White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Infusion for Hydration Initial 31 to 60 Minutes 96360

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	7003585
Hospital Revenue Code	260
Min. Negotiated Rate	$76.23
Max. Negotiated Rate	$609.84
Rate for Payer: Amerigroup CHIP/Medicaid	$76.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$254.10
Rate for Payer: BCBS of TX Blue Essentials	$304.92
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$338.80
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$609.84
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$609.84
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
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: Parkland Medicaid	$609.84
Rate for Payer: Scott and White EPO/PPO	$423.50
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$609.84
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

Infusion pump, programmable (implantable)

Facility

$67,127.00

Service Code	HCPCS C1772
Hospital Charge Code	990932
Hospital Revenue Code	278
Min. Negotiated Rate	$6,041.43
Max. Negotiated Rate	$48,331.44
Rate for Payer: Amerigroup CHIP/Medicaid	$6,041.43
Rate for Payer: BCBS of TX Blue Advantage	$20,138.10
Rate for Payer: BCBS of TX Blue Essentials	$24,165.72
Rate for Payer: BCBS of TX PPO	$26,850.80
Rate for Payer: Cash Price	$45,646.36
Rate for Payer: Cigna Medicaid	$48,331.44
Rate for Payer: Molina CHIP/Medicaid	$48,331.44
Rate for Payer: Multiplan Auto	$33,563.50
Rate for Payer: Multiplan Commercial	$33,563.50
Rate for Payer: Multiplan Workers Comp	$33,563.50
Rate for Payer: Parkland Medicaid	$48,331.44
Rate for Payer: Scott and White EPO/PPO	$33,563.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48,331.44
Rate for Payer: Superior Health Plan EPO	$9,129.27

Infusion pump, programmable (implantable)

Facility

$67,127.00

Service Code	HCPCS C1772
Hospital Charge Code	990932
Hospital Revenue Code	278
Min. Negotiated Rate	$16,781.75
Max. Negotiated Rate	$33,563.50
Rate for Payer: Cash Price	$45,646.36
Rate for Payer: Cigna Commercial	$16,781.75
Rate for Payer: Multiplan Auto	$33,563.50
Rate for Payer: Multiplan Commercial	$33,563.50
Rate for Payer: Multiplan Workers Comp	$33,563.50
Rate for Payer: Scott and White EPO/PPO	$33,563.50

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC

Facility

$28,965.50

Service Code	MSDRG 351
Min. Negotiated Rate	$12,900.86
Max. Negotiated Rate	$28,965.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,933.19
Rate for Payer: Amerigroup Medicare	$15,933.19
Rate for Payer: BCBS of TX Medicare	$15,933.19
Rate for Payer: Cigna Commercial	$19,635.56
Rate for Payer: Cigna Medicare	$15,933.19
Rate for Payer: Employer Direct Commercial	$15,933.19
Rate for Payer: Humana Medicare/TRICARE	$15,933.19
Rate for Payer: Molina Dual Medicare/Medicaid	$15,933.19
Rate for Payer: Molina Medicare	$15,933.19
Rate for Payer: Multiplan Auto	$28,965.50
Rate for Payer: Multiplan Commercial	$28,965.50
Rate for Payer: Multiplan Workers Comp	$28,965.50
Rate for Payer: Scott and White EPO/PPO	$13,339.38
Rate for Payer: Scott and White Medicare	$15,933.19
Rate for Payer: Superior Health Plan EPO	$15,933.19
Rate for Payer: Superior Health Plan Medicare	$15,933.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,933.19
Rate for Payer: Universal American Medicare	$15,933.19
Rate for Payer: Wellcare Medicare	$15,933.19
Rate for Payer: Wellmed Medicare	$15,933.19

