White Rock Medical Center

All Charges

Charge

Type

Setting

Price

COMP EP EVAL/LV RECORD

Facility

$6,966.00

Service Code	CPT 93622
Hospital Charge Code	4610612
Hospital Revenue Code	480
Rate for Payer: Cash Price	$6,130.08

COMP EP IND/ABLA SVT

Facility

$23,874.00

Service Code	CPT 93653
Hospital Charge Code	4613653
Hospital Revenue Code	480
Rate for Payer: Cash Price	$21,009.12

COMP EP IND/ABLA SVT

Facility

$23,874.00

Service Code	CPT 93653
Hospital Charge Code	4613653
Hospital Revenue Code	480
Min. Negotiated Rate	$388.45
Max. Negotiated Rate	$51,496.88
Rate for Payer: Aetna Commercial	$10,300.00
Rate for Payer: Aetna Medicare	$32,581.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2,148.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,720.85
Rate for Payer: Amerigroup Medicare	$21,720.85
Rate for Payer: BCBS of TX Blue Advantage	$34,126.90
Rate for Payer: BCBS of TX Blue Essentials	$40,870.54
Rate for Payer: BCBS of TX Medicare	$21,720.85
Rate for Payer: BCBS of TX PPO	$51,496.88
Rate for Payer: Cash Price	$21,009.12
Rate for Payer: Cash Price	$21,009.12
Rate for Payer: Cash Price	$21,009.12
Rate for Payer: Cigna Commercial	$49,204.03
Rate for Payer: Cigna Medicare	$21,720.85
Rate for Payer: Employer Direct Commercial	$21,720.85
Rate for Payer: Humana Medicare/TRICARE	$21,720.85
Rate for Payer: Molina Dual Medicare/Medicaid	$21,720.85
Rate for Payer: Molina Medicare	$21,720.85
Rate for Payer: Multiplan Auto	$15,518.10
Rate for Payer: Multiplan Commercial	$15,518.10
Rate for Payer: Multiplan Workers Comp	$15,518.10
Rate for Payer: Scott and White EPO/PPO	$388.45
Rate for Payer: Scott and White Medicare	$21,720.85
Rate for Payer: Superior Health Plan EPO	$21,720.85
Rate for Payer: Superior Health Plan Medicare	$21,720.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,720.85
Rate for Payer: Universal American Medicare	$21,720.85
Rate for Payer: Wellcare Medicare	$21,720.85
Rate for Payer: Wellmed Medicare	$21,720.85

COMP EP W/O INDUC/ARRYTH

Facility

$7,540.00

Service Code	CPT 93619
Hospital Charge Code	4610615
Hospital Revenue Code	480
Rate for Payer: Cash Price	$6,635.20

COMP EP W/O INDUC/ARRYTH

Facility

$7,540.00

Service Code	CPT 93619
Hospital Charge Code	4610615
Hospital Revenue Code	480
Min. Negotiated Rate	$122.15
Max. Negotiated Rate	$15,471.93
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$10,245.00
Rate for Payer: Amerigroup CHIP/Medicaid	$678.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,830.00
Rate for Payer: Amerigroup Medicare	$6,830.00
Rate for Payer: BCBS of TX Blue Advantage	$10,241.14
Rate for Payer: BCBS of TX Blue Essentials	$12,242.28
Rate for Payer: BCBS of TX Medicare	$6,830.00
Rate for Payer: BCBS of TX PPO	$13,654.85
Rate for Payer: Cash Price	$6,635.20
Rate for Payer: Cash Price	$6,635.20
Rate for Payer: Cash Price	$6,635.20
Rate for Payer: Cigna Commercial	$15,471.93
Rate for Payer: Cigna Medicare	$6,830.00
Rate for Payer: Employer Direct Commercial	$6,830.00
Rate for Payer: Humana Medicare/TRICARE	$6,830.00
Rate for Payer: Molina Dual Medicare/Medicaid	$6,830.00
Rate for Payer: Molina Medicare	$6,830.00
Rate for Payer: Multiplan Auto	$4,901.00
Rate for Payer: Multiplan Commercial	$4,901.00
Rate for Payer: Multiplan Workers Comp	$4,901.00
Rate for Payer: Scott and White EPO/PPO	$122.15
Rate for Payer: Scott and White Medicare	$6,830.00
Rate for Payer: Superior Health Plan EPO	$6,830.00
Rate for Payer: Superior Health Plan Medicare	$6,830.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,830.00
Rate for Payer: Universal American Medicare	$6,830.00
Rate for Payer: Wellcare Medicare	$6,830.00
Rate for Payer: Wellmed Medicare	$6,830.00

