White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHED REM FB EYE CONJUNCTIVAL SUPERFICIAL BCE

Facility

$619.27

Service Code	HCPCS 65205
Hospital Charge Code	9028991
Hospital Revenue Code	450
Rate for Payer: Cash Price	$421.10

CHED REM FB EYE CONJUNCTIVAL SUPERFICIAL BCE

Facility

$619.27

Service Code	HCPCS 65205
Hospital Charge Code	8984540
Hospital Revenue Code	450
Min. Negotiated Rate	$35.36
Max. Negotiated Rate	$445.87
Rate for Payer: Amerigroup CHIP/Medicaid	$55.73
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	$421.10
Rate for Payer: Cash Price	$421.10
Rate for Payer: Cash Price	$421.10
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$445.87
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	$445.87
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$402.53
Rate for Payer: Multiplan Commercial	$402.53
Rate for Payer: Multiplan Workers Comp	$402.53
Rate for Payer: Parkland Medicaid	$445.87
Rate for Payer: Scott and White EPO/PPO	$35.36
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$445.87
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 REMOVAL INTRAUTERINE DEVICE IUD BCE

Facility

$2,536.86

Service Code	HCPCS 58301
Hospital Charge Code	8910648
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,725.06

CHED REMOVAL INTRAUTERINE DEVICE IUD BCE

Facility

$2,536.86

Service Code	HCPCS 58301
Hospital Charge Code	8568928
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,725.06

CHED REMOVAL INTRAUTERINE DEVICE IUD BCE

Facility

$2,536.86

Service Code	HCPCS 58301
Hospital Charge Code	8910648
Hospital Revenue Code	450
Min. Negotiated Rate	$80.70
Max. Negotiated Rate	$1,826.54
Rate for Payer: Amerigroup CHIP/Medicaid	$228.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$306.12
Rate for Payer: Amerigroup Medicare	$306.12
Rate for Payer: BCBS of TX Blue Advantage	$87.39
Rate for Payer: BCBS of TX Blue Essentials	$104.66
Rate for Payer: BCBS of TX Medicare	$306.12
Rate for Payer: BCBS of TX PPO	$131.87
Rate for Payer: Cash Price	$1,725.06
Rate for Payer: Cash Price	$1,725.06
Rate for Payer: Cash Price	$1,725.06
Rate for Payer: Cigna Commercial	$647.08
Rate for Payer: Cigna Medicaid	$1,826.54
Rate for Payer: Cigna Medicare	$306.12
Rate for Payer: Employer Direct Commercial	$306.12
Rate for Payer: Humana Medicare/TRICARE	$306.12
Rate for Payer: Molina CHIP/Medicaid	$1,826.54
Rate for Payer: Molina Dual Medicare/Medicaid	$306.12
Rate for Payer: Molina Medicare	$306.12
Rate for Payer: Multiplan Auto	$1,648.96
Rate for Payer: Multiplan Commercial	$1,648.96
Rate for Payer: Multiplan Workers Comp	$1,648.96
Rate for Payer: Parkland Medicaid	$1,826.54
Rate for Payer: Scott and White EPO/PPO	$80.70
Rate for Payer: Scott and White Medicare	$306.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,826.54
Rate for Payer: Superior Health Plan EPO	$306.12
Rate for Payer: Superior Health Plan Medicare	$306.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$306.12
Rate for Payer: Universal American Medicare	$306.12
Rate for Payer: Wellcare Medicare	$306.12
Rate for Payer: Wellmed Medicare	$306.12

