White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direc

Facility

$154,966.56

Service Code	HCPCS 64590
Hospital Charge Code	9900817
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$111,575.92
Rate for Payer: Amerigroup CHIP/Medicaid	$14,745.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,488.52
Rate for Payer: Amerigroup Medicare	$19,488.52
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	$19,488.52
Rate for Payer: BCBS of TX PPO	$48,584.14
Rate for Payer: Cash Price	$105,377.26
Rate for Payer: Cash Price	$105,377.26
Rate for Payer: Cash Price	$105,377.26
Rate for Payer: Cigna Commercial	$41,195.19
Rate for Payer: Cigna Medicaid	$111,575.92
Rate for Payer: Cigna Medicare	$19,488.52
Rate for Payer: Employer Direct Commercial	$19,488.52
Rate for Payer: Humana Medicare/TRICARE	$19,488.52
Rate for Payer: Molina CHIP/Medicaid	$111,575.92
Rate for Payer: Molina Dual Medicare/Medicaid	$19,488.52
Rate for Payer: Molina Medicare	$19,488.52
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	$111,575.92
Rate for Payer: Scott and White EPO/PPO	$36,053.76
Rate for Payer: Scott and White Medicare	$19,488.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111,575.92
Rate for Payer: Superior Health Plan EPO	$19,488.52
Rate for Payer: Superior Health Plan Medicare	$19,488.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,488.52
Rate for Payer: Universal American Medicare	$19,488.52
Rate for Payer: Wellcare Medicare	$19,488.52
Rate for Payer: Wellmed Medicare	$19,488.52

INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES

Facility

$5,565.05

Service Code	APR-DRG 1761
Min. Negotiated Rate	$5,246.92
Max. Negotiated Rate	$5,565.05
Rate for Payer: Amerigroup CHIP/Medicaid	$5,246.92
Rate for Payer: Cigna Medicaid	$5,246.92
Rate for Payer: Molina CHIP/Medicaid	$5,246.92
Rate for Payer: Parkland Medicaid	$5,246.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,565.05

INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES

Facility

$15,397.23

Service Code	APR-DRG 1763
Min. Negotiated Rate	$14,517.05
Max. Negotiated Rate	$15,397.23
Rate for Payer: Amerigroup CHIP/Medicaid	$14,517.05
Rate for Payer: Cigna Medicaid	$14,517.05
Rate for Payer: Molina CHIP/Medicaid	$14,517.05
Rate for Payer: Parkland Medicaid	$14,517.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,397.23

INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES

Facility

$27,592.13

Service Code	APR-DRG 1764
Min. Negotiated Rate	$26,014.83
Max. Negotiated Rate	$27,592.13
Rate for Payer: Amerigroup CHIP/Medicaid	$26,014.83
Rate for Payer: Cigna Medicaid	$26,014.83
Rate for Payer: Molina CHIP/Medicaid	$26,014.83
Rate for Payer: Parkland Medicaid	$26,014.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,592.13

INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES

Facility

$6,783.37

Service Code	APR-DRG 1762
Min. Negotiated Rate	$6,395.60
Max. Negotiated Rate	$6,783.37
Rate for Payer: Amerigroup CHIP/Medicaid	$6,395.60
Rate for Payer: Cigna Medicaid	$6,395.60
Rate for Payer: Molina CHIP/Medicaid	$6,395.60
Rate for Payer: Parkland Medicaid	$6,395.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,783.37

INSERT NON-TUNNEL CV CATH

Facility

$4,645.00

Service Code	HCPCS 36556
Hospital Charge Code	2300531
Hospital Revenue Code	361
Min. Negotiated Rate	$1,118.22
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$2,723.99
Rate for Payer: BCBS of TX Blue Essentials	$3,262.26
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$4,110.45
Rate for Payer: Cash Price	$3,158.60
Rate for Payer: Cash Price	$3,158.60
Rate for Payer: Cash Price	$3,158.60
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$3,344.40
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$3,344.40
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$3,344.40
Rate for Payer: Scott and White EPO/PPO	$5,867.96
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,344.40
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