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC

Facility

$47,346.10

Service Code	MSDRG 350
Min. Negotiated Rate	$21,039.90
Max. Negotiated Rate	$47,346.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,023.29
Rate for Payer: Amerigroup Medicare	$23,023.29
Rate for Payer: BCBS of TX Medicare	$23,023.29
Rate for Payer: Cigna Commercial	$32,095.67
Rate for Payer: Cigna Medicare	$23,023.29
Rate for Payer: Employer Direct Commercial	$23,023.29
Rate for Payer: Humana Medicare/TRICARE	$23,023.29
Rate for Payer: Molina Dual Medicare/Medicaid	$23,023.29
Rate for Payer: Molina Medicare	$23,023.29
Rate for Payer: Multiplan Auto	$47,346.10
Rate for Payer: Multiplan Commercial	$47,346.10
Rate for Payer: Multiplan Workers Comp	$47,346.10
Rate for Payer: Scott and White EPO/PPO	$21,804.12
Rate for Payer: Scott and White Medicare	$23,023.29
Rate for Payer: Superior Health Plan EPO	$23,023.29
Rate for Payer: Superior Health Plan Medicare	$23,023.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,023.29
Rate for Payer: Universal American Medicare	$23,023.29
Rate for Payer: Wellcare Medicare	$23,023.29
Rate for Payer: Wellmed Medicare	$23,023.29

INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC

Facility

$22,188.20

Service Code	MSDRG 352
Min. Negotiated Rate	$9,060.10
Max. Negotiated Rate	$22,188.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,318.92
Rate for Payer: Amerigroup Medicare	$13,318.92
Rate for Payer: BCBS of TX Medicare	$13,318.92
Rate for Payer: Cigna Commercial	$15,041.26
Rate for Payer: Cigna Medicare	$13,318.92
Rate for Payer: Employer Direct Commercial	$13,318.92
Rate for Payer: Humana Medicare/TRICARE	$13,318.92
Rate for Payer: Molina Dual Medicare/Medicaid	$13,318.92
Rate for Payer: Molina Medicare	$13,318.92
Rate for Payer: Multiplan Auto	$22,188.20
Rate for Payer: Multiplan Commercial	$22,188.20
Rate for Payer: Multiplan Workers Comp	$22,188.20
Rate for Payer: Scott and White EPO/PPO	$10,218.25
Rate for Payer: Scott and White Medicare	$13,318.92
Rate for Payer: Superior Health Plan EPO	$13,318.92
Rate for Payer: Superior Health Plan Medicare	$13,318.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,318.92
Rate for Payer: Universal American Medicare	$13,318.92
Rate for Payer: Wellcare Medicare	$13,318.92
Rate for Payer: Wellmed Medicare	$13,318.92

INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES

Facility

$16,611.40

Service Code	APR-DRG 2284
Min. Negotiated Rate	$15,661.81
Max. Negotiated Rate	$16,611.40
Rate for Payer: Amerigroup CHIP/Medicaid	$15,661.81
Rate for Payer: Cigna Medicaid	$15,661.81
Rate for Payer: Molina CHIP/Medicaid	$15,661.81
Rate for Payer: Parkland Medicaid	$15,661.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,611.40

INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES

Facility

$3,860.15

Service Code	APR-DRG 2281
Min. Negotiated Rate	$3,639.49
Max. Negotiated Rate	$3,860.15
Rate for Payer: Amerigroup CHIP/Medicaid	$3,639.49
Rate for Payer: Cigna Medicaid	$3,639.49
Rate for Payer: Molina CHIP/Medicaid	$3,639.49
Rate for Payer: Parkland Medicaid	$3,639.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,860.15

INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES

Facility

$5,211.24

Service Code	APR-DRG 2282
Min. Negotiated Rate	$4,913.34
Max. Negotiated Rate	$5,211.24
Rate for Payer: Amerigroup CHIP/Medicaid	$4,913.34
Rate for Payer: Cigna Medicaid	$4,913.34
Rate for Payer: Molina CHIP/Medicaid	$4,913.34
Rate for Payer: Parkland Medicaid	$4,913.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,211.24

INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES

Facility

$8,638.76

Service Code	APR-DRG 2283
Min. Negotiated Rate	$8,144.93
Max. Negotiated Rate	$8,638.76
Rate for Payer: Amerigroup CHIP/Medicaid	$8,144.93
Rate for Payer: Cigna Medicaid	$8,144.93
Rate for Payer: Molina CHIP/Medicaid	$8,144.93
Rate for Payer: Parkland Medicaid	$8,144.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,638.76

INGUINAL & FEMORAL HERNIA PROCEDURES W CC

Facility

$28,965.50

Service Code	MSDRG 351
Min. Negotiated Rate	$12,900.86
Max. Negotiated Rate	$28,965.50
Rate for Payer: BCBS of TX Blue Advantage	$12,900.86
Rate for Payer: BCBS of TX Blue Essentials	$15,479.53
Rate for Payer: BCBS of TX PPO	$17,200.15

INGUINAL & FEMORAL HERNIA PROCEDURES W MCC

Facility

$47,346.10

Service Code	MSDRG 350
Min. Negotiated Rate	$21,039.90
Max. Negotiated Rate	$47,346.10
Rate for Payer: BCBS of TX Blue Advantage	$21,039.90
Rate for Payer: BCBS of TX Blue Essentials	$25,245.43
Rate for Payer: BCBS of TX PPO	$28,051.57

INGUINAL & FEMORAL HERNIA PROCEDURES W/O CC/MCC

Facility

$22,188.20

Service Code	MSDRG 352
Min. Negotiated Rate	$9,060.10
Max. Negotiated Rate	$22,188.20
Rate for Payer: BCBS of TX Blue Advantage	$9,060.10
Rate for Payer: BCBS of TX Blue Essentials	$10,871.07
Rate for Payer: BCBS of TX PPO	$12,079.43

Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure)

Facility

$12,960.81

Service Code	HCPCS 38760
Hospital Charge Code	9900638
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,813.35

Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure)

Facility

$14,100.07

Service Code	CPT 38760
Hospital Charge Code	36038760
Hospital Revenue Code	360
Min. Negotiated Rate	$1,845.21
Max. Negotiated Rate	$14,100.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,845.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Amerigroup Medicare	$6,670.43
Rate for Payer: BCBS of TX Blue Advantage	$8,746.27
Rate for Payer: BCBS of TX Blue Essentials	$10,474.58
Rate for Payer: BCBS of TX Medicare	$6,670.43
Rate for Payer: BCBS of TX PPO	$13,197.97
Rate for Payer: Cigna Commercial	$14,100.07
Rate for Payer: Cigna Medicare	$6,670.43
Rate for Payer: Employer Direct Commercial	$6,670.43
Rate for Payer: Humana Medicare/TRICARE	$6,670.43
Rate for Payer: Molina Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Molina Medicare	$6,670.43
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	$12,340.30
Rate for Payer: Scott and White Medicare	$6,670.43
Rate for Payer: Superior Health Plan EPO	$6,670.43
Rate for Payer: Superior Health Plan Medicare	$6,670.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Universal American Medicare	$6,670.43
Rate for Payer: Wellcare Medicare	$6,670.43
Rate for Payer: Wellmed Medicare	$6,670.43

Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure)

