White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$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	$5,392.94
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	$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 (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

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	$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

Insj stablj dev w/o dcmprn

Facility

$29,900.00

Service Code	HCPCS 22870
Hospital Charge Code	9900213
Hospital Revenue Code	360
Min. Negotiated Rate	$2,691.00
Max. Negotiated Rate	$21,528.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2,691.00
Rate for Payer: BCBS of TX Blue Advantage	$8,970.00
Rate for Payer: BCBS of TX Blue Essentials	$10,764.00
Rate for Payer: BCBS of TX PPO	$11,960.00
Rate for Payer: Cash Price	$20,332.00
Rate for Payer: Cash Price	$20,332.00
Rate for Payer: Cigna Medicaid	$21,528.00
Rate for Payer: Molina CHIP/Medicaid	$21,528.00
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: Parkland Medicaid	$21,528.00
Rate for Payer: Scott and White EPO/PPO	$14,950.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,528.00
Rate for Payer: Superior Health Plan EPO	$4,066.40

Insj stablj dev w/o dcmprn

Facility

$29,989.79

Service Code	CPT 22869
Hospital Charge Code	36022869
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$29,989.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Amerigroup Medicare	$12,897.19
Rate for Payer: BCBS of TX Blue Advantage	$19,874.19
Rate for Payer: BCBS of TX Blue Essentials	$23,801.42
Rate for Payer: BCBS of TX Medicare	$12,897.19
Rate for Payer: BCBS of TX PPO	$29,989.79
Rate for Payer: Cigna Commercial	$27,262.32
Rate for Payer: Cigna Medicare	$12,897.19
Rate for Payer: Employer Direct Commercial	$12,897.19
Rate for Payer: Humana Medicare/TRICARE	$12,897.19
Rate for Payer: Molina Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Molina Medicare	$12,897.19
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	$22,267.47
Rate for Payer: Scott and White Medicare	$12,897.19
Rate for Payer: Superior Health Plan EPO	$12,897.19
Rate for Payer: Superior Health Plan Medicare	$12,897.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Universal American Medicare	$12,897.19
Rate for Payer: Wellcare Medicare	$12,897.19
Rate for Payer: Wellmed Medicare	$12,897.19

Insj stablj dev w/o dcmprn

Facility

$29,900.00

Service Code	HCPCS 22870
Hospital Charge Code	9900213
Hospital Revenue Code	360
Rate for Payer: Cash Price	$20,332.00

Insj stablj dev w/o dcmprn

Facility

$55,416.42

Service Code	HCPCS 22869
Hospital Charge Code	9900212
Hospital Revenue Code	360
Rate for Payer: Cash Price	$37,683.17

Insj stablj dev w/o dcmprn

Facility

$55,416.42

Service Code	HCPCS 22869
Hospital Charge Code	9900212
Hospital Revenue Code	360
Min. Negotiated Rate	$4,987.48
Max. Negotiated Rate	$39,899.82
Rate for Payer: Amerigroup CHIP/Medicaid	$4,987.48
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Amerigroup Medicare	$12,897.19
Rate for Payer: BCBS of TX Blue Advantage	$19,874.19
Rate for Payer: BCBS of TX Blue Essentials	$23,801.42
Rate for Payer: BCBS of TX Medicare	$12,897.19
Rate for Payer: BCBS of TX PPO	$29,989.79
Rate for Payer: Cash Price	$37,683.17
Rate for Payer: Cash Price	$37,683.17
Rate for Payer: Cash Price	$37,683.17
Rate for Payer: Cigna Commercial	$27,262.32
Rate for Payer: Cigna Medicaid	$39,899.82
Rate for Payer: Cigna Medicare	$12,897.19
Rate for Payer: Employer Direct Commercial	$12,897.19
Rate for Payer: Humana Medicare/TRICARE	$12,897.19
Rate for Payer: Molina CHIP/Medicaid	$39,899.82
Rate for Payer: Molina Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Molina Medicare	$12,897.19
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	$39,899.82
Rate for Payer: Scott and White EPO/PPO	$22,267.47
Rate for Payer: Scott and White Medicare	$12,897.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39,899.82
Rate for Payer: Superior Health Plan EPO	$12,897.19
Rate for Payer: Superior Health Plan Medicare	$12,897.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Universal American Medicare	$12,897.19
Rate for Payer: Wellcare Medicare	$12,897.19
Rate for Payer: Wellmed Medicare	$12,897.19

