White Rock Medical Center

All Charges

Charge

Type

Setting

Price

RT CHARGE CPAP -> Subsequent

Facility

$699.00

Service Code	HCPCS 94660
Hospital Charge Code	4000105
Hospital Revenue Code	410
Min. Negotiated Rate	$45.14
Max. Negotiated Rate	$503.28
Rate for Payer: Amerigroup CHIP/Medicaid	$62.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$219.97
Rate for Payer: Amerigroup Medicare	$219.97
Rate for Payer: BCBS of TX Blue Advantage	$209.70
Rate for Payer: BCBS of TX Blue Essentials	$251.64
Rate for Payer: BCBS of TX Medicare	$219.97
Rate for Payer: BCBS of TX PPO	$279.60
Rate for Payer: Cash Price	$475.32
Rate for Payer: Cash Price	$475.32
Rate for Payer: Cash Price	$475.32
Rate for Payer: Cigna Commercial	$464.99
Rate for Payer: Cigna Medicaid	$503.28
Rate for Payer: Cigna Medicare	$219.97
Rate for Payer: Employer Direct Commercial	$219.97
Rate for Payer: Humana Medicare/TRICARE	$219.97
Rate for Payer: Molina CHIP/Medicaid	$503.28
Rate for Payer: Molina Dual Medicare/Medicaid	$219.97
Rate for Payer: Molina Medicare	$219.97
Rate for Payer: Multiplan Auto	$454.35
Rate for Payer: Multiplan Commercial	$454.35
Rate for Payer: Multiplan Workers Comp	$454.35
Rate for Payer: Parkland Medicaid	$503.28
Rate for Payer: Scott and White EPO/PPO	$45.14
Rate for Payer: Scott and White Medicare	$219.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$503.28
Rate for Payer: Superior Health Plan EPO	$219.97
Rate for Payer: Superior Health Plan Medicare	$219.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$219.97
Rate for Payer: Universal American Medicare	$219.97
Rate for Payer: Wellcare Medicare	$219.97
Rate for Payer: Wellmed Medicare	$219.97

RT CHARGE CPAP -> Subsequent

Facility

$699.00

Service Code	HCPCS 94660
Hospital Charge Code	4000105
Hospital Revenue Code	410
Rate for Payer: Cash Price	$475.32

RT CHARGE IPPB -> Yes

Facility

$170.00

Service Code	HCPCS 94640
Hospital Charge Code	4000576
Hospital Revenue Code	410
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$464.99
Rate for Payer: Amerigroup CHIP/Medicaid	$15.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$219.97
Rate for Payer: Amerigroup Medicare	$219.97
Rate for Payer: BCBS of TX Blue Advantage	$51.00
Rate for Payer: BCBS of TX Blue Essentials	$61.20
Rate for Payer: BCBS of TX Medicare	$219.97
Rate for Payer: BCBS of TX PPO	$68.00
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cigna Commercial	$464.99
Rate for Payer: Cigna Medicaid	$122.40
Rate for Payer: Cigna Medicare	$219.97
Rate for Payer: Employer Direct Commercial	$219.97
Rate for Payer: Humana Medicare/TRICARE	$219.97
Rate for Payer: Molina CHIP/Medicaid	$122.40
Rate for Payer: Molina Dual Medicare/Medicaid	$219.97
Rate for Payer: Molina Medicare	$219.97
Rate for Payer: Multiplan Auto	$110.50
Rate for Payer: Multiplan Commercial	$110.50
Rate for Payer: Multiplan Workers Comp	$110.50
Rate for Payer: Parkland Medicaid	$122.40
Rate for Payer: Scott and White EPO/PPO	$9.84
Rate for Payer: Scott and White Medicare	$219.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$122.40
Rate for Payer: Superior Health Plan EPO	$219.97
Rate for Payer: Superior Health Plan Medicare	$219.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$219.97
Rate for Payer: Universal American Medicare	$219.97
Rate for Payer: Wellcare Medicare	$219.97
Rate for Payer: Wellmed Medicare	$219.97

RT CHARGE IPPB -> Yes

Facility

$170.00

Service Code	HCPCS 94640
Hospital Charge Code	4000576
Hospital Revenue Code	410
Rate for Payer: Cash Price	$115.60

RT CHARGE MDI -> Demo/Initial

Facility

$170.00

Service Code	HCPCS 94640
Hospital Charge Code	4049128
Hospital Revenue Code	410
Rate for Payer: Cash Price	$115.60