CHED REMOVAL INTRAUTERINE DEVICE IUD BCE

Facility

$2,536.86

Service Code	HCPCS 58301
Hospital Charge Code	8568928
Hospital Revenue Code	450
Min. Negotiated Rate	$80.70
Max. Negotiated Rate	$1,826.54
Rate for Payer: Amerigroup CHIP/Medicaid	$228.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$306.12
Rate for Payer: Amerigroup Medicare	$306.12
Rate for Payer: BCBS of TX Blue Advantage	$87.39
Rate for Payer: BCBS of TX Blue Essentials	$104.66
Rate for Payer: BCBS of TX Medicare	$306.12
Rate for Payer: BCBS of TX PPO	$131.87
Rate for Payer: Cash Price	$1,725.06
Rate for Payer: Cash Price	$1,725.06
Rate for Payer: Cash Price	$1,725.06
Rate for Payer: Cigna Commercial	$647.08
Rate for Payer: Cigna Medicaid	$1,826.54
Rate for Payer: Cigna Medicare	$306.12
Rate for Payer: Employer Direct Commercial	$306.12
Rate for Payer: Humana Medicare/TRICARE	$306.12
Rate for Payer: Molina CHIP/Medicaid	$1,826.54
Rate for Payer: Molina Dual Medicare/Medicaid	$306.12
Rate for Payer: Molina Medicare	$306.12
Rate for Payer: Multiplan Auto	$1,648.96
Rate for Payer: Multiplan Commercial	$1,648.96
Rate for Payer: Multiplan Workers Comp	$1,648.96
Rate for Payer: Parkland Medicaid	$1,826.54
Rate for Payer: Scott and White EPO/PPO	$80.70
Rate for Payer: Scott and White Medicare	$306.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,826.54
Rate for Payer: Superior Health Plan EPO	$306.12
Rate for Payer: Superior Health Plan Medicare	$306.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$306.12
Rate for Payer: Universal American Medicare	$306.12
Rate for Payer: Wellcare Medicare	$306.12
Rate for Payer: Wellmed Medicare	$306.12

CHED REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM BCE

Facility

$3,028.03

Service Code	HCPCS 13121
Hospital Charge Code	8914632
Hospital Revenue Code	450
Min. Negotiated Rate	$272.52
Max. Negotiated Rate	$2,180.18
Rate for Payer: Amerigroup CHIP/Medicaid	$272.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
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	$408.37
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,059.06
Rate for Payer: Cash Price	$2,059.06
Rate for Payer: Cash Price	$2,059.06
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$2,180.18
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$2,180.18
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,968.22
Rate for Payer: Multiplan Commercial	$1,968.22
Rate for Payer: Multiplan Workers Comp	$1,968.22
Rate for Payer: Parkland Medicaid	$2,180.18
Rate for Payer: Scott and White EPO/PPO	$314.70
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,180.18
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

CHED REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM BCE

Facility

$3,028.03

Service Code	HCPCS 13121
Hospital Charge Code	8914632
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,059.06

CHED REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM BCE

Facility

$1,634.82

Service Code	HCPCS 12042
Hospital Charge Code	8912652
Hospital Revenue Code	450
Min. Negotiated Rate	$147.13
Max. Negotiated Rate	$1,177.07
Rate for Payer: Amerigroup CHIP/Medicaid	$147.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$269.62
Rate for Payer: BCBS of TX Blue Essentials	$322.90
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$406.85
Rate for Payer: Cash Price	$1,111.68
Rate for Payer: Cash Price	$1,111.68
Rate for Payer: Cash Price	$1,111.68
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,177.07
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$1,177.07
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,062.63
Rate for Payer: Multiplan Commercial	$1,062.63
Rate for Payer: Multiplan Workers Comp	$1,062.63
Rate for Payer: Parkland Medicaid	$1,177.07
Rate for Payer: Scott and White EPO/PPO	$240.22
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,177.07
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

CHED REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM BCE

Facility

$1,634.82

Service Code	HCPCS 12042
Hospital Charge Code	8912652
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,111.68

