White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED Fracture Site -> Tibia fx, Distal, w/ manipulation

Facility

$4,765.00

Service Code	HCPCS 27825
Hospital Charge Code	8910620
Hospital Revenue Code	450
Rate for Payer: Cash Price	$3,240.20

ED Fracture Site -> Tibia fx, Distal, w/ manipulation

Facility

$4,765.00

Service Code	HCPCS 27825
Hospital Charge Code	8910620
Hospital Revenue Code	450
Min. Negotiated Rate	$428.85
Max. Negotiated Rate	$3,430.80
Rate for Payer: Amerigroup CHIP/Medicaid	$428.85
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	$3,240.20
Rate for Payer: Cash Price	$3,240.20
Rate for Payer: Cash Price	$3,240.20
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$3,430.80
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	$3,430.80
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
Rate for Payer: Multiplan Auto	$3,097.25
Rate for Payer: Multiplan Commercial	$3,097.25
Rate for Payer: Multiplan Workers Comp	$3,097.25
Rate for Payer: Parkland Medicaid	$3,430.80
Rate for Payer: Scott and White EPO/PPO	$617.69
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,430.80
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 -> Toe, other than Great Toe, w/ manipulation

Facility

$1,001.00

Service Code	HCPCS 28515
Hospital Charge Code	5202530
Hospital Revenue Code	450
Rate for Payer: Cash Price	$680.68

ED Fracture Site -> Toe, other than Great Toe, w/ manipulation

Facility

$1,001.00

Service Code	HCPCS 28515
Hospital Charge Code	5202530
Hospital Revenue Code	450
Min. Negotiated Rate	$90.09
Max. Negotiated Rate	$720.72
Rate for Payer: Amerigroup CHIP/Medicaid	$90.09
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$176.59
Rate for Payer: BCBS of TX Blue Essentials	$211.48
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$266.46
Rate for Payer: Cash Price	$680.68
Rate for Payer: Cash Price	$680.68
Rate for Payer: Cash Price	$680.68
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$720.72
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	$720.72
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$650.65
Rate for Payer: Multiplan Commercial	$650.65
Rate for Payer: Multiplan Workers Comp	$650.65
Rate for Payer: Parkland Medicaid	$720.72
Rate for Payer: Scott and White EPO/PPO	$182.76
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$720.72
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 -> Toe, other than Great Toe, w/o manipulation

Facility

$579.00

Service Code	HCPCS 28510
Hospital Charge Code	8544471
Hospital Revenue Code	450
Min. Negotiated Rate	$52.11
Max. Negotiated Rate	$523.79
Rate for Payer: Amerigroup CHIP/Medicaid	$52.11
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$130.78
Rate for Payer: BCBS of TX Blue Essentials	$156.62
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$197.34
Rate for Payer: Cash Price	$393.72
Rate for Payer: Cash Price	$393.72
Rate for Payer: Cash Price	$393.72
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$416.88
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	$416.88
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$376.35
Rate for Payer: Multiplan Commercial	$376.35
Rate for Payer: Multiplan Workers Comp	$376.35
Rate for Payer: Parkland Medicaid	$416.88
Rate for Payer: Scott and White EPO/PPO	$154.01
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$416.88
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 -> Toe, other than Great Toe, w/o manipulation

Facility

$579.00

Service Code	HCPCS 28510
Hospital Charge Code	8544471
Hospital Revenue Code	450
Rate for Payer: Cash Price	$393.72

ED Fracture Site -> Trimalleolar fx, w/ manipulation

Facility

$2,762.00

Service Code	HCPCS 27818
Hospital Charge Code	5202528
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,878.16

ED Fracture Site -> Trimalleolar fx, w/ manipulation

Facility

$2,762.00

Service Code	HCPCS 27818
Hospital Charge Code	5202528
Hospital Revenue Code	450
Min. Negotiated Rate	$248.58
Max. Negotiated Rate	$3,415.58
Rate for Payer: Amerigroup CHIP/Medicaid	$248.58
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	$1,878.16
Rate for Payer: Cash Price	$1,878.16
Rate for Payer: Cash Price	$1,878.16
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$1,988.64
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	$1,988.64
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
Rate for Payer: Multiplan Auto	$1,795.30
Rate for Payer: Multiplan Commercial	$1,795.30
Rate for Payer: Multiplan Workers Comp	$1,795.30
Rate for Payer: Parkland Medicaid	$1,988.64
Rate for Payer: Scott and White EPO/PPO	$556.49
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,988.64
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 -> Ulnar Shaft, w/ manipulation