RT CHARGE MDI -> Demo/Initial

Facility

$170.00

Service Code	HCPCS 94640
Hospital Charge Code	4049128
Hospital Revenue Code	410
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$464.99
Rate for Payer: Amerigroup CHIP/Medicaid	$15.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$219.97
Rate for Payer: Amerigroup Medicare	$219.97
Rate for Payer: BCBS of TX Blue Advantage	$51.00
Rate for Payer: BCBS of TX Blue Essentials	$61.20
Rate for Payer: BCBS of TX Medicare	$219.97
Rate for Payer: BCBS of TX PPO	$68.00
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cigna Commercial	$464.99
Rate for Payer: Cigna Medicaid	$122.40
Rate for Payer: Cigna Medicare	$219.97
Rate for Payer: Employer Direct Commercial	$219.97
Rate for Payer: Humana Medicare/TRICARE	$219.97
Rate for Payer: Molina CHIP/Medicaid	$122.40
Rate for Payer: Molina Dual Medicare/Medicaid	$219.97
Rate for Payer: Molina Medicare	$219.97
Rate for Payer: Multiplan Auto	$110.50
Rate for Payer: Multiplan Commercial	$110.50
Rate for Payer: Multiplan Workers Comp	$110.50
Rate for Payer: Parkland Medicaid	$122.40
Rate for Payer: Scott and White EPO/PPO	$9.84
Rate for Payer: Scott and White Medicare	$219.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$122.40
Rate for Payer: Superior Health Plan EPO	$219.97
Rate for Payer: Superior Health Plan Medicare	$219.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$219.97
Rate for Payer: Universal American Medicare	$219.97
Rate for Payer: Wellcare Medicare	$219.97
Rate for Payer: Wellmed Medicare	$219.97

RT CHARGE PFT -> Body plethysmography (throacic gas volume)

Facility

$527.00

Service Code	HCPCS 94726
Hospital Charge Code	4049201
Hospital Revenue Code	460
Min. Negotiated Rate	$47.43
Max. Negotiated Rate	$792.38
Rate for Payer: Amerigroup CHIP/Medicaid	$47.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$374.86
Rate for Payer: Amerigroup Medicare	$374.86
Rate for Payer: BCBS of TX Blue Advantage	$158.10
Rate for Payer: BCBS of TX Blue Essentials	$189.72
Rate for Payer: BCBS of TX Medicare	$374.86
Rate for Payer: BCBS of TX PPO	$210.80
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cigna Commercial	$792.38
Rate for Payer: Cigna Medicaid	$379.44
Rate for Payer: Cigna Medicare	$374.86
Rate for Payer: Employer Direct Commercial	$374.86
Rate for Payer: Humana Medicare/TRICARE	$374.86
Rate for Payer: Molina CHIP/Medicaid	$379.44
Rate for Payer: Molina Dual Medicare/Medicaid	$374.86
Rate for Payer: Molina Medicare	$374.86
Rate for Payer: Multiplan Auto	$342.55
Rate for Payer: Multiplan Commercial	$342.55
Rate for Payer: Multiplan Workers Comp	$342.55
Rate for Payer: Parkland Medicaid	$379.44
Rate for Payer: Scott and White EPO/PPO	$69.12
Rate for Payer: Scott and White Medicare	$374.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$379.44
Rate for Payer: Superior Health Plan EPO	$374.86
Rate for Payer: Superior Health Plan Medicare	$374.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$374.86
Rate for Payer: Universal American Medicare	$374.86
Rate for Payer: Wellcare Medicare	$374.86
Rate for Payer: Wellmed Medicare	$374.86

RT CHARGE PFT -> Body plethysmography (throacic gas volume)

Facility

$527.00

Service Code	HCPCS 94726
Hospital Charge Code	4049201
Hospital Revenue Code	460
Rate for Payer: Cash Price	$358.36

RT CHARGE PFT -> Diffusion (DLCO)

Facility

$491.00

Service Code	HCPCS 94729
Hospital Charge Code	4049204
Hospital Revenue Code	460
Min. Negotiated Rate	$44.19
Max. Negotiated Rate	$353.52
Rate for Payer: Amerigroup CHIP/Medicaid	$44.19
Rate for Payer: BCBS of TX Blue Advantage	$147.30
Rate for Payer: BCBS of TX Blue Essentials	$176.76
Rate for Payer: BCBS of TX PPO	$196.40
Rate for Payer: Cash Price	$333.88
Rate for Payer: Cash Price	$333.88
Rate for Payer: Cigna Medicaid	$353.52
Rate for Payer: Molina CHIP/Medicaid	$353.52
Rate for Payer: Multiplan Auto	$319.15
Rate for Payer: Multiplan Commercial	$319.15
Rate for Payer: Multiplan Workers Comp	$319.15
Rate for Payer: Parkland Medicaid	$353.52
Rate for Payer: Scott and White EPO/PPO	$69.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$353.52
Rate for Payer: Superior Health Plan EPO	$66.78

