White Rock Medical Center

All Charges

Charge

Type

Setting

Price

REVASC TIB PER ATH ADD/O

Facility

$15,683.00

Service Code	CPT 37233
Hospital Charge Code	2320545
Hospital Revenue Code	360
Min. Negotiated Rate	$1,411.47
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$8,755.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,411.47
Rate for Payer: Cash Price	$13,801.04
Rate for Payer: Cash Price	$13,801.04
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	$7,841.50
Rate for Payer: Superior Health Plan EPO	$2,132.89

REVASC TIB PER ATH ADD/O

Facility

$15,683.00

Service Code	CPT 37233
Hospital Charge Code	2320545
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,801.04

REVASC TIBPER ST ATH ADD

Facility

$21,816.00

Service Code	CPT 37235
Hospital Charge Code	2320547
Hospital Revenue Code	360
Min. Negotiated Rate	$1,963.44
Max. Negotiated Rate	$10,908.00
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,963.44
Rate for Payer: Cash Price	$19,198.08
Rate for Payer: Cash Price	$19,198.08
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	$10,908.00
Rate for Payer: Superior Health Plan EPO	$2,966.98

REVASC TIBPER ST ATH ADD

Facility

$21,816.00

Service Code	CPT 37235
Hospital Charge Code	2320547
Hospital Revenue Code	360
Rate for Payer: Cash Price	$19,198.08

REVASC TIBPER W/ATHER

Facility

$37,778.00

Service Code	CPT 37229
Hospital Charge Code	2320541
Hospital Revenue Code	360
Rate for Payer: Cash Price	$33,244.64

REVASC TIBPER W/ATHER

Facility

$37,778.00

Service Code	CPT 37229
Hospital Charge Code	2320541
Hospital Revenue Code	360
Min. Negotiated Rate	$353.72
Max. Negotiated Rate	$40,168.72
Rate for Payer: Aetna Commercial	$8,755.00
Rate for Payer: Aetna Medicare	$24,055.02
Rate for Payer: Amerigroup CHIP/Medicaid	$8,618.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Amerigroup Medicare	$16,036.68
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	$16,036.68
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cash Price	$33,244.64
Rate for Payer: Cash Price	$33,244.64
Rate for Payer: Cigna Commercial	$36,327.72
Rate for Payer: Cigna Medicaid	$8,618.37
Rate for Payer: Cigna Medicare	$16,036.68
Rate for Payer: Employer Direct Commercial	$16,036.68
Rate for Payer: Humana Medicare/TRICARE	$16,036.68
Rate for Payer: Molina CHIP/Medicaid	$8,618.37
Rate for Payer: Molina Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Molina Medicare	$16,036.68
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	$8,618.37
Rate for Payer: Scott and White EPO/PPO	$353.72
Rate for Payer: Scott and White Medicare	$16,036.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,618.37
Rate for Payer: Superior Health Plan EPO	$16,036.68
Rate for Payer: Superior Health Plan Medicare	$16,036.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Universal American Medicare	$16,036.68
Rate for Payer: Wellcare Medicare	$16,036.68
Rate for Payer: Wellmed Medicare	$16,036.68

REVASC TIBPER WSTENTADD

Facility

$13,708.00

Service Code	CPT 37234
Hospital Charge Code	4610247
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,063.04

REVASC TIBPER WSTENTADD

Facility

$13,708.00

Service Code	CPT 37234
Hospital Charge Code	4610247
Hospital Revenue Code	360
Min. Negotiated Rate	$1,233.72
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,233.72
Rate for Payer: Cash Price	$12,063.04
Rate for Payer: Cash Price	$12,063.04
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	$6,854.00
Rate for Payer: Superior Health Plan EPO	$1,864.29

