White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CORO GRAFT REVAS D-ELU STENT 1 ART

Facility

$15,984.00

Service Code	HCPCS C9604
Hospital Charge Code	2350064
Hospital Revenue Code	481
Min. Negotiated Rate	$1,438.56
Max. Negotiated Rate	$24,969.37
Rate for Payer: Aetna Commercial	$8,755.00
Rate for Payer: Aetna Medicare	$15,091.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,438.56
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Amerigroup Medicare	$10,061.07
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$10,061.07
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$14,065.92
Rate for Payer: Cash Price	$14,065.92
Rate for Payer: Cash Price	$14,065.92
Rate for Payer: Cigna Commercial	$22,791.24
Rate for Payer: Cigna Medicare	$10,061.07
Rate for Payer: Employer Direct Commercial	$10,061.07
Rate for Payer: Humana Medicare/TRICARE	$10,061.07
Rate for Payer: Molina Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Molina Medicare	$10,061.07
Rate for Payer: Multiplan Auto	$10,389.60
Rate for Payer: Multiplan Commercial	$10,389.60
Rate for Payer: Multiplan Workers Comp	$10,389.60
Rate for Payer: Scott and White EPO/PPO	$7,992.00
Rate for Payer: Scott and White Medicare	$10,061.07
Rate for Payer: Superior Health Plan EPO	$10,061.07
Rate for Payer: Superior Health Plan Medicare	$10,061.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Universal American Medicare	$10,061.07
Rate for Payer: Wellcare Medicare	$10,061.07
Rate for Payer: Wellmed Medicare	$10,061.07

CORO GRAFT REVAS D-ELU STENT 1 ART

Facility

$15,984.00

Service Code	HCPCS C9604
Hospital Charge Code	2350064
Hospital Revenue Code	481
Rate for Payer: Cash Price	$14,065.92

CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC

Facility

$100,458.85

Service Code	MSDRG 233
Min. Negotiated Rate	$64,393.36
Max. Negotiated Rate	$100,458.85
Rate for Payer: Aetna Commercial	$87,745.50
Rate for Payer: Aetna Medicare	$87,769.80
Rate for Payer: BCBS of TX Blue Advantage	$64,393.36
Rate for Payer: BCBS of TX Blue Essentials	$78,813.43
Rate for Payer: BCBS of TX PPO	$87,573.87
Rate for Payer: Cigna Commercial	$100,458.85

CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC

Facility

$66,948.95

Service Code	MSDRG 234
Min. Negotiated Rate	$42,589.78
Max. Negotiated Rate	$66,948.95
Rate for Payer: Aetna Commercial	$58,476.38
Rate for Payer: Aetna Medicare	$59,920.96
Rate for Payer: BCBS of TX Blue Advantage	$42,589.78
Rate for Payer: BCBS of TX Blue Essentials	$53,113.96
Rate for Payer: BCBS of TX PPO	$59,017.80
Rate for Payer: Cigna Commercial	$66,948.95

CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC

Facility

$75,742.13

Service Code	MSDRG 235
Min. Negotiated Rate	$49,573.84
Max. Negotiated Rate	$75,742.13
Rate for Payer: Aetna Commercial	$66,156.75
Rate for Payer: Aetna Medicare	$67,228.65
Rate for Payer: BCBS of TX Blue Advantage	$49,573.84
Rate for Payer: BCBS of TX Blue Essentials	$59,952.36
Rate for Payer: BCBS of TX PPO	$66,616.31
Rate for Payer: Cigna Commercial	$75,742.13

CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC

Facility

$52,050.66

Service Code	MSDRG 236
Min. Negotiated Rate	$33,127.20
Max. Negotiated Rate	$52,050.66
Rate for Payer: Aetna Commercial	$45,463.50
Rate for Payer: Aetna Medicare	$47,539.56
Rate for Payer: BCBS of TX Blue Advantage	$33,127.20
Rate for Payer: BCBS of TX Blue Essentials	$40,515.49
Rate for Payer: BCBS of TX PPO	$45,018.96
Rate for Payer: Cigna Commercial	$52,050.66

CORONARY BYPASS WITH PTCA WITH MCC

Facility

$104,523.78

Service Code	MSDRG 231
Min. Negotiated Rate	$69,369.32
Max. Negotiated Rate	$104,523.78
Rate for Payer: Aetna Commercial	$91,296.00
Rate for Payer: Aetna Medicare	$91,148.01
Rate for Payer: BCBS of TX Blue Advantage	$69,369.32
Rate for Payer: BCBS of TX Blue Essentials	$86,668.25
Rate for Payer: BCBS of TX PPO	$96,301.79
Rate for Payer: Cigna Commercial	$104,523.78