Complement C3, Serum SO

Facility

$336.00

Service Code	CPT 86160
Hospital Charge Code	1702562
Hospital Revenue Code	302
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$218.40
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.00
Rate for Payer: Amerigroup Medicare	$12.00
Rate for Payer: BCBS of TX Blue Advantage	$19.80
Rate for Payer: BCBS of TX Blue Essentials	$23.76
Rate for Payer: BCBS of TX Medicare	$12.00
Rate for Payer: BCBS of TX PPO	$26.52
Rate for Payer: Cash Price	$295.68
Rate for Payer: Cash Price	$295.68
Rate for Payer: Cigna Medicaid	$12.00
Rate for Payer: Cigna Medicare	$12.00
Rate for Payer: Employer Direct Commercial	$12.00
Rate for Payer: Humana Medicare/TRICARE	$12.00
Rate for Payer: Molina CHIP/Medicaid	$12.00
Rate for Payer: Molina Dual Medicare/Medicaid	$12.00
Rate for Payer: Molina Medicare	$12.00
Rate for Payer: Multiplan Auto	$218.40
Rate for Payer: Multiplan Commercial	$218.40
Rate for Payer: Multiplan Workers Comp	$218.40
Rate for Payer: Parkland Medicaid	$12.00
Rate for Payer: Scott and White EPO/PPO	$15.00
Rate for Payer: Scott and White Medicare	$12.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.00
Rate for Payer: Superior Health Plan EPO	$12.00
Rate for Payer: Superior Health Plan Medicare	$12.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.00
Rate for Payer: Universal American Medicare	$12.00
Rate for Payer: Wellcare Medicare	$12.00
Rate for Payer: Wellmed Medicare	$12.00

Complement C4, Serum SO

Facility

$336.00

Service Code	CPT 86160
Hospital Charge Code	1702562
Hospital Revenue Code	302
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$218.40
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.00
Rate for Payer: Amerigroup Medicare	$12.00
Rate for Payer: BCBS of TX Blue Advantage	$19.80
Rate for Payer: BCBS of TX Blue Essentials	$23.76
Rate for Payer: BCBS of TX Medicare	$12.00
Rate for Payer: BCBS of TX PPO	$26.52
Rate for Payer: Cash Price	$295.68
Rate for Payer: Cash Price	$295.68
Rate for Payer: Cigna Medicaid	$12.00
Rate for Payer: Cigna Medicare	$12.00
Rate for Payer: Employer Direct Commercial	$12.00
Rate for Payer: Humana Medicare/TRICARE	$12.00
Rate for Payer: Molina CHIP/Medicaid	$12.00
Rate for Payer: Molina Dual Medicare/Medicaid	$12.00
Rate for Payer: Molina Medicare	$12.00
Rate for Payer: Multiplan Auto	$218.40
Rate for Payer: Multiplan Commercial	$218.40
Rate for Payer: Multiplan Workers Comp	$218.40
Rate for Payer: Parkland Medicaid	$12.00
Rate for Payer: Scott and White EPO/PPO	$15.00
Rate for Payer: Scott and White Medicare	$12.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.00
Rate for Payer: Superior Health Plan EPO	$12.00
Rate for Payer: Superior Health Plan Medicare	$12.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.00
Rate for Payer: Universal American Medicare	$12.00
Rate for Payer: Wellcare Medicare	$12.00
Rate for Payer: Wellmed Medicare	$12.00

Complement C6 Level SO

Facility

$336.00

Service Code	CPT 86160
Hospital Charge Code	1702562
Hospital Revenue Code	302
Rate for Payer: Cash Price	$295.68

