White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED EGD PLACE GASTROSTOMY TUBE BCE

Facility

$5,390.12

Service Code	HCPCS 43246
Hospital Charge Code	8796540
Hospital Revenue Code	450
Rate for Payer: Cash Price	$3,665.28

ED EGD PLACE GASTROSTOMY TUBE BCE

Facility

$5,390.12

Service Code	HCPCS 43246
Hospital Charge Code	8796540
Hospital Revenue Code	450
Min. Negotiated Rate	$241.66
Max. Negotiated Rate	$4,074.70
Rate for Payer: Amerigroup CHIP/Medicaid	$485.11
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Amerigroup Medicare	$1,927.65
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	$1,927.65
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cash Price	$3,665.28
Rate for Payer: Cash Price	$3,665.28
Rate for Payer: Cash Price	$3,665.28
Rate for Payer: Cigna Commercial	$4,074.70
Rate for Payer: Cigna Medicaid	$3,880.89
Rate for Payer: Cigna Medicare	$1,927.65
Rate for Payer: Employer Direct Commercial	$1,927.65
Rate for Payer: Humana Medicare/TRICARE	$1,927.65
Rate for Payer: Molina CHIP/Medicaid	$3,880.89
Rate for Payer: Molina Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Molina Medicare	$1,927.65
Rate for Payer: Multiplan Auto	$3,503.58
Rate for Payer: Multiplan Commercial	$3,503.58
Rate for Payer: Multiplan Workers Comp	$3,503.58
Rate for Payer: Parkland Medicaid	$3,880.89
Rate for Payer: Scott and White EPO/PPO	$241.66
Rate for Payer: Scott and White Medicare	$1,927.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,880.89
Rate for Payer: Superior Health Plan EPO	$1,927.65
Rate for Payer: Superior Health Plan Medicare	$1,927.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Universal American Medicare	$1,927.65
Rate for Payer: Wellcare Medicare	$1,927.65
Rate for Payer: Wellmed Medicare	$1,927.65

ED EXC B9 LES MRGN 3.1 TO 4.0CM BCE

Facility

$5,911.00

Service Code	HCPCS 11424
Hospital Charge Code	8402469
Hospital Revenue Code	450
Rate for Payer: Cash Price	$4,019.48

ED EXC B9 LES MRGN 3.1 TO 4.0CM BCE

Facility

$5,911.00

Service Code	HCPCS 11424
Hospital Charge Code	8402469
Hospital Revenue Code	450
Min. Negotiated Rate	$223.47
Max. Negotiated Rate	$4,255.92
Rate for Payer: Amerigroup CHIP/Medicaid	$531.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$4,019.48
Rate for Payer: Cash Price	$4,019.48
Rate for Payer: Cash Price	$4,019.48
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,255.92
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$4,255.92
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
Rate for Payer: Multiplan Auto	$3,842.15
Rate for Payer: Multiplan Commercial	$3,842.15
Rate for Payer: Multiplan Workers Comp	$3,842.15
Rate for Payer: Parkland Medicaid	$4,255.92
Rate for Payer: Scott and White EPO/PPO	$223.47
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,255.92
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

ED Eye Procedure -> Corneal w/o Slit Lamp

Facility

$923.00

Service Code	HCPCS 65220
Hospital Charge Code	5202518
Hospital Revenue Code	450
Rate for Payer: Cash Price	$627.64

