White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC

Facility

$44,289.17

Service Code	MSDRG 359
Min. Negotiated Rate	$29,961.67
Max. Negotiated Rate	$44,289.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29,961.67
Rate for Payer: Amerigroup Medicare	$29,961.67
Rate for Payer: BCBS of TX Medicare	$29,961.67
Rate for Payer: Cigna Commercial	$44,289.17
Rate for Payer: Cigna Medicare	$29,961.67
Rate for Payer: Employer Direct Commercial	$29,961.67
Rate for Payer: Humana Medicare/TRICARE	$29,961.67
Rate for Payer: Molina Dual Medicare/Medicaid	$29,961.67
Rate for Payer: Molina Medicare	$29,961.67
Rate for Payer: Scott and White Medicare	$29,961.67
Rate for Payer: Superior Health Plan EPO	$29,961.67
Rate for Payer: Superior Health Plan Medicare	$29,961.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$29,961.67
Rate for Payer: Universal American Medicare	$29,961.67
Rate for Payer: Wellcare Medicare	$29,961.67
Rate for Payer: Wellmed Medicare	$29,961.67

PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$31,096.18

Service Code	MSDRG 360
Min. Negotiated Rate	$22,454.56
Max. Negotiated Rate	$31,096.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,454.56
Rate for Payer: Amerigroup Medicare	$22,454.56
Rate for Payer: BCBS of TX Medicare	$22,454.56
Rate for Payer: Cigna Commercial	$31,096.18
Rate for Payer: Cigna Medicare	$22,454.56
Rate for Payer: Employer Direct Commercial	$22,454.56
Rate for Payer: Humana Medicare/TRICARE	$22,454.56
Rate for Payer: Molina Dual Medicare/Medicaid	$22,454.56
Rate for Payer: Molina Medicare	$22,454.56
Rate for Payer: Scott and White Medicare	$22,454.56
Rate for Payer: Superior Health Plan EPO	$22,454.56
Rate for Payer: Superior Health Plan Medicare	$22,454.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,454.56
Rate for Payer: Universal American Medicare	$22,454.56
Rate for Payer: Wellcare Medicare	$22,454.56
Rate for Payer: Wellmed Medicare	$22,454.56

PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE

Facility

$31,197.94

Service Code	MSDRG 318
Min. Negotiated Rate	$22,512.45
Max. Negotiated Rate	$31,197.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,512.45
Rate for Payer: Amerigroup Medicare	$22,512.45
Rate for Payer: BCBS of TX Medicare	$22,512.45
Rate for Payer: Cigna Commercial	$31,197.94
Rate for Payer: Cigna Medicare	$22,512.45
Rate for Payer: Employer Direct Commercial	$22,512.45
Rate for Payer: Humana Medicare/TRICARE	$22,512.45
Rate for Payer: Molina Dual Medicare/Medicaid	$22,512.45
Rate for Payer: Molina Medicare	$22,512.45
Rate for Payer: Scott and White Medicare	$22,512.45
Rate for Payer: Superior Health Plan EPO	$22,512.45
Rate for Payer: Superior Health Plan Medicare	$22,512.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,512.45
Rate for Payer: Universal American Medicare	$22,512.45
Rate for Payer: Wellcare Medicare	$22,512.45
Rate for Payer: Wellmed Medicare	$22,512.45

Percutaneous implantation of neurostimulator electrode array, epidural

Facility

$55,446.12

Service Code	HCPCS 63650
Hospital Charge Code	9900771
Hospital Revenue Code	360
Min. Negotiated Rate	$3,656.02
Max. Negotiated Rate	$39,921.21
Rate for Payer: Amerigroup CHIP/Medicaid	$3,656.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Amerigroup Medicare	$6,402.04
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	$6,402.04
Rate for Payer: BCBS of TX PPO	$15,591.57
Rate for Payer: Cash Price	$37,703.36
Rate for Payer: Cash Price	$37,703.36
Rate for Payer: Cash Price	$37,703.36
Rate for Payer: Cigna Commercial	$13,532.75
Rate for Payer: Cigna Medicaid	$39,921.21
Rate for Payer: Cigna Medicare	$6,402.04
Rate for Payer: Employer Direct Commercial	$6,402.04
Rate for Payer: Humana Medicare/TRICARE	$6,402.04
Rate for Payer: Molina CHIP/Medicaid	$39,921.21
Rate for Payer: Molina Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Molina Medicare	$6,402.04
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	$39,921.21
Rate for Payer: Scott and White EPO/PPO	$11,571.23
Rate for Payer: Scott and White Medicare	$6,402.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39,921.21
Rate for Payer: Superior Health Plan EPO	$6,402.04
Rate for Payer: Superior Health Plan Medicare	$6,402.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Universal American Medicare	$6,402.04
Rate for Payer: Wellcare Medicare	$6,402.04
Rate for Payer: Wellmed Medicare	$6,402.04

