White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Incision and drainage, upper arm or elbow area bursa

Facility

$4,924.50

Service Code	HCPCS 23931
Hospital Charge Code	9900235
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,348.66

Incision and drainage, upper arm or elbow area bursa

Facility

$4,924.50

Service Code	HCPCS 23931
Hospital Charge Code	9900235
Hospital Revenue Code	360
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$3,348.66
Rate for Payer: Cash Price	$3,348.66
Rate for Payer: Cash Price	$3,348.66
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$3,545.64
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$3,545.64
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$3,545.64
Rate for Payer: Scott and White EPO/PPO	$3,069.37
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,545.64
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Incision and drainage, upper arm or elbow area bursa

Facility

$10,000.00

Service Code	CPT 23931
Hospital Charge Code	36023931
Hospital Revenue Code	360
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$3,069.37
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Incision and drainage, upper arm or elbow area; deep abscess or hematoma

Facility

$10,829.40

Service Code	HCPCS 23930
Hospital Charge Code	991113
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	$7,363.99
Rate for Payer: Cash Price	$7,363.99
Rate for Payer: Cash Price	$7,363.99
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicaid	$7,797.17
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	$7,797.17
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	$7,797.17
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	$7,797.17
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, upper arm or elbow area; deep abscess or hematoma

Facility

$10,829.40

Service Code	HCPCS 23930
Hospital Charge Code	991113
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,363.99

Incision and removal of foreign body, subcutaneous tissues; complicated

Facility

$10,000.00

Service Code	CPT 10121
Hospital Charge Code	36010121
Hospital Revenue Code	360
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$3,069.37
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Incision and removal of foreign body, subcutaneous tissues; complicated

Facility

$5,998.20

Service Code	HCPCS 10121
Hospital Charge Code	9900075
Hospital Revenue Code	360
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$4,078.78
Rate for Payer: Cash Price	$4,078.78
Rate for Payer: Cash Price	$4,078.78
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,318.70
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$4,318.70
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$4,318.70
Rate for Payer: Scott and White EPO/PPO	$3,069.37
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,318.70
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Incision and removal of foreign body, subcutaneous tissues; complicated

Facility

$5,998.20

Service Code	HCPCS 10121
Hospital Charge Code	5202519
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,078.78

Incision and removal of foreign body, subcutaneous tissues; complicated

Facility

$5,998.20

Service Code	HCPCS 10121
Hospital Charge Code	5202519
Hospital Revenue Code	360
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$4,078.78
Rate for Payer: Cash Price	$4,078.78
Rate for Payer: Cash Price	$4,078.78
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,318.70
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$4,318.70
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$4,318.70
Rate for Payer: Scott and White EPO/PPO	$3,069.37
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,318.70
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Incision and removal of foreign body, subcutaneous tissues; complicated

Facility

$5,998.20

Service Code	HCPCS 10121
Hospital Charge Code	9900075
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,078.78

Incision and removal of foreign body, subcutaneous tissues simple

Facility

$2,057.12

Service Code	HCPCS 10120
Hospital Charge Code	9900074
Hospital Revenue Code	360
Min. Negotiated Rate	$86.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$86.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$178.41
Rate for Payer: BCBS of TX Blue Essentials	$213.66
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$269.21
Rate for Payer: Cash Price	$1,398.84
Rate for Payer: Cash Price	$1,398.84
Rate for Payer: Cash Price	$1,398.84
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,481.13
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	$1,481.13
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$1,481.13
Rate for Payer: Scott and White EPO/PPO	$755.48
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,481.13
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

Incision and removal of foreign body, subcutaneous tissues simple

Facility

$10,000.00

Service Code	CPT 10120
Hospital Charge Code	36010120
Hospital Revenue Code	360
Min. Negotiated Rate	$86.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$86.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$178.41
Rate for Payer: BCBS of TX Blue Essentials	$213.66
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$269.21
Rate for Payer: Cigna Commercial	$863.21
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 Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$755.48
Rate for Payer: Scott and White Medicare	$408.37
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

Incision and removal of foreign body, subcutaneous tissues simple

Facility

$2,057.12

Service Code	HCPCS 10120
Hospital Charge Code	9900074
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,398.84

Incision, bone cortex (eg, osteomyelitis or bone abscess), foot

Facility

$9,906.40

Service Code	HCPCS 28005
Hospital Charge Code	9900456
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,736.35

Incision, bone cortex (eg, osteomyelitis or bone abscess), foot

Facility

$10,000.00

Service Code	CPT 28005
Hospital Charge Code	36028005
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
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: Cigna Commercial	$6,947.94
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 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: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
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

Incision, bone cortex (eg, osteomyelitis or bone abscess), foot

Facility

$9,906.40

Service Code	HCPCS 28005
Hospital Charge Code	9900456
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
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	$6,736.35
Rate for Payer: Cash Price	$6,736.35
Rate for Payer: Cash Price	$6,736.35
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$7,132.61
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	$7,132.61
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	$7,132.61
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	$7,132.61
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

Incision, extensor tendon sheath, wrist (eg, de Quervains disease)

