White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Adjacent tissue transfer or rearrangement, scalp, arms and/or legs defect 10 sq cm or less

Facility

$4,419.00

Service Code	HCPCS 14020
Hospital Charge Code	9900118
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,004.92

Adjacent tissue transfer or rearrangement, scalp, arms and/or legs defect 10 sq cm or less

Facility

$10,000.00

Service Code	CPT 14020
Hospital Charge Code	36014020
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Adjacent tissue transfer or rearrangement, scalp, arms and/or legs defect 10 sq cm or less

Facility

$4,419.00

Service Code	HCPCS 14020
Hospital Charge Code	9900118
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$3,004.92
Rate for Payer: Cash Price	$3,004.92
Rate for Payer: Cash Price	$3,004.92
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$3,181.68
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$3,181.68
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$3,181.68
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,181.68
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Adjacent tissue transfer or rearrangement, trunk defect 10 sq cm or less

Facility

$4,419.00

Service Code	HCPCS 14000
Hospital Charge Code	9900117
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$3,004.92
Rate for Payer: Cash Price	$3,004.92
Rate for Payer: Cash Price	$3,004.92
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$3,181.68
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$3,181.68
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$3,181.68
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,181.68
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Adjacent tissue transfer or rearrangement, trunk defect 10 sq cm or less

Facility

$4,419.00

Service Code	HCPCS 14000
Hospital Charge Code	9900117
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,004.92

Adjacent tissue transfer or rearrangement, trunk defect 10 sq cm or less

Facility

$10,000.00

Service Code	CPT 14000
Hospital Charge Code	36014000
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES

Facility

$4,375.02

Service Code	APR-DRG 7553
Min. Negotiated Rate	$4,124.92
Max. Negotiated Rate	$4,375.02
Rate for Payer: Amerigroup CHIP/Medicaid	$4,124.92
Rate for Payer: Cigna Medicaid	$4,124.92
Rate for Payer: Molina CHIP/Medicaid	$4,124.92
Rate for Payer: Parkland Medicaid	$4,124.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,375.02

ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES

Facility

$8,327.96

Service Code	APR-DRG 7554
Min. Negotiated Rate	$7,851.89
Max. Negotiated Rate	$8,327.96
Rate for Payer: Amerigroup CHIP/Medicaid	$7,851.89
Rate for Payer: Cigna Medicaid	$7,851.89
Rate for Payer: Molina CHIP/Medicaid	$7,851.89
Rate for Payer: Parkland Medicaid	$7,851.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,327.96

ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES

Facility

$1,191.92

Service Code	APR-DRG 7551
Min. Negotiated Rate	$1,123.78
Max. Negotiated Rate	$1,191.92
Rate for Payer: Amerigroup CHIP/Medicaid	$1,123.78
Rate for Payer: Cigna Medicaid	$1,123.78
Rate for Payer: Molina CHIP/Medicaid	$1,123.78
Rate for Payer: Parkland Medicaid	$1,123.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,191.92

ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES

Facility

$1,974.21

Service Code	APR-DRG 7552
Min. Negotiated Rate	$1,861.35
Max. Negotiated Rate	$1,974.21
Rate for Payer: Amerigroup CHIP/Medicaid	$1,861.35
Rate for Payer: Cigna Medicaid	$1,861.35
Rate for Payer: Molina CHIP/Medicaid	$1,861.35
Rate for Payer: Parkland Medicaid	$1,861.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,974.21

Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline

Facility

$500.00

Service Code	HCPCS S2083
Hospital Charge Code	9900922
Hospital Revenue Code	360
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$45.00
Rate for Payer: BCBS of TX Blue Advantage	$1,805.34
Rate for Payer: BCBS of TX Blue Essentials	$2,162.08
Rate for Payer: BCBS of TX PPO	$2,724.22
Rate for Payer: Cash Price	$340.00
Rate for Payer: Cash Price	$340.00
Rate for Payer: Cash Price	$340.00
Rate for Payer: Cigna Medicaid	$360.00
Rate for Payer: Molina CHIP/Medicaid	$360.00
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	$360.00
Rate for Payer: Scott and White EPO/PPO	$250.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$360.00
Rate for Payer: Superior Health Plan EPO	$68.00

Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline

Facility

$500.00

Service Code	HCPCS S2083
Hospital Charge Code	9900922
Hospital Revenue Code	360
Rate for Payer: Cash Price	$340.00

Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline

Facility

$10,000.00

Service Code	CPT S2083
Hospital Charge Code	360S2083
Hospital Revenue Code	360
Min. Negotiated Rate	$1,805.34
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$1,805.34
Rate for Payer: BCBS of TX Blue Essentials	$2,162.08
Rate for Payer: BCBS of TX PPO	$2,724.22
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

