White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST BCE

Facility

$372.00

Service Code	HCPCS 30905
Hospital Charge Code	8734588
Hospital Revenue Code	450
Min. Negotiated Rate	$33.48
Max. Negotiated Rate	$282.53
Rate for Payer: Amerigroup CHIP/Medicaid	$33.48
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	$252.96
Rate for Payer: Cash Price	$252.96
Rate for Payer: Cash Price	$252.96
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$267.84
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	$267.84
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$241.80
Rate for Payer: Multiplan Commercial	$241.80
Rate for Payer: Multiplan Workers Comp	$241.80
Rate for Payer: Parkland Medicaid	$267.84
Rate for Payer: Scott and White EPO/PPO	$128.70
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$267.84
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

ED CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST BCE

Facility

$372.00

Service Code	HCPCS 30905
Hospital Charge Code	8734588
Hospital Revenue Code	450
Rate for Payer: Cash Price	$252.96

ED Debridement -> Addl 10% infected skin

Facility

$72.00

Service Code	HCPCS 11001
Hospital Charge Code	5202503
Hospital Revenue Code	450
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$3,520.00
Rate for Payer: Amerigroup CHIP/Medicaid	$6.48
Rate for Payer: BCBS of TX Blue Advantage	$21.60
Rate for Payer: BCBS of TX Blue Essentials	$25.92
Rate for Payer: BCBS of TX PPO	$3,520.00
Rate for Payer: Cash Price	$48.96
Rate for Payer: Cash Price	$48.96
Rate for Payer: Cash Price	$48.96
Rate for Payer: Cigna Medicaid	$51.84
Rate for Payer: Molina CHIP/Medicaid	$51.84
Rate for Payer: Multiplan Auto	$46.80
Rate for Payer: Multiplan Commercial	$46.80
Rate for Payer: Multiplan Workers Comp	$46.80
Rate for Payer: Parkland Medicaid	$51.84
Rate for Payer: Scott and White EPO/PPO	$18.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.84
Rate for Payer: Superior Health Plan EPO	$9.79

ED Debridement -> Addl 10% infected skin

Facility

$72.00

Service Code	HCPCS 11001
Hospital Charge Code	5202503
Hospital Revenue Code	450
Rate for Payer: Cash Price	$48.96

ED Debridement -> To devitalized tissue, <= 20 sq cm

Facility

$794.80

Service Code	HCPCS 97597
Hospital Charge Code	7150659
Hospital Revenue Code	450
Rate for Payer: Cash Price	$540.46

ED Debridement -> To devitalized tissue, <= 20 sq cm

Facility

$794.80

Service Code	HCPCS 97597
Hospital Charge Code	7150659
Hospital Revenue Code	450
Min. Negotiated Rate	$43.09
Max. Negotiated Rate	$3,520.00
Rate for Payer: Amerigroup CHIP/Medicaid	$71.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$238.44
Rate for Payer: BCBS of TX Blue Essentials	$286.13
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$3,520.00
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$572.26
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	$572.26
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$516.62
Rate for Payer: Multiplan Commercial	$516.62
Rate for Payer: Multiplan Workers Comp	$516.62
Rate for Payer: Parkland Medicaid	$572.26
Rate for Payer: Scott and White EPO/PPO	$43.09
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$572.26
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

ED Debridement -> To muscle/fascia, <= 20 sq cm

Facility

$4,383.94

Service Code	HCPCS 11043
Hospital Charge Code	7150170
Hospital Revenue Code	450
Min. Negotiated Rate	$187.09
Max. Negotiated Rate	$3,156.44
Rate for Payer: Amerigroup CHIP/Medicaid	$394.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
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	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,981.08
Rate for Payer: Cash Price	$2,981.08
Rate for Payer: Cash Price	$2,981.08
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$3,156.44
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina CHIP/Medicaid	$3,156.44
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
Rate for Payer: Multiplan Auto	$2,849.56
Rate for Payer: Multiplan Commercial	$2,849.56
Rate for Payer: Multiplan Workers Comp	$2,849.56
Rate for Payer: Parkland Medicaid	$3,156.44
Rate for Payer: Scott and White EPO/PPO	$187.09
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,156.44
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

ED Debridement -> To muscle/fascia, <= 20 sq cm

Facility

$4,383.94

Service Code	HCPCS 11043
Hospital Charge Code	7150170
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,981.08