Facility

$8,354.10

Service Code	HCPCS 25000
Hospital Charge Code	9900263
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	$5,680.79
Rate for Payer: Cash Price	$5,680.79
Rate for Payer: Cash Price	$5,680.79
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$6,014.95
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	$6,014.95
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	$6,014.95
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	$6,014.95
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, extensor tendon sheath, wrist (eg, de Quervains disease)

Facility

$8,354.10

Service Code	HCPCS 25000
Hospital Charge Code	9900263
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,680.79

Incision, extensor tendon sheath, wrist (eg, de Quervains disease)

Facility

$10,000.00

Service Code	CPT 25000
Hospital Charge Code	36025000
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 for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pul

Facility

$73,611.30

Service Code	HCPCS 64568
Hospital Charge Code	9900813
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$81,857.30
Rate for Payer: Amerigroup CHIP/Medicaid	$19,861.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Amerigroup Medicare	$44,247.19
Rate for Payer: BCBS of TX Blue Advantage	$48,628.30
Rate for Payer: BCBS of TX Blue Essentials	$58,237.48
Rate for Payer: BCBS of TX Medicare	$44,247.19
Rate for Payer: BCBS of TX PPO	$73,379.22
Rate for Payer: Cash Price	$50,055.68
Rate for Payer: Cash Price	$50,055.68
Rate for Payer: Cash Price	$50,055.68
Rate for Payer: Cigna Medicaid	$53,000.14
Rate for Payer: Cigna Medicare	$44,247.19
Rate for Payer: Employer Direct Commercial	$44,247.19
Rate for Payer: Humana Medicare/TRICARE	$44,247.19
Rate for Payer: Molina CHIP/Medicaid	$53,000.14
Rate for Payer: Molina Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Molina Medicare	$44,247.19
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	$53,000.14
Rate for Payer: Scott and White EPO/PPO	$81,857.30
Rate for Payer: Scott and White Medicare	$44,247.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53,000.14
Rate for Payer: Superior Health Plan EPO	$44,247.19
Rate for Payer: Superior Health Plan Medicare	$44,247.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Universal American Medicare	$44,247.19
Rate for Payer: Wellcare Medicare	$44,247.19
Rate for Payer: Wellmed Medicare	$44,247.19

Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pul

Facility

$73,611.30

Service Code	HCPCS 64568
Hospital Charge Code	9900813
Hospital Revenue Code	360
Rate for Payer: Cash Price	$50,055.68

Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pul

Facility

$81,857.30

Service Code	CPT 64568
Hospital Charge Code	36064568
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$81,857.30
Rate for Payer: Amerigroup CHIP/Medicaid	$19,861.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Amerigroup Medicare	$44,247.19
Rate for Payer: BCBS of TX Blue Advantage	$48,628.30
Rate for Payer: BCBS of TX Blue Essentials	$58,237.48
Rate for Payer: BCBS of TX Medicare	$44,247.19
Rate for Payer: BCBS of TX PPO	$73,379.22
Rate for Payer: Cigna Medicare	$44,247.19
Rate for Payer: Employer Direct Commercial	$44,247.19
Rate for Payer: Humana Medicare/TRICARE	$44,247.19
Rate for Payer: Molina Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Molina Medicare	$44,247.19
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	$81,857.30
Rate for Payer: Scott and White Medicare	$44,247.19
Rate for Payer: Superior Health Plan EPO	$44,247.19
Rate for Payer: Superior Health Plan Medicare	$44,247.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Universal American Medicare	$44,247.19
Rate for Payer: Wellcare Medicare	$44,247.19
Rate for Payer: Wellmed Medicare	$44,247.19

INDEFLATOR -- DHF

Facility

$1,917.67

Hospital Charge Code	80811854
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,304.02

INDEFLATOR -- DHF

Facility

$1,917.67

Hospital Charge Code	80811854
Hospital Revenue Code	272
Min. Negotiated Rate	$172.59
Max. Negotiated Rate	$1,380.72
Rate for Payer: Amerigroup CHIP/Medicaid	$172.59
Rate for Payer: BCBS of TX Blue Advantage	$575.30
Rate for Payer: BCBS of TX Blue Essentials	$690.36
Rate for Payer: BCBS of TX PPO	$767.07
Rate for Payer: Cash Price	$1,304.02
Rate for Payer: Cigna Medicaid	$1,380.72
Rate for Payer: Molina CHIP/Medicaid	$1,380.72
Rate for Payer: Multiplan Auto	$1,246.49
Rate for Payer: Multiplan Commercial	$1,246.49
Rate for Payer: Multiplan Workers Comp	$1,246.49
Rate for Payer: Parkland Medicaid	$1,380.72
Rate for Payer: Scott and White EPO/PPO	$958.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,380.72
Rate for Payer: Superior Health Plan EPO	$260.80

INDICATOR TEST ACECIDE-C

Facility

$485.78

Hospital Charge Code	993925
Hospital Revenue Code	279
Rate for Payer: Cash Price	$330.33

Know your out-of-pocket cost for care.

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