White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED OB/GYN Procedure -> Removal of Contraceptive Capsule

Facility

$1,718.00

Service Code	HCPCS 11976
Hospital Charge Code	5202577
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,168.24

ED OB/GYN Procedure -> Removal of Contraceptive Capsule

Facility

$1,718.00

Service Code	HCPCS 11976
Hospital Charge Code	5202577
Hospital Revenue Code	450
Min. Negotiated Rate	$125.97
Max. Negotiated Rate	$1,503.68
Rate for Payer: Amerigroup CHIP/Medicaid	$154.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
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	$711.36
Rate for Payer: BCBS of TX PPO	$190.08
Rate for Payer: Cash Price	$1,168.24
Rate for Payer: Cash Price	$1,168.24
Rate for Payer: Cash Price	$1,168.24
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$1,236.96
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	$1,236.96
Rate for Payer: Molina Dual Medicare/Medicaid	$711.36
Rate for Payer: Molina Medicare	$711.36
Rate for Payer: Multiplan Auto	$1,116.70
Rate for Payer: Multiplan Commercial	$1,116.70
Rate for Payer: Multiplan Workers Comp	$1,116.70
Rate for Payer: Parkland Medicaid	$1,236.96
Rate for Payer: Scott and White EPO/PPO	$859.00
Rate for Payer: Scott and White Medicare	$711.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,236.96
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 OPEN TX PHALANGEAL SHAFT FX PROXIMAL/MIDDLE PHALANX EA W/INT FIX WHEN PERFORMED BCE

Facility

$11,099.00

Service Code	HCPCS 26735
Hospital Charge Code	8470467
Hospital Revenue Code	450
Min. Negotiated Rate	$998.91
Max. Negotiated Rate	$7,991.28
Rate for Payer: Amerigroup CHIP/Medicaid	$998.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$7,547.32
Rate for Payer: Cash Price	$7,547.32
Rate for Payer: Cash Price	$7,547.32
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$7,991.28
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$7,991.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$7,214.35
Rate for Payer: Multiplan Commercial	$7,214.35
Rate for Payer: Multiplan Workers Comp	$7,214.35
Rate for Payer: Parkland Medicaid	$7,991.28
Rate for Payer: Scott and White EPO/PPO	$5,549.50
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,991.28
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

ED OPEN TX PHALANGEAL SHAFT FX PROXIMAL/MIDDLE PHALANX EA W/INT FIX WHEN PERFORMED BCE

Facility

$11,099.00

Service Code	HCPCS 26735
Hospital Charge Code	8470467
Hospital Revenue Code	450
Rate for Payer: Cash Price	$7,547.32

ED Orthopedic Cast Application -> Foot/Ankle

Facility

$580.00

Service Code	HCPCS 29405
Hospital Charge Code	8914630
Hospital Revenue Code	450
Min. Negotiated Rate	$52.20
Max. Negotiated Rate	$593.92
Rate for Payer: Amerigroup CHIP/Medicaid	$52.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$80.76
Rate for Payer: BCBS of TX Blue Essentials	$96.72
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$121.87
Rate for Payer: Cash Price	$394.40
Rate for Payer: Cash Price	$394.40
Rate for Payer: Cash Price	$394.40
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$417.60
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$417.60
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$377.00
Rate for Payer: Multiplan Commercial	$377.00
Rate for Payer: Multiplan Workers Comp	$377.00
Rate for Payer: Parkland Medicaid	$417.60
Rate for Payer: Scott and White EPO/PPO	$290.00
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$417.60
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

ED Orthopedic Cast Application -> Foot/Ankle

Facility

$580.00

Service Code	HCPCS 29405
Hospital Charge Code	8914630
Hospital Revenue Code	450
Rate for Payer: Cash Price	$394.40

ED Orthopedic Cast Application -> Forearm

Facility

$520.00

Service Code	HCPCS 29075
Hospital Charge Code	9220231
Hospital Revenue Code	450
Rate for Payer: Cash Price	$353.60

ED Orthopedic Cast Application -> Forearm

Facility

$520.00

Service Code	HCPCS 29075
Hospital Charge Code	9220231
Hospital Revenue Code	450
Min. Negotiated Rate	$46.80
Max. Negotiated Rate	$593.92
Rate for Payer: Amerigroup CHIP/Medicaid	$46.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$92.22
Rate for Payer: BCBS of TX Blue Essentials	$110.44
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$139.15
Rate for Payer: Cash Price	$353.60
Rate for Payer: Cash Price	$353.60
Rate for Payer: Cash Price	$353.60
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$374.40
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$374.40
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$338.00
Rate for Payer: Multiplan Commercial	$338.00
Rate for Payer: Multiplan Workers Comp	$338.00
Rate for Payer: Parkland Medicaid	$374.40
Rate for Payer: Scott and White EPO/PPO	$260.00
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$374.40
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

