White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED TX FX TIBIAL SHAFT W/O MAN CLSD BCE

Facility

$834.00

Service Code	HCPCS 27750
Hospital Charge Code	8764560
Hospital Revenue Code	450
Min. Negotiated Rate	$75.06
Max. Negotiated Rate	$600.48
Rate for Payer: Amerigroup CHIP/Medicaid	$75.06
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	$567.12
Rate for Payer: Cash Price	$567.12
Rate for Payer: Cash Price	$567.12
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$600.48
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	$600.48
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$542.10
Rate for Payer: Multiplan Commercial	$542.10
Rate for Payer: Multiplan Workers Comp	$542.10
Rate for Payer: Parkland Medicaid	$600.48
Rate for Payer: Scott and White EPO/PPO	$417.00
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$600.48
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 TX SPONTAN HIP DISLC ABDCT SPLNT/TRCJ W/O ANES BCE

Facility

$1,067.00

Service Code	HCPCS 27256
Hospital Charge Code	8910655
Hospital Revenue Code	450
Rate for Payer: Cash Price	$725.56

ED TX SPONTAN HIP DISLC ABDCT SPLNT/TRCJ W/O ANES BCE

Facility

$1,067.00

Service Code	HCPCS 27256
Hospital Charge Code	8910655
Hospital Revenue Code	450
Min. Negotiated Rate	$96.03
Max. Negotiated Rate	$768.24
Rate for Payer: Amerigroup CHIP/Medicaid	$96.03
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	$725.56
Rate for Payer: Cash Price	$725.56
Rate for Payer: Cash Price	$725.56
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$768.24
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	$768.24
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$693.55
Rate for Payer: Multiplan Commercial	$693.55
Rate for Payer: Multiplan Workers Comp	$693.55
Rate for Payer: Parkland Medicaid	$768.24
Rate for Payer: Scott and White EPO/PPO	$533.50
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$768.24
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

ED Wound Dehiscence -> Superficial

Facility

$1,641.00

Service Code	HCPCS 12020
Hospital Charge Code	5202583
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,115.88

ED Wound Dehiscence -> Superficial

Facility

$1,641.00

Service Code	HCPCS 12020
Hospital Charge Code	5202583
Hospital Revenue Code	450
Min. Negotiated Rate	$147.69
Max. Negotiated Rate	$1,569.38
Rate for Payer: Amerigroup CHIP/Medicaid	$147.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
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	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$1,115.88
Rate for Payer: Cash Price	$1,115.88
Rate for Payer: Cash Price	$1,115.88
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$1,181.52
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina CHIP/Medicaid	$1,181.52
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
Rate for Payer: Multiplan Auto	$1,066.65
Rate for Payer: Multiplan Commercial	$1,066.65
Rate for Payer: Multiplan Workers Comp	$1,066.65
Rate for Payer: Parkland Medicaid	$1,181.52
Rate for Payer: Scott and White EPO/PPO	$820.50
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,181.52
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

EEG Charges -> Cerebral Death Eval Only 95824

Facility

$1,212.00

Service Code	HCPCS 95824
Hospital Charge Code	3000189
Hospital Revenue Code	740
Rate for Payer: Cash Price	$824.16

