White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INBONE TALAR REAMER 10MM

Facility

$1,157.70

Hospital Charge Code	993444
Hospital Revenue Code	272
Rate for Payer: Cash Price	$787.24

INBONE TALAR REAMER 10MM

Facility

$1,157.70

Hospital Charge Code	993444
Hospital Revenue Code	272
Min. Negotiated Rate	$104.19
Max. Negotiated Rate	$833.54
Rate for Payer: Amerigroup CHIP/Medicaid	$104.19
Rate for Payer: BCBS of TX Blue Advantage	$347.31
Rate for Payer: BCBS of TX Blue Essentials	$416.77
Rate for Payer: BCBS of TX PPO	$463.08
Rate for Payer: Cash Price	$787.24
Rate for Payer: Cigna Medicaid	$833.54
Rate for Payer: Molina CHIP/Medicaid	$833.54
Rate for Payer: Multiplan Auto	$752.50
Rate for Payer: Multiplan Commercial	$752.50
Rate for Payer: Multiplan Workers Comp	$752.50
Rate for Payer: Parkland Medicaid	$833.54
Rate for Payer: Scott and White EPO/PPO	$578.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$833.54
Rate for Payer: Superior Health Plan EPO	$157.45

INBONE TALAR STEM 10MM LG

Facility

$9,632.53

Service Code	HCPCS C1734
Hospital Charge Code	992257
Hospital Revenue Code	278
Min. Negotiated Rate	$866.93
Max. Negotiated Rate	$6,935.42
Rate for Payer: Amerigroup CHIP/Medicaid	$866.93
Rate for Payer: BCBS of TX Blue Advantage	$2,889.76
Rate for Payer: BCBS of TX Blue Essentials	$3,467.71
Rate for Payer: BCBS of TX PPO	$3,853.01
Rate for Payer: Cash Price	$6,550.12
Rate for Payer: Cigna Medicaid	$6,935.42
Rate for Payer: Molina CHIP/Medicaid	$6,935.42
Rate for Payer: Multiplan Auto	$4,816.27
Rate for Payer: Multiplan Commercial	$4,816.27
Rate for Payer: Multiplan Workers Comp	$4,816.27
Rate for Payer: Parkland Medicaid	$6,935.42
Rate for Payer: Scott and White EPO/PPO	$4,816.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,935.42
Rate for Payer: Superior Health Plan EPO	$1,310.02

INBONE TALAR STEM 10MM LG

Facility

$9,632.53

Service Code	HCPCS C1734
Hospital Charge Code	992257
Hospital Revenue Code	278
Min. Negotiated Rate	$2,408.13
Max. Negotiated Rate	$4,816.27
Rate for Payer: Cash Price	$6,550.12
Rate for Payer: Cigna Commercial	$2,408.13
Rate for Payer: Multiplan Auto	$4,816.27
Rate for Payer: Multiplan Commercial	$4,816.27
Rate for Payer: Multiplan Workers Comp	$4,816.27
Rate for Payer: Scott and White EPO/PPO	$4,816.27

INBONE TIB TRAY LEFT SZ 2 LNG

Facility

$18,085.78

Service Code	HCPCS C1734
Hospital Charge Code	992260
Hospital Revenue Code	278
Min. Negotiated Rate	$1,627.72
Max. Negotiated Rate	$13,021.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,627.72
Rate for Payer: BCBS of TX Blue Advantage	$5,425.73
Rate for Payer: BCBS of TX Blue Essentials	$6,510.88
Rate for Payer: BCBS of TX PPO	$7,234.31
Rate for Payer: Cash Price	$12,298.33
Rate for Payer: Cigna Medicaid	$13,021.76
Rate for Payer: Molina CHIP/Medicaid	$13,021.76
Rate for Payer: Multiplan Auto	$9,042.89
Rate for Payer: Multiplan Commercial	$9,042.89
Rate for Payer: Multiplan Workers Comp	$9,042.89
Rate for Payer: Parkland Medicaid	$13,021.76
Rate for Payer: Scott and White EPO/PPO	$9,042.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,021.76
Rate for Payer: Superior Health Plan EPO	$2,459.67