ED Debridement -> To subcutaneous tissue, <= 20 sq cm

Facility

$1,546.00

Service Code	HCPCS 11042
Hospital Charge Code	7150162
Hospital Revenue Code	450
Min. Negotiated Rate	$74.08
Max. Negotiated Rate	$1,113.12
Rate for Payer: Amerigroup CHIP/Medicaid	$139.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,051.28
Rate for Payer: Cash Price	$1,051.28
Rate for Payer: Cash Price	$1,051.28
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,113.12
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$1,113.12
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,004.90
Rate for Payer: Multiplan Commercial	$1,004.90
Rate for Payer: Multiplan Workers Comp	$1,004.90
Rate for Payer: Parkland Medicaid	$1,113.12
Rate for Payer: Scott and White EPO/PPO	$74.08
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,113.12
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

ED Debridement -> To subcutaneous tissue, <= 20 sq cm

Facility

$1,546.00

Service Code	HCPCS 11042
Hospital Charge Code	7150162
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,051.28

ED Dislocation Repair Site -> Ankle w/o Anesthesia

Facility

$978.00

Service Code	HCPCS 27840
Hospital Charge Code	5202514
Hospital Revenue Code	450
Rate for Payer: Cash Price	$665.04

ED Dislocation Repair Site -> Ankle w/o Anesthesia

Facility

$978.00

Service Code	HCPCS 27840
Hospital Charge Code	5202514
Hospital Revenue Code	450
Min. Negotiated Rate	$88.02
Max. Negotiated Rate	$704.16
Rate for Payer: Amerigroup CHIP/Medicaid	$88.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$665.04
Rate for Payer: Cash Price	$665.04
Rate for Payer: Cash Price	$665.04
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$704.16
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$704.16
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$635.70
Rate for Payer: Multiplan Commercial	$635.70
Rate for Payer: Multiplan Workers Comp	$635.70
Rate for Payer: Parkland Medicaid	$704.16
Rate for Payer: Scott and White EPO/PPO	$490.23
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$704.16
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

ED Dislocation Repair Site -> Elbow w/ Anesthesia

Facility

$4,544.00

Service Code	HCPCS 24605
Hospital Charge Code	5202507
Hospital Revenue Code	450
Rate for Payer: Cash Price	$3,089.92

ED Dislocation Repair Site -> Elbow w/ Anesthesia

Facility

$4,544.00

Service Code	HCPCS 24605
Hospital Charge Code	5202507
Hospital Revenue Code	450
Min. Negotiated Rate	$408.96
Max. Negotiated Rate	$3,415.58
Rate for Payer: Amerigroup CHIP/Medicaid	$408.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cash Price	$3,089.92
Rate for Payer: Cash Price	$3,089.92
Rate for Payer: Cash Price	$3,089.92
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$3,271.68
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina CHIP/Medicaid	$3,271.68
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
Rate for Payer: Multiplan Auto	$2,953.60
Rate for Payer: Multiplan Commercial	$2,953.60
Rate for Payer: Multiplan Workers Comp	$2,953.60
Rate for Payer: Parkland Medicaid	$3,271.68
Rate for Payer: Scott and White EPO/PPO	$602.29
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,271.68
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

ED Dislocation Repair Site -> Elbow w/o Anesthesia

Facility

$1,399.00

Service Code	HCPCS 24600
Hospital Charge Code	5202506
Hospital Revenue Code	450
Rate for Payer: Cash Price	$951.32

ED Dislocation Repair Site -> Elbow w/o Anesthesia

Facility

$1,399.00

Service Code	HCPCS 24600
Hospital Charge Code	5202506
Hospital Revenue Code	450
Min. Negotiated Rate	$125.91
Max. Negotiated Rate	$1,007.28
Rate for Payer: Amerigroup CHIP/Medicaid	$125.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$951.32
Rate for Payer: Cash Price	$951.32
Rate for Payer: Cash Price	$951.32
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$1,007.28
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$1,007.28
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$909.35
Rate for Payer: Multiplan Commercial	$909.35
Rate for Payer: Multiplan Workers Comp	$909.35
Rate for Payer: Parkland Medicaid	$1,007.28
Rate for Payer: Scott and White EPO/PPO	$435.25
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,007.28
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

