White Rock Medical Center

All Charges

Charge

Type

Setting

Price

lactulose 10 g/15 mL Oral Syrup 30 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77652409
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord

Facility

$10,000.00

Service Code	CPT 63048
Hospital Charge Code	36063048
Hospital Revenue Code	360
Min. Negotiated Rate	$254.32
Max. Negotiated Rate	$10,000.00
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	$254.32

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord

Facility

$15,074.51

Service Code	CPT 63047
Hospital Charge Code	36063047
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
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	$2,398.52
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	$2,398.52
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	$2,398.52
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	$2,398.52
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

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar

Facility

$15,074.51

Service Code	CPT 63267
Hospital Charge Code	36063267
Hospital Revenue Code	360
Min. Negotiated Rate	$3,090.00
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$9,814.08
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 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 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: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$6,542.72
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

Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

Facility

$48,584.14

Service Code	CPT 63655
Hospital Charge Code	36063655
Hospital Revenue Code	360
Min. Negotiated Rate	$8,755.00
Max. Negotiated Rate	$48,584.14
Rate for Payer: Aetna Commercial	$8,755.00
Rate for Payer: Aetna Medicare	$30,009.31
Rate for Payer: Amerigroup CHIP/Medicaid	$13,714.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,006.21
Rate for Payer: Amerigroup Medicare	$20,006.21
Rate for Payer: BCBS of TX Blue Advantage	$32,196.63
Rate for Payer: BCBS of TX Blue Essentials	$38,558.84
Rate for Payer: BCBS of TX Medicare	$20,006.21
Rate for Payer: BCBS of TX PPO	$48,584.14
Rate for Payer: Cigna Commercial	$45,319.85
Rate for Payer: Cigna Medicaid	$13,714.30
Rate for Payer: Cigna Medicare	$20,006.21
Rate for Payer: Employer Direct Commercial	$20,006.21
Rate for Payer: Humana Medicare/TRICARE	$20,006.21
Rate for Payer: Molina CHIP/Medicaid	$13,714.30
Rate for Payer: Molina Dual Medicare/Medicaid	$20,006.21
Rate for Payer: Molina Medicare	$20,006.21
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	$13,714.30
Rate for Payer: Scott and White EPO/PPO	$37,011.49
Rate for Payer: Scott and White Medicare	$20,006.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,714.30
Rate for Payer: Superior Health Plan EPO	$20,006.21
Rate for Payer: Superior Health Plan Medicare	$20,006.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,006.21
Rate for Payer: Universal American Medicare	$20,006.21
Rate for Payer: Wellcare Medicare	$20,006.21
Rate for Payer: Wellmed Medicare	$20,006.21

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$15,074.51

Service Code	CPT 63030
Hospital Charge Code	36063030
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
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	$2,398.52
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	$2,398.52
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	$2,398.52
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	$2,398.52
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

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$15,074.51

Service Code	CPT 63042
Hospital Charge Code	36063042
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
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	$2,398.52
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	$2,398.52
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	$2,398.52
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	$2,398.52
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

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$10,000.00

Service Code	CPT 63035
Hospital Charge Code	36063035
Hospital Revenue Code	360
Min. Negotiated Rate	$281.89
Max. Negotiated Rate	$10,000.00
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	$281.89

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$15,074.51

Service Code	CPT 63020
Hospital Charge Code	36063020
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
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	$2,398.52
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	$2,398.52
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	$2,398.52
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	$2,398.52
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

lamoTRIgine 100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77653245
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

lamoTRIgine 100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77653245
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Lamotrigine (Lamictal), Serum SO

Facility

$161.00

Service Code	CPT 80175
Hospital Charge Code	1740990
Hospital Revenue Code	301
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$104.65
Rate for Payer: Aetna Commercial	$13.91
Rate for Payer: Aetna Medicare	$19.88
Rate for Payer: Amerigroup CHIP/Medicaid	$5.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.25
Rate for Payer: Amerigroup Medicare	$13.25
Rate for Payer: BCBS of TX Blue Advantage	$21.86
Rate for Payer: BCBS of TX Blue Essentials	$26.23
Rate for Payer: BCBS of TX Medicare	$13.25
Rate for Payer: BCBS of TX PPO	$29.28
Rate for Payer: Cash Price	$141.68
Rate for Payer: Cash Price	$141.68
Rate for Payer: Cigna Medicaid	$13.25
Rate for Payer: Cigna Medicare	$13.25
Rate for Payer: Employer Direct Commercial	$13.25
Rate for Payer: Humana Medicare/TRICARE	$13.25
Rate for Payer: Molina CHIP/Medicaid	$13.25
Rate for Payer: Molina Dual Medicare/Medicaid	$13.25
Rate for Payer: Molina Medicare	$13.25
Rate for Payer: Multiplan Auto	$104.65
Rate for Payer: Multiplan Commercial	$104.65
Rate for Payer: Multiplan Workers Comp	$104.65
Rate for Payer: Parkland Medicaid	$13.25
Rate for Payer: Scott and White EPO/PPO	$16.56
Rate for Payer: Scott and White Medicare	$13.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.25
Rate for Payer: Superior Health Plan EPO	$13.25
Rate for Payer: Superior Health Plan Medicare	$13.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.25
Rate for Payer: Universal American Medicare	$13.25
Rate for Payer: Wellcare Medicare	$13.25
Rate for Payer: Wellmed Medicare	$13.25

