White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane

Facility

$15,258.15

Service Code	HCPCS 69646
Hospital Charge Code	9900892
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cash Price	$10,375.54
Rate for Payer: Cash Price	$10,375.54
Rate for Payer: Cash Price	$10,375.54
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicaid	$10,985.87
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina CHIP/Medicaid	$10,985.87
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$10,985.87
Rate for Payer: Scott and White EPO/PPO	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,985.87
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane

Facility

$12,570.48

Service Code	CPT 69644
Hospital Charge Code	36069644
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repai

Facility

$28,534.00

Service Code	HCPCS 69643
Hospital Charge Code	9900890
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$20,544.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cash Price	$19,403.12
Rate for Payer: Cash Price	$19,403.12
Rate for Payer: Cash Price	$19,403.12
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicaid	$20,544.48
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina CHIP/Medicaid	$20,544.48
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$20,544.48
Rate for Payer: Scott and White EPO/PPO	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,544.48
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repai

Facility

$12,570.48

Service Code	CPT 69643
Hospital Charge Code	36069643
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repai

Facility

$28,534.00

Service Code	HCPCS 69643
Hospital Charge Code	9900890
Hospital Revenue Code	360
Rate for Payer: Cash Price	$19,403.12

Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), i

Facility

$12,715.13

Service Code	HCPCS 69631
Hospital Charge Code	9900888
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,646.29

Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), i

Facility

$12,715.13

Service Code	HCPCS 69633
Hospital Charge Code	9900889
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,646.29

Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), i

Facility

$12,715.13

Service Code	HCPCS 69631
Hospital Charge Code	9900888
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cash Price	$8,646.29
Rate for Payer: Cash Price	$8,646.29
Rate for Payer: Cash Price	$8,646.29
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicaid	$9,154.89
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina CHIP/Medicaid	$9,154.89
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$9,154.89
Rate for Payer: Scott and White EPO/PPO	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,154.89
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), i

Facility

$12,570.48

Service Code	CPT 69631
Hospital Charge Code	36069631
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), i

Facility

$12,715.13

Service Code	HCPCS 69633
Hospital Charge Code	9900889
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cash Price	$8,646.29
Rate for Payer: Cash Price	$8,646.29
Rate for Payer: Cash Price	$8,646.29
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicaid	$9,154.89
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina CHIP/Medicaid	$9,154.89
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$9,154.89
Rate for Payer: Scott and White EPO/PPO	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,154.89
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), i

Facility

$12,570.48

Service Code	CPT 69633
Hospital Charge Code	36069633
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Tympanostomy (requiring insertion of ventilating tube), general anesthesia

Facility

$5,411.16

Service Code	HCPCS 69436
Hospital Charge Code	9900886
Hospital Revenue Code	360
Min. Negotiated Rate	$420.64
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$420.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Amerigroup Medicare	$1,558.65
Rate for Payer: BCBS of TX Blue Advantage	$2,253.40
Rate for Payer: BCBS of TX Blue Essentials	$2,698.68
Rate for Payer: BCBS of TX Medicare	$1,558.65
Rate for Payer: BCBS of TX PPO	$3,400.34
Rate for Payer: Cash Price	$3,679.59
Rate for Payer: Cash Price	$3,679.59
Rate for Payer: Cash Price	$3,679.59
Rate for Payer: Cigna Commercial	$3,294.71
Rate for Payer: Cigna Medicaid	$3,896.04
Rate for Payer: Cigna Medicare	$1,558.65
Rate for Payer: Employer Direct Commercial	$1,558.65
Rate for Payer: Humana Medicare/TRICARE	$1,558.65
Rate for Payer: Molina CHIP/Medicaid	$3,896.04
Rate for Payer: Molina Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Molina Medicare	$1,558.65
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	$3,896.04
Rate for Payer: Scott and White EPO/PPO	$2,580.23
Rate for Payer: Scott and White Medicare	$1,558.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,896.04
Rate for Payer: Superior Health Plan EPO	$1,558.65
Rate for Payer: Superior Health Plan Medicare	$1,558.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Universal American Medicare	$1,558.65
Rate for Payer: Wellcare Medicare	$1,558.65
Rate for Payer: Wellmed Medicare	$1,558.65

Tympanostomy (requiring insertion of ventilating tube), general anesthesia

Facility

$10,000.00

Service Code	CPT 69436
Hospital Charge Code	36069436
Hospital Revenue Code	360
Min. Negotiated Rate	$420.64
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$420.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Amerigroup Medicare	$1,558.65
Rate for Payer: BCBS of TX Blue Advantage	$2,253.40
Rate for Payer: BCBS of TX Blue Essentials	$2,698.68
Rate for Payer: BCBS of TX Medicare	$1,558.65
Rate for Payer: BCBS of TX PPO	$3,400.34
Rate for Payer: Cigna Commercial	$3,294.71
Rate for Payer: Cigna Medicare	$1,558.65
Rate for Payer: Employer Direct Commercial	$1,558.65
Rate for Payer: Humana Medicare/TRICARE	$1,558.65
Rate for Payer: Molina Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Molina Medicare	$1,558.65
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	$2,580.23
Rate for Payer: Scott and White Medicare	$1,558.65
Rate for Payer: Superior Health Plan EPO	$1,558.65
Rate for Payer: Superior Health Plan Medicare	$1,558.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Universal American Medicare	$1,558.65
Rate for Payer: Wellcare Medicare	$1,558.65
Rate for Payer: Wellmed Medicare	$1,558.65

