White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHED Rhythm ECG 1-3 leads tracing only BCE

Facility

$220.24

Service Code	HCPCS 93041
Hospital Charge Code	8914635
Hospital Revenue Code	730
Rate for Payer: Cash Price	$149.76

CHED RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP BCE

Facility

$592.25

Service Code	HCPCS 65222
Hospital Charge Code	8910650
Hospital Revenue Code	450
Rate for Payer: Cash Price	$402.73

CHED RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP BCE

Facility

$592.25

Service Code	HCPCS 65222
Hospital Charge Code	8910650
Hospital Revenue Code	450
Min. Negotiated Rate	$53.30
Max. Negotiated Rate	$426.42
Rate for Payer: Amerigroup CHIP/Medicaid	$53.30
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	$402.73
Rate for Payer: Cash Price	$402.73
Rate for Payer: Cash Price	$402.73
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$426.42
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	$426.42
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$384.96
Rate for Payer: Multiplan Commercial	$384.96
Rate for Payer: Multiplan Workers Comp	$384.96
Rate for Payer: Parkland Medicaid	$426.42
Rate for Payer: Scott and White EPO/PPO	$61.29
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$426.42
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 RMVL NON-BIODEGRADABLE DRUG DELIV IMPLT BCE

Facility

$5,619.66

Service Code	HCPCS 11982
Hospital Charge Code	8910651
Hospital Revenue Code	450
Rate for Payer: Cash Price	$3,821.37

CHED RMVL NON-BIODEGRADABLE DRUG DELIV IMPLT BCE

Facility

$5,619.66

Service Code	HCPCS 11982
Hospital Charge Code	8910651
Hospital Revenue Code	450
Min. Negotiated Rate	$88.80
Max. Negotiated Rate	$4,046.16
Rate for Payer: Amerigroup CHIP/Medicaid	$505.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$448.76
Rate for Payer: Amerigroup Medicare	$448.76
Rate for Payer: BCBS of TX Blue Advantage	$607.20
Rate for Payer: BCBS of TX Blue Essentials	$727.18
Rate for Payer: BCBS of TX Medicare	$448.76
Rate for Payer: BCBS of TX PPO	$916.25
Rate for Payer: Cash Price	$3,821.37
Rate for Payer: Cash Price	$3,821.37
Rate for Payer: Cash Price	$3,821.37
Rate for Payer: Cigna Commercial	$948.59
Rate for Payer: Cigna Medicaid	$4,046.16
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	$4,046.16
Rate for Payer: Molina Dual Medicare/Medicaid	$448.76
Rate for Payer: Molina Medicare	$448.76
Rate for Payer: Multiplan Auto	$3,652.78
Rate for Payer: Multiplan Commercial	$3,652.78
Rate for Payer: Multiplan Workers Comp	$3,652.78
Rate for Payer: Parkland Medicaid	$4,046.16
Rate for Payer: Scott and White EPO/PPO	$88.80
Rate for Payer: Scott and White Medicare	$448.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,046.16
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 RMVL SUPFCL SOFT TISS FB SUBLINGUAL MUCOSA BCE

Facility

$2,749.00

Service Code	HCPCS 41599
Hospital Charge Code	8912655
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,869.32