ED Orthopedic Cast Application -> Hand

Facility

$745.00

Service Code	HCPCS 26600
Hospital Charge Code	9220210
Hospital Revenue Code	450
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$536.40
Rate for Payer: Amerigroup CHIP/Medicaid	$67.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$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	$506.60
Rate for Payer: Cash Price	$506.60
Rate for Payer: Cash Price	$506.60
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$536.40
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	$536.40
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$484.25
Rate for Payer: Multiplan Commercial	$484.25
Rate for Payer: Multiplan Workers Comp	$484.25
Rate for Payer: Parkland Medicaid	$536.40
Rate for Payer: Scott and White EPO/PPO	$372.50
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$536.40
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 Orthopedic Cast Application -> Hand

Facility

$745.00

Service Code	HCPCS 26600
Hospital Charge Code	9220210
Hospital Revenue Code	450
Rate for Payer: Cash Price	$506.60

ED Orthopedic Cast Application -> Lower extremity

Facility

$741.00

Service Code	HCPCS 29345
Hospital Charge Code	9220235
Hospital Revenue Code	450
Rate for Payer: Cash Price	$503.88

ED Orthopedic Cast Application -> Lower extremity

Facility

$741.00

Service Code	HCPCS 29345
Hospital Charge Code	9220235
Hospital Revenue Code	450
Min. Negotiated Rate	$66.69
Max. Negotiated Rate	$593.92
Rate for Payer: Amerigroup CHIP/Medicaid	$66.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$131.40
Rate for Payer: BCBS of TX Blue Essentials	$157.36
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$198.27
Rate for Payer: Cash Price	$503.88
Rate for Payer: Cash Price	$503.88
Rate for Payer: Cash Price	$503.88
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$533.52
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$533.52
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$481.65
Rate for Payer: Multiplan Commercial	$481.65
Rate for Payer: Multiplan Workers Comp	$481.65
Rate for Payer: Parkland Medicaid	$533.52
Rate for Payer: Scott and White EPO/PPO	$370.50
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$533.52
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

ED Orthopedic Cast Application -> Upper Arm/Elbow

Facility

$682.00

Service Code	HCPCS 29085
Hospital Charge Code	8912648
Hospital Revenue Code	450
Min. Negotiated Rate	$61.38
Max. Negotiated Rate	$491.04
Rate for Payer: Amerigroup CHIP/Medicaid	$61.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$100.05
Rate for Payer: BCBS of TX Blue Essentials	$119.82
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$150.97
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$491.04
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$491.04
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
Rate for Payer: Multiplan Auto	$443.30
Rate for Payer: Multiplan Commercial	$443.30
Rate for Payer: Multiplan Workers Comp	$443.30
Rate for Payer: Parkland Medicaid	$491.04
Rate for Payer: Scott and White EPO/PPO	$341.00
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$491.04
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

ED Orthopedic Cast Application -> Upper Arm/Elbow

Facility

$682.00

Service Code	HCPCS 29085
Hospital Charge Code	8912648
Hospital Revenue Code	450
Rate for Payer: Cash Price	$463.76

ED Orthopedic Cast Removal -> Arm/Leg

Facility

$644.00

Service Code	HCPCS 29705
Hospital Charge Code	5202579
Hospital Revenue Code	450
Min. Negotiated Rate	$57.26
Max. Negotiated Rate	$593.92
Rate for Payer: Amerigroup CHIP/Medicaid	$57.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$57.26
Rate for Payer: BCBS of TX Blue Essentials	$68.58
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$86.41
Rate for Payer: Cash Price	$437.92
Rate for Payer: Cash Price	$437.92
Rate for Payer: Cash Price	$437.92
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$463.68
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$463.68
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$418.60
Rate for Payer: Multiplan Commercial	$418.60
Rate for Payer: Multiplan Workers Comp	$418.60
Rate for Payer: Parkland Medicaid	$463.68
Rate for Payer: Scott and White EPO/PPO	$322.00
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$463.68
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

ED Orthopedic Cast Removal -> Arm/Leg

Facility

$644.00

Service Code	HCPCS 29705
Hospital Charge Code	5202579
Hospital Revenue Code	450
Rate for Payer: Cash Price	$437.92