Tympanostomy (requiring insertion of ventilating tube), general anesthesia

Facility

$5,411.16

Service Code	HCPCS 69436
Hospital Charge Code	9900886
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,679.59

U0005 SARS-CoV-2 T2 SO

Facility

$64.00

Hospital Charge Code	8698565
Hospital Revenue Code	300
Rate for Payer: Cash Price	$43.52

U0005 SARS-CoV-2 T2 SO

Facility

$64.00

Hospital Charge Code	8698565
Hospital Revenue Code	300
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$46.08
Rate for Payer: Amerigroup CHIP/Medicaid	$5.76
Rate for Payer: BCBS of TX Blue Advantage	$19.20
Rate for Payer: BCBS of TX Blue Essentials	$23.04
Rate for Payer: BCBS of TX PPO	$25.60
Rate for Payer: Cash Price	$43.52
Rate for Payer: Cigna Medicaid	$46.08
Rate for Payer: Molina CHIP/Medicaid	$46.08
Rate for Payer: Multiplan Auto	$41.60
Rate for Payer: Multiplan Commercial	$41.60
Rate for Payer: Multiplan Workers Comp	$41.60
Rate for Payer: Parkland Medicaid	$46.08
Rate for Payer: Scott and White EPO/PPO	$32.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.08
Rate for Payer: Superior Health Plan EPO	$8.70

U Histopls SO

Facility

$463.00

Service Code	HCPCS 87385
Hospital Charge Code	1707900
Hospital Revenue Code	306
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$333.36
Rate for Payer: Amerigroup CHIP/Medicaid	$5.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.25
Rate for Payer: Amerigroup Medicare	$13.25
Rate for Payer: BCBS of TX Blue Advantage	$138.90
Rate for Payer: BCBS of TX Blue Essentials	$166.68
Rate for Payer: BCBS of TX Medicare	$13.25
Rate for Payer: BCBS of TX PPO	$185.20
Rate for Payer: Cash Price	$314.84
Rate for Payer: Cash Price	$314.84
Rate for Payer: Cigna Medicaid	$333.36
Rate for Payer: Cigna Medicare	$13.25
Rate for Payer: Employer Direct Commercial	$13.25
Rate for Payer: Humana Medicare/TRICARE	$13.25
Rate for Payer: Molina CHIP/Medicaid	$333.36
Rate for Payer: Molina Dual Medicare/Medicaid	$13.25
Rate for Payer: Molina Medicare	$13.25
Rate for Payer: Multiplan Auto	$300.95
Rate for Payer: Multiplan Commercial	$300.95
Rate for Payer: Multiplan Workers Comp	$300.95
Rate for Payer: Parkland Medicaid	$333.36
Rate for Payer: Scott and White EPO/PPO	$16.56
Rate for Payer: Scott and White Medicare	$13.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$333.36
Rate for Payer: Superior Health Plan EPO	$13.25
Rate for Payer: Superior Health Plan Medicare	$13.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.25
Rate for Payer: Universal American Medicare	$13.25
Rate for Payer: Wellcare Medicare	$13.25
Rate for Payer: Wellmed Medicare	$13.25

U Histopls SO

Facility

$463.00

Service Code	HCPCS 87385
Hospital Charge Code	1707900
Hospital Revenue Code	306
Rate for Payer: Cash Price	$314.84

UHR Universal Head Bipolar Component (OD: 44mm, ID: 28mm)

Facility

$3,012.05

Service Code	HCPCS C1734
Hospital Charge Code	992183
Hospital Revenue Code	278
Min. Negotiated Rate	$753.01
Max. Negotiated Rate	$1,506.03
Rate for Payer: Cash Price	$2,048.19
Rate for Payer: Cigna Commercial	$753.01
Rate for Payer: Multiplan Auto	$1,506.03
Rate for Payer: Multiplan Commercial	$1,506.03
Rate for Payer: Multiplan Workers Comp	$1,506.03
Rate for Payer: Scott and White EPO/PPO	$1,506.03

UHR Universal Head Bipolar Component (OD: 44mm, ID: 28mm)

Facility

$3,012.05

Service Code	HCPCS C1734
Hospital Charge Code	992183
Hospital Revenue Code	278
Min. Negotiated Rate	$271.08
Max. Negotiated Rate	$2,168.68
Rate for Payer: Amerigroup CHIP/Medicaid	$271.08
Rate for Payer: BCBS of TX Blue Advantage	$903.62
Rate for Payer: BCBS of TX Blue Essentials	$1,084.34
Rate for Payer: BCBS of TX PPO	$1,204.82
Rate for Payer: Cash Price	$2,048.19
Rate for Payer: Cigna Medicaid	$2,168.68
Rate for Payer: Molina CHIP/Medicaid	$2,168.68
Rate for Payer: Multiplan Auto	$1,506.03
Rate for Payer: Multiplan Commercial	$1,506.03
Rate for Payer: Multiplan Workers Comp	$1,506.03
Rate for Payer: Parkland Medicaid	$2,168.68
Rate for Payer: Scott and White EPO/PPO	$1,506.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,168.68
Rate for Payer: Superior Health Plan EPO	$409.64