INBONE TIB TRAY LEFT SZ 2 LNG

Facility

$18,085.78

Service Code	HCPCS C1734
Hospital Charge Code	992260
Hospital Revenue Code	278
Min. Negotiated Rate	$4,521.44
Max. Negotiated Rate	$9,042.89
Rate for Payer: Cash Price	$12,298.33
Rate for Payer: Cigna Commercial	$4,521.44
Rate for Payer: Multiplan Auto	$9,042.89
Rate for Payer: Multiplan Commercial	$9,042.89
Rate for Payer: Multiplan Workers Comp	$9,042.89
Rate for Payer: Scott and White EPO/PPO	$9,042.89

INBONE TIB TRAY LEFT SZ 4 LNG

Facility

$37,915.66

Service Code	HCPCS C1734
Hospital Charge Code	992142
Hospital Revenue Code	278
Min. Negotiated Rate	$9,478.92
Max. Negotiated Rate	$18,957.83
Rate for Payer: Cash Price	$25,782.65
Rate for Payer: Cigna Commercial	$9,478.92
Rate for Payer: Multiplan Auto	$18,957.83
Rate for Payer: Multiplan Commercial	$18,957.83
Rate for Payer: Multiplan Workers Comp	$18,957.83
Rate for Payer: Scott and White EPO/PPO	$18,957.83

INBONE TIB TRAY LEFT SZ 4 LNG

Facility

$37,915.66

Service Code	HCPCS C1734
Hospital Charge Code	992142
Hospital Revenue Code	278
Min. Negotiated Rate	$3,412.41
Max. Negotiated Rate	$27,299.28
Rate for Payer: Amerigroup CHIP/Medicaid	$3,412.41
Rate for Payer: BCBS of TX Blue Advantage	$11,374.70
Rate for Payer: BCBS of TX Blue Essentials	$13,649.64
Rate for Payer: BCBS of TX PPO	$15,166.26
Rate for Payer: Cash Price	$25,782.65
Rate for Payer: Cigna Medicaid	$27,299.28
Rate for Payer: Molina CHIP/Medicaid	$27,299.28
Rate for Payer: Multiplan Auto	$18,957.83
Rate for Payer: Multiplan Commercial	$18,957.83
Rate for Payer: Multiplan Workers Comp	$18,957.83
Rate for Payer: Parkland Medicaid	$27,299.28
Rate for Payer: Scott and White EPO/PPO	$18,957.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,299.28
Rate for Payer: Superior Health Plan EPO	$5,156.53

INBORN AND OTHER DISORDERS OF METABOLISM

Facility

$27,019.90

Service Code	MSDRG 642
Min. Negotiated Rate	$10,866.10
Max. Negotiated Rate	$27,019.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,182.69
Rate for Payer: Amerigroup Medicare	$15,182.69
Rate for Payer: BCBS of TX Blue Advantage	$10,866.10
Rate for Payer: BCBS of TX Blue Essentials	$13,038.06
Rate for Payer: BCBS of TX Medicare	$15,182.69
Rate for Payer: BCBS of TX PPO	$14,487.29
Rate for Payer: Cigna Commercial	$18,316.65
Rate for Payer: Cigna Medicare	$15,182.69
Rate for Payer: Employer Direct Commercial	$15,182.69
Rate for Payer: Humana Medicare/TRICARE	$15,182.69
Rate for Payer: Molina Dual Medicare/Medicaid	$15,182.69
Rate for Payer: Molina Medicare	$15,182.69
Rate for Payer: Multiplan Auto	$27,019.90
Rate for Payer: Multiplan Commercial	$27,019.90
Rate for Payer: Multiplan Workers Comp	$27,019.90
Rate for Payer: Scott and White EPO/PPO	$12,443.38
Rate for Payer: Scott and White Medicare	$15,182.69
Rate for Payer: Superior Health Plan EPO	$15,182.69
Rate for Payer: Superior Health Plan Medicare	$15,182.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,182.69
Rate for Payer: Universal American Medicare	$15,182.69
Rate for Payer: Wellcare Medicare	$15,182.69
Rate for Payer: Wellmed Medicare	$15,182.69

