White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial

Facility

$137,420.80

Service Code	HCPCS 37231
Hospital Charge Code	9900630
Hospital Revenue Code	360
Rate for Payer: Cash Price	$93,446.14

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial

Facility

$137,420.80

Service Code	HCPCS 37231
Hospital Charge Code	9900630
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$98,942.98
Rate for Payer: Amerigroup CHIP/Medicaid	$12,367.87
Rate for Payer: BCBS of TX Blue Advantage	$26,619.75
Rate for Payer: BCBS of TX Blue Essentials	$31,879.94
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cigna Medicaid	$98,942.98
Rate for Payer: Molina CHIP/Medicaid	$98,942.98
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	$98,942.98
Rate for Payer: Scott and White EPO/PPO	$29,667.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98,942.98
Rate for Payer: Superior Health Plan EPO	$18,689.23

REVAS PERC TRANS TOT OCC

Facility

$17,676.00

Service Code	HCPCS 92943
Hospital Charge Code	2350041
Hospital Revenue Code	480
Rate for Payer: Cash Price	$12,019.68

REVAS PERC TRANS TOT OCC

Facility

$17,676.00

Service Code	HCPCS 92943
Hospital Charge Code	2350041
Hospital Revenue Code	480
Min. Negotiated Rate	$782.65
Max. Negotiated Rate	$24,969.37
Rate for Payer: Amerigroup CHIP/Medicaid	$1,590.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Amerigroup Medicare	$11,596.79
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$11,596.79
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$12,019.68
Rate for Payer: Cash Price	$12,019.68
Rate for Payer: Cash Price	$12,019.68
Rate for Payer: Cigna Commercial	$24,513.51
Rate for Payer: Cigna Medicaid	$12,726.72
Rate for Payer: Cigna Medicare	$11,596.79
Rate for Payer: Employer Direct Commercial	$11,596.79
Rate for Payer: Humana Medicare/TRICARE	$11,596.79
Rate for Payer: Molina CHIP/Medicaid	$12,726.72
Rate for Payer: Molina Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Molina Medicare	$11,596.79
Rate for Payer: Multiplan Auto	$11,489.40
Rate for Payer: Multiplan Commercial	$11,489.40
Rate for Payer: Multiplan Workers Comp	$11,489.40
Rate for Payer: Parkland Medicaid	$12,726.72
Rate for Payer: Scott and White EPO/PPO	$782.65
Rate for Payer: Scott and White Medicare	$11,596.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,726.72
Rate for Payer: Superior Health Plan EPO	$11,596.79
Rate for Payer: Superior Health Plan Medicare	$11,596.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Universal American Medicare	$11,596.79
Rate for Payer: Wellcare Medicare	$11,596.79
Rate for Payer: Wellmed Medicare	$11,596.79

Reverse T3, Serum SO

Facility

$121.00

Service Code	HCPCS 84482
Hospital Charge Code	1707470
Hospital Revenue Code	301
Min. Negotiated Rate	$6.15
Max. Negotiated Rate	$87.12
Rate for Payer: Amerigroup CHIP/Medicaid	$6.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.76
Rate for Payer: Amerigroup Medicare	$15.76
Rate for Payer: BCBS of TX Blue Advantage	$36.30
Rate for Payer: BCBS of TX Blue Essentials	$43.56
Rate for Payer: BCBS of TX Medicare	$15.76
Rate for Payer: BCBS of TX PPO	$48.40
Rate for Payer: Cash Price	$82.28
Rate for Payer: Cash Price	$82.28
Rate for Payer: Cigna Medicaid	$87.12
Rate for Payer: Cigna Medicare	$15.76
Rate for Payer: Employer Direct Commercial	$15.76
Rate for Payer: Humana Medicare/TRICARE	$15.76
Rate for Payer: Molina CHIP/Medicaid	$87.12
Rate for Payer: Molina Dual Medicare/Medicaid	$15.76
Rate for Payer: Molina Medicare	$15.76
Rate for Payer: Multiplan Auto	$78.65
Rate for Payer: Multiplan Commercial	$78.65
Rate for Payer: Multiplan Workers Comp	$78.65
Rate for Payer: Parkland Medicaid	$87.12
Rate for Payer: Scott and White EPO/PPO	$19.70
Rate for Payer: Scott and White Medicare	$15.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$87.12
Rate for Payer: Superior Health Plan EPO	$15.76
Rate for Payer: Superior Health Plan Medicare	$15.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.76
Rate for Payer: Universal American Medicare	$15.76
Rate for Payer: Wellcare Medicare	$15.76
Rate for Payer: Wellmed Medicare	$15.76

