White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED ID Aspiration -> For biopsy

Facility

$2,667.00

Service Code	HCPCS 10021
Hospital Charge Code	9250076
Hospital Revenue Code	450
Min. Negotiated Rate	$98.85
Max. Negotiated Rate	$1,920.24
Rate for Payer: Amerigroup CHIP/Medicaid	$240.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$98.85
Rate for Payer: BCBS of TX Blue Essentials	$118.38
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$149.16
Rate for Payer: Cash Price	$1,813.56
Rate for Payer: Cash Price	$1,813.56
Rate for Payer: Cash Price	$1,813.56
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,920.24
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	$1,920.24
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,733.55
Rate for Payer: Multiplan Commercial	$1,733.55
Rate for Payer: Multiplan Workers Comp	$1,733.55
Rate for Payer: Parkland Medicaid	$1,920.24
Rate for Payer: Scott and White EPO/PPO	$1,333.50
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,920.24
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 ID Aspiration -> For biopsy

Facility

$2,667.00

Service Code	HCPCS 10021
Hospital Charge Code	9250076
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,813.56

ED ID Aspiration -> Ganglion Cyst

Facility

$628.00

Service Code	HCPCS 20612
Hospital Charge Code	5202535
Hospital Revenue Code	450
Min. Negotiated Rate	$56.52
Max. Negotiated Rate	$651.79
Rate for Payer: Amerigroup CHIP/Medicaid	$56.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.35
Rate for Payer: Amerigroup Medicare	$308.35
Rate for Payer: BCBS of TX Blue Advantage	$58.47
Rate for Payer: BCBS of TX Blue Essentials	$70.02
Rate for Payer: BCBS of TX Medicare	$308.35
Rate for Payer: BCBS of TX PPO	$88.23
Rate for Payer: Cash Price	$427.04
Rate for Payer: Cash Price	$427.04
Rate for Payer: Cash Price	$427.04
Rate for Payer: Cigna Commercial	$651.79
Rate for Payer: Cigna Medicaid	$452.16
Rate for Payer: Cigna Medicare	$308.35
Rate for Payer: Employer Direct Commercial	$308.35
Rate for Payer: Humana Medicare/TRICARE	$308.35
Rate for Payer: Molina CHIP/Medicaid	$452.16
Rate for Payer: Molina Dual Medicare/Medicaid	$308.35
Rate for Payer: Molina Medicare	$308.35
Rate for Payer: Multiplan Auto	$408.20
Rate for Payer: Multiplan Commercial	$408.20
Rate for Payer: Multiplan Workers Comp	$408.20
Rate for Payer: Parkland Medicaid	$452.16
Rate for Payer: Scott and White EPO/PPO	$314.00
Rate for Payer: Scott and White Medicare	$308.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$452.16
Rate for Payer: Superior Health Plan EPO	$308.35
Rate for Payer: Superior Health Plan Medicare	$308.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.35
Rate for Payer: Universal American Medicare	$308.35
Rate for Payer: Wellcare Medicare	$308.35
Rate for Payer: Wellmed Medicare	$308.35

ED ID Aspiration -> Ganglion Cyst

Facility

$628.00

Service Code	HCPCS 20612
Hospital Charge Code	5202535
Hospital Revenue Code	450
Rate for Payer: Cash Price	$427.04

ED ID Body Site -> Bartholin's Gland

Facility

$695.00

Service Code	HCPCS 56420
Hospital Charge Code	8398503
Hospital Revenue Code	450
Min. Negotiated Rate	$62.55
Max. Negotiated Rate	$500.40
Rate for Payer: Amerigroup CHIP/Medicaid	$62.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$203.09
Rate for Payer: Amerigroup Medicare	$203.09
Rate for Payer: BCBS of TX Blue Advantage	$140.11
Rate for Payer: BCBS of TX Blue Essentials	$167.80
Rate for Payer: BCBS of TX Medicare	$203.09
Rate for Payer: BCBS of TX PPO	$211.43
Rate for Payer: Cash Price	$472.60
Rate for Payer: Cash Price	$472.60
Rate for Payer: Cash Price	$472.60
Rate for Payer: Cigna Commercial	$429.31
Rate for Payer: Cigna Medicaid	$500.40
Rate for Payer: Cigna Medicare	$203.09
Rate for Payer: Employer Direct Commercial	$203.09
Rate for Payer: Humana Medicare/TRICARE	$203.09
Rate for Payer: Molina CHIP/Medicaid	$500.40
Rate for Payer: Molina Dual Medicare/Medicaid	$203.09
Rate for Payer: Molina Medicare	$203.09
Rate for Payer: Multiplan Auto	$451.75
Rate for Payer: Multiplan Commercial	$451.75
Rate for Payer: Multiplan Workers Comp	$451.75
Rate for Payer: Parkland Medicaid	$500.40
Rate for Payer: Scott and White EPO/PPO	$347.50
Rate for Payer: Scott and White Medicare	$203.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$500.40
Rate for Payer: Superior Health Plan EPO	$203.09
Rate for Payer: Superior Health Plan Medicare	$203.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$203.09
Rate for Payer: Universal American Medicare	$203.09
Rate for Payer: Wellcare Medicare	$203.09
Rate for Payer: Wellmed Medicare	$203.09

