 13 | $28,880 |