CORONARY BYPASS WITH PTCA WITHOUT MCC

Facility

$76,617.97

Service Code	MSDRG 232
Min. Negotiated Rate	$50,631.64
Max. Negotiated Rate	$76,617.97
Rate for Payer: Aetna Commercial	$66,921.75
Rate for Payer: Aetna Medicare	$67,956.52
Rate for Payer: BCBS of TX Blue Advantage	$50,631.64
Rate for Payer: BCBS of TX Blue Essentials	$63,569.17
Rate for Payer: BCBS of TX PPO	$70,635.15
Rate for Payer: Cigna Commercial	$76,617.97

CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC

Facility

$53,323.20

Service Code	MSDRG 323
Min. Negotiated Rate	$46,575.00
Max. Negotiated Rate	$53,323.20
Rate for Payer: Aetna Commercial	$46,575.00
Rate for Payer: Aetna Medicare	$48,597.11
Rate for Payer: Cigna Commercial	$53,323.20

CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$38,235.57

Service Code	MSDRG 324
Min. Negotiated Rate	$33,396.75
Max. Negotiated Rate	$38,235.57
Rate for Payer: Aetna Commercial	$33,396.75
Rate for Payer: Aetna Medicare	$36,058.33
Rate for Payer: Cigna Commercial	$38,235.57

CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE

Facility

$34,058.58

Service Code	MSDRG 325
Min. Negotiated Rate	$29,748.38
Max. Negotiated Rate	$34,058.58
Rate for Payer: Aetna Commercial	$29,748.38
Rate for Payer: Aetna Medicare	$32,587.02
Rate for Payer: Cigna Commercial	$34,058.58

CORO REVAS D-E STENT/ACUT MI 1 ART

Facility

$22,708.00

Service Code	HCPCS C9606
Hospital Charge Code	2350066
Hospital Revenue Code	481
Rate for Payer: Cash Price	$19,983.04

CORO REVAS D-E STENT/ACUT MI 1 ART

Facility

$22,708.00

Service Code	HCPCS C9606
Hospital Charge Code	2350066
Hospital Revenue Code	481
Min. Negotiated Rate	$1,805.34
Max. Negotiated Rate	$14,760.20
Rate for Payer: Aetna Commercial	$4,017.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2,043.72
Rate for Payer: BCBS of TX Blue Advantage	$1,805.34
Rate for Payer: BCBS of TX Blue Essentials	$2,162.08
Rate for Payer: BCBS of TX PPO	$2,724.22
Rate for Payer: Cash Price	$19,983.04
Rate for Payer: Cash Price	$19,983.04
Rate for Payer: Cash Price	$19,983.04
Rate for Payer: Multiplan Auto	$14,760.20
Rate for Payer: Multiplan Commercial	$14,760.20
Rate for Payer: Multiplan Workers Comp	$14,760.20
Rate for Payer: Scott and White EPO/PPO	$11,354.00
Rate for Payer: Superior Health Plan EPO	$3,088.29

CORO STENT W ANGIOPLASTY 1ST ART

Facility

$14,349.00

Service Code	CPT 92928
Hospital Charge Code	2350034
Hospital Revenue Code	481
Rate for Payer: Cash Price	$12,627.12

CORO STENT W ANGIOPLASTY 1ST ART

Facility

$14,349.00

Service Code	CPT 92928
Hospital Charge Code	2350034
Hospital Revenue Code	481
Min. Negotiated Rate	$697.11
Max. Negotiated Rate	$24,969.37
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$15,091.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,291.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Amerigroup Medicare	$10,061.07
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$10,061.07
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$12,627.12
Rate for Payer: Cash Price	$12,627.12
Rate for Payer: Cash Price	$12,627.12
Rate for Payer: Cigna Commercial	$22,791.24
Rate for Payer: Cigna Medicare	$10,061.07
Rate for Payer: Employer Direct Commercial	$10,061.07
Rate for Payer: Humana Medicare/TRICARE	$10,061.07
Rate for Payer: Molina Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Molina Medicare	$10,061.07
Rate for Payer: Multiplan Auto	$9,326.85
Rate for Payer: Multiplan Commercial	$9,326.85
Rate for Payer: Multiplan Workers Comp	$9,326.85
Rate for Payer: Scott and White EPO/PPO	$697.11
Rate for Payer: Scott and White Medicare	$10,061.07
Rate for Payer: Superior Health Plan EPO	$10,061.07
Rate for Payer: Superior Health Plan Medicare	$10,061.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Universal American Medicare	$10,061.07
Rate for Payer: Wellcare Medicare	$10,061.07
Rate for Payer: Wellmed Medicare	$10,061.07