ED ID Body Site -> Bartholin's Gland

Facility

$695.00

Service Code	HCPCS 56420
Hospital Charge Code	8398503
Hospital Revenue Code	450
Rate for Payer: Cash Price	$472.60

ED ID Body Site -> Finger, Complex

Facility

$2,073.00

Service Code	HCPCS 26011
Hospital Charge Code	5202538
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,409.64

ED ID Body Site -> Finger, Complex

Facility

$2,073.00

Service Code	HCPCS 26011
Hospital Charge Code	5202538
Hospital Revenue Code	450
Min. Negotiated Rate	$186.57
Max. Negotiated Rate	$3,507.10
Rate for Payer: Amerigroup CHIP/Medicaid	$186.57
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	$1,409.64
Rate for Payer: Cash Price	$1,409.64
Rate for Payer: Cash Price	$1,409.64
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$1,492.56
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	$1,492.56
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
Rate for Payer: Multiplan Auto	$1,347.45
Rate for Payer: Multiplan Commercial	$1,347.45
Rate for Payer: Multiplan Workers Comp	$1,347.45
Rate for Payer: Parkland Medicaid	$1,492.56
Rate for Payer: Scott and White EPO/PPO	$1,036.50
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,492.56
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 ID Body Site -> Hematoma, Seroma, Fluid collection

Facility

$6,773.30

Service Code	HCPCS 10140
Hospital Charge Code	5050140
Hospital Revenue Code	450
Min. Negotiated Rate	$183.82
Max. Negotiated Rate	$4,876.78
Rate for Payer: Amerigroup CHIP/Medicaid	$609.60
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	$183.82
Rate for Payer: BCBS of TX Blue Essentials	$220.14
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$277.38
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,876.78
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	$4,876.78
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
Rate for Payer: Multiplan Auto	$4,402.65
Rate for Payer: Multiplan Commercial	$4,402.65
Rate for Payer: Multiplan Workers Comp	$4,402.65
Rate for Payer: Parkland Medicaid	$4,876.78
Rate for Payer: Scott and White EPO/PPO	$3,386.65
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,876.78
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 ID Body Site -> Hematoma, Seroma, Fluid collection

Facility

$6,773.30

Service Code	HCPCS 10140
Hospital Charge Code	5050140
Hospital Revenue Code	450
Rate for Payer: Cash Price	$4,605.84

ED ID Body Site -> Hematoma, Seroma, Fluid collection

Facility

$6,773.30

Service Code	HCPCS 10140
Hospital Charge Code	9900076
Hospital Revenue Code	450
Min. Negotiated Rate	$183.82
Max. Negotiated Rate	$4,876.78
Rate for Payer: Amerigroup CHIP/Medicaid	$609.60
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	$183.82
Rate for Payer: BCBS of TX Blue Essentials	$220.14
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$277.38
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,876.78
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	$4,876.78
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
Rate for Payer: Multiplan Auto	$4,402.65
Rate for Payer: Multiplan Commercial	$4,402.65
Rate for Payer: Multiplan Workers Comp	$4,402.65
Rate for Payer: Parkland Medicaid	$4,876.78
Rate for Payer: Scott and White EPO/PPO	$3,386.65
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,876.78
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 ID Body Site -> Hematoma, Seroma, Fluid collection

Facility

$6,773.30

Service Code	HCPCS 10140
Hospital Charge Code	9900076
Hospital Revenue Code	450
Rate for Payer: Cash Price	$4,605.84

ED ID Body Site -> I&D Abscess/Cyst Complex

Facility

$2,238.42

Service Code	HCPCS 10061
Hospital Charge Code	7150097
Hospital Revenue Code	450
Min. Negotiated Rate	$192.87
Max. Negotiated Rate	$1,611.66
Rate for Payer: Amerigroup CHIP/Medicaid	$201.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$192.87
Rate for Payer: BCBS of TX Blue Essentials	$230.98
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$291.03
Rate for Payer: Cash Price	$1,522.13
Rate for Payer: Cash Price	$1,522.13
Rate for Payer: Cash Price	$1,522.13
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,611.66
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	$1,611.66
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,454.97
Rate for Payer: Multiplan Commercial	$1,454.97
Rate for Payer: Multiplan Workers Comp	$1,454.97
Rate for Payer: Parkland Medicaid	$1,611.66
Rate for Payer: Scott and White EPO/PPO	$1,119.21
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,611.66
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 ID Body Site -> I&D Abscess/Cyst Complex

