White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED Burns Dress/Debride Large Burn, >10% BCE

Facility

$922.00

Service Code	CPT 16030
Hospital Charge Code	5202502
Hospital Revenue Code	450
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$507.10
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$82.98
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	$811.36
Rate for Payer: Cash Price	$811.36
Rate for Payer: Cash Price	$811.36
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	$599.30
Rate for Payer: Multiplan Commercial	$599.30
Rate for Payer: Multiplan Workers Comp	$599.30
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

ED Burns Dress/Debride Large Burn, >10% BCE

Facility

$922.00

Service Code	CPT 16030
Hospital Charge Code	5202502
Hospital Revenue Code	450
Rate for Payer: Cash Price	$811.36

ED Burns: Dress/Debride Medium Burn, 5-10%

Facility

$445.00

Service Code	CPT 16025
Hospital Charge Code	5200040
Hospital Revenue Code	450
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$244.75
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$40.05
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	$391.60
Rate for Payer: Cash Price	$391.60
Rate for Payer: Cash Price	$391.60
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$74.34
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 CHIP/Medicaid	$74.34
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$289.25
Rate for Payer: Multiplan Commercial	$289.25
Rate for Payer: Multiplan Workers Comp	$289.25
Rate for Payer: Parkland Medicaid	$74.34
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 CHIP/Medicaid	$74.34
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

ED Burns Dress/Debride Medium Burn, 5-10% BCE

Facility

$445.00

Service Code	CPT 16025
Hospital Charge Code	5200040
Hospital Revenue Code	450
Rate for Payer: Cash Price	$391.60

ED Burns Dress/Debride Medium Burn, 5-10% BCE

Facility

$445.00

Service Code	CPT 16025
Hospital Charge Code	5200040
Hospital Revenue Code	450
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$244.75
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$40.05
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	$391.60
Rate for Payer: Cash Price	$391.60
Rate for Payer: Cash Price	$391.60
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$74.34
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 CHIP/Medicaid	$74.34
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$289.25
Rate for Payer: Multiplan Commercial	$289.25
Rate for Payer: Multiplan Workers Comp	$289.25
Rate for Payer: Parkland Medicaid	$74.34
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 CHIP/Medicaid	$74.34
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

ED Burns: Dress/Debride Small Burn, <5%

Facility

$413.00

Service Code	CPT 16020
Hospital Charge Code	7150819
Hospital Revenue Code	450
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$227.15
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$37.17
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	$363.44
Rate for Payer: Cash Price	$363.44
Rate for Payer: Cash Price	$363.44
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$44.31
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 CHIP/Medicaid	$44.31
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$268.45
Rate for Payer: Multiplan Commercial	$268.45
Rate for Payer: Multiplan Workers Comp	$268.45
Rate for Payer: Parkland Medicaid	$44.31
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 CHIP/Medicaid	$44.31
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

ED Burns Dress/Debride Small Burn, <5% BCE

Facility

$413.00

Service Code	CPT 16020
Hospital Charge Code	7150819
Hospital Revenue Code	450
Rate for Payer: Cash Price	$363.44

ED Burns Dress/Debride Small Burn, <5% BCE

Facility

$413.00

Service Code	CPT 16020
Hospital Charge Code	7150819
Hospital Revenue Code	450
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$227.15
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$37.17
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	$363.44
Rate for Payer: Cash Price	$363.44
Rate for Payer: Cash Price	$363.44
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$44.31
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 CHIP/Medicaid	$44.31
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$268.45
Rate for Payer: Multiplan Commercial	$268.45
Rate for Payer: Multiplan Workers Comp	$268.45
Rate for Payer: Parkland Medicaid	$44.31
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 CHIP/Medicaid	$44.31
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

