White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Laparoscopy, surgical with biopsy (single or multiple)

Facility

$20,695.00

Service Code	HCPCS 49321
Hospital Charge Code	9900710
Hospital Revenue Code	360
Min. Negotiated Rate	$1,888.85
Max. Negotiated Rate	$14,900.40
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	$14,072.60
Rate for Payer: Cash Price	$14,072.60
Rate for Payer: Cash Price	$14,072.60
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$14,900.40
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	$14,900.40
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	$14,900.40
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,900.40
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 with biopsy (single or multiple)

Facility

$20,695.00

Service Code	HCPCS 49321
Hospital Charge Code	9900710
Hospital Revenue Code	360
Rate for Payer: Cash Price	$14,072.60

Laparoscopy, surgical with biopsy (single or multiple)

Facility

$12,837.39

Service Code	CPT 49321
Hospital Charge Code	36049321
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	$9,762.30
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; with insertion of tunneled intraperitoneal catheter

Facility

$21,990.36

Service Code	HCPCS 49324
Hospital Charge Code	991111
Hospital Revenue Code	360
Min. Negotiated Rate	$1,888.85
Max. Negotiated Rate	$15,833.06
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	$14,953.44
Rate for Payer: Cash Price	$14,953.44
Rate for Payer: Cash Price	$14,953.44
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$15,833.06
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	$15,833.06
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	$15,833.06
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,833.06
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; with insertion of tunneled intraperitoneal catheter

Facility

$21,990.36

Service Code	HCPCS 49324
Hospital Charge Code	991111
Hospital Revenue Code	360
Rate for Payer: Cash Price	$14,953.44

Laparotomy T-Sheet Drape, Sterile

Facility

$22.14

Hospital Charge Code	992778
Hospital Revenue Code	272
Rate for Payer: Cash Price	$15.06

Laparotomy T-Sheet Drape, Sterile

Facility

$22.14

Hospital Charge Code	992778
Hospital Revenue Code	272
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$15.94
Rate for Payer: Amerigroup CHIP/Medicaid	$1.99
Rate for Payer: BCBS of TX Blue Advantage	$6.64
Rate for Payer: BCBS of TX Blue Essentials	$7.97
Rate for Payer: BCBS of TX PPO	$8.86
Rate for Payer: Cash Price	$15.06
Rate for Payer: Cigna Medicaid	$15.94
Rate for Payer: Molina CHIP/Medicaid	$15.94
Rate for Payer: Multiplan Auto	$14.39
Rate for Payer: Multiplan Commercial	$14.39
Rate for Payer: Multiplan Workers Comp	$14.39
Rate for Payer: Parkland Medicaid	$15.94
Rate for Payer: Scott and White EPO/PPO	$11.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.94
Rate for Payer: Superior Health Plan EPO	$3.01

Lap Band Standard RapidPortC-2360

Facility

$27,650.60

Service Code	HCPCS A4301
Hospital Charge Code	994171
Hospital Revenue Code	278
Min. Negotiated Rate	$2,488.55
Max. Negotiated Rate	$19,908.43
Rate for Payer: Amerigroup CHIP/Medicaid	$2,488.55
Rate for Payer: BCBS of TX Blue Advantage	$8,295.18
Rate for Payer: BCBS of TX Blue Essentials	$9,954.22
Rate for Payer: BCBS of TX PPO	$11,060.24
Rate for Payer: Cash Price	$18,802.41
Rate for Payer: Cigna Medicaid	$19,908.43
Rate for Payer: Molina CHIP/Medicaid	$19,908.43
Rate for Payer: Multiplan Auto	$13,825.30
Rate for Payer: Multiplan Commercial	$13,825.30
Rate for Payer: Multiplan Workers Comp	$13,825.30
Rate for Payer: Parkland Medicaid	$19,908.43
Rate for Payer: Scott and White EPO/PPO	$13,825.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,908.43
Rate for Payer: Superior Health Plan EPO	$3,760.48

Lap Band Standard RapidPortC-2360

Facility

$27,650.60

Service Code	HCPCS A4301
Hospital Charge Code	994171
Hospital Revenue Code	278
Min. Negotiated Rate	$6,912.65
Max. Negotiated Rate	$13,825.30
Rate for Payer: Cash Price	$18,802.41
Rate for Payer: Cigna Commercial	$6,912.65
Rate for Payer: Multiplan Auto	$13,825.30
Rate for Payer: Multiplan Commercial	$13,825.30
Rate for Payer: Multiplan Workers Comp	$13,825.30
Rate for Payer: Scott and White EPO/PPO	$13,825.30

Lap closure of internal hernia and reduction of internal hernia

Facility

$20,242.00

Service Code	HCPCS 44238
Hospital Charge Code	994114
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,764.56

Lap closure of internal hernia and reduction of internal hernia

Facility

$20,242.00

Service Code	HCPCS 44238
Hospital Charge Code	9900696
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$14,574.24
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	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$14,574.24
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	$14,574.24
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	$14,574.24
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,574.24
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

Lap closure of internal hernia and reduction of internal hernia

Facility

$20,242.00

Service Code	HCPCS 44238
Hospital Charge Code	994114
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$14,574.24
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	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$14,574.24
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	$14,574.24
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	$14,574.24
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,574.24
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

Lap closure of internal hernia and reduction of internal hernia

Facility

$20,242.00

Service Code	HCPCS 44238
Hospital Charge Code	9900696
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,764.56

Lap gastric restrictive; removal of adjustable gastric restrictive device component only