CORO STENT W ANGIOPLASTY EA AD ART

Facility

$8,615.00

Service Code	CPT 92929
Hospital Charge Code	2350035
Hospital Revenue Code	481
Min. Negotiated Rate	$775.35
Max. Negotiated Rate	$7,210.00
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Amerigroup CHIP/Medicaid	$775.35
Rate for Payer: Cash Price	$7,581.20
Rate for Payer: Cash Price	$7,581.20
Rate for Payer: Multiplan Auto	$5,599.75
Rate for Payer: Multiplan Commercial	$5,599.75
Rate for Payer: Multiplan Workers Comp	$5,599.75
Rate for Payer: Scott and White EPO/PPO	$4,307.50
Rate for Payer: Superior Health Plan EPO	$1,171.64

CORO STENT W ANGIOPLASTY EA AD ART

Facility

$8,615.00

Service Code	CPT 92929
Hospital Charge Code	2350035
Hospital Revenue Code	481
Rate for Payer: Cash Price	$7,581.20

Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed with distal metatarsa

Facility

$10,000.00

Service Code	CPT 28296
Hospital Charge Code	36028296
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed with double osteotomy

Facility

$15,074.51

Service Code	CPT 28299
Hospital Charge Code	36028299
Hospital Revenue Code	360
Min. Negotiated Rate	$3,132.58
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3,132.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicaid	$3,132.58
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina CHIP/Medicaid	$3,132.58
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
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	$3,132.58
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,132.58
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed with first metatarsal

Facility

$15,074.51

Service Code	CPT 28297
Hospital Charge Code	36028297
Hospital Revenue Code	360
Min. Negotiated Rate	$3,508.38
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3,508.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicaid	$3,508.38
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina CHIP/Medicaid	$3,508.38
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
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	$3,508.38
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,508.38
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed with proximal phalanx

Facility

$15,074.51

Service Code	CPT 28298
Hospital Charge Code	36028298
Hospital Revenue Code	360
Min. Negotiated Rate	$3,103.16
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3,103.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicaid	$3,103.16
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina CHIP/Medicaid	$3,103.16
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
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	$3,103.16
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,103.16
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed with resection of pro

Facility

$10,000.00

Service Code	CPT 28292
Hospital Charge Code	36028292
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)

Facility

$10,000.00

Service Code	CPT 28285
Hospital Charge Code	36028285
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Correction of inverted nipples

Facility

$10,000.00

Service Code	CPT 19355
Hospital Charge Code	36019355
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$5,229.02
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,486.01
Rate for Payer: Amerigroup Medicare	$3,486.01
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,486.01
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cigna Commercial	$7,896.82
Rate for Payer: Cigna Medicaid	$963.66
Rate for Payer: Cigna Medicare	$3,486.01
Rate for Payer: Employer Direct Commercial	$3,486.01
Rate for Payer: Humana Medicare/TRICARE	$3,486.01
Rate for Payer: Molina CHIP/Medicaid	$963.66
Rate for Payer: Molina Dual Medicare/Medicaid	$3,486.01
Rate for Payer: Molina Medicare	$3,486.01
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	$963.66
Rate for Payer: Scott and White EPO/PPO	$6,449.12
Rate for Payer: Scott and White Medicare	$3,486.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$963.66
Rate for Payer: Superior Health Plan EPO	$3,486.01
Rate for Payer: Superior Health Plan Medicare	$3,486.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,486.01
Rate for Payer: Universal American Medicare	$3,486.01
Rate for Payer: Wellcare Medicare	$3,486.01
Rate for Payer: Wellmed Medicare	$3,486.01

COR THROMBLYS-INTRA COR

Facility

$4,107.00

Service Code	CPT 92975
Hospital Charge Code	4612975
Hospital Revenue Code	481
Rate for Payer: Cash Price	$3,614.16

Know your out-of-pocket cost for care.

All Charges