Complement C6 Level SO

Facility

$336.00

Service Code	CPT 86160
Hospital Charge Code	1702562
Hospital Revenue Code	302
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$218.40
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.00
Rate for Payer: Amerigroup Medicare	$12.00
Rate for Payer: BCBS of TX Blue Advantage	$19.80
Rate for Payer: BCBS of TX Blue Essentials	$23.76
Rate for Payer: BCBS of TX Medicare	$12.00
Rate for Payer: BCBS of TX PPO	$26.52
Rate for Payer: Cash Price	$295.68
Rate for Payer: Cash Price	$295.68
Rate for Payer: Cigna Medicaid	$12.00
Rate for Payer: Cigna Medicare	$12.00
Rate for Payer: Employer Direct Commercial	$12.00
Rate for Payer: Humana Medicare/TRICARE	$12.00
Rate for Payer: Molina CHIP/Medicaid	$12.00
Rate for Payer: Molina Dual Medicare/Medicaid	$12.00
Rate for Payer: Molina Medicare	$12.00
Rate for Payer: Multiplan Auto	$218.40
Rate for Payer: Multiplan Commercial	$218.40
Rate for Payer: Multiplan Workers Comp	$218.40
Rate for Payer: Parkland Medicaid	$12.00
Rate for Payer: Scott and White EPO/PPO	$15.00
Rate for Payer: Scott and White Medicare	$12.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.00
Rate for Payer: Superior Health Plan EPO	$12.00
Rate for Payer: Superior Health Plan Medicare	$12.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.00
Rate for Payer: Universal American Medicare	$12.00
Rate for Payer: Wellcare Medicare	$12.00
Rate for Payer: Wellmed Medicare	$12.00

Complement Component 5 SO

Facility

$336.00

Service Code	CPT 86160
Hospital Charge Code	1702562
Hospital Revenue Code	302
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$218.40
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.00
Rate for Payer: Amerigroup Medicare	$12.00
Rate for Payer: BCBS of TX Blue Advantage	$19.80
Rate for Payer: BCBS of TX Blue Essentials	$23.76
Rate for Payer: BCBS of TX Medicare	$12.00
Rate for Payer: BCBS of TX PPO	$26.52
Rate for Payer: Cash Price	$295.68
Rate for Payer: Cash Price	$295.68
Rate for Payer: Cigna Medicaid	$12.00
Rate for Payer: Cigna Medicare	$12.00
Rate for Payer: Employer Direct Commercial	$12.00
Rate for Payer: Humana Medicare/TRICARE	$12.00
Rate for Payer: Molina CHIP/Medicaid	$12.00
Rate for Payer: Molina Dual Medicare/Medicaid	$12.00
Rate for Payer: Molina Medicare	$12.00
Rate for Payer: Multiplan Auto	$218.40
Rate for Payer: Multiplan Commercial	$218.40
Rate for Payer: Multiplan Workers Comp	$218.40
Rate for Payer: Parkland Medicaid	$12.00
Rate for Payer: Scott and White EPO/PPO	$15.00
Rate for Payer: Scott and White Medicare	$12.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.00
Rate for Payer: Superior Health Plan EPO	$12.00
Rate for Payer: Superior Health Plan Medicare	$12.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.00
Rate for Payer: Universal American Medicare	$12.00
Rate for Payer: Wellcare Medicare	$12.00
Rate for Payer: Wellmed Medicare	$12.00

Complement, Total (CH50) SO

Facility

$215.00

Service Code	CPT 86162
Hospital Charge Code	1702521
Hospital Revenue Code	302
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$139.75
Rate for Payer: Aetna Commercial	$21.33
Rate for Payer: Aetna Medicare	$30.48
Rate for Payer: Amerigroup CHIP/Medicaid	$7.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.32
Rate for Payer: Amerigroup Medicare	$20.32
Rate for Payer: BCBS of TX Blue Advantage	$33.53
Rate for Payer: BCBS of TX Blue Essentials	$40.23
Rate for Payer: BCBS of TX Medicare	$20.32
Rate for Payer: BCBS of TX PPO	$44.91
Rate for Payer: Cash Price	$189.20
Rate for Payer: Cash Price	$189.20
Rate for Payer: Cigna Medicaid	$20.32
Rate for Payer: Cigna Medicare	$20.32
Rate for Payer: Employer Direct Commercial	$20.32
Rate for Payer: Humana Medicare/TRICARE	$20.32
Rate for Payer: Molina CHIP/Medicaid	$20.32
Rate for Payer: Molina Dual Medicare/Medicaid	$20.32
Rate for Payer: Molina Medicare	$20.32
Rate for Payer: Multiplan Auto	$139.75
Rate for Payer: Multiplan Commercial	$139.75
Rate for Payer: Multiplan Workers Comp	$139.75
Rate for Payer: Parkland Medicaid	$20.32
Rate for Payer: Scott and White EPO/PPO	$25.40
Rate for Payer: Scott and White Medicare	$20.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.32
Rate for Payer: Superior Health Plan EPO	$20.32
Rate for Payer: Superior Health Plan Medicare	$20.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.32
Rate for Payer: Universal American Medicare	$20.32
Rate for Payer: Wellcare Medicare	$20.32
Rate for Payer: Wellmed Medicare	$20.32

