White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Laparoscopy, surgical; cholecystectomy with cholangiography

Facility

$31,006.14

Service Code	HCPCS 47563
Hospital Charge Code	9900707
Hospital Revenue Code	360
Rate for Payer: Cash Price	$21,084.18

Laparoscopy, surgical; cholecystectomy with cholangiography

Facility

$31,006.14

Service Code	HCPCS 47563
Hospital Charge Code	9900707
Hospital Revenue Code	360
Min. Negotiated Rate	$1,888.85
Max. Negotiated Rate	$22,324.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,888.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$21,084.18
Rate for Payer: Cash Price	$21,084.18
Rate for Payer: Cash Price	$21,084.18
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$22,324.42
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$22,324.42
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$22,324.42
Rate for Payer: Scott and White EPO/PPO	$11,235.20
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,324.42
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Laparoscopy, surgical; cholecystectomy with cholangiography

Facility

$12,837.39

Service Code	CPT 47563
Hospital Charge Code	36047563
Hospital Revenue Code	360
Min. Negotiated Rate	$1,888.85
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup CHIP/Medicaid	$1,888.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$11,235.20
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Laparoscopy, surgical; colectomy, partial, with anastomosis

Facility

$24,600.00

Service Code	HCPCS 44204
Hospital Charge Code	994177
Hospital Revenue Code	360
Min. Negotiated Rate	$2,214.00
Max. Negotiated Rate	$17,712.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2,214.00
Rate for Payer: BCBS of TX Blue Advantage	$2,684.86
Rate for Payer: BCBS of TX Blue Essentials	$3,215.40
Rate for Payer: BCBS of TX PPO	$4,051.40
Rate for Payer: Cash Price	$16,728.00
Rate for Payer: Cash Price	$16,728.00
Rate for Payer: Cash Price	$16,728.00
Rate for Payer: Cigna Medicaid	$17,712.00
Rate for Payer: Molina CHIP/Medicaid	$17,712.00
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	$17,712.00
Rate for Payer: Scott and White EPO/PPO	$12,300.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,712.00
Rate for Payer: Superior Health Plan EPO	$3,345.60

Laparoscopy, surgical; colectomy, partial, with anastomosis

Facility

$24,600.00

Service Code	HCPCS 44204
Hospital Charge Code	994177
Hospital Revenue Code	360
Rate for Payer: Cash Price	$16,728.00

Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis

Facility

$23,325.00

Service Code	HCPCS 44202
Hospital Charge Code	9900925
Hospital Revenue Code	360
Min. Negotiated Rate	$2,099.25
Max. Negotiated Rate	$16,794.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2,099.25
Rate for Payer: BCBS of TX Blue Advantage	$2,415.24
Rate for Payer: BCBS of TX Blue Essentials	$2,892.50
Rate for Payer: BCBS of TX PPO	$3,644.55
Rate for Payer: Cash Price	$15,861.00
Rate for Payer: Cash Price	$15,861.00
Rate for Payer: Cash Price	$15,861.00
Rate for Payer: Cigna Medicaid	$16,794.00
Rate for Payer: Molina CHIP/Medicaid	$16,794.00
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	$16,794.00
Rate for Payer: Scott and White EPO/PPO	$11,662.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,794.00
Rate for Payer: Superior Health Plan EPO	$3,172.20

Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis

Facility

$23,325.00

Service Code	HCPCS 44202
Hospital Charge Code	9900925
Hospital Revenue Code	360
Rate for Payer: Cash Price	$15,861.00

Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure)

Facility

$12,837.39

Service Code	CPT 44180
Hospital Charge Code	36044180
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$11,235.20
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure)

Facility

$79,281.84

Service Code	HCPCS 44180
Hospital Charge Code	9900695
Hospital Revenue Code	360
Rate for Payer: Cash Price	$53,911.65

Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure)

Facility

$79,281.84

Service Code	HCPCS 44180
Hospital Charge Code	9900695
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$57,082.92
Rate for Payer: Amerigroup CHIP/Medicaid	$7,135.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$53,911.65
Rate for Payer: Cash Price	$53,911.65
Rate for Payer: Cash Price	$53,911.65
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$57,082.92
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$57,082.92
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$57,082.92
Rate for Payer: Scott and White EPO/PPO	$11,235.20
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$57,082.92
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures)