INBORN ERRORS OF METABOLISM

Facility

$10,270.10

Service Code	APR-DRG 4232
Min. Negotiated Rate	$9,683.01
Max. Negotiated Rate	$10,270.10
Rate for Payer: Amerigroup CHIP/Medicaid	$9,683.01
Rate for Payer: Cigna Medicaid	$9,683.01
Rate for Payer: Molina CHIP/Medicaid	$9,683.01
Rate for Payer: Parkland Medicaid	$9,683.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,270.10

INBORN ERRORS OF METABOLISM

Facility

$15,941.14

Service Code	APR-DRG 4234
Min. Negotiated Rate	$15,029.86
Max. Negotiated Rate	$15,941.14
Rate for Payer: Amerigroup CHIP/Medicaid	$15,029.86
Rate for Payer: Cigna Medicaid	$15,029.86
Rate for Payer: Molina CHIP/Medicaid	$15,029.86
Rate for Payer: Parkland Medicaid	$15,029.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,941.14

INBORN ERRORS OF METABOLISM

Facility

$7,649.02

Service Code	APR-DRG 4231
Min. Negotiated Rate	$7,211.76
Max. Negotiated Rate	$7,649.02
Rate for Payer: Amerigroup CHIP/Medicaid	$7,211.76
Rate for Payer: Cigna Medicaid	$7,211.76
Rate for Payer: Molina CHIP/Medicaid	$7,211.76
Rate for Payer: Parkland Medicaid	$7,211.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,649.02

INBORN ERRORS OF METABOLISM

Facility

$12,891.19

Service Code	APR-DRG 4233
Min. Negotiated Rate	$12,154.26
Max. Negotiated Rate	$12,891.19
Rate for Payer: Amerigroup CHIP/Medicaid	$12,154.26
Rate for Payer: Cigna Medicaid	$12,154.26
Rate for Payer: Molina CHIP/Medicaid	$12,154.26
Rate for Payer: Parkland Medicaid	$12,154.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,891.19

INCISIONAL BX SKIN SEP/ADDL

Facility

$1,014.00

Service Code	HCPCS 11107
Hospital Charge Code	7150056
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$730.08
Rate for Payer: Amerigroup CHIP/Medicaid	$91.26
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$689.52
Rate for Payer: Cash Price	$689.52
Rate for Payer: Cigna Medicaid	$730.08
Rate for Payer: Molina CHIP/Medicaid	$730.08
Rate for Payer: Multiplan Auto	$659.10
Rate for Payer: Multiplan Commercial	$659.10
Rate for Payer: Multiplan Workers Comp	$659.10
Rate for Payer: Parkland Medicaid	$730.08
Rate for Payer: Scott and White EPO/PPO	$507.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$730.08
Rate for Payer: Superior Health Plan EPO	$137.90

INCISIONAL BX SKIN SEP/ADDL

Facility

$1,014.00

Service Code	HCPCS 11107
Hospital Charge Code	7150056
Hospital Revenue Code	761
Rate for Payer: Cash Price	$689.52

Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal s

Facility

$8,535.06

Service Code	HCPCS 28002
Hospital Charge Code	9900455
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cash Price	$5,803.84
Rate for Payer: Cash Price	$5,803.84
Rate for Payer: Cash Price	$5,803.84
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$6,145.24
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina CHIP/Medicaid	$6,145.24
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$6,145.24
Rate for Payer: Scott and White EPO/PPO	$2,988.34
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,145.24
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal s

Facility

$8,535.06

Service Code	HCPCS 28002
Hospital Charge Code	9900455
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,803.84

Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal s

Facility

$10,000.00

Service Code	CPT 28002
Hospital Charge Code	36028002
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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: Scott and White EPO/PPO	$2,988.34
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

Incision and drainage, complex, postoperative wound infection

Facility

$7,110.03

Service Code	HCPCS 10180
Hospital Charge Code	9900077
Hospital Revenue Code	360
Min. Negotiated Rate	$815.20
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Amerigroup Medicare	$2,917.95
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,917.95
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cash Price	$4,834.82
Rate for Payer: Cash Price	$4,834.82
Rate for Payer: Cash Price	$4,834.82
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicaid	$5,119.22
Rate for Payer: Cigna Medicare	$2,917.95
Rate for Payer: Employer Direct Commercial	$2,917.95
Rate for Payer: Humana Medicare/TRICARE	$2,917.95
Rate for Payer: Molina CHIP/Medicaid	$5,119.22
Rate for Payer: Molina Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Molina Medicare	$2,917.95
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	$5,119.22
Rate for Payer: Scott and White EPO/PPO	$5,398.21
Rate for Payer: Scott and White Medicare	$2,917.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,119.22
Rate for Payer: Superior Health Plan EPO	$2,917.95
Rate for Payer: Superior Health Plan Medicare	$2,917.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Universal American Medicare	$2,917.95
Rate for Payer: Wellcare Medicare	$2,917.95
Rate for Payer: Wellmed Medicare	$2,917.95

