White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OSTEOMYELITIS W/O CC/MCC

Facility

$14,658.50

Service Code	MSDRG 541
Min. Negotiated Rate	$6,750.62
Max. Negotiated Rate	$14,658.50
Rate for Payer: BCBS of TX Blue Advantage	$7,591.22
Rate for Payer: BCBS of TX Blue Essentials	$9,108.58
Rate for Payer: BCBS of TX PPO	$10,121.04

OSTEOSPARX 10CC BONE PUTTY

Facility

$6,159.00

Service Code	HCPCS C9359
Hospital Charge Code	8394480
Hospital Revenue Code	278
Min. Negotiated Rate	$1,539.75
Max. Negotiated Rate	$3,079.50
Rate for Payer: Cash Price	$4,188.12
Rate for Payer: Cigna Commercial	$1,539.75
Rate for Payer: Multiplan Auto	$3,079.50
Rate for Payer: Multiplan Commercial	$3,079.50
Rate for Payer: Multiplan Workers Comp	$3,079.50
Rate for Payer: Scott and White EPO/PPO	$3,079.50

OSTEOSPARX 10CC BONE PUTTY

Facility

$6,159.00

Service Code	HCPCS C9359
Hospital Charge Code	8394480
Hospital Revenue Code	278
Min. Negotiated Rate	$554.31
Max. Negotiated Rate	$4,434.48
Rate for Payer: Amerigroup CHIP/Medicaid	$554.31
Rate for Payer: BCBS of TX Blue Advantage	$1,847.70
Rate for Payer: BCBS of TX Blue Essentials	$2,217.24
Rate for Payer: BCBS of TX PPO	$2,463.60
Rate for Payer: Cash Price	$4,188.12
Rate for Payer: Cigna Medicaid	$4,434.48
Rate for Payer: Molina CHIP/Medicaid	$4,434.48
Rate for Payer: Multiplan Auto	$3,079.50
Rate for Payer: Multiplan Commercial	$3,079.50
Rate for Payer: Multiplan Workers Comp	$3,079.50
Rate for Payer: Parkland Medicaid	$4,434.48
Rate for Payer: Scott and White EPO/PPO	$3,079.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,434.48
Rate for Payer: Superior Health Plan EPO	$837.62

Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixation

Facility

$15,408.22

Service Code	CPT 28300
Hospital Charge Code	36028300
Hospital Revenue Code	360
Min. Negotiated Rate	$3,382.73
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,382.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixation

Facility

$14,352.00

Service Code	HCPCS 28300
Hospital Charge Code	9900507
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,759.36

Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixation

Facility

$14,352.00

Service Code	HCPCS 28300
Hospital Charge Code	9900507
Hospital Revenue Code	360
Min. Negotiated Rate	$3,382.73
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,382.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$9,759.36
Rate for Payer: Cash Price	$9,759.36
Rate for Payer: Cash Price	$9,759.36
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$10,333.44
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$10,333.44
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$10,333.44
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,333.44
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (in

Facility

$73,888.56

Service Code	HCPCS 23485
Hospital Charge Code	9900227
Hospital Revenue Code	360
Min. Negotiated Rate	$6,757.06
Max. Negotiated Rate	$53,199.76
Rate for Payer: Amerigroup CHIP/Medicaid	$6,757.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Amerigroup Medicare	$12,897.19
Rate for Payer: BCBS of TX Blue Advantage	$19,874.19
Rate for Payer: BCBS of TX Blue Essentials	$23,801.42
Rate for Payer: BCBS of TX Medicare	$12,897.19
Rate for Payer: BCBS of TX PPO	$29,989.79
Rate for Payer: Cash Price	$50,244.22
Rate for Payer: Cash Price	$50,244.22
Rate for Payer: Cash Price	$50,244.22
Rate for Payer: Cigna Commercial	$27,262.32
Rate for Payer: Cigna Medicaid	$53,199.76
Rate for Payer: Cigna Medicare	$12,897.19
Rate for Payer: Employer Direct Commercial	$12,897.19
Rate for Payer: Humana Medicare/TRICARE	$12,897.19
Rate for Payer: Molina CHIP/Medicaid	$53,199.76
Rate for Payer: Molina Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Molina Medicare	$12,897.19
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	$53,199.76
Rate for Payer: Scott and White EPO/PPO	$23,859.80
Rate for Payer: Scott and White Medicare	$12,897.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53,199.76
Rate for Payer: Superior Health Plan EPO	$12,897.19
Rate for Payer: Superior Health Plan Medicare	$12,897.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Universal American Medicare	$12,897.19
Rate for Payer: Wellcare Medicare	$12,897.19
Rate for Payer: Wellmed Medicare	$12,897.19

Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (in

Facility

$73,888.56

Service Code	HCPCS 23485
Hospital Charge Code	9900227
Hospital Revenue Code	360
Rate for Payer: Cash Price	$50,244.22

Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (in

Facility

$29,989.79

Service Code	CPT 23485
Hospital Charge Code	36023485
Hospital Revenue Code	360
Min. Negotiated Rate	$6,757.06
Max. Negotiated Rate	$29,989.79
Rate for Payer: Amerigroup CHIP/Medicaid	$6,757.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Amerigroup Medicare	$12,897.19
Rate for Payer: BCBS of TX Blue Advantage	$19,874.19
Rate for Payer: BCBS of TX Blue Essentials	$23,801.42
Rate for Payer: BCBS of TX Medicare	$12,897.19
Rate for Payer: BCBS of TX PPO	$29,989.79
Rate for Payer: Cigna Commercial	$27,262.32
Rate for Payer: Cigna Medicare	$12,897.19
Rate for Payer: Employer Direct Commercial	$12,897.19
Rate for Payer: Humana Medicare/TRICARE	$12,897.19
Rate for Payer: Molina Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Molina Medicare	$12,897.19
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	$23,859.80
Rate for Payer: Scott and White Medicare	$12,897.19
Rate for Payer: Superior Health Plan EPO	$12,897.19
Rate for Payer: Superior Health Plan Medicare	$12,897.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Universal American Medicare	$12,897.19
Rate for Payer: Wellcare Medicare	$12,897.19
Rate for Payer: Wellmed Medicare	$12,897.19

Osteotomy, femur, shaft or supracondylar; with fixation

Facility

$15,408.22

Service Code	CPT 27450
Hospital Charge Code	36027450
Hospital Revenue Code	360
Min. Negotiated Rate	$1,763.44
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$1,763.44
Rate for Payer: BCBS of TX Blue Essentials	$2,111.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$2,660.99
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Osteotomy, femur, shaft or supracondylar; with fixation

Facility

$23,400.00

Service Code	HCPCS 27450
Hospital Charge Code	9900410
Hospital Revenue Code	360
Rate for Payer: Cash Price	$15,912.00

Osteotomy, femur, shaft or supracondylar; with fixation

Facility

$23,400.00

Service Code	HCPCS 27450
Hospital Charge Code	9900410
Hospital Revenue Code	360
Min. Negotiated Rate	$1,763.44
Max. Negotiated Rate	$16,848.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2,106.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$1,763.44
Rate for Payer: BCBS of TX Blue Essentials	$2,111.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$2,660.99
Rate for Payer: Cash Price	$15,912.00
Rate for Payer: Cash Price	$15,912.00
Rate for Payer: Cash Price	$15,912.00
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$16,848.00
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$16,848.00
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$16,848.00
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,848.00
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Osteotomy; fibula

Facility

$12,336.12

Service Code	HCPCS 27707
Hospital Charge Code	991031
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,388.56