ED Cardiovascular Procedure: Cardioversion

Facility

$1,363.00

Service Code	CPT 92960
Hospital Charge Code	2300077
Hospital Revenue Code	450
Min. Negotiated Rate	$10.64
Max. Negotiated Rate	$1,400.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$892.82
Rate for Payer: Amerigroup CHIP/Medicaid	$122.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$595.21
Rate for Payer: Amerigroup Medicare	$595.21
Rate for Payer: BCBS of TX Blue Advantage	$895.89
Rate for Payer: BCBS of TX Blue Essentials	$1,072.92
Rate for Payer: BCBS of TX Medicare	$595.21
Rate for Payer: BCBS of TX PPO	$1,351.88
Rate for Payer: Cash Price	$1,199.44
Rate for Payer: Cash Price	$1,199.44
Rate for Payer: Cash Price	$1,199.44
Rate for Payer: Cigna Commercial	$1,348.32
Rate for Payer: Cigna Medicare	$595.21
Rate for Payer: Employer Direct Commercial	$595.21
Rate for Payer: Humana Medicare/TRICARE	$595.21
Rate for Payer: Molina Dual Medicare/Medicaid	$595.21
Rate for Payer: Molina Medicare	$595.21
Rate for Payer: Multiplan Auto	$885.95
Rate for Payer: Multiplan Commercial	$885.95
Rate for Payer: Multiplan Workers Comp	$885.95
Rate for Payer: Scott and White EPO/PPO	$10.64
Rate for Payer: Scott and White Medicare	$595.21
Rate for Payer: Superior Health Plan EPO	$595.21
Rate for Payer: Superior Health Plan Medicare	$595.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$595.21
Rate for Payer: Universal American Medicare	$595.21
Rate for Payer: Wellcare Medicare	$595.21
Rate for Payer: Wellmed Medicare	$595.21

ED Cardiovascular Procedure Cardioversion BCE

Facility

$1,363.00

Service Code	CPT 92960
Hospital Charge Code	2300077
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,199.44

ED Cardiovascular Procedure Cardioversion BCE

Facility

$1,363.00

Service Code	CPT 92960
Hospital Charge Code	2300077
Hospital Revenue Code	450
Min. Negotiated Rate	$10.64
Max. Negotiated Rate	$1,400.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$892.82
Rate for Payer: Amerigroup CHIP/Medicaid	$122.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$595.21
Rate for Payer: Amerigroup Medicare	$595.21
Rate for Payer: BCBS of TX Blue Advantage	$895.89
Rate for Payer: BCBS of TX Blue Essentials	$1,072.92
Rate for Payer: BCBS of TX Medicare	$595.21
Rate for Payer: BCBS of TX PPO	$1,351.88
Rate for Payer: Cash Price	$1,199.44
Rate for Payer: Cash Price	$1,199.44
Rate for Payer: Cash Price	$1,199.44
Rate for Payer: Cigna Commercial	$1,348.32
Rate for Payer: Cigna Medicare	$595.21
Rate for Payer: Employer Direct Commercial	$595.21
Rate for Payer: Humana Medicare/TRICARE	$595.21
Rate for Payer: Molina Dual Medicare/Medicaid	$595.21
Rate for Payer: Molina Medicare	$595.21
Rate for Payer: Multiplan Auto	$885.95
Rate for Payer: Multiplan Commercial	$885.95
Rate for Payer: Multiplan Workers Comp	$885.95
Rate for Payer: Scott and White EPO/PPO	$10.64
Rate for Payer: Scott and White Medicare	$595.21
Rate for Payer: Superior Health Plan EPO	$595.21
Rate for Payer: Superior Health Plan Medicare	$595.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$595.21
Rate for Payer: Universal American Medicare	$595.21
Rate for Payer: Wellcare Medicare	$595.21
Rate for Payer: Wellmed Medicare	$595.21