Facility

$15,218.12

Service Code	HCPCS 43772
Hospital Charge Code	994151
Hospital Revenue Code	360
Min. Negotiated Rate	$1,369.63
Max. Negotiated Rate	$10,957.05
Rate for Payer: Amerigroup CHIP/Medicaid	$1,369.63
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	$10,348.32
Rate for Payer: Cash Price	$10,348.32
Rate for Payer: Cash Price	$10,348.32
Rate for Payer: Cigna Commercial	$8,186.91
Rate for Payer: Cigna Medicaid	$10,957.05
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	$10,957.05
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	$10,957.05
Rate for Payer: Scott and White EPO/PPO	$6,479.61
Rate for Payer: Scott and White Medicare	$3,873.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,957.05
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

Lap gastric restrictive; removal of adjustable gastric restrictive device component only

Facility

$15,218.12

Service Code	HCPCS 43772
Hospital Charge Code	994151
Hospital Revenue Code	360
Rate for Payer: Cash Price	$10,348.32

LAPOPLASTY SYS 2 ANTOMIC BIPLANAR IMPLANT

Facility

$29,729.00

Service Code	HCPCS C1776
Hospital Charge Code	145460
Hospital Revenue Code	278
Min. Negotiated Rate	$7,432.25
Max. Negotiated Rate	$14,864.50
Rate for Payer: Cash Price	$20,215.72
Rate for Payer: Cigna Commercial	$7,432.25
Rate for Payer: Multiplan Auto	$14,864.50
Rate for Payer: Multiplan Commercial	$14,864.50
Rate for Payer: Multiplan Workers Comp	$14,864.50
Rate for Payer: Scott and White EPO/PPO	$14,864.50

LAPOPLASTY SYS 2 ANTOMIC BIPLANAR IMPLANT

Facility

$29,729.00

Service Code	HCPCS C1776
Hospital Charge Code	145460
Hospital Revenue Code	278
Min. Negotiated Rate	$2,675.61
Max. Negotiated Rate	$21,404.88
Rate for Payer: Amerigroup CHIP/Medicaid	$2,675.61
Rate for Payer: BCBS of TX Blue Advantage	$8,918.70
Rate for Payer: BCBS of TX Blue Essentials	$10,702.44
Rate for Payer: BCBS of TX PPO	$11,891.60
Rate for Payer: Cash Price	$20,215.72
Rate for Payer: Cigna Medicaid	$21,404.88
Rate for Payer: Molina CHIP/Medicaid	$21,404.88
Rate for Payer: Multiplan Auto	$14,864.50
Rate for Payer: Multiplan Commercial	$14,864.50
Rate for Payer: Multiplan Workers Comp	$14,864.50
Rate for Payer: Parkland Medicaid	$21,404.88
Rate for Payer: Scott and White EPO/PPO	$14,864.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,404.88
Rate for Payer: Superior Health Plan EPO	$4,043.14

Lap Revision Gastric Bypass to Distal Bypass

Facility

$20,242.00

Service Code	HCPCS 43659
Hospital Charge Code	994113
Hospital Revenue Code	360
Min. Negotiated Rate	$1,821.78
Max. Negotiated Rate	$14,574.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,821.78
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	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$14,574.24
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	$14,574.24
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	$14,574.24
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,574.24
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

Lap Revision Gastric Bypass to Distal Bypass

Facility

$20,242.00

Service Code	HCPCS 43659
Hospital Charge Code	994113
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,764.56

Lap Revision LSG

Facility

$20,242.00

Service Code	HCPCS 43659
Hospital Charge Code	994124
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,764.56

Lap Revision LSG

Facility

$20,242.00

Service Code	HCPCS 43659
Hospital Charge Code	994124
Hospital Revenue Code	360
Min. Negotiated Rate	$1,821.78
Max. Negotiated Rate	$14,574.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,821.78
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	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$14,574.24
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	$14,574.24
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	$14,574.24
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,574.24
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

Lap revision sleeve gastrectomy to gastric bypass

Facility

$20,242.00

Service Code	HCPCS 43659
Hospital Charge Code	994130
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,764.56

Lap revision sleeve gastrectomy to gastric bypass

Facility

$20,242.00

Service Code	HCPCS 43659
Hospital Charge Code	994130
Hospital Revenue Code	360
Min. Negotiated Rate	$1,821.78
Max. Negotiated Rate	$14,574.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,821.78
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	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$14,574.24
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	$14,574.24
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	$14,574.24
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,574.24
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

LARYNGEAL MASK, SZ 3, FLEXIBLE, DISP

Facility

$77.98

Hospital Charge Code	993791
Hospital Revenue Code	272
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$56.15
Rate for Payer: Amerigroup CHIP/Medicaid	$7.02
Rate for Payer: BCBS of TX Blue Advantage	$23.39
Rate for Payer: BCBS of TX Blue Essentials	$28.07
Rate for Payer: BCBS of TX PPO	$31.19
Rate for Payer: Cash Price	$53.03
Rate for Payer: Cigna Medicaid	$56.15
Rate for Payer: Molina CHIP/Medicaid	$56.15
Rate for Payer: Multiplan Auto	$50.69
Rate for Payer: Multiplan Commercial	$50.69
Rate for Payer: Multiplan Workers Comp	$50.69
Rate for Payer: Parkland Medicaid	$56.15
Rate for Payer: Scott and White EPO/PPO	$38.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56.15
Rate for Payer: Superior Health Plan EPO	$10.61

LARYNGEAL MASK, SZ 3, FLEXIBLE, DISP

Facility

$77.98

Hospital Charge Code	993791
Hospital Revenue Code	272
Rate for Payer: Cash Price	$53.03

Know your out-of-pocket cost for care.

All Charges