White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHED SMPL RPR WND FACE/EAR/EYELID/NOSE/LIP 7.6 TO 12.5 CM BC

Facility

$918.00

Service Code	CPT 12015
Hospital Charge Code	8912658
Hospital Revenue Code	450
Rate for Payer: Cash Price	$807.84

CHED SMPL RPR WND S/N/A/GEN/TRNK 20.1 TO 30.0 CM BCE

Facility

$1,187.00

Service Code	CPT 12006
Hospital Charge Code	8912657
Hospital Revenue Code	450
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$652.85
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$106.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,044.56
Rate for Payer: Cash Price	$1,044.56
Rate for Payer: Cash Price	$1,044.56
Rate for Payer: Cigna Commercial	$826.08
Rate for Payer: Cigna Medicaid	$143.08
Rate for Payer: Cigna Medicare	$364.67
Rate for Payer: Employer Direct Commercial	$364.67
Rate for Payer: Humana Medicare/TRICARE	$364.67
Rate for Payer: Molina CHIP/Medicaid	$143.08
Rate for Payer: Molina Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$771.55
Rate for Payer: Multiplan Commercial	$771.55
Rate for Payer: Multiplan Workers Comp	$771.55
Rate for Payer: Parkland Medicaid	$143.08
Rate for Payer: Scott and White EPO/PPO	$6.52
Rate for Payer: Scott and White Medicare	$364.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.08
Rate for Payer: Superior Health Plan EPO	$364.67
Rate for Payer: Superior Health Plan Medicare	$364.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.67
Rate for Payer: Universal American Medicare	$364.67
Rate for Payer: Wellcare Medicare	$364.67
Rate for Payer: Wellmed Medicare	$364.67

CHED SMPL RPR WND S/N/A/GEN/TRNK 20.1 TO 30.0 CM BCE

Facility

$1,187.00

Service Code	CPT 12006
Hospital Charge Code	8912657
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,044.56

CHED Throat Procedures Dental Surgery BCE

Facility

$16,333.67

Service Code	CPT 41899
Hospital Charge Code	8912664
Hospital Revenue Code	450
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$10,616.89
Rate for Payer: Aetna Commercial	$8,983.52
Rate for Payer: Aetna Medicare	$335.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1,470.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$223.39
Rate for Payer: Amerigroup Medicare	$223.39
Rate for Payer: BCBS of TX Blue Advantage	$340.08
Rate for Payer: BCBS of TX Blue Essentials	$407.28
Rate for Payer: BCBS of TX Medicare	$223.39
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cash Price	$14,373.63
Rate for Payer: Cash Price	$14,373.63
Rate for Payer: Cash Price	$14,373.63
Rate for Payer: Cigna Commercial	$506.05
Rate for Payer: Cigna Medicare	$223.39
Rate for Payer: Employer Direct Commercial	$223.39
Rate for Payer: Humana Medicare/TRICARE	$223.39
Rate for Payer: Molina Dual Medicare/Medicaid	$223.39
Rate for Payer: Molina Medicare	$223.39
Rate for Payer: Multiplan Auto	$10,616.89
Rate for Payer: Multiplan Commercial	$10,616.89
Rate for Payer: Multiplan Workers Comp	$10,616.89
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Scott and White Medicare	$223.39
Rate for Payer: Superior Health Plan EPO	$223.39
Rate for Payer: Superior Health Plan Medicare	$223.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$223.39
Rate for Payer: Universal American Medicare	$223.39
Rate for Payer: Wellcare Medicare	$223.39
Rate for Payer: Wellmed Medicare	$223.39

CHED Throat Procedures Dental Surgery BCE

Facility

$16,333.67

Service Code	CPT 41899
Hospital Charge Code	8912664
Hospital Revenue Code	450
Rate for Payer: Cash Price	$14,373.63

CHED TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT BCE

Facility

$2,181.00

Service Code	CPT 31502
Hospital Charge Code	8912662
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,919.28

