White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Comprehensive Metabolic Panel

Facility

$661.00

Service Code	CPT 80053
Hospital Charge Code	1603190
Hospital Revenue Code	301
Rate for Payer: Cash Price	$581.68

Comprehensive Metabolic Panel

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

COMPRESSION SLEEVE BARIATRIC VP501B

Facility

$62.43

Hospital Charge Code	145255
Hospital Revenue Code	270
Rate for Payer: Cash Price	$54.94

COMPRESSION SLEEVE BARIATRIC VP501B

Facility

$62.43

Hospital Charge Code	145255
Hospital Revenue Code	270
Min. Negotiated Rate	$5.62
Max. Negotiated Rate	$40.58
Rate for Payer: Aetna Commercial	$34.34
Rate for Payer: Amerigroup CHIP/Medicaid	$5.62
Rate for Payer: BCBS of TX Blue Advantage	$18.73
Rate for Payer: BCBS of TX Blue Essentials	$22.47
Rate for Payer: BCBS of TX PPO	$24.97
Rate for Payer: Cash Price	$54.94
Rate for Payer: Multiplan Auto	$40.58
Rate for Payer: Multiplan Commercial	$40.58
Rate for Payer: Multiplan Workers Comp	$40.58
Rate for Payer: Scott and White EPO/PPO	$31.22
Rate for Payer: Superior Health Plan EPO	$8.49

COMPRESSION SLEEVE MED/LG VP501M/VP501L

Facility

$39.91

Hospital Charge Code	145251
Hospital Revenue Code	270
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$25.94
Rate for Payer: Aetna Commercial	$21.95
Rate for Payer: Amerigroup CHIP/Medicaid	$3.59
Rate for Payer: BCBS of TX Blue Advantage	$11.97
Rate for Payer: BCBS of TX Blue Essentials	$14.37
Rate for Payer: BCBS of TX PPO	$15.96
Rate for Payer: Cash Price	$35.12
Rate for Payer: Multiplan Auto	$25.94
Rate for Payer: Multiplan Commercial	$25.94
Rate for Payer: Multiplan Workers Comp	$25.94
Rate for Payer: Scott and White EPO/PPO	$19.96
Rate for Payer: Superior Health Plan EPO	$5.43

COMPRESSION SLEEVE MED/LG VP501M/VP501L

Facility

$39.91

Hospital Charge Code	145251
Hospital Revenue Code	270
Rate for Payer: Cash Price	$35.12

Computer Crossmatch Interp BCE

Facility

$198.00

Service Code	CPT 86923
Hospital Charge Code	1600001
Hospital Revenue Code	300
Rate for Payer: Cash Price	$174.24

Computer Crossmatch Interp BCE

Facility

$198.00

Service Code	CPT 86923
Hospital Charge Code	1600001
Hospital Revenue Code	300
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$353.86
Rate for Payer: Aetna Commercial	$30.57
Rate for Payer: Aetna Medicare	$234.32
Rate for Payer: Amerigroup CHIP/Medicaid	$17.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.21
Rate for Payer: Amerigroup Medicare	$156.21
Rate for Payer: BCBS of TX Blue Advantage	$236.78
Rate for Payer: BCBS of TX Blue Essentials	$284.13
Rate for Payer: BCBS of TX Medicare	$156.21
Rate for Payer: BCBS of TX PPO	$317.14
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cigna Commercial	$353.86
Rate for Payer: Cigna Medicare	$156.21
Rate for Payer: Employer Direct Commercial	$156.21
Rate for Payer: Humana Medicare/TRICARE	$156.21
Rate for Payer: Molina Dual Medicare/Medicaid	$156.21
Rate for Payer: Molina Medicare	$156.21
Rate for Payer: Multiplan Auto	$128.70
Rate for Payer: Multiplan Commercial	$128.70
Rate for Payer: Multiplan Workers Comp	$128.70
Rate for Payer: Scott and White EPO/PPO	$2.79
Rate for Payer: Scott and White Medicare	$156.21
Rate for Payer: Superior Health Plan EPO	$156.21
Rate for Payer: Superior Health Plan Medicare	$156.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.21
Rate for Payer: Universal American Medicare	$156.21
Rate for Payer: Wellcare Medicare	$156.21
Rate for Payer: Wellmed Medicare	$156.21