Facility

$5,129.00

Service Code	HCPCS 25535
Hospital Charge Code	5202524
Hospital Revenue Code	450
Min. Negotiated Rate	$247.79
Max. Negotiated Rate	$3,692.88
Rate for Payer: Amerigroup CHIP/Medicaid	$461.61
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	$3,487.72
Rate for Payer: Cash Price	$3,487.72
Rate for Payer: Cash Price	$3,487.72
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$3,692.88
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	$3,692.88
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$3,333.85
Rate for Payer: Multiplan Commercial	$3,333.85
Rate for Payer: Multiplan Workers Comp	$3,333.85
Rate for Payer: Parkland Medicaid	$3,692.88
Rate for Payer: Scott and White EPO/PPO	$580.46
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,692.88
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 -> Ulnar Shaft, w/ manipulation

Facility

$5,129.00

Service Code	HCPCS 25535
Hospital Charge Code	5202524
Hospital Revenue Code	450
Rate for Payer: Cash Price	$3,487.72

ED GI/GU/Rectal Procedure -> Anoscopy

Facility

$712.00

Service Code	HCPCS 46600
Hospital Charge Code	9330051
Hospital Revenue Code	450
Min. Negotiated Rate	$50.73
Max. Negotiated Rate	$512.64
Rate for Payer: Amerigroup CHIP/Medicaid	$64.08
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	$484.16
Rate for Payer: Cash Price	$484.16
Rate for Payer: Cash Price	$484.16
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$512.64
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	$512.64
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$462.80
Rate for Payer: Multiplan Commercial	$462.80
Rate for Payer: Multiplan Workers Comp	$462.80
Rate for Payer: Parkland Medicaid	$512.64
Rate for Payer: Scott and White EPO/PPO	$50.73
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$512.64
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 GI/GU/Rectal Procedure -> Anoscopy

Facility

$712.00

Service Code	HCPCS 46600
Hospital Charge Code	9330051
Hospital Revenue Code	450
Rate for Payer: Cash Price	$484.16

ED GI/GU/Rectal Procedure -> Cystostomy/Foley change

Facility

$2,426.00

Service Code	HCPCS 51705
Hospital Charge Code	4901705
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,649.68

ED GI/GU/Rectal Procedure -> Cystostomy/Foley change

Facility

$2,426.00

Service Code	HCPCS 51705
Hospital Charge Code	4901705
Hospital Revenue Code	450
Min. Negotiated Rate	$63.04
Max. Negotiated Rate	$1,746.72
Rate for Payer: Amerigroup CHIP/Medicaid	$218.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$250.99
Rate for Payer: Amerigroup Medicare	$250.99
Rate for Payer: BCBS of TX Blue Advantage	$102.45
Rate for Payer: BCBS of TX Blue Essentials	$122.70
Rate for Payer: BCBS of TX Medicare	$250.99
Rate for Payer: BCBS of TX PPO	$154.60
Rate for Payer: Cash Price	$1,649.68
Rate for Payer: Cash Price	$1,649.68
Rate for Payer: Cash Price	$1,649.68
Rate for Payer: Cigna Commercial	$530.54
Rate for Payer: Cigna Medicaid	$1,746.72
Rate for Payer: Cigna Medicare	$250.99
Rate for Payer: Employer Direct Commercial	$250.99
Rate for Payer: Humana Medicare/TRICARE	$250.99
Rate for Payer: Molina CHIP/Medicaid	$1,746.72
Rate for Payer: Molina Dual Medicare/Medicaid	$250.99
Rate for Payer: Molina Medicare	$250.99
Rate for Payer: Multiplan Auto	$1,576.90
Rate for Payer: Multiplan Commercial	$1,576.90
Rate for Payer: Multiplan Workers Comp	$1,576.90
Rate for Payer: Parkland Medicaid	$1,746.72
Rate for Payer: Scott and White EPO/PPO	$63.04
Rate for Payer: Scott and White Medicare	$250.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,746.72
Rate for Payer: Superior Health Plan EPO	$250.99
Rate for Payer: Superior Health Plan Medicare	$250.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$250.99
Rate for Payer: Universal American Medicare	$250.99
Rate for Payer: Wellcare Medicare	$250.99
Rate for Payer: Wellmed Medicare	$250.99

