White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

REPROCESSED HARMONIC ACE+7 SHEARS WITH ADV. HEMOSTASIS, USE ONLY WITH GEN11 SW V2018-1.1 AND LOWER 5 MM X 23 CM (ETHICON HARH23)

Facility

$6,377.17

Hospital Charge Code	993109
Hospital Revenue Code	270
Min. Negotiated Rate	$573.95
Max. Negotiated Rate	$4,591.56
Rate for Payer: Amerigroup CHIP/Medicaid	$573.95
Rate for Payer: BCBS of TX Blue Advantage	$1,913.15
Rate for Payer: BCBS of TX Blue Essentials	$2,295.78
Rate for Payer: BCBS of TX PPO	$2,550.87
Rate for Payer: Cash Price	$4,336.48
Rate for Payer: Cigna Medicaid	$4,591.56
Rate for Payer: Molina CHIP/Medicaid	$4,591.56
Rate for Payer: Multiplan Auto	$4,145.16
Rate for Payer: Multiplan Commercial	$4,145.16
Rate for Payer: Multiplan Workers Comp	$4,145.16
Rate for Payer: Parkland Medicaid	$4,591.56
Rate for Payer: Scott and White EPO/PPO	$3,188.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,591.56
Rate for Payer: Superior Health Plan EPO	$867.30

REPROCESSED HARMONIC ACE+7 SHEARS WITH ADV. HEMOSTASIS, USE ONLY WITH GEN11 SW V2018-1.1 AND LOWER 5 MM X 23 CM (ETHICON HARH23)

Facility

$6,377.17

Hospital Charge Code	993109
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4,336.48

REPS TRNSV LD RT ATR/VNT

Facility

$6,691.00

Service Code	HCPCS 33215
Hospital Charge Code	2312932
Hospital Revenue Code	481
Rate for Payer: Cash Price	$4,549.88

REPS TRNSV LD RT ATR/VNT

Facility

$6,691.00

Service Code	HCPCS 33215
Hospital Charge Code	2312932
Hospital Revenue Code	481
Min. Negotiated Rate	$602.19
Max. Negotiated Rate	$6,983.63
Rate for Payer: Amerigroup CHIP/Medicaid	$602.19
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	$4,549.88
Rate for Payer: Cash Price	$4,549.88
Rate for Payer: Cash Price	$4,549.88
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$4,817.52
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	$4,817.52
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
Rate for Payer: Multiplan Auto	$4,349.15
Rate for Payer: Multiplan Commercial	$4,349.15
Rate for Payer: Multiplan Workers Comp	$4,349.15
Rate for Payer: Parkland Medicaid	$4,817.52
Rate for Payer: Scott and White EPO/PPO	$3,345.50
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,817.52
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

Rescue Fixed Screw, 4.5x14mm

Facility

$903.61

Service Code	HCPCS C1713
Hospital Charge Code	992221
Hospital Revenue Code	278
Min. Negotiated Rate	$225.90
Max. Negotiated Rate	$451.81
Rate for Payer: Cash Price	$614.45
Rate for Payer: Cigna Commercial	$225.90
Rate for Payer: Multiplan Auto	$451.81
Rate for Payer: Multiplan Commercial	$451.81
Rate for Payer: Multiplan Workers Comp	$451.81
Rate for Payer: Scott and White EPO/PPO	$451.81

Rescue Fixed Screw, 4.5x14mm

Facility

$903.61

Service Code	HCPCS C1713
Hospital Charge Code	992221
Hospital Revenue Code	278
Min. Negotiated Rate	$81.32
Max. Negotiated Rate	$650.60
Rate for Payer: Amerigroup CHIP/Medicaid	$81.32
Rate for Payer: BCBS of TX Blue Advantage	$271.08
Rate for Payer: BCBS of TX Blue Essentials	$325.30
Rate for Payer: BCBS of TX PPO	$361.44
Rate for Payer: Cash Price	$614.45
Rate for Payer: Cigna Medicaid	$650.60
Rate for Payer: Molina CHIP/Medicaid	$650.60
Rate for Payer: Multiplan Auto	$451.81
Rate for Payer: Multiplan Commercial	$451.81
Rate for Payer: Multiplan Workers Comp	$451.81
Rate for Payer: Parkland Medicaid	$650.60
Rate for Payer: Scott and White EPO/PPO	$451.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$650.60
Rate for Payer: Superior Health Plan EPO	$122.89

Resection, condyle(s), distal end of phalanx, each toe

Facility

$7,783.60

Service Code	HCPCS 28153
Hospital Charge Code	9900484
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	$5,292.85
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$5,604.19
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	$5,604.19
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	$5,604.19
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,604.19
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

Resection, condyle(s), distal end of phalanx, each toe

Facility

$7,783.60

Service Code	HCPCS 28153
Hospital Charge Code	9900484
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,292.85

Resection, condyle(s), distal end of phalanx, each toe

Facility

$10,000.00

Service Code	CPT 28153
Hospital Charge Code	36028153
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	$6,080.78
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

