White Rock Medical Center

All Charges

Charge

Type

Setting

Price

C-Reactive Protein

Facility

$282.00

Service Code	HCPCS 86140
Hospital Charge Code	1601384
Hospital Revenue Code	302
Rate for Payer: Cash Price	$191.76

C-Reactive Protein

Facility

$282.00

Service Code	HCPCS 86140
Hospital Charge Code	1601384
Hospital Revenue Code	302
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$203.04
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$84.60
Rate for Payer: BCBS of TX Blue Essentials	$101.52
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$112.80
Rate for Payer: Cash Price	$191.76
Rate for Payer: Cash Price	$191.76
Rate for Payer: Cigna Medicaid	$203.04
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$203.04
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$183.30
Rate for Payer: Multiplan Commercial	$183.30
Rate for Payer: Multiplan Workers Comp	$183.30
Rate for Payer: Parkland Medicaid	$203.04
Rate for Payer: Scott and White EPO/PPO	$6.47
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$203.04
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

C-Reactive Protein, Cardiac SO

Facility

$154.00

Service Code	HCPCS 86141
Hospital Charge Code	1739614
Hospital Revenue Code	302
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$110.88
Rate for Payer: Amerigroup CHIP/Medicaid	$5.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.95
Rate for Payer: Amerigroup Medicare	$12.95
Rate for Payer: BCBS of TX Blue Advantage	$46.20
Rate for Payer: BCBS of TX Blue Essentials	$55.44
Rate for Payer: BCBS of TX Medicare	$12.95
Rate for Payer: BCBS of TX PPO	$61.60
Rate for Payer: Cash Price	$104.72
Rate for Payer: Cash Price	$104.72
Rate for Payer: Cigna Medicaid	$110.88
Rate for Payer: Cigna Medicare	$12.95
Rate for Payer: Employer Direct Commercial	$12.95
Rate for Payer: Humana Medicare/TRICARE	$12.95
Rate for Payer: Molina CHIP/Medicaid	$110.88
Rate for Payer: Molina Dual Medicare/Medicaid	$12.95
Rate for Payer: Molina Medicare	$12.95
Rate for Payer: Multiplan Auto	$100.10
Rate for Payer: Multiplan Commercial	$100.10
Rate for Payer: Multiplan Workers Comp	$100.10
Rate for Payer: Parkland Medicaid	$110.88
Rate for Payer: Scott and White EPO/PPO	$16.19
Rate for Payer: Scott and White Medicare	$12.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.88
Rate for Payer: Superior Health Plan EPO	$12.95
Rate for Payer: Superior Health Plan Medicare	$12.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.95
Rate for Payer: Universal American Medicare	$12.95
Rate for Payer: Wellcare Medicare	$12.95
Rate for Payer: Wellmed Medicare	$12.95

C-Reactive Protein, Cardiac SO

Facility

$154.00

Service Code	HCPCS 86141
Hospital Charge Code	1739614
Hospital Revenue Code	302
Rate for Payer: Cash Price	$104.72

Creatine Kinase (CK), MB SO

Facility

$394.00

Service Code	HCPCS 82553
Hospital Charge Code	8520510
Hospital Revenue Code	301
Rate for Payer: Cash Price	$267.92

Creatine Kinase (CK), MB SO

Facility

$394.00

Service Code	HCPCS 82553
Hospital Charge Code	8520510
Hospital Revenue Code	301
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$283.68
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.55
Rate for Payer: Amerigroup Medicare	$11.55
Rate for Payer: BCBS of TX Blue Advantage	$118.20
Rate for Payer: BCBS of TX Blue Essentials	$141.84
Rate for Payer: BCBS of TX Medicare	$11.55
Rate for Payer: BCBS of TX PPO	$157.60
Rate for Payer: Cash Price	$267.92
Rate for Payer: Cash Price	$267.92
Rate for Payer: Cigna Medicaid	$283.68
Rate for Payer: Cigna Medicare	$11.55
Rate for Payer: Employer Direct Commercial	$11.55
Rate for Payer: Humana Medicare/TRICARE	$11.55
Rate for Payer: Molina CHIP/Medicaid	$283.68
Rate for Payer: Molina Dual Medicare/Medicaid	$11.55
Rate for Payer: Molina Medicare	$11.55
Rate for Payer: Multiplan Auto	$256.10
Rate for Payer: Multiplan Commercial	$256.10
Rate for Payer: Multiplan Workers Comp	$256.10
Rate for Payer: Parkland Medicaid	$283.68
Rate for Payer: Scott and White EPO/PPO	$14.44
Rate for Payer: Scott and White Medicare	$11.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$283.68
Rate for Payer: Superior Health Plan EPO	$11.55
Rate for Payer: Superior Health Plan Medicare	$11.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.55
Rate for Payer: Universal American Medicare	$11.55
Rate for Payer: Wellcare Medicare	$11.55
Rate for Payer: Wellmed Medicare	$11.55

