White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHED OB/GYNProcedure Delivery, Vaginal BCE

Facility

$6,736.83

Service Code	HCPCS 59409
Hospital Charge Code	8912643
Hospital Revenue Code	450
Min. Negotiated Rate	$606.31
Max. Negotiated Rate	$6,873.88
Rate for Payer: Amerigroup CHIP/Medicaid	$606.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,251.88
Rate for Payer: Amerigroup Medicare	$3,251.88
Rate for Payer: BCBS of TX Blue Advantage	$4,171.83
Rate for Payer: BCBS of TX Blue Essentials	$4,996.20
Rate for Payer: BCBS of TX Medicare	$3,251.88
Rate for Payer: BCBS of TX PPO	$6,295.21
Rate for Payer: Cash Price	$4,581.04
Rate for Payer: Cash Price	$4,581.04
Rate for Payer: Cash Price	$4,581.04
Rate for Payer: Cigna Commercial	$6,873.88
Rate for Payer: Cigna Medicaid	$4,850.52
Rate for Payer: Cigna Medicare	$3,251.88
Rate for Payer: Employer Direct Commercial	$3,251.88
Rate for Payer: Humana Medicare/TRICARE	$3,251.88
Rate for Payer: Molina CHIP/Medicaid	$4,850.52
Rate for Payer: Molina Dual Medicare/Medicaid	$3,251.88
Rate for Payer: Molina Medicare	$3,251.88
Rate for Payer: Multiplan Auto	$4,378.94
Rate for Payer: Multiplan Commercial	$4,378.94
Rate for Payer: Multiplan Workers Comp	$4,378.94
Rate for Payer: Parkland Medicaid	$4,850.52
Rate for Payer: Scott and White EPO/PPO	$971.16
Rate for Payer: Scott and White Medicare	$3,251.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,850.52
Rate for Payer: Superior Health Plan EPO	$3,251.88
Rate for Payer: Superior Health Plan Medicare	$3,251.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,251.88
Rate for Payer: Universal American Medicare	$3,251.88
Rate for Payer: Wellcare Medicare	$3,251.88
Rate for Payer: Wellmed Medicare	$3,251.88

CHED OB/GYNProcedure Delivery, Vaginal BCE

Facility

$6,736.83

Service Code	HCPCS 59409
Hospital Charge Code	8912643
Hospital Revenue Code	450
Rate for Payer: Cash Price	$4,581.04

CHED OB/GYNProcedure Removal of Contraceptive Capsule BCE

Facility

$1,718.00

Service Code	HCPCS 11976
Hospital Charge Code	8914626
Hospital Revenue Code	450
Min. Negotiated Rate	$112.86
Max. Negotiated Rate	$1,503.68
Rate for Payer: Amerigroup CHIP/Medicaid	$154.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
Rate for Payer: BCBS of TX Blue Advantage	$125.97
Rate for Payer: BCBS of TX Blue Essentials	$150.86
Rate for Payer: BCBS of TX Medicare	$711.36
Rate for Payer: BCBS of TX PPO	$190.08
Rate for Payer: Cash Price	$1,168.24
Rate for Payer: Cash Price	$1,168.24
Rate for Payer: Cash Price	$1,168.24
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$1,236.96
Rate for Payer: Cigna Medicare	$711.36
Rate for Payer: Employer Direct Commercial	$711.36
Rate for Payer: Humana Medicare/TRICARE	$711.36
Rate for Payer: Molina CHIP/Medicaid	$1,236.96
Rate for Payer: Molina Dual Medicare/Medicaid	$711.36
Rate for Payer: Molina Medicare	$711.36
Rate for Payer: Multiplan Auto	$1,116.70
Rate for Payer: Multiplan Commercial	$1,116.70
Rate for Payer: Multiplan Workers Comp	$1,116.70
Rate for Payer: Parkland Medicaid	$1,236.96
Rate for Payer: Scott and White EPO/PPO	$112.86
Rate for Payer: Scott and White Medicare	$711.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,236.96
Rate for Payer: Superior Health Plan EPO	$711.36
Rate for Payer: Superior Health Plan Medicare	$711.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$711.36
Rate for Payer: Universal American Medicare	$711.36
Rate for Payer: Wellcare Medicare	$711.36
Rate for Payer: Wellmed Medicare	$711.36