Facility

$12,960.81

Service Code	HCPCS 38760
Hospital Charge Code	9900638
Hospital Revenue Code	360
Min. Negotiated Rate	$1,845.21
Max. Negotiated Rate	$14,100.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,845.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Amerigroup Medicare	$6,670.43
Rate for Payer: BCBS of TX Blue Advantage	$8,746.27
Rate for Payer: BCBS of TX Blue Essentials	$10,474.58
Rate for Payer: BCBS of TX Medicare	$6,670.43
Rate for Payer: BCBS of TX PPO	$13,197.97
Rate for Payer: Cash Price	$8,813.35
Rate for Payer: Cash Price	$8,813.35
Rate for Payer: Cash Price	$8,813.35
Rate for Payer: Cigna Commercial	$14,100.07
Rate for Payer: Cigna Medicaid	$9,331.78
Rate for Payer: Cigna Medicare	$6,670.43
Rate for Payer: Employer Direct Commercial	$6,670.43
Rate for Payer: Humana Medicare/TRICARE	$6,670.43
Rate for Payer: Molina CHIP/Medicaid	$9,331.78
Rate for Payer: Molina Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Molina Medicare	$6,670.43
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	$9,331.78
Rate for Payer: Scott and White EPO/PPO	$12,340.30
Rate for Payer: Scott and White Medicare	$6,670.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,331.78
Rate for Payer: Superior Health Plan EPO	$6,670.43
Rate for Payer: Superior Health Plan Medicare	$6,670.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Universal American Medicare	$6,670.43
Rate for Payer: Wellcare Medicare	$6,670.43
Rate for Payer: Wellmed Medicare	$6,670.43

Inhibin A, Ultrasensitive SO

Facility

$239.60

Service Code	HCPCS 86336
Hospital Charge Code	1708908
Hospital Revenue Code	302
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$172.51
Rate for Payer: Amerigroup CHIP/Medicaid	$6.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.59
Rate for Payer: Amerigroup Medicare	$15.59
Rate for Payer: BCBS of TX Blue Advantage	$71.88
Rate for Payer: BCBS of TX Blue Essentials	$86.26
Rate for Payer: BCBS of TX Medicare	$15.59
Rate for Payer: BCBS of TX PPO	$95.84
Rate for Payer: Cash Price	$162.93
Rate for Payer: Cash Price	$162.93
Rate for Payer: Cigna Medicaid	$172.51
Rate for Payer: Cigna Medicare	$15.59
Rate for Payer: Employer Direct Commercial	$15.59
Rate for Payer: Humana Medicare/TRICARE	$15.59
Rate for Payer: Molina CHIP/Medicaid	$172.51
Rate for Payer: Molina Dual Medicare/Medicaid	$15.59
Rate for Payer: Molina Medicare	$15.59
Rate for Payer: Multiplan Auto	$155.74
Rate for Payer: Multiplan Commercial	$155.74
Rate for Payer: Multiplan Workers Comp	$155.74
Rate for Payer: Parkland Medicaid	$172.51
Rate for Payer: Scott and White EPO/PPO	$19.49
Rate for Payer: Scott and White Medicare	$15.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$172.51
Rate for Payer: Superior Health Plan EPO	$15.59
Rate for Payer: Superior Health Plan Medicare	$15.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.59
Rate for Payer: Universal American Medicare	$15.59
Rate for Payer: Wellcare Medicare	$15.59
Rate for Payer: Wellmed Medicare	$15.59

Inhibin A, Ultrasensitive SO

Facility

$239.60

Service Code	HCPCS 86336
Hospital Charge Code	1708908
Hospital Revenue Code	302
Rate for Payer: Cash Price	$162.93

Initial hospital or birthing center care normal newborn

Facility

$515.48

Service Code	HCPCS 99463
Hospital Charge Code	994129
Hospital Revenue Code	450
Rate for Payer: Cash Price	$350.53