CHED TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT BCE

Facility

$2,181.00

Service Code	CPT 31502
Hospital Charge Code	8912662
Hospital Revenue Code	450
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$1,417.65
Rate for Payer: Aetna Commercial	$1,199.55
Rate for Payer: Aetna Medicare	$335.08
Rate for Payer: Amerigroup CHIP/Medicaid	$196.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$223.39
Rate for Payer: Amerigroup Medicare	$223.39
Rate for Payer: BCBS of TX Blue Advantage	$340.08
Rate for Payer: BCBS of TX Blue Essentials	$407.28
Rate for Payer: BCBS of TX Medicare	$223.39
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cash Price	$1,919.28
Rate for Payer: Cash Price	$1,919.28
Rate for Payer: Cash Price	$1,919.28
Rate for Payer: Cigna Commercial	$506.05
Rate for Payer: Cigna Medicaid	$87.58
Rate for Payer: Cigna Medicare	$223.39
Rate for Payer: Employer Direct Commercial	$223.39
Rate for Payer: Humana Medicare/TRICARE	$223.39
Rate for Payer: Molina CHIP/Medicaid	$87.58
Rate for Payer: Molina Dual Medicare/Medicaid	$223.39
Rate for Payer: Molina Medicare	$223.39
Rate for Payer: Multiplan Auto	$1,417.65
Rate for Payer: Multiplan Commercial	$1,417.65
Rate for Payer: Multiplan Workers Comp	$1,417.65
Rate for Payer: Parkland Medicaid	$87.58
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Scott and White Medicare	$223.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$87.58
Rate for Payer: Superior Health Plan EPO	$223.39
Rate for Payer: Superior Health Plan Medicare	$223.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$223.39
Rate for Payer: Universal American Medicare	$223.39
Rate for Payer: Wellcare Medicare	$223.39
Rate for Payer: Wellmed Medicare	$223.39

CHED Trauma 1 (full) BCE

Facility

$7,088.00

Service Code	HCPCS G0390
Hospital Charge Code	8930546
Hospital Revenue Code	681
Min. Negotiated Rate	$22.39
Max. Negotiated Rate	$4,607.20
Rate for Payer: Aetna Commercial	$3,898.40
Rate for Payer: Aetna Medicare	$1,878.16
Rate for Payer: Amerigroup CHIP/Medicaid	$637.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Amerigroup Medicare	$1,252.11
Rate for Payer: BCBS of TX Blue Advantage	$1,550.60
Rate for Payer: BCBS of TX Blue Essentials	$1,853.59
Rate for Payer: BCBS of TX Medicare	$1,252.11
Rate for Payer: BCBS of TX PPO	$2,067.47
Rate for Payer: Cash Price	$6,237.44
Rate for Payer: Cash Price	$6,237.44
Rate for Payer: Cash Price	$6,237.44
Rate for Payer: Cigna Commercial	$2,836.40
Rate for Payer: Cigna Medicare	$1,252.11
Rate for Payer: Employer Direct Commercial	$1,252.11
Rate for Payer: Humana Medicare/TRICARE	$1,252.11
Rate for Payer: Molina Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Molina Medicare	$1,252.11
Rate for Payer: Multiplan Auto	$4,607.20
Rate for Payer: Multiplan Commercial	$4,607.20
Rate for Payer: Multiplan Workers Comp	$4,607.20
Rate for Payer: Scott and White EPO/PPO	$22.39
Rate for Payer: Scott and White Medicare	$1,252.11
Rate for Payer: Superior Health Plan EPO	$1,252.11
Rate for Payer: Superior Health Plan Medicare	$1,252.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Universal American Medicare	$1,252.11
Rate for Payer: Wellcare Medicare	$1,252.11
Rate for Payer: Wellmed Medicare	$1,252.11

CHED Trauma 1 (full) BCE

Facility

$7,088.00

Service Code	HCPCS G0390
Hospital Charge Code	8930546
Hospital Revenue Code	681
Rate for Payer: Cash Price	$6,237.44

