White Rock Medical Center

All Charges

Charge

Type

Setting

Price

LD DFIB DURATA 7122Q SJ4 -- DHF

Facility

$23,025.42

Service Code	HCPCS C1777
Hospital Charge Code	40085912
Hospital Revenue Code	278
Min. Negotiated Rate	$2,072.29
Max. Negotiated Rate	$11,512.71
Rate for Payer: Aetna Commercial	$6,907.63
Rate for Payer: Amerigroup CHIP/Medicaid	$2,072.29
Rate for Payer: BCBS of TX Blue Advantage	$6,907.63
Rate for Payer: BCBS of TX Blue Essentials	$8,289.15
Rate for Payer: BCBS of TX PPO	$9,210.17
Rate for Payer: Cash Price	$20,262.37
Rate for Payer: Multiplan Auto	$11,512.71
Rate for Payer: Multiplan Commercial	$11,512.71
Rate for Payer: Multiplan Workers Comp	$11,512.71
Rate for Payer: Scott and White EPO/PPO	$11,512.71
Rate for Payer: Superior Health Plan EPO	$3,131.46

LD DFIB DURATA 7122Q SJ4 -- DHF

Facility

$23,025.42

Service Code	HCPCS C1777
Hospital Charge Code	40085912
Hospital Revenue Code	278
Min. Negotiated Rate	$5,756.36
Max. Negotiated Rate	$11,512.71
Rate for Payer: Aetna Commercial	$6,907.63
Rate for Payer: Cash Price	$20,262.37
Rate for Payer: Cigna Commercial	$5,756.36
Rate for Payer: Multiplan Auto	$11,512.71
Rate for Payer: Multiplan Commercial	$11,512.71
Rate for Payer: Multiplan Workers Comp	$11,512.71
Rate for Payer: Scott and White EPO/PPO	$11,512.71

L&D Flu Initial Admin Charge 90471/G0008 BCE

Facility

$124.00

Service Code	CPT 90471
Hospital Charge Code	315368
Hospital Revenue Code	771
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$68.20
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$105.22
Rate for Payer: BCBS of TX Blue Essentials	$125.78
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$140.29
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Scott and White EPO/PPO	$1.15
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

L&D - Flu Vaccine Adm G0008

Facility

$124.00

Service Code	HCPCS G0008
Hospital Charge Code	315368
Hospital Revenue Code	771
Rate for Payer: Cash Price	$109.12

L&D - Flu Vaccine Adm G0008

Facility

$124.00

Service Code	HCPCS G0008
Hospital Charge Code	315368
Hospital Revenue Code	771
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$98.40
Rate for Payer: Aetna Commercial	$68.20
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$41.39
Rate for Payer: BCBS of TX Blue Essentials	$49.48
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$55.19
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

LDH SO

Facility

$254.00

Service Code	CPT 83615
Hospital Charge Code	1602093
Hospital Revenue Code	301
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$165.10
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: Aetna Medicare	$9.06
Rate for Payer: Amerigroup CHIP/Medicaid	$2.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.04
Rate for Payer: Amerigroup Medicare	$6.04
Rate for Payer: BCBS of TX Blue Advantage	$9.97
Rate for Payer: BCBS of TX Blue Essentials	$11.96
Rate for Payer: BCBS of TX Medicare	$6.04
Rate for Payer: BCBS of TX PPO	$13.35
Rate for Payer: Cash Price	$223.52
Rate for Payer: Cash Price	$223.52
Rate for Payer: Cigna Medicaid	$6.04
Rate for Payer: Cigna Medicare	$6.04
Rate for Payer: Employer Direct Commercial	$6.04
Rate for Payer: Humana Medicare/TRICARE	$6.04
Rate for Payer: Molina CHIP/Medicaid	$6.04
Rate for Payer: Molina Dual Medicare/Medicaid	$6.04
Rate for Payer: Molina Medicare	$6.04
Rate for Payer: Multiplan Auto	$165.10
Rate for Payer: Multiplan Commercial	$165.10
Rate for Payer: Multiplan Workers Comp	$165.10
Rate for Payer: Parkland Medicaid	$6.04
Rate for Payer: Scott and White EPO/PPO	$7.55
Rate for Payer: Scott and White Medicare	$6.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.04
Rate for Payer: Superior Health Plan EPO	$6.04
Rate for Payer: Superior Health Plan Medicare	$6.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.04
Rate for Payer: Universal American Medicare	$6.04
Rate for Payer: Wellcare Medicare	$6.04
Rate for Payer: Wellmed Medicare	$6.04

