White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TRIDENT 0 DEGREE INSERT 36MM

Facility

$6,024.10

Service Code	HCPCS C1776
Hospital Charge Code	992152
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.03
Max. Negotiated Rate	$3,012.05
Rate for Payer: Cash Price	$4,096.39
Rate for Payer: Cigna Commercial	$1,506.03
Rate for Payer: Multiplan Auto	$3,012.05
Rate for Payer: Multiplan Commercial	$3,012.05
Rate for Payer: Multiplan Workers Comp	$3,012.05
Rate for Payer: Scott and White EPO/PPO	$3,012.05

TRIDENT II TEITANIUM CLUSTERHOLD 50D

Facility

$7,228.92

Service Code	HCPCS C1776
Hospital Charge Code	992153
Hospital Revenue Code	278
Min. Negotiated Rate	$650.60
Max. Negotiated Rate	$5,204.82
Rate for Payer: Amerigroup CHIP/Medicaid	$650.60
Rate for Payer: BCBS of TX Blue Advantage	$2,168.68
Rate for Payer: BCBS of TX Blue Essentials	$2,602.41
Rate for Payer: BCBS of TX PPO	$2,891.57
Rate for Payer: Cash Price	$4,915.67
Rate for Payer: Cigna Medicaid	$5,204.82
Rate for Payer: Molina CHIP/Medicaid	$5,204.82
Rate for Payer: Multiplan Auto	$3,614.46
Rate for Payer: Multiplan Commercial	$3,614.46
Rate for Payer: Multiplan Workers Comp	$3,614.46
Rate for Payer: Parkland Medicaid	$5,204.82
Rate for Payer: Scott and White EPO/PPO	$3,614.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,204.82
Rate for Payer: Superior Health Plan EPO	$983.13

TRIDENT II TEITANIUM CLUSTERHOLD 50D

Facility

$7,228.92

Service Code	HCPCS C1776
Hospital Charge Code	992153
Hospital Revenue Code	278
Min. Negotiated Rate	$1,807.23
Max. Negotiated Rate	$3,614.46
Rate for Payer: Cash Price	$4,915.67
Rate for Payer: Cigna Commercial	$1,807.23
Rate for Payer: Multiplan Auto	$3,614.46
Rate for Payer: Multiplan Commercial	$3,614.46
Rate for Payer: Multiplan Workers Comp	$3,614.46
Rate for Payer: Scott and White EPO/PPO	$3,614.46

Triglyceride Body Fluid

Facility

$309.00

Service Code	HCPCS 84478
Hospital Charge Code	1601731
Hospital Revenue Code	301
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$2.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.74
Rate for Payer: Amerigroup Medicare	$5.74
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	$5.74
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	$5.74
Rate for Payer: Employer Direct Commercial	$5.74
Rate for Payer: Humana Medicare/TRICARE	$5.74
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$5.74
Rate for Payer: Molina Medicare	$5.74
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	$7.17
Rate for Payer: Scott and White Medicare	$5.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$5.74
Rate for Payer: Superior Health Plan Medicare	$5.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.74
Rate for Payer: Universal American Medicare	$5.74
Rate for Payer: Wellcare Medicare	$5.74
Rate for Payer: Wellmed Medicare	$5.74

Triglyceride Body Fluid

Facility

$309.00

Service Code	HCPCS 84478
Hospital Charge Code	1601731
Hospital Revenue Code	301
Rate for Payer: Cash Price	$210.12

Triglycerides

Facility

$309.00

Service Code	HCPCS 84478
Hospital Charge Code	4104475
Hospital Revenue Code	301
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$2.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.74
Rate for Payer: Amerigroup Medicare	$5.74
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	$5.74
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	$5.74
Rate for Payer: Employer Direct Commercial	$5.74
Rate for Payer: Humana Medicare/TRICARE	$5.74
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$5.74
Rate for Payer: Molina Medicare	$5.74
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	$7.17
Rate for Payer: Scott and White Medicare	$5.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$5.74
Rate for Payer: Superior Health Plan Medicare	$5.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.74
Rate for Payer: Universal American Medicare	$5.74
Rate for Payer: Wellcare Medicare	$5.74
Rate for Payer: Wellmed Medicare	$5.74

Triglycerides

Facility

$309.00

Service Code	HCPCS 84478
Hospital Charge Code	4104475
Hospital Revenue Code	301
Rate for Payer: Cash Price	$210.12

Triiodothyronine (T3), Free SO

Facility

$453.00

Service Code	HCPCS 84481
Hospital Charge Code	1703008
Hospital Revenue Code	301
Rate for Payer: Cash Price	$308.04

