White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED Pneum Initial Admin Charge 90471/G0009 BCE

Facility

$124.00

Service Code	CPT 90471
Hospital Charge Code	5200050
Hospital Revenue Code	771
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$68.20
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$105.22
Rate for Payer: BCBS of TX Blue Essentials	$125.78
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$140.29
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Scott and White EPO/PPO	$1.15
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

ED -Pneum Vacc Adm G0009

Facility

$124.00

Service Code	HCPCS G0009
Hospital Charge Code	5200050
Hospital Revenue Code	771
Rate for Payer: Cash Price	$109.12

ED -Pneum Vacc Adm G0009

Facility

$124.00

Service Code	HCPCS G0009
Hospital Charge Code	5200050
Hospital Revenue Code	771
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$111.20
Rate for Payer: Aetna Commercial	$68.20
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$83.40
Rate for Payer: BCBS of TX Blue Essentials	$99.69
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$111.20
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

ED PRESSD NONPRESSD INHAL TRMENT BCE

Facility

$170.00

Service Code	CPT 94640
Hospital Charge Code	8402468
Hospital Revenue Code	410
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$441.88
Rate for Payer: Aetna Commercial	$93.50
Rate for Payer: Aetna Medicare	$292.59
Rate for Payer: Amerigroup CHIP/Medicaid	$15.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$195.06
Rate for Payer: Amerigroup Medicare	$195.06
Rate for Payer: BCBS of TX Blue Advantage	$320.09
Rate for Payer: BCBS of TX Blue Essentials	$382.64
Rate for Payer: BCBS of TX Medicare	$195.06
Rate for Payer: BCBS of TX PPO	$426.79
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cigna Commercial	$441.88
Rate for Payer: Cigna Medicare	$195.06
Rate for Payer: Employer Direct Commercial	$195.06
Rate for Payer: Humana Medicare/TRICARE	$195.06
Rate for Payer: Molina Dual Medicare/Medicaid	$195.06
Rate for Payer: Molina Medicare	$195.06
Rate for Payer: Multiplan Auto	$110.50
Rate for Payer: Multiplan Commercial	$110.50
Rate for Payer: Multiplan Workers Comp	$110.50
Rate for Payer: Scott and White EPO/PPO	$3.49
Rate for Payer: Scott and White Medicare	$195.06
Rate for Payer: Superior Health Plan EPO	$195.06
Rate for Payer: Superior Health Plan Medicare	$195.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$195.06
Rate for Payer: Universal American Medicare	$195.06
Rate for Payer: Wellcare Medicare	$195.06
Rate for Payer: Wellmed Medicare	$195.06

ED PRESSD NONPRESSD INHAL TRMENT BCE

Facility

$170.00

Service Code	CPT 94640
Hospital Charge Code	8402468
Hospital Revenue Code	410
Rate for Payer: Cash Price	$149.60

ED PUNCTURE ASPIRATION CYST BREAST BCE

Facility

$647.00

Service Code	CPT 19000
Hospital Charge Code	8926640
Hospital Revenue Code	450
Rate for Payer: Cash Price	$569.36

ED PUNCTURE ASPIRATION CYST BREAST BCE

Facility

$647.00

Service Code	CPT 19000
Hospital Charge Code	8926640
Hospital Revenue Code	450
Min. Negotiated Rate	$11.51
Max. Negotiated Rate	$1,457.60
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$965.18
Rate for Payer: Amerigroup CHIP/Medicaid	$58.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$643.45
Rate for Payer: Amerigroup Medicare	$643.45
Rate for Payer: BCBS of TX Blue Advantage	$130.18
Rate for Payer: BCBS of TX Blue Essentials	$155.90
Rate for Payer: BCBS of TX Medicare	$643.45
Rate for Payer: BCBS of TX PPO	$196.43
Rate for Payer: Cash Price	$569.36
Rate for Payer: Cash Price	$569.36
Rate for Payer: Cash Price	$569.36
Rate for Payer: Cigna Commercial	$1,457.60
Rate for Payer: Cigna Medicaid	$59.25
Rate for Payer: Cigna Medicare	$643.45
Rate for Payer: Employer Direct Commercial	$643.45
Rate for Payer: Humana Medicare/TRICARE	$643.45
Rate for Payer: Molina CHIP/Medicaid	$59.25
Rate for Payer: Molina Dual Medicare/Medicaid	$643.45
Rate for Payer: Molina Medicare	$643.45
Rate for Payer: Multiplan Auto	$420.55
Rate for Payer: Multiplan Commercial	$420.55
Rate for Payer: Multiplan Workers Comp	$420.55
Rate for Payer: Parkland Medicaid	$59.25
Rate for Payer: Scott and White EPO/PPO	$11.51
Rate for Payer: Scott and White Medicare	$643.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.25
Rate for Payer: Superior Health Plan EPO	$643.45
Rate for Payer: Superior Health Plan Medicare	$643.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$643.45
Rate for Payer: Universal American Medicare	$643.45
Rate for Payer: Wellcare Medicare	$643.45
Rate for Payer: Wellmed Medicare	$643.45

