White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Repair umbilical hernia, age 5 years or older incarcerated or strangulated

Facility

$10,000.00

Service Code	CPT 49587
Hospital Charge Code	36049587
Hospital Revenue Code	360
Min. Negotiated Rate	$5,192.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX PPO	$7,835.54
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

Repair umbilical hernia, age 5 years or older incarcerated or strangulated

Facility

$14,325.35

Service Code	HCPCS 49587
Hospital Charge Code	9900722
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,741.24

Repair umbilical hernia, age 5 years or older reducible

Facility

$10,000.00

Service Code	CPT 49585
Hospital Charge Code	36049585
Hospital Revenue Code	360
Min. Negotiated Rate	$5,192.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX PPO	$7,835.54
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

Repair umbilical hernia, age 5 years or older reducible

Facility

$35,615.00

Service Code	HCPCS 49585
Hospital Charge Code	9900721
Hospital Revenue Code	360
Rate for Payer: Cash Price	$24,218.20

Repair umbilical hernia, age 5 years or older reducible

Facility

$35,615.00

Service Code	HCPCS 49585
Hospital Charge Code	9900721
Hospital Revenue Code	360
Min. Negotiated Rate	$3,205.35
Max. Negotiated Rate	$25,642.80
Rate for Payer: Amerigroup CHIP/Medicaid	$3,205.35
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cash Price	$24,218.20
Rate for Payer: Cash Price	$24,218.20
Rate for Payer: Cash Price	$24,218.20
Rate for Payer: Cigna Medicaid	$25,642.80
Rate for Payer: Molina CHIP/Medicaid	$25,642.80
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	$25,642.80
Rate for Payer: Scott and White EPO/PPO	$17,807.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,642.80
Rate for Payer: Superior Health Plan EPO	$4,843.64

Replacement of a tunneled centrally inserted w/out subcutaneous port or pump

Facility

$12,148.04

Service Code	HCPCS 36581
Hospital Charge Code	991054
Hospital Revenue Code	480
Rate for Payer: Cash Price	$8,260.67

Replacement of a tunneled centrally inserted w/out subcutaneous port or pump

Facility

$12,148.04

Service Code	HCPCS 36581
Hospital Charge Code	991054
Hospital Revenue Code	480
Min. Negotiated Rate	$1,093.32
Max. Negotiated Rate	$8,746.59
Rate for Payer: Amerigroup CHIP/Medicaid	$1,093.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$8,260.67
Rate for Payer: Cash Price	$8,260.67
Rate for Payer: Cash Price	$8,260.67
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$8,746.59
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$8,746.59
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
Rate for Payer: Multiplan Auto	$7,896.23
Rate for Payer: Multiplan Commercial	$7,896.23
Rate for Payer: Multiplan Workers Comp	$7,896.23
Rate for Payer: Parkland Medicaid	$8,746.59
Rate for Payer: Scott and White EPO/PPO	$6,074.02
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,746.59
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

Replacement of tissue expander with permanent implant

Facility

$14,602.61

Service Code	HCPCS 11970
Hospital Charge Code	9900105
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,929.77

Replacement of tissue expander with permanent implant

Facility

$14,602.61

Service Code	HCPCS 11970
Hospital Charge Code	9900105
Hospital Revenue Code	360
Min. Negotiated Rate	$3,108.99
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,108.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$9,929.77
Rate for Payer: Cash Price	$9,929.77
Rate for Payer: Cash Price	$9,929.77
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$10,513.88
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$10,513.88
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$10,513.88
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,513.88
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Replacement of tissue expander with permanent implant