ED Eye Procedure -> Corneal w/o Slit Lamp

Facility

$923.00

Service Code	HCPCS 65220
Hospital Charge Code	5202518
Hospital Revenue Code	450
Min. Negotiated Rate	$50.34
Max. Negotiated Rate	$948.59
Rate for Payer: Amerigroup CHIP/Medicaid	$83.07
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$448.76
Rate for Payer: Amerigroup Medicare	$448.76
Rate for Payer: BCBS of TX Blue Advantage	$607.20
Rate for Payer: BCBS of TX Blue Essentials	$727.18
Rate for Payer: BCBS of TX Medicare	$448.76
Rate for Payer: BCBS of TX PPO	$916.25
Rate for Payer: Cash Price	$627.64
Rate for Payer: Cash Price	$627.64
Rate for Payer: Cash Price	$627.64
Rate for Payer: Cigna Commercial	$948.59
Rate for Payer: Cigna Medicaid	$664.56
Rate for Payer: Cigna Medicare	$448.76
Rate for Payer: Employer Direct Commercial	$448.76
Rate for Payer: Humana Medicare/TRICARE	$448.76
Rate for Payer: Molina CHIP/Medicaid	$664.56
Rate for Payer: Molina Dual Medicare/Medicaid	$448.76
Rate for Payer: Molina Medicare	$448.76
Rate for Payer: Multiplan Auto	$599.95
Rate for Payer: Multiplan Commercial	$599.95
Rate for Payer: Multiplan Workers Comp	$599.95
Rate for Payer: Parkland Medicaid	$664.56
Rate for Payer: Scott and White EPO/PPO	$50.34
Rate for Payer: Scott and White Medicare	$448.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$664.56
Rate for Payer: Superior Health Plan EPO	$448.76
Rate for Payer: Superior Health Plan Medicare	$448.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$448.76
Rate for Payer: Universal American Medicare	$448.76
Rate for Payer: Wellcare Medicare	$448.76
Rate for Payer: Wellmed Medicare	$448.76

ED Foreign Body Removal Site -> Auditory canal, external w/o anesthesia

Facility

$476.00

Service Code	HCPCS 69200
Hospital Charge Code	9250012
Hospital Revenue Code	450
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$342.72
Rate for Payer: Amerigroup CHIP/Medicaid	$42.84
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	$323.68
Rate for Payer: Cash Price	$323.68
Rate for Payer: Cash Price	$323.68
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$342.72
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	$342.72
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$309.40
Rate for Payer: Multiplan Commercial	$309.40
Rate for Payer: Multiplan Workers Comp	$309.40
Rate for Payer: Parkland Medicaid	$342.72
Rate for Payer: Scott and White EPO/PPO	$58.06
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$342.72
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 Foreign Body Removal Site -> Auditory canal, external w/o anesthesia

Facility

$476.00

Service Code	HCPCS 69200
Hospital Charge Code	9250012
Hospital Revenue Code	450
Rate for Payer: Cash Price	$323.68

ED Foreign Body Removal Site -> Intranasal

Facility

$323.00

Service Code	HCPCS 30300
Hospital Charge Code	5202521
Hospital Revenue Code	450
Rate for Payer: Cash Price	$219.64

ED Foreign Body Removal Site -> Intranasal

Facility

$323.00

Service Code	HCPCS 30300
Hospital Charge Code	5202521
Hospital Revenue Code	450
Min. Negotiated Rate	$29.07
Max. Negotiated Rate	$282.53
Rate for Payer: Amerigroup CHIP/Medicaid	$29.07
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	$219.64
Rate for Payer: Cash Price	$219.64
Rate for Payer: Cash Price	$219.64
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$232.56
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	$232.56
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$209.95
Rate for Payer: Multiplan Commercial	$209.95
Rate for Payer: Multiplan Workers Comp	$209.95
Rate for Payer: Parkland Medicaid	$232.56
Rate for Payer: Scott and White EPO/PPO	$152.65
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$232.56
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 Foreign Body Removal Site -> Scrotum

Facility

$8,880.00

Service Code	HCPCS 55120
Hospital Charge Code	8912598
Hospital Revenue Code	450
Rate for Payer: Cash Price	$6,038.40