Lamotrigine (Lamictal), Serum SO

Facility

$161.00

Service Code	CPT 80175
Hospital Charge Code	1740990
Hospital Revenue Code	301
Rate for Payer: Cash Price	$141.68

Laparo proc abdm/per/oment

Facility

$12,180.95

Service Code	CPT 49329
Hospital Charge Code	36049329
Hospital Revenue Code	360
Min. Negotiated Rate	$5,276.92
Max. Negotiated Rate	$12,180.95
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$7,915.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Amerigroup Medicare	$5,276.92
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$5,276.92
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$11,953.74
Rate for Payer: Cigna Medicare	$5,276.92
Rate for Payer: Employer Direct Commercial	$5,276.92
Rate for Payer: Humana Medicare/TRICARE	$5,276.92
Rate for Payer: Molina Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Molina Medicare	$5,276.92
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	$9,762.30
Rate for Payer: Scott and White Medicare	$5,276.92
Rate for Payer: Superior Health Plan EPO	$5,276.92
Rate for Payer: Superior Health Plan Medicare	$5,276.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Universal American Medicare	$5,276.92
Rate for Payer: Wellcare Medicare	$5,276.92
Rate for Payer: Wellmed Medicare	$5,276.92

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC

Facility

$21,780.15

Service Code	MSDRG 418
Min. Negotiated Rate	$14,189.14
Max. Negotiated Rate	$21,780.15
Rate for Payer: Aetna Commercial	$18,390.38
Rate for Payer: Aetna Medicare	$21,780.15
Rate for Payer: BCBS of TX Blue Advantage	$14,189.14
Rate for Payer: BCBS of TX Blue Essentials	$17,172.88
Rate for Payer: BCBS of TX PPO	$19,081.72
Rate for Payer: Cigna Commercial	$21,054.94

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC

Facility

$29,853.26

Service Code	MSDRG 417
Min. Negotiated Rate	$20,591.84
Max. Negotiated Rate	$29,853.26
Rate for Payer: Aetna Commercial	$26,075.25
Rate for Payer: Aetna Medicare	$29,092.10
Rate for Payer: BCBS of TX Blue Advantage	$20,591.84
Rate for Payer: BCBS of TX Blue Essentials	$25,007.06
Rate for Payer: BCBS of TX PPO	$27,786.70
Rate for Payer: Cigna Commercial	$29,853.26

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$18,338.78

Service Code	MSDRG 419
Min. Negotiated Rate	$10,852.34
Max. Negotiated Rate	$18,338.78
Rate for Payer: Aetna Commercial	$14,773.50
Rate for Payer: Aetna Medicare	$18,338.78
Rate for Payer: BCBS of TX Blue Advantage	$10,852.34
Rate for Payer: BCBS of TX Blue Essentials	$13,458.04
Rate for Payer: BCBS of TX PPO	$14,953.96
Rate for Payer: Cigna Commercial	$16,914.02

Laparoscopic Liver Biopsy

Facility

$12,180.95

Service Code	CPT 47379
Hospital Charge Code	36047379
Hospital Revenue Code	360
Min. Negotiated Rate	$5,276.92
Max. Negotiated Rate	$12,180.95
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$7,915.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Amerigroup Medicare	$5,276.92
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$5,276.92
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$11,953.74
Rate for Payer: Cigna Medicare	$5,276.92
Rate for Payer: Employer Direct Commercial	$5,276.92
Rate for Payer: Humana Medicare/TRICARE	$5,276.92
Rate for Payer: Molina Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Molina Medicare	$5,276.92
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	$9,762.30
Rate for Payer: Scott and White Medicare	$5,276.92
Rate for Payer: Superior Health Plan EPO	$5,276.92
Rate for Payer: Superior Health Plan Medicare	$5,276.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Universal American Medicare	$5,276.92
Rate for Payer: Wellcare Medicare	$5,276.92
Rate for Payer: Wellmed Medicare	$5,276.92

Laparoscopic Roux-en-Y Gastric Bypass (Must Include DRG 620/621 and CPT 43644)

Facility

$16,500.00

Service Code	MSDRG 621
Hospital Charge Code	2
Min. Negotiated Rate	$16,500.00
Max. Negotiated Rate	$16,500.00
Rate for Payer: BARInet Commercial	$16,500.00