ED Cardiovascular Procedure: CPR

Facility

$1,150.00

Service Code	CPT 92950
Hospital Charge Code	4000121
Hospital Revenue Code	450
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$747.50
Rate for Payer: Aetna Commercial	$632.50
Rate for Payer: Aetna Medicare	$430.59
Rate for Payer: Amerigroup CHIP/Medicaid	$103.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$287.06
Rate for Payer: Amerigroup Medicare	$287.06
Rate for Payer: BCBS of TX Blue Advantage	$422.68
Rate for Payer: BCBS of TX Blue Essentials	$506.20
Rate for Payer: BCBS of TX Medicare	$287.06
Rate for Payer: BCBS of TX PPO	$637.81
Rate for Payer: Cash Price	$1,012.00
Rate for Payer: Cash Price	$1,012.00
Rate for Payer: Cash Price	$1,012.00
Rate for Payer: Cigna Commercial	$650.28
Rate for Payer: Cigna Medicare	$287.06
Rate for Payer: Employer Direct Commercial	$287.06
Rate for Payer: Humana Medicare/TRICARE	$287.06
Rate for Payer: Molina Dual Medicare/Medicaid	$287.06
Rate for Payer: Molina Medicare	$287.06
Rate for Payer: Multiplan Auto	$747.50
Rate for Payer: Multiplan Commercial	$747.50
Rate for Payer: Multiplan Workers Comp	$747.50
Rate for Payer: Scott and White EPO/PPO	$5.13
Rate for Payer: Scott and White Medicare	$287.06
Rate for Payer: Superior Health Plan EPO	$287.06
Rate for Payer: Superior Health Plan Medicare	$287.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$287.06
Rate for Payer: Universal American Medicare	$287.06
Rate for Payer: Wellcare Medicare	$287.06
Rate for Payer: Wellmed Medicare	$287.06

ED Cardiovascular Procedure CPR BCE

Facility

$1,150.00

Service Code	CPT 92950
Hospital Charge Code	4000121
Hospital Revenue Code	450
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$747.50
Rate for Payer: Aetna Commercial	$632.50
Rate for Payer: Aetna Medicare	$430.59
Rate for Payer: Amerigroup CHIP/Medicaid	$103.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$287.06
Rate for Payer: Amerigroup Medicare	$287.06
Rate for Payer: BCBS of TX Blue Advantage	$422.68
Rate for Payer: BCBS of TX Blue Essentials	$506.20
Rate for Payer: BCBS of TX Medicare	$287.06
Rate for Payer: BCBS of TX PPO	$637.81
Rate for Payer: Cash Price	$1,012.00
Rate for Payer: Cash Price	$1,012.00
Rate for Payer: Cash Price	$1,012.00
Rate for Payer: Cigna Commercial	$650.28
Rate for Payer: Cigna Medicare	$287.06
Rate for Payer: Employer Direct Commercial	$287.06
Rate for Payer: Humana Medicare/TRICARE	$287.06
Rate for Payer: Molina Dual Medicare/Medicaid	$287.06
Rate for Payer: Molina Medicare	$287.06
Rate for Payer: Multiplan Auto	$747.50
Rate for Payer: Multiplan Commercial	$747.50
Rate for Payer: Multiplan Workers Comp	$747.50
Rate for Payer: Scott and White EPO/PPO	$5.13
Rate for Payer: Scott and White Medicare	$287.06
Rate for Payer: Superior Health Plan EPO	$287.06
Rate for Payer: Superior Health Plan Medicare	$287.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$287.06
Rate for Payer: Universal American Medicare	$287.06
Rate for Payer: Wellcare Medicare	$287.06
Rate for Payer: Wellmed Medicare	$287.06

ED Cardiovascular Procedure CPR BCE

Facility

$1,150.00

Service Code	CPT 92950
Hospital Charge Code	4000121
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,012.00