CHED RMVL SUPFCL SOFT TISS FB SUBLINGUAL MUCOSA BCE

Facility

$2,749.00

Service Code	HCPCS 41599
Hospital Charge Code	8912655
Hospital Revenue Code	450
Min. Negotiated Rate	$237.93
Max. Negotiated Rate	$1,979.28
Rate for Payer: Amerigroup CHIP/Medicaid	$247.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$237.93
Rate for Payer: Amerigroup Medicare	$237.93
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	$237.93
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cash Price	$1,869.32
Rate for Payer: Cash Price	$1,869.32
Rate for Payer: Cash Price	$1,869.32
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$1,979.28
Rate for Payer: Cigna Medicare	$237.93
Rate for Payer: Employer Direct Commercial	$237.93
Rate for Payer: Humana Medicare/TRICARE	$237.93
Rate for Payer: Molina CHIP/Medicaid	$1,979.28
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
Rate for Payer: Multiplan Auto	$1,786.85
Rate for Payer: Multiplan Commercial	$1,786.85
Rate for Payer: Multiplan Workers Comp	$1,786.85
Rate for Payer: Parkland Medicaid	$1,979.28
Rate for Payer: Scott and White EPO/PPO	$1,374.50
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,979.28
Rate for Payer: Superior Health Plan EPO	$237.93
Rate for Payer: Superior Health Plan Medicare	$237.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$237.93
Rate for Payer: Universal American Medicare	$237.93
Rate for Payer: Wellcare Medicare	$237.93
Rate for Payer: Wellmed Medicare	$237.93

CHED Routine ECG 12 lead/15 lead tracing only BCE

Facility

$673.00

Service Code	HCPCS 93005
Hospital Charge Code	8910653
Hospital Revenue Code	730
Min. Negotiated Rate	$7.78
Max. Negotiated Rate	$484.56
Rate for Payer: Amerigroup CHIP/Medicaid	$60.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$201.90
Rate for Payer: BCBS of TX Blue Essentials	$242.28
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$269.20
Rate for Payer: Cash Price	$457.64
Rate for Payer: Cash Price	$457.64
Rate for Payer: Cash Price	$457.64
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$484.56
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	$484.56
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
Rate for Payer: Multiplan Auto	$437.45
Rate for Payer: Multiplan Commercial	$437.45
Rate for Payer: Multiplan Workers Comp	$437.45
Rate for Payer: Parkland Medicaid	$484.56
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	$484.56
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

CHED Routine ECG 12 lead/15 lead tracing only BCE

Facility

$673.00

Service Code	HCPCS 93005
Hospital Charge Code	8910653
Hospital Revenue Code	730
Rate for Payer: Cash Price	$457.64

CHED RPLC GASTRO/CECOSTOMY TUBE PERC W/GUIDE CNTRST IMG BCE

Facility

$2,430.57

Service Code	HCPCS 49450
Hospital Charge Code	8912656
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,652.79

CHED RPLC GASTRO/CECOSTOMY TUBE PERC W/GUIDE CNTRST IMG BCE

Facility

$2,430.57

Service Code	HCPCS 49450
Hospital Charge Code	8912656
Hospital Revenue Code	450
Min. Negotiated Rate	$78.15
Max. Negotiated Rate	$1,980.52
Rate for Payer: Amerigroup CHIP/Medicaid	$218.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$911.12
Rate for Payer: Amerigroup Medicare	$911.12
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	$911.12
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cash Price	$1,652.79
Rate for Payer: Cash Price	$1,652.79
Rate for Payer: Cash Price	$1,652.79
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicaid	$1,750.01
Rate for Payer: Cigna Medicare	$911.12
Rate for Payer: Employer Direct Commercial	$911.12
Rate for Payer: Humana Medicare/TRICARE	$911.12
Rate for Payer: Molina CHIP/Medicaid	$1,750.01
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
Rate for Payer: Multiplan Auto	$1,579.87
Rate for Payer: Multiplan Commercial	$1,579.87
Rate for Payer: Multiplan Workers Comp	$1,579.87
Rate for Payer: Parkland Medicaid	$1,750.01
Rate for Payer: Scott and White EPO/PPO	$78.15
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,750.01
Rate for Payer: Superior Health Plan EPO	$911.12
Rate for Payer: Superior Health Plan Medicare	$911.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$911.12
Rate for Payer: Universal American Medicare	$911.12
Rate for Payer: Wellcare Medicare	$911.12
Rate for Payer: Wellmed Medicare	$911.12