RT CHARGE PFT -> Diffusion (DLCO)

Facility

$491.00

Service Code	HCPCS 94729
Hospital Charge Code	4049204
Hospital Revenue Code	460
Rate for Payer: Cash Price	$333.88

RT CHARGE PFT -> Flow volume loop

Facility

$360.00

Service Code	HCPCS 94375
Hospital Charge Code	4049086
Hospital Revenue Code	460
Rate for Payer: Cash Price	$244.80

RT CHARGE PFT -> Flow volume loop

Facility

$360.00

Service Code	HCPCS 94375
Hospital Charge Code	4049086
Hospital Revenue Code	460
Min. Negotiated Rate	$32.40
Max. Negotiated Rate	$458.51
Rate for Payer: Amerigroup CHIP/Medicaid	$32.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$108.00
Rate for Payer: BCBS of TX Blue Essentials	$129.60
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$144.00
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$259.20
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$259.20
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
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: Parkland Medicaid	$259.20
Rate for Payer: Scott and White EPO/PPO	$48.16
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$259.20
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

RT CHARGE PFT -> O2 Uptake CO2 Output 94681

Facility

$843.00

Service Code	HCPCS 94681
Hospital Charge Code	5504681
Hospital Revenue Code	460
Rate for Payer: Cash Price	$573.24

RT CHARGE PFT -> O2 Uptake CO2 Output 94681

Facility

$843.00

Service Code	HCPCS 94681
Hospital Charge Code	5504681
Hospital Revenue Code	460
Min. Negotiated Rate	$59.23
Max. Negotiated Rate	$792.38
Rate for Payer: Amerigroup CHIP/Medicaid	$75.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$374.86
Rate for Payer: Amerigroup Medicare	$374.86
Rate for Payer: BCBS of TX Blue Advantage	$252.90
Rate for Payer: BCBS of TX Blue Essentials	$303.48
Rate for Payer: BCBS of TX Medicare	$374.86
Rate for Payer: BCBS of TX PPO	$337.20
Rate for Payer: Cash Price	$573.24
Rate for Payer: Cash Price	$573.24
Rate for Payer: Cash Price	$573.24
Rate for Payer: Cigna Commercial	$792.38
Rate for Payer: Cigna Medicaid	$606.96
Rate for Payer: Cigna Medicare	$374.86
Rate for Payer: Employer Direct Commercial	$374.86
Rate for Payer: Humana Medicare/TRICARE	$374.86
Rate for Payer: Molina CHIP/Medicaid	$606.96
Rate for Payer: Molina Dual Medicare/Medicaid	$374.86
Rate for Payer: Molina Medicare	$374.86
Rate for Payer: Multiplan Auto	$547.95
Rate for Payer: Multiplan Commercial	$547.95
Rate for Payer: Multiplan Workers Comp	$547.95
Rate for Payer: Parkland Medicaid	$606.96
Rate for Payer: Scott and White EPO/PPO	$59.23
Rate for Payer: Scott and White Medicare	$374.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$606.96
Rate for Payer: Superior Health Plan EPO	$374.86
Rate for Payer: Superior Health Plan Medicare	$374.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$374.86
Rate for Payer: Universal American Medicare	$374.86
Rate for Payer: Wellcare Medicare	$374.86
Rate for Payer: Wellmed Medicare	$374.86

RT CHARGE PFT -> Spirometry

Facility

$295.00

Service Code	HCPCS 94010
Hospital Charge Code	4000162
Hospital Revenue Code	460
Rate for Payer: Cash Price	$200.60

RT CHARGE PFT -> Spirometry

Facility

$295.00

Service Code	HCPCS 94010
Hospital Charge Code	4000162
Hospital Revenue Code	460
Min. Negotiated Rate	$26.55
Max. Negotiated Rate	$458.51
Rate for Payer: Amerigroup CHIP/Medicaid	$26.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$88.50
Rate for Payer: BCBS of TX Blue Essentials	$106.20
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$118.00
Rate for Payer: Cash Price	$200.60
Rate for Payer: Cash Price	$200.60
Rate for Payer: Cash Price	$200.60
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$212.40
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$212.40
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$191.75
Rate for Payer: Multiplan Commercial	$191.75
Rate for Payer: Multiplan Workers Comp	$191.75
Rate for Payer: Parkland Medicaid	$212.40
Rate for Payer: Scott and White EPO/PPO	$33.73
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$212.40
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

