White Rock Medical Center

All Charges

Charge

Type

Setting

Price

kerecis omega3 7x20 (ea) per sq cm

Facility

$323.00

Service Code	HCPCS Q4158
Hospital Charge Code	8630552
Hospital Revenue Code	278
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$161.50
Rate for Payer: Cash Price	$219.64
Rate for Payer: Cigna Commercial	$80.75
Rate for Payer: Multiplan Auto	$161.50
Rate for Payer: Multiplan Commercial	$161.50
Rate for Payer: Multiplan Workers Comp	$161.50
Rate for Payer: Scott and White EPO/PPO	$161.50

kerecis omega3 7x7cm 50200s04b0d sq cm

Facility

$202.00

Service Code	HCPCS Q4158
Hospital Charge Code	8638507
Hospital Revenue Code	278
Min. Negotiated Rate	$50.50
Max. Negotiated Rate	$101.00
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cigna Commercial	$50.50
Rate for Payer: Multiplan Auto	$101.00
Rate for Payer: Multiplan Commercial	$101.00
Rate for Payer: Multiplan Workers Comp	$101.00
Rate for Payer: Scott and White EPO/PPO	$101.00

kerecis omega3 7x7cm 50200s04b0d sq cm

Facility

$202.00

Service Code	HCPCS Q4158
Hospital Charge Code	8638507
Hospital Revenue Code	278
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$264.25
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$60.60
Rate for Payer: BCBS of TX Blue Essentials	$72.72
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$80.80
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$145.44
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$145.44
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$101.00
Rate for Payer: Multiplan Commercial	$101.00
Rate for Payer: Multiplan Workers Comp	$101.00
Rate for Payer: Parkland Medicaid	$145.44
Rate for Payer: Scott and White EPO/PPO	$101.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.44
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

ketamine 50 mg/ml Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	79732735
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

ketamine 50 mg/ml Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	79732735
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

ketoconazole 2% Cream 15 g

Facility

$51.30

Service Code	HCPCS J3490
Hospital Charge Code	78435133
Hospital Revenue Code	250
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$36.94
Rate for Payer: Amerigroup CHIP/Medicaid	$4.62
Rate for Payer: BCBS of TX Blue Advantage	$15.39
Rate for Payer: BCBS of TX Blue Essentials	$18.47
Rate for Payer: BCBS of TX PPO	$20.52
Rate for Payer: Cash Price	$34.88
Rate for Payer: Cigna Medicaid	$36.94
Rate for Payer: Molina CHIP/Medicaid	$36.94
Rate for Payer: Multiplan Auto	$33.34
Rate for Payer: Multiplan Commercial	$33.34
Rate for Payer: Multiplan Workers Comp	$33.34
Rate for Payer: Parkland Medicaid	$36.94
Rate for Payer: Scott and White EPO/PPO	$25.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.94
Rate for Payer: Superior Health Plan EPO	$6.98

ketoconazole 2% Cream 15 g

Facility

$51.30

Service Code	HCPCS J3490
Hospital Charge Code	78435133
Hospital Revenue Code	250
Rate for Payer: Cash Price	$34.88

Ketone body(s) (eg, acetone, acetoacetic acid, beta-hydroxybutyrate); quantitative

Facility

$174.00

Service Code	HCPCS 82010 QW
Hospital Charge Code	1708809
Hospital Revenue Code	301
Rate for Payer: Cash Price	$118.32

Ketone body(s) (eg, acetone, acetoacetic acid, beta-hydroxybutyrate); quantitative

