White Rock Medical Center

All Charges

Charge

Type

Setting

Price

naloxone 0.4 mg/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2310
Hospital Charge Code	77720016
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

naloxone 0.4 mg/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2310
Hospital Charge Code	77720016
Hospital Revenue Code	636
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$23.92
Rate for Payer: BCBS of TX Blue Essentials	$28.71
Rate for Payer: BCBS of TX PPO	$31.84
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

naloxone 1 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J2310
Hospital Charge Code	77720128
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

naloxone 1 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J2310
Hospital Charge Code	77720128
Hospital Revenue Code	636
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$23.92
Rate for Payer: BCBS of TX Blue Essentials	$28.71
Rate for Payer: BCBS of TX PPO	$31.84
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

naproxen 250 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77720899
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

naproxen 250 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77720899
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

Nasal Culture

Facility

$309.00

Service Code	CPT 87070
Hospital Charge Code	4107043
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$200.85
Rate for Payer: Aetna Commercial	$9.05
Rate for Payer: Aetna Medicare	$12.93
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$14.22
Rate for Payer: BCBS of TX Blue Essentials	$17.07
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$19.05
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cigna Medicaid	$8.62
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$8.62
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$8.62
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.62
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Nasal/sinus endoscopy, surgical with concha bullosa resection

Facility

$10,000.00

Service Code	CPT 31240
Hospital Charge Code	36031240
Hospital Revenue Code	360
Min. Negotiated Rate	$34.24
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$2,328.34
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Amerigroup Medicare	$1,552.23
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,552.23
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cigna Commercial	$3,516.25
Rate for Payer: Cigna Medicaid	$525.71
Rate for Payer: Cigna Medicare	$1,552.23
Rate for Payer: Employer Direct Commercial	$1,552.23
Rate for Payer: Humana Medicare/TRICARE	$1,552.23
Rate for Payer: Molina CHIP/Medicaid	$525.71
Rate for Payer: Molina Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Molina Medicare	$1,552.23
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	$525.71
Rate for Payer: Scott and White EPO/PPO	$34.24
Rate for Payer: Scott and White Medicare	$1,552.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$525.71
Rate for Payer: Superior Health Plan EPO	$1,552.23
Rate for Payer: Superior Health Plan Medicare	$1,552.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Universal American Medicare	$1,552.23
Rate for Payer: Wellcare Medicare	$1,552.23
Rate for Payer: Wellmed Medicare	$1,552.23

Nasal/sinus endoscopy, surgical with control of nasal hemorrhage

Facility

$10,000.00

Service Code	CPT 31238
Hospital Charge Code	36031238
Hospital Revenue Code	360
Min. Negotiated Rate	$34.24
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,328.34
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Amerigroup Medicare	$1,552.23
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,552.23
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cigna Commercial	$3,516.25
Rate for Payer: Cigna Medicaid	$525.71
Rate for Payer: Cigna Medicare	$1,552.23
Rate for Payer: Employer Direct Commercial	$1,552.23
Rate for Payer: Humana Medicare/TRICARE	$1,552.23
Rate for Payer: Molina CHIP/Medicaid	$525.71
Rate for Payer: Molina Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Molina Medicare	$1,552.23
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	$525.71
Rate for Payer: Scott and White EPO/PPO	$34.24
Rate for Payer: Scott and White Medicare	$1,552.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$525.71
Rate for Payer: Superior Health Plan EPO	$1,552.23
Rate for Payer: Superior Health Plan Medicare	$1,552.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Universal American Medicare	$1,552.23
Rate for Payer: Wellcare Medicare	$1,552.23
Rate for Payer: Wellmed Medicare	$1,552.23

Nasal/sinus endoscopy, surgical with ethmoidectomy partial (anterior)