Incision and drainage, complex, postoperative wound infection

Facility

$10,000.00

Service Code	CPT 10180
Hospital Charge Code	36010180
Hospital Revenue Code	360
Min. Negotiated Rate	$815.20
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Amerigroup Medicare	$2,917.95
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,917.95
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicare	$2,917.95
Rate for Payer: Employer Direct Commercial	$2,917.95
Rate for Payer: Humana Medicare/TRICARE	$2,917.95
Rate for Payer: Molina Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Molina Medicare	$2,917.95
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: Scott and White EPO/PPO	$5,398.21
Rate for Payer: Scott and White Medicare	$2,917.95
Rate for Payer: Superior Health Plan EPO	$2,917.95
Rate for Payer: Superior Health Plan Medicare	$2,917.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Universal American Medicare	$2,917.95
Rate for Payer: Wellcare Medicare	$2,917.95
Rate for Payer: Wellmed Medicare	$2,917.95

Incision and drainage, complex, postoperative wound infection

Facility

$7,110.03

Service Code	HCPCS 10180
Hospital Charge Code	9900077
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,834.82

Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region

Facility

$10,333.00

Service Code	HCPCS 27301
Hospital Charge Code	9900389
Hospital Revenue Code	360
Min. Negotiated Rate	$815.20
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Amerigroup Medicare	$2,917.95
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,917.95
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cash Price	$7,026.44
Rate for Payer: Cash Price	$7,026.44
Rate for Payer: Cash Price	$7,026.44
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicaid	$7,439.76
Rate for Payer: Cigna Medicare	$2,917.95
Rate for Payer: Employer Direct Commercial	$2,917.95
Rate for Payer: Humana Medicare/TRICARE	$2,917.95
Rate for Payer: Molina CHIP/Medicaid	$7,439.76
Rate for Payer: Molina Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Molina Medicare	$2,917.95
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	$7,439.76
Rate for Payer: Scott and White EPO/PPO	$5,398.21
Rate for Payer: Scott and White Medicare	$2,917.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,439.76
Rate for Payer: Superior Health Plan EPO	$2,917.95
Rate for Payer: Superior Health Plan Medicare	$2,917.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Universal American Medicare	$2,917.95
Rate for Payer: Wellcare Medicare	$2,917.95
Rate for Payer: Wellmed Medicare	$2,917.95

Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region

Facility

$10,333.00

Service Code	HCPCS 27301
Hospital Charge Code	9900389
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,026.44

Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region

Facility

$10,000.00

Service Code	CPT 27301
Hospital Charge Code	36027301
Hospital Revenue Code	360
Min. Negotiated Rate	$815.20
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Amerigroup Medicare	$2,917.95
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,917.95
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicare	$2,917.95
Rate for Payer: Employer Direct Commercial	$2,917.95
Rate for Payer: Humana Medicare/TRICARE	$2,917.95
Rate for Payer: Molina Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Molina Medicare	$2,917.95
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: Scott and White EPO/PPO	$5,398.21
Rate for Payer: Scott and White Medicare	$2,917.95
Rate for Payer: Superior Health Plan EPO	$2,917.95
Rate for Payer: Superior Health Plan Medicare	$2,917.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Universal American Medicare	$2,917.95
Rate for Payer: Wellcare Medicare	$2,917.95
Rate for Payer: Wellmed Medicare	$2,917.95

Incision and drainage, forearm and/or wrist; deep abscess or hematoma

Facility

$16,982.40

Service Code	HCPCS 25028
Hospital Charge Code	9900264
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$12,227.33
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
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	$11,548.03
Rate for Payer: Cash Price	$11,548.03
Rate for Payer: Cash Price	$11,548.03
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$12,227.33
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	$12,227.33
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$12,227.33
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,227.33
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

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