White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED Orthopedic Cast Removal -> Arm/Leg

Facility

$644.00

Service Code	HCPCS 29705
Hospital Charge Code	5202579
Hospital Revenue Code	450
Min. Negotiated Rate	$54.30
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	$54.30
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	$35.46
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	$35.46
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	$50.80
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
Min. Negotiated Rate	$64.60
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	$64.60
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 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 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	$49.89
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	$49.89
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

ED Orthopedic Splinting Site -> Posterior Short Leg Splint

Facility

$569.00

Service Code	HCPCS 29515
Hospital Charge Code	9220241
Hospital Revenue Code	450
Min. Negotiated Rate	$51.21
Max. Negotiated Rate	$409.68
Rate for Payer: Amerigroup CHIP/Medicaid	$51.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$70.51
Rate for Payer: BCBS of TX Blue Essentials	$84.44
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$106.39
Rate for Payer: Cash Price	$386.92
Rate for Payer: Cash Price	$386.92
Rate for Payer: Cash Price	$386.92
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$409.68
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	$409.68
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
Rate for Payer: Multiplan Auto	$369.85
Rate for Payer: Multiplan Commercial	$369.85
Rate for Payer: Multiplan Workers Comp	$369.85
Rate for Payer: Parkland Medicaid	$409.68
Rate for Payer: Scott and White EPO/PPO	$61.36
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$409.68
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 Strapping Site -> Toes

Facility

$329.00

Service Code	HCPCS 29550
Hospital Charge Code	5202581
Hospital Revenue Code	450
Rate for Payer: Cash Price	$223.72

ED Orthopedic Strapping Site -> Toes

Facility

$329.00

Service Code	HCPCS 29550
Hospital Charge Code	5202581
Hospital Revenue Code	450
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$236.88
Rate for Payer: Amerigroup CHIP/Medicaid	$29.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
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	$59.26
Rate for Payer: BCBS of TX PPO	$138.63
Rate for Payer: Cash Price	$223.72
Rate for Payer: Cash Price	$223.72
Rate for Payer: Cash Price	$223.72
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$236.88
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$236.88
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
Rate for Payer: Multiplan Auto	$213.85
Rate for Payer: Multiplan Commercial	$213.85
Rate for Payer: Multiplan Workers Comp	$213.85
Rate for Payer: Parkland Medicaid	$236.88
Rate for Payer: Scott and White EPO/PPO	$13.54
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$236.88
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

ED Paracentesis -> with imaging

Facility

$1,947.00

Service Code	HCPCS 49083
Hospital Charge Code	2170756
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,323.96

ED Paracentesis -> with imaging

Facility

$1,947.00

Service Code	HCPCS 49083
Hospital Charge Code	2170756
Hospital Revenue Code	450
Min. Negotiated Rate	$127.86
Max. Negotiated Rate	$1,980.52
Rate for Payer: Amerigroup CHIP/Medicaid	$175.23
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	$1,323.96
Rate for Payer: Cash Price	$1,323.96
Rate for Payer: Cash Price	$1,323.96
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicaid	$1,401.84
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	$1,401.84
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
Rate for Payer: Multiplan Auto	$1,265.55
Rate for Payer: Multiplan Commercial	$1,265.55
Rate for Payer: Multiplan Workers Comp	$1,265.55
Rate for Payer: Parkland Medicaid	$1,401.84
Rate for Payer: Scott and White EPO/PPO	$127.86
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,401.84
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 Paracentesis -> without imaging

Facility

$1,573.00

Service Code	HCPCS 49082
Hospital Charge Code	8910647
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,069.64

ED Paracentesis -> without imaging

Facility

$1,573.00

Service Code	HCPCS 49082
Hospital Charge Code	8910647
Hospital Revenue Code	450
Min. Negotiated Rate	$89.05
Max. Negotiated Rate	$1,980.52
Rate for Payer: Amerigroup CHIP/Medicaid	$141.57
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	$1,069.64
Rate for Payer: Cash Price	$1,069.64
Rate for Payer: Cash Price	$1,069.64
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicaid	$1,132.56
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	$1,132.56
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
Rate for Payer: Multiplan Auto	$1,022.45
Rate for Payer: Multiplan Commercial	$1,022.45
Rate for Payer: Multiplan Workers Comp	$1,022.45
Rate for Payer: Parkland Medicaid	$1,132.56
Rate for Payer: Scott and White EPO/PPO	$89.05
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,132.56
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 PRESSD NONPRESSD INHAL TRMENT BCE