Facility

$14,179.42

Service Code	CPT 31254
Hospital Charge Code	36031254
Hospital Revenue Code	360
Min. Negotiated Rate	$138.06
Max. Negotiated Rate	$14,179.42
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$9,389.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1,630.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Amerigroup Medicare	$6,259.43
Rate for Payer: BCBS of TX Blue Advantage	$9,085.40
Rate for Payer: BCBS of TX Blue Essentials	$10,880.72
Rate for Payer: BCBS of TX Medicare	$6,259.43
Rate for Payer: BCBS of TX PPO	$13,709.71
Rate for Payer: Cigna Commercial	$14,179.42
Rate for Payer: Cigna Medicaid	$1,630.12
Rate for Payer: Cigna Medicare	$6,259.43
Rate for Payer: Employer Direct Commercial	$6,259.43
Rate for Payer: Humana Medicare/TRICARE	$6,259.43
Rate for Payer: Molina CHIP/Medicaid	$1,630.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Molina Medicare	$6,259.43
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	$1,630.12
Rate for Payer: Scott and White EPO/PPO	$138.06
Rate for Payer: Scott and White Medicare	$6,259.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,630.12
Rate for Payer: Superior Health Plan EPO	$6,259.43
Rate for Payer: Superior Health Plan Medicare	$6,259.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Universal American Medicare	$6,259.43
Rate for Payer: Wellcare Medicare	$6,259.43
Rate for Payer: Wellmed Medicare	$6,259.43

Nasal/sinus endoscopy, surgical with ethmoidectomy total (anterior and posterior)

Facility

$14,179.42

Service Code	CPT 31255
Hospital Charge Code	36031255
Hospital Revenue Code	360
Min. Negotiated Rate	$138.06
Max. Negotiated Rate	$14,179.42
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,389.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1,630.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Amerigroup Medicare	$6,259.43
Rate for Payer: BCBS of TX Blue Advantage	$9,085.40
Rate for Payer: BCBS of TX Blue Essentials	$10,880.72
Rate for Payer: BCBS of TX Medicare	$6,259.43
Rate for Payer: BCBS of TX PPO	$13,709.71
Rate for Payer: Cigna Commercial	$14,179.42
Rate for Payer: Cigna Medicaid	$1,630.12
Rate for Payer: Cigna Medicare	$6,259.43
Rate for Payer: Employer Direct Commercial	$6,259.43
Rate for Payer: Humana Medicare/TRICARE	$6,259.43
Rate for Payer: Molina CHIP/Medicaid	$1,630.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Molina Medicare	$6,259.43
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	$1,630.12
Rate for Payer: Scott and White EPO/PPO	$138.06
Rate for Payer: Scott and White Medicare	$6,259.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,630.12
Rate for Payer: Superior Health Plan EPO	$6,259.43
Rate for Payer: Superior Health Plan Medicare	$6,259.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Universal American Medicare	$6,259.43
Rate for Payer: Wellcare Medicare	$6,259.43
Rate for Payer: Wellmed Medicare	$6,259.43

Nasal/sinus endoscopy, surgical with ethmoidectomy total (anterior and posterior), including fronta

Facility

$14,179.42

Service Code	CPT 31253
Hospital Charge Code	36031253
Hospital Revenue Code	360
Min. Negotiated Rate	$138.06
Max. Negotiated Rate	$14,179.42
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,389.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1,630.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Amerigroup Medicare	$6,259.43
Rate for Payer: BCBS of TX Blue Advantage	$9,085.40
Rate for Payer: BCBS of TX Blue Essentials	$10,880.72
Rate for Payer: BCBS of TX Medicare	$6,259.43
Rate for Payer: BCBS of TX PPO	$13,709.71
Rate for Payer: Cigna Commercial	$14,179.42
Rate for Payer: Cigna Medicaid	$1,630.12
Rate for Payer: Cigna Medicare	$6,259.43
Rate for Payer: Employer Direct Commercial	$6,259.43
Rate for Payer: Humana Medicare/TRICARE	$6,259.43
Rate for Payer: Molina CHIP/Medicaid	$1,630.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Molina Medicare	$6,259.43
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	$1,630.12
Rate for Payer: Scott and White EPO/PPO	$138.06
Rate for Payer: Scott and White Medicare	$6,259.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,630.12
Rate for Payer: Superior Health Plan EPO	$6,259.43
Rate for Payer: Superior Health Plan Medicare	$6,259.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Universal American Medicare	$6,259.43
Rate for Payer: Wellcare Medicare	$6,259.43
Rate for Payer: Wellmed Medicare	$6,259.43

Nasal/sinus endoscopy, surgical with ethmoidectomy total (anterior and posterior), including spheno