EEG Charges -> Cerebral Death Eval Only 95824

Facility

$1,212.00

Service Code	HCPCS 95824
Hospital Charge Code	3000189
Hospital Revenue Code	740
Min. Negotiated Rate	$109.08
Max. Negotiated Rate	$872.64
Rate for Payer: Amerigroup CHIP/Medicaid	$109.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$374.86
Rate for Payer: Amerigroup Medicare	$374.86
Rate for Payer: BCBS of TX Blue Advantage	$363.60
Rate for Payer: BCBS of TX Blue Essentials	$436.32
Rate for Payer: BCBS of TX Medicare	$374.86
Rate for Payer: BCBS of TX PPO	$484.80
Rate for Payer: Cash Price	$824.16
Rate for Payer: Cash Price	$824.16
Rate for Payer: Cash Price	$824.16
Rate for Payer: Cigna Commercial	$792.38
Rate for Payer: Cigna Medicaid	$872.64
Rate for Payer: Cigna Medicare	$374.86
Rate for Payer: Employer Direct Commercial	$374.86
Rate for Payer: Humana Medicare/TRICARE	$374.86
Rate for Payer: Molina CHIP/Medicaid	$872.64
Rate for Payer: Molina Dual Medicare/Medicaid	$374.86
Rate for Payer: Molina Medicare	$374.86
Rate for Payer: Multiplan Auto	$787.80
Rate for Payer: Multiplan Commercial	$787.80
Rate for Payer: Multiplan Workers Comp	$787.80
Rate for Payer: Parkland Medicaid	$872.64
Rate for Payer: Scott and White EPO/PPO	$606.00
Rate for Payer: Scott and White Medicare	$374.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$872.64
Rate for Payer: Superior Health Plan EPO	$374.86
Rate for Payer: Superior Health Plan Medicare	$374.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$374.86
Rate for Payer: Universal American Medicare	$374.86
Rate for Payer: Wellcare Medicare	$374.86
Rate for Payer: Wellmed Medicare	$374.86

EEG Charges -> EEG 24 hr Intermittent Monitoring w/o video 95709

Facility

$4,128.96

Service Code	HCPCS 95709
Hospital Charge Code	8794578
Hospital Revenue Code	740
Min. Negotiated Rate	$371.61
Max. Negotiated Rate	$2,972.85
Rate for Payer: Amerigroup CHIP/Medicaid	$371.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$374.86
Rate for Payer: Amerigroup Medicare	$374.86
Rate for Payer: BCBS of TX Blue Advantage	$1,238.69
Rate for Payer: BCBS of TX Blue Essentials	$1,486.43
Rate for Payer: BCBS of TX Medicare	$374.86
Rate for Payer: BCBS of TX PPO	$1,651.58
Rate for Payer: Cash Price	$2,807.69
Rate for Payer: Cash Price	$2,807.69
Rate for Payer: Cash Price	$2,807.69
Rate for Payer: Cigna Commercial	$792.38
Rate for Payer: Cigna Medicaid	$2,972.85
Rate for Payer: Cigna Medicare	$374.86
Rate for Payer: Employer Direct Commercial	$374.86
Rate for Payer: Humana Medicare/TRICARE	$374.86
Rate for Payer: Molina CHIP/Medicaid	$2,972.85
Rate for Payer: Molina Dual Medicare/Medicaid	$374.86
Rate for Payer: Molina Medicare	$374.86
Rate for Payer: Multiplan Auto	$2,683.82
Rate for Payer: Multiplan Commercial	$2,683.82
Rate for Payer: Multiplan Workers Comp	$2,683.82
Rate for Payer: Parkland Medicaid	$2,972.85
Rate for Payer: Scott and White EPO/PPO	$2,064.48
Rate for Payer: Scott and White Medicare	$374.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,972.85
Rate for Payer: Superior Health Plan EPO	$374.86
Rate for Payer: Superior Health Plan Medicare	$374.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$374.86
Rate for Payer: Universal American Medicare	$374.86
Rate for Payer: Wellcare Medicare	$374.86
Rate for Payer: Wellmed Medicare	$374.86

EEG Charges -> EEG 24 hr Intermittent Monitoring w/o video 95709

Facility

$4,128.96

Service Code	HCPCS 95709
Hospital Charge Code	8794578
Hospital Revenue Code	740
Rate for Payer: Cash Price	$2,807.69

EEG Charges -> EEG 24 hr Intermittent Monitoring w/ video 95715

Facility

$5,225.24

Service Code	HCPCS 95715
Hospital Charge Code	8794577
Hospital Revenue Code	740
Rate for Payer: Cash Price	$3,553.16