CHED Trauma Response - Level II Trauma BCE

Facility

$5,316.00

Service Code	HCPCS G0390
Hospital Charge Code	8932548
Hospital Revenue Code	682
Rate for Payer: Cash Price	$4,678.08

CHED Trauma Response - Level II Trauma BCE

Facility

$5,316.00

Service Code	HCPCS G0390
Hospital Charge Code	8932548
Hospital Revenue Code	682
Min. Negotiated Rate	$22.39
Max. Negotiated Rate	$3,455.40
Rate for Payer: Aetna Commercial	$2,923.80
Rate for Payer: Aetna Medicare	$1,878.16
Rate for Payer: Amerigroup CHIP/Medicaid	$478.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Amerigroup Medicare	$1,252.11
Rate for Payer: BCBS of TX Blue Advantage	$1,550.60
Rate for Payer: BCBS of TX Blue Essentials	$1,853.59
Rate for Payer: BCBS of TX Medicare	$1,252.11
Rate for Payer: BCBS of TX PPO	$2,067.47
Rate for Payer: Cash Price	$4,678.08
Rate for Payer: Cash Price	$4,678.08
Rate for Payer: Cash Price	$4,678.08
Rate for Payer: Cigna Commercial	$2,836.40
Rate for Payer: Cigna Medicare	$1,252.11
Rate for Payer: Employer Direct Commercial	$1,252.11
Rate for Payer: Humana Medicare/TRICARE	$1,252.11
Rate for Payer: Molina Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Molina Medicare	$1,252.11
Rate for Payer: Multiplan Auto	$3,455.40
Rate for Payer: Multiplan Commercial	$3,455.40
Rate for Payer: Multiplan Workers Comp	$3,455.40
Rate for Payer: Scott and White EPO/PPO	$22.39
Rate for Payer: Scott and White Medicare	$1,252.11
Rate for Payer: Superior Health Plan EPO	$1,252.11
Rate for Payer: Superior Health Plan Medicare	$1,252.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Universal American Medicare	$1,252.11
Rate for Payer: Wellcare Medicare	$1,252.11
Rate for Payer: Wellmed Medicare	$1,252.11

CHED TX FX METACARPAL W/O MAN CLSD BCE

Facility

$682.00

Service Code	CPT 26600
Hospital Charge Code	8912663
Hospital Revenue Code	450
Rate for Payer: Cash Price	$600.16

CHED TX FX METACARPAL W/O MAN CLSD BCE

Facility

$682.00

Service Code	CPT 26600
Hospital Charge Code	8912663
Hospital Revenue Code	450
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$488.55
Rate for Payer: Aetna Commercial	$375.10
Rate for Payer: Aetna Medicare	$323.50
Rate for Payer: Amerigroup CHIP/Medicaid	$61.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$215.67
Rate for Payer: Amerigroup Medicare	$215.67
Rate for Payer: BCBS of TX Blue Advantage	$181.96
Rate for Payer: BCBS of TX Blue Essentials	$217.92
Rate for Payer: BCBS of TX Medicare	$215.67
Rate for Payer: BCBS of TX PPO	$274.58
Rate for Payer: Cash Price	$600.16
Rate for Payer: Cash Price	$600.16
Rate for Payer: Cash Price	$600.16
Rate for Payer: Cigna Commercial	$488.55
Rate for Payer: Cigna Medicaid	$85.32
Rate for Payer: Cigna Medicare	$215.67
Rate for Payer: Employer Direct Commercial	$215.67
Rate for Payer: Humana Medicare/TRICARE	$215.67
Rate for Payer: Molina CHIP/Medicaid	$85.32
Rate for Payer: Molina Dual Medicare/Medicaid	$215.67
Rate for Payer: Molina Medicare	$215.67
Rate for Payer: Multiplan Auto	$443.30
Rate for Payer: Multiplan Commercial	$443.30
Rate for Payer: Multiplan Workers Comp	$443.30
Rate for Payer: Parkland Medicaid	$85.32
Rate for Payer: Scott and White EPO/PPO	$3.86
Rate for Payer: Scott and White Medicare	$215.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$85.32
Rate for Payer: Superior Health Plan EPO	$215.67
Rate for Payer: Superior Health Plan Medicare	$215.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$215.67
Rate for Payer: Universal American Medicare	$215.67
Rate for Payer: Wellcare Medicare	$215.67
Rate for Payer: Wellmed Medicare	$215.67