ED REMOVAL INTRAUTERINE DEVICE IUD BCE

Facility

$2,537.00

Service Code	CPT 58301
Hospital Charge Code	8568928
Hospital Revenue Code	450
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$1,649.05
Rate for Payer: Aetna Commercial	$1,395.35
Rate for Payer: Aetna Medicare	$440.08
Rate for Payer: Amerigroup CHIP/Medicaid	$228.33
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$293.39
Rate for Payer: Amerigroup Medicare	$293.39
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	$293.39
Rate for Payer: BCBS of TX PPO	$131.87
Rate for Payer: Cash Price	$2,232.56
Rate for Payer: Cash Price	$2,232.56
Rate for Payer: Cash Price	$2,232.56
Rate for Payer: Cigna Commercial	$664.62
Rate for Payer: Cigna Medicaid	$51.22
Rate for Payer: Cigna Medicare	$293.39
Rate for Payer: Employer Direct Commercial	$293.39
Rate for Payer: Humana Medicare/TRICARE	$293.39
Rate for Payer: Molina CHIP/Medicaid	$51.22
Rate for Payer: Molina Dual Medicare/Medicaid	$293.39
Rate for Payer: Molina Medicare	$293.39
Rate for Payer: Multiplan Auto	$1,649.05
Rate for Payer: Multiplan Commercial	$1,649.05
Rate for Payer: Multiplan Workers Comp	$1,649.05
Rate for Payer: Parkland Medicaid	$51.22
Rate for Payer: Scott and White EPO/PPO	$5.25
Rate for Payer: Scott and White Medicare	$293.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.22
Rate for Payer: Superior Health Plan EPO	$293.39
Rate for Payer: Superior Health Plan Medicare	$293.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$293.39
Rate for Payer: Universal American Medicare	$293.39
Rate for Payer: Wellcare Medicare	$293.39
Rate for Payer: Wellmed Medicare	$293.39

ED REMOVAL INTRAUTERINE DEVICE IUD BCE

Facility

$2,537.00

Service Code	CPT 58301
Hospital Charge Code	8568928
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,232.56

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

Facility

$1,514.00

Service Code	CPT 13121
Hospital Charge Code	8568926
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,332.32

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

Facility

$1,514.00

Service Code	CPT 13121
Hospital Charge Code	8568926
Hospital Revenue Code	450
Min. Negotiated Rate	$10.27
Max. Negotiated Rate	$1,301.14
Rate for Payer: Aetna Commercial	$832.70
Rate for Payer: Aetna Medicare	$861.57
Rate for Payer: Amerigroup CHIP/Medicaid	$136.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$574.38
Rate for Payer: Amerigroup Medicare	$574.38
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$574.38
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$1,332.32
Rate for Payer: Cash Price	$1,332.32
Rate for Payer: Cash Price	$1,332.32
Rate for Payer: Cigna Commercial	$1,301.14
Rate for Payer: Cigna Medicaid	$216.80
Rate for Payer: Cigna Medicare	$574.38
Rate for Payer: Employer Direct Commercial	$574.38
Rate for Payer: Humana Medicare/TRICARE	$574.38
Rate for Payer: Molina CHIP/Medicaid	$216.80
Rate for Payer: Molina Dual Medicare/Medicaid	$574.38
Rate for Payer: Molina Medicare	$574.38
Rate for Payer: Multiplan Auto	$984.10
Rate for Payer: Multiplan Commercial	$984.10
Rate for Payer: Multiplan Workers Comp	$984.10
Rate for Payer: Parkland Medicaid	$216.80
Rate for Payer: Scott and White EPO/PPO	$10.27
Rate for Payer: Scott and White Medicare	$574.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.80
Rate for Payer: Superior Health Plan EPO	$574.38
Rate for Payer: Superior Health Plan Medicare	$574.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$574.38
Rate for Payer: Universal American Medicare	$574.38
Rate for Payer: Wellcare Medicare	$574.38
Rate for Payer: Wellmed Medicare	$574.38