Laparoscopic Roux-en-Y Gastric Bypass (Must Include DRG 620/621 and CPT 43644)

Facility

$16,500.00

Service Code	MSDRG 620
Hospital Charge Code	1
Min. Negotiated Rate	$16,500.00
Max. Negotiated Rate	$16,500.00
Rate for Payer: BARInet Commercial	$16,500.00

Laparoscopic Roux-en-Y Gastric Bypass (Must Include DRG 620/621 and CPT 43644)

Facility

$16,500.00

Service Code	MSDRG 621
Hospital Charge Code	1
Min. Negotiated Rate	$16,500.00
Max. Negotiated Rate	$16,500.00
Rate for Payer: BARInet Commercial	$16,500.00

Laparoscopic Roux-en-Y Gastric Bypass (Must Include DRG 620/621 and CPT 43644)

Facility

$16,500.00

Service Code	MSDRG 620
Hospital Charge Code	2
Min. Negotiated Rate	$16,500.00
Max. Negotiated Rate	$16,500.00
Rate for Payer: BARInet Commercial	$16,500.00

Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s)

Facility

$12,180.95

Service Code	CPT 49320
Hospital Charge Code	36049320
Hospital Revenue Code	360
Min. Negotiated Rate	$1,888.85
Max. Negotiated Rate	$12,180.95
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$7,915.38
Rate for Payer: Amerigroup CHIP/Medicaid	$1,888.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Amerigroup Medicare	$5,276.92
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$5,276.92
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$11,953.74
Rate for Payer: Cigna Medicaid	$1,888.85
Rate for Payer: Cigna Medicare	$5,276.92
Rate for Payer: Employer Direct Commercial	$5,276.92
Rate for Payer: Humana Medicare/TRICARE	$5,276.92
Rate for Payer: Molina CHIP/Medicaid	$1,888.85
Rate for Payer: Molina Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Molina Medicare	$5,276.92
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	$1,888.85
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$5,276.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,888.85
Rate for Payer: Superior Health Plan EPO	$5,276.92
Rate for Payer: Superior Health Plan Medicare	$5,276.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Universal American Medicare	$5,276.92
Rate for Payer: Wellcare Medicare	$5,276.92
Rate for Payer: Wellmed Medicare	$5,276.92

Laparoscopy, surgical cholecystectomy

Facility

$12,180.95

Service Code	CPT 47562
Hospital Charge Code	36047562
Hospital Revenue Code	360
Min. Negotiated Rate	$1,888.85
Max. Negotiated Rate	$12,180.95
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$7,915.38
Rate for Payer: Amerigroup CHIP/Medicaid	$1,888.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Amerigroup Medicare	$5,276.92
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$5,276.92
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$11,953.74
Rate for Payer: Cigna Medicaid	$1,888.85
Rate for Payer: Cigna Medicare	$5,276.92
Rate for Payer: Employer Direct Commercial	$5,276.92
Rate for Payer: Humana Medicare/TRICARE	$5,276.92
Rate for Payer: Molina CHIP/Medicaid	$1,888.85
Rate for Payer: Molina Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Molina Medicare	$5,276.92
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	$1,888.85
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$5,276.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,888.85
Rate for Payer: Superior Health Plan EPO	$5,276.92
Rate for Payer: Superior Health Plan Medicare	$5,276.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Universal American Medicare	$5,276.92
Rate for Payer: Wellcare Medicare	$5,276.92
Rate for Payer: Wellmed Medicare	$5,276.92

Laparoscopy, surgical; cholecystectomy with cholangiography

Facility

$12,180.95

Service Code	CPT 47563
Hospital Charge Code	36047563
Hospital Revenue Code	360
Min. Negotiated Rate	$1,888.85
Max. Negotiated Rate	$12,180.95
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$7,915.38
Rate for Payer: Amerigroup CHIP/Medicaid	$1,888.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Amerigroup Medicare	$5,276.92
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$5,276.92
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$11,953.74
Rate for Payer: Cigna Medicaid	$1,888.85
Rate for Payer: Cigna Medicare	$5,276.92
Rate for Payer: Employer Direct Commercial	$5,276.92
Rate for Payer: Humana Medicare/TRICARE	$5,276.92
Rate for Payer: Molina CHIP/Medicaid	$1,888.85
Rate for Payer: Molina Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Molina Medicare	$5,276.92
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	$1,888.85
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$5,276.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,888.85
Rate for Payer: Superior Health Plan EPO	$5,276.92
Rate for Payer: Superior Health Plan Medicare	$5,276.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Universal American Medicare	$5,276.92
Rate for Payer: Wellcare Medicare	$5,276.92
Rate for Payer: Wellmed Medicare	$5,276.92

Know your out-of-pocket cost for care.

All Charges