White Rock Medical Center

All Charges

Charge

Type

Setting

Price

RT CHARGE IPPB BCE

Facility

$170.00

Service Code	CPT 94640
Hospital Charge Code	4000576
Hospital Revenue Code	410
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$441.88
Rate for Payer: Aetna Commercial	$93.50
Rate for Payer: Aetna Medicare	$292.59
Rate for Payer: Amerigroup CHIP/Medicaid	$15.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$195.06
Rate for Payer: Amerigroup Medicare	$195.06
Rate for Payer: BCBS of TX Blue Advantage	$320.09
Rate for Payer: BCBS of TX Blue Essentials	$382.64
Rate for Payer: BCBS of TX Medicare	$195.06
Rate for Payer: BCBS of TX PPO	$426.79
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cigna Commercial	$441.88
Rate for Payer: Cigna Medicare	$195.06
Rate for Payer: Employer Direct Commercial	$195.06
Rate for Payer: Humana Medicare/TRICARE	$195.06
Rate for Payer: Molina Dual Medicare/Medicaid	$195.06
Rate for Payer: Molina Medicare	$195.06
Rate for Payer: Multiplan Auto	$110.50
Rate for Payer: Multiplan Commercial	$110.50
Rate for Payer: Multiplan Workers Comp	$110.50
Rate for Payer: Scott and White EPO/PPO	$3.49
Rate for Payer: Scott and White Medicare	$195.06
Rate for Payer: Superior Health Plan EPO	$195.06
Rate for Payer: Superior Health Plan Medicare	$195.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$195.06
Rate for Payer: Universal American Medicare	$195.06
Rate for Payer: Wellcare Medicare	$195.06
Rate for Payer: Wellmed Medicare	$195.06

RT CHARGE IPPB BCE

Facility

$170.00

Service Code	CPT 94640
Hospital Charge Code	4000576
Hospital Revenue Code	410
Rate for Payer: Cash Price	$149.60

RT CHARGE IPPB:Yes

Facility

$170.00

Service Code	CPT 94640
Hospital Charge Code	4000576
Hospital Revenue Code	410
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$441.88
Rate for Payer: Aetna Commercial	$93.50
Rate for Payer: Aetna Medicare	$292.59
Rate for Payer: Amerigroup CHIP/Medicaid	$15.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$195.06
Rate for Payer: Amerigroup Medicare	$195.06
Rate for Payer: BCBS of TX Blue Advantage	$320.09
Rate for Payer: BCBS of TX Blue Essentials	$382.64
Rate for Payer: BCBS of TX Medicare	$195.06
Rate for Payer: BCBS of TX PPO	$426.79
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cigna Commercial	$441.88
Rate for Payer: Cigna Medicare	$195.06
Rate for Payer: Employer Direct Commercial	$195.06
Rate for Payer: Humana Medicare/TRICARE	$195.06
Rate for Payer: Molina Dual Medicare/Medicaid	$195.06
Rate for Payer: Molina Medicare	$195.06
Rate for Payer: Multiplan Auto	$110.50
Rate for Payer: Multiplan Commercial	$110.50
Rate for Payer: Multiplan Workers Comp	$110.50
Rate for Payer: Scott and White EPO/PPO	$3.49
Rate for Payer: Scott and White Medicare	$195.06
Rate for Payer: Superior Health Plan EPO	$195.06
Rate for Payer: Superior Health Plan Medicare	$195.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$195.06
Rate for Payer: Universal American Medicare	$195.06
Rate for Payer: Wellcare Medicare	$195.06
Rate for Payer: Wellmed Medicare	$195.06