Facility

$174.00

Service Code	HCPCS 82010 QW
Hospital Charge Code	1708809
Hospital Revenue Code	301
Min. Negotiated Rate	$3.19
Max. Negotiated Rate	$125.28
Rate for Payer: Amerigroup CHIP/Medicaid	$3.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.17
Rate for Payer: Amerigroup Medicare	$8.17
Rate for Payer: BCBS of TX Blue Advantage	$52.20
Rate for Payer: BCBS of TX Blue Essentials	$62.64
Rate for Payer: BCBS of TX Medicare	$8.17
Rate for Payer: BCBS of TX PPO	$69.60
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cigna Medicaid	$125.28
Rate for Payer: Cigna Medicare	$8.17
Rate for Payer: Employer Direct Commercial	$8.17
Rate for Payer: Humana Medicare/TRICARE	$8.17
Rate for Payer: Molina CHIP/Medicaid	$125.28
Rate for Payer: Molina Dual Medicare/Medicaid	$8.17
Rate for Payer: Molina Medicare	$8.17
Rate for Payer: Multiplan Auto	$113.10
Rate for Payer: Multiplan Commercial	$113.10
Rate for Payer: Multiplan Workers Comp	$113.10
Rate for Payer: Parkland Medicaid	$125.28
Rate for Payer: Scott and White EPO/PPO	$10.21
Rate for Payer: Scott and White Medicare	$8.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.28
Rate for Payer: Superior Health Plan EPO	$8.17
Rate for Payer: Superior Health Plan Medicare	$8.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.17
Rate for Payer: Universal American Medicare	$8.17
Rate for Payer: Wellcare Medicare	$8.17
Rate for Payer: Wellmed Medicare	$8.17

ketorolac 15 mg/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J1885
Hospital Charge Code	78411482
Hospital Revenue Code	636
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$0.29
Rate for Payer: Amerigroup Medicare	$0.29
Rate for Payer: BCBS of TX Blue Advantage	$0.26
Rate for Payer: BCBS of TX Blue Essentials	$0.31
Rate for Payer: BCBS of TX Medicare	$0.29
Rate for Payer: BCBS of TX PPO	$0.35
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Cigna Medicare	$0.29
Rate for Payer: Employer Direct Commercial	$0.29
Rate for Payer: Humana Medicare/TRICARE	$0.29
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Molina Dual Medicare/Medicaid	$0.29
Rate for Payer: Molina Medicare	$0.29
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Scott and White Medicare	$0.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$0.29
Rate for Payer: Superior Health Plan Medicare	$0.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$0.29
Rate for Payer: Universal American Medicare	$0.29
Rate for Payer: Wellcare Medicare	$0.29
Rate for Payer: Wellmed Medicare	$0.29

ketorolac 15 mg/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J1885
Hospital Charge Code	78411482
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

ketorolac 30 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1885
Hospital Charge Code	78470543
Hospital Revenue Code	636
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$0.29
Rate for Payer: Amerigroup Medicare	$0.29
Rate for Payer: BCBS of TX Blue Advantage	$0.26
Rate for Payer: BCBS of TX Blue Essentials	$0.31
Rate for Payer: BCBS of TX Medicare	$0.29
Rate for Payer: BCBS of TX PPO	$0.35
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Cigna Medicare	$0.29
Rate for Payer: Employer Direct Commercial	$0.29
Rate for Payer: Humana Medicare/TRICARE	$0.29
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Molina Dual Medicare/Medicaid	$0.29
Rate for Payer: Molina Medicare	$0.29
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Scott and White Medicare	$0.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$0.29
Rate for Payer: Superior Health Plan Medicare	$0.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$0.29
Rate for Payer: Universal American Medicare	$0.29
Rate for Payer: Wellcare Medicare	$0.29
Rate for Payer: Wellmed Medicare	$0.29

ketorolac 30 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1885
Hospital Charge Code	78470543
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC

Facility

$34,770.00

Service Code	MSDRG 657
Min. Negotiated Rate	$16,012.50
Max. Negotiated Rate	$34,770.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,172.19
Rate for Payer: Amerigroup Medicare	$18,172.19
Rate for Payer: BCBS of TX Medicare	$18,172.19
Rate for Payer: Cigna Commercial	$23,570.40
Rate for Payer: Cigna Medicare	$18,172.19
Rate for Payer: Employer Direct Commercial	$18,172.19
Rate for Payer: Humana Medicare/TRICARE	$18,172.19
Rate for Payer: Molina Dual Medicare/Medicaid	$18,172.19
Rate for Payer: Molina Medicare	$18,172.19
Rate for Payer: Multiplan Auto	$34,770.00
Rate for Payer: Multiplan Commercial	$34,770.00
Rate for Payer: Multiplan Workers Comp	$34,770.00
Rate for Payer: Scott and White EPO/PPO	$16,012.50
Rate for Payer: Scott and White Medicare	$18,172.19
Rate for Payer: Superior Health Plan EPO	$18,172.19
Rate for Payer: Superior Health Plan Medicare	$18,172.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,172.19
Rate for Payer: Universal American Medicare	$18,172.19
Rate for Payer: Wellcare Medicare	$18,172.19
Rate for Payer: Wellmed Medicare	$18,172.19

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC

Facility

$60,492.20

Service Code	MSDRG 656
Min. Negotiated Rate	$27,858.25
Max. Negotiated Rate	$60,492.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,094.23
Rate for Payer: Amerigroup Medicare	$28,094.23
Rate for Payer: BCBS of TX Medicare	$28,094.23
Rate for Payer: Cigna Commercial	$41,007.34
Rate for Payer: Cigna Medicare	$28,094.23
Rate for Payer: Employer Direct Commercial	$28,094.23
Rate for Payer: Humana Medicare/TRICARE	$28,094.23
Rate for Payer: Molina Dual Medicare/Medicaid	$28,094.23
Rate for Payer: Molina Medicare	$28,094.23
Rate for Payer: Multiplan Auto	$60,492.20
Rate for Payer: Multiplan Commercial	$60,492.20
Rate for Payer: Multiplan Workers Comp	$60,492.20
Rate for Payer: Scott and White EPO/PPO	$27,858.25
Rate for Payer: Scott and White Medicare	$28,094.23
Rate for Payer: Superior Health Plan EPO	$28,094.23
Rate for Payer: Superior Health Plan Medicare	$28,094.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,094.23
Rate for Payer: Universal American Medicare	$28,094.23
Rate for Payer: Wellcare Medicare	$28,094.23
Rate for Payer: Wellmed Medicare	$28,094.23

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC

Facility

$29,484.20

Service Code	MSDRG 658
Min. Negotiated Rate	$13,471.04
Max. Negotiated Rate	$29,484.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,133.26
Rate for Payer: Amerigroup Medicare	$16,133.26
Rate for Payer: BCBS of TX Medicare	$16,133.26
Rate for Payer: Cigna Commercial	$19,987.18
Rate for Payer: Cigna Medicare	$16,133.26
Rate for Payer: Employer Direct Commercial	$16,133.26
Rate for Payer: Humana Medicare/TRICARE	$16,133.26
Rate for Payer: Molina Dual Medicare/Medicaid	$16,133.26
Rate for Payer: Molina Medicare	$16,133.26
Rate for Payer: Multiplan Auto	$29,484.20
Rate for Payer: Multiplan Commercial	$29,484.20
Rate for Payer: Multiplan Workers Comp	$29,484.20
Rate for Payer: Scott and White EPO/PPO	$13,578.25
Rate for Payer: Scott and White Medicare	$16,133.26
Rate for Payer: Superior Health Plan EPO	$16,133.26
Rate for Payer: Superior Health Plan Medicare	$16,133.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,133.26
Rate for Payer: Universal American Medicare	$16,133.26
Rate for Payer: Wellcare Medicare	$16,133.26
Rate for Payer: Wellmed Medicare	$16,133.26