ED Dislocation Repair Site -> Finger w/o Anesthesia

Facility

$594.00

Service Code	HCPCS 26770
Hospital Charge Code	5202511
Hospital Revenue Code	450
Min. Negotiated Rate	$53.46
Max. Negotiated Rate	$543.41
Rate for Payer: Amerigroup CHIP/Medicaid	$53.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$403.92
Rate for Payer: Cash Price	$403.92
Rate for Payer: Cash Price	$403.92
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$427.68
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$427.68
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$386.10
Rate for Payer: Multiplan Commercial	$386.10
Rate for Payer: Multiplan Workers Comp	$386.10
Rate for Payer: Parkland Medicaid	$427.68
Rate for Payer: Scott and White EPO/PPO	$337.25
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$427.68
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

ED Dislocation Repair Site -> Finger w/o Anesthesia

Facility

$594.00

Service Code	HCPCS 26770
Hospital Charge Code	5202511
Hospital Revenue Code	450
Rate for Payer: Cash Price	$403.92

ED Dislocation Repair Site -> Hand

Facility

$811.00

Service Code	HCPCS 26670
Hospital Charge Code	5202509
Hospital Revenue Code	450
Min. Negotiated Rate	$72.99
Max. Negotiated Rate	$583.92
Rate for Payer: Amerigroup CHIP/Medicaid	$72.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$181.96
Rate for Payer: BCBS of TX Blue Essentials	$217.92
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$274.58
Rate for Payer: Cash Price	$551.48
Rate for Payer: Cash Price	$551.48
Rate for Payer: Cash Price	$551.48
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$583.92
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$583.92
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$527.15
Rate for Payer: Multiplan Commercial	$527.15
Rate for Payer: Multiplan Workers Comp	$527.15
Rate for Payer: Parkland Medicaid	$583.92
Rate for Payer: Scott and White EPO/PPO	$400.45
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$583.92
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

ED Dislocation Repair Site -> Hand

Facility

$811.00

Service Code	HCPCS 26670
Hospital Charge Code	5202509
Hospital Revenue Code	450
Rate for Payer: Cash Price	$551.48

ED Dislocation Repair Site -> Hip Post Arthroplasty

Facility

$1,045.00

Service Code	HCPCS 27265
Hospital Charge Code	9220218
Hospital Revenue Code	450
Rate for Payer: Cash Price	$710.60

ED Dislocation Repair Site -> Hip Post Arthroplasty

Facility

$1,045.00

Service Code	HCPCS 27265
Hospital Charge Code	9220218
Hospital Revenue Code	450
Min. Negotiated Rate	$94.05
Max. Negotiated Rate	$752.40
Rate for Payer: Amerigroup CHIP/Medicaid	$94.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$710.60
Rate for Payer: Cash Price	$710.60
Rate for Payer: Cash Price	$710.60
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$752.40
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$752.40
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$679.25
Rate for Payer: Multiplan Commercial	$679.25
Rate for Payer: Multiplan Workers Comp	$679.25
Rate for Payer: Parkland Medicaid	$752.40
Rate for Payer: Scott and White EPO/PPO	$526.65
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$752.40
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

ED Dislocation Repair Site -> Jaw

Facility

$514.00

Service Code	HCPCS 21480
Hospital Charge Code	5202504
Hospital Revenue Code	450
Min. Negotiated Rate	$37.79
Max. Negotiated Rate	$543.41
Rate for Payer: Amerigroup CHIP/Medicaid	$46.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$349.52
Rate for Payer: Cash Price	$349.52
Rate for Payer: Cash Price	$349.52
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$370.08
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$370.08
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$334.10
Rate for Payer: Multiplan Commercial	$334.10
Rate for Payer: Multiplan Workers Comp	$334.10
Rate for Payer: Parkland Medicaid	$370.08
Rate for Payer: Scott and White EPO/PPO	$37.79
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$370.08
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

ED Dislocation Repair Site -> Jaw

Facility

$514.00

Service Code	HCPCS 21480
Hospital Charge Code	5202504
Hospital Revenue Code	450
Rate for Payer: Cash Price	$349.52

ED Dislocation Repair Site -> Kneecap w/o Anesthesia

Facility

$825.00

Service Code	HCPCS 27560
Hospital Charge Code	5202513
Hospital Revenue Code	450
Min. Negotiated Rate	$74.25
Max. Negotiated Rate	$594.00
Rate for Payer: Amerigroup CHIP/Medicaid	$74.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$594.00
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$594.00
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$536.25
Rate for Payer: Multiplan Commercial	$536.25
Rate for Payer: Multiplan Workers Comp	$536.25
Rate for Payer: Parkland Medicaid	$594.00
Rate for Payer: Scott and White EPO/PPO	$434.84
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$594.00
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

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