White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TUBING, INSUFLOW LAPAROSCOPIC FILTER HEATER 8'4'''' -- DHF

Facility

$1,930.01

Hospital Charge Code	80324957
Hospital Revenue Code	270
Min. Negotiated Rate	$173.70
Max. Negotiated Rate	$1,254.51
Rate for Payer: Aetna Commercial	$1,061.51
Rate for Payer: Amerigroup CHIP/Medicaid	$173.70
Rate for Payer: BCBS of TX Blue Advantage	$579.00
Rate for Payer: BCBS of TX Blue Essentials	$694.80
Rate for Payer: BCBS of TX PPO	$772.00
Rate for Payer: Cash Price	$1,698.41
Rate for Payer: Multiplan Auto	$1,254.51
Rate for Payer: Multiplan Commercial	$1,254.51
Rate for Payer: Multiplan Workers Comp	$1,254.51
Rate for Payer: Scott and White EPO/PPO	$965.00
Rate for Payer: Superior Health Plan EPO	$262.48

tubing irrigation 24hr erbe pump

Facility

$43.13

Hospital Charge Code	8626513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$37.95

tubing irrigation 24hr erbe pump

Facility

$43.13

Hospital Charge Code	8626513
Hospital Revenue Code	272
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$28.03
Rate for Payer: Aetna Commercial	$23.72
Rate for Payer: Amerigroup CHIP/Medicaid	$3.88
Rate for Payer: BCBS of TX Blue Advantage	$12.94
Rate for Payer: BCBS of TX Blue Essentials	$15.53
Rate for Payer: BCBS of TX PPO	$17.25
Rate for Payer: Cash Price	$37.95
Rate for Payer: Multiplan Auto	$28.03
Rate for Payer: Multiplan Commercial	$28.03
Rate for Payer: Multiplan Workers Comp	$28.03
Rate for Payer: Scott and White EPO/PPO	$21.56
Rate for Payer: Superior Health Plan EPO	$5.87

TUBING KLEIN PUMP 24600800

Facility

$92.53

Hospital Charge Code	133085
Hospital Revenue Code	272
Rate for Payer: Cash Price	$81.43

TUBING KLEIN PUMP 24600800

Facility

$92.53

Hospital Charge Code	133085
Hospital Revenue Code	272
Min. Negotiated Rate	$8.33
Max. Negotiated Rate	$60.14
Rate for Payer: Aetna Commercial	$50.89
Rate for Payer: Amerigroup CHIP/Medicaid	$8.33
Rate for Payer: BCBS of TX Blue Advantage	$27.76
Rate for Payer: BCBS of TX Blue Essentials	$33.31
Rate for Payer: BCBS of TX PPO	$37.01
Rate for Payer: Cash Price	$81.43
Rate for Payer: Multiplan Auto	$60.14
Rate for Payer: Multiplan Commercial	$60.14
Rate for Payer: Multiplan Workers Comp	$60.14
Rate for Payer: Scott and White EPO/PPO	$46.26
Rate for Payer: Superior Health Plan EPO	$12.58

TUBING, PUMP MAIN FOR AR-6400 ARTHROSCOPY PUMP -- DHF

Facility

$1,305.07

Hospital Charge Code	81776908
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,148.46

TUBING, PUMP MAIN FOR AR-6400 ARTHROSCOPY PUMP -- DHF

Facility

$1,305.07

Hospital Charge Code	81776908
Hospital Revenue Code	272
Min. Negotiated Rate	$117.46
Max. Negotiated Rate	$848.30
Rate for Payer: Aetna Commercial	$717.79
Rate for Payer: Amerigroup CHIP/Medicaid	$117.46
Rate for Payer: BCBS of TX Blue Advantage	$391.52
Rate for Payer: BCBS of TX Blue Essentials	$469.83
Rate for Payer: BCBS of TX PPO	$522.03
Rate for Payer: Cash Price	$1,148.46
Rate for Payer: Multiplan Auto	$848.30
Rate for Payer: Multiplan Commercial	$848.30
Rate for Payer: Multiplan Workers Comp	$848.30
Rate for Payer: Scott and White EPO/PPO	$652.54
Rate for Payer: Superior Health Plan EPO	$177.49

TUBING, VAC-COLLECT MEDGYN

Facility

$43.08

Hospital Charge Code	8574470
Hospital Revenue Code	272
Rate for Payer: Cash Price	$37.91