INSERT NON-TUNNEL CV CATH

Facility

$4,645.00

Service Code	HCPCS 36556
Hospital Charge Code	2300531
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,158.60

INSERT PACING LEAD & CONNECT

Facility

$16,178.00

Service Code	HCPCS 33224
Hospital Charge Code	2303303
Hospital Revenue Code	481
Min. Negotiated Rate	$1,456.02
Max. Negotiated Rate	$25,834.89
Rate for Payer: Amerigroup CHIP/Medicaid	$1,456.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Amerigroup Medicare	$10,499.62
Rate for Payer: BCBS of TX Blue Advantage	$17,120.74
Rate for Payer: BCBS of TX Blue Essentials	$20,503.88
Rate for Payer: BCBS of TX Medicare	$10,499.62
Rate for Payer: BCBS of TX PPO	$25,834.89
Rate for Payer: Cash Price	$11,001.04
Rate for Payer: Cash Price	$11,001.04
Rate for Payer: Cash Price	$11,001.04
Rate for Payer: Cigna Commercial	$22,194.30
Rate for Payer: Cigna Medicaid	$11,648.16
Rate for Payer: Cigna Medicare	$10,499.62
Rate for Payer: Employer Direct Commercial	$10,499.62
Rate for Payer: Humana Medicare/TRICARE	$10,499.62
Rate for Payer: Molina CHIP/Medicaid	$11,648.16
Rate for Payer: Molina Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Molina Medicare	$10,499.62
Rate for Payer: Multiplan Auto	$10,515.70
Rate for Payer: Multiplan Commercial	$10,515.70
Rate for Payer: Multiplan Workers Comp	$10,515.70
Rate for Payer: Parkland Medicaid	$11,648.16
Rate for Payer: Scott and White EPO/PPO	$8,089.00
Rate for Payer: Scott and White Medicare	$10,499.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,648.16
Rate for Payer: Superior Health Plan EPO	$10,499.62
Rate for Payer: Superior Health Plan Medicare	$10,499.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Universal American Medicare	$10,499.62
Rate for Payer: Wellcare Medicare	$10,499.62
Rate for Payer: Wellmed Medicare	$10,499.62

INSERT PACING LEAD & CONNECT

Facility

$16,178.00

Service Code	HCPCS 33224
Hospital Charge Code	2303303
Hospital Revenue Code	481
Rate for Payer: Cash Price	$11,001.04

Insert/Redo Spine Generator

Facility

$73,379.22

Service Code	CPT 63685
Hospital Charge Code	36063685
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$73,379.22
Rate for Payer: Amerigroup CHIP/Medicaid	$19,537.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,998.31
Rate for Payer: Amerigroup Medicare	$30,998.31
Rate for Payer: BCBS of TX Blue Advantage	$48,628.30
Rate for Payer: BCBS of TX Blue Essentials	$58,237.48
Rate for Payer: BCBS of TX Medicare	$30,998.31
Rate for Payer: BCBS of TX PPO	$73,379.22
Rate for Payer: Cigna Commercial	$65,524.82
Rate for Payer: Cigna Medicare	$30,998.31
Rate for Payer: Employer Direct Commercial	$30,998.31
Rate for Payer: Humana Medicare/TRICARE	$30,998.31
Rate for Payer: Molina Dual Medicare/Medicaid	$30,998.31
Rate for Payer: Molina Medicare	$30,998.31
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	$57,346.87
Rate for Payer: Scott and White Medicare	$30,998.31
Rate for Payer: Superior Health Plan EPO	$30,998.31
Rate for Payer: Superior Health Plan Medicare	$30,998.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,998.31
Rate for Payer: Universal American Medicare	$30,998.31
Rate for Payer: Wellcare Medicare	$30,998.31
Rate for Payer: Wellmed Medicare	$30,998.31

Insert/Redo Spine Generator

Facility

$174,156.00

Service Code	HCPCS 63685
Hospital Charge Code	9900776
Hospital Revenue Code	360
Rate for Payer: Cash Price	$118,426.08