Insj stablj dev w/o dcmprn

Facility

$10,000.00

Service Code	CPT 22870
Hospital Charge Code	36022870
Hospital Revenue Code	360
Min. Negotiated Rate	$143.00
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	$143.00

INS/RPL PPM LDLESS VENT

Facility

$31,613.00

Service Code	HCPCS 33274
Hospital Charge Code	2300306
Hospital Revenue Code	360
Rate for Payer: Cash Price	$21,496.84

INS/RPL PPM LDLESS VENT

Facility

$31,613.00

Service Code	HCPCS 33274
Hospital Charge Code	2300306
Hospital Revenue Code	360
Min. Negotiated Rate	$2,845.17
Max. Negotiated Rate	$40,901.26
Rate for Payer: Amerigroup CHIP/Medicaid	$2,845.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,349.47
Rate for Payer: Amerigroup Medicare	$19,349.47
Rate for Payer: BCBS of TX Blue Advantage	$26,619.75
Rate for Payer: BCBS of TX Blue Essentials	$31,879.94
Rate for Payer: BCBS of TX Medicare	$19,349.47
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cash Price	$21,496.84
Rate for Payer: Cash Price	$21,496.84
Rate for Payer: Cash Price	$21,496.84
Rate for Payer: Cigna Commercial	$40,901.26
Rate for Payer: Cigna Medicaid	$22,761.36
Rate for Payer: Cigna Medicare	$19,349.47
Rate for Payer: Employer Direct Commercial	$19,349.47
Rate for Payer: Humana Medicare/TRICARE	$19,349.47
Rate for Payer: Molina CHIP/Medicaid	$22,761.36
Rate for Payer: Molina Dual Medicare/Medicaid	$19,349.47
Rate for Payer: Molina Medicare	$19,349.47
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	$22,761.36
Rate for Payer: Scott and White EPO/PPO	$32,967.26
Rate for Payer: Scott and White Medicare	$19,349.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,761.36
Rate for Payer: Superior Health Plan EPO	$19,349.47
Rate for Payer: Superior Health Plan Medicare	$19,349.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,349.47
Rate for Payer: Universal American Medicare	$19,349.47
Rate for Payer: Wellcare Medicare	$19,349.47
Rate for Payer: Wellmed Medicare	$19,349.47

INSRT DUAL CHAMBER AICD GENERATOR

Facility

$52,602.00

Service Code	HCPCS 33240
Hospital Charge Code	2312650
Hospital Revenue Code	481
Rate for Payer: Cash Price	$35,769.36

INSRT DUAL CHAMBER AICD GENERATOR

Facility

$52,602.00

Service Code	HCPCS 33240
Hospital Charge Code	2312650
Hospital Revenue Code	481
Min. Negotiated Rate	$442.31
Max. Negotiated Rate	$57,236.48
Rate for Payer: Amerigroup CHIP/Medicaid	$4,734.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,344.94
Rate for Payer: Amerigroup Medicare	$22,344.94
Rate for Payer: BCBS of TX Blue Advantage	$37,930.53
Rate for Payer: BCBS of TX Blue Essentials	$45,425.78
Rate for Payer: BCBS of TX Medicare	$22,344.94
Rate for Payer: BCBS of TX PPO	$57,236.48
Rate for Payer: Cash Price	$35,769.36
Rate for Payer: Cash Price	$35,769.36
Rate for Payer: Cash Price	$35,769.36
Rate for Payer: Cigna Commercial	$47,233.14
Rate for Payer: Cigna Medicaid	$37,873.44
Rate for Payer: Cigna Medicare	$22,344.94
Rate for Payer: Employer Direct Commercial	$22,344.94
Rate for Payer: Humana Medicare/TRICARE	$22,344.94
Rate for Payer: Molina CHIP/Medicaid	$37,873.44
Rate for Payer: Molina Dual Medicare/Medicaid	$22,344.94
Rate for Payer: Molina Medicare	$22,344.94
Rate for Payer: Multiplan Auto	$34,191.30
Rate for Payer: Multiplan Commercial	$34,191.30
Rate for Payer: Multiplan Workers Comp	$34,191.30
Rate for Payer: Parkland Medicaid	$37,873.44
Rate for Payer: Scott and White EPO/PPO	$442.31
Rate for Payer: Scott and White Medicare	$22,344.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37,873.44
Rate for Payer: Superior Health Plan EPO	$22,344.94
Rate for Payer: Superior Health Plan Medicare	$22,344.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,344.94
Rate for Payer: Universal American Medicare	$22,344.94
Rate for Payer: Wellcare Medicare	$22,344.94
Rate for Payer: Wellmed Medicare	$22,344.94