Creatine Kinase MB

Facility

$394.00

Service Code	HCPCS 82553
Hospital Charge Code	1601764
Hospital Revenue Code	301
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$283.68
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.55
Rate for Payer: Amerigroup Medicare	$11.55
Rate for Payer: BCBS of TX Blue Advantage	$118.20
Rate for Payer: BCBS of TX Blue Essentials	$141.84
Rate for Payer: BCBS of TX Medicare	$11.55
Rate for Payer: BCBS of TX PPO	$157.60
Rate for Payer: Cash Price	$267.92
Rate for Payer: Cash Price	$267.92
Rate for Payer: Cigna Medicaid	$283.68
Rate for Payer: Cigna Medicare	$11.55
Rate for Payer: Employer Direct Commercial	$11.55
Rate for Payer: Humana Medicare/TRICARE	$11.55
Rate for Payer: Molina CHIP/Medicaid	$283.68
Rate for Payer: Molina Dual Medicare/Medicaid	$11.55
Rate for Payer: Molina Medicare	$11.55
Rate for Payer: Multiplan Auto	$256.10
Rate for Payer: Multiplan Commercial	$256.10
Rate for Payer: Multiplan Workers Comp	$256.10
Rate for Payer: Parkland Medicaid	$283.68
Rate for Payer: Scott and White EPO/PPO	$14.44
Rate for Payer: Scott and White Medicare	$11.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$283.68
Rate for Payer: Superior Health Plan EPO	$11.55
Rate for Payer: Superior Health Plan Medicare	$11.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.55
Rate for Payer: Universal American Medicare	$11.55
Rate for Payer: Wellcare Medicare	$11.55
Rate for Payer: Wellmed Medicare	$11.55

Creatine Kinase MB

Facility

$394.00

Service Code	HCPCS 82553
Hospital Charge Code	1601764
Hospital Revenue Code	301
Rate for Payer: Cash Price	$267.92

Creatine Kinase,Total

Facility

$277.00

Service Code	HCPCS 82550
Hospital Charge Code	1601756
Hospital Revenue Code	301
Min. Negotiated Rate	$2.54
Max. Negotiated Rate	$199.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.51
Rate for Payer: Amerigroup Medicare	$6.51
Rate for Payer: BCBS of TX Blue Advantage	$83.10
Rate for Payer: BCBS of TX Blue Essentials	$99.72
Rate for Payer: BCBS of TX Medicare	$6.51
Rate for Payer: BCBS of TX PPO	$110.80
Rate for Payer: Cash Price	$188.36
Rate for Payer: Cash Price	$188.36
Rate for Payer: Cigna Medicaid	$199.44
Rate for Payer: Cigna Medicare	$6.51
Rate for Payer: Employer Direct Commercial	$6.51
Rate for Payer: Humana Medicare/TRICARE	$6.51
Rate for Payer: Molina CHIP/Medicaid	$199.44
Rate for Payer: Molina Dual Medicare/Medicaid	$6.51
Rate for Payer: Molina Medicare	$6.51
Rate for Payer: Multiplan Auto	$180.05
Rate for Payer: Multiplan Commercial	$180.05
Rate for Payer: Multiplan Workers Comp	$180.05
Rate for Payer: Parkland Medicaid	$199.44
Rate for Payer: Scott and White EPO/PPO	$8.14
Rate for Payer: Scott and White Medicare	$6.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$199.44
Rate for Payer: Superior Health Plan EPO	$6.51
Rate for Payer: Superior Health Plan Medicare	$6.51
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.51
Rate for Payer: Universal American Medicare	$6.51
Rate for Payer: Wellcare Medicare	$6.51
Rate for Payer: Wellmed Medicare	$6.51

Creatine Kinase,Total

Facility

$277.00

Service Code	HCPCS 82550
Hospital Charge Code	1601756
Hospital Revenue Code	301
Rate for Payer: Cash Price	$188.36

Creatine Kinase,Total SO

Facility

$277.00

Service Code	HCPCS 82550
Hospital Charge Code	9096973
Hospital Revenue Code	301
Rate for Payer: Cash Price	$188.36