CHED REPAIR INTERMEDIATE S A T E 12.6-20.0CM BCE

Facility

$2,495.00

Service Code	HCPCS 12035
Hospital Charge Code	8910649
Hospital Revenue Code	450
Min. Negotiated Rate	$224.55
Max. Negotiated Rate	$1,796.40
Rate for Payer: Amerigroup CHIP/Medicaid	$224.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
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	$408.37
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,696.60
Rate for Payer: Cash Price	$1,696.60
Rate for Payer: Cash Price	$1,696.60
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,796.40
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$1,796.40
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,621.75
Rate for Payer: Multiplan Commercial	$1,621.75
Rate for Payer: Multiplan Workers Comp	$1,621.75
Rate for Payer: Parkland Medicaid	$1,796.40
Rate for Payer: Scott and White EPO/PPO	$295.62
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,796.40
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

CHED REPAIR INTERMEDIATE S A T E 12.6-20.0CM BCE

Facility

$2,495.00

Service Code	HCPCS 12035
Hospital Charge Code	8910649
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,696.60

CHED REPAIR INTERMEDIATE WOUNDS S/A/T/E EXCL HAND/FEET 7.6 CM TO 12.5 CM BCE

Facility

$2,164.94

Service Code	HCPCS 12034
Hospital Charge Code	8914633
Hospital Revenue Code	450
Min. Negotiated Rate	$194.84
Max. Negotiated Rate	$1,558.76
Rate for Payer: Amerigroup CHIP/Medicaid	$194.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
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	$408.37
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,472.16
Rate for Payer: Cash Price	$1,472.16
Rate for Payer: Cash Price	$1,472.16
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,558.76
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$1,558.76
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,407.21
Rate for Payer: Multiplan Commercial	$1,407.21
Rate for Payer: Multiplan Workers Comp	$1,407.21
Rate for Payer: Parkland Medicaid	$1,558.76
Rate for Payer: Scott and White EPO/PPO	$251.84
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,558.76
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

CHED REPAIR INTERMEDIATE WOUNDS S/A/T/E EXCL HAND/FEET 7.6 CM TO 12.5 CM BCE

Facility

$2,164.94

Service Code	HCPCS 12034
Hospital Charge Code	8914633
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,472.16

CHED REPAIR INTERM F/E/E/N/L/MUC 5.1-7.5 CM BCE

Facility

$1,569.58

Service Code	HCPCS 12053
Hospital Charge Code	8498470
Hospital Revenue Code	450
Min. Negotiated Rate	$141.26
Max. Negotiated Rate	$1,130.10
Rate for Payer: Amerigroup CHIP/Medicaid	$141.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$269.62
Rate for Payer: BCBS of TX Blue Essentials	$322.90
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$406.85
Rate for Payer: Cash Price	$1,067.31
Rate for Payer: Cash Price	$1,067.31
Rate for Payer: Cash Price	$1,067.31
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,130.10
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$1,130.10
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,020.23
Rate for Payer: Multiplan Commercial	$1,020.23
Rate for Payer: Multiplan Workers Comp	$1,020.23
Rate for Payer: Parkland Medicaid	$1,130.10
Rate for Payer: Scott and White EPO/PPO	$263.82
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,130.10
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

CHED REPAIR INTERM F/E/E/N/L/MUC 5.1-7.5 CM BCE

Facility

$1,569.58

Service Code	HCPCS 12053
Hospital Charge Code	8912651
Hospital Revenue Code	450
Min. Negotiated Rate	$141.26
Max. Negotiated Rate	$1,130.10
Rate for Payer: Amerigroup CHIP/Medicaid	$141.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$269.62
Rate for Payer: BCBS of TX Blue Essentials	$322.90
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$406.85
Rate for Payer: Cash Price	$1,067.31
Rate for Payer: Cash Price	$1,067.31
Rate for Payer: Cash Price	$1,067.31
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,130.10
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$1,130.10
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,020.23
Rate for Payer: Multiplan Commercial	$1,020.23
Rate for Payer: Multiplan Workers Comp	$1,020.23
Rate for Payer: Parkland Medicaid	$1,130.10
Rate for Payer: Scott and White EPO/PPO	$263.82
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,130.10
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

CHED REPAIR INTERM F/E/E/N/L/MUC 5.1-7.5 CM BCE

Facility

$1,569.58

Service Code	HCPCS 12053
Hospital Charge Code	8498470
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,067.31