Percutaneous implantation of neurostimulator electrode array, epidural

Facility

$15,591.57

Service Code	CPT 63650
Hospital Charge Code	36063650
Hospital Revenue Code	360
Min. Negotiated Rate	$3,656.02
Max. Negotiated Rate	$15,591.57
Rate for Payer: Amerigroup CHIP/Medicaid	$3,656.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Amerigroup Medicare	$6,402.04
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	$6,402.04
Rate for Payer: BCBS of TX PPO	$15,591.57
Rate for Payer: Cigna Commercial	$13,532.75
Rate for Payer: Cigna Medicare	$6,402.04
Rate for Payer: Employer Direct Commercial	$6,402.04
Rate for Payer: Humana Medicare/TRICARE	$6,402.04
Rate for Payer: Molina Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Molina Medicare	$6,402.04
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	$11,571.23
Rate for Payer: Scott and White Medicare	$6,402.04
Rate for Payer: Superior Health Plan EPO	$6,402.04
Rate for Payer: Superior Health Plan Medicare	$6,402.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Universal American Medicare	$6,402.04
Rate for Payer: Wellcare Medicare	$6,402.04
Rate for Payer: Wellmed Medicare	$6,402.04

Percutaneous implantation of neurostimulator electrode array, epidural

Facility

$55,446.12

Service Code	HCPCS 63650
Hospital Charge Code	9900771
Hospital Revenue Code	360
Rate for Payer: Cash Price	$37,703.36

Percutaneous implantation of neurostimulator electrode array peripheral nerve (excludes sacral nerv

Facility

$15,591.57

Service Code	CPT 64555
Hospital Charge Code	36064555
Hospital Revenue Code	360
Min. Negotiated Rate	$3,908.38
Max. Negotiated Rate	$15,591.57
Rate for Payer: Amerigroup CHIP/Medicaid	$3,908.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Amerigroup Medicare	$6,402.04
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	$6,402.04
Rate for Payer: BCBS of TX PPO	$15,591.57
Rate for Payer: Cigna Commercial	$13,532.75
Rate for Payer: Cigna Medicare	$6,402.04
Rate for Payer: Employer Direct Commercial	$6,402.04
Rate for Payer: Humana Medicare/TRICARE	$6,402.04
Rate for Payer: Molina Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Molina Medicare	$6,402.04
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	$11,571.23
Rate for Payer: Scott and White Medicare	$6,402.04
Rate for Payer: Superior Health Plan EPO	$6,402.04
Rate for Payer: Superior Health Plan Medicare	$6,402.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Universal American Medicare	$6,402.04
Rate for Payer: Wellcare Medicare	$6,402.04
Rate for Payer: Wellmed Medicare	$6,402.04

Percutaneous implantation of neurostimulator electrode array peripheral nerve (excludes sacral nerv

Facility

$27,723.06

Service Code	HCPCS 64555
Hospital Charge Code	9900812
Hospital Revenue Code	360
Rate for Payer: Cash Price	$18,851.68

Percutaneous implantation of neurostimulator electrode array peripheral nerve (excludes sacral nerv

Facility

$27,723.06

Service Code	HCPCS 64555
Hospital Charge Code	9900812
Hospital Revenue Code	360
Min. Negotiated Rate	$3,908.38
Max. Negotiated Rate	$19,960.60
Rate for Payer: Amerigroup CHIP/Medicaid	$3,908.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Amerigroup Medicare	$6,402.04
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	$6,402.04
Rate for Payer: BCBS of TX PPO	$15,591.57
Rate for Payer: Cash Price	$18,851.68
Rate for Payer: Cash Price	$18,851.68
Rate for Payer: Cash Price	$18,851.68
Rate for Payer: Cigna Commercial	$13,532.75
Rate for Payer: Cigna Medicaid	$19,960.60
Rate for Payer: Cigna Medicare	$6,402.04
Rate for Payer: Employer Direct Commercial	$6,402.04
Rate for Payer: Humana Medicare/TRICARE	$6,402.04
Rate for Payer: Molina CHIP/Medicaid	$19,960.60
Rate for Payer: Molina Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Molina Medicare	$6,402.04
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	$19,960.60
Rate for Payer: Scott and White EPO/PPO	$11,571.23
Rate for Payer: Scott and White Medicare	$6,402.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,960.60
Rate for Payer: Superior Health Plan EPO	$6,402.04
Rate for Payer: Superior Health Plan Medicare	$6,402.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,402.04
Rate for Payer: Universal American Medicare	$6,402.04
Rate for Payer: Wellcare Medicare	$6,402.04
Rate for Payer: Wellmed Medicare	$6,402.04

PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC

Facility

$76,247.00

Service Code	MSDRG 273
Min. Negotiated Rate	$31,411.50
Max. Negotiated Rate	$76,247.00
Rate for Payer: BCBS of TX Blue Advantage	$31,411.50
Rate for Payer: BCBS of TX Blue Essentials	$37,690.15
Rate for Payer: BCBS of TX PPO	$41,879.57

PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC

Facility

$63,830.50

Service Code	MSDRG 274
Min. Negotiated Rate	$25,613.38
Max. Negotiated Rate	$63,830.50
Rate for Payer: BCBS of TX Blue Advantage	$25,613.38
Rate for Payer: BCBS of TX Blue Essentials	$30,733.08
Rate for Payer: BCBS of TX PPO	$34,149.19

PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES

Facility

$10,139.59

Service Code	APR-DRG 0301
Min. Negotiated Rate	$9,559.97
Max. Negotiated Rate	$10,139.59
Rate for Payer: Amerigroup CHIP/Medicaid	$9,559.97
Rate for Payer: Cigna Medicaid	$9,559.97
Rate for Payer: Molina CHIP/Medicaid	$9,559.97
Rate for Payer: Parkland Medicaid	$9,559.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,139.59

PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES

Facility

$13,360.79

Service Code	APR-DRG 0302
Min. Negotiated Rate	$12,597.02
Max. Negotiated Rate	$13,360.79
Rate for Payer: Amerigroup CHIP/Medicaid	$12,597.02
Rate for Payer: Cigna Medicaid	$12,597.02
Rate for Payer: Molina CHIP/Medicaid	$12,597.02
Rate for Payer: Parkland Medicaid	$12,597.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,360.79

PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES

Facility

$25,409.34

Service Code	APR-DRG 0304
Min. Negotiated Rate	$23,956.81
Max. Negotiated Rate	$25,409.34
Rate for Payer: Amerigroup CHIP/Medicaid	$23,956.81
Rate for Payer: Cigna Medicaid	$23,956.81
Rate for Payer: Molina CHIP/Medicaid	$23,956.81
Rate for Payer: Parkland Medicaid	$23,956.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,409.34

PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES

Facility

$18,139.77

Service Code	APR-DRG 0303
Min. Negotiated Rate	$17,102.81
Max. Negotiated Rate	$18,139.77
Rate for Payer: Amerigroup CHIP/Medicaid	$17,102.81
Rate for Payer: Cigna Medicaid	$17,102.81
Rate for Payer: Molina CHIP/Medicaid	$17,102.81
Rate for Payer: Parkland Medicaid	$17,102.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,139.77

Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme)

Facility

$2,261.77

Service Code	HCPCS 62263
Hospital Charge Code	9900739
Hospital Revenue Code	360
Min. Negotiated Rate	$340.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$340.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$888.50
Rate for Payer: Amerigroup Medicare	$888.50
Rate for Payer: BCBS of TX Blue Advantage	$1,356.12
Rate for Payer: BCBS of TX Blue Essentials	$1,624.10
Rate for Payer: BCBS of TX Medicare	$888.50
Rate for Payer: BCBS of TX PPO	$2,046.37
Rate for Payer: Cash Price	$1,538.00
Rate for Payer: Cash Price	$1,538.00
Rate for Payer: Cash Price	$1,538.00
Rate for Payer: Cigna Commercial	$1,878.13
Rate for Payer: Cigna Medicaid	$1,628.47
Rate for Payer: Cigna Medicare	$888.50
Rate for Payer: Employer Direct Commercial	$888.50
Rate for Payer: Humana Medicare/TRICARE	$888.50
Rate for Payer: Molina CHIP/Medicaid	$1,628.47
Rate for Payer: Molina Dual Medicare/Medicaid	$888.50
Rate for Payer: Molina Medicare	$888.50
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	$1,628.47
Rate for Payer: Scott and White EPO/PPO	$1,542.14
Rate for Payer: Scott and White Medicare	$888.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,628.47
Rate for Payer: Superior Health Plan EPO	$888.50
Rate for Payer: Superior Health Plan Medicare	$888.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$888.50
Rate for Payer: Universal American Medicare	$888.50
Rate for Payer: Wellcare Medicare	$888.50
Rate for Payer: Wellmed Medicare	$888.50

Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme)