RT CHARGE MDI:Demo/Initial

Facility

$170.00

Service Code	CPT 94640
Hospital Charge Code	4049128
Hospital Revenue Code	410
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$441.88
Rate for Payer: Aetna Commercial	$93.50
Rate for Payer: Aetna Medicare	$292.59
Rate for Payer: Amerigroup CHIP/Medicaid	$15.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$195.06
Rate for Payer: Amerigroup Medicare	$195.06
Rate for Payer: BCBS of TX Blue Advantage	$320.09
Rate for Payer: BCBS of TX Blue Essentials	$382.64
Rate for Payer: BCBS of TX Medicare	$195.06
Rate for Payer: BCBS of TX PPO	$426.79
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cigna Commercial	$441.88
Rate for Payer: Cigna Medicare	$195.06
Rate for Payer: Employer Direct Commercial	$195.06
Rate for Payer: Humana Medicare/TRICARE	$195.06
Rate for Payer: Molina Dual Medicare/Medicaid	$195.06
Rate for Payer: Molina Medicare	$195.06
Rate for Payer: Multiplan Auto	$110.50
Rate for Payer: Multiplan Commercial	$110.50
Rate for Payer: Multiplan Workers Comp	$110.50
Rate for Payer: Scott and White EPO/PPO	$3.49
Rate for Payer: Scott and White Medicare	$195.06
Rate for Payer: Superior Health Plan EPO	$195.06
Rate for Payer: Superior Health Plan Medicare	$195.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$195.06
Rate for Payer: Universal American Medicare	$195.06
Rate for Payer: Wellcare Medicare	$195.06
Rate for Payer: Wellmed Medicare	$195.06

RT CHARGE MDI Demo/Initial BCE

Facility

$170.00

Service Code	CPT 94640
Hospital Charge Code	4049128
Hospital Revenue Code	410
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$441.88
Rate for Payer: Aetna Commercial	$93.50
Rate for Payer: Aetna Medicare	$292.59
Rate for Payer: Amerigroup CHIP/Medicaid	$15.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$195.06
Rate for Payer: Amerigroup Medicare	$195.06
Rate for Payer: BCBS of TX Blue Advantage	$320.09
Rate for Payer: BCBS of TX Blue Essentials	$382.64
Rate for Payer: BCBS of TX Medicare	$195.06
Rate for Payer: BCBS of TX PPO	$426.79
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cigna Commercial	$441.88
Rate for Payer: Cigna Medicare	$195.06
Rate for Payer: Employer Direct Commercial	$195.06
Rate for Payer: Humana Medicare/TRICARE	$195.06
Rate for Payer: Molina Dual Medicare/Medicaid	$195.06
Rate for Payer: Molina Medicare	$195.06
Rate for Payer: Multiplan Auto	$110.50
Rate for Payer: Multiplan Commercial	$110.50
Rate for Payer: Multiplan Workers Comp	$110.50
Rate for Payer: Scott and White EPO/PPO	$3.49
Rate for Payer: Scott and White Medicare	$195.06
Rate for Payer: Superior Health Plan EPO	$195.06
Rate for Payer: Superior Health Plan Medicare	$195.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$195.06
Rate for Payer: Universal American Medicare	$195.06
Rate for Payer: Wellcare Medicare	$195.06
Rate for Payer: Wellmed Medicare	$195.06

RT CHARGE MDI Demo/Initial BCE

Facility

$170.00

Service Code	CPT 94640
Hospital Charge Code	4049128
Hospital Revenue Code	410
Rate for Payer: Cash Price	$149.60

RT CHARGE MDI:Subsequent

Facility

$170.00

Service Code	CPT 94640 76
Hospital Charge Code	4049136
Hospital Revenue Code	410
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$441.88
Rate for Payer: Aetna Commercial	$93.50
Rate for Payer: Aetna Medicare	$292.59
Rate for Payer: Amerigroup CHIP/Medicaid	$15.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$195.06
Rate for Payer: Amerigroup Medicare	$195.06
Rate for Payer: BCBS of TX Blue Advantage	$320.09
Rate for Payer: BCBS of TX Blue Essentials	$382.64
Rate for Payer: BCBS of TX Medicare	$195.06
Rate for Payer: BCBS of TX PPO	$426.79
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cigna Commercial	$441.88
Rate for Payer: Cigna Medicare	$195.06
Rate for Payer: Employer Direct Commercial	$195.06
Rate for Payer: Humana Medicare/TRICARE	$195.06
Rate for Payer: Molina Dual Medicare/Medicaid	$195.06
Rate for Payer: Molina Medicare	$195.06
Rate for Payer: Multiplan Auto	$110.50
Rate for Payer: Multiplan Commercial	$110.50
Rate for Payer: Multiplan Workers Comp	$110.50
Rate for Payer: Scott and White EPO/PPO	$3.49
Rate for Payer: Scott and White Medicare	$195.06
Rate for Payer: Superior Health Plan EPO	$195.06
Rate for Payer: Superior Health Plan Medicare	$195.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$195.06
Rate for Payer: Universal American Medicare	$195.06
Rate for Payer: Wellcare Medicare	$195.06
Rate for Payer: Wellmed Medicare	$195.06