CHED REPAIR INTERM F/E/E/N/L/MUC 5.1-7.5 CM BCE

Facility

$1,569.58

Service Code	HCPCS 12053
Hospital Charge Code	8912651
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,067.31

CHED REPAIR LAC 2.5 CM OR LESS FLOOR OF MOUTH AND/OR ANT TWO-THIRDS OF TONGUE BCE

Facility

$814.48

Service Code	HCPCS 41250
Hospital Charge Code	8912653
Hospital Revenue Code	450
Rate for Payer: Cash Price	$553.85

CHED REPAIR LAC 2.5 CM OR LESS FLOOR OF MOUTH AND/OR ANT TWO-THIRDS OF TONGUE BCE

Facility

$814.48

Service Code	HCPCS 41250
Hospital Charge Code	8912653
Hospital Revenue Code	450
Min. Negotiated Rate	$73.30
Max. Negotiated Rate	$948.59
Rate for Payer: Amerigroup CHIP/Medicaid	$73.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$448.76
Rate for Payer: Amerigroup Medicare	$448.76
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	$448.76
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cash Price	$553.85
Rate for Payer: Cash Price	$553.85
Rate for Payer: Cash Price	$553.85
Rate for Payer: Cigna Commercial	$948.59
Rate for Payer: Cigna Medicaid	$586.43
Rate for Payer: Cigna Medicare	$448.76
Rate for Payer: Employer Direct Commercial	$448.76
Rate for Payer: Humana Medicare/TRICARE	$448.76
Rate for Payer: Molina CHIP/Medicaid	$586.43
Rate for Payer: Molina Dual Medicare/Medicaid	$448.76
Rate for Payer: Molina Medicare	$448.76
Rate for Payer: Multiplan Auto	$529.41
Rate for Payer: Multiplan Commercial	$529.41
Rate for Payer: Multiplan Workers Comp	$529.41
Rate for Payer: Parkland Medicaid	$586.43
Rate for Payer: Scott and White EPO/PPO	$189.55
Rate for Payer: Scott and White Medicare	$448.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$586.43
Rate for Payer: Superior Health Plan EPO	$448.76
Rate for Payer: Superior Health Plan Medicare	$448.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$448.76
Rate for Payer: Universal American Medicare	$448.76
Rate for Payer: Wellcare Medicare	$448.76
Rate for Payer: Wellmed Medicare	$448.76

CHED REPAIR LIP FULL THICKNESS VERMILION ONLY BCE

Facility

$2,794.28

Service Code	HCPCS 40650
Hospital Charge Code	8568466
Hospital Revenue Code	450
Min. Negotiated Rate	$251.49
Max. Negotiated Rate	$2,011.88
Rate for Payer: Amerigroup CHIP/Medicaid	$251.49
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$541.79
Rate for Payer: Amerigroup Medicare	$541.79
Rate for Payer: BCBS of TX Blue Advantage	$737.67
Rate for Payer: BCBS of TX Blue Essentials	$883.44
Rate for Payer: BCBS of TX Medicare	$541.79
Rate for Payer: BCBS of TX PPO	$1,113.13
Rate for Payer: Cash Price	$1,900.11
Rate for Payer: Cash Price	$1,900.11
Rate for Payer: Cash Price	$1,900.11
Rate for Payer: Cigna Commercial	$1,145.24
Rate for Payer: Cigna Medicaid	$2,011.88
Rate for Payer: Cigna Medicare	$541.79
Rate for Payer: Employer Direct Commercial	$541.79
Rate for Payer: Humana Medicare/TRICARE	$541.79
Rate for Payer: Molina CHIP/Medicaid	$2,011.88
Rate for Payer: Molina Dual Medicare/Medicaid	$541.79
Rate for Payer: Molina Medicare	$541.79
Rate for Payer: Multiplan Auto	$1,816.28
Rate for Payer: Multiplan Commercial	$1,816.28
Rate for Payer: Multiplan Workers Comp	$1,816.28
Rate for Payer: Parkland Medicaid	$2,011.88
Rate for Payer: Scott and White EPO/PPO	$393.19
Rate for Payer: Scott and White Medicare	$541.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,011.88
Rate for Payer: Superior Health Plan EPO	$541.79
Rate for Payer: Superior Health Plan Medicare	$541.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$541.79
Rate for Payer: Universal American Medicare	$541.79
Rate for Payer: Wellcare Medicare	$541.79
Rate for Payer: Wellmed Medicare	$541.79