ED Foreign Body Removal Site -> Scrotum

Facility

$8,880.00

Service Code	HCPCS 55120
Hospital Charge Code	8912598
Hospital Revenue Code	450
Min. Negotiated Rate	$439.05
Max. Negotiated Rate	$6,393.60
Rate for Payer: Amerigroup CHIP/Medicaid	$799.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Amerigroup Medicare	$2,099.91
Rate for Payer: BCBS of TX Blue Advantage	$2,958.49
Rate for Payer: BCBS of TX Blue Essentials	$3,543.10
Rate for Payer: BCBS of TX Medicare	$2,099.91
Rate for Payer: BCBS of TX PPO	$4,464.31
Rate for Payer: Cash Price	$6,038.40
Rate for Payer: Cash Price	$6,038.40
Rate for Payer: Cash Price	$6,038.40
Rate for Payer: Cigna Commercial	$4,438.84
Rate for Payer: Cigna Medicaid	$6,393.60
Rate for Payer: Cigna Medicare	$2,099.91
Rate for Payer: Employer Direct Commercial	$2,099.91
Rate for Payer: Humana Medicare/TRICARE	$2,099.91
Rate for Payer: Molina CHIP/Medicaid	$6,393.60
Rate for Payer: Molina Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Molina Medicare	$2,099.91
Rate for Payer: Multiplan Auto	$5,772.00
Rate for Payer: Multiplan Commercial	$5,772.00
Rate for Payer: Multiplan Workers Comp	$5,772.00
Rate for Payer: Parkland Medicaid	$6,393.60
Rate for Payer: Scott and White EPO/PPO	$439.05
Rate for Payer: Scott and White Medicare	$2,099.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,393.60
Rate for Payer: Superior Health Plan EPO	$2,099.91
Rate for Payer: Superior Health Plan Medicare	$2,099.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Universal American Medicare	$2,099.91
Rate for Payer: Wellcare Medicare	$2,099.91
Rate for Payer: Wellmed Medicare	$2,099.91

ED Foreign Body Removal Site -> Skin, Subcutaneous Simple FB

Facility

$2,057.12

Service Code	HCPCS 10120
Hospital Charge Code	7150139
Hospital Revenue Code	450
Min. Negotiated Rate	$130.89
Max. Negotiated Rate	$1,481.13
Rate for Payer: Amerigroup CHIP/Medicaid	$185.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$178.41
Rate for Payer: BCBS of TX Blue Essentials	$213.66
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$269.21
Rate for Payer: Cash Price	$1,398.84
Rate for Payer: Cash Price	$1,398.84
Rate for Payer: Cash Price	$1,398.84
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,481.13
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	$1,481.13
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,337.13
Rate for Payer: Multiplan Commercial	$1,337.13
Rate for Payer: Multiplan Workers Comp	$1,337.13
Rate for Payer: Parkland Medicaid	$1,481.13
Rate for Payer: Scott and White EPO/PPO	$130.89
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,481.13
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 Foreign Body Removal Site -> Skin, Subcutaneous Simple FB

Facility

$2,057.12

Service Code	HCPCS 10120
Hospital Charge Code	7150139
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,398.84

ED Foreign Body Removal Site -> Upper Arm/Elbow

Facility

$2,714.00

Service Code	HCPCS 24200
Hospital Charge Code	5202520
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,845.52

ED Foreign Body Removal Site -> Upper Arm/Elbow

Facility

$2,714.00

Service Code	HCPCS 24200
Hospital Charge Code	5202520
Hospital Revenue Code	450
Min. Negotiated Rate	$175.78
Max. Negotiated Rate	$3,507.10
Rate for Payer: Amerigroup CHIP/Medicaid	$244.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$245.91
Rate for Payer: BCBS of TX Blue Essentials	$294.50
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$371.07
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$1,954.08
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$1,954.08
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
Rate for Payer: Multiplan Auto	$1,764.10
Rate for Payer: Multiplan Commercial	$1,764.10
Rate for Payer: Multiplan Workers Comp	$1,764.10
Rate for Payer: Parkland Medicaid	$1,954.08
Rate for Payer: Scott and White EPO/PPO	$175.78
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.08
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

ED Fracture Site -> Bimalleolar Fx, w/o Manipulation

Facility

$1,059.00

Service Code	HCPCS 27808
Hospital Charge Code	9220225
Hospital Revenue Code	450
Rate for Payer: Cash Price	$720.12

ED Fracture Site -> Bimalleolar Fx, w/o Manipulation

Facility

$1,059.00

Service Code	HCPCS 27808
Hospital Charge Code	9220225
Hospital Revenue Code	450
Min. Negotiated Rate	$95.31
Max. Negotiated Rate	$762.48
Rate for Payer: Amerigroup CHIP/Medicaid	$95.31
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	$720.12
Rate for Payer: Cash Price	$720.12
Rate for Payer: Cash Price	$720.12
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$762.48
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	$762.48
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$688.35
Rate for Payer: Multiplan Commercial	$688.35
Rate for Payer: Multiplan Workers Comp	$688.35
Rate for Payer: Parkland Medicaid	$762.48
Rate for Payer: Scott and White EPO/PPO	$391.91
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$762.48
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 Fracture Site -> Elbow/ Monteggia w/ manipulation

