White Rock Medical Center

All Charges

Charge

Type

Setting

Price

eptifibatide 2 mg/mL IV Soln 10 mL

Facility

$260.33

Service Code	HCPCS J1327
Hospital Charge Code	77550190
Hospital Revenue Code	636
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$169.21
Rate for Payer: Aetna Medicare	$5.02
Rate for Payer: Amerigroup CHIP/Medicaid	$23.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.35
Rate for Payer: Amerigroup Medicare	$3.35
Rate for Payer: BCBS of TX Blue Advantage	$22.04
Rate for Payer: BCBS of TX Blue Essentials	$26.45
Rate for Payer: BCBS of TX Medicare	$3.35
Rate for Payer: BCBS of TX PPO	$29.34
Rate for Payer: Cash Price	$177.02
Rate for Payer: Cash Price	$177.02
Rate for Payer: Cigna Medicare	$3.35
Rate for Payer: Employer Direct Commercial	$3.35
Rate for Payer: Humana Medicare/TRICARE	$3.35
Rate for Payer: Molina Dual Medicare/Medicaid	$3.35
Rate for Payer: Molina Medicare	$3.35
Rate for Payer: Multiplan Auto	$169.21
Rate for Payer: Multiplan Commercial	$169.21
Rate for Payer: Multiplan Workers Comp	$169.21
Rate for Payer: Scott and White EPO/PPO	$130.16
Rate for Payer: Scott and White Medicare	$3.35
Rate for Payer: Superior Health Plan EPO	$3.35
Rate for Payer: Superior Health Plan Medicare	$3.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.35
Rate for Payer: Universal American Medicare	$3.35
Rate for Payer: Wellcare Medicare	$3.35
Rate for Payer: Wellmed Medicare	$3.35

ergocalciferol 50,000 intl units (1.25 mg) Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77550304
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ergocalciferol 50,000 intl units (1.25 mg) Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77550304
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

ertapenem 1 g Inj

Facility

$240.40

Service Code	HCPCS J1335
Hospital Charge Code	77550728
Hospital Revenue Code	636
Min. Negotiated Rate	$21.64
Max. Negotiated Rate	$156.26
Rate for Payer: Amerigroup CHIP/Medicaid	$21.64
Rate for Payer: BCBS of TX Blue Advantage	$48.89
Rate for Payer: BCBS of TX Blue Essentials	$58.67
Rate for Payer: BCBS of TX PPO	$65.08
Rate for Payer: Cash Price	$163.47
Rate for Payer: Cash Price	$163.47
Rate for Payer: Multiplan Auto	$156.26
Rate for Payer: Multiplan Commercial	$156.26
Rate for Payer: Multiplan Workers Comp	$156.26
Rate for Payer: Scott and White EPO/PPO	$120.20
Rate for Payer: Superior Health Plan EPO	$32.69

ertapenem 1 g Inj

Facility

$240.40

Service Code	HCPCS J1335
Hospital Charge Code	77550728
Hospital Revenue Code	636
Min. Negotiated Rate	$60.10
Max. Negotiated Rate	$120.20
Rate for Payer: Cash Price	$163.47
Rate for Payer: Cigna Commercial	$60.10
Rate for Payer: Scott and White EPO/PPO	$120.20

erythromycin 0.5% Ophth Oint 1 g

Facility

$47.80

Service Code	HCPCS J3490
Hospital Charge Code	77550785
Hospital Revenue Code	636
Min. Negotiated Rate	$11.95
Max. Negotiated Rate	$23.90
Rate for Payer: Cash Price	$32.50
Rate for Payer: Cigna Commercial	$11.95
Rate for Payer: Scott and White EPO/PPO	$23.90

erythromycin 0.5% Ophth Oint 1 g

Facility

$47.80

Service Code	HCPCS J3490
Hospital Charge Code	77550785
Hospital Revenue Code	636
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$31.07
Rate for Payer: Amerigroup CHIP/Medicaid	$4.30
Rate for Payer: BCBS of TX Blue Advantage	$14.34
Rate for Payer: BCBS of TX Blue Essentials	$17.21
Rate for Payer: BCBS of TX PPO	$19.12
Rate for Payer: Cash Price	$32.50
Rate for Payer: Multiplan Auto	$31.07
Rate for Payer: Multiplan Commercial	$31.07
Rate for Payer: Multiplan Workers Comp	$31.07
Rate for Payer: Scott and White EPO/PPO	$23.90
Rate for Payer: Superior Health Plan EPO	$6.50