Facility

$170.00

Service Code	HCPCS 94640
Hospital Charge Code	8402468
Hospital Revenue Code	410
Rate for Payer: Cash Price	$115.60

ED PRESSD NONPRESSD INHAL TRMENT BCE

Facility

$170.00

Service Code	HCPCS 94640
Hospital Charge Code	8402468
Hospital Revenue Code	410
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$464.99
Rate for Payer: Amerigroup CHIP/Medicaid	$15.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$219.97
Rate for Payer: Amerigroup Medicare	$219.97
Rate for Payer: BCBS of TX Blue Advantage	$51.00
Rate for Payer: BCBS of TX Blue Essentials	$61.20
Rate for Payer: BCBS of TX Medicare	$219.97
Rate for Payer: BCBS of TX PPO	$68.00
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cigna Commercial	$464.99
Rate for Payer: Cigna Medicaid	$122.40
Rate for Payer: Cigna Medicare	$219.97
Rate for Payer: Employer Direct Commercial	$219.97
Rate for Payer: Humana Medicare/TRICARE	$219.97
Rate for Payer: Molina CHIP/Medicaid	$122.40
Rate for Payer: Molina Dual Medicare/Medicaid	$219.97
Rate for Payer: Molina Medicare	$219.97
Rate for Payer: Multiplan Auto	$110.50
Rate for Payer: Multiplan Commercial	$110.50
Rate for Payer: Multiplan Workers Comp	$110.50
Rate for Payer: Parkland Medicaid	$122.40
Rate for Payer: Scott and White EPO/PPO	$9.84
Rate for Payer: Scott and White Medicare	$219.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$122.40
Rate for Payer: Superior Health Plan EPO	$219.97
Rate for Payer: Superior Health Plan Medicare	$219.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$219.97
Rate for Payer: Universal American Medicare	$219.97
Rate for Payer: Wellcare Medicare	$219.97
Rate for Payer: Wellmed Medicare	$219.97

ED REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM BCE

Facility

$1,514.00

Service Code	HCPCS 13121
Hospital Charge Code	8568926
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,029.52

ED REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM BCE

Facility

$1,514.00

Service Code	HCPCS 13121
Hospital Charge Code	8568926
Hospital Revenue Code	450
Min. Negotiated Rate	$136.26
Max. Negotiated Rate	$1,252.49
Rate for Payer: Amerigroup CHIP/Medicaid	$136.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$1,029.52
Rate for Payer: Cash Price	$1,029.52
Rate for Payer: Cash Price	$1,029.52
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,090.08
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	$1,090.08
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$984.10
Rate for Payer: Multiplan Commercial	$984.10
Rate for Payer: Multiplan Workers Comp	$984.10
Rate for Payer: Parkland Medicaid	$1,090.08
Rate for Payer: Scott and White EPO/PPO	$314.70
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,090.08
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 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM BCE

Facility

$1,545.00

Service Code	HCPCS 12042
Hospital Charge Code	8568927
Hospital Revenue Code	450
Min. Negotiated Rate	$139.05
Max. Negotiated Rate	$1,112.40
Rate for Payer: Amerigroup CHIP/Medicaid	$139.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$269.62
Rate for Payer: BCBS of TX Blue Essentials	$322.90
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$406.85
Rate for Payer: Cash Price	$1,050.60
Rate for Payer: Cash Price	$1,050.60
Rate for Payer: Cash Price	$1,050.60
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,112.40
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	$1,112.40
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,004.25
Rate for Payer: Multiplan Commercial	$1,004.25
Rate for Payer: Multiplan Workers Comp	$1,004.25
Rate for Payer: Parkland Medicaid	$1,112.40
Rate for Payer: Scott and White EPO/PPO	$240.22
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,112.40
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 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM BCE

Facility

$1,545.00

Service Code	HCPCS 12042
Hospital Charge Code	8568927
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,050.60

ED REPAIR INTERMEDIATE S A T E 12.6-20.0CM BCE

Facility

$1,248.00

Service Code	HCPCS 12035
Hospital Charge Code	8404451
Hospital Revenue Code	450
Rate for Payer: Cash Price	$848.64

Know your out-of-pocket cost for care.

All Charges