ED Cardiovascular Procedure: Pacemaker, transcutaneous

Facility

$1,357.00

Service Code	CPT 92953
Hospital Charge Code	5201553
Hospital Revenue Code	450
Min. Negotiated Rate	$10.64
Max. Negotiated Rate	$1,400.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$892.82
Rate for Payer: Amerigroup CHIP/Medicaid	$122.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$595.21
Rate for Payer: Amerigroup Medicare	$595.21
Rate for Payer: BCBS of TX Blue Advantage	$895.89
Rate for Payer: BCBS of TX Blue Essentials	$1,072.92
Rate for Payer: BCBS of TX Medicare	$595.21
Rate for Payer: BCBS of TX PPO	$1,351.88
Rate for Payer: Cash Price	$1,194.16
Rate for Payer: Cash Price	$1,194.16
Rate for Payer: Cash Price	$1,194.16
Rate for Payer: Cigna Commercial	$1,348.32
Rate for Payer: Cigna Medicare	$595.21
Rate for Payer: Employer Direct Commercial	$595.21
Rate for Payer: Humana Medicare/TRICARE	$595.21
Rate for Payer: Molina Dual Medicare/Medicaid	$595.21
Rate for Payer: Molina Medicare	$595.21
Rate for Payer: Multiplan Auto	$882.05
Rate for Payer: Multiplan Commercial	$882.05
Rate for Payer: Multiplan Workers Comp	$882.05
Rate for Payer: Scott and White EPO/PPO	$10.64
Rate for Payer: Scott and White Medicare	$595.21
Rate for Payer: Superior Health Plan EPO	$595.21
Rate for Payer: Superior Health Plan Medicare	$595.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$595.21
Rate for Payer: Universal American Medicare	$595.21
Rate for Payer: Wellcare Medicare	$595.21
Rate for Payer: Wellmed Medicare	$595.21

ED Cardiovascular Procedure Pacemaker, transcutaneous BCE

Facility

$1,357.00

Service Code	CPT 92953
Hospital Charge Code	5201553
Hospital Revenue Code	450
Min. Negotiated Rate	$10.64
Max. Negotiated Rate	$1,400.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$892.82
Rate for Payer: Amerigroup CHIP/Medicaid	$122.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$595.21
Rate for Payer: Amerigroup Medicare	$595.21
Rate for Payer: BCBS of TX Blue Advantage	$895.89
Rate for Payer: BCBS of TX Blue Essentials	$1,072.92
Rate for Payer: BCBS of TX Medicare	$595.21
Rate for Payer: BCBS of TX PPO	$1,351.88
Rate for Payer: Cash Price	$1,194.16
Rate for Payer: Cash Price	$1,194.16
Rate for Payer: Cash Price	$1,194.16
Rate for Payer: Cigna Commercial	$1,348.32
Rate for Payer: Cigna Medicare	$595.21
Rate for Payer: Employer Direct Commercial	$595.21
Rate for Payer: Humana Medicare/TRICARE	$595.21
Rate for Payer: Molina Dual Medicare/Medicaid	$595.21
Rate for Payer: Molina Medicare	$595.21
Rate for Payer: Multiplan Auto	$882.05
Rate for Payer: Multiplan Commercial	$882.05
Rate for Payer: Multiplan Workers Comp	$882.05
Rate for Payer: Scott and White EPO/PPO	$10.64
Rate for Payer: Scott and White Medicare	$595.21
Rate for Payer: Superior Health Plan EPO	$595.21
Rate for Payer: Superior Health Plan Medicare	$595.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$595.21
Rate for Payer: Universal American Medicare	$595.21
Rate for Payer: Wellcare Medicare	$595.21
Rate for Payer: Wellmed Medicare	$595.21

ED Cardiovascular Procedure Pacemaker, transcutaneous BCE

Facility

$1,357.00

Service Code	CPT 92953
Hospital Charge Code	5201553
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,194.16