Triiodothyronine (T3), Free SO

Facility

$453.00

Service Code	HCPCS 84481
Hospital Charge Code	1703008
Hospital Revenue Code	301
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$326.16
Rate for Payer: Amerigroup CHIP/Medicaid	$6.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.94
Rate for Payer: Amerigroup Medicare	$16.94
Rate for Payer: BCBS of TX Blue Advantage	$135.90
Rate for Payer: BCBS of TX Blue Essentials	$163.08
Rate for Payer: BCBS of TX Medicare	$16.94
Rate for Payer: BCBS of TX PPO	$181.20
Rate for Payer: Cash Price	$308.04
Rate for Payer: Cash Price	$308.04
Rate for Payer: Cigna Medicaid	$326.16
Rate for Payer: Cigna Medicare	$16.94
Rate for Payer: Employer Direct Commercial	$16.94
Rate for Payer: Humana Medicare/TRICARE	$16.94
Rate for Payer: Molina CHIP/Medicaid	$326.16
Rate for Payer: Molina Dual Medicare/Medicaid	$16.94
Rate for Payer: Molina Medicare	$16.94
Rate for Payer: Multiplan Auto	$294.45
Rate for Payer: Multiplan Commercial	$294.45
Rate for Payer: Multiplan Workers Comp	$294.45
Rate for Payer: Parkland Medicaid	$326.16
Rate for Payer: Scott and White EPO/PPO	$21.18
Rate for Payer: Scott and White Medicare	$16.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$326.16
Rate for Payer: Superior Health Plan EPO	$16.94
Rate for Payer: Superior Health Plan Medicare	$16.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.94
Rate for Payer: Universal American Medicare	$16.94
Rate for Payer: Wellcare Medicare	$16.94
Rate for Payer: Wellmed Medicare	$16.94

Triiodothyronine (T3) SO

Facility

$400.00

Service Code	HCPCS 84480
Hospital Charge Code	1602309
Hospital Revenue Code	301
Min. Negotiated Rate	$5.53
Max. Negotiated Rate	$288.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.18
Rate for Payer: Amerigroup Medicare	$14.18
Rate for Payer: BCBS of TX Blue Advantage	$120.00
Rate for Payer: BCBS of TX Blue Essentials	$144.00
Rate for Payer: BCBS of TX Medicare	$14.18
Rate for Payer: BCBS of TX PPO	$160.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cigna Medicaid	$288.00
Rate for Payer: Cigna Medicare	$14.18
Rate for Payer: Employer Direct Commercial	$14.18
Rate for Payer: Humana Medicare/TRICARE	$14.18
Rate for Payer: Molina CHIP/Medicaid	$288.00
Rate for Payer: Molina Dual Medicare/Medicaid	$14.18
Rate for Payer: Molina Medicare	$14.18
Rate for Payer: Multiplan Auto	$260.00
Rate for Payer: Multiplan Commercial	$260.00
Rate for Payer: Multiplan Workers Comp	$260.00
Rate for Payer: Parkland Medicaid	$288.00
Rate for Payer: Scott and White EPO/PPO	$17.73
Rate for Payer: Scott and White Medicare	$14.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$288.00
Rate for Payer: Superior Health Plan EPO	$14.18
Rate for Payer: Superior Health Plan Medicare	$14.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.18
Rate for Payer: Universal American Medicare	$14.18
Rate for Payer: Wellcare Medicare	$14.18
Rate for Payer: Wellmed Medicare	$14.18

Triiodothyronine (T3) SO

Facility

$400.00

Service Code	HCPCS 84480
Hospital Charge Code	1602309
Hospital Revenue Code	301
Rate for Payer: Cash Price	$272.00

Tri‑membrane wrap - per unit/ sq. cm

Facility

$771.08

Service Code	HCPCS Q4344
Hospital Charge Code	994155
Hospital Revenue Code	272
Min. Negotiated Rate	$69.40
Max. Negotiated Rate	$555.18
Rate for Payer: Amerigroup CHIP/Medicaid	$69.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$231.32
Rate for Payer: BCBS of TX Blue Essentials	$277.59
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$308.43
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$555.18
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$555.18
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$501.20
Rate for Payer: Multiplan Commercial	$501.20
Rate for Payer: Multiplan Workers Comp	$501.20
Rate for Payer: Parkland Medicaid	$555.18
Rate for Payer: Scott and White EPO/PPO	$385.54
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$555.18
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

Tri‑membrane wrap - per unit/ sq. cm

Facility

$771.08

Service Code	HCPCS Q4344
Hospital Charge Code	994155
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.33