Facility

$10,000.00

Service Code	CPT 62263
Hospital Charge Code	36062263
Hospital Revenue Code	360
Min. Negotiated Rate	$340.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$340.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$888.50
Rate for Payer: Amerigroup Medicare	$888.50
Rate for Payer: BCBS of TX Blue Advantage	$1,356.12
Rate for Payer: BCBS of TX Blue Essentials	$1,624.10
Rate for Payer: BCBS of TX Medicare	$888.50
Rate for Payer: BCBS of TX PPO	$2,046.37
Rate for Payer: Cigna Commercial	$1,878.13
Rate for Payer: Cigna Medicare	$888.50
Rate for Payer: Employer Direct Commercial	$888.50
Rate for Payer: Humana Medicare/TRICARE	$888.50
Rate for Payer: Molina Dual Medicare/Medicaid	$888.50
Rate for Payer: Molina Medicare	$888.50
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	$1,542.14
Rate for Payer: Scott and White Medicare	$888.50
Rate for Payer: Superior Health Plan EPO	$888.50
Rate for Payer: Superior Health Plan Medicare	$888.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$888.50
Rate for Payer: Universal American Medicare	$888.50
Rate for Payer: Wellcare Medicare	$888.50
Rate for Payer: Wellmed Medicare	$888.50

Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme)

Facility

$2,261.77

Service Code	HCPCS 62263
Hospital Charge Code	9900739
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,538.00

Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or

Facility

$10,000.00

Service Code	CPT 62264
Hospital Charge Code	36062264
Hospital Revenue Code	360
Min. Negotiated Rate	$340.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$340.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$888.50
Rate for Payer: Amerigroup Medicare	$888.50
Rate for Payer: BCBS of TX Blue Advantage	$1,356.12
Rate for Payer: BCBS of TX Blue Essentials	$1,624.10
Rate for Payer: BCBS of TX Medicare	$888.50
Rate for Payer: BCBS of TX PPO	$2,046.37
Rate for Payer: Cigna Commercial	$1,878.13
Rate for Payer: Cigna Medicare	$888.50
Rate for Payer: Employer Direct Commercial	$888.50
Rate for Payer: Humana Medicare/TRICARE	$888.50
Rate for Payer: Molina Dual Medicare/Medicaid	$888.50
Rate for Payer: Molina Medicare	$888.50
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	$1,542.14
Rate for Payer: Scott and White Medicare	$888.50
Rate for Payer: Superior Health Plan EPO	$888.50
Rate for Payer: Superior Health Plan Medicare	$888.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$888.50
Rate for Payer: Universal American Medicare	$888.50
Rate for Payer: Wellcare Medicare	$888.50
Rate for Payer: Wellmed Medicare	$888.50

Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or

Facility

$4,934.76

Service Code	HCPCS 62264
Hospital Charge Code	9900740
Hospital Revenue Code	360
Min. Negotiated Rate	$340.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$340.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$888.50
Rate for Payer: Amerigroup Medicare	$888.50
Rate for Payer: BCBS of TX Blue Advantage	$1,356.12
Rate for Payer: BCBS of TX Blue Essentials	$1,624.10
Rate for Payer: BCBS of TX Medicare	$888.50
Rate for Payer: BCBS of TX PPO	$2,046.37
Rate for Payer: Cash Price	$3,355.64
Rate for Payer: Cash Price	$3,355.64
Rate for Payer: Cash Price	$3,355.64
Rate for Payer: Cigna Commercial	$1,878.13
Rate for Payer: Cigna Medicaid	$3,553.03
Rate for Payer: Cigna Medicare	$888.50
Rate for Payer: Employer Direct Commercial	$888.50
Rate for Payer: Humana Medicare/TRICARE	$888.50
Rate for Payer: Molina CHIP/Medicaid	$3,553.03
Rate for Payer: Molina Dual Medicare/Medicaid	$888.50
Rate for Payer: Molina Medicare	$888.50
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	$3,553.03
Rate for Payer: Scott and White EPO/PPO	$1,542.14
Rate for Payer: Scott and White Medicare	$888.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,553.03
Rate for Payer: Superior Health Plan EPO	$888.50
Rate for Payer: Superior Health Plan Medicare	$888.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$888.50
Rate for Payer: Universal American Medicare	$888.50
Rate for Payer: Wellcare Medicare	$888.50
Rate for Payer: Wellmed Medicare	$888.50

Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or

Facility

$4,934.76

Service Code	HCPCS 62264
Hospital Charge Code	9900740
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,355.64

Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation,

Facility

$10,000.00

Service Code	CPT 26676
Hospital Charge Code	36026676
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation,

Facility

$12,336.12

Service Code	HCPCS 26676
Hospital Charge Code	9900362
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,882.01
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$8,882.01
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$8,882.01
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,882.01
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation,

Facility

$12,336.12

Service Code	HCPCS 26676
Hospital Charge Code	9900362
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,388.56

Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each

Facility

$11,906.64

Service Code	HCPCS 26756
Hospital Charge Code	9900368
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,096.52

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