RT CHARGE PFT -> Spirometry before & after

Facility

$694.00

Service Code	HCPCS 94060
Hospital Charge Code	4000170
Hospital Revenue Code	460
Min. Negotiated Rate	$48.15
Max. Negotiated Rate	$792.38
Rate for Payer: Amerigroup CHIP/Medicaid	$62.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$374.86
Rate for Payer: Amerigroup Medicare	$374.86
Rate for Payer: BCBS of TX Blue Advantage	$208.20
Rate for Payer: BCBS of TX Blue Essentials	$249.84
Rate for Payer: BCBS of TX Medicare	$374.86
Rate for Payer: BCBS of TX PPO	$277.60
Rate for Payer: Cash Price	$471.92
Rate for Payer: Cash Price	$471.92
Rate for Payer: Cash Price	$471.92
Rate for Payer: Cigna Commercial	$792.38
Rate for Payer: Cigna Medicaid	$499.68
Rate for Payer: Cigna Medicare	$374.86
Rate for Payer: Employer Direct Commercial	$374.86
Rate for Payer: Humana Medicare/TRICARE	$374.86
Rate for Payer: Molina CHIP/Medicaid	$499.68
Rate for Payer: Molina Dual Medicare/Medicaid	$374.86
Rate for Payer: Molina Medicare	$374.86
Rate for Payer: Multiplan Auto	$451.10
Rate for Payer: Multiplan Commercial	$451.10
Rate for Payer: Multiplan Workers Comp	$451.10
Rate for Payer: Parkland Medicaid	$499.68
Rate for Payer: Scott and White EPO/PPO	$48.15
Rate for Payer: Scott and White Medicare	$374.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$499.68
Rate for Payer: Superior Health Plan EPO	$374.86
Rate for Payer: Superior Health Plan Medicare	$374.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$374.86
Rate for Payer: Universal American Medicare	$374.86
Rate for Payer: Wellcare Medicare	$374.86
Rate for Payer: Wellmed Medicare	$374.86

RT CHARGE PFT -> Spirometry before & after

Facility

$694.00

Service Code	HCPCS 94060
Hospital Charge Code	4000170
Hospital Revenue Code	460
Rate for Payer: Cash Price	$471.92

RT CHARGE PFT -> Total vital capacity

Facility

$278.00

Service Code	HCPCS 94150
Hospital Charge Code	4049052
Hospital Revenue Code	460
Rate for Payer: Cash Price	$189.04

RT CHARGE PFT -> Total vital capacity

Facility

$278.00

Service Code	HCPCS 94150
Hospital Charge Code	4049052
Hospital Revenue Code	460
Min. Negotiated Rate	$25.02
Max. Negotiated Rate	$273.24
Rate for Payer: Amerigroup CHIP/Medicaid	$25.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$129.26
Rate for Payer: Amerigroup Medicare	$129.26
Rate for Payer: BCBS of TX Blue Advantage	$83.40
Rate for Payer: BCBS of TX Blue Essentials	$100.08
Rate for Payer: BCBS of TX Medicare	$129.26
Rate for Payer: BCBS of TX PPO	$111.20
Rate for Payer: Cash Price	$189.04
Rate for Payer: Cash Price	$189.04
Rate for Payer: Cash Price	$189.04
Rate for Payer: Cigna Commercial	$273.24
Rate for Payer: Cigna Medicaid	$200.16
Rate for Payer: Cigna Medicare	$129.26
Rate for Payer: Employer Direct Commercial	$129.26
Rate for Payer: Humana Medicare/TRICARE	$129.26
Rate for Payer: Molina CHIP/Medicaid	$200.16
Rate for Payer: Molina Dual Medicare/Medicaid	$129.26
Rate for Payer: Molina Medicare	$129.26
Rate for Payer: Multiplan Auto	$180.70
Rate for Payer: Multiplan Commercial	$180.70
Rate for Payer: Multiplan Workers Comp	$180.70
Rate for Payer: Parkland Medicaid	$200.16
Rate for Payer: Scott and White EPO/PPO	$139.00
Rate for Payer: Scott and White Medicare	$129.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$200.16
Rate for Payer: Superior Health Plan EPO	$129.26
Rate for Payer: Superior Health Plan Medicare	$129.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$129.26
Rate for Payer: Universal American Medicare	$129.26
Rate for Payer: Wellcare Medicare	$129.26
Rate for Payer: Wellmed Medicare	$129.26