Creatine Kinase,Total SO

Facility

$277.00

Service Code	HCPCS 82550
Hospital Charge Code	9096973
Hospital Revenue Code	301
Min. Negotiated Rate	$2.54
Max. Negotiated Rate	$199.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.51
Rate for Payer: Amerigroup Medicare	$6.51
Rate for Payer: BCBS of TX Blue Advantage	$83.10
Rate for Payer: BCBS of TX Blue Essentials	$99.72
Rate for Payer: BCBS of TX Medicare	$6.51
Rate for Payer: BCBS of TX PPO	$110.80
Rate for Payer: Cash Price	$188.36
Rate for Payer: Cash Price	$188.36
Rate for Payer: Cigna Medicaid	$199.44
Rate for Payer: Cigna Medicare	$6.51
Rate for Payer: Employer Direct Commercial	$6.51
Rate for Payer: Humana Medicare/TRICARE	$6.51
Rate for Payer: Molina CHIP/Medicaid	$199.44
Rate for Payer: Molina Dual Medicare/Medicaid	$6.51
Rate for Payer: Molina Medicare	$6.51
Rate for Payer: Multiplan Auto	$180.05
Rate for Payer: Multiplan Commercial	$180.05
Rate for Payer: Multiplan Workers Comp	$180.05
Rate for Payer: Parkland Medicaid	$199.44
Rate for Payer: Scott and White EPO/PPO	$8.14
Rate for Payer: Scott and White Medicare	$6.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$199.44
Rate for Payer: Superior Health Plan EPO	$6.51
Rate for Payer: Superior Health Plan Medicare	$6.51
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.51
Rate for Payer: Universal American Medicare	$6.51
Rate for Payer: Wellcare Medicare	$6.51
Rate for Payer: Wellmed Medicare	$6.51

Creatinine

Facility

$169.00

Service Code	HCPCS 82565
Hospital Charge Code	1601780
Hospital Revenue Code	301
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$121.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.12
Rate for Payer: Amerigroup Medicare	$5.12
Rate for Payer: BCBS of TX Blue Advantage	$50.70
Rate for Payer: BCBS of TX Blue Essentials	$60.84
Rate for Payer: BCBS of TX Medicare	$5.12
Rate for Payer: BCBS of TX PPO	$67.60
Rate for Payer: Cash Price	$114.92
Rate for Payer: Cash Price	$114.92
Rate for Payer: Cigna Medicaid	$121.68
Rate for Payer: Cigna Medicare	$5.12
Rate for Payer: Employer Direct Commercial	$5.12
Rate for Payer: Humana Medicare/TRICARE	$5.12
Rate for Payer: Molina CHIP/Medicaid	$121.68
Rate for Payer: Molina Dual Medicare/Medicaid	$5.12
Rate for Payer: Molina Medicare	$5.12
Rate for Payer: Multiplan Auto	$109.85
Rate for Payer: Multiplan Commercial	$109.85
Rate for Payer: Multiplan Workers Comp	$109.85
Rate for Payer: Parkland Medicaid	$121.68
Rate for Payer: Scott and White EPO/PPO	$6.40
Rate for Payer: Scott and White Medicare	$5.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$121.68
Rate for Payer: Superior Health Plan EPO	$5.12
Rate for Payer: Superior Health Plan Medicare	$5.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.12
Rate for Payer: Universal American Medicare	$5.12
Rate for Payer: Wellcare Medicare	$5.12
Rate for Payer: Wellmed Medicare	$5.12

Creatinine

Facility

$169.00

Service Code	HCPCS 82565
Hospital Charge Code	1601780
Hospital Revenue Code	301
Rate for Payer: Cash Price	$114.92

Creatinine Clearance

Facility

$336.00

Service Code	HCPCS 82575
Hospital Charge Code	1602507
Hospital Revenue Code	301
Rate for Payer: Cash Price	$228.48