Computer XM OK

Facility

$198.00

Service Code	CPT 86923
Hospital Charge Code	1600001
Hospital Revenue Code	300
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$353.86
Rate for Payer: Aetna Commercial	$30.57
Rate for Payer: Aetna Medicare	$234.32
Rate for Payer: Amerigroup CHIP/Medicaid	$17.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.21
Rate for Payer: Amerigroup Medicare	$156.21
Rate for Payer: BCBS of TX Blue Advantage	$236.78
Rate for Payer: BCBS of TX Blue Essentials	$284.13
Rate for Payer: BCBS of TX Medicare	$156.21
Rate for Payer: BCBS of TX PPO	$317.14
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cigna Commercial	$353.86
Rate for Payer: Cigna Medicare	$156.21
Rate for Payer: Employer Direct Commercial	$156.21
Rate for Payer: Humana Medicare/TRICARE	$156.21
Rate for Payer: Molina Dual Medicare/Medicaid	$156.21
Rate for Payer: Molina Medicare	$156.21
Rate for Payer: Multiplan Auto	$128.70
Rate for Payer: Multiplan Commercial	$128.70
Rate for Payer: Multiplan Workers Comp	$128.70
Rate for Payer: Scott and White EPO/PPO	$2.79
Rate for Payer: Scott and White Medicare	$156.21
Rate for Payer: Superior Health Plan EPO	$156.21
Rate for Payer: Superior Health Plan Medicare	$156.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.21
Rate for Payer: Universal American Medicare	$156.21
Rate for Payer: Wellcare Medicare	$156.21
Rate for Payer: Wellmed Medicare	$156.21

CONCHA COLUMN -- DHF

Facility

$60.77

Hospital Charge Code	82020959
Hospital Revenue Code	270
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$39.50
Rate for Payer: Aetna Commercial	$33.42
Rate for Payer: Amerigroup CHIP/Medicaid	$5.47
Rate for Payer: BCBS of TX Blue Advantage	$18.23
Rate for Payer: BCBS of TX Blue Essentials	$21.88
Rate for Payer: BCBS of TX PPO	$24.31
Rate for Payer: Cash Price	$53.48
Rate for Payer: Multiplan Auto	$39.50
Rate for Payer: Multiplan Commercial	$39.50
Rate for Payer: Multiplan Workers Comp	$39.50
Rate for Payer: Scott and White EPO/PPO	$30.38
Rate for Payer: Superior Health Plan EPO	$8.26

CONCHA COLUMN -- DHF

Facility

$60.77

Hospital Charge Code	82020959
Hospital Revenue Code	270
Rate for Payer: Cash Price	$53.48

CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES

Facility

$204,643.30

Service Code	MSDRG 212
Min. Negotiated Rate	$79,715.14
Max. Negotiated Rate	$204,643.30
Rate for Payer: Aetna Commercial	$121,170.38
Rate for Payer: Aetna Medicare	$119,572.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$79,715.14
Rate for Payer: Amerigroup Medicare	$79,715.14
Rate for Payer: BCBS of TX Medicare	$79,715.14
Rate for Payer: Cigna Commercial	$138,726.62
Rate for Payer: Cigna Medicare	$79,715.14
Rate for Payer: Employer Direct Commercial	$79,715.14
Rate for Payer: Humana Medicare/TRICARE	$79,715.14
Rate for Payer: Molina Dual Medicare/Medicaid	$79,715.14
Rate for Payer: Molina Medicare	$79,715.14
Rate for Payer: Multiplan Auto	$204,643.30
Rate for Payer: Multiplan Commercial	$204,643.30
Rate for Payer: Multiplan Workers Comp	$204,643.30
Rate for Payer: Scott and White EPO/PPO	$94,243.62
Rate for Payer: Scott and White Medicare	$79,715.14
Rate for Payer: Superior Health Plan EPO	$79,715.14
Rate for Payer: Superior Health Plan Medicare	$79,715.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$79,715.14
Rate for Payer: Universal American Medicare	$79,715.14
Rate for Payer: Wellcare Medicare	$79,715.14
Rate for Payer: Wellmed Medicare	$79,715.14