Erythropoietin (EPO), Serum SO

Facility

$306.00

Service Code	CPT 82668
Hospital Charge Code	1701937
Hospital Revenue Code	301
Rate for Payer: Cash Price	$269.28

Erythropoietin (EPO), Serum SO

Facility

$306.00

Service Code	CPT 82668
Hospital Charge Code	1701937
Hospital Revenue Code	301
Min. Negotiated Rate	$7.33
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna Commercial	$19.72
Rate for Payer: Aetna Medicare	$28.18
Rate for Payer: Amerigroup CHIP/Medicaid	$7.33
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.79
Rate for Payer: Amerigroup Medicare	$18.79
Rate for Payer: BCBS of TX Blue Advantage	$31.00
Rate for Payer: BCBS of TX Blue Essentials	$37.20
Rate for Payer: BCBS of TX Medicare	$18.79
Rate for Payer: BCBS of TX PPO	$41.53
Rate for Payer: Cash Price	$269.28
Rate for Payer: Cash Price	$269.28
Rate for Payer: Cigna Medicaid	$18.79
Rate for Payer: Cigna Medicare	$18.79
Rate for Payer: Employer Direct Commercial	$18.79
Rate for Payer: Humana Medicare/TRICARE	$18.79
Rate for Payer: Molina CHIP/Medicaid	$18.79
Rate for Payer: Molina Dual Medicare/Medicaid	$18.79
Rate for Payer: Molina Medicare	$18.79
Rate for Payer: Multiplan Auto	$198.90
Rate for Payer: Multiplan Commercial	$198.90
Rate for Payer: Multiplan Workers Comp	$198.90
Rate for Payer: Parkland Medicaid	$18.79
Rate for Payer: Scott and White EPO/PPO	$23.49
Rate for Payer: Scott and White Medicare	$18.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.79
Rate for Payer: Superior Health Plan EPO	$18.79
Rate for Payer: Superior Health Plan Medicare	$18.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.79
Rate for Payer: Universal American Medicare	$18.79
Rate for Payer: Wellcare Medicare	$18.79
Rate for Payer: Wellmed Medicare	$18.79

escitalopram 10 mg Tab

Facility

$32.90

Service Code	HCPCS J3490
Hospital Charge Code	77552051
Hospital Revenue Code	250
Rate for Payer: Cash Price	$22.37

escitalopram 10 mg Tab

Facility

$32.90

Service Code	HCPCS J3490
Hospital Charge Code	77552051
Hospital Revenue Code	250
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$21.38
Rate for Payer: Amerigroup CHIP/Medicaid	$2.96
Rate for Payer: BCBS of TX Blue Advantage	$9.87
Rate for Payer: BCBS of TX Blue Essentials	$11.84
Rate for Payer: BCBS of TX PPO	$13.16
Rate for Payer: Cash Price	$22.37
Rate for Payer: Multiplan Auto	$21.38
Rate for Payer: Multiplan Commercial	$21.38
Rate for Payer: Multiplan Workers Comp	$21.38
Rate for Payer: Scott and White EPO/PPO	$16.45
Rate for Payer: Superior Health Plan EPO	$4.47

esmolol 10 mg/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77552459
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

esmolol 10 mg/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77552459
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC

Facility

$24,238.30

Service Code	MSDRG 391
Min. Negotiated Rate	$10,291.62
Max. Negotiated Rate	$24,238.30
Rate for Payer: Aetna Commercial	$14,351.62
Rate for Payer: Aetna Medicare	$17,937.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,958.26
Rate for Payer: Amerigroup Medicare	$11,958.26
Rate for Payer: BCBS of TX Blue Advantage	$10,291.62
Rate for Payer: BCBS of TX Blue Essentials	$12,604.66
Rate for Payer: BCBS of TX Medicare	$11,958.26
Rate for Payer: BCBS of TX PPO	$14,005.72
Rate for Payer: Cigna Commercial	$16,431.02
Rate for Payer: Cigna Medicare	$11,958.26
Rate for Payer: Employer Direct Commercial	$11,958.26
Rate for Payer: Humana Medicare/TRICARE	$11,958.26
Rate for Payer: Molina Dual Medicare/Medicaid	$11,958.26
Rate for Payer: Molina Medicare	$11,958.26
Rate for Payer: Multiplan Auto	$24,238.30
Rate for Payer: Multiplan Commercial	$24,238.30
Rate for Payer: Multiplan Workers Comp	$24,238.30
Rate for Payer: Scott and White EPO/PPO	$11,162.38
Rate for Payer: Scott and White Medicare	$11,958.26
Rate for Payer: Superior Health Plan EPO	$11,958.26
Rate for Payer: Superior Health Plan Medicare	$11,958.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,958.26
Rate for Payer: Universal American Medicare	$11,958.26
Rate for Payer: Wellcare Medicare	$11,958.26
Rate for Payer: Wellmed Medicare	$11,958.26

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC

Facility

$14,926.40

Service Code	MSDRG 392
Min. Negotiated Rate	$6,365.72
Max. Negotiated Rate	$14,926.40
Rate for Payer: Aetna Commercial	$8,838.00
Rate for Payer: Aetna Medicare	$12,691.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,460.87
Rate for Payer: Amerigroup Medicare	$8,460.87
Rate for Payer: BCBS of TX Blue Advantage	$6,365.72
Rate for Payer: BCBS of TX Blue Essentials	$7,794.97
Rate for Payer: BCBS of TX Medicare	$8,460.87
Rate for Payer: BCBS of TX PPO	$8,661.42
Rate for Payer: Cigna Commercial	$10,118.53
Rate for Payer: Cigna Medicare	$8,460.87
Rate for Payer: Employer Direct Commercial	$8,460.87
Rate for Payer: Humana Medicare/TRICARE	$8,460.87
Rate for Payer: Molina Dual Medicare/Medicaid	$8,460.87
Rate for Payer: Molina Medicare	$8,460.87
Rate for Payer: Multiplan Auto	$14,926.40
Rate for Payer: Multiplan Commercial	$14,926.40
Rate for Payer: Multiplan Workers Comp	$14,926.40
Rate for Payer: Scott and White EPO/PPO	$6,874.00
Rate for Payer: Scott and White Medicare	$8,460.87
Rate for Payer: Superior Health Plan EPO	$8,460.87
Rate for Payer: Superior Health Plan Medicare	$8,460.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,460.87
Rate for Payer: Universal American Medicare	$8,460.87
Rate for Payer: Wellcare Medicare	$8,460.87
Rate for Payer: Wellmed Medicare	$8,460.87