CHED OB/GYNProcedure Removal of Contraceptive Capsule BCE

Facility

$1,718.00

Service Code	HCPCS 11976
Hospital Charge Code	8914626
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,168.24

CHED OPEN TX PHLNGL SHFT FX PRXML/MDL PHLNX EA W/INT FX WHEN PRFRMD BCE

Facility

$11,099.03

Service Code	HCPCS 26735
Hospital Charge Code	8912644
Hospital Revenue Code	450
Rate for Payer: Cash Price	$7,547.34

CHED OPEN TX PHLNGL SHFT FX PRXML/MDL PHLNX EA W/INT FX WHEN PRFRMD BCE

Facility

$11,099.03

Service Code	HCPCS 26735
Hospital Charge Code	8912644
Hospital Revenue Code	450
Min. Negotiated Rate	$744.58
Max. Negotiated Rate	$7,991.30
Rate for Payer: Amerigroup CHIP/Medicaid	$998.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$7,547.34
Rate for Payer: Cash Price	$7,547.34
Rate for Payer: Cash Price	$7,547.34
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$7,991.30
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$7,991.30
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$7,214.37
Rate for Payer: Multiplan Commercial	$7,214.37
Rate for Payer: Multiplan Workers Comp	$7,214.37
Rate for Payer: Parkland Medicaid	$7,991.30
Rate for Payer: Scott and White EPO/PPO	$744.58
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,991.30
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

CHED Orthopedic Cast Application Forearm BCE

Facility

$520.00

Service Code	HCPCS 29075
Hospital Charge Code	8914629
Hospital Revenue Code	450
Rate for Payer: Cash Price	$353.60

CHED Orthopedic Cast Application Forearm BCE

Facility

$520.00

Service Code	HCPCS 29075
Hospital Charge Code	8914629
Hospital Revenue Code	450
Min. Negotiated Rate	$46.80
Max. Negotiated Rate	$593.92
Rate for Payer: Amerigroup CHIP/Medicaid	$46.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$92.22
Rate for Payer: BCBS of TX Blue Essentials	$110.44
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$139.15
Rate for Payer: Cash Price	$353.60
Rate for Payer: Cash Price	$353.60
Rate for Payer: Cash Price	$353.60
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$374.40
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$374.40
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$338.00
Rate for Payer: Multiplan Commercial	$338.00
Rate for Payer: Multiplan Workers Comp	$338.00
Rate for Payer: Parkland Medicaid	$374.40
Rate for Payer: Scott and White EPO/PPO	$77.22
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$374.40
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

CHED Orthopedic Cast Application Hand BCE

Facility

$682.00

Service Code	HCPCS 29085
Hospital Charge Code	9220230
Hospital Revenue Code	450
Rate for Payer: Cash Price	$463.76

CHED Orthopedic Cast Application Hand BCE

Facility

$682.00

Service Code	HCPCS 29085
Hospital Charge Code	9220230
Hospital Revenue Code	450
Min. Negotiated Rate	$61.38
Max. Negotiated Rate	$491.04
Rate for Payer: Amerigroup CHIP/Medicaid	$61.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$100.05
Rate for Payer: BCBS of TX Blue Essentials	$119.82
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$150.97
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$491.04
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$491.04
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
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	$491.04
Rate for Payer: Scott and White EPO/PPO	$83.38
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$491.04
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

CHED Orthopedic Cast Application Lower Extremity BCE

Facility

$740.50

Service Code	HCPCS 29345
Hospital Charge Code	8912649
Hospital Revenue Code	450
Rate for Payer: Cash Price	$503.54

CHED Orthopedic Cast Application Lower Extremity BCE

Facility

$740.50

Service Code	HCPCS 29345
Hospital Charge Code	8912649
Hospital Revenue Code	450
Min. Negotiated Rate	$66.64
Max. Negotiated Rate	$593.92
Rate for Payer: Amerigroup CHIP/Medicaid	$66.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$131.40
Rate for Payer: BCBS of TX Blue Essentials	$157.36
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$198.27
Rate for Payer: Cash Price	$503.54
Rate for Payer: Cash Price	$503.54
Rate for Payer: Cash Price	$503.54
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$533.16
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$533.16
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$481.32
Rate for Payer: Multiplan Commercial	$481.32
Rate for Payer: Multiplan Workers Comp	$481.32
Rate for Payer: Parkland Medicaid	$533.16
Rate for Payer: Scott and White EPO/PPO	$121.67
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$533.16
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