.TR Interpretation

Facility

$386.00

Service Code	HCPCS 86078
Hospital Charge Code	1600002
Hospital Revenue Code	300
Rate for Payer: Cash Price	$262.48

.TR Interpretation

Facility

$386.00

Service Code	HCPCS 86078
Hospital Charge Code	1600002
Hospital Revenue Code	300
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$361.78
Rate for Payer: Amerigroup CHIP/Medicaid	$20.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$171.15
Rate for Payer: Amerigroup Medicare	$171.15
Rate for Payer: BCBS of TX Blue Advantage	$115.80
Rate for Payer: BCBS of TX Blue Essentials	$138.96
Rate for Payer: BCBS of TX Medicare	$171.15
Rate for Payer: BCBS of TX PPO	$154.40
Rate for Payer: Cash Price	$262.48
Rate for Payer: Cash Price	$262.48
Rate for Payer: Cash Price	$262.48
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$277.92
Rate for Payer: Cigna Medicare	$171.15
Rate for Payer: Employer Direct Commercial	$171.15
Rate for Payer: Humana Medicare/TRICARE	$171.15
Rate for Payer: Molina CHIP/Medicaid	$277.92
Rate for Payer: Molina Dual Medicare/Medicaid	$171.15
Rate for Payer: Molina Medicare	$171.15
Rate for Payer: Multiplan Auto	$250.90
Rate for Payer: Multiplan Commercial	$250.90
Rate for Payer: Multiplan Workers Comp	$250.90
Rate for Payer: Parkland Medicaid	$277.92
Rate for Payer: Scott and White EPO/PPO	$59.24
Rate for Payer: Scott and White Medicare	$171.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$277.92
Rate for Payer: Superior Health Plan EPO	$171.15
Rate for Payer: Superior Health Plan Medicare	$171.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$171.15
Rate for Payer: Universal American Medicare	$171.15
Rate for Payer: Wellcare Medicare	$171.15
Rate for Payer: Wellmed Medicare	$171.15

TRIPLE LUMEN BUNDLE KIT W/CATHETER

Facility

$644.71

Service Code	HCPCS C1725
Hospital Charge Code	992522
Hospital Revenue Code	270
Min. Negotiated Rate	$58.02
Max. Negotiated Rate	$464.19
Rate for Payer: Amerigroup CHIP/Medicaid	$58.02
Rate for Payer: BCBS of TX Blue Advantage	$193.41
Rate for Payer: BCBS of TX Blue Essentials	$232.10
Rate for Payer: BCBS of TX PPO	$257.88
Rate for Payer: Cash Price	$438.40
Rate for Payer: Cigna Medicaid	$464.19
Rate for Payer: Molina CHIP/Medicaid	$464.19
Rate for Payer: Multiplan Auto	$419.06
Rate for Payer: Multiplan Commercial	$419.06
Rate for Payer: Multiplan Workers Comp	$419.06
Rate for Payer: Parkland Medicaid	$464.19
Rate for Payer: Scott and White EPO/PPO	$322.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$464.19
Rate for Payer: Superior Health Plan EPO	$87.68

TRIPLE LUMEN BUNDLE KIT W/CATHETER

Facility

$644.71

Service Code	HCPCS C1725
Hospital Charge Code	992522
Hospital Revenue Code	270
Rate for Payer: Cash Price	$438.40

TRLUML BALO ANGIOP S&I ADDL ART

Facility

$10,885.00

Service Code	HCPCS 37247
Hospital Charge Code	2351114
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,401.80

TRLUML BALO ANGIOP S&I ADDL ART

Facility

$10,885.00

Service Code	HCPCS 37247
Hospital Charge Code	2351114
Hospital Revenue Code	360
Min. Negotiated Rate	$979.65
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$979.65
Rate for Payer: BCBS of TX Blue Advantage	$3,265.50
Rate for Payer: BCBS of TX Blue Essentials	$3,918.60
Rate for Payer: BCBS of TX PPO	$4,354.00
Rate for Payer: Cash Price	$7,401.80
Rate for Payer: Cash Price	$7,401.80
Rate for Payer: Cigna Medicaid	$7,837.20
Rate for Payer: Molina CHIP/Medicaid	$7,837.20
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	$7,837.20
Rate for Payer: Scott and White EPO/PPO	$5,442.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,837.20
Rate for Payer: Superior Health Plan EPO	$1,480.36

TRLUML BALO ANGIOP S&I ADDL VEIN

Facility

$5,591.00

Service Code	HCPCS 37249
Hospital Charge Code	2351116
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,801.88