CHED RPLC GASTRO TUBE PERC WO IMG NO REVSN GASTRO TRCT BCE

Facility

$1,239.24

Service Code	HCPCS 43762
Hospital Charge Code	8910652
Hospital Revenue Code	450
Min. Negotiated Rate	$45.12
Max. Negotiated Rate	$892.25
Rate for Payer: Amerigroup CHIP/Medicaid	$111.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$250.99
Rate for Payer: Amerigroup Medicare	$250.99
Rate for Payer: BCBS of TX Blue Advantage	$392.28
Rate for Payer: BCBS of TX Blue Essentials	$469.80
Rate for Payer: BCBS of TX Medicare	$250.99
Rate for Payer: BCBS of TX PPO	$591.95
Rate for Payer: Cash Price	$842.68
Rate for Payer: Cash Price	$842.68
Rate for Payer: Cash Price	$842.68
Rate for Payer: Cigna Commercial	$530.54
Rate for Payer: Cigna Medicaid	$892.25
Rate for Payer: Cigna Medicare	$250.99
Rate for Payer: Employer Direct Commercial	$250.99
Rate for Payer: Humana Medicare/TRICARE	$250.99
Rate for Payer: Molina CHIP/Medicaid	$892.25
Rate for Payer: Molina Dual Medicare/Medicaid	$250.99
Rate for Payer: Molina Medicare	$250.99
Rate for Payer: Multiplan Auto	$805.51
Rate for Payer: Multiplan Commercial	$805.51
Rate for Payer: Multiplan Workers Comp	$805.51
Rate for Payer: Parkland Medicaid	$892.25
Rate for Payer: Scott and White EPO/PPO	$45.12
Rate for Payer: Scott and White Medicare	$250.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$892.25
Rate for Payer: Superior Health Plan EPO	$250.99
Rate for Payer: Superior Health Plan Medicare	$250.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$250.99
Rate for Payer: Universal American Medicare	$250.99
Rate for Payer: Wellcare Medicare	$250.99
Rate for Payer: Wellmed Medicare	$250.99

CHED RPLC GASTRO TUBE PERC WO IMG NO REVSN GASTRO TRCT BCE

Facility

$1,239.24

Service Code	HCPCS 43762
Hospital Charge Code	8910652
Hospital Revenue Code	450
Rate for Payer: Cash Price	$842.68

CHED RPR LAC 2.5 CM TONGUE LACERATION BCE

Facility

$872.00

Service Code	HCPCS 41250
Hospital Charge Code	9075003
Hospital Revenue Code	450
Rate for Payer: Cash Price	$592.96

CHED RPR LAC 2.5 CM TONGUE LACERATION BCE

Facility

$872.00

Service Code	HCPCS 41250
Hospital Charge Code	9075003
Hospital Revenue Code	450
Min. Negotiated Rate	$78.48
Max. Negotiated Rate	$948.59
Rate for Payer: Amerigroup CHIP/Medicaid	$78.48
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	$592.96
Rate for Payer: Cash Price	$592.96
Rate for Payer: Cash Price	$592.96
Rate for Payer: Cigna Commercial	$948.59
Rate for Payer: Cigna Medicaid	$627.84
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	$627.84
Rate for Payer: Molina Dual Medicare/Medicaid	$448.76
Rate for Payer: Molina Medicare	$448.76
Rate for Payer: Multiplan Auto	$566.80
Rate for Payer: Multiplan Commercial	$566.80
Rate for Payer: Multiplan Workers Comp	$566.80
Rate for Payer: Parkland Medicaid	$627.84
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	$627.84
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 RPR S N A GEN TRK 12.6 TO 20.0CM BCE

Facility

$993.50

Service Code	HCPCS 12005
Hospital Charge Code	8914634
Hospital Revenue Code	450
Min. Negotiated Rate	$89.42
Max. Negotiated Rate	$863.21
Rate for Payer: Amerigroup CHIP/Medicaid	$89.42
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	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$715.32
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	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$645.77
Rate for Payer: Multiplan Commercial	$645.77
Rate for Payer: Multiplan Workers Comp	$645.77
Rate for Payer: Parkland Medicaid	$715.32
Rate for Payer: Scott and White EPO/PPO	$114.84
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
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 RPR S N A GEN TRK 12.6 TO 20.0CM BCE