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

Facility

$1,545.00

Service Code	CPT 12042
Hospital Charge Code	8568927
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,359.60

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

Facility

$1,545.00

Service Code	CPT 12042
Hospital Charge Code	8568927
Hospital Revenue Code	450
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$1,004.25
Rate for Payer: Aetna Commercial	$849.75
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$139.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
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	$364.67
Rate for Payer: BCBS of TX PPO	$406.85
Rate for Payer: Cash Price	$1,359.60
Rate for Payer: Cash Price	$1,359.60
Rate for Payer: Cash Price	$1,359.60
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	$1,004.25
Rate for Payer: Multiplan Commercial	$1,004.25
Rate for Payer: Multiplan Workers Comp	$1,004.25
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 REPAIR INTERMEDIATE S A T E 12.6-20.0CM BCE

Facility

$1,248.00

Service Code	CPT 12035
Hospital Charge Code	8404451
Hospital Revenue Code	450
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$686.40
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$112.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,098.24
Rate for Payer: Cash Price	$1,098.24
Rate for Payer: Cash Price	$1,098.24
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	$811.20
Rate for Payer: Multiplan Commercial	$811.20
Rate for Payer: Multiplan Workers Comp	$811.20
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 REPAIR INTERMEDIATE S A T E 12.6-20.0CM BCE

Facility

$1,248.00

Service Code	CPT 12035
Hospital Charge Code	8404451
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,098.24

ED REPAIR INTERMEDIATE WOUNDS S/A/T/E EXCL HAND/FEET 7.6 CM

Facility

$1,082.00

Service Code	CPT 12034
Hospital Charge Code	8470466
Hospital Revenue Code	450
Rate for Payer: Cash Price	$952.16

ED REPAIR INTERMEDIATE WOUNDS S/A/T/E EXCL HAND/FEET 7.6 CM

Facility

$1,082.00

Service Code	CPT 12034
Hospital Charge Code	8470466
Hospital Revenue Code	450
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$595.10
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$97.38
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	$952.16
Rate for Payer: Cash Price	$952.16
Rate for Payer: Cash Price	$952.16
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	$703.30
Rate for Payer: Multiplan Commercial	$703.30
Rate for Payer: Multiplan Workers Comp	$703.30
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 REPAIR INTERM F/E/E/N/L/MUC 5.1-7.5 CM BCE

Facility

$1,570.00

Service Code	CPT 12053
Hospital Charge Code	8498470
Hospital Revenue Code	450
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$1,020.50
Rate for Payer: Aetna Commercial	$863.50
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$141.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
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	$364.67
Rate for Payer: BCBS of TX PPO	$406.85
Rate for Payer: Cash Price	$1,381.60
Rate for Payer: Cash Price	$1,381.60
Rate for Payer: Cash Price	$1,381.60
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	$1,020.50
Rate for Payer: Multiplan Commercial	$1,020.50
Rate for Payer: Multiplan Workers Comp	$1,020.50
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 REPAIR INTERM F/E/E/N/L/MUC 5.1-7.5 CM BCE

Facility

$1,570.00

Service Code	CPT 12053
Hospital Charge Code	8498470
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,381.60