Facility

$15,408.22

Service Code	CPT 11970
Hospital Charge Code	36011970
Hospital Revenue Code	360
Min. Negotiated Rate	$3,108.99
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,108.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

reporting injection of platelet rich plasma to a targeted site

Facility

$1,575.00

Service Code	HCPCS 0232T
Hospital Charge Code	9900913
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,071.00

reporting injection of platelet rich plasma to a targeted site

Facility

$10,000.00

Service Code	CPT 0232T
Hospital Charge Code	3600232T
Hospital Revenue Code	360
Min. Negotiated Rate	$448.76
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$448.76
Rate for Payer: Amerigroup Medicare	$448.76
Rate for Payer: BCBS of TX Blue Advantage	$607.20
Rate for Payer: BCBS of TX Blue Essentials	$727.18
Rate for Payer: BCBS of TX Medicare	$448.76
Rate for Payer: BCBS of TX PPO	$916.25
Rate for Payer: Cigna Commercial	$948.59
Rate for Payer: Cigna Medicare	$448.76
Rate for Payer: Employer Direct Commercial	$448.76
Rate for Payer: Humana Medicare/TRICARE	$448.76
Rate for Payer: Molina Dual Medicare/Medicaid	$448.76
Rate for Payer: Molina Medicare	$448.76
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 Medicare	$448.76
Rate for Payer: Superior Health Plan EPO	$448.76
Rate for Payer: Superior Health Plan Medicare	$448.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$448.76
Rate for Payer: Universal American Medicare	$448.76
Rate for Payer: Wellcare Medicare	$448.76
Rate for Payer: Wellmed Medicare	$448.76

reporting injection of platelet rich plasma to a targeted site

Facility

$1,575.00

Service Code	HCPCS 0232T
Hospital Charge Code	9900913
Hospital Revenue Code	360
Min. Negotiated Rate	$141.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$141.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$448.76
Rate for Payer: Amerigroup Medicare	$448.76
Rate for Payer: BCBS of TX Blue Advantage	$607.20
Rate for Payer: BCBS of TX Blue Essentials	$727.18
Rate for Payer: BCBS of TX Medicare	$448.76
Rate for Payer: BCBS of TX PPO	$916.25
Rate for Payer: Cash Price	$1,071.00
Rate for Payer: Cash Price	$1,071.00
Rate for Payer: Cash Price	$1,071.00
Rate for Payer: Cigna Commercial	$948.59
Rate for Payer: Cigna Medicaid	$1,134.00
Rate for Payer: Cigna Medicare	$448.76
Rate for Payer: Employer Direct Commercial	$448.76
Rate for Payer: Humana Medicare/TRICARE	$448.76
Rate for Payer: Molina CHIP/Medicaid	$1,134.00
Rate for Payer: Molina Dual Medicare/Medicaid	$448.76
Rate for Payer: Molina Medicare	$448.76
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	$1,134.00
Rate for Payer: Scott and White EPO/PPO	$787.50
Rate for Payer: Scott and White Medicare	$448.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,134.00
Rate for Payer: Superior Health Plan EPO	$448.76
Rate for Payer: Superior Health Plan Medicare	$448.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$448.76
Rate for Payer: Universal American Medicare	$448.76
Rate for Payer: Wellcare Medicare	$448.76
Rate for Payer: Wellmed Medicare	$448.76

REPOS ENDO VENACAVA FILT

Facility

$17,664.00

Service Code	HCPCS 37192
Hospital Charge Code	4617192
Hospital Revenue Code	361
Min. Negotiated Rate	$1,589.76
Max. Negotiated Rate	$12,718.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1,589.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$12,011.52
Rate for Payer: Cash Price	$12,011.52
Rate for Payer: Cash Price	$12,011.52
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$12,718.08
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$12,718.08
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$12,718.08
Rate for Payer: Scott and White EPO/PPO	$5,867.96
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,718.08
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

REPOS ENDO VENACAVA FILT

Facility

$17,664.00

Service Code	HCPCS 37192
Hospital Charge Code	4617192
Hospital Revenue Code	361
Rate for Payer: Cash Price	$12,011.52

REPOSITION 1 VENTRIC LEAD

Facility

$9,924.00

Service Code	HCPCS 33226
Hospital Charge Code	2303329
Hospital Revenue Code	481
Rate for Payer: Cash Price	$6,748.32