CHED TX FX TIBIAL SHAFT W/O MAN CLSD BCE

Facility

$775.26

Service Code	CPT 27750
Hospital Charge Code	8910654
Hospital Revenue Code	450
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$543.41
Rate for Payer: Aetna Commercial	$426.39
Rate for Payer: Aetna Medicare	$323.50
Rate for Payer: Amerigroup CHIP/Medicaid	$69.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$215.67
Rate for Payer: Amerigroup Medicare	$215.67
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$215.67
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$682.23
Rate for Payer: Cash Price	$682.23
Rate for Payer: Cash Price	$682.23
Rate for Payer: Cigna Commercial	$488.55
Rate for Payer: Cigna Medicaid	$85.32
Rate for Payer: Cigna Medicare	$215.67
Rate for Payer: Employer Direct Commercial	$215.67
Rate for Payer: Humana Medicare/TRICARE	$215.67
Rate for Payer: Molina CHIP/Medicaid	$85.32
Rate for Payer: Molina Dual Medicare/Medicaid	$215.67
Rate for Payer: Molina Medicare	$215.67
Rate for Payer: Multiplan Auto	$503.92
Rate for Payer: Multiplan Commercial	$503.92
Rate for Payer: Multiplan Workers Comp	$503.92
Rate for Payer: Parkland Medicaid	$85.32
Rate for Payer: Scott and White EPO/PPO	$3.86
Rate for Payer: Scott and White Medicare	$215.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$85.32
Rate for Payer: Superior Health Plan EPO	$215.67
Rate for Payer: Superior Health Plan Medicare	$215.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$215.67
Rate for Payer: Universal American Medicare	$215.67
Rate for Payer: Wellcare Medicare	$215.67
Rate for Payer: Wellmed Medicare	$215.67

CHED TX FX TIBIAL SHAFT W/O MAN CLSD BCE

Facility

$775.26

Service Code	CPT 27750
Hospital Charge Code	8910654
Hospital Revenue Code	450
Rate for Payer: Cash Price	$682.23

CHED TX SPONTAN HIP DISLC ABDCT SPLNT/TRCJ W/O ANES BCE

Facility

$1,066.75

Service Code	CPT 27256
Hospital Charge Code	8910655
Hospital Revenue Code	450
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$693.39
Rate for Payer: Aetna Commercial	$586.71
Rate for Payer: Aetna Medicare	$323.50
Rate for Payer: Amerigroup CHIP/Medicaid	$96.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$215.67
Rate for Payer: Amerigroup Medicare	$215.67
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$215.67
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$938.74
Rate for Payer: Cash Price	$938.74
Rate for Payer: Cash Price	$938.74
Rate for Payer: Cigna Commercial	$488.55
Rate for Payer: Cigna Medicaid	$85.32
Rate for Payer: Cigna Medicare	$215.67
Rate for Payer: Employer Direct Commercial	$215.67
Rate for Payer: Humana Medicare/TRICARE	$215.67
Rate for Payer: Molina CHIP/Medicaid	$85.32
Rate for Payer: Molina Dual Medicare/Medicaid	$215.67
Rate for Payer: Molina Medicare	$215.67
Rate for Payer: Multiplan Auto	$693.39
Rate for Payer: Multiplan Commercial	$693.39
Rate for Payer: Multiplan Workers Comp	$693.39
Rate for Payer: Parkland Medicaid	$85.32
Rate for Payer: Scott and White EPO/PPO	$3.86
Rate for Payer: Scott and White Medicare	$215.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$85.32
Rate for Payer: Superior Health Plan EPO	$215.67
Rate for Payer: Superior Health Plan Medicare	$215.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$215.67
Rate for Payer: Universal American Medicare	$215.67
Rate for Payer: Wellcare Medicare	$215.67
Rate for Payer: Wellmed Medicare	$215.67