Facility

$14,179.42

Service Code	CPT 31259
Hospital Charge Code	36031259
Hospital Revenue Code	360
Min. Negotiated Rate	$138.06
Max. Negotiated Rate	$14,179.42
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,389.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1,630.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Amerigroup Medicare	$6,259.43
Rate for Payer: BCBS of TX Blue Advantage	$9,085.40
Rate for Payer: BCBS of TX Blue Essentials	$10,880.72
Rate for Payer: BCBS of TX Medicare	$6,259.43
Rate for Payer: BCBS of TX PPO	$13,709.71
Rate for Payer: Cigna Commercial	$14,179.42
Rate for Payer: Cigna Medicaid	$1,630.12
Rate for Payer: Cigna Medicare	$6,259.43
Rate for Payer: Employer Direct Commercial	$6,259.43
Rate for Payer: Humana Medicare/TRICARE	$6,259.43
Rate for Payer: Molina CHIP/Medicaid	$1,630.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Molina Medicare	$6,259.43
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	$1,630.12
Rate for Payer: Scott and White EPO/PPO	$138.06
Rate for Payer: Scott and White Medicare	$6,259.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,630.12
Rate for Payer: Superior Health Plan EPO	$6,259.43
Rate for Payer: Superior Health Plan Medicare	$6,259.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Universal American Medicare	$6,259.43
Rate for Payer: Wellcare Medicare	$6,259.43
Rate for Payer: Wellmed Medicare	$6,259.43

Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including spheno

Facility

$14,179.42

Service Code	CPT 31257
Hospital Charge Code	36031257
Hospital Revenue Code	360
Min. Negotiated Rate	$138.06
Max. Negotiated Rate	$14,179.42
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,389.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1,630.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Amerigroup Medicare	$6,259.43
Rate for Payer: BCBS of TX Blue Advantage	$9,085.40
Rate for Payer: BCBS of TX Blue Essentials	$10,880.72
Rate for Payer: BCBS of TX Medicare	$6,259.43
Rate for Payer: BCBS of TX PPO	$13,709.71
Rate for Payer: Cigna Commercial	$14,179.42
Rate for Payer: Cigna Medicaid	$1,630.12
Rate for Payer: Cigna Medicare	$6,259.43
Rate for Payer: Employer Direct Commercial	$6,259.43
Rate for Payer: Humana Medicare/TRICARE	$6,259.43
Rate for Payer: Molina CHIP/Medicaid	$1,630.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Molina Medicare	$6,259.43
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	$1,630.12
Rate for Payer: Scott and White EPO/PPO	$138.06
Rate for Payer: Scott and White Medicare	$6,259.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,630.12
Rate for Payer: Superior Health Plan EPO	$6,259.43
Rate for Payer: Superior Health Plan Medicare	$6,259.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Universal American Medicare	$6,259.43
Rate for Payer: Wellcare Medicare	$6,259.43
Rate for Payer: Wellmed Medicare	$6,259.43

Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from fr

Facility

$14,179.42

Service Code	CPT 31276
Hospital Charge Code	36031276
Hospital Revenue Code	360
Min. Negotiated Rate	$138.06
Max. Negotiated Rate	$14,179.42
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,389.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1,630.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Amerigroup Medicare	$6,259.43
Rate for Payer: BCBS of TX Blue Advantage	$9,085.40
Rate for Payer: BCBS of TX Blue Essentials	$10,880.72
Rate for Payer: BCBS of TX Medicare	$6,259.43
Rate for Payer: BCBS of TX PPO	$13,709.71
Rate for Payer: Cigna Commercial	$14,179.42
Rate for Payer: Cigna Medicaid	$1,630.12
Rate for Payer: Cigna Medicare	$6,259.43
Rate for Payer: Employer Direct Commercial	$6,259.43
Rate for Payer: Humana Medicare/TRICARE	$6,259.43
Rate for Payer: Molina CHIP/Medicaid	$1,630.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Molina Medicare	$6,259.43
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	$1,630.12
Rate for Payer: Scott and White EPO/PPO	$138.06
Rate for Payer: Scott and White Medicare	$6,259.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,630.12
Rate for Payer: Superior Health Plan EPO	$6,259.43
Rate for Payer: Superior Health Plan Medicare	$6,259.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Universal American Medicare	$6,259.43
Rate for Payer: Wellcare Medicare	$6,259.43
Rate for Payer: Wellmed Medicare	$6,259.43