REPOSITION 1 VENTRIC LEAD

Facility

$9,924.00

Service Code	HCPCS 33226
Hospital Charge Code	2303329
Hospital Revenue Code	481
Min. Negotiated Rate	$893.16
Max. Negotiated Rate	$7,145.28
Rate for Payer: Amerigroup CHIP/Medicaid	$893.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$6,748.32
Rate for Payer: Cash Price	$6,748.32
Rate for Payer: Cash Price	$6,748.32
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$7,145.28
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$7,145.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
Rate for Payer: Multiplan Auto	$6,450.60
Rate for Payer: Multiplan Commercial	$6,450.60
Rate for Payer: Multiplan Workers Comp	$6,450.60
Rate for Payer: Parkland Medicaid	$7,145.28
Rate for Payer: Scott and White EPO/PPO	$4,962.00
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,145.28
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure)

Facility

$5,717.69

Service Code	HCPCS 66825
Hospital Charge Code	9900867
Hospital Revenue Code	360
Min. Negotiated Rate	$849.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$849.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Amerigroup Medicare	$2,318.34
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	$2,318.34
Rate for Payer: BCBS of TX PPO	$5,095.09
Rate for Payer: Cash Price	$3,888.03
Rate for Payer: Cash Price	$3,888.03
Rate for Payer: Cash Price	$3,888.03
Rate for Payer: Cigna Commercial	$4,900.56
Rate for Payer: Cigna Medicaid	$4,116.74
Rate for Payer: Cigna Medicare	$2,318.34
Rate for Payer: Employer Direct Commercial	$2,318.34
Rate for Payer: Humana Medicare/TRICARE	$2,318.34
Rate for Payer: Molina CHIP/Medicaid	$4,116.74
Rate for Payer: Molina Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Molina Medicare	$2,318.34
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	$4,116.74
Rate for Payer: Scott and White EPO/PPO	$4,288.93
Rate for Payer: Scott and White Medicare	$2,318.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,116.74
Rate for Payer: Superior Health Plan EPO	$2,318.34
Rate for Payer: Superior Health Plan Medicare	$2,318.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Universal American Medicare	$2,318.34
Rate for Payer: Wellcare Medicare	$2,318.34
Rate for Payer: Wellmed Medicare	$2,318.34

Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure)

Facility

$10,000.00

Service Code	CPT 66825
Hospital Charge Code	36066825
Hospital Revenue Code	360
Min. Negotiated Rate	$849.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$849.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Amerigroup Medicare	$2,318.34
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	$2,318.34
Rate for Payer: BCBS of TX PPO	$5,095.09
Rate for Payer: Cigna Commercial	$4,900.56
Rate for Payer: Cigna Medicare	$2,318.34
Rate for Payer: Employer Direct Commercial	$2,318.34
Rate for Payer: Humana Medicare/TRICARE	$2,318.34
Rate for Payer: Molina Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Molina Medicare	$2,318.34
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	$4,288.93
Rate for Payer: Scott and White Medicare	$2,318.34
Rate for Payer: Superior Health Plan EPO	$2,318.34
Rate for Payer: Superior Health Plan Medicare	$2,318.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Universal American Medicare	$2,318.34
Rate for Payer: Wellcare Medicare	$2,318.34
Rate for Payer: Wellmed Medicare	$2,318.34

Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure)

Facility

$5,717.69

Service Code	HCPCS 66825
Hospital Charge Code	9900867
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,888.03