ED GI/GU/Rectal Procedure -> Gastric Intubation w/ Lavage

Facility

$576.00

Service Code	HCPCS 43753
Hospital Charge Code	5210316
Hospital Revenue Code	450
Rate for Payer: Cash Price	$391.68

ED GI/GU/Rectal Procedure -> Gastric Intubation w/ Lavage

Facility

$576.00

Service Code	HCPCS 43753
Hospital Charge Code	5210316
Hospital Revenue Code	450
Min. Negotiated Rate	$26.02
Max. Negotiated Rate	$637.81
Rate for Payer: Amerigroup CHIP/Medicaid	$51.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$422.68
Rate for Payer: BCBS of TX Blue Essentials	$506.20
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$637.81
Rate for Payer: Cash Price	$391.68
Rate for Payer: Cash Price	$391.68
Rate for Payer: Cash Price	$391.68
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$414.72
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$414.72
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$374.40
Rate for Payer: Multiplan Commercial	$374.40
Rate for Payer: Multiplan Workers Comp	$374.40
Rate for Payer: Parkland Medicaid	$414.72
Rate for Payer: Scott and White EPO/PPO	$26.02
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$414.72
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

ED GI/GU/Rectal Procedure -> Paraphimosis treatment

Facility

$2,269.00

Service Code	HCPCS 54450
Hospital Charge Code	5202534
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,542.92

ED GI/GU/Rectal Procedure -> Paraphimosis treatment

Facility

$2,269.00

Service Code	HCPCS 54450
Hospital Charge Code	5202534
Hospital Revenue Code	450
Min. Negotiated Rate	$69.10
Max. Negotiated Rate	$1,633.68
Rate for Payer: Amerigroup CHIP/Medicaid	$204.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$250.99
Rate for Payer: Amerigroup Medicare	$250.99
Rate for Payer: BCBS of TX Blue Advantage	$392.28
Rate for Payer: BCBS of TX Blue Essentials	$469.80
Rate for Payer: BCBS of TX Medicare	$250.99
Rate for Payer: BCBS of TX PPO	$591.95
Rate for Payer: Cash Price	$1,542.92
Rate for Payer: Cash Price	$1,542.92
Rate for Payer: Cash Price	$1,542.92
Rate for Payer: Cigna Commercial	$530.54
Rate for Payer: Cigna Medicaid	$1,633.68
Rate for Payer: Cigna Medicare	$250.99
Rate for Payer: Employer Direct Commercial	$250.99
Rate for Payer: Humana Medicare/TRICARE	$250.99
Rate for Payer: Molina CHIP/Medicaid	$1,633.68
Rate for Payer: Molina Dual Medicare/Medicaid	$250.99
Rate for Payer: Molina Medicare	$250.99
Rate for Payer: Multiplan Auto	$1,474.85
Rate for Payer: Multiplan Commercial	$1,474.85
Rate for Payer: Multiplan Workers Comp	$1,474.85
Rate for Payer: Parkland Medicaid	$1,633.68
Rate for Payer: Scott and White EPO/PPO	$69.10
Rate for Payer: Scott and White Medicare	$250.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,633.68
Rate for Payer: Superior Health Plan EPO	$250.99
Rate for Payer: Superior Health Plan Medicare	$250.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$250.99
Rate for Payer: Universal American Medicare	$250.99
Rate for Payer: Wellcare Medicare	$250.99
Rate for Payer: Wellmed Medicare	$250.99

ED GI/GU/Rectal Procedure -> Removal of hemorrhoid clot

Facility

$6,289.00

Service Code	HCPCS 46320
Hospital Charge Code	5202532
Hospital Revenue Code	450
Rate for Payer: Cash Price	$4,276.52