Adjustment or revision of external fixation system requiring anesthesia (eg, new pin[s] or wire[s] a

Facility

$15,408.22

Service Code	CPT 20693
Hospital Charge Code	36020693
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Adjustment or revision of external fixation system requiring anesthesia (eg, new pin[s] or wire[s] a

Facility

$18,794.85

Service Code	HCPCS 20693
Hospital Charge Code	9900183
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$13,532.29
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$13,532.29
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$13,532.29
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,532.29
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Adjustment or revision of external fixation system requiring anesthesia (eg, new pin[s] or wire[s] a

Facility

$18,794.85

Service Code	HCPCS 20693
Hospital Charge Code	9900183
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,780.50

Admin Immunization Charge -> ED - Initial Admin Charge 90471

Facility

$124.00

Service Code	HCPCS 90471
Hospital Charge Code	5202064
Hospital Revenue Code	771
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$152.89
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$37.20
Rate for Payer: BCBS of TX Blue Essentials	$44.64
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$49.60
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$89.28
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$89.28
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
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: Parkland Medicaid	$89.28
Rate for Payer: Scott and White EPO/PPO	$25.52
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.28
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

Admin Immunization Charge -> ED - Initial Admin Charge 90471

Facility

$124.00

Service Code	HCPCS 90471
Hospital Charge Code	5202064
Hospital Revenue Code	771
Rate for Payer: Cash Price	$84.32

Admin Immunization Charge - Flu -> ED - Initial Admin Charge 90471

Facility

$124.00

Service Code	HCPCS 90471
Hospital Charge Code	5200043
Hospital Revenue Code	771
Rate for Payer: Cash Price	$84.32

Admin Immunization Charge - Flu -> ED - Initial Admin Charge 90471

Facility

$124.00

Service Code	HCPCS 90471
Hospital Charge Code	5200043
Hospital Revenue Code	771
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$152.89
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$37.20
Rate for Payer: BCBS of TX Blue Essentials	$44.64
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$49.60
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$89.28
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$89.28
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
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: Parkland Medicaid	$89.28
Rate for Payer: Scott and White EPO/PPO	$25.52
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.28
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

Admin Immunization Charge - Flu -> IV Therapy/Nursing - Initial Admin Charge 90471

Facility

$124.00

Service Code	HCPCS 90471
Hospital Charge Code	1500305
Hospital Revenue Code	771
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$152.89
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$37.20
Rate for Payer: BCBS of TX Blue Essentials	$44.64
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$49.60
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$89.28
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$89.28
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
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: Parkland Medicaid	$89.28
Rate for Payer: Scott and White EPO/PPO	$25.52
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.28
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

Admin Immunization Charge - Flu -> IV Therapy/Nursing - Initial Admin Charge 90471

Facility

$124.00

Service Code	HCPCS 90471
Hospital Charge Code	1500305
Hospital Revenue Code	771
Rate for Payer: Cash Price	$84.32

Admin Immunization Charge - Flu -> L&D - Addl Admin Charge 90472

Facility

$88.00

Service Code	HCPCS 90472
Hospital Charge Code	315387
Hospital Revenue Code	771
Rate for Payer: Cash Price	$59.84

Admin Immunization Charge - Flu -> L&D - Addl Admin Charge 90472

Facility

$88.00

Service Code	HCPCS 90472
Hospital Charge Code	315387
Hospital Revenue Code	771
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$63.36
Rate for Payer: Amerigroup CHIP/Medicaid	$7.92
Rate for Payer: BCBS of TX Blue Advantage	$26.40
Rate for Payer: BCBS of TX Blue Essentials	$31.68
Rate for Payer: BCBS of TX PPO	$35.20
Rate for Payer: Cash Price	$59.84
Rate for Payer: Cash Price	$59.84
Rate for Payer: Cigna Medicaid	$63.36
Rate for Payer: Molina CHIP/Medicaid	$63.36
Rate for Payer: Multiplan Auto	$57.20
Rate for Payer: Multiplan Commercial	$57.20
Rate for Payer: Multiplan Workers Comp	$57.20
Rate for Payer: Parkland Medicaid	$63.36
Rate for Payer: Scott and White EPO/PPO	$18.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.36
Rate for Payer: Superior Health Plan EPO	$11.97

Admin Immunization Charge - Flu -> L&D - Initial Admin Charge 90471

Facility

$124.00

Service Code	HCPCS 90471
Hospital Charge Code	315368
Hospital Revenue Code	771
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$152.89
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$37.20
Rate for Payer: BCBS of TX Blue Essentials	$44.64
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$49.60
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$89.28
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$89.28
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
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: Parkland Medicaid	$89.28
Rate for Payer: Scott and White EPO/PPO	$25.52
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.28
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

Know your out-of-pocket cost for care.

All Charges