CONCUSSION WITH CC

Facility

$21,848.10

Service Code	MSDRG 089
Min. Negotiated Rate	$8,738.46
Max. Negotiated Rate	$21,848.10
Rate for Payer: Aetna Commercial	$12,936.38
Rate for Payer: Aetna Medicare	$16,590.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,060.55
Rate for Payer: Amerigroup Medicare	$11,060.55
Rate for Payer: BCBS of TX Blue Advantage	$8,738.46
Rate for Payer: BCBS of TX Blue Essentials	$11,015.53
Rate for Payer: BCBS of TX Medicare	$11,060.55
Rate for Payer: BCBS of TX PPO	$12,239.96
Rate for Payer: Cigna Commercial	$14,810.71
Rate for Payer: Cigna Medicare	$11,060.55
Rate for Payer: Employer Direct Commercial	$11,060.55
Rate for Payer: Humana Medicare/TRICARE	$11,060.55
Rate for Payer: Molina Dual Medicare/Medicaid	$11,060.55
Rate for Payer: Molina Medicare	$11,060.55
Rate for Payer: Multiplan Auto	$21,848.10
Rate for Payer: Multiplan Commercial	$21,848.10
Rate for Payer: Multiplan Workers Comp	$21,848.10
Rate for Payer: Scott and White EPO/PPO	$10,061.62
Rate for Payer: Scott and White Medicare	$11,060.55
Rate for Payer: Superior Health Plan EPO	$11,060.55
Rate for Payer: Superior Health Plan Medicare	$11,060.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,060.55
Rate for Payer: Universal American Medicare	$11,060.55
Rate for Payer: Wellcare Medicare	$11,060.55
Rate for Payer: Wellmed Medicare	$11,060.55

CONCUSSION WITH MCC

Facility

$29,142.20

Service Code	MSDRG 088
Min. Negotiated Rate	$12,763.26
Max. Negotiated Rate	$29,142.20
Rate for Payer: Aetna Commercial	$17,255.25
Rate for Payer: Aetna Medicare	$20,700.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,800.08
Rate for Payer: Amerigroup Medicare	$13,800.08
Rate for Payer: BCBS of TX Blue Advantage	$12,763.26
Rate for Payer: BCBS of TX Blue Essentials	$15,267.99
Rate for Payer: BCBS of TX Medicare	$13,800.08
Rate for Payer: BCBS of TX PPO	$16,965.09
Rate for Payer: Cigna Commercial	$19,755.34
Rate for Payer: Cigna Medicare	$13,800.08
Rate for Payer: Employer Direct Commercial	$13,800.08
Rate for Payer: Humana Medicare/TRICARE	$13,800.08
Rate for Payer: Molina Dual Medicare/Medicaid	$13,800.08
Rate for Payer: Molina Medicare	$13,800.08
Rate for Payer: Multiplan Auto	$29,142.20
Rate for Payer: Multiplan Commercial	$29,142.20
Rate for Payer: Multiplan Workers Comp	$29,142.20
Rate for Payer: Scott and White EPO/PPO	$13,420.75
Rate for Payer: Scott and White Medicare	$13,800.08
Rate for Payer: Superior Health Plan EPO	$13,800.08
Rate for Payer: Superior Health Plan Medicare	$13,800.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,800.08
Rate for Payer: Universal American Medicare	$13,800.08
Rate for Payer: Wellcare Medicare	$13,800.08
Rate for Payer: Wellmed Medicare	$13,800.08