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; wit

Facility

$40,168.72

Service Code	CPT 37227
Hospital Charge Code	36037227
Hospital Revenue Code	360
Min. Negotiated Rate	$353.72
Max. Negotiated Rate	$40,168.72
Rate for Payer: Aetna Commercial	$13,390.00
Rate for Payer: Aetna Medicare	$24,055.02
Rate for Payer: Amerigroup CHIP/Medicaid	$9,226.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Amerigroup Medicare	$16,036.68
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	$16,036.68
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cigna Commercial	$36,327.72
Rate for Payer: Cigna Medicaid	$9,226.90
Rate for Payer: Cigna Medicare	$16,036.68
Rate for Payer: Employer Direct Commercial	$16,036.68
Rate for Payer: Humana Medicare/TRICARE	$16,036.68
Rate for Payer: Molina CHIP/Medicaid	$9,226.90
Rate for Payer: Molina Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Molina Medicare	$16,036.68
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	$9,226.90
Rate for Payer: Scott and White EPO/PPO	$353.72
Rate for Payer: Scott and White Medicare	$16,036.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,226.90
Rate for Payer: Superior Health Plan EPO	$16,036.68
Rate for Payer: Superior Health Plan Medicare	$16,036.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Universal American Medicare	$16,036.68
Rate for Payer: Wellcare Medicare	$16,036.68
Rate for Payer: Wellmed Medicare	$16,036.68

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial

Facility

$40,168.72

Service Code	CPT 37231
Hospital Charge Code	36037231
Hospital Revenue Code	360
Min. Negotiated Rate	$353.72
Max. Negotiated Rate	$40,168.72
Rate for Payer: Aetna Commercial	$13,390.00
Rate for Payer: Aetna Medicare	$24,055.02
Rate for Payer: Amerigroup CHIP/Medicaid	$8,648.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Amerigroup Medicare	$16,036.68
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	$16,036.68
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cigna Commercial	$36,327.72
Rate for Payer: Cigna Medicaid	$8,648.77
Rate for Payer: Cigna Medicare	$16,036.68
Rate for Payer: Employer Direct Commercial	$16,036.68
Rate for Payer: Humana Medicare/TRICARE	$16,036.68
Rate for Payer: Molina CHIP/Medicaid	$8,648.77
Rate for Payer: Molina Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Molina Medicare	$16,036.68
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	$8,648.77
Rate for Payer: Scott and White EPO/PPO	$353.72
Rate for Payer: Scott and White Medicare	$16,036.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,648.77
Rate for Payer: Superior Health Plan EPO	$16,036.68
Rate for Payer: Superior Health Plan Medicare	$16,036.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Universal American Medicare	$16,036.68
Rate for Payer: Wellcare Medicare	$16,036.68
Rate for Payer: Wellmed Medicare	$16,036.68

REVAS PERC TRANS TOT OCC

Facility

$17,676.00

Service Code	CPT 92943
Hospital Charge Code	2350041
Hospital Revenue Code	480
Min. Negotiated Rate	$179.93
Max. Negotiated Rate	$24,969.37
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$15,091.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,590.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Amerigroup Medicare	$10,061.07
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$10,061.07
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$15,554.88
Rate for Payer: Cash Price	$15,554.88
Rate for Payer: Cash Price	$15,554.88
Rate for Payer: Cigna Commercial	$22,791.24
Rate for Payer: Cigna Medicare	$10,061.07
Rate for Payer: Employer Direct Commercial	$10,061.07
Rate for Payer: Humana Medicare/TRICARE	$10,061.07
Rate for Payer: Molina Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Molina Medicare	$10,061.07
Rate for Payer: Multiplan Auto	$11,489.40
Rate for Payer: Multiplan Commercial	$11,489.40
Rate for Payer: Multiplan Workers Comp	$11,489.40
Rate for Payer: Scott and White EPO/PPO	$179.93
Rate for Payer: Scott and White Medicare	$10,061.07
Rate for Payer: Superior Health Plan EPO	$10,061.07
Rate for Payer: Superior Health Plan Medicare	$10,061.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Universal American Medicare	$10,061.07
Rate for Payer: Wellcare Medicare	$10,061.07
Rate for Payer: Wellmed Medicare	$10,061.07

REVAS PERC TRANS TOT OCC

Facility

$17,676.00

Service Code	CPT 92943
Hospital Charge Code	2350041
Hospital Revenue Code	480
Rate for Payer: Cash Price	$15,554.88