ED GI/GU/Rectal Procedure -> Removal of hemorrhoid clot

Facility

$6,289.00

Service Code	HCPCS 46320
Hospital Charge Code	5202532
Hospital Revenue Code	450
Min. Negotiated Rate	$140.10
Max. Negotiated Rate	$4,528.08
Rate for Payer: Amerigroup CHIP/Medicaid	$566.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,202.09
Rate for Payer: Amerigroup Medicare	$1,202.09
Rate for Payer: BCBS of TX Blue Advantage	$224.80
Rate for Payer: BCBS of TX Blue Essentials	$269.22
Rate for Payer: BCBS of TX Medicare	$1,202.09
Rate for Payer: BCBS of TX PPO	$339.22
Rate for Payer: Cash Price	$4,276.52
Rate for Payer: Cash Price	$4,276.52
Rate for Payer: Cash Price	$4,276.52
Rate for Payer: Cigna Commercial	$2,541.00
Rate for Payer: Cigna Medicaid	$4,528.08
Rate for Payer: Cigna Medicare	$1,202.09
Rate for Payer: Employer Direct Commercial	$1,202.09
Rate for Payer: Humana Medicare/TRICARE	$1,202.09
Rate for Payer: Molina CHIP/Medicaid	$4,528.08
Rate for Payer: Molina Dual Medicare/Medicaid	$1,202.09
Rate for Payer: Molina Medicare	$1,202.09
Rate for Payer: Multiplan Auto	$4,087.85
Rate for Payer: Multiplan Commercial	$4,087.85
Rate for Payer: Multiplan Workers Comp	$4,087.85
Rate for Payer: Parkland Medicaid	$4,528.08
Rate for Payer: Scott and White EPO/PPO	$140.10
Rate for Payer: Scott and White Medicare	$1,202.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,528.08
Rate for Payer: Superior Health Plan EPO	$1,202.09
Rate for Payer: Superior Health Plan Medicare	$1,202.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,202.09
Rate for Payer: Universal American Medicare	$1,202.09
Rate for Payer: Wellcare Medicare	$1,202.09
Rate for Payer: Wellmed Medicare	$1,202.09

ED GI/GU/Rectal Procedure -> Removal of rectal obstruction

Facility

$4,010.00

Service Code	HCPCS 45915
Hospital Charge Code	5202531
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,726.80

ED GI/GU/Rectal Procedure -> Removal of rectal obstruction

Facility

$4,010.00

Service Code	HCPCS 45915
Hospital Charge Code	5202531
Hospital Revenue Code	450
Min. Negotiated Rate	$281.31
Max. Negotiated Rate	$2,887.20
Rate for Payer: Amerigroup CHIP/Medicaid	$360.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,202.09
Rate for Payer: Amerigroup Medicare	$1,202.09
Rate for Payer: BCBS of TX Blue Advantage	$1,677.05
Rate for Payer: BCBS of TX Blue Essentials	$2,008.44
Rate for Payer: BCBS of TX Medicare	$1,202.09
Rate for Payer: BCBS of TX PPO	$2,530.63
Rate for Payer: Cash Price	$2,726.80
Rate for Payer: Cash Price	$2,726.80
Rate for Payer: Cash Price	$2,726.80
Rate for Payer: Cigna Commercial	$2,541.00
Rate for Payer: Cigna Medicaid	$2,887.20
Rate for Payer: Cigna Medicare	$1,202.09
Rate for Payer: Employer Direct Commercial	$1,202.09
Rate for Payer: Humana Medicare/TRICARE	$1,202.09
Rate for Payer: Molina CHIP/Medicaid	$2,887.20
Rate for Payer: Molina Dual Medicare/Medicaid	$1,202.09
Rate for Payer: Molina Medicare	$1,202.09
Rate for Payer: Multiplan Auto	$2,606.50
Rate for Payer: Multiplan Commercial	$2,606.50
Rate for Payer: Multiplan Workers Comp	$2,606.50
Rate for Payer: Parkland Medicaid	$2,887.20
Rate for Payer: Scott and White EPO/PPO	$281.31
Rate for Payer: Scott and White Medicare	$1,202.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,887.20
Rate for Payer: Superior Health Plan EPO	$1,202.09
Rate for Payer: Superior Health Plan Medicare	$1,202.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,202.09
Rate for Payer: Universal American Medicare	$1,202.09
Rate for Payer: Wellcare Medicare	$1,202.09
Rate for Payer: Wellmed Medicare	$1,202.09