RT CHARGE MDI:Subsequent

Facility

$170.00

Service Code	CPT 94640 76
Hospital Charge Code	4049136
Hospital Revenue Code	410
Rate for Payer: Cash Price	$149.60

RT CHARGE Smoke/Tobacco Counseling >10 min BCE

Facility

$97.00

Service Code	CPT 99407
Hospital Charge Code	5500376
Hospital Revenue Code	942
Rate for Payer: Cash Price	$85.36

RT CHARGE Smoke/Tobacco Counseling >10 min BCE

Facility

$97.00

Service Code	CPT 99407
Hospital Charge Code	5500376
Hospital Revenue Code	942
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$63.05
Rate for Payer: Aetna Commercial	$53.35
Rate for Payer: Aetna Medicare	$39.36
Rate for Payer: Amerigroup CHIP/Medicaid	$8.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.24
Rate for Payer: Amerigroup Medicare	$26.24
Rate for Payer: BCBS of TX Blue Advantage	$45.78
Rate for Payer: BCBS of TX Blue Essentials	$54.72
Rate for Payer: BCBS of TX Medicare	$26.24
Rate for Payer: BCBS of TX PPO	$61.04
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cigna Commercial	$59.45
Rate for Payer: Cigna Medicaid	$20.07
Rate for Payer: Cigna Medicare	$26.24
Rate for Payer: Employer Direct Commercial	$26.24
Rate for Payer: Humana Medicare/TRICARE	$26.24
Rate for Payer: Molina CHIP/Medicaid	$20.07
Rate for Payer: Molina Dual Medicare/Medicaid	$26.24
Rate for Payer: Molina Medicare	$26.24
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$20.07
Rate for Payer: Scott and White EPO/PPO	$0.47
Rate for Payer: Scott and White Medicare	$26.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.07
Rate for Payer: Superior Health Plan EPO	$26.24
Rate for Payer: Superior Health Plan Medicare	$26.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.24
Rate for Payer: Universal American Medicare	$26.24
Rate for Payer: Wellcare Medicare	$26.24
Rate for Payer: Wellmed Medicare	$26.24

RT CHARGE Smoke/Tobacco Counseling 3-10 min BCE

Facility

$53.00

Service Code	CPT 99406
Hospital Charge Code	5500375
Hospital Revenue Code	942
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$59.45
Rate for Payer: Aetna Commercial	$29.15
Rate for Payer: Aetna Medicare	$39.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.24
Rate for Payer: Amerigroup Medicare	$26.24
Rate for Payer: BCBS of TX Blue Advantage	$21.94
Rate for Payer: BCBS of TX Blue Essentials	$26.23
Rate for Payer: BCBS of TX Medicare	$26.24
Rate for Payer: BCBS of TX PPO	$29.26
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cigna Commercial	$59.45
Rate for Payer: Cigna Medicaid	$10.29
Rate for Payer: Cigna Medicare	$26.24
Rate for Payer: Employer Direct Commercial	$26.24
Rate for Payer: Humana Medicare/TRICARE	$26.24
Rate for Payer: Molina CHIP/Medicaid	$10.29
Rate for Payer: Molina Dual Medicare/Medicaid	$26.24
Rate for Payer: Molina Medicare	$26.24
Rate for Payer: Multiplan Auto	$34.45
Rate for Payer: Multiplan Commercial	$34.45
Rate for Payer: Multiplan Workers Comp	$34.45
Rate for Payer: Parkland Medicaid	$10.29
Rate for Payer: Scott and White EPO/PPO	$0.47
Rate for Payer: Scott and White Medicare	$26.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.29
Rate for Payer: Superior Health Plan EPO	$26.24
Rate for Payer: Superior Health Plan Medicare	$26.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.24
Rate for Payer: Universal American Medicare	$26.24
Rate for Payer: Wellcare Medicare	$26.24
Rate for Payer: Wellmed Medicare	$26.24