REVAS TIBPER STNT ATHER

Facility

$39,954.00

Service Code	CPT 37231
Hospital Charge Code	2320543
Hospital Revenue Code	360
Min. Negotiated Rate	$353.72
Max. Negotiated Rate	$40,168.72
Rate for Payer: Aetna Commercial	$13,390.00
Rate for Payer: Aetna Medicare	$24,055.02
Rate for Payer: Amerigroup CHIP/Medicaid	$8,648.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Amerigroup Medicare	$16,036.68
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	$16,036.68
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cash Price	$35,159.52
Rate for Payer: Cash Price	$35,159.52
Rate for Payer: Cigna Commercial	$36,327.72
Rate for Payer: Cigna Medicaid	$8,648.77
Rate for Payer: Cigna Medicare	$16,036.68
Rate for Payer: Employer Direct Commercial	$16,036.68
Rate for Payer: Humana Medicare/TRICARE	$16,036.68
Rate for Payer: Molina CHIP/Medicaid	$8,648.77
Rate for Payer: Molina Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Molina Medicare	$16,036.68
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	$8,648.77
Rate for Payer: Scott and White EPO/PPO	$353.72
Rate for Payer: Scott and White Medicare	$16,036.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,648.77
Rate for Payer: Superior Health Plan EPO	$16,036.68
Rate for Payer: Superior Health Plan Medicare	$16,036.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Universal American Medicare	$16,036.68
Rate for Payer: Wellcare Medicare	$16,036.68
Rate for Payer: Wellmed Medicare	$16,036.68

REVAS TIBPER STNT ATHER

Facility

$39,954.00

Service Code	CPT 37231
Hospital Charge Code	2320543
Hospital Revenue Code	360
Rate for Payer: Cash Price	$35,159.52

Reverse T3, Serum SO

Facility

$121.00

Service Code	CPT 84482
Hospital Charge Code	1707470
Hospital Revenue Code	301
Min. Negotiated Rate	$6.15
Max. Negotiated Rate	$78.65
Rate for Payer: Aetna Commercial	$16.56
Rate for Payer: Aetna Medicare	$23.64
Rate for Payer: Amerigroup CHIP/Medicaid	$6.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.76
Rate for Payer: Amerigroup Medicare	$15.76
Rate for Payer: BCBS of TX Blue Advantage	$26.00
Rate for Payer: BCBS of TX Blue Essentials	$31.20
Rate for Payer: BCBS of TX Medicare	$15.76
Rate for Payer: BCBS of TX PPO	$34.83
Rate for Payer: Cash Price	$106.48
Rate for Payer: Cash Price	$106.48
Rate for Payer: Cigna Medicaid	$15.76
Rate for Payer: Cigna Medicare	$15.76
Rate for Payer: Employer Direct Commercial	$15.76
Rate for Payer: Humana Medicare/TRICARE	$15.76
Rate for Payer: Molina CHIP/Medicaid	$15.76
Rate for Payer: Molina Dual Medicare/Medicaid	$15.76
Rate for Payer: Molina Medicare	$15.76
Rate for Payer: Multiplan Auto	$78.65
Rate for Payer: Multiplan Commercial	$78.65
Rate for Payer: Multiplan Workers Comp	$78.65
Rate for Payer: Parkland Medicaid	$15.76
Rate for Payer: Scott and White EPO/PPO	$19.70
Rate for Payer: Scott and White Medicare	$15.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.76
Rate for Payer: Superior Health Plan EPO	$15.76
Rate for Payer: Superior Health Plan Medicare	$15.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.76
Rate for Payer: Universal American Medicare	$15.76
Rate for Payer: Wellcare Medicare	$15.76
Rate for Payer: Wellmed Medicare	$15.76

Reverse T3, Serum SO

Facility

$121.00

Service Code	CPT 84482
Hospital Charge Code	1707470
Hospital Revenue Code	301
Rate for Payer: Cash Price	$106.48

REVISE/RELOCATE PACER SKIN POCKET

Facility

$3,818.00

Service Code	CPT 33222
Hospital Charge Code	2302461
Hospital Revenue Code	481
Rate for Payer: Cash Price	$3,359.84