RT CHARGE Procedures with RT Assist -> BRONCHOSCOPY WITH BIOPSY

Facility

$6,035.99

Service Code	HCPCS 31625
Hospital Charge Code	4010011
Hospital Revenue Code	361
Min. Negotiated Rate	$525.71
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Amerigroup Medicare	$1,788.01
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,788.01
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cash Price	$4,104.47
Rate for Payer: Cash Price	$4,104.47
Rate for Payer: Cash Price	$4,104.47
Rate for Payer: Cigna Commercial	$3,779.52
Rate for Payer: Cigna Medicaid	$4,345.91
Rate for Payer: Cigna Medicare	$1,788.01
Rate for Payer: Employer Direct Commercial	$1,788.01
Rate for Payer: Humana Medicare/TRICARE	$1,788.01
Rate for Payer: Molina CHIP/Medicaid	$4,345.91
Rate for Payer: Molina Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Molina Medicare	$1,788.01
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	$4,345.91
Rate for Payer: Scott and White EPO/PPO	$2,871.63
Rate for Payer: Scott and White Medicare	$1,788.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,345.91
Rate for Payer: Superior Health Plan EPO	$1,788.01
Rate for Payer: Superior Health Plan Medicare	$1,788.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Universal American Medicare	$1,788.01
Rate for Payer: Wellcare Medicare	$1,788.01
Rate for Payer: Wellmed Medicare	$1,788.01

RT CHARGE Procedures with RT Assist -> BRONCHOSCOPY WITH BIOPSY

Facility

$6,035.99

Service Code	HCPCS 31625
Hospital Charge Code	4010011
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,104.47

RT CHARGE Procedures with RT Assist -> BRONCHOSCOPY WITH BRUSHINGS

Facility

$2,972.00

Service Code	HCPCS 31623
Hospital Charge Code	4010018
Hospital Revenue Code	361
Min. Negotiated Rate	$525.71
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Amerigroup Medicare	$1,788.01
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,788.01
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cash Price	$2,020.96
Rate for Payer: Cash Price	$2,020.96
Rate for Payer: Cash Price	$2,020.96
Rate for Payer: Cigna Commercial	$3,779.52
Rate for Payer: Cigna Medicaid	$2,139.84
Rate for Payer: Cigna Medicare	$1,788.01
Rate for Payer: Employer Direct Commercial	$1,788.01
Rate for Payer: Humana Medicare/TRICARE	$1,788.01
Rate for Payer: Molina CHIP/Medicaid	$2,139.84
Rate for Payer: Molina Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Molina Medicare	$1,788.01
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	$2,139.84
Rate for Payer: Scott and White EPO/PPO	$2,871.63
Rate for Payer: Scott and White Medicare	$1,788.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,139.84
Rate for Payer: Superior Health Plan EPO	$1,788.01
Rate for Payer: Superior Health Plan Medicare	$1,788.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Universal American Medicare	$1,788.01
Rate for Payer: Wellcare Medicare	$1,788.01
Rate for Payer: Wellmed Medicare	$1,788.01

RT CHARGE Procedures with RT Assist -> BRONCHOSCOPY WITH BRUSHINGS

Facility

$2,972.00

Service Code	HCPCS 31623
Hospital Charge Code	4010018
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,020.96

RT CHARGE Procedures with RT Assist -> BRONCHOSCOPY WITH CYTOLOGY

Facility

$3,076.00

Service Code	HCPCS 31624
Hospital Charge Code	4010010
Hospital Revenue Code	361
Min. Negotiated Rate	$525.71
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Amerigroup Medicare	$1,788.01
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,788.01
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cash Price	$2,091.68
Rate for Payer: Cash Price	$2,091.68
Rate for Payer: Cash Price	$2,091.68
Rate for Payer: Cigna Commercial	$3,779.52
Rate for Payer: Cigna Medicaid	$2,214.72
Rate for Payer: Cigna Medicare	$1,788.01
Rate for Payer: Employer Direct Commercial	$1,788.01
Rate for Payer: Humana Medicare/TRICARE	$1,788.01
Rate for Payer: Molina CHIP/Medicaid	$2,214.72
Rate for Payer: Molina Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Molina Medicare	$1,788.01
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	$2,214.72
Rate for Payer: Scott and White EPO/PPO	$2,871.63
Rate for Payer: Scott and White Medicare	$1,788.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,214.72
Rate for Payer: Superior Health Plan EPO	$1,788.01
Rate for Payer: Superior Health Plan Medicare	$1,788.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Universal American Medicare	$1,788.01
Rate for Payer: Wellcare Medicare	$1,788.01
Rate for Payer: Wellmed Medicare	$1,788.01

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