INSRT PERM PACER, DUAL GEN

Facility

$18,041.00

Service Code	HCPCS 33213
Hospital Charge Code	2302446
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,267.88

INSRT PERM PACER, DUAL GEN

Facility

$18,041.00

Service Code	HCPCS 33213
Hospital Charge Code	2302446
Hospital Revenue Code	360
Min. Negotiated Rate	$6,437.50
Max. Negotiated Rate	$25,834.89
Rate for Payer: Amerigroup CHIP/Medicaid	$6,437.50
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	$12,267.88
Rate for Payer: Cash Price	$12,267.88
Rate for Payer: Cash Price	$12,267.88
Rate for Payer: Cigna Commercial	$22,194.30
Rate for Payer: Cigna Medicaid	$12,989.52
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	$12,989.52
Rate for Payer: Molina Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Molina Medicare	$10,499.62
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	$12,989.52
Rate for Payer: Scott and White EPO/PPO	$18,066.67
Rate for Payer: Scott and White Medicare	$10,499.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,989.52
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

INSRT PERM PACER SNGL GEN

Facility

$16,509.00

Service Code	HCPCS 33212
Hospital Charge Code	2302438
Hospital Revenue Code	481
Rate for Payer: Cash Price	$11,226.12

INSRT PERM PACER SNGL GEN

Facility

$16,509.00

Service Code	HCPCS 33212
Hospital Charge Code	2302438
Hospital Revenue Code	481
Min. Negotiated Rate	$388.32
Max. Negotiated Rate	$19,257.46
Rate for Payer: Amerigroup CHIP/Medicaid	$1,485.81
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	$11,226.12
Rate for Payer: Cash Price	$11,226.12
Rate for Payer: Cash Price	$11,226.12
Rate for Payer: Cigna Commercial	$17,572.38
Rate for Payer: Cigna Medicaid	$11,886.48
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	$11,886.48
Rate for Payer: Molina Dual Medicare/Medicaid	$8,313.10
Rate for Payer: Molina Medicare	$8,313.10
Rate for Payer: Multiplan Auto	$10,730.85
Rate for Payer: Multiplan Commercial	$10,730.85
Rate for Payer: Multiplan Workers Comp	$10,730.85
Rate for Payer: Parkland Medicaid	$11,886.48
Rate for Payer: Scott and White EPO/PPO	$388.32
Rate for Payer: Scott and White Medicare	$8,313.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,886.48
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

INSRT PICC NO PRT/PMP>5 NO IMG

Facility

$4,307.00

Service Code	HCPCS 36569
Hospital Charge Code	2303451
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,928.76

INSRT PICC NO PRT/PMP>5 NO IMG

Facility

$4,307.00

Service Code	HCPCS 36569
Hospital Charge Code	2303451
Hospital Revenue Code	361
Min. Negotiated Rate	$446.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$446.27
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	$2,928.76
Rate for Payer: Cash Price	$2,928.76
Rate for Payer: Cash Price	$2,928.76
Rate for Payer: Cigna Commercial	$3,342.63
Rate for Payer: Cigna Medicaid	$3,101.04
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	$3,101.04
Rate for Payer: Molina Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Molina Medicare	$1,581.33
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	$3,101.04
Rate for Payer: Scott and White EPO/PPO	$2,709.66
Rate for Payer: Scott and White Medicare	$1,581.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,101.04
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

Know your out-of-pocket cost for care.

All Charges