TRLUML BALO ANGIOP S&I ADDL VEIN

Facility

$5,591.00

Service Code	HCPCS 37249
Hospital Charge Code	2351116
Hospital Revenue Code	360
Min. Negotiated Rate	$503.19
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$503.19
Rate for Payer: BCBS of TX Blue Advantage	$1,677.30
Rate for Payer: BCBS of TX Blue Essentials	$2,012.76
Rate for Payer: BCBS of TX PPO	$2,236.40
Rate for Payer: Cash Price	$3,801.88
Rate for Payer: Cash Price	$3,801.88
Rate for Payer: Cigna Medicaid	$4,025.52
Rate for Payer: Molina CHIP/Medicaid	$4,025.52
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	$4,025.52
Rate for Payer: Scott and White EPO/PPO	$2,795.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,025.52
Rate for Payer: Superior Health Plan EPO	$760.38

TRLUML BALO ANGIOP S&I INT ART

Facility

$13,299.00

Service Code	HCPCS 37246
Hospital Charge Code	2351113
Hospital Revenue Code	360
Min. Negotiated Rate	$2,300.22
Max. Negotiated Rate	$12,483.85
Rate for Payer: Amerigroup CHIP/Medicaid	$2,300.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Amerigroup Medicare	$5,717.50
Rate for Payer: BCBS of TX Blue Advantage	$8,273.03
Rate for Payer: BCBS of TX Blue Essentials	$9,907.82
Rate for Payer: BCBS of TX Medicare	$5,717.50
Rate for Payer: BCBS of TX PPO	$12,483.85
Rate for Payer: Cash Price	$9,043.32
Rate for Payer: Cash Price	$9,043.32
Rate for Payer: Cash Price	$9,043.32
Rate for Payer: Cigna Commercial	$12,085.75
Rate for Payer: Cigna Medicaid	$9,575.28
Rate for Payer: Cigna Medicare	$5,717.50
Rate for Payer: Employer Direct Commercial	$5,717.50
Rate for Payer: Humana Medicare/TRICARE	$5,717.50
Rate for Payer: Molina CHIP/Medicaid	$9,575.28
Rate for Payer: Molina Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Molina Medicare	$5,717.50
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	$9,575.28
Rate for Payer: Scott and White EPO/PPO	$9,670.39
Rate for Payer: Scott and White Medicare	$5,717.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,575.28
Rate for Payer: Superior Health Plan EPO	$5,717.50
Rate for Payer: Superior Health Plan Medicare	$5,717.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Universal American Medicare	$5,717.50
Rate for Payer: Wellcare Medicare	$5,717.50
Rate for Payer: Wellmed Medicare	$5,717.50

TRLUML BALO ANGIOP S&I INT ART

Facility

$13,299.00

Service Code	HCPCS 37246
Hospital Charge Code	2351113
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,043.32

TRLUML BALO ANGIOP S&I INT VEIN

Facility

$9,216.00

Service Code	HCPCS 37248
Hospital Charge Code	2351115
Hospital Revenue Code	360
Min. Negotiated Rate	$1,764.89
Max. Negotiated Rate	$12,483.85
Rate for Payer: Amerigroup CHIP/Medicaid	$1,764.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Amerigroup Medicare	$5,717.50
Rate for Payer: BCBS of TX Blue Advantage	$8,273.03
Rate for Payer: BCBS of TX Blue Essentials	$9,907.82
Rate for Payer: BCBS of TX Medicare	$5,717.50
Rate for Payer: BCBS of TX PPO	$12,483.85
Rate for Payer: Cash Price	$6,266.88
Rate for Payer: Cash Price	$6,266.88
Rate for Payer: Cash Price	$6,266.88
Rate for Payer: Cigna Commercial	$12,085.75
Rate for Payer: Cigna Medicaid	$6,635.52
Rate for Payer: Cigna Medicare	$5,717.50
Rate for Payer: Employer Direct Commercial	$5,717.50
Rate for Payer: Humana Medicare/TRICARE	$5,717.50
Rate for Payer: Molina CHIP/Medicaid	$6,635.52
Rate for Payer: Molina Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Molina Medicare	$5,717.50
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	$6,635.52
Rate for Payer: Scott and White EPO/PPO	$9,670.39
Rate for Payer: Scott and White Medicare	$5,717.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,635.52
Rate for Payer: Superior Health Plan EPO	$5,717.50
Rate for Payer: Superior Health Plan Medicare	$5,717.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Universal American Medicare	$5,717.50
Rate for Payer: Wellcare Medicare	$5,717.50
Rate for Payer: Wellmed Medicare	$5,717.50

TRLUML BALO ANGIOP S&I INT VEIN

Facility

$9,216.00

Service Code	HCPCS 37248
Hospital Charge Code	2351115
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,266.88

Know your out-of-pocket cost for care.

All Charges