CONCUSSION WITHOUT CC/MCC

Facility

$17,761.20

Service Code	MSDRG 090
Min. Negotiated Rate	$6,567.82
Max. Negotiated Rate	$17,761.20
Rate for Payer: Aetna Commercial	$10,516.50
Rate for Payer: Aetna Medicare	$14,288.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,525.57
Rate for Payer: Amerigroup Medicare	$9,525.57
Rate for Payer: BCBS of TX Blue Advantage	$6,567.82
Rate for Payer: BCBS of TX Blue Essentials	$8,187.09
Rate for Payer: BCBS of TX Medicare	$9,525.57
Rate for Payer: BCBS of TX PPO	$9,097.12
Rate for Payer: Cigna Commercial	$12,040.22
Rate for Payer: Cigna Medicare	$9,525.57
Rate for Payer: Employer Direct Commercial	$9,525.57
Rate for Payer: Humana Medicare/TRICARE	$9,525.57
Rate for Payer: Molina Dual Medicare/Medicaid	$9,525.57
Rate for Payer: Molina Medicare	$9,525.57
Rate for Payer: Multiplan Auto	$17,761.20
Rate for Payer: Multiplan Commercial	$17,761.20
Rate for Payer: Multiplan Workers Comp	$17,761.20
Rate for Payer: Scott and White EPO/PPO	$8,179.50
Rate for Payer: Scott and White Medicare	$9,525.57
Rate for Payer: Superior Health Plan EPO	$9,525.57
Rate for Payer: Superior Health Plan Medicare	$9,525.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,525.57
Rate for Payer: Universal American Medicare	$9,525.57
Rate for Payer: Wellcare Medicare	$9,525.57
Rate for Payer: Wellmed Medicare	$9,525.57

CONFIRM CARDIAC MONITOR DM3500

Facility

$20,198.86

Service Code	HCPCS C1764
Hospital Charge Code	8550485
Hospital Revenue Code	278
Min. Negotiated Rate	$5,049.72
Max. Negotiated Rate	$10,099.43
Rate for Payer: Aetna Commercial	$6,059.66
Rate for Payer: Cash Price	$17,775.00
Rate for Payer: Cigna Commercial	$5,049.72
Rate for Payer: Multiplan Auto	$10,099.43
Rate for Payer: Multiplan Commercial	$10,099.43
Rate for Payer: Multiplan Workers Comp	$10,099.43
Rate for Payer: Scott and White EPO/PPO	$10,099.43

CONFIRM CARDIAC MONITOR DM3500

Facility

$20,198.86

Service Code	HCPCS C1764
Hospital Charge Code	8550485
Hospital Revenue Code	278
Min. Negotiated Rate	$1,817.90
Max. Negotiated Rate	$10,099.43
Rate for Payer: Aetna Commercial	$6,059.66
Rate for Payer: Amerigroup CHIP/Medicaid	$1,817.90
Rate for Payer: BCBS of TX Blue Advantage	$6,059.66
Rate for Payer: BCBS of TX Blue Essentials	$7,271.59
Rate for Payer: BCBS of TX PPO	$8,079.54
Rate for Payer: Cash Price	$17,775.00
Rate for Payer: Multiplan Auto	$10,099.43
Rate for Payer: Multiplan Commercial	$10,099.43
Rate for Payer: Multiplan Workers Comp	$10,099.43
Rate for Payer: Scott and White EPO/PPO	$10,099.43
Rate for Payer: Superior Health Plan EPO	$2,747.04

Conjunctivoplasty, reconstruction cul-de-sac with conjunctival graft or extensive rearrangement