Insert/Redo Spine Generator

Facility

$174,156.00

Service Code	HCPCS 63685
Hospital Charge Code	9900776
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$125,392.32
Rate for Payer: Amerigroup CHIP/Medicaid	$19,537.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,998.31
Rate for Payer: Amerigroup Medicare	$30,998.31
Rate for Payer: BCBS of TX Blue Advantage	$48,628.30
Rate for Payer: BCBS of TX Blue Essentials	$58,237.48
Rate for Payer: BCBS of TX Medicare	$30,998.31
Rate for Payer: BCBS of TX PPO	$73,379.22
Rate for Payer: Cash Price	$118,426.08
Rate for Payer: Cash Price	$118,426.08
Rate for Payer: Cash Price	$118,426.08
Rate for Payer: Cigna Commercial	$65,524.82
Rate for Payer: Cigna Medicaid	$125,392.32
Rate for Payer: Cigna Medicare	$30,998.31
Rate for Payer: Employer Direct Commercial	$30,998.31
Rate for Payer: Humana Medicare/TRICARE	$30,998.31
Rate for Payer: Molina CHIP/Medicaid	$125,392.32
Rate for Payer: Molina Dual Medicare/Medicaid	$30,998.31
Rate for Payer: Molina Medicare	$30,998.31
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	$125,392.32
Rate for Payer: Scott and White EPO/PPO	$57,346.87
Rate for Payer: Scott and White Medicare	$30,998.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125,392.32
Rate for Payer: Superior Health Plan EPO	$30,998.31
Rate for Payer: Superior Health Plan Medicare	$30,998.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,998.31
Rate for Payer: Universal American Medicare	$30,998.31
Rate for Payer: Wellcare Medicare	$30,998.31
Rate for Payer: Wellmed Medicare	$30,998.31

INSERT/REPOSIT DUAL CHMBR ELECT

Facility

$15,170.00

Service Code	HCPCS 33217
Hospital Charge Code	2302263
Hospital Revenue Code	481
Min. Negotiated Rate	$1,365.30
Max. Negotiated Rate	$19,257.46
Rate for Payer: Amerigroup CHIP/Medicaid	$1,365.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,313.10
Rate for Payer: Amerigroup Medicare	$8,313.10
Rate for Payer: BCBS of TX Blue Advantage	$12,761.89
Rate for Payer: BCBS of TX Blue Essentials	$15,283.70
Rate for Payer: BCBS of TX Medicare	$8,313.10
Rate for Payer: BCBS of TX PPO	$19,257.46
Rate for Payer: Cash Price	$10,315.60
Rate for Payer: Cash Price	$10,315.60
Rate for Payer: Cash Price	$10,315.60
Rate for Payer: Cigna Commercial	$17,572.38
Rate for Payer: Cigna Medicaid	$10,922.40
Rate for Payer: Cigna Medicare	$8,313.10
Rate for Payer: Employer Direct Commercial	$8,313.10
Rate for Payer: Humana Medicare/TRICARE	$8,313.10
Rate for Payer: Molina CHIP/Medicaid	$10,922.40
Rate for Payer: Molina Dual Medicare/Medicaid	$8,313.10
Rate for Payer: Molina Medicare	$8,313.10
Rate for Payer: Multiplan Auto	$9,860.50
Rate for Payer: Multiplan Commercial	$9,860.50
Rate for Payer: Multiplan Workers Comp	$9,860.50
Rate for Payer: Parkland Medicaid	$10,922.40
Rate for Payer: Scott and White EPO/PPO	$7,585.00
Rate for Payer: Scott and White Medicare	$8,313.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,922.40
Rate for Payer: Superior Health Plan EPO	$8,313.10
Rate for Payer: Superior Health Plan Medicare	$8,313.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,313.10
Rate for Payer: Universal American Medicare	$8,313.10
Rate for Payer: Wellcare Medicare	$8,313.10
Rate for Payer: Wellmed Medicare	$8,313.10