Complement, Total (CH50) SO

Facility

$215.00

Service Code	CPT 86162
Hospital Charge Code	1702521
Hospital Revenue Code	302
Rate for Payer: Cash Price	$189.20

COMPLICATED PEPTIC ULCER WITH CC

Facility

$20,387.00

Service Code	MSDRG 381
Min. Negotiated Rate	$9,245.00
Max. Negotiated Rate	$20,387.00
Rate for Payer: Aetna Commercial	$12,071.25
Rate for Payer: Aetna Medicare	$15,767.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,511.77
Rate for Payer: Amerigroup Medicare	$10,511.77
Rate for Payer: BCBS of TX Blue Advantage	$9,245.00
Rate for Payer: BCBS of TX Blue Essentials	$11,299.30
Rate for Payer: BCBS of TX Medicare	$10,511.77
Rate for Payer: BCBS of TX PPO	$12,555.27
Rate for Payer: Cigna Commercial	$13,820.24
Rate for Payer: Cigna Medicare	$10,511.77
Rate for Payer: Employer Direct Commercial	$10,511.77
Rate for Payer: Humana Medicare/TRICARE	$10,511.77
Rate for Payer: Molina Dual Medicare/Medicaid	$10,511.77
Rate for Payer: Molina Medicare	$10,511.77
Rate for Payer: Multiplan Auto	$20,387.00
Rate for Payer: Multiplan Commercial	$20,387.00
Rate for Payer: Multiplan Workers Comp	$20,387.00
Rate for Payer: Scott and White EPO/PPO	$9,388.75
Rate for Payer: Scott and White Medicare	$10,511.77
Rate for Payer: Superior Health Plan EPO	$10,511.77
Rate for Payer: Superior Health Plan Medicare	$10,511.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,511.77
Rate for Payer: Universal American Medicare	$10,511.77
Rate for Payer: Wellcare Medicare	$10,511.77
Rate for Payer: Wellmed Medicare	$10,511.77

COMPLICATED PEPTIC ULCER WITH MCC

Facility

$37,021.50

Service Code	MSDRG 380
Min. Negotiated Rate	$16,759.39
Max. Negotiated Rate	$37,021.50
Rate for Payer: Aetna Commercial	$21,920.62
Rate for Payer: Aetna Medicare	$25,139.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,759.39
Rate for Payer: Amerigroup Medicare	$16,759.39
Rate for Payer: BCBS of TX Blue Advantage	$17,368.56
Rate for Payer: BCBS of TX Blue Essentials	$20,080.77
Rate for Payer: BCBS of TX Medicare	$16,759.39
Rate for Payer: BCBS of TX PPO	$22,312.84
Rate for Payer: Cigna Commercial	$25,096.68
Rate for Payer: Cigna Medicare	$16,759.39
Rate for Payer: Employer Direct Commercial	$16,759.39
Rate for Payer: Humana Medicare/TRICARE	$16,759.39
Rate for Payer: Molina Dual Medicare/Medicaid	$16,759.39
Rate for Payer: Molina Medicare	$16,759.39
Rate for Payer: Multiplan Auto	$37,021.50
Rate for Payer: Multiplan Commercial	$37,021.50
Rate for Payer: Multiplan Workers Comp	$37,021.50
Rate for Payer: Scott and White EPO/PPO	$17,049.38
Rate for Payer: Scott and White Medicare	$16,759.39
Rate for Payer: Superior Health Plan EPO	$16,759.39
Rate for Payer: Superior Health Plan Medicare	$16,759.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,759.39
Rate for Payer: Universal American Medicare	$16,759.39
Rate for Payer: Wellcare Medicare	$16,759.39
Rate for Payer: Wellmed Medicare	$16,759.39