RT CHARGE Smoke/Tobacco Counseling 3-10 min BCE

Facility

$53.00

Service Code	CPT 99406
Hospital Charge Code	5500375
Hospital Revenue Code	942
Rate for Payer: Cash Price	$46.64

RT CHARGE SpO2:Continuous

Facility

$128.00

Service Code	CPT 94761
Hospital Charge Code	4000238
Hospital Revenue Code	460
Min. Negotiated Rate	$7.52
Max. Negotiated Rate	$83.20
Rate for Payer: Aetna Commercial	$70.40
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$7.52
Rate for Payer: BCBS of TX Blue Essentials	$8.99
Rate for Payer: BCBS of TX PPO	$10.02
Rate for Payer: Cash Price	$112.64
Rate for Payer: Cash Price	$112.64
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

RT CHARGE SpO2 Continuous BCE

Facility

$128.00

Service Code	CPT 94761
Hospital Charge Code	4000238
Hospital Revenue Code	460
Rate for Payer: Cash Price	$112.64

RT CHARGE SpO2 Continuous BCE

Facility

$128.00

Service Code	CPT 94761
Hospital Charge Code	4000238
Hospital Revenue Code	460
Min. Negotiated Rate	$7.52
Max. Negotiated Rate	$83.20
Rate for Payer: Aetna Commercial	$70.40
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$7.52
Rate for Payer: BCBS of TX Blue Essentials	$8.99
Rate for Payer: BCBS of TX PPO	$10.02
Rate for Payer: Cash Price	$112.64
Rate for Payer: Cash Price	$112.64
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

RT CHARGE SpO2:Single

Facility

$122.00

Service Code	CPT 94760
Hospital Charge Code	4000188
Hospital Revenue Code	460
Min. Negotiated Rate	$4.38
Max. Negotiated Rate	$79.30
Rate for Payer: Aetna Commercial	$67.10
Rate for Payer: Amerigroup CHIP/Medicaid	$10.98
Rate for Payer: BCBS of TX Blue Advantage	$4.38
Rate for Payer: BCBS of TX Blue Essentials	$5.24
Rate for Payer: BCBS of TX PPO	$5.85
Rate for Payer: Cash Price	$107.36
Rate for Payer: Cash Price	$107.36
Rate for Payer: Multiplan Auto	$79.30
Rate for Payer: Multiplan Commercial	$79.30
Rate for Payer: Multiplan Workers Comp	$79.30
Rate for Payer: Scott and White EPO/PPO	$61.00
Rate for Payer: Superior Health Plan EPO	$16.59

RT CHARGE SpO2 Single BCE

Facility

$122.00

Service Code	CPT 94760
Hospital Charge Code	4000188
Hospital Revenue Code	460
Min. Negotiated Rate	$4.38
Max. Negotiated Rate	$79.30
Rate for Payer: Aetna Commercial	$67.10
Rate for Payer: Amerigroup CHIP/Medicaid	$10.98
Rate for Payer: BCBS of TX Blue Advantage	$4.38
Rate for Payer: BCBS of TX Blue Essentials	$5.24
Rate for Payer: BCBS of TX PPO	$5.85
Rate for Payer: Cash Price	$107.36
Rate for Payer: Cash Price	$107.36
Rate for Payer: Multiplan Auto	$79.30
Rate for Payer: Multiplan Commercial	$79.30
Rate for Payer: Multiplan Workers Comp	$79.30
Rate for Payer: Scott and White EPO/PPO	$61.00
Rate for Payer: Superior Health Plan EPO	$16.59

RT CHARGE SpO2 Single BCE

Facility

$122.00

Service Code	CPT 94760
Hospital Charge Code	4000188
Hospital Revenue Code	460
Rate for Payer: Cash Price	$107.36