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC

Facility

$25,112.30

Service Code	MSDRG 660
Min. Negotiated Rate	$11,564.88
Max. Negotiated Rate	$25,112.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,446.85
Rate for Payer: Amerigroup Medicare	$14,446.85
Rate for Payer: BCBS of TX Medicare	$14,446.85
Rate for Payer: Cigna Commercial	$17,023.50
Rate for Payer: Cigna Medicare	$14,446.85
Rate for Payer: Employer Direct Commercial	$14,446.85
Rate for Payer: Humana Medicare/TRICARE	$14,446.85
Rate for Payer: Molina Dual Medicare/Medicaid	$14,446.85
Rate for Payer: Molina Medicare	$14,446.85
Rate for Payer: Multiplan Auto	$25,112.30
Rate for Payer: Multiplan Commercial	$25,112.30
Rate for Payer: Multiplan Workers Comp	$25,112.30
Rate for Payer: Scott and White EPO/PPO	$11,564.88
Rate for Payer: Scott and White Medicare	$14,446.85
Rate for Payer: Superior Health Plan EPO	$14,446.85
Rate for Payer: Superior Health Plan Medicare	$14,446.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,446.85
Rate for Payer: Universal American Medicare	$14,446.85
Rate for Payer: Wellcare Medicare	$14,446.85
Rate for Payer: Wellmed Medicare	$14,446.85

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC

Facility

$48,277.10

Service Code	MSDRG 659
Min. Negotiated Rate	$22,232.88
Max. Negotiated Rate	$48,277.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,382.40
Rate for Payer: Amerigroup Medicare	$23,382.40
Rate for Payer: BCBS of TX Medicare	$23,382.40
Rate for Payer: Cigna Commercial	$32,726.79
Rate for Payer: Cigna Medicare	$23,382.40
Rate for Payer: Employer Direct Commercial	$23,382.40
Rate for Payer: Humana Medicare/TRICARE	$23,382.40
Rate for Payer: Molina Dual Medicare/Medicaid	$23,382.40
Rate for Payer: Molina Medicare	$23,382.40
Rate for Payer: Multiplan Auto	$48,277.10
Rate for Payer: Multiplan Commercial	$48,277.10
Rate for Payer: Multiplan Workers Comp	$48,277.10
Rate for Payer: Scott and White EPO/PPO	$22,232.88
Rate for Payer: Scott and White Medicare	$23,382.40
Rate for Payer: Superior Health Plan EPO	$23,382.40
Rate for Payer: Superior Health Plan Medicare	$23,382.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,382.40
Rate for Payer: Universal American Medicare	$23,382.40
Rate for Payer: Wellcare Medicare	$23,382.40
Rate for Payer: Wellmed Medicare	$23,382.40

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC

Facility

$19,672.60

Service Code	MSDRG 661
Min. Negotiated Rate	$9,059.75
Max. Negotiated Rate	$19,672.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,348.55
Rate for Payer: Amerigroup Medicare	$12,348.55
Rate for Payer: BCBS of TX Medicare	$12,348.55
Rate for Payer: Cigna Commercial	$13,335.95
Rate for Payer: Cigna Medicare	$12,348.55
Rate for Payer: Employer Direct Commercial	$12,348.55
Rate for Payer: Humana Medicare/TRICARE	$12,348.55
Rate for Payer: Molina Dual Medicare/Medicaid	$12,348.55
Rate for Payer: Molina Medicare	$12,348.55
Rate for Payer: Multiplan Auto	$19,672.60
Rate for Payer: Multiplan Commercial	$19,672.60
Rate for Payer: Multiplan Workers Comp	$19,672.60
Rate for Payer: Scott and White EPO/PPO	$9,059.75
Rate for Payer: Scott and White Medicare	$12,348.55
Rate for Payer: Superior Health Plan EPO	$12,348.55
Rate for Payer: Superior Health Plan Medicare	$12,348.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,348.55
Rate for Payer: Universal American Medicare	$12,348.55
Rate for Payer: Wellcare Medicare	$12,348.55
Rate for Payer: Wellmed Medicare	$12,348.55

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$2,773.47

Service Code	APR-DRG 4632
Min. Negotiated Rate	$2,614.93
Max. Negotiated Rate	$2,773.47
Rate for Payer: Amerigroup CHIP/Medicaid	$2,614.93
Rate for Payer: Cigna Medicaid	$2,614.93
Rate for Payer: Molina CHIP/Medicaid	$2,614.93
Rate for Payer: Parkland Medicaid	$2,614.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,773.47