CHED Orthopedic Cast Application Upper Arm/Elbow BCE

Facility

$544.34

Service Code	HCPCS 29065
Hospital Charge Code	8926599
Hospital Revenue Code	450
Min. Negotiated Rate	$48.99
Max. Negotiated Rate	$593.92
Rate for Payer: Amerigroup CHIP/Medicaid	$48.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$100.65
Rate for Payer: BCBS of TX Blue Essentials	$120.54
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$151.88
Rate for Payer: Cash Price	$370.15
Rate for Payer: Cash Price	$370.15
Rate for Payer: Cash Price	$370.15
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$391.92
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$391.92
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$353.82
Rate for Payer: Multiplan Commercial	$353.82
Rate for Payer: Multiplan Workers Comp	$353.82
Rate for Payer: Parkland Medicaid	$391.92
Rate for Payer: Scott and White EPO/PPO	$84.15
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$391.92
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

CHED Orthopedic Cast Application Upper Arm/Elbow BCE

Facility

$544.34

Service Code	HCPCS 29065
Hospital Charge Code	8926599
Hospital Revenue Code	450
Rate for Payer: Cash Price	$370.15

CHED Orthopedic Cast Removal Arm/Leg BCE

Facility

$644.00

Service Code	HCPCS 29705
Hospital Charge Code	8912645
Hospital Revenue Code	450
Min. Negotiated Rate	$54.30
Max. Negotiated Rate	$593.92
Rate for Payer: Amerigroup CHIP/Medicaid	$57.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$57.26
Rate for Payer: BCBS of TX Blue Essentials	$68.58
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$86.41
Rate for Payer: Cash Price	$437.92
Rate for Payer: Cash Price	$437.92
Rate for Payer: Cash Price	$437.92
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$463.68
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$463.68
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$418.60
Rate for Payer: Multiplan Commercial	$418.60
Rate for Payer: Multiplan Workers Comp	$418.60
Rate for Payer: Parkland Medicaid	$463.68
Rate for Payer: Scott and White EPO/PPO	$54.30
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$463.68
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

CHED Orthopedic Cast Removal Arm/Leg BCE

Facility

$644.00

Service Code	HCPCS 29705
Hospital Charge Code	8912645
Hospital Revenue Code	450
Rate for Payer: Cash Price	$437.92

CHED Orthopedic Splinting Site Finger Splint, static BCE

Facility

$344.90

Service Code	HCPCS 29130
Hospital Charge Code	8912646
Hospital Revenue Code	450
Rate for Payer: Cash Price	$234.53

CHED Orthopedic Splinting Site Finger Splint, static BCE

Facility

$344.90

Service Code	HCPCS 29130
Hospital Charge Code	8912646
Hospital Revenue Code	450
Min. Negotiated Rate	$31.04
Max. Negotiated Rate	$282.53
Rate for Payer: Amerigroup CHIP/Medicaid	$31.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$91.87
Rate for Payer: BCBS of TX Blue Essentials	$110.02
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$138.63
Rate for Payer: Cash Price	$234.53
Rate for Payer: Cash Price	$234.53
Rate for Payer: Cash Price	$234.53
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$248.33
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$248.33
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$224.19
Rate for Payer: Multiplan Commercial	$224.19
Rate for Payer: Multiplan Workers Comp	$224.19
Rate for Payer: Parkland Medicaid	$248.33
Rate for Payer: Scott and White EPO/PPO	$35.46
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$248.33
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