CHED TX SPONTAN HIP DISLC ABDCT SPLNT/TRCJ W/O ANES BCE

Facility

$1,066.75

Service Code	CPT 27256
Hospital Charge Code	8910655
Hospital Revenue Code	450
Rate for Payer: Cash Price	$938.74

CHED Unlisted Procedure ESOPHAGUS BCE

Facility

$7,810.77

Service Code	CPT 43499
Hospital Charge Code	8912665
Hospital Revenue Code	450
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$5,077.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$1,243.53
Rate for Payer: Amerigroup CHIP/Medicaid	$702.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$829.02
Rate for Payer: Amerigroup Medicare	$829.02
Rate for Payer: BCBS of TX Blue Advantage	$1,312.49
Rate for Payer: BCBS of TX Blue Essentials	$1,571.84
Rate for Payer: BCBS of TX Medicare	$829.02
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cash Price	$6,873.48
Rate for Payer: Cash Price	$6,873.48
Rate for Payer: Cash Price	$6,873.48
Rate for Payer: Cigna Commercial	$1,877.98
Rate for Payer: Cigna Medicare	$829.02
Rate for Payer: Employer Direct Commercial	$829.02
Rate for Payer: Humana Medicare/TRICARE	$829.02
Rate for Payer: Molina Dual Medicare/Medicaid	$829.02
Rate for Payer: Molina Medicare	$829.02
Rate for Payer: Multiplan Auto	$5,077.00
Rate for Payer: Multiplan Commercial	$5,077.00
Rate for Payer: Multiplan Workers Comp	$5,077.00
Rate for Payer: Scott and White EPO/PPO	$14.83
Rate for Payer: Scott and White Medicare	$829.02
Rate for Payer: Superior Health Plan EPO	$829.02
Rate for Payer: Superior Health Plan Medicare	$829.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$829.02
Rate for Payer: Universal American Medicare	$829.02
Rate for Payer: Wellcare Medicare	$829.02
Rate for Payer: Wellmed Medicare	$829.02

CHED Unlisted Procedure ESOPHAGUS BCE

Facility

$7,810.77

Service Code	CPT 43499
Hospital Charge Code	8912665
Hospital Revenue Code	450
Rate for Payer: Cash Price	$6,873.48

CHED WEDGE EXCISION SKIN NAIL FOLD (EG, TOENAIL) BCE

Facility

$828.01

Service Code	CPT 11765
Hospital Charge Code	8914638
Hospital Revenue Code	450
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$455.41
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$74.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$728.65
Rate for Payer: Cash Price	$728.65
Rate for Payer: Cash Price	$728.65
Rate for Payer: Cigna Commercial	$826.08
Rate for Payer: Cigna Medicare	$364.67
Rate for Payer: Employer Direct Commercial	$364.67
Rate for Payer: Humana Medicare/TRICARE	$364.67
Rate for Payer: Molina Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$538.21
Rate for Payer: Multiplan Commercial	$538.21
Rate for Payer: Multiplan Workers Comp	$538.21
Rate for Payer: Scott and White EPO/PPO	$6.52
Rate for Payer: Scott and White Medicare	$364.67
Rate for Payer: Superior Health Plan EPO	$364.67
Rate for Payer: Superior Health Plan Medicare	$364.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.67
Rate for Payer: Universal American Medicare	$364.67
Rate for Payer: Wellcare Medicare	$364.67
Rate for Payer: Wellmed Medicare	$364.67

CHED WEDGE EXCISION SKIN NAIL FOLD (EG, TOENAIL) BCE

Facility

$828.01

Service Code	CPT 11765
Hospital Charge Code	8914638
Hospital Revenue Code	450
Rate for Payer: Cash Price	$728.65