RT CHARGE Ventilator Initiate BCE

Facility

$3,836.00

Service Code	CPT 94002
Hospital Charge Code	4020004
Hospital Revenue Code	410
Min. Negotiated Rate	$10.25
Max. Negotiated Rate	$2,493.40
Rate for Payer: Aetna Commercial	$2,109.80
Rate for Payer: Aetna Medicare	$859.66
Rate for Payer: Amerigroup CHIP/Medicaid	$345.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$573.11
Rate for Payer: Amerigroup Medicare	$573.11
Rate for Payer: BCBS of TX Blue Advantage	$808.28
Rate for Payer: BCBS of TX Blue Essentials	$966.22
Rate for Payer: BCBS of TX Medicare	$573.11
Rate for Payer: BCBS of TX PPO	$1,077.71
Rate for Payer: Cash Price	$3,375.68
Rate for Payer: Cash Price	$3,375.68
Rate for Payer: Cash Price	$3,375.68
Rate for Payer: Cigna Commercial	$1,298.27
Rate for Payer: Cigna Medicare	$573.11
Rate for Payer: Employer Direct Commercial	$573.11
Rate for Payer: Humana Medicare/TRICARE	$573.11
Rate for Payer: Molina Dual Medicare/Medicaid	$573.11
Rate for Payer: Molina Medicare	$573.11
Rate for Payer: Multiplan Auto	$2,493.40
Rate for Payer: Multiplan Commercial	$2,493.40
Rate for Payer: Multiplan Workers Comp	$2,493.40
Rate for Payer: Scott and White EPO/PPO	$10.25
Rate for Payer: Scott and White Medicare	$573.11
Rate for Payer: Superior Health Plan EPO	$573.11
Rate for Payer: Superior Health Plan Medicare	$573.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$573.11
Rate for Payer: Universal American Medicare	$573.11
Rate for Payer: Wellcare Medicare	$573.11
Rate for Payer: Wellmed Medicare	$573.11

RT CHARGE Ventilator Initiate BCE

Facility

$3,836.00

Service Code	CPT 94002
Hospital Charge Code	4020004
Hospital Revenue Code	410
Rate for Payer: Cash Price	$3,375.68

RT CHARGE Ventilator Initiate:Yes

Facility

$3,836.00

Service Code	CPT 94002
Hospital Charge Code	4020004
Hospital Revenue Code	410
Min. Negotiated Rate	$10.25
Max. Negotiated Rate	$2,493.40
Rate for Payer: Aetna Commercial	$2,109.80
Rate for Payer: Aetna Medicare	$859.66
Rate for Payer: Amerigroup CHIP/Medicaid	$345.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$573.11
Rate for Payer: Amerigroup Medicare	$573.11
Rate for Payer: BCBS of TX Blue Advantage	$808.28
Rate for Payer: BCBS of TX Blue Essentials	$966.22
Rate for Payer: BCBS of TX Medicare	$573.11
Rate for Payer: BCBS of TX PPO	$1,077.71
Rate for Payer: Cash Price	$3,375.68
Rate for Payer: Cash Price	$3,375.68
Rate for Payer: Cash Price	$3,375.68
Rate for Payer: Cigna Commercial	$1,298.27
Rate for Payer: Cigna Medicare	$573.11
Rate for Payer: Employer Direct Commercial	$573.11
Rate for Payer: Humana Medicare/TRICARE	$573.11
Rate for Payer: Molina Dual Medicare/Medicaid	$573.11
Rate for Payer: Molina Medicare	$573.11
Rate for Payer: Multiplan Auto	$2,493.40
Rate for Payer: Multiplan Commercial	$2,493.40
Rate for Payer: Multiplan Workers Comp	$2,493.40
Rate for Payer: Scott and White EPO/PPO	$10.25
Rate for Payer: Scott and White Medicare	$573.11
Rate for Payer: Superior Health Plan EPO	$573.11
Rate for Payer: Superior Health Plan Medicare	$573.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$573.11
Rate for Payer: Universal American Medicare	$573.11
Rate for Payer: Wellcare Medicare	$573.11
Rate for Payer: Wellmed Medicare	$573.11

RT CHARGE Ventilator Subsequent BCE

Facility

$2,841.00

Service Code	CPT 94003
Hospital Charge Code	4020012
Hospital Revenue Code	410
Rate for Payer: Cash Price	$2,500.08