Facility

$3,361.00

Service Code	HCPCS 24620
Hospital Charge Code	9220202
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,285.48

ED Fracture Site -> Elbow/ Monteggia w/ manipulation

Facility

$3,361.00

Service Code	HCPCS 24620
Hospital Charge Code	9220202
Hospital Revenue Code	450
Min. Negotiated Rate	$302.49
Max. Negotiated Rate	$3,415.58
Rate for Payer: Amerigroup CHIP/Medicaid	$302.49
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	$2,285.48
Rate for Payer: Cash Price	$2,285.48
Rate for Payer: Cash Price	$2,285.48
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$2,419.92
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	$2,419.92
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
Rate for Payer: Multiplan Auto	$2,184.65
Rate for Payer: Multiplan Commercial	$2,184.65
Rate for Payer: Multiplan Workers Comp	$2,184.65
Rate for Payer: Parkland Medicaid	$2,419.92
Rate for Payer: Scott and White EPO/PPO	$738.81
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,419.92
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 Fracture Site -> Fibula Fx, Distal, w/ manipulation

Facility

$323.00

Service Code	HCPCS 27788
Hospital Charge Code	5202527
Hospital Revenue Code	450
Rate for Payer: Cash Price	$219.64

ED Fracture Site -> Fibula Fx, Distal, w/ manipulation

Facility

$323.00

Service Code	HCPCS 27788
Hospital Charge Code	5202527
Hospital Revenue Code	450
Min. Negotiated Rate	$29.07
Max. Negotiated Rate	$543.41
Rate for Payer: Amerigroup CHIP/Medicaid	$29.07
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	$219.64
Rate for Payer: Cash Price	$219.64
Rate for Payer: Cash Price	$219.64
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$232.56
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	$232.56
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$209.95
Rate for Payer: Multiplan Commercial	$209.95
Rate for Payer: Multiplan Workers Comp	$209.95
Rate for Payer: Parkland Medicaid	$232.56
Rate for Payer: Scott and White EPO/PPO	$488.46
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$232.56
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 Fracture Site -> Fibula Fx, Distal, w/o manipulation

Facility

$243.00

Service Code	HCPCS 27786
Hospital Charge Code	9220224
Hospital Revenue Code	450
Rate for Payer: Cash Price	$165.24

ED Fracture Site -> Fibula Fx, Distal, w/o manipulation

Facility

$243.00

Service Code	HCPCS 27786
Hospital Charge Code	9220224
Hospital Revenue Code	450
Min. Negotiated Rate	$21.87
Max. Negotiated Rate	$543.41
Rate for Payer: Amerigroup CHIP/Medicaid	$21.87
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	$165.24
Rate for Payer: Cash Price	$165.24
Rate for Payer: Cash Price	$165.24
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$174.96
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	$174.96
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$157.95
Rate for Payer: Multiplan Commercial	$157.95
Rate for Payer: Multiplan Workers Comp	$157.95
Rate for Payer: Parkland Medicaid	$174.96
Rate for Payer: Scott and White EPO/PPO	$367.34
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$174.96
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 Fracture Site -> Great Toe w/ manipulation

Facility

$1,117.00

Service Code	HCPCS 28495
Hospital Charge Code	9220229
Hospital Revenue Code	450
Min. Negotiated Rate	$100.53
Max. Negotiated Rate	$804.24
Rate for Payer: Amerigroup CHIP/Medicaid	$100.53
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	$759.56
Rate for Payer: Cash Price	$759.56
Rate for Payer: Cash Price	$759.56
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$804.24
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	$804.24
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$726.05
Rate for Payer: Multiplan Commercial	$726.05
Rate for Payer: Multiplan Workers Comp	$726.05
Rate for Payer: Parkland Medicaid	$804.24
Rate for Payer: Scott and White EPO/PPO	$189.69
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$804.24
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

Know your out-of-pocket cost for care.

All Charges