COMPLICATED PEPTIC ULCER WITHOUT CC/MCC

Facility

$14,384.90

Service Code	MSDRG 382
Min. Negotiated Rate	$6,586.74
Max. Negotiated Rate	$14,384.90
Rate for Payer: Aetna Commercial	$8,517.38
Rate for Payer: Aetna Medicare	$12,386.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,257.50
Rate for Payer: Amerigroup Medicare	$8,257.50
Rate for Payer: BCBS of TX Blue Advantage	$6,586.74
Rate for Payer: BCBS of TX Blue Essentials	$7,922.93
Rate for Payer: BCBS of TX Medicare	$8,257.50
Rate for Payer: BCBS of TX PPO	$8,803.59
Rate for Payer: Cigna Commercial	$9,751.45
Rate for Payer: Cigna Medicare	$8,257.50
Rate for Payer: Employer Direct Commercial	$8,257.50
Rate for Payer: Humana Medicare/TRICARE	$8,257.50
Rate for Payer: Molina Dual Medicare/Medicaid	$8,257.50
Rate for Payer: Molina Medicare	$8,257.50
Rate for Payer: Multiplan Auto	$14,384.90
Rate for Payer: Multiplan Commercial	$14,384.90
Rate for Payer: Multiplan Workers Comp	$14,384.90
Rate for Payer: Scott and White EPO/PPO	$6,624.62
Rate for Payer: Scott and White Medicare	$8,257.50
Rate for Payer: Superior Health Plan EPO	$8,257.50
Rate for Payer: Superior Health Plan Medicare	$8,257.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,257.50
Rate for Payer: Universal American Medicare	$8,257.50
Rate for Payer: Wellcare Medicare	$8,257.50
Rate for Payer: Wellmed Medicare	$8,257.50

COMPLICATIONS OF TREATMENT WITH CC

Facility

$19,642.20

Service Code	MSDRG 920
Min. Negotiated Rate	$8,663.64
Max. Negotiated Rate	$19,642.20
Rate for Payer: Aetna Commercial	$11,630.25
Rate for Payer: Aetna Medicare	$15,348.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,232.05
Rate for Payer: Amerigroup Medicare	$10,232.05
Rate for Payer: BCBS of TX Blue Advantage	$8,663.64
Rate for Payer: BCBS of TX Blue Essentials	$10,350.99
Rate for Payer: BCBS of TX Medicare	$10,232.05
Rate for Payer: BCBS of TX PPO	$11,501.54
Rate for Payer: Cigna Commercial	$13,315.34
Rate for Payer: Cigna Medicare	$10,232.05
Rate for Payer: Employer Direct Commercial	$10,232.05
Rate for Payer: Humana Medicare/TRICARE	$10,232.05
Rate for Payer: Molina Dual Medicare/Medicaid	$10,232.05
Rate for Payer: Molina Medicare	$10,232.05
Rate for Payer: Multiplan Auto	$19,642.20
Rate for Payer: Multiplan Commercial	$19,642.20
Rate for Payer: Multiplan Workers Comp	$19,642.20
Rate for Payer: Scott and White EPO/PPO	$9,045.75
Rate for Payer: Scott and White Medicare	$10,232.05
Rate for Payer: Superior Health Plan EPO	$10,232.05
Rate for Payer: Superior Health Plan Medicare	$10,232.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,232.05
Rate for Payer: Universal American Medicare	$10,232.05
Rate for Payer: Wellcare Medicare	$10,232.05
Rate for Payer: Wellmed Medicare	$10,232.05