Esophagogastroduodenoscopy

Facility

$10,000.00

Service Code	CPT 43239
Hospital Charge Code	36043239
Hospital Revenue Code	360
Min. Negotiated Rate	$18.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$1,243.53
Rate for Payer: Amerigroup CHIP/Medicaid	$334.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$829.02
Rate for Payer: Amerigroup Medicare	$829.02
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	$829.02
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cigna Commercial	$1,877.98
Rate for Payer: Cigna Medicaid	$334.95
Rate for Payer: Cigna Medicare	$829.02
Rate for Payer: Employer Direct Commercial	$829.02
Rate for Payer: Humana Medicare/TRICARE	$829.02
Rate for Payer: Molina CHIP/Medicaid	$334.95
Rate for Payer: Molina Dual Medicare/Medicaid	$829.02
Rate for Payer: Molina Medicare	$829.02
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$334.95
Rate for Payer: Scott and White EPO/PPO	$18.29
Rate for Payer: Scott and White Medicare	$829.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$334.95
Rate for Payer: Superior Health Plan EPO	$829.02
Rate for Payer: Superior Health Plan Medicare	$829.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$829.02
Rate for Payer: Universal American Medicare	$829.02
Rate for Payer: Wellcare Medicare	$829.02
Rate for Payer: Wellmed Medicare	$829.02

Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s)

Facility

$10,000.00

Service Code	CPT 43235
Hospital Charge Code	36043235
Hospital Revenue Code	360
Min. Negotiated Rate	$18.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$1,243.53
Rate for Payer: Amerigroup CHIP/Medicaid	$334.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$829.02
Rate for Payer: Amerigroup Medicare	$829.02
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	$829.02
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cigna Commercial	$1,877.98
Rate for Payer: Cigna Medicaid	$334.95
Rate for Payer: Cigna Medicare	$829.02
Rate for Payer: Employer Direct Commercial	$829.02
Rate for Payer: Humana Medicare/TRICARE	$829.02
Rate for Payer: Molina CHIP/Medicaid	$334.95
Rate for Payer: Molina Dual Medicare/Medicaid	$829.02
Rate for Payer: Molina Medicare	$829.02
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$334.95
Rate for Payer: Scott and White EPO/PPO	$18.29
Rate for Payer: Scott and White Medicare	$829.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$334.95
Rate for Payer: Superior Health Plan EPO	$829.02
Rate for Payer: Superior Health Plan Medicare	$829.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$829.02
Rate for Payer: Universal American Medicare	$829.02
Rate for Payer: Wellcare Medicare	$829.02
Rate for Payer: Wellmed Medicare	$829.02

Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method

Facility

$10,000.00

Service Code	CPT 43255
Hospital Charge Code	36043255
Hospital Revenue Code	360
Min. Negotiated Rate	$38.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,610.33
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Amerigroup Medicare	$1,740.22
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,740.22
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cigna Commercial	$3,942.10
Rate for Payer: Cigna Medicaid	$564.97
Rate for Payer: Cigna Medicare	$1,740.22
Rate for Payer: Employer Direct Commercial	$1,740.22
Rate for Payer: Humana Medicare/TRICARE	$1,740.22
Rate for Payer: Molina CHIP/Medicaid	$564.97
Rate for Payer: Molina Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Molina Medicare	$1,740.22
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$564.97
Rate for Payer: Scott and White EPO/PPO	$38.38
Rate for Payer: Scott and White Medicare	$1,740.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.97
Rate for Payer: Superior Health Plan EPO	$1,740.22
Rate for Payer: Superior Health Plan Medicare	$1,740.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Universal American Medicare	$1,740.22
Rate for Payer: Wellcare Medicare	$1,740.22
Rate for Payer: Wellmed Medicare	$1,740.22

Esophagogastroduodenoscopy, flexible, transoral with dilation of gastric/duodenal stricture(s) (eg,

Facility

$10,000.00

Service Code	CPT 43245
Hospital Charge Code	36043245
Hospital Revenue Code	360
Min. Negotiated Rate	$38.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,610.33
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Amerigroup Medicare	$1,740.22
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,740.22
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cigna Commercial	$3,942.10
Rate for Payer: Cigna Medicaid	$564.97
Rate for Payer: Cigna Medicare	$1,740.22
Rate for Payer: Employer Direct Commercial	$1,740.22
Rate for Payer: Humana Medicare/TRICARE	$1,740.22
Rate for Payer: Molina CHIP/Medicaid	$564.97
Rate for Payer: Molina Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Molina Medicare	$1,740.22
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$564.97
Rate for Payer: Scott and White EPO/PPO	$38.38
Rate for Payer: Scott and White Medicare	$1,740.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.97
Rate for Payer: Superior Health Plan EPO	$1,740.22
Rate for Payer: Superior Health Plan Medicare	$1,740.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Universal American Medicare	$1,740.22
Rate for Payer: Wellcare Medicare	$1,740.22
Rate for Payer: Wellmed Medicare	$1,740.22

Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substanc

Facility

$10,000.00

Service Code	CPT 43236
Hospital Charge Code	36043236
Hospital Revenue Code	360
Min. Negotiated Rate	$18.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$1,243.53
Rate for Payer: Amerigroup CHIP/Medicaid	$334.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$829.02
Rate for Payer: Amerigroup Medicare	$829.02
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	$829.02
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cigna Commercial	$1,877.98
Rate for Payer: Cigna Medicaid	$334.95
Rate for Payer: Cigna Medicare	$829.02
Rate for Payer: Employer Direct Commercial	$829.02
Rate for Payer: Humana Medicare/TRICARE	$829.02
Rate for Payer: Molina CHIP/Medicaid	$334.95
Rate for Payer: Molina Dual Medicare/Medicaid	$829.02
Rate for Payer: Molina Medicare	$829.02
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$334.95
Rate for Payer: Scott and White EPO/PPO	$18.29
Rate for Payer: Scott and White Medicare	$829.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$334.95
Rate for Payer: Superior Health Plan EPO	$829.02
Rate for Payer: Superior Health Plan Medicare	$829.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$829.02
Rate for Payer: Universal American Medicare	$829.02
Rate for Payer: Wellcare Medicare	$829.02
Rate for Payer: Wellmed Medicare	$829.02

Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)

Facility

$10,000.00

Service Code	CPT 43247
Hospital Charge Code	36043247
Hospital Revenue Code	360
Min. Negotiated Rate	$18.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$1,243.53
Rate for Payer: Amerigroup CHIP/Medicaid	$334.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$829.02
Rate for Payer: Amerigroup Medicare	$829.02
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	$829.02
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cigna Commercial	$1,877.98
Rate for Payer: Cigna Medicaid	$334.95
Rate for Payer: Cigna Medicare	$829.02
Rate for Payer: Employer Direct Commercial	$829.02
Rate for Payer: Humana Medicare/TRICARE	$829.02
Rate for Payer: Molina CHIP/Medicaid	$334.95
Rate for Payer: Molina Dual Medicare/Medicaid	$829.02
Rate for Payer: Molina Medicare	$829.02
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$334.95
Rate for Payer: Scott and White EPO/PPO	$18.29
Rate for Payer: Scott and White Medicare	$829.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$334.95
Rate for Payer: Superior Health Plan EPO	$829.02
Rate for Payer: Superior Health Plan Medicare	$829.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$829.02
Rate for Payer: Universal American Medicare	$829.02
Rate for Payer: Wellcare Medicare	$829.02
Rate for Payer: Wellmed Medicare	$829.02

Esophagogastroduodenoscopy, flexible, transoral with removal of tumor(s), polyp(s), or other lesion

Facility

$10,000.00

Service Code	CPT 43250
Hospital Charge Code	36043250
Hospital Revenue Code	360
Min. Negotiated Rate	$38.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,610.33
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Amerigroup Medicare	$1,740.22
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,740.22
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cigna Commercial	$3,942.10
Rate for Payer: Cigna Medicaid	$564.97
Rate for Payer: Cigna Medicare	$1,740.22
Rate for Payer: Employer Direct Commercial	$1,740.22
Rate for Payer: Humana Medicare/TRICARE	$1,740.22
Rate for Payer: Molina CHIP/Medicaid	$564.97
Rate for Payer: Molina Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Molina Medicare	$1,740.22
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$564.97
Rate for Payer: Scott and White EPO/PPO	$38.38
Rate for Payer: Scott and White Medicare	$1,740.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.97
Rate for Payer: Superior Health Plan EPO	$1,740.22
Rate for Payer: Superior Health Plan Medicare	$1,740.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Universal American Medicare	$1,740.22
Rate for Payer: Wellcare Medicare	$1,740.22
Rate for Payer: Wellmed Medicare	$1,740.22

Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion

Facility

$10,000.00

Service Code	CPT 43251
Hospital Charge Code	36043251
Hospital Revenue Code	360
Min. Negotiated Rate	$38.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,610.33
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Amerigroup Medicare	$1,740.22
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,740.22
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cigna Commercial	$3,942.10
Rate for Payer: Cigna Medicaid	$564.97
Rate for Payer: Cigna Medicare	$1,740.22
Rate for Payer: Employer Direct Commercial	$1,740.22
Rate for Payer: Humana Medicare/TRICARE	$1,740.22
Rate for Payer: Molina CHIP/Medicaid	$564.97
Rate for Payer: Molina Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Molina Medicare	$1,740.22
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$564.97
Rate for Payer: Scott and White EPO/PPO	$38.38
Rate for Payer: Scott and White Medicare	$1,740.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.97
Rate for Payer: Superior Health Plan EPO	$1,740.22
Rate for Payer: Superior Health Plan Medicare	$1,740.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Universal American Medicare	$1,740.22
Rate for Payer: Wellcare Medicare	$1,740.22
Rate for Payer: Wellmed Medicare	$1,740.22

Esophagogastroduodenoscopy, flexible, transoral with transendoscopic balloon dilation of esophagus

Facility

$10,000.00

Service Code	CPT 43249
Hospital Charge Code	36043249
Hospital Revenue Code	360
Min. Negotiated Rate	$38.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,610.33
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Amerigroup Medicare	$1,740.22
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,740.22
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cigna Commercial	$3,942.10
Rate for Payer: Cigna Medicaid	$564.97
Rate for Payer: Cigna Medicare	$1,740.22
Rate for Payer: Employer Direct Commercial	$1,740.22
Rate for Payer: Humana Medicare/TRICARE	$1,740.22
Rate for Payer: Molina CHIP/Medicaid	$564.97
Rate for Payer: Molina Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Molina Medicare	$1,740.22
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$564.97
Rate for Payer: Scott and White EPO/PPO	$38.38
Rate for Payer: Scott and White Medicare	$1,740.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.97
Rate for Payer: Superior Health Plan EPO	$1,740.22
Rate for Payer: Superior Health Plan Medicare	$1,740.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Universal American Medicare	$1,740.22
Rate for Payer: Wellcare Medicare	$1,740.22
Rate for Payer: Wellmed Medicare	$1,740.22

Esophagoscopy, flexible, transoral with transendoscopic balloon dilation (less than 30 mm diameter)

Facility

$10,000.00

Service Code	CPT 43220
Hospital Charge Code	36043220
Hospital Revenue Code	360
Min. Negotiated Rate	$38.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,610.33
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Amerigroup Medicare	$1,740.22
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,740.22
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cigna Commercial	$3,942.10
Rate for Payer: Cigna Medicaid	$564.97
Rate for Payer: Cigna Medicare	$1,740.22
Rate for Payer: Employer Direct Commercial	$1,740.22
Rate for Payer: Humana Medicare/TRICARE	$1,740.22
Rate for Payer: Molina CHIP/Medicaid	$564.97
Rate for Payer: Molina Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Molina Medicare	$1,740.22
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$564.97
Rate for Payer: Scott and White EPO/PPO	$38.38
Rate for Payer: Scott and White Medicare	$1,740.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.97
Rate for Payer: Superior Health Plan EPO	$1,740.22
Rate for Payer: Superior Health Plan Medicare	$1,740.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Universal American Medicare	$1,740.22
Rate for Payer: Wellcare Medicare	$1,740.22
Rate for Payer: Wellmed Medicare	$1,740.22

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