ED CHANGE CYSTOSTOMY TUBE COMPLICATED BCE

Facility

$4,406.63

Service Code	CPT 51710
Hospital Charge Code	8772541
Hospital Revenue Code	450
Min. Negotiated Rate	$11.17
Max. Negotiated Rate	$2,864.31
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$937.10
Rate for Payer: Amerigroup CHIP/Medicaid	$396.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$624.73
Rate for Payer: Amerigroup Medicare	$624.73
Rate for Payer: BCBS of TX Blue Advantage	$929.41
Rate for Payer: BCBS of TX Blue Essentials	$1,113.06
Rate for Payer: BCBS of TX Medicare	$624.73
Rate for Payer: BCBS of TX PPO	$1,402.46
Rate for Payer: Cash Price	$3,877.83
Rate for Payer: Cash Price	$3,877.83
Rate for Payer: Cash Price	$3,877.83
Rate for Payer: Cigna Commercial	$1,415.20
Rate for Payer: Cigna Medicaid	$238.15
Rate for Payer: Cigna Medicare	$624.73
Rate for Payer: Employer Direct Commercial	$624.73
Rate for Payer: Humana Medicare/TRICARE	$624.73
Rate for Payer: Molina CHIP/Medicaid	$238.15
Rate for Payer: Molina Dual Medicare/Medicaid	$624.73
Rate for Payer: Molina Medicare	$624.73
Rate for Payer: Multiplan Auto	$2,864.31
Rate for Payer: Multiplan Commercial	$2,864.31
Rate for Payer: Multiplan Workers Comp	$2,864.31
Rate for Payer: Parkland Medicaid	$238.15
Rate for Payer: Scott and White EPO/PPO	$11.17
Rate for Payer: Scott and White Medicare	$624.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$238.15
Rate for Payer: Superior Health Plan EPO	$624.73
Rate for Payer: Superior Health Plan Medicare	$624.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$624.73
Rate for Payer: Universal American Medicare	$624.73
Rate for Payer: Wellcare Medicare	$624.73
Rate for Payer: Wellmed Medicare	$624.73

ED CHANGE CYSTOSTOMY TUBE COMPLICATED BCE

Facility

$4,406.63

Service Code	CPT 51710
Hospital Charge Code	8772541
Hospital Revenue Code	450
Rate for Payer: Cash Price	$3,877.83

ED Chemical Cautery: Yes

Facility

$410.00

Service Code	CPT 17250
Hospital Charge Code	7150345
Hospital Revenue Code	450
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

ED Chemical Cautery Yes BCE

Facility

$410.00

Service Code	CPT 17250
Hospital Charge Code	7150345
Hospital Revenue Code	450
Rate for Payer: Cash Price	$360.80

ED Chemical Cautery Yes BCE

Facility

$410.00

Service Code	CPT 17250
Hospital Charge Code	7150345
Hospital Revenue Code	450
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

ED CLOSED TREATMENT OF HIP DISLC TRAUMATIC W/O ANESTHESIA BC

Facility

$638.00

Service Code	CPT 27250
Hospital Charge Code	8470468
Hospital Revenue Code	450
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$543.41
Rate for Payer: Aetna Commercial	$350.90
Rate for Payer: Aetna Medicare	$323.50
Rate for Payer: Amerigroup CHIP/Medicaid	$57.42
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	$561.44
Rate for Payer: Cash Price	$561.44
Rate for Payer: Cash Price	$561.44
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	$414.70
Rate for Payer: Multiplan Commercial	$414.70
Rate for Payer: Multiplan Workers Comp	$414.70
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

ED CLOSED TREATMENT OF HIP DISLC TRAUMATIC W/O ANESTHESIA BC

Facility

$638.00

Service Code	CPT 27250
Hospital Charge Code	8470468
Hospital Revenue Code	450
Rate for Payer: Cash Price	$561.44

ED CLOSED TX FEMORAL SHAFT FX W/O MANIPULATION BCE

Facility

$1,220.00

Service Code	CPT 27500
Hospital Charge Code	8498466
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,073.60

Know your out-of-pocket cost for care.

All Charges