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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
TX
TXDOI-MRF-CPT-52356
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Texas Department of Insurance (TDI) & CMS Novitas JH Payer MRF Index — Dallas-Fort Worth MSA
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Travis County, TX
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Filing / IDR Window: 2026-11-18
TX Commercial Payer TiC MRF & NSA IDR Cohort — CPT 52000 / 52356 Urology
Commercial payer TiC MRF negotiated rate audit, CMS Medicare MPFS RVU/GPCI locality repricing, and ERISA 29 CFR § 2560.503-1 / Federal No Surprises Act (45 CFR § 149.510) IDR arbitration package for Urology & Lithotripsy in TX (CPT 52356 Cystourethroscopy with Lithotripsy & Stent Insertion).
Cohort MRF 75th-Pct Value
$1,845,000
Target % of Medicare
228.5% MPFS
Statutory Authority
TX-GPCI-2026-DFW (Medicare Locality 04412-11 & TX Ins. Code § 1301.103 18% Prompt-Pay)
ERISA / Timely-Filing Window
180 Days
1. Commercial Payer TiC MRF Allowed-Amount Benchmarks (API #02)
| CPT / DRG Code | Clinical Procedure Description | Unit | Cohort Claims | MRF 25th Pct | MRF Median (QPA) | MRF 75th Pct |
|---|---|---|---|---|---|---|
| CPT-52356 | Urology & Lithotripsy: Cystourethroscopy with Ureteroscopy, Lithotripsy & Indwelling Stent Insertion | CLAIM | 230 | $810.00 | $1,240.00 | $1,745.00 |
| CPT-29881 | Knee Arthroscopy, Surgical, with Meniscectomy (Medial OR Lateral, ASC Facility + Pro) | CLAIM | 420 | $640.00 | $1,485.00 | $1,890.00 |
| CPT-27447 | Arthroplasty, Knee, Condyle and Plateau; Medial AND Lateral Compartments (Total Knee) | CLAIM | 115 | $4,850.00 | $9,420.00 | $11,850.00 |
| CPT-29827 | Shoulder Arthroscopy, Surgical, with Rotator Cuff Repair (Modifier 59 / XU Audit) | CLAIM | 210 | $1,120.00 | $2,340.00 | $2,890.00 |
| CPT-64483 | Transforaminal Epidural Injection, Lumbar or Sacral, Single Level (Fluoroscopic Guidance) | CLAIM | 680 | $285.00 | $615.00 | $780.00 |
| CPT-99214-25 | Level 4 Established Patient Office/Outpatient E/M with Significant Separately Identifiable Mod 25 | CLAIM | 1,450 | $118.00 | $176.00 | $208.00 |
| CPT-63030 | Neurosurgery & Spine: Lumbar Laminotomy/Discectomy (1 Interspace) & CPT 22551 Anterior Cervical ACDF | CLAIM | 185 | $1,480.00 | $2,190.00 | $2,940.00 |
| CPT-45380 | Gastroenterology & Endoscopy ASC: Flexible Colonoscopy with Biopsy & CPT 43239 Upper GI EGD | CLAIM | 610 | $520.00 | $795.00 | $1,140.00 |
| CPT-66984 | Ophthalmology & Ophthalmic ASC: Extracapsular Cataract Removal with IOL Prosthesis & CPT 67028 | CLAIM | 540 | $680.00 | $985.00 | $1,390.00 |
| CPT-70553 | Diagnostic Radiology & Cardiology: Brain MRI w/ & w/o Contrast, CPT 74177 CT & CPT 93306 Echo | CLAIM | 480 | $410.00 | $685.00 | $995.00 |
| CPT-99285 | Emergency Medicine, Pathology & Anesthesia: Level-5 E/M, CPT 88305 Surgical Path & CPT 01402 QPA | CLAIM | 890 | $340.00 | $565.00 | $845.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Urology AustinTX Regional Urology Associates PATX Ambulatory Urology Center LLC