Creatinine Clearance

Facility

$336.00

Service Code	HCPCS 82575
Hospital Charge Code	1602507
Hospital Revenue Code	301
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$241.92
Rate for Payer: Amerigroup CHIP/Medicaid	$3.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.46
Rate for Payer: Amerigroup Medicare	$9.46
Rate for Payer: BCBS of TX Blue Advantage	$100.80
Rate for Payer: BCBS of TX Blue Essentials	$120.96
Rate for Payer: BCBS of TX Medicare	$9.46
Rate for Payer: BCBS of TX PPO	$134.40
Rate for Payer: Cash Price	$228.48
Rate for Payer: Cash Price	$228.48
Rate for Payer: Cigna Medicaid	$241.92
Rate for Payer: Cigna Medicare	$9.46
Rate for Payer: Employer Direct Commercial	$9.46
Rate for Payer: Humana Medicare/TRICARE	$9.46
Rate for Payer: Molina CHIP/Medicaid	$241.92
Rate for Payer: Molina Dual Medicare/Medicaid	$9.46
Rate for Payer: Molina Medicare	$9.46
Rate for Payer: Multiplan Auto	$218.40
Rate for Payer: Multiplan Commercial	$218.40
Rate for Payer: Multiplan Workers Comp	$218.40
Rate for Payer: Parkland Medicaid	$241.92
Rate for Payer: Scott and White EPO/PPO	$11.82
Rate for Payer: Scott and White Medicare	$9.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$241.92
Rate for Payer: Superior Health Plan EPO	$9.46
Rate for Payer: Superior Health Plan Medicare	$9.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.46
Rate for Payer: Universal American Medicare	$9.46
Rate for Payer: Wellcare Medicare	$9.46
Rate for Payer: Wellmed Medicare	$9.46

Creatinine, Urine SO

Facility

$96.00

Service Code	HCPCS 82570
Hospital Charge Code	9333006
Hospital Revenue Code	301
Rate for Payer: Cash Price	$65.28

Creatinine, Urine SO

Facility

$96.00

Service Code	HCPCS 82570
Hospital Charge Code	9333006
Hospital Revenue Code	301
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$69.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$28.80
Rate for Payer: BCBS of TX Blue Essentials	$34.56
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$38.40
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cigna Medicaid	$69.12
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$69.12
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$62.40
Rate for Payer: Multiplan Commercial	$62.40
Rate for Payer: Multiplan Workers Comp	$62.40
Rate for Payer: Parkland Medicaid	$69.12
Rate for Payer: Scott and White EPO/PPO	$6.47
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.12
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

Creation of arteriovenous fistula

Facility

$20,943.68

Service Code	HCPCS 36830
Hospital Charge Code	991067
Hospital Revenue Code	480
Min. Negotiated Rate	$793.19
Max. Negotiated Rate	$15,079.45
Rate for Payer: Amerigroup CHIP/Medicaid	$1,884.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Amerigroup Medicare	$5,589.84
Rate for Payer: BCBS of TX Blue Advantage	$7,675.64
Rate for Payer: BCBS of TX Blue Essentials	$9,192.38
Rate for Payer: BCBS of TX Medicare	$5,589.84
Rate for Payer: BCBS of TX PPO	$11,582.40
Rate for Payer: Cash Price	$14,241.70
Rate for Payer: Cash Price	$14,241.70
Rate for Payer: Cash Price	$14,241.70
Rate for Payer: Cigna Commercial	$11,815.91
Rate for Payer: Cigna Medicaid	$15,079.45
Rate for Payer: Cigna Medicare	$5,589.84
Rate for Payer: Employer Direct Commercial	$5,589.84
Rate for Payer: Humana Medicare/TRICARE	$5,589.84
Rate for Payer: Molina CHIP/Medicaid	$15,079.45
Rate for Payer: Molina Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Molina Medicare	$5,589.84
Rate for Payer: Multiplan Auto	$13,613.39
Rate for Payer: Multiplan Commercial	$13,613.39
Rate for Payer: Multiplan Workers Comp	$13,613.39
Rate for Payer: Parkland Medicaid	$15,079.45
Rate for Payer: Scott and White EPO/PPO	$793.19
Rate for Payer: Scott and White Medicare	$5,589.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,079.45
Rate for Payer: Superior Health Plan EPO	$5,589.84
Rate for Payer: Superior Health Plan Medicare	$5,589.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Universal American Medicare	$5,589.84
Rate for Payer: Wellcare Medicare	$5,589.84
Rate for Payer: Wellmed Medicare	$5,589.84

Creation of arteriovenous fistula

Facility

$20,943.68

Service Code	HCPCS 36830
Hospital Charge Code	991067
Hospital Revenue Code	480
Rate for Payer: Cash Price	$14,241.70