EEG Charges -> EEG 24 hr Intermittent Monitoring w/ video 95715

Facility

$5,225.24

Service Code	HCPCS 95715
Hospital Charge Code	8794577
Hospital Revenue Code	740
Min. Negotiated Rate	$374.86
Max. Negotiated Rate	$3,762.17
Rate for Payer: Amerigroup CHIP/Medicaid	$470.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$374.86
Rate for Payer: Amerigroup Medicare	$374.86
Rate for Payer: BCBS of TX Blue Advantage	$1,567.57
Rate for Payer: BCBS of TX Blue Essentials	$1,881.09
Rate for Payer: BCBS of TX Medicare	$374.86
Rate for Payer: BCBS of TX PPO	$2,090.10
Rate for Payer: Cash Price	$3,553.16
Rate for Payer: Cash Price	$3,553.16
Rate for Payer: Cash Price	$3,553.16
Rate for Payer: Cigna Commercial	$792.38
Rate for Payer: Cigna Medicaid	$3,762.17
Rate for Payer: Cigna Medicare	$374.86
Rate for Payer: Employer Direct Commercial	$374.86
Rate for Payer: Humana Medicare/TRICARE	$374.86
Rate for Payer: Molina CHIP/Medicaid	$3,762.17
Rate for Payer: Molina Dual Medicare/Medicaid	$374.86
Rate for Payer: Molina Medicare	$374.86
Rate for Payer: Multiplan Auto	$3,396.41
Rate for Payer: Multiplan Commercial	$3,396.41
Rate for Payer: Multiplan Workers Comp	$3,396.41
Rate for Payer: Parkland Medicaid	$3,762.17
Rate for Payer: Scott and White EPO/PPO	$2,612.62
Rate for Payer: Scott and White Medicare	$374.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,762.17
Rate for Payer: Superior Health Plan EPO	$374.86
Rate for Payer: Superior Health Plan Medicare	$374.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$374.86
Rate for Payer: Universal American Medicare	$374.86
Rate for Payer: Wellcare Medicare	$374.86
Rate for Payer: Wellmed Medicare	$374.86

EEG Charges -> EEG 24 hr Unmonitored w/o video 95708

Facility

$3,150.00

Service Code	HCPCS 95708
Hospital Charge Code	8794575
Hospital Revenue Code	740
Rate for Payer: Cash Price	$2,142.00

EEG Charges -> EEG 24 hr Unmonitored w/o video 95708

Facility

$3,150.00

Service Code	HCPCS 95708
Hospital Charge Code	8794575
Hospital Revenue Code	740
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$2,268.00
Rate for Payer: Amerigroup CHIP/Medicaid	$283.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$374.86
Rate for Payer: Amerigroup Medicare	$374.86
Rate for Payer: BCBS of TX Blue Advantage	$945.00
Rate for Payer: BCBS of TX Blue Essentials	$1,134.00
Rate for Payer: BCBS of TX Medicare	$374.86
Rate for Payer: BCBS of TX PPO	$1,260.00
Rate for Payer: Cash Price	$2,142.00
Rate for Payer: Cash Price	$2,142.00
Rate for Payer: Cash Price	$2,142.00
Rate for Payer: Cigna Commercial	$792.38
Rate for Payer: Cigna Medicaid	$2,268.00
Rate for Payer: Cigna Medicare	$374.86
Rate for Payer: Employer Direct Commercial	$374.86
Rate for Payer: Humana Medicare/TRICARE	$374.86
Rate for Payer: Molina CHIP/Medicaid	$2,268.00
Rate for Payer: Molina Dual Medicare/Medicaid	$374.86
Rate for Payer: Molina Medicare	$374.86
Rate for Payer: Multiplan Auto	$2,047.50
Rate for Payer: Multiplan Commercial	$2,047.50
Rate for Payer: Multiplan Workers Comp	$2,047.50
Rate for Payer: Parkland Medicaid	$2,268.00
Rate for Payer: Scott and White EPO/PPO	$1,575.00
Rate for Payer: Scott and White Medicare	$374.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,268.00
Rate for Payer: Superior Health Plan EPO	$374.86
Rate for Payer: Superior Health Plan Medicare	$374.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$374.86
Rate for Payer: Universal American Medicare	$374.86
Rate for Payer: Wellcare Medicare	$374.86
Rate for Payer: Wellmed Medicare	$374.86