ED REPAIR LAC 2.5 CM OR LESS FLOOR OF MOUTH AND/OR ANT TWO-T

Facility

$536.00

Service Code	CPT 41250
Hospital Charge Code	8472467
Hospital Revenue Code	450
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$825.46
Rate for Payer: Aetna Commercial	$294.80
Rate for Payer: Aetna Medicare	$546.58
Rate for Payer: Amerigroup CHIP/Medicaid	$48.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.39
Rate for Payer: Amerigroup Medicare	$364.39
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	$364.39
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cash Price	$471.68
Rate for Payer: Cash Price	$471.68
Rate for Payer: Cash Price	$471.68
Rate for Payer: Cigna Commercial	$825.46
Rate for Payer: Cigna Medicare	$364.39
Rate for Payer: Employer Direct Commercial	$364.39
Rate for Payer: Humana Medicare/TRICARE	$364.39
Rate for Payer: Molina Dual Medicare/Medicaid	$364.39
Rate for Payer: Molina Medicare	$364.39
Rate for Payer: Multiplan Auto	$348.40
Rate for Payer: Multiplan Commercial	$348.40
Rate for Payer: Multiplan Workers Comp	$348.40
Rate for Payer: Scott and White EPO/PPO	$6.52
Rate for Payer: Scott and White Medicare	$364.39
Rate for Payer: Superior Health Plan EPO	$364.39
Rate for Payer: Superior Health Plan Medicare	$364.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.39
Rate for Payer: Universal American Medicare	$364.39
Rate for Payer: Wellcare Medicare	$364.39
Rate for Payer: Wellmed Medicare	$364.39

ED REPAIR LAC 2.5 CM OR LESS FLOOR OF MOUTH AND/OR ANT TWO-T

Facility

$536.00

Service Code	CPT 41250
Hospital Charge Code	8472467
Hospital Revenue Code	450
Rate for Payer: Cash Price	$471.68

ED REPAIR LIP FULL THICKNESS VERMILION ONLY BCE

Facility

$1,397.00

Service Code	CPT 40650
Hospital Charge Code	8568466
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,229.36

ED REPAIR LIP FULL THICKNESS VERMILION ONLY BCE

Facility

$1,397.00

Service Code	CPT 40650
Hospital Charge Code	8568466
Hospital Revenue Code	450
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$1,139.87
Rate for Payer: Aetna Commercial	$768.35
Rate for Payer: Aetna Medicare	$754.78
Rate for Payer: Amerigroup CHIP/Medicaid	$125.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$503.19
Rate for Payer: Amerigroup Medicare	$503.19
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	$503.19
Rate for Payer: BCBS of TX PPO	$1,113.13
Rate for Payer: Cash Price	$1,229.36
Rate for Payer: Cash Price	$1,229.36
Rate for Payer: Cash Price	$1,229.36
Rate for Payer: Cigna Commercial	$1,139.87
Rate for Payer: Cigna Medicaid	$187.22
Rate for Payer: Cigna Medicare	$503.19
Rate for Payer: Employer Direct Commercial	$503.19
Rate for Payer: Humana Medicare/TRICARE	$503.19
Rate for Payer: Molina CHIP/Medicaid	$187.22
Rate for Payer: Molina Dual Medicare/Medicaid	$503.19
Rate for Payer: Molina Medicare	$503.19
Rate for Payer: Multiplan Auto	$908.05
Rate for Payer: Multiplan Commercial	$908.05
Rate for Payer: Multiplan Workers Comp	$908.05
Rate for Payer: Parkland Medicaid	$187.22
Rate for Payer: Scott and White EPO/PPO	$9.00
Rate for Payer: Scott and White Medicare	$503.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$187.22
Rate for Payer: Superior Health Plan EPO	$503.19
Rate for Payer: Superior Health Plan Medicare	$503.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$503.19
Rate for Payer: Universal American Medicare	$503.19
Rate for Payer: Wellcare Medicare	$503.19
Rate for Payer: Wellmed Medicare	$503.19

ED Rhythm ECG 1-3 leads tracing only BCE

Facility

$242.00

Service Code	CPT 93041
Hospital Charge Code	5367567
Hospital Revenue Code	730
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$157.30
Rate for Payer: Aetna Commercial	$9.55
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$21.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$95.72
Rate for Payer: BCBS of TX Blue Essentials	$114.42
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$127.62
Rate for Payer: Cash Price	$212.96
Rate for Payer: Cash Price	$212.96
Rate for Payer: Cash Price	$212.96
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
Rate for Payer: Multiplan Auto	$157.30
Rate for Payer: Multiplan Commercial	$157.30
Rate for Payer: Multiplan Workers Comp	$157.30
Rate for Payer: Scott and White EPO/PPO	$1.00
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

ED RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP BCE

Facility

$494.00

Service Code	CPT 65222
Hospital Charge Code	8726549
Hospital Revenue Code	450
Rate for Payer: Cash Price	$434.72

Know your out-of-pocket cost for care.

All Charges