RESP FUNCT OTH IND 15MIN Minutes

Facility

$158.00

Service Code	HCPCS G0238
Hospital Charge Code	6030238
Hospital Revenue Code	419
Rate for Payer: Cash Price	$107.44

RESP FUNCT OTH IND 15MIN Minutes

Facility

$158.00

Service Code	HCPCS G0238
Hospital Charge Code	6030238
Hospital Revenue Code	419
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$180.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29.06
Rate for Payer: Amerigroup Medicare	$29.06
Rate for Payer: BCBS of TX Blue Advantage	$47.40
Rate for Payer: BCBS of TX Blue Essentials	$56.88
Rate for Payer: BCBS of TX Medicare	$29.06
Rate for Payer: BCBS of TX PPO	$63.20
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cigna Commercial	$61.41
Rate for Payer: Cigna Medicaid	$113.76
Rate for Payer: Cigna Medicare	$29.06
Rate for Payer: Employer Direct Commercial	$29.06
Rate for Payer: Humana Medicare/TRICARE	$29.06
Rate for Payer: Molina CHIP/Medicaid	$113.76
Rate for Payer: Molina Dual Medicare/Medicaid	$29.06
Rate for Payer: Molina Medicare	$29.06
Rate for Payer: Multiplan Auto	$102.70
Rate for Payer: Multiplan Commercial	$102.70
Rate for Payer: Multiplan Workers Comp	$102.70
Rate for Payer: Parkland Medicaid	$113.76
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Scott and White Medicare	$29.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.76
Rate for Payer: Superior Health Plan EPO	$29.06
Rate for Payer: Superior Health Plan Medicare	$29.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$29.06
Rate for Payer: Universal American Medicare	$29.06
Rate for Payer: Wellcare Medicare	$29.06
Rate for Payer: Wellmed Medicare	$29.06

Respiratory Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107033
Hospital Revenue Code	306
Rate for Payer: Cash Price	$210.12

Respiratory Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107033
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$92.70
Rate for Payer: BCBS of TX Blue Essentials	$111.24
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$123.60
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cigna Medicaid	$222.48
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$222.48
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

RESPIRATORY FAILURE

Facility

$2,488.69

Service Code	APR-DRG 1331
Min. Negotiated Rate	$2,346.43
Max. Negotiated Rate	$2,488.69
Rate for Payer: Amerigroup CHIP/Medicaid	$2,346.43
Rate for Payer: Cigna Medicaid	$2,346.43
Rate for Payer: Molina CHIP/Medicaid	$2,346.43
Rate for Payer: Parkland Medicaid	$2,346.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,488.69

RESPIRATORY FAILURE

Facility

$10,636.73

Service Code	APR-DRG 1334
Min. Negotiated Rate	$10,028.68
Max. Negotiated Rate	$10,636.73
Rate for Payer: Amerigroup CHIP/Medicaid	$10,028.68
Rate for Payer: Cigna Medicaid	$10,028.68
Rate for Payer: Molina CHIP/Medicaid	$10,028.68
Rate for Payer: Parkland Medicaid	$10,028.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,636.73

RESPIRATORY FAILURE

Facility

$7,324.63

Service Code	APR-DRG 1333
Min. Negotiated Rate	$6,905.92
Max. Negotiated Rate	$7,324.63
Rate for Payer: Amerigroup CHIP/Medicaid	$6,905.92
Rate for Payer: Cigna Medicaid	$6,905.92
Rate for Payer: Molina CHIP/Medicaid	$6,905.92
Rate for Payer: Parkland Medicaid	$6,905.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,324.63

RESPIRATORY FAILURE

Facility

$3,877.88

Service Code	APR-DRG 1332
Min. Negotiated Rate	$3,656.20
Max. Negotiated Rate	$3,877.88
Rate for Payer: Amerigroup CHIP/Medicaid	$3,656.20
Rate for Payer: Cigna Medicaid	$3,656.20
Rate for Payer: Molina CHIP/Medicaid	$3,656.20
Rate for Payer: Parkland Medicaid	$3,656.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,877.88

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC

Facility

$18,544.00

Service Code	MSDRG 178
Min. Negotiated Rate	$8,540.00
Max. Negotiated Rate	$18,544.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,913.21
Rate for Payer: Amerigroup Medicare	$11,913.21
Rate for Payer: BCBS of TX Medicare	$11,913.21
Rate for Payer: Cigna Commercial	$12,570.88
Rate for Payer: Cigna Medicare	$11,913.21
Rate for Payer: Employer Direct Commercial	$11,913.21
Rate for Payer: Humana Medicare/TRICARE	$11,913.21
Rate for Payer: Molina Dual Medicare/Medicaid	$11,913.21
Rate for Payer: Molina Medicare	$11,913.21
Rate for Payer: Multiplan Auto	$18,544.00
Rate for Payer: Multiplan Commercial	$18,544.00
Rate for Payer: Multiplan Workers Comp	$18,544.00
Rate for Payer: Scott and White EPO/PPO	$8,540.00
Rate for Payer: Scott and White Medicare	$11,913.21
Rate for Payer: Superior Health Plan EPO	$11,913.21
Rate for Payer: Superior Health Plan Medicare	$11,913.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,913.21
Rate for Payer: Universal American Medicare	$11,913.21
Rate for Payer: Wellcare Medicare	$11,913.21
Rate for Payer: Wellmed Medicare	$11,913.21