Facility

$2,238.42

Service Code	HCPCS 10061
Hospital Charge Code	7150097
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,522.13

ED ID Body Site -> I&D Abscess/Cyst Simple

Facility

$993.50

Service Code	HCPCS 10060
Hospital Charge Code	7150089
Hospital Revenue Code	450
Min. Negotiated Rate	$89.42
Max. Negotiated Rate	$715.32
Rate for Payer: Amerigroup CHIP/Medicaid	$89.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$125.97
Rate for Payer: BCBS of TX Blue Essentials	$150.86
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$190.08
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$715.32
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	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$645.77
Rate for Payer: Multiplan Commercial	$645.77
Rate for Payer: Multiplan Workers Comp	$645.77
Rate for Payer: Parkland Medicaid	$715.32
Rate for Payer: Scott and White EPO/PPO	$496.75
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
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 ID Body Site -> I&D Abscess/Cyst Simple

Facility

$993.50

Service Code	HCPCS 10060
Hospital Charge Code	7150089
Hospital Revenue Code	450
Rate for Payer: Cash Price	$675.58

ED ID Body Site -> Perianal, superficial

Facility

$1,869.00

Service Code	HCPCS 46050
Hospital Charge Code	5202541
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,270.92

ED ID Body Site -> Perianal, superficial

Facility

$1,869.00

Service Code	HCPCS 46050
Hospital Charge Code	5202541
Hospital Revenue Code	450
Min. Negotiated Rate	$168.21
Max. Negotiated Rate	$1,974.73
Rate for Payer: Amerigroup CHIP/Medicaid	$168.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$934.20
Rate for Payer: Amerigroup Medicare	$934.20
Rate for Payer: BCBS of TX Blue Advantage	$1,275.68
Rate for Payer: BCBS of TX Blue Essentials	$1,527.76
Rate for Payer: BCBS of TX Medicare	$934.20
Rate for Payer: BCBS of TX PPO	$1,924.98
Rate for Payer: Cash Price	$1,270.92
Rate for Payer: Cash Price	$1,270.92
Rate for Payer: Cash Price	$1,270.92
Rate for Payer: Cigna Commercial	$1,974.73
Rate for Payer: Cigna Medicaid	$1,345.68
Rate for Payer: Cigna Medicare	$934.20
Rate for Payer: Employer Direct Commercial	$934.20
Rate for Payer: Humana Medicare/TRICARE	$934.20
Rate for Payer: Molina CHIP/Medicaid	$1,345.68
Rate for Payer: Molina Dual Medicare/Medicaid	$934.20
Rate for Payer: Molina Medicare	$934.20
Rate for Payer: Multiplan Auto	$1,214.85
Rate for Payer: Multiplan Commercial	$1,214.85
Rate for Payer: Multiplan Workers Comp	$1,214.85
Rate for Payer: Parkland Medicaid	$1,345.68
Rate for Payer: Scott and White EPO/PPO	$934.50
Rate for Payer: Scott and White Medicare	$934.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,345.68
Rate for Payer: Superior Health Plan EPO	$934.20
Rate for Payer: Superior Health Plan Medicare	$934.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$934.20
Rate for Payer: Universal American Medicare	$934.20
Rate for Payer: Wellcare Medicare	$934.20
Rate for Payer: Wellmed Medicare	$934.20

ED ID Body Site -> Peritonsillar

Facility

$1,336.00

Service Code	HCPCS 42700
Hospital Charge Code	9250040
Hospital Revenue Code	450
Rate for Payer: Cash Price	$908.48

ED ID Body Site -> Peritonsillar

Facility

$1,336.00

Service Code	HCPCS 42700
Hospital Charge Code	9250040
Hospital Revenue Code	450
Min. Negotiated Rate	$120.24
Max. Negotiated Rate	$961.92
Rate for Payer: Amerigroup CHIP/Medicaid	$120.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$237.93
Rate for Payer: Amerigroup Medicare	$237.93
Rate for Payer: BCBS of TX Blue Advantage	$340.08
Rate for Payer: BCBS of TX Blue Essentials	$407.28
Rate for Payer: BCBS of TX Medicare	$237.93
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cash Price	$908.48
Rate for Payer: Cash Price	$908.48
Rate for Payer: Cash Price	$908.48
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$961.92
Rate for Payer: Cigna Medicare	$237.93
Rate for Payer: Employer Direct Commercial	$237.93
Rate for Payer: Humana Medicare/TRICARE	$237.93
Rate for Payer: Molina CHIP/Medicaid	$961.92
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
Rate for Payer: Multiplan Auto	$868.40
Rate for Payer: Multiplan Commercial	$868.40
Rate for Payer: Multiplan Workers Comp	$868.40
Rate for Payer: Parkland Medicaid	$961.92
Rate for Payer: Scott and White EPO/PPO	$668.00
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$961.92
Rate for Payer: Superior Health Plan EPO	$237.93
Rate for Payer: Superior Health Plan Medicare	$237.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$237.93
Rate for Payer: Universal American Medicare	$237.93
Rate for Payer: Wellcare Medicare	$237.93
Rate for Payer: Wellmed Medicare	$237.93