Facility

$22,571.94

Service Code	CPT 43280
Hospital Charge Code	36043280
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$22,571.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Amerigroup Medicare	$10,678.27
Rate for Payer: BCBS of TX Blue Advantage	$14,049.89
Rate for Payer: BCBS of TX Blue Essentials	$16,826.22
Rate for Payer: BCBS of TX Medicare	$10,678.27
Rate for Payer: BCBS of TX PPO	$21,201.04
Rate for Payer: Cigna Commercial	$22,571.94
Rate for Payer: Cigna Medicare	$10,678.27
Rate for Payer: Employer Direct Commercial	$10,678.27
Rate for Payer: Humana Medicare/TRICARE	$10,678.27
Rate for Payer: Molina Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Molina Medicare	$10,678.27
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	$19,754.80
Rate for Payer: Scott and White Medicare	$10,678.27
Rate for Payer: Superior Health Plan EPO	$10,678.27
Rate for Payer: Superior Health Plan Medicare	$10,678.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Universal American Medicare	$10,678.27
Rate for Payer: Wellcare Medicare	$10,678.27
Rate for Payer: Wellmed Medicare	$10,678.27

Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures)

Facility

$1,817.46

Service Code	HCPCS 43280
Hospital Charge Code	9900679
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,235.87

Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures)

Facility

$1,817.46

Service Code	HCPCS 43280
Hospital Charge Code	9900679
Hospital Revenue Code	360
Min. Negotiated Rate	$163.57
Max. Negotiated Rate	$22,571.94
Rate for Payer: Amerigroup CHIP/Medicaid	$163.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Amerigroup Medicare	$10,678.27
Rate for Payer: BCBS of TX Blue Advantage	$14,049.89
Rate for Payer: BCBS of TX Blue Essentials	$16,826.22
Rate for Payer: BCBS of TX Medicare	$10,678.27
Rate for Payer: BCBS of TX PPO	$21,201.04
Rate for Payer: Cash Price	$1,235.87
Rate for Payer: Cash Price	$1,235.87
Rate for Payer: Cash Price	$1,235.87
Rate for Payer: Cigna Commercial	$22,571.94
Rate for Payer: Cigna Medicaid	$1,308.57
Rate for Payer: Cigna Medicare	$10,678.27
Rate for Payer: Employer Direct Commercial	$10,678.27
Rate for Payer: Humana Medicare/TRICARE	$10,678.27
Rate for Payer: Molina CHIP/Medicaid	$1,308.57
Rate for Payer: Molina Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Molina Medicare	$10,678.27
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	$1,308.57
Rate for Payer: Scott and White EPO/PPO	$19,754.80
Rate for Payer: Scott and White Medicare	$10,678.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,308.57
Rate for Payer: Superior Health Plan EPO	$10,678.27
Rate for Payer: Superior Health Plan Medicare	$10,678.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Universal American Medicare	$10,678.27
Rate for Payer: Wellcare Medicare	$10,678.27
Rate for Payer: Wellmed Medicare	$10,678.27

Laparoscopy, surgical, gastric restrictive procedure

Facility

$13,649.51

Service Code	HCPCS 43775
Hospital Charge Code	9900690
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,281.67

Laparoscopy, surgical, gastric restrictive procedure

Facility

$13,649.51

Service Code	HCPCS 43775
Hospital Charge Code	9900690
Hospital Revenue Code	360
Min. Negotiated Rate	$1,228.46
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,228.46
Rate for Payer: BARInet Commercial	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$1,947.60
Rate for Payer: BCBS of TX Blue Essentials	$2,332.46
Rate for Payer: BCBS of TX PPO	$2,938.90
Rate for Payer: Cash Price	$9,281.67
Rate for Payer: Cash Price	$9,281.67
Rate for Payer: Cash Price	$9,281.67
Rate for Payer: Cigna Medicaid	$9,827.65
Rate for Payer: Molina CHIP/Medicaid	$9,827.65
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	$9,827.65
Rate for Payer: Scott and White EPO/PPO	$6,824.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,827.65
Rate for Payer: Superior Health Plan EPO	$1,856.33

Laparoscopy, surgical, gastric restrictive procedure longitudinal gastrectomy (ie, sleeve gastrecto

Facility

$10,000.00

Service Code	CPT 43775
Hospital Charge Code	36043775
Hospital Revenue Code	360
Min. Negotiated Rate	$1,947.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: BARInet Commercial	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$1,947.60
Rate for Payer: BCBS of TX Blue Essentials	$2,332.46
Rate for Payer: BCBS of TX PPO	$2,938.90
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