EEG Charges -> EEG 24 hr Unmonitored w/ video 95714

Facility

$4,301.75

Service Code	HCPCS 95714
Hospital Charge Code	8794576
Hospital Revenue Code	740
Min. Negotiated Rate	$374.86
Max. Negotiated Rate	$3,097.26
Rate for Payer: Amerigroup CHIP/Medicaid	$387.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$374.86
Rate for Payer: Amerigroup Medicare	$374.86
Rate for Payer: BCBS of TX Blue Advantage	$1,290.53
Rate for Payer: BCBS of TX Blue Essentials	$1,548.63
Rate for Payer: BCBS of TX Medicare	$374.86
Rate for Payer: BCBS of TX PPO	$1,720.70
Rate for Payer: Cash Price	$2,925.19
Rate for Payer: Cash Price	$2,925.19
Rate for Payer: Cash Price	$2,925.19
Rate for Payer: Cigna Commercial	$792.38
Rate for Payer: Cigna Medicaid	$3,097.26
Rate for Payer: Cigna Medicare	$374.86
Rate for Payer: Employer Direct Commercial	$374.86
Rate for Payer: Humana Medicare/TRICARE	$374.86
Rate for Payer: Molina CHIP/Medicaid	$3,097.26
Rate for Payer: Molina Dual Medicare/Medicaid	$374.86
Rate for Payer: Molina Medicare	$374.86
Rate for Payer: Multiplan Auto	$2,796.14
Rate for Payer: Multiplan Commercial	$2,796.14
Rate for Payer: Multiplan Workers Comp	$2,796.14
Rate for Payer: Parkland Medicaid	$3,097.26
Rate for Payer: Scott and White EPO/PPO	$2,150.88
Rate for Payer: Scott and White Medicare	$374.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,097.26
Rate for Payer: Superior Health Plan EPO	$374.86
Rate for Payer: Superior Health Plan Medicare	$374.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$374.86
Rate for Payer: Universal American Medicare	$374.86
Rate for Payer: Wellcare Medicare	$374.86
Rate for Payer: Wellmed Medicare	$374.86

EEG Charges -> EEG 24 hr Unmonitored w/ video 95714

Facility

$4,301.75

Service Code	HCPCS 95714
Hospital Charge Code	8794576
Hospital Revenue Code	740
Rate for Payer: Cash Price	$2,925.19

EEG Charges -> EEG Awake/Asleep 95819

Facility

$2,059.00

Service Code	HCPCS 95819
Hospital Charge Code	3000023
Hospital Revenue Code	740
Min. Negotiated Rate	$185.31
Max. Negotiated Rate	$1,482.48
Rate for Payer: Amerigroup CHIP/Medicaid	$185.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$617.70
Rate for Payer: BCBS of TX Blue Essentials	$741.24
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$823.60
Rate for Payer: Cash Price	$1,400.12
Rate for Payer: Cash Price	$1,400.12
Rate for Payer: Cash Price	$1,400.12
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$1,482.48
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	$1,482.48
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$1,338.35
Rate for Payer: Multiplan Commercial	$1,338.35
Rate for Payer: Multiplan Workers Comp	$1,338.35
Rate for Payer: Parkland Medicaid	$1,482.48
Rate for Payer: Scott and White EPO/PPO	$1,029.50
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,482.48
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

EEG Charges -> EEG Awake/Asleep 95819

Facility

$2,059.00

Service Code	HCPCS 95819
Hospital Charge Code	3000023
Hospital Revenue Code	740
Rate for Payer: Cash Price	$1,400.12

EEG Charges -> EEG Awake/Drowsy 95816

Facility

$1,908.00

Service Code	HCPCS 95816
Hospital Charge Code	3000015
Hospital Revenue Code	740
Min. Negotiated Rate	$171.72
Max. Negotiated Rate	$1,373.76
Rate for Payer: Amerigroup CHIP/Medicaid	$171.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$572.40
Rate for Payer: BCBS of TX Blue Essentials	$686.88
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$763.20
Rate for Payer: Cash Price	$1,297.44
Rate for Payer: Cash Price	$1,297.44
Rate for Payer: Cash Price	$1,297.44
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$1,373.76
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	$1,373.76
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$1,240.20
Rate for Payer: Multiplan Commercial	$1,240.20
Rate for Payer: Multiplan Workers Comp	$1,240.20
Rate for Payer: Parkland Medicaid	$1,373.76
Rate for Payer: Scott and White EPO/PPO	$954.00
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,373.76
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