ED ID Body Site -> Pilonidal cyst, multiple

Facility

$1,780.00

Service Code	HCPCS 10081
Hospital Charge Code	5202537
Hospital Revenue Code	450
Min. Negotiated Rate	$160.20
Max. Negotiated Rate	$1,503.68
Rate for Payer: Amerigroup CHIP/Medicaid	$160.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
Rate for Payer: BCBS of TX Blue Advantage	$348.36
Rate for Payer: BCBS of TX Blue Essentials	$417.20
Rate for Payer: BCBS of TX Medicare	$711.36
Rate for Payer: BCBS of TX PPO	$525.67
Rate for Payer: Cash Price	$1,210.40
Rate for Payer: Cash Price	$1,210.40
Rate for Payer: Cash Price	$1,210.40
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$1,281.60
Rate for Payer: Cigna Medicare	$711.36
Rate for Payer: Employer Direct Commercial	$711.36
Rate for Payer: Humana Medicare/TRICARE	$711.36
Rate for Payer: Molina CHIP/Medicaid	$1,281.60
Rate for Payer: Molina Dual Medicare/Medicaid	$711.36
Rate for Payer: Molina Medicare	$711.36
Rate for Payer: Multiplan Auto	$1,157.00
Rate for Payer: Multiplan Commercial	$1,157.00
Rate for Payer: Multiplan Workers Comp	$1,157.00
Rate for Payer: Parkland Medicaid	$1,281.60
Rate for Payer: Scott and White EPO/PPO	$890.00
Rate for Payer: Scott and White Medicare	$711.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,281.60
Rate for Payer: Superior Health Plan EPO	$711.36
Rate for Payer: Superior Health Plan Medicare	$711.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$711.36
Rate for Payer: Universal American Medicare	$711.36
Rate for Payer: Wellcare Medicare	$711.36
Rate for Payer: Wellmed Medicare	$711.36

ED ID Body Site -> Pilonidal cyst, multiple

Facility

$1,780.00

Service Code	HCPCS 10081
Hospital Charge Code	5202537
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,210.40

ED ID Body Site -> Pilonidal cyst, single

Facility

$266.00

Service Code	HCPCS 10080
Hospital Charge Code	5202536
Hospital Revenue Code	450
Rate for Payer: Cash Price	$180.88

ED ID Body Site -> Pilonidal cyst, single

Facility

$266.00

Service Code	HCPCS 10080
Hospital Charge Code	5202536
Hospital Revenue Code	450
Min. Negotiated Rate	$23.94
Max. Negotiated Rate	$1,503.68
Rate for Payer: Amerigroup CHIP/Medicaid	$23.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
Rate for Payer: BCBS of TX Blue Advantage	$276.03
Rate for Payer: BCBS of TX Blue Essentials	$330.58
Rate for Payer: BCBS of TX Medicare	$711.36
Rate for Payer: BCBS of TX PPO	$416.53
Rate for Payer: Cash Price	$180.88
Rate for Payer: Cash Price	$180.88
Rate for Payer: Cash Price	$180.88
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$191.52
Rate for Payer: Cigna Medicare	$711.36
Rate for Payer: Employer Direct Commercial	$711.36
Rate for Payer: Humana Medicare/TRICARE	$711.36
Rate for Payer: Molina CHIP/Medicaid	$191.52
Rate for Payer: Molina Dual Medicare/Medicaid	$711.36
Rate for Payer: Molina Medicare	$711.36
Rate for Payer: Multiplan Auto	$172.90
Rate for Payer: Multiplan Commercial	$172.90
Rate for Payer: Multiplan Workers Comp	$172.90
Rate for Payer: Parkland Medicaid	$191.52
Rate for Payer: Scott and White EPO/PPO	$133.00
Rate for Payer: Scott and White Medicare	$711.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$191.52
Rate for Payer: Superior Health Plan EPO	$711.36
Rate for Payer: Superior Health Plan Medicare	$711.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$711.36
Rate for Payer: Universal American Medicare	$711.36
Rate for Payer: Wellcare Medicare	$711.36
Rate for Payer: Wellmed Medicare	$711.36

ED ID Body Site -> Scrotal Space

Facility

$7,660.00

Service Code	HCPCS 54700
Hospital Charge Code	5202542
Hospital Revenue Code	450
Rate for Payer: Cash Price	$5,208.80

Know your out-of-pocket cost for care.

All Charges