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC

Facility

$29,691.30

Service Code	MSDRG 177
Min. Negotiated Rate	$13,673.62
Max. Negotiated Rate	$29,691.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,213.15
Rate for Payer: Amerigroup Medicare	$16,213.15
Rate for Payer: BCBS of TX Medicare	$16,213.15
Rate for Payer: Cigna Commercial	$20,127.58
Rate for Payer: Cigna Medicare	$16,213.15
Rate for Payer: Employer Direct Commercial	$16,213.15
Rate for Payer: Humana Medicare/TRICARE	$16,213.15
Rate for Payer: Molina Dual Medicare/Medicaid	$16,213.15
Rate for Payer: Molina Medicare	$16,213.15
Rate for Payer: Multiplan Auto	$29,691.30
Rate for Payer: Multiplan Commercial	$29,691.30
Rate for Payer: Multiplan Workers Comp	$29,691.30
Rate for Payer: Scott and White EPO/PPO	$13,673.62
Rate for Payer: Scott and White Medicare	$16,213.15
Rate for Payer: Superior Health Plan EPO	$16,213.15
Rate for Payer: Superior Health Plan Medicare	$16,213.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,213.15
Rate for Payer: Universal American Medicare	$16,213.15
Rate for Payer: Wellcare Medicare	$16,213.15
Rate for Payer: Wellmed Medicare	$16,213.15

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC

Facility

$14,345.00

Service Code	MSDRG 179
Min. Negotiated Rate	$6,606.25
Max. Negotiated Rate	$14,345.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,293.50
Rate for Payer: Amerigroup Medicare	$10,293.50
Rate for Payer: BCBS of TX Medicare	$10,293.50
Rate for Payer: Cigna Commercial	$9,724.40
Rate for Payer: Cigna Medicare	$10,293.50
Rate for Payer: Employer Direct Commercial	$10,293.50
Rate for Payer: Humana Medicare/TRICARE	$10,293.50
Rate for Payer: Molina Dual Medicare/Medicaid	$10,293.50
Rate for Payer: Molina Medicare	$10,293.50
Rate for Payer: Multiplan Auto	$14,345.00
Rate for Payer: Multiplan Commercial	$14,345.00
Rate for Payer: Multiplan Workers Comp	$14,345.00
Rate for Payer: Scott and White EPO/PPO	$6,606.25
Rate for Payer: Scott and White Medicare	$10,293.50
Rate for Payer: Superior Health Plan EPO	$10,293.50
Rate for Payer: Superior Health Plan Medicare	$10,293.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,293.50
Rate for Payer: Universal American Medicare	$10,293.50
Rate for Payer: Wellcare Medicare	$10,293.50
Rate for Payer: Wellmed Medicare	$10,293.50

RESPIRATORY INFECTIONS & INFLAMMATIONS W CC

Facility

$18,544.00

Service Code	MSDRG 178
Min. Negotiated Rate	$8,540.00
Max. Negotiated Rate	$18,544.00
Rate for Payer: BCBS of TX Blue Advantage	$10,959.84
Rate for Payer: BCBS of TX Blue Essentials	$13,150.53
Rate for Payer: BCBS of TX PPO	$14,612.27

RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC

Facility

$29,691.30

Service Code	MSDRG 177
Min. Negotiated Rate	$13,673.62
Max. Negotiated Rate	$29,691.30
Rate for Payer: BCBS of TX Blue Advantage	$15,830.88
Rate for Payer: BCBS of TX Blue Essentials	$18,995.22
Rate for Payer: BCBS of TX PPO	$21,106.61

RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC

Facility

$14,345.00

Service Code	MSDRG 179
Min. Negotiated Rate	$6,606.25
Max. Negotiated Rate	$14,345.00
Rate for Payer: BCBS of TX Blue Advantage	$7,924.90
Rate for Payer: BCBS of TX Blue Essentials	$9,508.96
Rate for Payer: BCBS of TX PPO	$10,565.92

RESPIRATORY MALIGNANCY

Facility

$11,411.10

Service Code	APR-DRG 1364
Min. Negotiated Rate	$10,758.78
Max. Negotiated Rate	$11,411.10
Rate for Payer: Amerigroup CHIP/Medicaid	$10,758.78
Rate for Payer: Cigna Medicaid	$10,758.78
Rate for Payer: Molina CHIP/Medicaid	$10,758.78
Rate for Payer: Parkland Medicaid	$10,758.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,411.10

Know your out-of-pocket cost for care.

All Charges