INSERT/REPOSIT DUAL CHMBR ELECT

Facility

$15,170.00

Service Code	HCPCS 33217
Hospital Charge Code	2302263
Hospital Revenue Code	481
Rate for Payer: Cash Price	$10,315.60

INSERT SWANGANZ CATHETER

Facility

$4,967.00

Service Code	HCPCS 93503
Hospital Charge Code	4613535
Hospital Revenue Code	481
Rate for Payer: Cash Price	$3,377.56

INSERT SWANGANZ CATHETER

Facility

$4,967.00

Service Code	HCPCS 93503
Hospital Charge Code	4613535
Hospital Revenue Code	481
Min. Negotiated Rate	$447.03
Max. Negotiated Rate	$4,110.45
Rate for Payer: Amerigroup CHIP/Medicaid	$447.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Amerigroup Medicare	$1,581.33
Rate for Payer: BCBS of TX Blue Advantage	$2,723.99
Rate for Payer: BCBS of TX Blue Essentials	$3,262.26
Rate for Payer: BCBS of TX Medicare	$1,581.33
Rate for Payer: BCBS of TX PPO	$4,110.45
Rate for Payer: Cash Price	$3,377.56
Rate for Payer: Cash Price	$3,377.56
Rate for Payer: Cash Price	$3,377.56
Rate for Payer: Cigna Commercial	$3,342.63
Rate for Payer: Cigna Medicaid	$3,576.24
Rate for Payer: Cigna Medicare	$1,581.33
Rate for Payer: Employer Direct Commercial	$1,581.33
Rate for Payer: Humana Medicare/TRICARE	$1,581.33
Rate for Payer: Molina CHIP/Medicaid	$3,576.24
Rate for Payer: Molina Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Molina Medicare	$1,581.33
Rate for Payer: Multiplan Auto	$3,228.55
Rate for Payer: Multiplan Commercial	$3,228.55
Rate for Payer: Multiplan Workers Comp	$3,228.55
Rate for Payer: Parkland Medicaid	$3,576.24
Rate for Payer: Scott and White EPO/PPO	$2,483.50
Rate for Payer: Scott and White Medicare	$1,581.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,576.24
Rate for Payer: Superior Health Plan EPO	$1,581.33
Rate for Payer: Superior Health Plan Medicare	$1,581.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Universal American Medicare	$1,581.33
Rate for Payer: Wellcare Medicare	$1,581.33
Rate for Payer: Wellmed Medicare	$1,581.33

Insert tunneled cv cath

Facility

$12,148.04

Service Code	HCPCS 36561
Hospital Charge Code	9900628
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,260.67

Insert tunneled cv cath

Facility

$12,148.04

Service Code	HCPCS 36561
Hospital Charge Code	9900628
Hospital Revenue Code	360
Min. Negotiated Rate	$1,118.22
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$8,260.67
Rate for Payer: Cash Price	$8,260.67
Rate for Payer: Cash Price	$8,260.67
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$8,746.59
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$8,746.59
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$8,746.59
Rate for Payer: Scott and White EPO/PPO	$5,867.96
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,746.59
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

INSERT TUNNELED CV CATH

Facility

$6,847.00

Service Code	HCPCS 36558
Hospital Charge Code	2300770
Hospital Revenue Code	361
Min. Negotiated Rate	$1,118.22
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$4,655.96
Rate for Payer: Cash Price	$4,655.96
Rate for Payer: Cash Price	$4,655.96
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$4,929.84
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$4,929.84
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$4,929.84
Rate for Payer: Scott and White EPO/PPO	$5,867.96
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,929.84
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

INSERT TUNNELED CV CATH

Facility

$6,847.00

Service Code	HCPCS 36558
Hospital Charge Code	2300770
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,655.96

INSIGNIA COLLARED STANDARD 6

Facility

$14,909.64

Service Code	HCPCS C1776
Hospital Charge Code	992154
Hospital Revenue Code	278
Min. Negotiated Rate	$3,727.41
Max. Negotiated Rate	$7,454.82
Rate for Payer: Cash Price	$10,138.56
Rate for Payer: Cigna Commercial	$3,727.41
Rate for Payer: Multiplan Auto	$7,454.82
Rate for Payer: Multiplan Commercial	$7,454.82
Rate for Payer: Multiplan Workers Comp	$7,454.82
Rate for Payer: Scott and White EPO/PPO	$7,454.82