CHED Wound Dehiscence Superficial BCE

Facility

$3,282.13

Service Code	CPT 12020
Hospital Charge Code	8912666
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,888.27

CHED Wound Dehiscence Superficial BCE

Facility

$3,282.13

Service Code	CPT 12020
Hospital Charge Code	8912666
Hospital Revenue Code	450
Min. Negotiated Rate	$10.27
Max. Negotiated Rate	$2,133.38
Rate for Payer: Aetna Commercial	$1,805.17
Rate for Payer: Aetna Medicare	$861.57
Rate for Payer: Amerigroup CHIP/Medicaid	$295.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$574.38
Rate for Payer: Amerigroup Medicare	$574.38
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$574.38
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,888.27
Rate for Payer: Cash Price	$2,888.27
Rate for Payer: Cash Price	$2,888.27
Rate for Payer: Cigna Commercial	$1,301.14
Rate for Payer: Cigna Medicaid	$216.80
Rate for Payer: Cigna Medicare	$574.38
Rate for Payer: Employer Direct Commercial	$574.38
Rate for Payer: Humana Medicare/TRICARE	$574.38
Rate for Payer: Molina CHIP/Medicaid	$216.80
Rate for Payer: Molina Dual Medicare/Medicaid	$574.38
Rate for Payer: Molina Medicare	$574.38
Rate for Payer: Multiplan Auto	$2,133.38
Rate for Payer: Multiplan Commercial	$2,133.38
Rate for Payer: Multiplan Workers Comp	$2,133.38
Rate for Payer: Parkland Medicaid	$216.80
Rate for Payer: Scott and White EPO/PPO	$10.27
Rate for Payer: Scott and White Medicare	$574.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.80
Rate for Payer: Superior Health Plan EPO	$574.38
Rate for Payer: Superior Health Plan Medicare	$574.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$574.38
Rate for Payer: Universal American Medicare	$574.38
Rate for Payer: Wellcare Medicare	$574.38
Rate for Payer: Wellmed Medicare	$574.38

Chemical Cauterization of Wound

Facility

$410.00

Service Code	CPT 17250
Hospital Charge Code	7150345
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$225.50
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$36.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$360.80
Rate for Payer: Cash Price	$360.80
Rate for Payer: Cash Price	$360.80
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$266.50
Rate for Payer: Multiplan Commercial	$266.50
Rate for Payer: Multiplan Workers Comp	$266.50
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

Chemodenervation of muscle(s) muscle(s) innervated by facial, trigeminal, cervical spinal and acces

Facility

$10,000.00

Service Code	CPT 64615
Hospital Charge Code	36064615
Hospital Revenue Code	360
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$406.30
Rate for Payer: Amerigroup CHIP/Medicaid	$59.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$270.87
Rate for Payer: Amerigroup Medicare	$270.87
Rate for Payer: BCBS of TX Blue Advantage	$113.91
Rate for Payer: BCBS of TX Blue Essentials	$136.42
Rate for Payer: BCBS of TX Medicare	$270.87
Rate for Payer: BCBS of TX PPO	$171.89
Rate for Payer: Cigna Commercial	$613.60
Rate for Payer: Cigna Medicaid	$59.25
Rate for Payer: Cigna Medicare	$270.87
Rate for Payer: Employer Direct Commercial	$270.87
Rate for Payer: Humana Medicare/TRICARE	$270.87
Rate for Payer: Molina CHIP/Medicaid	$59.25
Rate for Payer: Molina Dual Medicare/Medicaid	$270.87
Rate for Payer: Molina Medicare	$270.87
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	$59.25
Rate for Payer: Scott and White EPO/PPO	$5.97
Rate for Payer: Scott and White Medicare	$270.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.25
Rate for Payer: Superior Health Plan EPO	$270.87
Rate for Payer: Superior Health Plan Medicare	$270.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$270.87
Rate for Payer: Universal American Medicare	$270.87
Rate for Payer: Wellcare Medicare	$270.87
Rate for Payer: Wellmed Medicare	$270.87

Know your out-of-pocket cost for care.

All Charges