ED GI/GU/Rectal Procedure -> Replace G-J Tube

Facility

$1,457.00

Service Code	HCPCS 49452
Hospital Charge Code	2181015
Hospital Revenue Code	450
Min. Negotiated Rate	$131.13
Max. Negotiated Rate	$1,980.52
Rate for Payer: Amerigroup CHIP/Medicaid	$131.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$911.12
Rate for Payer: Amerigroup Medicare	$911.12
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	$911.12
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cash Price	$990.76
Rate for Payer: Cash Price	$990.76
Rate for Payer: Cash Price	$990.76
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicaid	$1,049.04
Rate for Payer: Cigna Medicare	$911.12
Rate for Payer: Employer Direct Commercial	$911.12
Rate for Payer: Humana Medicare/TRICARE	$911.12
Rate for Payer: Molina CHIP/Medicaid	$1,049.04
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
Rate for Payer: Multiplan Auto	$947.05
Rate for Payer: Multiplan Commercial	$947.05
Rate for Payer: Multiplan Workers Comp	$947.05
Rate for Payer: Parkland Medicaid	$1,049.04
Rate for Payer: Scott and White EPO/PPO	$162.50
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,049.04
Rate for Payer: Superior Health Plan EPO	$911.12
Rate for Payer: Superior Health Plan Medicare	$911.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$911.12
Rate for Payer: Universal American Medicare	$911.12
Rate for Payer: Wellcare Medicare	$911.12
Rate for Payer: Wellmed Medicare	$911.12

ED GI/GU/Rectal Procedure -> Replace G-J Tube

Facility

$1,457.00

Service Code	HCPCS 49452
Hospital Charge Code	2181015
Hospital Revenue Code	450
Rate for Payer: Cash Price	$990.76

ED GI/GU/Rectal Procedure -> Replace G-Tube

Facility

$620.00

Service Code	HCPCS 43762
Hospital Charge Code	8424451
Hospital Revenue Code	450
Min. Negotiated Rate	$45.12
Max. Negotiated Rate	$591.95
Rate for Payer: Amerigroup CHIP/Medicaid	$55.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$250.99
Rate for Payer: Amerigroup Medicare	$250.99
Rate for Payer: BCBS of TX Blue Advantage	$392.28
Rate for Payer: BCBS of TX Blue Essentials	$469.80
Rate for Payer: BCBS of TX Medicare	$250.99
Rate for Payer: BCBS of TX PPO	$591.95
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cigna Commercial	$530.54
Rate for Payer: Cigna Medicaid	$446.40
Rate for Payer: Cigna Medicare	$250.99
Rate for Payer: Employer Direct Commercial	$250.99
Rate for Payer: Humana Medicare/TRICARE	$250.99
Rate for Payer: Molina CHIP/Medicaid	$446.40
Rate for Payer: Molina Dual Medicare/Medicaid	$250.99
Rate for Payer: Molina Medicare	$250.99
Rate for Payer: Multiplan Auto	$403.00
Rate for Payer: Multiplan Commercial	$403.00
Rate for Payer: Multiplan Workers Comp	$403.00
Rate for Payer: Parkland Medicaid	$446.40
Rate for Payer: Scott and White EPO/PPO	$45.12
Rate for Payer: Scott and White Medicare	$250.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$446.40
Rate for Payer: Superior Health Plan EPO	$250.99
Rate for Payer: Superior Health Plan Medicare	$250.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$250.99
Rate for Payer: Universal American Medicare	$250.99
Rate for Payer: Wellcare Medicare	$250.99
Rate for Payer: Wellmed Medicare	$250.99

Know your out-of-pocket cost for care.

All Charges