TUBING, VAC-COLLECT MEDGYN

Facility

$43.08

Hospital Charge Code	8574470
Hospital Revenue Code	272
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$23.69
Rate for Payer: Amerigroup CHIP/Medicaid	$3.88
Rate for Payer: BCBS of TX Blue Advantage	$12.92
Rate for Payer: BCBS of TX Blue Essentials	$15.51
Rate for Payer: BCBS of TX PPO	$17.23
Rate for Payer: Cash Price	$37.91
Rate for Payer: Multiplan Auto	$28.00
Rate for Payer: Multiplan Commercial	$28.00
Rate for Payer: Multiplan Workers Comp	$28.00
Rate for Payer: Scott and White EPO/PPO	$21.54
Rate for Payer: Superior Health Plan EPO	$5.86

TUBING VERIFLOW

Facility

$227.00

Hospital Charge Code	144831
Hospital Revenue Code	272
Rate for Payer: Cash Price	$199.76

TUBING VERIFLOW

Facility

$227.00

Hospital Charge Code	144831
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$147.55
Rate for Payer: Aetna Commercial	$124.85
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$199.76
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan EPO	$30.87

TUNNELER, CATHETER AND SHEATH 17GX8'''' DISPOSABLE -- DHF

Facility

$813.30

Hospital Charge Code	81826406
Hospital Revenue Code	272
Rate for Payer: Cash Price	$715.70

TUNNELER, CATHETER AND SHEATH 17GX8'''' DISPOSABLE -- DHF

Facility

$813.30

Hospital Charge Code	81826406
Hospital Revenue Code	272
Min. Negotiated Rate	$73.20
Max. Negotiated Rate	$528.64
Rate for Payer: Aetna Commercial	$447.32
Rate for Payer: Amerigroup CHIP/Medicaid	$73.20
Rate for Payer: BCBS of TX Blue Advantage	$243.99
Rate for Payer: BCBS of TX Blue Essentials	$292.79
Rate for Payer: BCBS of TX PPO	$325.32
Rate for Payer: Cash Price	$715.70
Rate for Payer: Multiplan Auto	$528.64
Rate for Payer: Multiplan Commercial	$528.64
Rate for Payer: Multiplan Workers Comp	$528.64
Rate for Payer: Scott and White EPO/PPO	$406.65
Rate for Payer: Superior Health Plan EPO	$110.61

Tx Prophylactic Diagnostic Each Addl Seq IVP Same Drug 96376

Facility

$330.00

Service Code	CPT 96376
Hospital Charge Code	1500404
Hospital Revenue Code	260
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$214.50
Rate for Payer: Aetna Commercial	$181.50
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: BCBS of TX Blue Advantage	$41.39
Rate for Payer: BCBS of TX Blue Essentials	$49.48
Rate for Payer: BCBS of TX PPO	$55.19
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Scott and White EPO/PPO	$165.00
Rate for Payer: Superior Health Plan EPO	$44.88

Tx Prophylactic Diagnostic Each Addl Seq IVP Same Drug 96376

Facility

$330.00

Service Code	CPT 96376
Hospital Charge Code	1500404
Hospital Revenue Code	260
Rate for Payer: Cash Price	$290.40

Tx Prophylactic or Diag IVP Single or Initial Drug 96374

Facility

$360.00

Service Code	CPT 96374
Hospital Charge Code	1500388
Hospital Revenue Code	260
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$444.05
Rate for Payer: Aetna Commercial	$198.00
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$32.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$68.97
Rate for Payer: BCBS of TX Blue Essentials	$82.45
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$91.96
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$444.05
Rate for Payer: Cigna Medicare	$196.02
Rate for Payer: Employer Direct Commercial	$196.02
Rate for Payer: Humana Medicare/TRICARE	$196.02
Rate for Payer: Molina Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
Rate for Payer: Multiplan Auto	$234.00
Rate for Payer: Multiplan Commercial	$234.00
Rate for Payer: Multiplan Workers Comp	$234.00
Rate for Payer: Scott and White EPO/PPO	$3.51
Rate for Payer: Scott and White Medicare	$196.02
Rate for Payer: Superior Health Plan EPO	$196.02
Rate for Payer: Superior Health Plan Medicare	$196.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$196.02
Rate for Payer: Universal American Medicare	$196.02
Rate for Payer: Wellcare Medicare	$196.02
Rate for Payer: Wellmed Medicare	$196.02

Tx Prophylactic or Diag IVP Single or Initial Drug 96374

Facility

$360.00

Service Code	CPT 96374
Hospital Charge Code	1500388
Hospital Revenue Code	260
Rate for Payer: Cash Price	$316.80

Tympanic membrane repair, with or without site preparation of perforation for closure, with or witho