Facility

$993.50

Service Code	HCPCS 12005
Hospital Charge Code	8400484
Hospital Revenue Code	450
Min. Negotiated Rate	$89.42
Max. Negotiated Rate	$863.21
Rate for Payer: Amerigroup CHIP/Medicaid	$89.42
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	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$715.32
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	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$645.77
Rate for Payer: Multiplan Commercial	$645.77
Rate for Payer: Multiplan Workers Comp	$645.77
Rate for Payer: Parkland Medicaid	$715.32
Rate for Payer: Scott and White EPO/PPO	$114.84
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
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 RPR S N A GEN TRK 12.6 TO 20.0CM BCE

Facility

$993.50

Service Code	HCPCS 12005
Hospital Charge Code	8914634
Hospital Revenue Code	450
Rate for Payer: Cash Price	$675.58

CHED RPR S N A GEN TRK 12.6 TO 20.0CM BCE

Facility

$993.50

Service Code	HCPCS 12005
Hospital Charge Code	8400484
Hospital Revenue Code	450
Rate for Payer: Cash Price	$675.58

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

Facility

$918.00

Service Code	HCPCS 12015
Hospital Charge Code	8912658
Hospital Revenue Code	450
Rate for Payer: Cash Price	$624.24

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

Facility

$918.00

Service Code	HCPCS 12015
Hospital Charge Code	8912658
Hospital Revenue Code	450
Min. Negotiated Rate	$82.62
Max. Negotiated Rate	$660.96
Rate for Payer: Amerigroup CHIP/Medicaid	$82.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
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	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$624.24
Rate for Payer: Cash Price	$624.24
Rate for Payer: Cash Price	$624.24
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$660.96
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$660.96
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$596.70
Rate for Payer: Multiplan Commercial	$596.70
Rate for Payer: Multiplan Workers Comp	$596.70
Rate for Payer: Parkland Medicaid	$660.96
Rate for Payer: Scott and White EPO/PPO	$114.01
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$660.96
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

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

Facility

$1,187.00

Service Code	HCPCS 12006
Hospital Charge Code	8538503
Hospital Revenue Code	450
Rate for Payer: Cash Price	$807.16

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

Facility

$1,187.00

Service Code	HCPCS 12006
Hospital Charge Code	8538503
Hospital Revenue Code	450
Min. Negotiated Rate	$106.83
Max. Negotiated Rate	$863.21
Rate for Payer: Amerigroup CHIP/Medicaid	$106.83
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	$807.16
Rate for Payer: Cash Price	$807.16
Rate for Payer: Cash Price	$807.16
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$854.64
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	$854.64
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$854.64
Rate for Payer: Scott and White EPO/PPO	$140.50
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$854.64
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 Throat Procedures Dental Surgery BCE

Facility

$16,333.67

Service Code	HCPCS 41899
Hospital Charge Code	8912664
Hospital Revenue Code	450
Rate for Payer: Cash Price	$11,106.90

CHED Throat Procedures Dental Surgery BCE

Facility

$16,333.67

Service Code	HCPCS 41899
Hospital Charge Code	8912664
Hospital Revenue Code	450
Min. Negotiated Rate	$237.93
Max. Negotiated Rate	$11,760.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,470.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$237.93
Rate for Payer: Amerigroup Medicare	$237.93
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	$237.93
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cash Price	$11,106.90
Rate for Payer: Cash Price	$11,106.90
Rate for Payer: Cash Price	$11,106.90
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$11,760.24
Rate for Payer: Cigna Medicare	$237.93
Rate for Payer: Employer Direct Commercial	$237.93
Rate for Payer: Humana Medicare/TRICARE	$237.93
Rate for Payer: Molina CHIP/Medicaid	$11,760.24
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
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: Parkland Medicaid	$11,760.24
Rate for Payer: Scott and White EPO/PPO	$8,166.84
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,760.24
Rate for Payer: Superior Health Plan EPO	$237.93
Rate for Payer: Superior Health Plan Medicare	$237.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$237.93
Rate for Payer: Universal American Medicare	$237.93
Rate for Payer: Wellcare Medicare	$237.93
Rate for Payer: Wellmed Medicare	$237.93

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