CHED REPAIR LIP FULL THICKNESS VERMILION ONLY BCE

Facility

$2,794.28

Service Code	HCPCS 40650
Hospital Charge Code	8912654
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,900.11

CHED REPAIR LIP FULL THICKNESS VERMILION ONLY BCE

Facility

$2,794.28

Service Code	HCPCS 40650
Hospital Charge Code	8912654
Hospital Revenue Code	450
Min. Negotiated Rate	$251.49
Max. Negotiated Rate	$2,011.88
Rate for Payer: Amerigroup CHIP/Medicaid	$251.49
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$541.79
Rate for Payer: Amerigroup Medicare	$541.79
Rate for Payer: BCBS of TX Blue Advantage	$737.67
Rate for Payer: BCBS of TX Blue Essentials	$883.44
Rate for Payer: BCBS of TX Medicare	$541.79
Rate for Payer: BCBS of TX PPO	$1,113.13
Rate for Payer: Cash Price	$1,900.11
Rate for Payer: Cash Price	$1,900.11
Rate for Payer: Cash Price	$1,900.11
Rate for Payer: Cigna Commercial	$1,145.24
Rate for Payer: Cigna Medicaid	$2,011.88
Rate for Payer: Cigna Medicare	$541.79
Rate for Payer: Employer Direct Commercial	$541.79
Rate for Payer: Humana Medicare/TRICARE	$541.79
Rate for Payer: Molina CHIP/Medicaid	$2,011.88
Rate for Payer: Molina Dual Medicare/Medicaid	$541.79
Rate for Payer: Molina Medicare	$541.79
Rate for Payer: Multiplan Auto	$1,816.28
Rate for Payer: Multiplan Commercial	$1,816.28
Rate for Payer: Multiplan Workers Comp	$1,816.28
Rate for Payer: Parkland Medicaid	$2,011.88
Rate for Payer: Scott and White EPO/PPO	$393.19
Rate for Payer: Scott and White Medicare	$541.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,011.88
Rate for Payer: Superior Health Plan EPO	$541.79
Rate for Payer: Superior Health Plan Medicare	$541.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$541.79
Rate for Payer: Universal American Medicare	$541.79
Rate for Payer: Wellcare Medicare	$541.79
Rate for Payer: Wellmed Medicare	$541.79

CHED REPAIR LIP FULL THICKNESS VERMILION ONLY BCE

Facility

$2,794.28

Service Code	HCPCS 40650
Hospital Charge Code	8568466
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,900.11

CHED Rhythm ECG 1-3 leads tracing only BCE

Facility

$220.24

Service Code	HCPCS 93041
Hospital Charge Code	8914635
Hospital Revenue Code	730
Min. Negotiated Rate	$7.78
Max. Negotiated Rate	$158.57
Rate for Payer: Amerigroup CHIP/Medicaid	$19.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$66.07
Rate for Payer: BCBS of TX Blue Essentials	$79.29
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$88.10
Rate for Payer: Cash Price	$149.76
Rate for Payer: Cash Price	$149.76
Rate for Payer: Cash Price	$149.76
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$158.57
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$158.57
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
Rate for Payer: Multiplan Auto	$143.16
Rate for Payer: Multiplan Commercial	$143.16
Rate for Payer: Multiplan Workers Comp	$143.16
Rate for Payer: Parkland Medicaid	$158.57
Rate for Payer: Scott and White EPO/PPO	$7.78
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$158.57
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

Know your out-of-pocket cost for care.

All Charges