Nasal/sinus endoscopy, surgical, with maxillary antrostomy

Facility

$10,000.00

Service Code	CPT 31256
Hospital Charge Code	36031256
Hospital Revenue Code	360
Min. Negotiated Rate	$75.54
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$5,137.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,062.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,424.83
Rate for Payer: Amerigroup Medicare	$3,424.83
Rate for Payer: BCBS of TX Blue Advantage	$4,904.64
Rate for Payer: BCBS of TX Blue Essentials	$5,873.82
Rate for Payer: BCBS of TX Medicare	$3,424.83
Rate for Payer: BCBS of TX PPO	$7,401.01
Rate for Payer: Cigna Commercial	$7,758.23
Rate for Payer: Cigna Medicaid	$1,062.24
Rate for Payer: Cigna Medicare	$3,424.83
Rate for Payer: Employer Direct Commercial	$3,424.83
Rate for Payer: Humana Medicare/TRICARE	$3,424.83
Rate for Payer: Molina CHIP/Medicaid	$1,062.24
Rate for Payer: Molina Dual Medicare/Medicaid	$3,424.83
Rate for Payer: Molina Medicare	$3,424.83
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	$1,062.24
Rate for Payer: Scott and White EPO/PPO	$75.54
Rate for Payer: Scott and White Medicare	$3,424.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,062.24
Rate for Payer: Superior Health Plan EPO	$3,424.83
Rate for Payer: Superior Health Plan Medicare	$3,424.83
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,424.83
Rate for Payer: Universal American Medicare	$3,424.83
Rate for Payer: Wellcare Medicare	$3,424.83
Rate for Payer: Wellmed Medicare	$3,424.83

Nasal/sinus endoscopy, surgical, with maxillary antrostomy with removal of tissue from maxillary si

Facility

$14,179.42

Service Code	CPT 31267
Hospital Charge Code	36031267
Hospital Revenue Code	360
Min. Negotiated Rate	$138.06
Max. Negotiated Rate	$14,179.42
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$9,389.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1,630.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Amerigroup Medicare	$6,259.43
Rate for Payer: BCBS of TX Blue Advantage	$9,085.40
Rate for Payer: BCBS of TX Blue Essentials	$10,880.72
Rate for Payer: BCBS of TX Medicare	$6,259.43
Rate for Payer: BCBS of TX PPO	$13,709.71
Rate for Payer: Cigna Commercial	$14,179.42
Rate for Payer: Cigna Medicaid	$1,630.12
Rate for Payer: Cigna Medicare	$6,259.43
Rate for Payer: Employer Direct Commercial	$6,259.43
Rate for Payer: Humana Medicare/TRICARE	$6,259.43
Rate for Payer: Molina CHIP/Medicaid	$1,630.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Molina Medicare	$6,259.43
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	$1,630.12
Rate for Payer: Scott and White EPO/PPO	$138.06
Rate for Payer: Scott and White Medicare	$6,259.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,630.12
Rate for Payer: Superior Health Plan EPO	$6,259.43
Rate for Payer: Superior Health Plan Medicare	$6,259.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Universal American Medicare	$6,259.43
Rate for Payer: Wellcare Medicare	$6,259.43
Rate for Payer: Wellmed Medicare	$6,259.43