ED Orthopedic Splinting Site -> Finger splint, static

Facility

$488.00

Service Code	HCPCS 29130
Hospital Charge Code	4272028
Hospital Revenue Code	450
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$351.36
Rate for Payer: Amerigroup CHIP/Medicaid	$43.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$91.87
Rate for Payer: BCBS of TX Blue Essentials	$110.02
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$138.63
Rate for Payer: Cash Price	$331.84
Rate for Payer: Cash Price	$331.84
Rate for Payer: Cash Price	$331.84
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$351.36
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	$351.36
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$317.20
Rate for Payer: Multiplan Commercial	$317.20
Rate for Payer: Multiplan Workers Comp	$317.20
Rate for Payer: Parkland Medicaid	$351.36
Rate for Payer: Scott and White EPO/PPO	$244.00
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$351.36
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 Orthopedic Splinting Site -> Finger splint, static

Facility

$488.00

Service Code	HCPCS 29130
Hospital Charge Code	4272028
Hospital Revenue Code	450
Rate for Payer: Cash Price	$331.84

ED Orthopedic Splinting Site -> Posterior Long Arm Splint

Facility

$490.00

Service Code	HCPCS 29105
Hospital Charge Code	5202580
Hospital Revenue Code	450
Rate for Payer: Cash Price	$333.20

ED Orthopedic Splinting Site -> Posterior Long Arm Splint

Facility

$490.00

Service Code	HCPCS 29105
Hospital Charge Code	5202580
Hospital Revenue Code	450
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$352.80
Rate for Payer: Amerigroup CHIP/Medicaid	$44.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$83.17
Rate for Payer: BCBS of TX Blue Essentials	$99.60
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$125.50
Rate for Payer: Cash Price	$333.20
Rate for Payer: Cash Price	$333.20
Rate for Payer: Cash Price	$333.20
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$352.80
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$352.80
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
Rate for Payer: Multiplan Auto	$318.50
Rate for Payer: Multiplan Commercial	$318.50
Rate for Payer: Multiplan Workers Comp	$318.50
Rate for Payer: Parkland Medicaid	$352.80
Rate for Payer: Scott and White EPO/PPO	$245.00
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$352.80
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

ED Orthopedic Splinting Site -> Posterior Long Leg Splint

Facility

$841.00

Service Code	HCPCS 29505
Hospital Charge Code	9220240
Hospital Revenue Code	450
Rate for Payer: Cash Price	$571.88

ED Orthopedic Splinting Site -> Posterior Long Leg Splint

Facility

$841.00

Service Code	HCPCS 29505
Hospital Charge Code	9220240
Hospital Revenue Code	450
Min. Negotiated Rate	$75.69
Max. Negotiated Rate	$605.52
Rate for Payer: Amerigroup CHIP/Medicaid	$75.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$97.03
Rate for Payer: BCBS of TX Blue Essentials	$116.20
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$146.41
Rate for Payer: Cash Price	$571.88
Rate for Payer: Cash Price	$571.88
Rate for Payer: Cash Price	$571.88
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$605.52
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$605.52
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
Rate for Payer: Multiplan Auto	$546.65
Rate for Payer: Multiplan Commercial	$546.65
Rate for Payer: Multiplan Workers Comp	$546.65
Rate for Payer: Parkland Medicaid	$605.52
Rate for Payer: Scott and White EPO/PPO	$420.50
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$605.52
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

ED Orthopedic Splinting Site -> Posterior Short Arm Splint

Facility

$618.00

Service Code	HCPCS 29125
Hospital Charge Code	4272026
Hospital Revenue Code	450
Rate for Payer: Cash Price	$420.24

ED Orthopedic Splinting Site -> Posterior Short Arm Splint

Facility

$618.00

Service Code	HCPCS 29125
Hospital Charge Code	4272026
Hospital Revenue Code	450
Min. Negotiated Rate	$55.62
Max. Negotiated Rate	$444.96
Rate for Payer: Amerigroup CHIP/Medicaid	$55.62
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	$420.24
Rate for Payer: Cash Price	$420.24
Rate for Payer: Cash Price	$420.24
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$444.96
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	$444.96
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$401.70
Rate for Payer: Multiplan Commercial	$401.70
Rate for Payer: Multiplan Workers Comp	$401.70
Rate for Payer: Parkland Medicaid	$444.96
Rate for Payer: Scott and White EPO/PPO	$309.00
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$444.96
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 Orthopedic Splinting Site -> Posterior Short Leg Splint

Facility

$569.00

Service Code	HCPCS 29515
Hospital Charge Code	9220241
Hospital Revenue Code	450
Rate for Payer: Cash Price	$386.92

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