Initial hospital or birthing center care normal newborn

Facility

$515.48

Service Code	HCPCS 99463
Hospital Charge Code	994129
Hospital Revenue Code	450
Min. Negotiated Rate	$46.39
Max. Negotiated Rate	$371.15
Rate for Payer: Amerigroup CHIP/Medicaid	$46.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.74
Rate for Payer: Amerigroup Medicare	$133.74
Rate for Payer: BCBS of TX Blue Advantage	$154.64
Rate for Payer: BCBS of TX Blue Essentials	$185.57
Rate for Payer: BCBS of TX Medicare	$133.74
Rate for Payer: BCBS of TX PPO	$206.19
Rate for Payer: Cash Price	$350.53
Rate for Payer: Cash Price	$350.53
Rate for Payer: Cash Price	$350.53
Rate for Payer: Cigna Commercial	$282.70
Rate for Payer: Cigna Medicaid	$371.15
Rate for Payer: Cigna Medicare	$133.74
Rate for Payer: Employer Direct Commercial	$133.74
Rate for Payer: Humana Medicare/TRICARE	$133.74
Rate for Payer: Molina CHIP/Medicaid	$371.15
Rate for Payer: Molina Dual Medicare/Medicaid	$133.74
Rate for Payer: Molina Medicare	$133.74
Rate for Payer: Multiplan Auto	$335.06
Rate for Payer: Multiplan Commercial	$335.06
Rate for Payer: Multiplan Workers Comp	$335.06
Rate for Payer: Parkland Medicaid	$371.15
Rate for Payer: Scott and White EPO/PPO	$257.74
Rate for Payer: Scott and White Medicare	$133.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$371.15
Rate for Payer: Superior Health Plan EPO	$133.74
Rate for Payer: Superior Health Plan Medicare	$133.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.74
Rate for Payer: Universal American Medicare	$133.74
Rate for Payer: Wellcare Medicare	$133.74
Rate for Payer: Wellmed Medicare	$133.74

Initial treatment, first degree burn, when no more than local treatment is required

Facility

$794.80

Service Code	HCPCS 16000
Hospital Charge Code	991215
Hospital Revenue Code	360
Min. Negotiated Rate	$71.53
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$71.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$572.26
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$572.26
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
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	$572.26
Rate for Payer: Scott and White EPO/PPO	$372.87
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$572.26
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

Initial treatment, first degree burn, when no more than local treatment is required

Facility

$794.80

Service Code	HCPCS 16000
Hospital Charge Code	991215
Hospital Revenue Code	360
Rate for Payer: Cash Price	$540.46

INJ CM EVAL JTUBE

Facility

$857.00

Service Code	HCPCS 49465
Hospital Charge Code	4619467
Hospital Revenue Code	361
Rate for Payer: Cash Price	$582.76

INJ CM EVAL JTUBE

Facility

$857.00

Service Code	HCPCS 49465
Hospital Charge Code	4619467
Hospital Revenue Code	361
Min. Negotiated Rate	$77.13
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$77.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$389.18
Rate for Payer: BCBS of TX Blue Essentials	$466.08
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$587.26
Rate for Payer: Cash Price	$582.76
Rate for Payer: Cash Price	$582.76
Rate for Payer: Cash Price	$582.76
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$617.04
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$617.04
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
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	$617.04
Rate for Payer: Scott and White EPO/PPO	$443.43
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$617.04
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

INJECT CONGEN CARD CATH

Facility

$2,708.00

Service Code	HCPCS 93563
Hospital Charge Code	4613563
Hospital Revenue Code	481
Min. Negotiated Rate	$243.72
Max. Negotiated Rate	$1,949.76
Rate for Payer: Amerigroup CHIP/Medicaid	$243.72
Rate for Payer: BCBS of TX Blue Advantage	$812.40
Rate for Payer: BCBS of TX Blue Essentials	$974.88
Rate for Payer: BCBS of TX PPO	$1,083.20
Rate for Payer: Cash Price	$1,841.44
Rate for Payer: Cigna Medicaid	$1,949.76
Rate for Payer: Molina CHIP/Medicaid	$1,949.76
Rate for Payer: Multiplan Auto	$1,760.20
Rate for Payer: Multiplan Commercial	$1,760.20
Rate for Payer: Multiplan Workers Comp	$1,760.20
Rate for Payer: Parkland Medicaid	$1,949.76
Rate for Payer: Scott and White EPO/PPO	$1,354.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,949.76
Rate for Payer: Superior Health Plan EPO	$368.29

Know your out-of-pocket cost for care.

All Charges