Facility

$10,000.00

Service Code	CPT 69610
Hospital Charge Code	36069610
Hospital Revenue Code	360
Min. Negotiated Rate	$30.76
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$2,092.08
Rate for Payer: Amerigroup CHIP/Medicaid	$174.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,394.72
Rate for Payer: Amerigroup Medicare	$1,394.72
Rate for Payer: BCBS of TX Blue Advantage	$341.13
Rate for Payer: BCBS of TX Blue Essentials	$408.54
Rate for Payer: BCBS of TX Medicare	$1,394.72
Rate for Payer: BCBS of TX PPO	$514.76
Rate for Payer: Cigna Commercial	$3,159.45
Rate for Payer: Cigna Medicaid	$174.97
Rate for Payer: Cigna Medicare	$1,394.72
Rate for Payer: Employer Direct Commercial	$1,394.72
Rate for Payer: Humana Medicare/TRICARE	$1,394.72
Rate for Payer: Molina CHIP/Medicaid	$174.97
Rate for Payer: Molina Dual Medicare/Medicaid	$1,394.72
Rate for Payer: Molina Medicare	$1,394.72
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	$174.97
Rate for Payer: Scott and White EPO/PPO	$30.76
Rate for Payer: Scott and White Medicare	$1,394.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$174.97
Rate for Payer: Superior Health Plan EPO	$1,394.72
Rate for Payer: Superior Health Plan Medicare	$1,394.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,394.72
Rate for Payer: Universal American Medicare	$1,394.72
Rate for Payer: Wellcare Medicare	$1,394.72
Rate for Payer: Wellmed Medicare	$1,394.72

Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane

Facility

$12,223.34

Service Code	CPT 69644
Hospital Charge Code	36069644
Hospital Revenue Code	360
Min. Negotiated Rate	$118.13
Max. Negotiated Rate	$12,223.34
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$8,033.61
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Amerigroup Medicare	$5,355.74
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,355.74
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,132.30
Rate for Payer: Cigna Medicaid	$1,954.22
Rate for Payer: Cigna Medicare	$5,355.74
Rate for Payer: Employer Direct Commercial	$5,355.74
Rate for Payer: Humana Medicare/TRICARE	$5,355.74
Rate for Payer: Molina CHIP/Medicaid	$1,954.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Molina Medicare	$5,355.74
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	$1,954.22
Rate for Payer: Scott and White EPO/PPO	$118.13
Rate for Payer: Scott and White Medicare	$5,355.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.22
Rate for Payer: Superior Health Plan EPO	$5,355.74
Rate for Payer: Superior Health Plan Medicare	$5,355.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Universal American Medicare	$5,355.74
Rate for Payer: Wellcare Medicare	$5,355.74
Rate for Payer: Wellmed Medicare	$5,355.74

Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane

Facility

$12,223.34

Service Code	CPT 69646
Hospital Charge Code	36069646
Hospital Revenue Code	360
Min. Negotiated Rate	$118.13
Max. Negotiated Rate	$12,223.34
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$8,033.61
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Amerigroup Medicare	$5,355.74
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,355.74
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,132.30
Rate for Payer: Cigna Medicaid	$1,954.22
Rate for Payer: Cigna Medicare	$5,355.74
Rate for Payer: Employer Direct Commercial	$5,355.74
Rate for Payer: Humana Medicare/TRICARE	$5,355.74
Rate for Payer: Molina CHIP/Medicaid	$1,954.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Molina Medicare	$5,355.74
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	$1,954.22
Rate for Payer: Scott and White EPO/PPO	$118.13
Rate for Payer: Scott and White Medicare	$5,355.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.22
Rate for Payer: Superior Health Plan EPO	$5,355.74
Rate for Payer: Superior Health Plan Medicare	$5,355.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Universal American Medicare	$5,355.74
Rate for Payer: Wellcare Medicare	$5,355.74
Rate for Payer: Wellmed Medicare	$5,355.74

Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repai

Facility

$12,223.34

Service Code	CPT 69643
Hospital Charge Code	36069643
Hospital Revenue Code	360
Min. Negotiated Rate	$118.13
Max. Negotiated Rate	$12,223.34
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$8,033.61
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Amerigroup Medicare	$5,355.74
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,355.74
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,132.30
Rate for Payer: Cigna Medicaid	$1,954.22
Rate for Payer: Cigna Medicare	$5,355.74
Rate for Payer: Employer Direct Commercial	$5,355.74
Rate for Payer: Humana Medicare/TRICARE	$5,355.74
Rate for Payer: Molina CHIP/Medicaid	$1,954.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Molina Medicare	$5,355.74
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	$1,954.22
Rate for Payer: Scott and White EPO/PPO	$118.13
Rate for Payer: Scott and White Medicare	$5,355.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.22
Rate for Payer: Superior Health Plan EPO	$5,355.74
Rate for Payer: Superior Health Plan Medicare	$5,355.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Universal American Medicare	$5,355.74
Rate for Payer: Wellcare Medicare	$5,355.74
Rate for Payer: Wellmed Medicare	$5,355.74

Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), i

Facility

$12,223.34

Service Code	CPT 69633
Hospital Charge Code	36069633
Hospital Revenue Code	360
Min. Negotiated Rate	$118.13
Max. Negotiated Rate	$12,223.34
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$8,033.61
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Amerigroup Medicare	$5,355.74
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,355.74
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,132.30
Rate for Payer: Cigna Medicaid	$1,954.22
Rate for Payer: Cigna Medicare	$5,355.74
Rate for Payer: Employer Direct Commercial	$5,355.74
Rate for Payer: Humana Medicare/TRICARE	$5,355.74
Rate for Payer: Molina CHIP/Medicaid	$1,954.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Molina Medicare	$5,355.74
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	$1,954.22
Rate for Payer: Scott and White EPO/PPO	$118.13
Rate for Payer: Scott and White Medicare	$5,355.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.22
Rate for Payer: Superior Health Plan EPO	$5,355.74
Rate for Payer: Superior Health Plan Medicare	$5,355.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Universal American Medicare	$5,355.74
Rate for Payer: Wellcare Medicare	$5,355.74
Rate for Payer: Wellmed Medicare	$5,355.74

Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), i

Facility

$12,223.34

Service Code	CPT 69631
Hospital Charge Code	36069631
Hospital Revenue Code	360
Min. Negotiated Rate	$118.13
Max. Negotiated Rate	$12,223.34
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$8,033.61
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Amerigroup Medicare	$5,355.74
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,355.74
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,132.30
Rate for Payer: Cigna Medicaid	$1,954.22
Rate for Payer: Cigna Medicare	$5,355.74
Rate for Payer: Employer Direct Commercial	$5,355.74
Rate for Payer: Humana Medicare/TRICARE	$5,355.74
Rate for Payer: Molina CHIP/Medicaid	$1,954.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Molina Medicare	$5,355.74
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	$1,954.22
Rate for Payer: Scott and White EPO/PPO	$118.13
Rate for Payer: Scott and White Medicare	$5,355.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.22
Rate for Payer: Superior Health Plan EPO	$5,355.74
Rate for Payer: Superior Health Plan Medicare	$5,355.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Universal American Medicare	$5,355.74
Rate for Payer: Wellcare Medicare	$5,355.74
Rate for Payer: Wellmed Medicare	$5,355.74

Tympanostomy (requiring insertion of ventilating tube), general anesthesia

Facility

$10,000.00

Service Code	CPT 69436
Hospital Charge Code	36069436
Hospital Revenue Code	360
Min. Negotiated Rate	$30.76
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,092.08
Rate for Payer: Amerigroup CHIP/Medicaid	$420.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,394.72
Rate for Payer: Amerigroup Medicare	$1,394.72
Rate for Payer: BCBS of TX Blue Advantage	$2,253.40
Rate for Payer: BCBS of TX Blue Essentials	$2,698.68
Rate for Payer: BCBS of TX Medicare	$1,394.72
Rate for Payer: BCBS of TX PPO	$3,400.34
Rate for Payer: Cigna Commercial	$3,159.45
Rate for Payer: Cigna Medicaid	$420.64
Rate for Payer: Cigna Medicare	$1,394.72
Rate for Payer: Employer Direct Commercial	$1,394.72
Rate for Payer: Humana Medicare/TRICARE	$1,394.72
Rate for Payer: Molina CHIP/Medicaid	$420.64
Rate for Payer: Molina Dual Medicare/Medicaid	$1,394.72
Rate for Payer: Molina Medicare	$1,394.72
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	$420.64
Rate for Payer: Scott and White EPO/PPO	$30.76
Rate for Payer: Scott and White Medicare	$1,394.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$420.64
Rate for Payer: Superior Health Plan EPO	$1,394.72
Rate for Payer: Superior Health Plan Medicare	$1,394.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,394.72
Rate for Payer: Universal American Medicare	$1,394.72
Rate for Payer: Wellcare Medicare	$1,394.72
Rate for Payer: Wellmed Medicare	$1,394.72

U0005 SARS-CoV-2 T2 SO

Facility

$64.00

Service Code	HCPCS U0005
Hospital Charge Code	8698565
Hospital Revenue Code	300
Rate for Payer: Cash Price	$56.32

Know your out-of-pocket cost for care.

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