C/R EXER PROGRAM

Facility

$40.00

Service Code	HCPCS 93799
Hospital Charge Code	6010154
Hospital Revenue Code	943
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$273.24
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$129.26
Rate for Payer: Amerigroup Medicare	$129.26
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX Medicare	$129.26
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna Commercial	$273.24
Rate for Payer: Cigna Medicaid	$28.80
Rate for Payer: Cigna Medicare	$129.26
Rate for Payer: Employer Direct Commercial	$129.26
Rate for Payer: Humana Medicare/TRICARE	$129.26
Rate for Payer: Molina CHIP/Medicaid	$28.80
Rate for Payer: Molina Dual Medicare/Medicaid	$129.26
Rate for Payer: Molina Medicare	$129.26
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Parkland Medicaid	$28.80
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Scott and White Medicare	$129.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.80
Rate for Payer: Superior Health Plan EPO	$129.26
Rate for Payer: Superior Health Plan Medicare	$129.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$129.26
Rate for Payer: Universal American Medicare	$129.26
Rate for Payer: Wellcare Medicare	$129.26
Rate for Payer: Wellmed Medicare	$129.26

C/R EXER PROGRAM

Facility

$40.00

Service Code	HCPCS 93799
Hospital Charge Code	6010154
Hospital Revenue Code	943
Rate for Payer: Cash Price	$27.20

Critical Care Ill/Injured Patient Addl 30 Min 99292

Facility

$1,680.00

Service Code	HCPCS 99292
Hospital Charge Code	5210174
Hospital Revenue Code	450
Min. Negotiated Rate	$130.21
Max. Negotiated Rate	$3,520.00
Rate for Payer: Amerigroup CHIP/Medicaid	$151.20
Rate for Payer: BCBS of TX Blue Advantage	$2,640.00
Rate for Payer: BCBS of TX Blue Essentials	$3,168.00
Rate for Payer: BCBS of TX PPO	$3,520.00
Rate for Payer: Cash Price	$1,142.40
Rate for Payer: Cash Price	$1,142.40
Rate for Payer: Cash Price	$1,142.40
Rate for Payer: Cigna Medicaid	$1,209.60
Rate for Payer: Molina CHIP/Medicaid	$1,209.60
Rate for Payer: Multiplan Auto	$1,092.00
Rate for Payer: Multiplan Commercial	$1,092.00
Rate for Payer: Multiplan Workers Comp	$1,092.00
Rate for Payer: Parkland Medicaid	$1,209.60
Rate for Payer: Scott and White EPO/PPO	$130.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,209.60
Rate for Payer: Superior Health Plan EPO	$228.48

Critical Care Ill/Injured Patient Addl 30 Min 99292

Facility

$1,680.00

Service Code	HCPCS 99292
Hospital Charge Code	5210174
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,142.40

Critical Care Ill/Injured Patient Init 30-74 Min 99291

Facility

$3,605.00

Service Code	HCPCS 99291
Hospital Charge Code	5201678
Hospital Revenue Code	450
Min. Negotiated Rate	$258.57
Max. Negotiated Rate	$4,117.38
Rate for Payer: Amerigroup CHIP/Medicaid	$324.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$829.79
Rate for Payer: Amerigroup Medicare	$829.79
Rate for Payer: BCBS of TX Blue Advantage	$2,640.00
Rate for Payer: BCBS of TX Blue Essentials	$3,168.00
Rate for Payer: BCBS of TX Medicare	$829.79
Rate for Payer: BCBS of TX PPO	$3,520.00
Rate for Payer: Cash Price	$2,451.40
Rate for Payer: Cash Price	$2,451.40
Rate for Payer: Cash Price	$2,451.40
Rate for Payer: Cigna Commercial	$4,117.38
Rate for Payer: Cigna Medicaid	$2,595.60
Rate for Payer: Cigna Medicare	$829.79
Rate for Payer: Employer Direct Commercial	$829.79
Rate for Payer: Humana Medicare/TRICARE	$829.79
Rate for Payer: Molina CHIP/Medicaid	$2,595.60
Rate for Payer: Molina Dual Medicare/Medicaid	$829.79
Rate for Payer: Molina Medicare	$829.79
Rate for Payer: Multiplan Auto	$2,343.25
Rate for Payer: Multiplan Commercial	$2,343.25
Rate for Payer: Multiplan Workers Comp	$2,343.25
Rate for Payer: Parkland Medicaid	$2,595.60
Rate for Payer: Scott and White EPO/PPO	$258.57
Rate for Payer: Scott and White Medicare	$829.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,595.60
Rate for Payer: Superior Health Plan EPO	$829.79
Rate for Payer: Superior Health Plan Medicare	$829.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$829.79
Rate for Payer: Universal American Medicare	$829.79
Rate for Payer: Wellcare Medicare	$829.79
Rate for Payer: Wellmed Medicare	$829.79

Know your out-of-pocket cost for care.

All Charges