L&D Inf Hydration Each Addl Hr 96361 BCE

Facility

$251.00

Service Code	CPT 96361
Hospital Charge Code	301135
Hospital Revenue Code	260
Rate for Payer: Cash Price	$220.88

L&D Inf Hydration Each Addl Hr 96361 BCE

Facility

$251.00

Service Code	CPT 96361
Hospital Charge Code	301135
Hospital Revenue Code	260
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$163.15
Rate for Payer: Aetna Commercial	$138.05
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$22.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$23.82
Rate for Payer: BCBS of TX Blue Essentials	$28.48
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$31.76
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$163.15
Rate for Payer: Multiplan Commercial	$163.15
Rate for Payer: Multiplan Workers Comp	$163.15
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

L&D Inf Hydration Initial 31 to 60 Min 96360 BCE

Facility

$847.00

Service Code	CPT 96360
Hospital Charge Code	301127
Hospital Revenue Code	260
Rate for Payer: Cash Price	$745.36

L&D Inf Hydration Initial 31 to 60 Min 96360 BCE

Facility

$847.00

Service Code	CPT 96360
Hospital Charge Code	301127
Hospital Revenue Code	260
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$550.55
Rate for Payer: Aetna Commercial	$465.85
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$76.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$67.09
Rate for Payer: BCBS of TX Blue Essentials	$80.20
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$89.46
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cigna Commercial	$444.05
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 Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
Rate for Payer: Multiplan Auto	$550.55
Rate for Payer: Multiplan Commercial	$550.55
Rate for Payer: Multiplan Workers Comp	$550.55
Rate for Payer: Scott and White EPO/PPO	$3.51
Rate for Payer: Scott and White Medicare	$196.02
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

L&D Inf Ther Proph Dx Each Addl Hr 96366 BCE

Facility

$153.00

Service Code	CPT 96366
Hospital Charge Code	301150
Hospital Revenue Code	260
Rate for Payer: Cash Price	$134.64

L&D Inf Ther Proph Dx Each Addl Hr 96366 BCE

Facility

$153.00

Service Code	CPT 96366
Hospital Charge Code	301150
Hospital Revenue Code	260
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$99.45
Rate for Payer: Aetna Commercial	$84.15
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$38.25
Rate for Payer: BCBS of TX Blue Essentials	$45.72
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$50.99
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

L&D Inf Tx Prophylaxis Dx New Drug 96367 BCE

Facility

$175.00

Service Code	CPT 96367
Hospital Charge Code	315370
Hospital Revenue Code	260
Rate for Payer: Cash Price	$154.00

L&D Inf Tx Prophylaxis Dx New Drug 96367 BCE

Facility

$175.00

Service Code	CPT 96367
Hospital Charge Code	315370
Hospital Revenue Code	260
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$55.18
Rate for Payer: BCBS of TX Blue Essentials	$65.96
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$73.57
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Scott and White EPO/PPO	$1.15
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

L&D Inf Tx Prophylaxis Dx New Drug 96368 BCE

Facility

$149.00

Service Code	CPT 96368
Hospital Charge Code	315380
Hospital Revenue Code	260
Rate for Payer: Cash Price	$131.12

L&D Inf Tx Prophylaxis Dx New Drug 96368 BCE

Facility

$149.00

Service Code	CPT 96368
Hospital Charge Code	315380
Hospital Revenue Code	260
Min. Negotiated Rate	$13.41
Max. Negotiated Rate	$96.85
Rate for Payer: Aetna Commercial	$81.95
Rate for Payer: Amerigroup CHIP/Medicaid	$13.41
Rate for Payer: BCBS of TX Blue Advantage	$36.99
Rate for Payer: BCBS of TX Blue Essentials	$44.22
Rate for Payer: BCBS of TX PPO	$49.32
Rate for Payer: Cash Price	$131.12
Rate for Payer: Cash Price	$131.12
Rate for Payer: Multiplan Auto	$96.85
Rate for Payer: Multiplan Commercial	$96.85
Rate for Payer: Multiplan Workers Comp	$96.85
Rate for Payer: Scott and White EPO/PPO	$74.50
Rate for Payer: Superior Health Plan EPO	$20.26