Reverse T3, Serum SO

Facility

$121.00

Service Code	HCPCS 84482
Hospital Charge Code	1707470
Hospital Revenue Code	301
Rate for Payer: Cash Price	$82.28

REVISE/RELOCATE PACER SKIN POCKET

Facility

$3,818.00

Service Code	HCPCS 33222
Hospital Charge Code	2302461
Hospital Revenue Code	481
Rate for Payer: Cash Price	$2,596.24

REVISE/RELOCATE PACER SKIN POCKET

Facility

$3,818.00

Service Code	HCPCS 33222
Hospital Charge Code	2302461
Hospital Revenue Code	481
Min. Negotiated Rate	$343.62
Max. Negotiated Rate	$4,381.27
Rate for Payer: Amerigroup CHIP/Medicaid	$343.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$2,596.24
Rate for Payer: Cash Price	$2,596.24
Rate for Payer: Cash Price	$2,596.24
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$2,748.96
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$2,748.96
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
Rate for Payer: Multiplan Auto	$2,481.70
Rate for Payer: Multiplan Commercial	$2,481.70
Rate for Payer: Multiplan Workers Comp	$2,481.70
Rate for Payer: Parkland Medicaid	$2,748.96
Rate for Payer: Scott and White EPO/PPO	$414.43
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,748.96
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Revise ulnar nerve at elbow

Facility

$10,526.34

Service Code	HCPCS 64718
Hospital Charge Code	9900840
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,157.91

Revise ulnar nerve at elbow

Facility

$10,526.34

Service Code	HCPCS 64718
Hospital Charge Code	9900840
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$7,578.96
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$7,578.96
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$7,578.96
Rate for Payer: Scott and White EPO/PPO	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,578.96
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Revise ulnar nerve at elbow

Facility

$10,000.00

Service Code	CPT 64718
Hospital Charge Code	36064718
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Revise ulnar nerve at wrist

Facility

$6,140.37

Service Code	HCPCS 64719
Hospital Charge Code	9900841
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,175.45

Revise ulnar nerve at wrist

Facility

$6,140.37

Service Code	HCPCS 64719
Hospital Charge Code	9900841
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cash Price	$4,175.45
Rate for Payer: Cash Price	$4,175.45
Rate for Payer: Cash Price	$4,175.45
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$4,421.07
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$4,421.07
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$4,421.07
Rate for Payer: Scott and White EPO/PPO	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,421.07
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Revise ulnar nerve at wrist

Facility

$10,000.00

Service Code	CPT 64719
Hospital Charge Code	36064719
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous arr

Facility

$15,591.57

Service Code	CPT 63663
Hospital Charge Code	36063663
Hospital Revenue Code	360
Min. Negotiated Rate	$3,676.17
Max. Negotiated Rate	$15,591.57
Rate for Payer: Amerigroup CHIP/Medicaid	$3,676.17
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

Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous arr

Facility

$30,803.40

Service Code	HCPCS 63663
Hospital Charge Code	9900775
Hospital Revenue Code	360
Min. Negotiated Rate	$3,676.17
Max. Negotiated Rate	$22,178.45
Rate for Payer: Amerigroup CHIP/Medicaid	$3,676.17
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	$20,946.31
Rate for Payer: Cash Price	$20,946.31
Rate for Payer: Cash Price	$20,946.31
Rate for Payer: Cigna Commercial	$13,532.75
Rate for Payer: Cigna Medicaid	$22,178.45
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	$22,178.45
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	$22,178.45
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	$22,178.45
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

Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous arr

Facility

$30,803.40

Service Code	HCPCS 63663
Hospital Charge Code	9900775
Hospital Revenue Code	360
Rate for Payer: Cash Price	$20,946.31

Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft

Facility

$8,483.44

Service Code	HCPCS 66185
Hospital Charge Code	9900864
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,768.74

Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft

Facility

$8,483.44

Service Code	HCPCS 66185
Hospital Charge Code	9900864
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	$5,768.74
Rate for Payer: Cash Price	$5,768.74
Rate for Payer: Cash Price	$5,768.74
Rate for Payer: Cigna Commercial	$4,900.56
Rate for Payer: Cigna Medicaid	$6,108.08
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	$6,108.08
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	$6,108.08
Rate for Payer: Scott and White EPO/PPO	$3,942.78
Rate for Payer: Scott and White Medicare	$2,318.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,108.08
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

Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft

Facility

$10,000.00

Service Code	CPT 66185
Hospital Charge Code	36066185
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	$3,942.78
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

Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy

Facility

$64,200.00

Service Code	HCPCS 43860
Hospital Charge Code	994011
Hospital Revenue Code	360
Rate for Payer: Cash Price	$43,656.00

Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy

Facility

$64,200.00

Service Code	HCPCS 43860
Hospital Charge Code	994011
Hospital Revenue Code	360
Min. Negotiated Rate	$2,854.58
Max. Negotiated Rate	$46,224.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,778.00
Rate for Payer: BCBS of TX Blue Advantage	$2,854.58
Rate for Payer: BCBS of TX Blue Essentials	$3,418.66
Rate for Payer: BCBS of TX PPO	$4,307.51
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cigna Medicaid	$46,224.00
Rate for Payer: Molina CHIP/Medicaid	$46,224.00
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	$46,224.00
Rate for Payer: Scott and White EPO/PPO	$32,100.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,224.00
Rate for Payer: Superior Health Plan EPO	$8,731.20

REVISION OF HIP OR KNEE REPLACEMENT W CC

Facility

$68,892.10

Service Code	MSDRG 467
Min. Negotiated Rate	$29,845.44
Max. Negotiated Rate	$68,892.10
Rate for Payer: BCBS of TX Blue Advantage	$29,845.44
Rate for Payer: BCBS of TX Blue Essentials	$35,811.06
Rate for Payer: BCBS of TX PPO	$39,791.61

REVISION OF HIP OR KNEE REPLACEMENT WITH CC

Facility

$68,892.10

Service Code	MSDRG 467
Min. Negotiated Rate	$29,845.44
Max. Negotiated Rate	$68,892.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,606.63
Rate for Payer: Amerigroup Medicare	$30,606.63
Rate for Payer: BCBS of TX Medicare	$30,606.63
Rate for Payer: Cigna Commercial	$45,422.61
Rate for Payer: Cigna Medicare	$30,606.63
Rate for Payer: Employer Direct Commercial	$30,606.63
Rate for Payer: Humana Medicare/TRICARE	$30,606.63
Rate for Payer: Molina Dual Medicare/Medicaid	$30,606.63
Rate for Payer: Molina Medicare	$30,606.63
Rate for Payer: Multiplan Auto	$68,892.10
Rate for Payer: Multiplan Commercial	$68,892.10
Rate for Payer: Multiplan Workers Comp	$68,892.10
Rate for Payer: Scott and White EPO/PPO	$31,726.62
Rate for Payer: Scott and White Medicare	$30,606.63
Rate for Payer: Superior Health Plan EPO	$30,606.63
Rate for Payer: Superior Health Plan Medicare	$30,606.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,606.63
Rate for Payer: Universal American Medicare	$30,606.63
Rate for Payer: Wellcare Medicare	$30,606.63
Rate for Payer: Wellmed Medicare	$30,606.63

REVISION OF HIP OR KNEE REPLACEMENT WITH MCC

Facility

$99,656.90

Service Code	MSDRG 466
Min. Negotiated Rate	$42,910.59
Max. Negotiated Rate	$99,656.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42,910.59
Rate for Payer: Amerigroup Medicare	$42,910.59
Rate for Payer: BCBS of TX Medicare	$42,910.59
Rate for Payer: Cigna Commercial	$67,045.55
Rate for Payer: Cigna Medicare	$42,910.59
Rate for Payer: Employer Direct Commercial	$42,910.59
Rate for Payer: Humana Medicare/TRICARE	$42,910.59
Rate for Payer: Molina Dual Medicare/Medicaid	$42,910.59
Rate for Payer: Molina Medicare	$42,910.59
Rate for Payer: Multiplan Auto	$99,656.90
Rate for Payer: Multiplan Commercial	$99,656.90
Rate for Payer: Multiplan Workers Comp	$99,656.90
Rate for Payer: Scott and White EPO/PPO	$45,894.62
Rate for Payer: Scott and White Medicare	$42,910.59
Rate for Payer: Superior Health Plan EPO	$42,910.59
Rate for Payer: Superior Health Plan Medicare	$42,910.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$42,910.59
Rate for Payer: Universal American Medicare	$42,910.59
Rate for Payer: Wellcare Medicare	$42,910.59
Rate for Payer: Wellmed Medicare	$42,910.59

Know your out-of-pocket cost for care.

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