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$1,957.99

Service Code	APR-DRG 4631
Min. Negotiated Rate	$1,846.06
Max. Negotiated Rate	$1,957.99
Rate for Payer: Amerigroup CHIP/Medicaid	$1,846.06
Rate for Payer: Cigna Medicaid	$1,846.06
Rate for Payer: Molina CHIP/Medicaid	$1,846.06
Rate for Payer: Parkland Medicaid	$1,846.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,957.99

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$8,092.59

Service Code	APR-DRG 4634
Min. Negotiated Rate	$7,629.98
Max. Negotiated Rate	$8,092.59
Rate for Payer: Amerigroup CHIP/Medicaid	$7,629.98
Rate for Payer: Cigna Medicaid	$7,629.98
Rate for Payer: Molina CHIP/Medicaid	$7,629.98
Rate for Payer: Parkland Medicaid	$7,629.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,092.59

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$4,256.96

Service Code	APR-DRG 4633
Min. Negotiated Rate	$4,013.61
Max. Negotiated Rate	$4,256.96
Rate for Payer: Amerigroup CHIP/Medicaid	$4,013.61
Rate for Payer: Cigna Medicaid	$4,013.61
Rate for Payer: Molina CHIP/Medicaid	$4,013.61
Rate for Payer: Parkland Medicaid	$4,013.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,256.96

KIDNEY AND URINARY TRACT INFECTIONS WITH MCC

Facility

$22,045.70

Service Code	MSDRG 689
Min. Negotiated Rate	$9,559.76
Max. Negotiated Rate	$22,045.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,263.96
Rate for Payer: Amerigroup Medicare	$13,263.96
Rate for Payer: BCBS of TX Medicare	$13,263.96
Rate for Payer: Cigna Commercial	$14,944.66
Rate for Payer: Cigna Medicare	$13,263.96
Rate for Payer: Employer Direct Commercial	$13,263.96
Rate for Payer: Humana Medicare/TRICARE	$13,263.96
Rate for Payer: Molina Dual Medicare/Medicaid	$13,263.96
Rate for Payer: Molina Medicare	$13,263.96
Rate for Payer: Multiplan Auto	$22,045.70
Rate for Payer: Multiplan Commercial	$22,045.70
Rate for Payer: Multiplan Workers Comp	$22,045.70
Rate for Payer: Scott and White EPO/PPO	$10,152.62
Rate for Payer: Scott and White Medicare	$13,263.96
Rate for Payer: Superior Health Plan EPO	$13,263.96
Rate for Payer: Superior Health Plan Medicare	$13,263.96
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,263.96
Rate for Payer: Universal American Medicare	$13,263.96
Rate for Payer: Wellcare Medicare	$13,263.96
Rate for Payer: Wellmed Medicare	$13,263.96

KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC

Facility

$15,380.50

Service Code	MSDRG 690
Min. Negotiated Rate	$6,829.26
Max. Negotiated Rate	$15,380.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,692.94
Rate for Payer: Amerigroup Medicare	$10,692.94
Rate for Payer: BCBS of TX Medicare	$10,692.94
Rate for Payer: Cigna Commercial	$10,426.36
Rate for Payer: Cigna Medicare	$10,692.94
Rate for Payer: Employer Direct Commercial	$10,692.94
Rate for Payer: Humana Medicare/TRICARE	$10,692.94
Rate for Payer: Molina Dual Medicare/Medicaid	$10,692.94
Rate for Payer: Molina Medicare	$10,692.94
Rate for Payer: Multiplan Auto	$15,380.50
Rate for Payer: Multiplan Commercial	$15,380.50
Rate for Payer: Multiplan Workers Comp	$15,380.50
Rate for Payer: Scott and White EPO/PPO	$7,083.12
Rate for Payer: Scott and White Medicare	$10,692.94
Rate for Payer: Superior Health Plan EPO	$10,692.94
Rate for Payer: Superior Health Plan Medicare	$10,692.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,692.94
Rate for Payer: Universal American Medicare	$10,692.94
Rate for Payer: Wellcare Medicare	$10,692.94
Rate for Payer: Wellmed Medicare	$10,692.94

Know your out-of-pocket cost for care.

All Charges