RT CHARGE Ventilator Subsequent BCE

Facility

$2,841.00

Service Code	CPT 94003
Hospital Charge Code	4020012
Hospital Revenue Code	410
Min. Negotiated Rate	$10.25
Max. Negotiated Rate	$1,846.65
Rate for Payer: Aetna Commercial	$1,562.55
Rate for Payer: Aetna Medicare	$859.66
Rate for Payer: Amerigroup CHIP/Medicaid	$255.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$573.11
Rate for Payer: Amerigroup Medicare	$573.11
Rate for Payer: BCBS of TX Blue Advantage	$808.28
Rate for Payer: BCBS of TX Blue Essentials	$966.22
Rate for Payer: BCBS of TX Medicare	$573.11
Rate for Payer: BCBS of TX PPO	$1,077.71
Rate for Payer: Cash Price	$2,500.08
Rate for Payer: Cash Price	$2,500.08
Rate for Payer: Cash Price	$2,500.08
Rate for Payer: Cigna Commercial	$1,298.27
Rate for Payer: Cigna Medicare	$573.11
Rate for Payer: Employer Direct Commercial	$573.11
Rate for Payer: Humana Medicare/TRICARE	$573.11
Rate for Payer: Molina Dual Medicare/Medicaid	$573.11
Rate for Payer: Molina Medicare	$573.11
Rate for Payer: Multiplan Auto	$1,846.65
Rate for Payer: Multiplan Commercial	$1,846.65
Rate for Payer: Multiplan Workers Comp	$1,846.65
Rate for Payer: Scott and White EPO/PPO	$10.25
Rate for Payer: Scott and White Medicare	$573.11
Rate for Payer: Superior Health Plan EPO	$573.11
Rate for Payer: Superior Health Plan Medicare	$573.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$573.11
Rate for Payer: Universal American Medicare	$573.11
Rate for Payer: Wellcare Medicare	$573.11
Rate for Payer: Wellmed Medicare	$573.11

RT CHARGE Ventilator Subsequent:Yes

Facility

$2,841.00

Service Code	CPT 94003
Hospital Charge Code	4020012
Hospital Revenue Code	410
Min. Negotiated Rate	$10.25
Max. Negotiated Rate	$1,846.65
Rate for Payer: Aetna Commercial	$1,562.55
Rate for Payer: Aetna Medicare	$859.66
Rate for Payer: Amerigroup CHIP/Medicaid	$255.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$573.11
Rate for Payer: Amerigroup Medicare	$573.11
Rate for Payer: BCBS of TX Blue Advantage	$808.28
Rate for Payer: BCBS of TX Blue Essentials	$966.22
Rate for Payer: BCBS of TX Medicare	$573.11
Rate for Payer: BCBS of TX PPO	$1,077.71
Rate for Payer: Cash Price	$2,500.08
Rate for Payer: Cash Price	$2,500.08
Rate for Payer: Cash Price	$2,500.08
Rate for Payer: Cigna Commercial	$1,298.27
Rate for Payer: Cigna Medicare	$573.11
Rate for Payer: Employer Direct Commercial	$573.11
Rate for Payer: Humana Medicare/TRICARE	$573.11
Rate for Payer: Molina Dual Medicare/Medicaid	$573.11
Rate for Payer: Molina Medicare	$573.11
Rate for Payer: Multiplan Auto	$1,846.65
Rate for Payer: Multiplan Commercial	$1,846.65
Rate for Payer: Multiplan Workers Comp	$1,846.65
Rate for Payer: Scott and White EPO/PPO	$10.25
Rate for Payer: Scott and White Medicare	$573.11
Rate for Payer: Superior Health Plan EPO	$573.11
Rate for Payer: Superior Health Plan Medicare	$573.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$573.11
Rate for Payer: Universal American Medicare	$573.11
Rate for Payer: Wellcare Medicare	$573.11
Rate for Payer: Wellmed Medicare	$573.11

RT EKG 12 Lead Tracing BCE

Facility

$700.00

Service Code	CPT 93005
Hospital Charge Code	5503006
Hospital Revenue Code	730
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$455.00
Rate for Payer: Aetna Commercial	$10.11
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$63.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$95.72
Rate for Payer: BCBS of TX Blue Essentials	$114.42
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$127.62
Rate for Payer: Cash Price	$616.00
Rate for Payer: Cash Price	$616.00
Rate for Payer: Cash Price	$616.00
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
Rate for Payer: Multiplan Auto	$455.00
Rate for Payer: Multiplan Commercial	$455.00
Rate for Payer: Multiplan Workers Comp	$455.00
Rate for Payer: Scott and White EPO/PPO	$1.00
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

Know your out-of-pocket cost for care.

All Charges