COMPLICATIONS OF TREATMENT WITH MCC

Facility

$34,669.30

Service Code	MSDRG 919
Min. Negotiated Rate	$15,247.80
Max. Negotiated Rate	$34,669.30
Rate for Payer: Aetna Commercial	$20,527.88
Rate for Payer: Aetna Medicare	$23,813.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,875.95
Rate for Payer: Amerigroup Medicare	$15,875.95
Rate for Payer: BCBS of TX Blue Advantage	$15,247.80
Rate for Payer: BCBS of TX Blue Essentials	$18,824.95
Rate for Payer: BCBS of TX Medicare	$15,875.95
Rate for Payer: BCBS of TX PPO	$20,917.42
Rate for Payer: Cigna Commercial	$23,502.14
Rate for Payer: Cigna Medicare	$15,875.95
Rate for Payer: Employer Direct Commercial	$15,875.95
Rate for Payer: Humana Medicare/TRICARE	$15,875.95
Rate for Payer: Molina Dual Medicare/Medicaid	$15,875.95
Rate for Payer: Molina Medicare	$15,875.95
Rate for Payer: Multiplan Auto	$34,669.30
Rate for Payer: Multiplan Commercial	$34,669.30
Rate for Payer: Multiplan Workers Comp	$34,669.30
Rate for Payer: Scott and White EPO/PPO	$15,966.12
Rate for Payer: Scott and White Medicare	$15,875.95
Rate for Payer: Superior Health Plan EPO	$15,875.95
Rate for Payer: Superior Health Plan Medicare	$15,875.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,875.95
Rate for Payer: Universal American Medicare	$15,875.95
Rate for Payer: Wellcare Medicare	$15,875.95
Rate for Payer: Wellmed Medicare	$15,875.95

COMPLICATIONS OF TREATMENT WITHOUT CC/MCC

Facility

$13,258.20

Service Code	MSDRG 921
Min. Negotiated Rate	$5,977.00
Max. Negotiated Rate	$13,258.20
Rate for Payer: Aetna Commercial	$7,850.25
Rate for Payer: Aetna Medicare	$11,751.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,834.33
Rate for Payer: Amerigroup Medicare	$7,834.33
Rate for Payer: BCBS of TX Blue Advantage	$5,977.00
Rate for Payer: BCBS of TX Blue Essentials	$7,291.41
Rate for Payer: BCBS of TX Medicare	$7,834.33
Rate for Payer: BCBS of TX PPO	$8,101.88
Rate for Payer: Cigna Commercial	$8,987.66
Rate for Payer: Cigna Medicare	$7,834.33
Rate for Payer: Employer Direct Commercial	$7,834.33
Rate for Payer: Humana Medicare/TRICARE	$7,834.33
Rate for Payer: Molina Dual Medicare/Medicaid	$7,834.33
Rate for Payer: Molina Medicare	$7,834.33
Rate for Payer: Multiplan Auto	$13,258.20
Rate for Payer: Multiplan Commercial	$13,258.20
Rate for Payer: Multiplan Workers Comp	$13,258.20
Rate for Payer: Scott and White EPO/PPO	$6,105.75
Rate for Payer: Scott and White Medicare	$7,834.33
Rate for Payer: Superior Health Plan EPO	$7,834.33
Rate for Payer: Superior Health Plan Medicare	$7,834.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,834.33
Rate for Payer: Universal American Medicare	$7,834.33
Rate for Payer: Wellcare Medicare	$7,834.33
Rate for Payer: Wellmed Medicare	$7,834.33

COMPLX CHRON CARE PLANNING Units

Facility

$139.00

Service Code	HCPCS G0506
Hospital Charge Code	6019903
Hospital Revenue Code	510
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$107.86
Rate for Payer: Aetna Commercial	$76.45
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$80.89
Rate for Payer: BCBS of TX Blue Essentials	$96.70
Rate for Payer: BCBS of TX PPO	$107.86
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Scott and White EPO/PPO	$69.50

Complx Chron Care Planning Units BCE

Facility

$139.00

Service Code	HCPCS G0506
Hospital Charge Code	6019903
Hospital Revenue Code	510
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$107.86
Rate for Payer: Aetna Commercial	$76.45
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$80.89
Rate for Payer: BCBS of TX Blue Essentials	$96.70
Rate for Payer: BCBS of TX PPO	$107.86
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Scott and White EPO/PPO	$69.50

Complx Chron Care Planning Units BCE

Facility

$139.00

Service Code	HCPCS G0506
Hospital Charge Code	6019903
Hospital Revenue Code	510
Rate for Payer: Cash Price	$122.32