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC

Facility

$71,692.66

Service Code	MSDRG 278
Min. Negotiated Rate	$45,554.90
Max. Negotiated Rate	$71,692.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$45,554.90
Rate for Payer: Amerigroup Medicare	$45,554.90
Rate for Payer: BCBS of TX Medicare	$45,554.90
Rate for Payer: Cigna Commercial	$71,692.66
Rate for Payer: Cigna Medicare	$45,554.90
Rate for Payer: Employer Direct Commercial	$45,554.90
Rate for Payer: Humana Medicare/TRICARE	$45,554.90
Rate for Payer: Molina Dual Medicare/Medicaid	$45,554.90
Rate for Payer: Molina Medicare	$45,554.90
Rate for Payer: Scott and White Medicare	$45,554.90
Rate for Payer: Superior Health Plan EPO	$45,554.90
Rate for Payer: Superior Health Plan Medicare	$45,554.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$45,554.90
Rate for Payer: Universal American Medicare	$45,554.90
Rate for Payer: Wellcare Medicare	$45,554.90
Rate for Payer: Wellmed Medicare	$45,554.90

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC

Facility

$46,450.43

Service Code	MSDRG 279
Min. Negotiated Rate	$31,191.47
Max. Negotiated Rate	$46,450.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$31,191.47
Rate for Payer: Amerigroup Medicare	$31,191.47
Rate for Payer: BCBS of TX Medicare	$31,191.47
Rate for Payer: Cigna Commercial	$46,450.43
Rate for Payer: Cigna Medicare	$31,191.47
Rate for Payer: Employer Direct Commercial	$31,191.47
Rate for Payer: Humana Medicare/TRICARE	$31,191.47
Rate for Payer: Molina Dual Medicare/Medicaid	$31,191.47
Rate for Payer: Molina Medicare	$31,191.47
Rate for Payer: Scott and White Medicare	$31,191.47
Rate for Payer: Superior Health Plan EPO	$31,191.47
Rate for Payer: Superior Health Plan Medicare	$31,191.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$31,191.47
Rate for Payer: Universal American Medicare	$31,191.47
Rate for Payer: Wellcare Medicare	$31,191.47
Rate for Payer: Wellmed Medicare	$31,191.47

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM

Facility

$38,336.03

Service Code	MSDRG 173
Min. Negotiated Rate	$26,574.19
Max. Negotiated Rate	$38,336.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,574.19
Rate for Payer: Amerigroup Medicare	$26,574.19
Rate for Payer: BCBS of TX Medicare	$26,574.19
Rate for Payer: Cigna Commercial	$38,336.03
Rate for Payer: Cigna Medicare	$26,574.19
Rate for Payer: Employer Direct Commercial	$26,574.19
Rate for Payer: Humana Medicare/TRICARE	$26,574.19
Rate for Payer: Molina Dual Medicare/Medicaid	$26,574.19
Rate for Payer: Molina Medicare	$26,574.19
Rate for Payer: Scott and White Medicare	$26,574.19
Rate for Payer: Superior Health Plan EPO	$26,574.19
Rate for Payer: Superior Health Plan Medicare	$26,574.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,574.19
Rate for Payer: Universal American Medicare	$26,574.19
Rate for Payer: Wellcare Medicare	$26,574.19
Rate for Payer: Wellmed Medicare	$26,574.19

Ultrasound guidance for vascular access

Facility

$1,094.00

Service Code	HCPCS 76937
Hospital Charge Code	990934
Hospital Revenue Code	402
Rate for Payer: Cash Price	$743.92

Ultrasound guidance for vascular access

Facility

$1,094.00

Service Code	HCPCS 76937
Hospital Charge Code	990934
Hospital Revenue Code	402
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$787.68
Rate for Payer: Amerigroup CHIP/Medicaid	$98.46
Rate for Payer: BCBS of TX Blue Advantage	$32.70
Rate for Payer: BCBS of TX Blue Essentials	$39.24
Rate for Payer: BCBS of TX PPO	$43.80
Rate for Payer: Cash Price	$743.92
Rate for Payer: Cash Price	$743.92
Rate for Payer: Cigna Medicaid	$787.68
Rate for Payer: Molina CHIP/Medicaid	$787.68
Rate for Payer: Multiplan Auto	$711.10
Rate for Payer: Multiplan Commercial	$711.10
Rate for Payer: Multiplan Workers Comp	$711.10
Rate for Payer: Parkland Medicaid	$787.68
Rate for Payer: Scott and White EPO/PPO	$47.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$787.68
Rate for Payer: Superior Health Plan EPO	$148.78

Know your out-of-pocket cost for care.

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