REVISE/RELOCATE PACER SKIN POCKET

Facility

$3,818.00

Service Code	CPT 33222
Hospital Charge Code	2302461
Hospital Revenue Code	481
Min. Negotiated Rate	$29.83
Max. Negotiated Rate	$4,089.30
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,501.68
Rate for Payer: Amerigroup CHIP/Medicaid	$343.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Amerigroup Medicare	$1,667.79
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	$1,667.79
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$3,359.84
Rate for Payer: Cash Price	$3,359.84
Rate for Payer: Cash Price	$3,359.84
Rate for Payer: Cigna Commercial	$3,778.02
Rate for Payer: Cigna Medicaid	$709.01
Rate for Payer: Cigna Medicare	$1,667.79
Rate for Payer: Employer Direct Commercial	$1,667.79
Rate for Payer: Humana Medicare/TRICARE	$1,667.79
Rate for Payer: Molina CHIP/Medicaid	$709.01
Rate for Payer: Molina Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Molina Medicare	$1,667.79
Rate for Payer: Multiplan Auto	$2,481.70
Rate for Payer: Multiplan Commercial	$2,481.70
Rate for Payer: Multiplan Workers Comp	$2,481.70
Rate for Payer: Parkland Medicaid	$709.01
Rate for Payer: Scott and White EPO/PPO	$29.83
Rate for Payer: Scott and White Medicare	$1,667.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$709.01
Rate for Payer: Superior Health Plan EPO	$1,667.79
Rate for Payer: Superior Health Plan Medicare	$1,667.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Universal American Medicare	$1,667.79
Rate for Payer: Wellcare Medicare	$1,667.79
Rate for Payer: Wellmed Medicare	$1,667.79

Revise ulnar nerve at elbow

Facility

$10,000.00

Service Code	CPT 64718
Hospital Charge Code	36064718
Hospital Revenue Code	360
Min. Negotiated Rate	$38.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$2,648.68
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,765.79
Rate for Payer: Amerigroup Medicare	$1,765.79
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,765.79
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,000.01
Rate for Payer: Cigna Medicaid	$659.94
Rate for Payer: Cigna Medicare	$1,765.79
Rate for Payer: Employer Direct Commercial	$1,765.79
Rate for Payer: Humana Medicare/TRICARE	$1,765.79
Rate for Payer: Molina CHIP/Medicaid	$659.94
Rate for Payer: Molina Dual Medicare/Medicaid	$1,765.79
Rate for Payer: Molina Medicare	$1,765.79
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	$659.94
Rate for Payer: Scott and White EPO/PPO	$38.95
Rate for Payer: Scott and White Medicare	$1,765.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$659.94
Rate for Payer: Superior Health Plan EPO	$1,765.79
Rate for Payer: Superior Health Plan Medicare	$1,765.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,765.79
Rate for Payer: Universal American Medicare	$1,765.79
Rate for Payer: Wellcare Medicare	$1,765.79
Rate for Payer: Wellmed Medicare	$1,765.79

Revise ulnar nerve at wrist

Facility

$10,000.00

Service Code	CPT 64719
Hospital Charge Code	36064719
Hospital Revenue Code	360
Min. Negotiated Rate	$38.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$2,648.68
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,765.79
Rate for Payer: Amerigroup Medicare	$1,765.79
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,765.79
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,000.01
Rate for Payer: Cigna Medicaid	$659.94
Rate for Payer: Cigna Medicare	$1,765.79
Rate for Payer: Employer Direct Commercial	$1,765.79
Rate for Payer: Humana Medicare/TRICARE	$1,765.79
Rate for Payer: Molina CHIP/Medicaid	$659.94
Rate for Payer: Molina Dual Medicare/Medicaid	$1,765.79
Rate for Payer: Molina Medicare	$1,765.79
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	$659.94
Rate for Payer: Scott and White EPO/PPO	$38.95
Rate for Payer: Scott and White Medicare	$1,765.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$659.94
Rate for Payer: Superior Health Plan EPO	$1,765.79
Rate for Payer: Superior Health Plan Medicare	$1,765.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,765.79
Rate for Payer: Universal American Medicare	$1,765.79
Rate for Payer: Wellcare Medicare	$1,765.79
Rate for Payer: Wellmed Medicare	$1,765.79

Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous arr

Facility

$15,591.57

Service Code	CPT 63663
Hospital Charge Code	36063663
Hospital Revenue Code	360
Min. Negotiated Rate	$137.96
Max. Negotiated Rate	$15,591.57
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$9,382.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3,676.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,254.72
Rate for Payer: Amerigroup Medicare	$6,254.72
Rate for Payer: BCBS of TX Blue Advantage	$10,332.51
Rate for Payer: BCBS of TX Blue Essentials	$12,374.26
Rate for Payer: BCBS of TX Medicare	$6,254.72
Rate for Payer: BCBS of TX PPO	$15,591.57
Rate for Payer: Cigna Commercial	$14,168.74
Rate for Payer: Cigna Medicaid	$3,676.17
Rate for Payer: Cigna Medicare	$6,254.72
Rate for Payer: Employer Direct Commercial	$6,254.72
Rate for Payer: Humana Medicare/TRICARE	$6,254.72
Rate for Payer: Molina CHIP/Medicaid	$3,676.17
Rate for Payer: Molina Dual Medicare/Medicaid	$6,254.72
Rate for Payer: Molina Medicare	$6,254.72
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	$3,676.17
Rate for Payer: Scott and White EPO/PPO	$137.96
Rate for Payer: Scott and White Medicare	$6,254.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,676.17
Rate for Payer: Superior Health Plan EPO	$6,254.72
Rate for Payer: Superior Health Plan Medicare	$6,254.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,254.72
Rate for Payer: Universal American Medicare	$6,254.72
Rate for Payer: Wellcare Medicare	$6,254.72
Rate for Payer: Wellmed Medicare	$6,254.72

Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft

Facility

$10,000.00

Service Code	CPT 66185
Hospital Charge Code	36066185
Hospital Revenue Code	360
Min. Negotiated Rate	$47.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$3,196.84
Rate for Payer: Amerigroup CHIP/Medicaid	$849.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,131.23
Rate for Payer: Amerigroup Medicare	$2,131.23
Rate for Payer: BCBS of TX Blue Advantage	$3,376.51
Rate for Payer: BCBS of TX Blue Essentials	$4,043.72
Rate for Payer: BCBS of TX Medicare	$2,131.23
Rate for Payer: BCBS of TX PPO	$5,095.09
Rate for Payer: Cigna Commercial	$4,827.84
Rate for Payer: Cigna Medicaid	$849.94
Rate for Payer: Cigna Medicare	$2,131.23
Rate for Payer: Employer Direct Commercial	$2,131.23
Rate for Payer: Humana Medicare/TRICARE	$2,131.23
Rate for Payer: Molina CHIP/Medicaid	$849.94
Rate for Payer: Molina Dual Medicare/Medicaid	$2,131.23
Rate for Payer: Molina Medicare	$2,131.23
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	$849.94
Rate for Payer: Scott and White EPO/PPO	$47.01
Rate for Payer: Scott and White Medicare	$2,131.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$849.94
Rate for Payer: Superior Health Plan EPO	$2,131.23
Rate for Payer: Superior Health Plan Medicare	$2,131.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,131.23
Rate for Payer: Universal American Medicare	$2,131.23
Rate for Payer: Wellcare Medicare	$2,131.23
Rate for Payer: Wellmed Medicare	$2,131.23

REVISION OF HIP OR KNEE REPLACEMENT WITH CC

Facility

$66,239.70

Service Code	MSDRG 467
Min. Negotiated Rate	$27,733.24
Max. Negotiated Rate	$66,239.70
Rate for Payer: Aetna Commercial	$39,220.88
Rate for Payer: Aetna Medicare	$41,599.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27,733.24
Rate for Payer: Amerigroup Medicare	$27,733.24
Rate for Payer: BCBS of TX Blue Advantage	$29,594.32
Rate for Payer: BCBS of TX Blue Essentials	$35,811.06
Rate for Payer: BCBS of TX Medicare	$27,733.24
Rate for Payer: BCBS of TX PPO	$39,791.61
Rate for Payer: Cigna Commercial	$44,903.54
Rate for Payer: Cigna Medicare	$27,733.24
Rate for Payer: Employer Direct Commercial	$27,733.24
Rate for Payer: Humana Medicare/TRICARE	$27,733.24
Rate for Payer: Molina Dual Medicare/Medicaid	$27,733.24
Rate for Payer: Molina Medicare	$27,733.24
Rate for Payer: Multiplan Auto	$66,239.70
Rate for Payer: Multiplan Commercial	$66,239.70
Rate for Payer: Multiplan Workers Comp	$66,239.70
Rate for Payer: Scott and White EPO/PPO	$30,505.12
Rate for Payer: Scott and White Medicare	$27,733.24
Rate for Payer: Superior Health Plan EPO	$27,733.24
Rate for Payer: Superior Health Plan Medicare	$27,733.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$27,733.24
Rate for Payer: Universal American Medicare	$27,733.24
Rate for Payer: Wellcare Medicare	$27,733.24
Rate for Payer: Wellmed Medicare	$27,733.24