L&D Inf Tx Prophylaxis Dx up to 1 Hour 96365 BCE

Facility

$300.00

Service Code	CPT 96365
Hospital Charge Code	301143
Hospital Revenue Code	260
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$444.05
Rate for Payer: Aetna Commercial	$165.00
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$27.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$126.67
Rate for Payer: BCBS of TX Blue Essentials	$151.42
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$168.90
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cigna Commercial	$444.05
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 Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
Rate for Payer: Multiplan Auto	$195.00
Rate for Payer: Multiplan Commercial	$195.00
Rate for Payer: Multiplan Workers Comp	$195.00
Rate for Payer: Scott and White EPO/PPO	$3.51
Rate for Payer: Scott and White Medicare	$196.02
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

L&D Inf Tx Prophylaxis Dx up to 1 Hour 96365 BCE

Facility

$300.00

Service Code	CPT 96365
Hospital Charge Code	301143
Hospital Revenue Code	260
Rate for Payer: Cash Price	$264.00

L&D - Initial Admin Charge 90471

Facility

$124.00

Service Code	CPT 90471
Hospital Charge Code	315367
Hospital Revenue Code	771
Rate for Payer: Cash Price	$109.12

L&D - Initial Admin Charge 90471

Facility

$124.00

Service Code	CPT 90471
Hospital Charge Code	315367
Hospital Revenue Code	771
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$68.20
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$105.22
Rate for Payer: BCBS of TX Blue Essentials	$125.78
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$140.29
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Scott and White EPO/PPO	$1.15
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

L&D - Initial Admin Charge 90471

Facility

$124.00

Service Code	CPT 90471
Hospital Charge Code	315368
Hospital Revenue Code	771
Rate for Payer: Cash Price	$109.12

L&D - Initial Admin Charge 90471

Facility

$124.00

Service Code	CPT 90471
Hospital Charge Code	315368
Hospital Revenue Code	771
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$68.20
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$105.22
Rate for Payer: BCBS of TX Blue Essentials	$125.78
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$140.29
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Scott and White EPO/PPO	$1.15
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

L&D Initial Admin Charge 90471 BCE

Facility

$124.00

Service Code	CPT 90471
Hospital Charge Code	315367
Hospital Revenue Code	771
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$68.20
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$105.22
Rate for Payer: BCBS of TX Blue Essentials	$125.78
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$140.29
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Scott and White EPO/PPO	$1.15
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

LD PACE/SENS DFB SGL COIL 0672 -- DHF

Facility

$21,686.75

Service Code	HCPCS C1777
Hospital Charge Code	40087496
Hospital Revenue Code	278
Min. Negotiated Rate	$5,421.69
Max. Negotiated Rate	$10,843.38
Rate for Payer: Aetna Commercial	$6,506.02
Rate for Payer: Cash Price	$19,084.34
Rate for Payer: Cigna Commercial	$5,421.69
Rate for Payer: Multiplan Auto	$10,843.38
Rate for Payer: Multiplan Commercial	$10,843.38
Rate for Payer: Multiplan Workers Comp	$10,843.38
Rate for Payer: Scott and White EPO/PPO	$10,843.38

LD PACE/SENS DFB SGL COIL 0672 -- DHF

Facility

$21,686.75

Service Code	HCPCS C1777
Hospital Charge Code	40087496
Hospital Revenue Code	278
Min. Negotiated Rate	$1,951.81
Max. Negotiated Rate	$10,843.38
Rate for Payer: Aetna Commercial	$6,506.02
Rate for Payer: Amerigroup CHIP/Medicaid	$1,951.81
Rate for Payer: BCBS of TX Blue Advantage	$6,506.02
Rate for Payer: BCBS of TX Blue Essentials	$7,807.23
Rate for Payer: BCBS of TX PPO	$8,674.70
Rate for Payer: Cash Price	$19,084.34
Rate for Payer: Multiplan Auto	$10,843.38
Rate for Payer: Multiplan Commercial	$10,843.38
Rate for Payer: Multiplan Workers Comp	$10,843.38
Rate for Payer: Scott and White EPO/PPO	$10,843.38
Rate for Payer: Superior Health Plan EPO	$2,949.40

Know your out-of-pocket cost for care.

All Charges