Facility

$10,000.00

Service Code	CPT 68326
Hospital Charge Code	36068326
Hospital Revenue Code	360
Min. Negotiated Rate	$77.99
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$5,303.98
Rate for Payer: Amerigroup CHIP/Medicaid	$1,103.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,535.99
Rate for Payer: Amerigroup Medicare	$3,535.99
Rate for Payer: BCBS of TX Blue Advantage	$5,222.19
Rate for Payer: BCBS of TX Blue Essentials	$6,254.12
Rate for Payer: BCBS of TX Medicare	$3,535.99
Rate for Payer: BCBS of TX PPO	$7,880.19
Rate for Payer: Cigna Commercial	$8,010.04
Rate for Payer: Cigna Medicaid	$1,103.42
Rate for Payer: Cigna Medicare	$3,535.99
Rate for Payer: Employer Direct Commercial	$3,535.99
Rate for Payer: Humana Medicare/TRICARE	$3,535.99
Rate for Payer: Molina CHIP/Medicaid	$1,103.42
Rate for Payer: Molina Dual Medicare/Medicaid	$3,535.99
Rate for Payer: Molina Medicare	$3,535.99
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	$1,103.42
Rate for Payer: Scott and White EPO/PPO	$77.99
Rate for Payer: Scott and White Medicare	$3,535.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,103.42
Rate for Payer: Superior Health Plan EPO	$3,535.99
Rate for Payer: Superior Health Plan Medicare	$3,535.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,535.99
Rate for Payer: Universal American Medicare	$3,535.99
Rate for Payer: Wellcare Medicare	$3,535.99
Rate for Payer: Wellmed Medicare	$3,535.99

CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$22,786.70

Service Code	MSDRG 546
Min. Negotiated Rate	$9,761.00
Max. Negotiated Rate	$22,786.70
Rate for Payer: Aetna Commercial	$13,492.12
Rate for Payer: Aetna Medicare	$17,119.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,413.06
Rate for Payer: Amerigroup Medicare	$11,413.06
Rate for Payer: BCBS of TX Blue Advantage	$9,761.00
Rate for Payer: BCBS of TX Blue Essentials	$12,531.39
Rate for Payer: BCBS of TX Medicare	$11,413.06
Rate for Payer: BCBS of TX PPO	$13,924.31
Rate for Payer: Cigna Commercial	$15,446.98
Rate for Payer: Cigna Medicare	$11,413.06
Rate for Payer: Employer Direct Commercial	$11,413.06
Rate for Payer: Humana Medicare/TRICARE	$11,413.06
Rate for Payer: Molina Dual Medicare/Medicaid	$11,413.06
Rate for Payer: Molina Medicare	$11,413.06
Rate for Payer: Multiplan Auto	$22,786.70
Rate for Payer: Multiplan Commercial	$22,786.70
Rate for Payer: Multiplan Workers Comp	$22,786.70
Rate for Payer: Scott and White EPO/PPO	$10,493.88
Rate for Payer: Scott and White Medicare	$11,413.06
Rate for Payer: Superior Health Plan EPO	$11,413.06
Rate for Payer: Superior Health Plan Medicare	$11,413.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,413.06
Rate for Payer: Universal American Medicare	$11,413.06
Rate for Payer: Wellcare Medicare	$11,413.06
Rate for Payer: Wellmed Medicare	$11,413.06

CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$47,370.80

Service Code	MSDRG 545
Min. Negotiated Rate	$20,646.40
Max. Negotiated Rate	$47,370.80
Rate for Payer: Aetna Commercial	$28,048.50
Rate for Payer: Aetna Medicare	$30,969.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,646.40
Rate for Payer: Amerigroup Medicare	$20,646.40
Rate for Payer: BCBS of TX Blue Advantage	$21,070.00
Rate for Payer: BCBS of TX Blue Essentials	$25,581.83
Rate for Payer: BCBS of TX Medicare	$20,646.40
Rate for Payer: BCBS of TX PPO	$28,425.36
Rate for Payer: Cigna Commercial	$32,112.42
Rate for Payer: Cigna Medicare	$20,646.40
Rate for Payer: Employer Direct Commercial	$20,646.40
Rate for Payer: Humana Medicare/TRICARE	$20,646.40
Rate for Payer: Molina Dual Medicare/Medicaid	$20,646.40
Rate for Payer: Molina Medicare	$20,646.40
Rate for Payer: Multiplan Auto	$47,370.80
Rate for Payer: Multiplan Commercial	$47,370.80
Rate for Payer: Multiplan Workers Comp	$47,370.80
Rate for Payer: Scott and White EPO/PPO	$21,815.50
Rate for Payer: Scott and White Medicare	$20,646.40
Rate for Payer: Superior Health Plan EPO	$20,646.40
Rate for Payer: Superior Health Plan Medicare	$20,646.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,646.40
Rate for Payer: Universal American Medicare	$20,646.40
Rate for Payer: Wellcare Medicare	$20,646.40
Rate for Payer: Wellmed Medicare	$20,646.40

CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$15,454.60

Service Code	MSDRG 547
Min. Negotiated Rate	$6,848.18
Max. Negotiated Rate	$15,454.60
Rate for Payer: Aetna Commercial	$9,150.75
Rate for Payer: Aetna Medicare	$13,094.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,729.90
Rate for Payer: Amerigroup Medicare	$8,729.90
Rate for Payer: BCBS of TX Blue Advantage	$6,848.18
Rate for Payer: BCBS of TX Blue Essentials	$8,849.57
Rate for Payer: BCBS of TX Medicare	$8,729.90
Rate for Payer: BCBS of TX PPO	$9,833.24
Rate for Payer: Cigna Commercial	$10,476.59
Rate for Payer: Cigna Medicare	$8,729.90
Rate for Payer: Employer Direct Commercial	$8,729.90
Rate for Payer: Humana Medicare/TRICARE	$8,729.90
Rate for Payer: Molina Dual Medicare/Medicaid	$8,729.90
Rate for Payer: Molina Medicare	$8,729.90
Rate for Payer: Multiplan Auto	$15,454.60
Rate for Payer: Multiplan Commercial	$15,454.60
Rate for Payer: Multiplan Workers Comp	$15,454.60
Rate for Payer: Scott and White EPO/PPO	$7,117.25
Rate for Payer: Scott and White Medicare	$8,729.90
Rate for Payer: Superior Health Plan EPO	$8,729.90
Rate for Payer: Superior Health Plan Medicare	$8,729.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,729.90
Rate for Payer: Universal American Medicare	$8,729.90
Rate for Payer: Wellcare Medicare	$8,729.90
Rate for Payer: Wellmed Medicare	$8,729.90

CONTRAST VENOGRAPHY INJECTION

Facility

$2,682.00

Service Code	CPT 36005
Hospital Charge Code	2303576
Hospital Revenue Code	361
Min. Negotiated Rate	$241.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,475.10
Rate for Payer: Amerigroup CHIP/Medicaid	$241.38
Rate for Payer: Cash Price	$2,360.16
Rate for Payer: Cash Price	$2,360.16
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	$1,341.00
Rate for Payer: Superior Health Plan EPO	$364.75

CONTRAST VENOGRAPHY INJECTION

Facility

$2,682.00

Service Code	CPT 36005
Hospital Charge Code	2303576
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,360.16

CONTRST EVAL EXISTNG CVD

Facility

$921.00

Service Code	CPT 36598
Hospital Charge Code	4616598
Hospital Revenue Code	361
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$506.55
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$79.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$155.04
Rate for Payer: BCBS of TX Blue Essentials	$185.68
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$233.96
Rate for Payer: Cash Price	$810.48
Rate for Payer: Cash Price	$810.48
Rate for Payer: Cash Price	$810.48
Rate for Payer: Cigna Commercial	$444.05
Rate for Payer: Cigna Medicaid	$79.46
Rate for Payer: Cigna Medicare	$196.02
Rate for Payer: Employer Direct Commercial	$196.02
Rate for Payer: Humana Medicare/TRICARE	$196.02
Rate for Payer: Molina CHIP/Medicaid	$79.46
Rate for Payer: Molina Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
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	$79.46
Rate for Payer: Scott and White EPO/PPO	$4.32
Rate for Payer: Scott and White Medicare	$196.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.46
Rate for Payer: Superior Health Plan EPO	$196.02
Rate for Payer: Superior Health Plan Medicare	$196.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$196.02
Rate for Payer: Universal American Medicare	$196.02
Rate for Payer: Wellcare Medicare	$196.02
Rate for Payer: Wellmed Medicare	$196.02

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