INSIGNIA COLLARED STANDARD 6

Facility

$14,909.64

Service Code	HCPCS C1776
Hospital Charge Code	992154
Hospital Revenue Code	278
Min. Negotiated Rate	$1,341.87
Max. Negotiated Rate	$10,734.94
Rate for Payer: Amerigroup CHIP/Medicaid	$1,341.87
Rate for Payer: BCBS of TX Blue Advantage	$4,472.89
Rate for Payer: BCBS of TX Blue Essentials	$5,367.47
Rate for Payer: BCBS of TX PPO	$5,963.86
Rate for Payer: Cash Price	$10,138.56
Rate for Payer: Cigna Medicaid	$10,734.94
Rate for Payer: Molina CHIP/Medicaid	$10,734.94
Rate for Payer: Multiplan Auto	$7,454.82
Rate for Payer: Multiplan Commercial	$7,454.82
Rate for Payer: Multiplan Workers Comp	$7,454.82
Rate for Payer: Parkland Medicaid	$10,734.94
Rate for Payer: Scott and White EPO/PPO	$7,454.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,734.94
Rate for Payer: Superior Health Plan EPO	$2,027.71

INSIGNIA HIP STEM STANDARD OFFSET 32.5 X 101

Facility

$14,909.64

Service Code	HCPCS C1734
Hospital Charge Code	992161
Hospital Revenue Code	278
Min. Negotiated Rate	$3,727.41
Max. Negotiated Rate	$7,454.82
Rate for Payer: Cash Price	$10,138.56
Rate for Payer: Cigna Commercial	$3,727.41
Rate for Payer: Multiplan Auto	$7,454.82
Rate for Payer: Multiplan Commercial	$7,454.82
Rate for Payer: Multiplan Workers Comp	$7,454.82
Rate for Payer: Scott and White EPO/PPO	$7,454.82

INSIGNIA HIP STEM STANDARD OFFSET 32.5 X 101

Facility

$14,909.64

Service Code	HCPCS C1734
Hospital Charge Code	992161
Hospital Revenue Code	278
Min. Negotiated Rate	$1,341.87
Max. Negotiated Rate	$10,734.94
Rate for Payer: Amerigroup CHIP/Medicaid	$1,341.87
Rate for Payer: BCBS of TX Blue Advantage	$4,472.89
Rate for Payer: BCBS of TX Blue Essentials	$5,367.47
Rate for Payer: BCBS of TX PPO	$5,963.86
Rate for Payer: Cash Price	$10,138.56
Rate for Payer: Cigna Medicaid	$10,734.94
Rate for Payer: Molina CHIP/Medicaid	$10,734.94
Rate for Payer: Multiplan Auto	$7,454.82
Rate for Payer: Multiplan Commercial	$7,454.82
Rate for Payer: Multiplan Workers Comp	$7,454.82
Rate for Payer: Parkland Medicaid	$10,734.94
Rate for Payer: Scott and White EPO/PPO	$7,454.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,734.94
Rate for Payer: Superior Health Plan EPO	$2,027.71

Insignia Hip Stem - Standard Offset (Size: 5, NK LNTH: 35mm, STM LNTH: 105mm, OFFST: STD

Facility

$14,909.64

Service Code	HCPCS C1776
Hospital Charge Code	992182
Hospital Revenue Code	278
Min. Negotiated Rate	$3,727.41
Max. Negotiated Rate	$7,454.82
Rate for Payer: Cash Price	$10,138.56
Rate for Payer: Cigna Commercial	$3,727.41
Rate for Payer: Multiplan Auto	$7,454.82
Rate for Payer: Multiplan Commercial	$7,454.82
Rate for Payer: Multiplan Workers Comp	$7,454.82
Rate for Payer: Scott and White EPO/PPO	$7,454.82

Know your out-of-pocket cost for care.

All Charges