CHED Orthopedic Splinting Site Posterior Long Arm Splint BCE

Facility

$510.32

Service Code	HCPCS 29105
Hospital Charge Code	8910642
Hospital Revenue Code	450
Min. Negotiated Rate	$45.93
Max. Negotiated Rate	$367.43
Rate for Payer: Amerigroup CHIP/Medicaid	$45.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$83.17
Rate for Payer: BCBS of TX Blue Essentials	$99.60
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$125.50
Rate for Payer: Cash Price	$347.02
Rate for Payer: Cash Price	$347.02
Rate for Payer: Cash Price	$347.02
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$367.43
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$367.43
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
Rate for Payer: Multiplan Auto	$331.71
Rate for Payer: Multiplan Commercial	$331.71
Rate for Payer: Multiplan Workers Comp	$331.71
Rate for Payer: Parkland Medicaid	$367.43
Rate for Payer: Scott and White EPO/PPO	$50.80
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$367.43
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

CHED Orthopedic Splinting Site Posterior Long Arm Splint BCE

Facility

$510.32

Service Code	HCPCS 29105
Hospital Charge Code	8910642
Hospital Revenue Code	450
Rate for Payer: Cash Price	$347.02

CHED Orthopedic Splinting Site Posterior Long Leg Splint BCE

Facility

$591.52

Service Code	HCPCS 29505
Hospital Charge Code	8914627
Hospital Revenue Code	450
Rate for Payer: Cash Price	$402.23

CHED Orthopedic Splinting Site Posterior Long Leg Splint BCE

Facility

$591.52

Service Code	HCPCS 29505
Hospital Charge Code	8914627
Hospital Revenue Code	450
Min. Negotiated Rate	$53.24
Max. Negotiated Rate	$425.89
Rate for Payer: Amerigroup CHIP/Medicaid	$53.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$97.03
Rate for Payer: BCBS of TX Blue Essentials	$116.20
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$146.41
Rate for Payer: Cash Price	$402.23
Rate for Payer: Cash Price	$402.23
Rate for Payer: Cash Price	$402.23
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$425.89
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$425.89
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
Rate for Payer: Multiplan Auto	$384.49
Rate for Payer: Multiplan Commercial	$384.49
Rate for Payer: Multiplan Workers Comp	$384.49
Rate for Payer: Parkland Medicaid	$425.89
Rate for Payer: Scott and White EPO/PPO	$64.60
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$425.89
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

CHED Orthopedic Splinting Site Posterior Short Arm Splint BCE

Facility

$618.22

Service Code	HCPCS 29125
Hospital Charge Code	8910643
Hospital Revenue Code	450
Min. Negotiated Rate	$49.89
Max. Negotiated Rate	$445.12
Rate for Payer: Amerigroup CHIP/Medicaid	$55.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$182.08
Rate for Payer: BCBS of TX Blue Essentials	$218.06
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cash Price	$420.39
Rate for Payer: Cash Price	$420.39
Rate for Payer: Cash Price	$420.39
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$445.12
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$445.12
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$401.84
Rate for Payer: Multiplan Commercial	$401.84
Rate for Payer: Multiplan Workers Comp	$401.84
Rate for Payer: Parkland Medicaid	$445.12
Rate for Payer: Scott and White EPO/PPO	$49.89
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$445.12
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

CHED Orthopedic Splinting Site Posterior Short Arm Splint BCE

Facility

$618.22

Service Code	HCPCS 29125
Hospital Charge Code	8910643
Hospital Revenue Code	450
Rate for Payer: Cash Price	$420.39

CHED Orthopedic Splinting Site Posterior Short Leg Splint BCE

Facility

$553.30

Service Code	HCPCS 29515
Hospital Charge Code	8910644
Hospital Revenue Code	450
Min. Negotiated Rate	$49.80
Max. Negotiated Rate	$398.38
Rate for Payer: Amerigroup CHIP/Medicaid	$49.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$70.51
Rate for Payer: BCBS of TX Blue Essentials	$84.44
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$106.39
Rate for Payer: Cash Price	$376.24
Rate for Payer: Cash Price	$376.24
Rate for Payer: Cash Price	$376.24
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$398.38
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$398.38
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
Rate for Payer: Multiplan Auto	$359.64
Rate for Payer: Multiplan Commercial	$359.64
Rate for Payer: Multiplan Workers Comp	$359.64
Rate for Payer: Parkland Medicaid	$398.38
Rate for Payer: Scott and White EPO/PPO	$61.36
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$398.38
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

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