Repositioning of periotoneal dialysis cath w/ Fluoroscopic

Facility

$3,706.52

Service Code	HCPCS 49999
Hospital Charge Code	994228
Hospital Revenue Code	360
Min. Negotiated Rate	$911.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$911.12
Rate for Payer: Amerigroup Medicare	$911.12
Rate for Payer: BCBS of TX Blue Advantage	$1,312.49
Rate for Payer: BCBS of TX Blue Essentials	$1,571.84
Rate for Payer: BCBS of TX Medicare	$911.12
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cash Price	$2,520.43
Rate for Payer: Cash Price	$2,520.43
Rate for Payer: Cash Price	$2,520.43
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicaid	$2,668.69
Rate for Payer: Cigna Medicare	$911.12
Rate for Payer: Employer Direct Commercial	$911.12
Rate for Payer: Humana Medicare/TRICARE	$911.12
Rate for Payer: Molina CHIP/Medicaid	$2,668.69
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
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	$2,668.69
Rate for Payer: Scott and White EPO/PPO	$1,685.57
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,668.69
Rate for Payer: Superior Health Plan EPO	$911.12
Rate for Payer: Superior Health Plan Medicare	$911.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$911.12
Rate for Payer: Universal American Medicare	$911.12
Rate for Payer: Wellcare Medicare	$911.12
Rate for Payer: Wellmed Medicare	$911.12

Repositioning of periotoneal dialysis cath w/ Fluoroscopic

Facility

$3,706.52

Service Code	HCPCS 49999
Hospital Charge Code	994228
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,520.43

repositioning sleeve

Facility

$53.34

Hospital Charge Code	993561
Hospital Revenue Code	270
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$38.40
Rate for Payer: Amerigroup CHIP/Medicaid	$4.80
Rate for Payer: BCBS of TX Blue Advantage	$16.00
Rate for Payer: BCBS of TX Blue Essentials	$19.20
Rate for Payer: BCBS of TX PPO	$21.34
Rate for Payer: Cash Price	$36.27
Rate for Payer: Cigna Medicaid	$38.40
Rate for Payer: Molina CHIP/Medicaid	$38.40
Rate for Payer: Multiplan Auto	$34.67
Rate for Payer: Multiplan Commercial	$34.67
Rate for Payer: Multiplan Workers Comp	$34.67
Rate for Payer: Parkland Medicaid	$38.40
Rate for Payer: Scott and White EPO/PPO	$26.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.40
Rate for Payer: Superior Health Plan EPO	$7.25

repositioning sleeve

Facility

$53.34

Hospital Charge Code	993561
Hospital Revenue Code	270
Rate for Payer: Cash Price	$36.27

REPOSITN CV CATH W/FLURO

Facility

$1,788.00

Service Code	HCPCS 36597
Hospital Charge Code	4614241
Hospital Revenue Code	361
Min. Negotiated Rate	$446.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$446.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Amerigroup Medicare	$1,581.33
Rate for Payer: BCBS of TX Blue Advantage	$2,723.99
Rate for Payer: BCBS of TX Blue Essentials	$3,262.26
Rate for Payer: BCBS of TX Medicare	$1,581.33
Rate for Payer: BCBS of TX PPO	$4,110.45
Rate for Payer: Cash Price	$1,215.84
Rate for Payer: Cash Price	$1,215.84
Rate for Payer: Cash Price	$1,215.84
Rate for Payer: Cigna Commercial	$3,342.63
Rate for Payer: Cigna Medicaid	$1,287.36
Rate for Payer: Cigna Medicare	$1,581.33
Rate for Payer: Employer Direct Commercial	$1,581.33
Rate for Payer: Humana Medicare/TRICARE	$1,581.33
Rate for Payer: Molina CHIP/Medicaid	$1,287.36
Rate for Payer: Molina Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Molina Medicare	$1,581.33
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	$1,287.36
Rate for Payer: Scott and White EPO/PPO	$2,925.46
Rate for Payer: Scott and White Medicare	$1,581.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,287.36
Rate for Payer: Superior Health Plan EPO	$1,581.33
Rate for Payer: Superior Health Plan Medicare	$1,581.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Universal American Medicare	$1,581.33
Rate for Payer: Wellcare Medicare	$1,581.33
Rate for Payer: Wellmed Medicare	$1,581.33

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