Nasal/sinus endoscopy, surgical, with sphenoidotomy

Facility

$14,179.42

Service Code	CPT 31287
Hospital Charge Code	36031287
Hospital Revenue Code	360
Min. Negotiated Rate	$138.06
Max. Negotiated Rate	$14,179.42
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,389.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1,630.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Amerigroup Medicare	$6,259.43
Rate for Payer: BCBS of TX Blue Advantage	$9,085.40
Rate for Payer: BCBS of TX Blue Essentials	$10,880.72
Rate for Payer: BCBS of TX Medicare	$6,259.43
Rate for Payer: BCBS of TX PPO	$13,709.71
Rate for Payer: Cigna Commercial	$14,179.42
Rate for Payer: Cigna Medicaid	$1,630.12
Rate for Payer: Cigna Medicare	$6,259.43
Rate for Payer: Employer Direct Commercial	$6,259.43
Rate for Payer: Humana Medicare/TRICARE	$6,259.43
Rate for Payer: Molina CHIP/Medicaid	$1,630.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Molina Medicare	$6,259.43
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	$1,630.12
Rate for Payer: Scott and White EPO/PPO	$138.06
Rate for Payer: Scott and White Medicare	$6,259.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,630.12
Rate for Payer: Superior Health Plan EPO	$6,259.43
Rate for Payer: Superior Health Plan Medicare	$6,259.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,259.43
Rate for Payer: Universal American Medicare	$6,259.43
Rate for Payer: Wellcare Medicare	$6,259.43
Rate for Payer: Wellmed Medicare	$6,259.43

NDL BX -- DHF

Facility

$67.90

Hospital Charge Code	80327802
Hospital Revenue Code	272
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$44.14
Rate for Payer: Aetna Commercial	$37.34
Rate for Payer: Amerigroup CHIP/Medicaid	$6.11
Rate for Payer: BCBS of TX Blue Advantage	$20.37
Rate for Payer: BCBS of TX Blue Essentials	$24.44
Rate for Payer: BCBS of TX PPO	$27.16
Rate for Payer: Cash Price	$59.75
Rate for Payer: Multiplan Auto	$44.14
Rate for Payer: Multiplan Commercial	$44.14
Rate for Payer: Multiplan Workers Comp	$44.14
Rate for Payer: Scott and White EPO/PPO	$33.95
Rate for Payer: Superior Health Plan EPO	$9.23

NDL BX -- DHF

Facility

$67.90

Hospital Charge Code	80327802
Hospital Revenue Code	272
Rate for Payer: Cash Price	$59.75

NDL BX GRN -- DHF

Facility

$643.48

Hospital Charge Code	80327901
Hospital Revenue Code	272
Rate for Payer: Cash Price	$566.26

NDL BX GRN -- DHF

Facility

$643.48

Hospital Charge Code	80327901
Hospital Revenue Code	272
Min. Negotiated Rate	$57.91
Max. Negotiated Rate	$418.26
Rate for Payer: Aetna Commercial	$353.91
Rate for Payer: Amerigroup CHIP/Medicaid	$57.91
Rate for Payer: BCBS of TX Blue Advantage	$193.04
Rate for Payer: BCBS of TX Blue Essentials	$231.65
Rate for Payer: BCBS of TX PPO	$257.39
Rate for Payer: Cash Price	$566.26
Rate for Payer: Multiplan Auto	$418.26
Rate for Payer: Multiplan Commercial	$418.26
Rate for Payer: Multiplan Workers Comp	$418.26
Rate for Payer: Scott and White EPO/PPO	$321.74
Rate for Payer: Superior Health Plan EPO	$87.51

NDL CENTESIS YUEH -- DHF

Facility

$134.49

Hospital Charge Code	81781718
Hospital Revenue Code	272
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$87.42
Rate for Payer: Aetna Commercial	$73.97
Rate for Payer: Amerigroup CHIP/Medicaid	$12.10
Rate for Payer: BCBS of TX Blue Advantage	$40.35
Rate for Payer: BCBS of TX Blue Essentials	$48.42
Rate for Payer: BCBS of TX PPO	$53.80
Rate for Payer: Cash Price	$118.35
Rate for Payer: Multiplan Auto	$87.42
Rate for Payer: Multiplan Commercial	$87.42
Rate for Payer: Multiplan Workers Comp	$87.42
Rate for Payer: Scott and White EPO/PPO	$67.24
Rate for Payer: Superior Health Plan EPO	$18.29

NDL CENTESIS YUEH -- DHF

Facility

$134.49

Hospital Charge Code	81781718
Hospital Revenue Code	272
Rate for Payer: Cash Price	$118.35

NDL ELECTRD INSULATED -- DHF

Facility

$64.94

Hospital Charge Code	80328073
Hospital Revenue Code	272
Rate for Payer: Cash Price	$57.15

Know your out-of-pocket cost for care.

All Charges