EEG Charges -> EEG Awake/Drowsy 95816

Facility

$1,908.00

Service Code	HCPCS 95816
Hospital Charge Code	3000015
Hospital Revenue Code	740
Rate for Payer: Cash Price	$1,297.44

EEG Charges -> EEG Intraop 95955

Facility

$2,056.60

Service Code	HCPCS 95955
Hospital Charge Code	3000064
Hospital Revenue Code	740
Min. Negotiated Rate	$185.09
Max. Negotiated Rate	$1,480.75
Rate for Payer: Amerigroup CHIP/Medicaid	$185.09
Rate for Payer: BCBS of TX Blue Advantage	$616.98
Rate for Payer: BCBS of TX Blue Essentials	$740.38
Rate for Payer: BCBS of TX PPO	$822.64
Rate for Payer: Cash Price	$1,398.49
Rate for Payer: Cigna Medicaid	$1,480.75
Rate for Payer: Molina CHIP/Medicaid	$1,480.75
Rate for Payer: Multiplan Auto	$1,336.79
Rate for Payer: Multiplan Commercial	$1,336.79
Rate for Payer: Multiplan Workers Comp	$1,336.79
Rate for Payer: Parkland Medicaid	$1,480.75
Rate for Payer: Scott and White EPO/PPO	$1,028.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,480.75
Rate for Payer: Superior Health Plan EPO	$279.70

EEG Charges -> EEG Intraop 95955

Facility

$2,056.60

Service Code	HCPCS 95955
Hospital Charge Code	3000064
Hospital Revenue Code	740
Rate for Payer: Cash Price	$1,398.49

EEG Charges -> EEG Setup/Disconnect for LT-VEEG 95700

Facility

$1,431.50

Service Code	HCPCS 95700
Hospital Charge Code	12102306
Hospital Revenue Code	740
Min. Negotiated Rate	$128.84
Max. Negotiated Rate	$1,030.68
Rate for Payer: Amerigroup CHIP/Medicaid	$128.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$429.45
Rate for Payer: BCBS of TX Blue Essentials	$515.34
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$572.60
Rate for Payer: Cash Price	$973.42
Rate for Payer: Cash Price	$973.42
Rate for Payer: Cash Price	$973.42
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$1,030.68
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	$1,030.68
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$930.48
Rate for Payer: Multiplan Commercial	$930.48
Rate for Payer: Multiplan Workers Comp	$930.48
Rate for Payer: Parkland Medicaid	$1,030.68
Rate for Payer: Scott and White EPO/PPO	$715.75
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,030.68
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

EEG Charges -> EEG Setup/Disconnect for LT-VEEG 95700

Facility

$1,431.50

Service Code	HCPCS 95700
Hospital Charge Code	12102306
Hospital Revenue Code	740
Rate for Payer: Cash Price	$973.42

Egd balloon dil esoph30 mm/>

Facility

$7,251.96

Service Code	HCPCS 43233
Hospital Charge Code	9900669
Hospital Revenue Code	360
Min. Negotiated Rate	$564.97
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
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	$4,931.33
Rate for Payer: Cash Price	$4,931.33
Rate for Payer: Cash Price	$4,931.33
Rate for Payer: Cigna Commercial	$4,074.70
Rate for Payer: Cigna Medicaid	$5,221.41
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	$5,221.41
Rate for Payer: Molina Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Molina Medicare	$1,927.65
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$5,221.41
Rate for Payer: Scott and White EPO/PPO	$3,566.15
Rate for Payer: Scott and White Medicare	$1,927.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,221.41
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

Egd balloon dil esoph30 mm/>

Facility

$7,251.96

Service Code	HCPCS 43233
Hospital Charge Code	9900669
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,931.33

Know your out-of-pocket cost for care.

All Charges