Comp. Metabolic Panel (14) SO

Facility

$661.00

Service Code	CPT 80053
Hospital Charge Code	1603190
Hospital Revenue Code	301
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$429.65
Rate for Payer: Aetna Commercial	$11.10
Rate for Payer: Aetna Medicare	$15.84
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.56
Rate for Payer: Amerigroup Medicare	$10.56
Rate for Payer: BCBS of TX Blue Advantage	$17.42
Rate for Payer: BCBS of TX Blue Essentials	$20.91
Rate for Payer: BCBS of TX Medicare	$10.56
Rate for Payer: BCBS of TX PPO	$23.34
Rate for Payer: Cash Price	$581.68
Rate for Payer: Cash Price	$581.68
Rate for Payer: Cigna Medicaid	$10.56
Rate for Payer: Cigna Medicare	$10.56
Rate for Payer: Employer Direct Commercial	$10.56
Rate for Payer: Humana Medicare/TRICARE	$10.56
Rate for Payer: Molina CHIP/Medicaid	$10.56
Rate for Payer: Molina Dual Medicare/Medicaid	$10.56
Rate for Payer: Molina Medicare	$10.56
Rate for Payer: Multiplan Auto	$429.65
Rate for Payer: Multiplan Commercial	$429.65
Rate for Payer: Multiplan Workers Comp	$429.65
Rate for Payer: Parkland Medicaid	$10.56
Rate for Payer: Scott and White EPO/PPO	$13.20
Rate for Payer: Scott and White Medicare	$10.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.56
Rate for Payer: Superior Health Plan EPO	$10.56
Rate for Payer: Superior Health Plan Medicare	$10.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.56
Rate for Payer: Universal American Medicare	$10.56
Rate for Payer: Wellcare Medicare	$10.56
Rate for Payer: Wellmed Medicare	$10.56

COMPONENT ART GRFT HERO -- DHF

Facility

$4,120.42

Service Code	HCPCS C1768
Hospital Charge Code	81741225
Hospital Revenue Code	278
Min. Negotiated Rate	$370.84
Max. Negotiated Rate	$2,060.21
Rate for Payer: Aetna Commercial	$1,236.13
Rate for Payer: Amerigroup CHIP/Medicaid	$370.84
Rate for Payer: BCBS of TX Blue Advantage	$1,236.13
Rate for Payer: BCBS of TX Blue Essentials	$1,483.35
Rate for Payer: BCBS of TX PPO	$1,648.17
Rate for Payer: Cash Price	$3,625.97
Rate for Payer: Multiplan Auto	$2,060.21
Rate for Payer: Multiplan Commercial	$2,060.21
Rate for Payer: Multiplan Workers Comp	$2,060.21
Rate for Payer: Scott and White EPO/PPO	$2,060.21
Rate for Payer: Superior Health Plan EPO	$560.38

COMPONENT ART GRFT HERO -- DHF

Facility

$4,120.42

Service Code	HCPCS C1768
Hospital Charge Code	81741225
Hospital Revenue Code	278
Min. Negotiated Rate	$1,030.10
Max. Negotiated Rate	$2,060.21
Rate for Payer: Aetna Commercial	$1,236.13
Rate for Payer: Cash Price	$3,625.97
Rate for Payer: Cigna Commercial	$1,030.10
Rate for Payer: Multiplan Auto	$2,060.21
Rate for Payer: Multiplan Commercial	$2,060.21
Rate for Payer: Multiplan Workers Comp	$2,060.21
Rate for Payer: Scott and White EPO/PPO	$2,060.21

COMPONENT VEN OUTFLOW -- DHF

Facility

$9,229.40

Service Code	HCPCS C1750
Hospital Charge Code	81737991
Hospital Revenue Code	278
Min. Negotiated Rate	$2,307.35
Max. Negotiated Rate	$4,614.70
Rate for Payer: Aetna Commercial	$2,768.82
Rate for Payer: Cash Price	$8,121.87
Rate for Payer: Cigna Commercial	$2,307.35
Rate for Payer: Multiplan Auto	$4,614.70
Rate for Payer: Multiplan Commercial	$4,614.70
Rate for Payer: Multiplan Workers Comp	$4,614.70
Rate for Payer: Scott and White EPO/PPO	$4,614.70

Know your out-of-pocket cost for care.

All Charges