Laparoscopy, surgical, gastric restrictive procedure placement of adjustable gastric restrictive de

Facility

$22,571.94

Service Code	CPT 43770
Hospital Charge Code	36043770
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$22,571.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Amerigroup Medicare	$10,678.27
Rate for Payer: BCBS of TX Blue Advantage	$14,049.89
Rate for Payer: BCBS of TX Blue Essentials	$16,826.22
Rate for Payer: BCBS of TX Medicare	$10,678.27
Rate for Payer: BCBS of TX PPO	$21,201.04
Rate for Payer: Cigna Commercial	$22,571.94
Rate for Payer: Cigna Medicare	$10,678.27
Rate for Payer: Employer Direct Commercial	$10,678.27
Rate for Payer: Humana Medicare/TRICARE	$10,678.27
Rate for Payer: Molina Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Molina Medicare	$10,678.27
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	$19,754.80
Rate for Payer: Scott and White Medicare	$10,678.27
Rate for Payer: Superior Health Plan EPO	$10,678.27
Rate for Payer: Superior Health Plan Medicare	$10,678.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Universal American Medicare	$10,678.27
Rate for Payer: Wellcare Medicare	$10,678.27
Rate for Payer: Wellmed Medicare	$10,678.27

Laparoscopy, surgical, gastric restrictive procedure placement of adjustable gastric restrictive de

Facility

$9,216.90

Service Code	HCPCS 43770
Hospital Charge Code	9900688
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,267.49

Laparoscopy, surgical, gastric restrictive procedure placement of adjustable gastric restrictive de

Facility

$9,216.90

Service Code	HCPCS 43770
Hospital Charge Code	9900688
Hospital Revenue Code	360
Min. Negotiated Rate	$829.52
Max. Negotiated Rate	$22,571.94
Rate for Payer: Amerigroup CHIP/Medicaid	$829.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Amerigroup Medicare	$10,678.27
Rate for Payer: BCBS of TX Blue Advantage	$14,049.89
Rate for Payer: BCBS of TX Blue Essentials	$16,826.22
Rate for Payer: BCBS of TX Medicare	$10,678.27
Rate for Payer: BCBS of TX PPO	$21,201.04
Rate for Payer: Cash Price	$6,267.49
Rate for Payer: Cash Price	$6,267.49
Rate for Payer: Cash Price	$6,267.49
Rate for Payer: Cigna Commercial	$22,571.94
Rate for Payer: Cigna Medicaid	$6,636.17
Rate for Payer: Cigna Medicare	$10,678.27
Rate for Payer: Employer Direct Commercial	$10,678.27
Rate for Payer: Humana Medicare/TRICARE	$10,678.27
Rate for Payer: Molina CHIP/Medicaid	$6,636.17
Rate for Payer: Molina Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Molina Medicare	$10,678.27
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	$6,636.17
Rate for Payer: Scott and White EPO/PPO	$19,754.80
Rate for Payer: Scott and White Medicare	$10,678.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,636.17
Rate for Payer: Superior Health Plan EPO	$10,678.27
Rate for Payer: Superior Health Plan Medicare	$10,678.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Universal American Medicare	$10,678.27
Rate for Payer: Wellcare Medicare	$10,678.27
Rate for Payer: Wellmed Medicare	$10,678.27

Laparoscopy, surgical, gastric restrictive procedure removal of adjustable gastric restrictive devi

Facility

$13,863.56

Service Code	HCPCS 43774
Hospital Charge Code	9900689
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,427.22

Laparoscopy, surgical, gastric restrictive procedure removal of adjustable gastric restrictive devi

Facility

$10,000.00

Service Code	CPT 43774
Hospital Charge Code	36043774
Hospital Revenue Code	360
Min. Negotiated Rate	$3,873.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,873.04
Rate for Payer: Amerigroup Medicare	$3,873.04
Rate for Payer: BCBS of TX Blue Advantage	$5,008.46
Rate for Payer: BCBS of TX Blue Essentials	$5,998.16
Rate for Payer: BCBS of TX Medicare	$3,873.04
Rate for Payer: BCBS of TX PPO	$7,557.68
Rate for Payer: Cigna Commercial	$8,186.91
Rate for Payer: Cigna Medicare	$3,873.04
Rate for Payer: Employer Direct Commercial	$3,873.04
Rate for Payer: Humana Medicare/TRICARE	$3,873.04
Rate for Payer: Molina Dual Medicare/Medicaid	$3,873.04
Rate for Payer: Molina Medicare	$3,873.04
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	$7,165.12
Rate for Payer: Scott and White Medicare	$3,873.04
Rate for Payer: Superior Health Plan EPO	$3,873.04
Rate for Payer: Superior Health Plan Medicare	$3,873.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,873.04
Rate for Payer: Universal American Medicare	$3,873.04
Rate for Payer: Wellcare Medicare	$3,873.04
Rate for Payer: Wellmed Medicare	$3,873.04