REVISION OF HIP OR KNEE REPLACEMENT WITH MCC

Facility

$98,545.40

Service Code	MSDRG 466
Min. Negotiated Rate	$39,866.66
Max. Negotiated Rate	$98,545.40
Rate for Payer: Aetna Commercial	$58,349.25
Rate for Payer: Aetna Medicare	$59,799.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$39,866.66
Rate for Payer: Amerigroup Medicare	$39,866.66
Rate for Payer: BCBS of TX Blue Advantage	$43,214.14
Rate for Payer: BCBS of TX Blue Essentials	$52,763.11
Rate for Payer: BCBS of TX Medicare	$39,866.66
Rate for Payer: BCBS of TX PPO	$58,627.95
Rate for Payer: Cigna Commercial	$66,803.41
Rate for Payer: Cigna Medicare	$39,866.66
Rate for Payer: Employer Direct Commercial	$39,866.66
Rate for Payer: Humana Medicare/TRICARE	$39,866.66
Rate for Payer: Molina Dual Medicare/Medicaid	$39,866.66
Rate for Payer: Molina Medicare	$39,866.66
Rate for Payer: Multiplan Auto	$98,545.40
Rate for Payer: Multiplan Commercial	$98,545.40
Rate for Payer: Multiplan Workers Comp	$98,545.40
Rate for Payer: Scott and White EPO/PPO	$45,382.75
Rate for Payer: Scott and White Medicare	$39,866.66
Rate for Payer: Superior Health Plan EPO	$39,866.66
Rate for Payer: Superior Health Plan Medicare	$39,866.66
Rate for Payer: Universal American Dual Medicare/Medicaid	$39,866.66
Rate for Payer: Universal American Medicare	$39,866.66
Rate for Payer: Wellcare Medicare	$39,866.66
Rate for Payer: Wellmed Medicare	$39,866.66

REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC

Facility

$50,722.40

Service Code	MSDRG 468
Min. Negotiated Rate	$21,905.20
Max. Negotiated Rate	$50,722.40
Rate for Payer: Aetna Commercial	$30,033.00
Rate for Payer: Aetna Medicare	$32,857.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,905.20
Rate for Payer: Amerigroup Medicare	$21,905.20
Rate for Payer: BCBS of TX Blue Advantage	$24,024.96
Rate for Payer: BCBS of TX Blue Essentials	$28,804.46
Rate for Payer: BCBS of TX Medicare	$21,905.20
Rate for Payer: BCBS of TX PPO	$32,006.19
Rate for Payer: Cigna Commercial	$34,384.45
Rate for Payer: Cigna Medicare	$21,905.20
Rate for Payer: Employer Direct Commercial	$21,905.20
Rate for Payer: Humana Medicare/TRICARE	$21,905.20
Rate for Payer: Molina Dual Medicare/Medicaid	$21,905.20
Rate for Payer: Molina Medicare	$21,905.20
Rate for Payer: Multiplan Auto	$50,722.40
Rate for Payer: Multiplan Commercial	$50,722.40
Rate for Payer: Multiplan Workers Comp	$50,722.40
Rate for Payer: Scott and White EPO/PPO	$23,359.00
Rate for Payer: Scott and White Medicare	$21,905.20
Rate for Payer: Superior Health Plan EPO	$21,905.20
Rate for Payer: Superior Health Plan Medicare	$21,905.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,905.20
Rate for Payer: Universal American Medicare	$21,905.20
Rate for Payer: Wellcare Medicare	$21,905.20
Rate for Payer: Wellmed Medicare	$21,905.20

Know your out-of-pocket cost for care.

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