Laparoscopy, surgical, gastric restrictive procedure removal of adjustable gastric restrictive devi

Facility

$13,863.56

Service Code	HCPCS 43774
Hospital Charge Code	9900689
Hospital Revenue Code	360
Min. Negotiated Rate	$1,247.72
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,247.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,873.04
Rate for Payer: Amerigroup Medicare	$3,873.04
Rate for Payer: BCBS of TX Blue Advantage	$5,008.46
Rate for Payer: BCBS of TX Blue Essentials	$5,998.16
Rate for Payer: BCBS of TX Medicare	$3,873.04
Rate for Payer: BCBS of TX PPO	$7,557.68
Rate for Payer: Cash Price	$9,427.22
Rate for Payer: Cash Price	$9,427.22
Rate for Payer: Cash Price	$9,427.22
Rate for Payer: Cigna Commercial	$8,186.91
Rate for Payer: Cigna Medicaid	$9,981.76
Rate for Payer: Cigna Medicare	$3,873.04
Rate for Payer: Employer Direct Commercial	$3,873.04
Rate for Payer: Humana Medicare/TRICARE	$3,873.04
Rate for Payer: Molina CHIP/Medicaid	$9,981.76
Rate for Payer: Molina Dual Medicare/Medicaid	$3,873.04
Rate for Payer: Molina Medicare	$3,873.04
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	$9,981.76
Rate for Payer: Scott and White EPO/PPO	$7,165.12
Rate for Payer: Scott and White Medicare	$3,873.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,981.76
Rate for Payer: Superior Health Plan EPO	$3,873.04
Rate for Payer: Superior Health Plan Medicare	$3,873.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,873.04
Rate for Payer: Universal American Medicare	$3,873.04
Rate for Payer: Wellcare Medicare	$3,873.04
Rate for Payer: Wellmed Medicare	$3,873.04

Laparoscopy, surgical, gastric restrictive procedure with gastric bypass and Roux-en-Y gastroentero

Facility

$8,999.01

Service Code	HCPCS 43644
Hospital Charge Code	9900686
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,119.33

Laparoscopy, surgical, gastric restrictive procedure with gastric bypass and Roux-en-Y gastroentero

Facility

$16,500.00

Service Code	CPT 43644
Hospital Charge Code	36043644
Hospital Revenue Code	360
Min. Negotiated Rate	$3,023.70
Max. Negotiated Rate	$16,500.00
Rate for Payer: BARInet Commercial	$16,500.00
Rate for Payer: BCBS of TX Blue Advantage	$3,023.70
Rate for Payer: BCBS of TX Blue Essentials	$3,621.20
Rate for Payer: BCBS of TX PPO	$4,562.71
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

Laparoscopy, surgical, gastric restrictive procedure with gastric bypass and Roux-en-Y gastroentero

Facility

$8,999.01

Service Code	HCPCS 43644
Hospital Charge Code	9900686
Hospital Revenue Code	360
Min. Negotiated Rate	$809.91
Max. Negotiated Rate	$16,500.00
Rate for Payer: Amerigroup CHIP/Medicaid	$809.91
Rate for Payer: BARInet Commercial	$16,500.00
Rate for Payer: BCBS of TX Blue Advantage	$3,023.70
Rate for Payer: BCBS of TX Blue Essentials	$3,621.20
Rate for Payer: BCBS of TX PPO	$4,562.71
Rate for Payer: Cash Price	$6,119.33
Rate for Payer: Cash Price	$6,119.33
Rate for Payer: Cash Price	$6,119.33
Rate for Payer: Cigna Medicaid	$6,479.29
Rate for Payer: Molina CHIP/Medicaid	$6,479.29
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	$6,479.29
Rate for Payer: Scott and White EPO/PPO	$4,499.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,479.29
Rate for Payer: Superior Health Plan EPO	$1,223.87

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