Osteotomy; fibula

Facility

$12,336.12

Service Code	HCPCS 27707
Hospital Charge Code	991031
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	$8,388.56
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,882.01
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	$8,882.01
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	$8,882.01
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	$8,882.01
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

Osteotomy, iliac, acetabular or innominate bone

Facility

$5,310.08

Service Code	HCPCS 27146
Hospital Charge Code	9900384
Hospital Revenue Code	360
Min. Negotiated Rate	$477.91
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$477.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$2,217.23
Rate for Payer: BCBS of TX Blue Essentials	$2,655.36
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$3,345.75
Rate for Payer: Cash Price	$3,610.85
Rate for Payer: Cash Price	$3,610.85
Rate for Payer: Cash Price	$3,610.85
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$3,823.26
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$3,823.26
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$3,823.26
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,823.26
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Osteotomy, iliac, acetabular or innominate bone

Facility

$15,408.22

Service Code	CPT 27146
Hospital Charge Code	36027146
Hospital Revenue Code	360
Min. Negotiated Rate	$2,217.23
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$2,217.23
Rate for Payer: BCBS of TX Blue Essentials	$2,655.36
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$3,345.75
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Osteotomy, iliac, acetabular or innominate bone

Facility

$5,310.08

Service Code	HCPCS 27146
Hospital Charge Code	9900384
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,610.85

Osteotomy, mandible, segmental; with genioglossus advancement

Facility

$22,318.84

Service Code	HCPCS 21199
Hospital Charge Code	990963
Hospital Revenue Code	360
Rate for Payer: Cash Price	$15,176.81

Osteotomy, mandible, segmental; with genioglossus advancement

Facility

$22,318.84

Service Code	HCPCS 21199
Hospital Charge Code	990963
Hospital Revenue Code	360
Min. Negotiated Rate	$2,552.50
Max. Negotiated Rate	$16,069.56
Rate for Payer: Amerigroup CHIP/Medicaid	$2,552.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cash Price	$15,176.81
Rate for Payer: Cash Price	$15,176.81
Rate for Payer: Cash Price	$15,176.81
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicaid	$16,069.56
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina CHIP/Medicaid	$16,069.56
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$16,069.56
Rate for Payer: Scott and White EPO/PPO	$11,001.60
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,069.56
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Osteotomy radius AND ulna

Facility

$16,200.00

Service Code	HCPCS 25365
Hospital Charge Code	9900291
Hospital Revenue Code	360
Min. Negotiated Rate	$4,811.02
Max. Negotiated Rate	$29,989.79
Rate for Payer: Amerigroup CHIP/Medicaid	$4,811.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Amerigroup Medicare	$12,897.19
Rate for Payer: BCBS of TX Blue Advantage	$19,874.19
Rate for Payer: BCBS of TX Blue Essentials	$23,801.42
Rate for Payer: BCBS of TX Medicare	$12,897.19
Rate for Payer: BCBS of TX PPO	$29,989.79
Rate for Payer: Cash Price	$11,016.00
Rate for Payer: Cash Price	$11,016.00
Rate for Payer: Cash Price	$11,016.00
Rate for Payer: Cigna Commercial	$27,262.32
Rate for Payer: Cigna Medicaid	$11,664.00
Rate for Payer: Cigna Medicare	$12,897.19
Rate for Payer: Employer Direct Commercial	$12,897.19
Rate for Payer: Humana Medicare/TRICARE	$12,897.19
Rate for Payer: Molina CHIP/Medicaid	$11,664.00
Rate for Payer: Molina Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Molina Medicare	$12,897.19
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	$11,664.00
Rate for Payer: Scott and White EPO/PPO	$23,859.80
Rate for Payer: Scott and White Medicare	$12,897.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,664.00
Rate for Payer: Superior Health Plan EPO	$12,897.19
Rate for Payer: Superior Health Plan Medicare	$12,897.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Universal American Medicare	$12,897.19
Rate for Payer: Wellcare Medicare	$12,897.19
Rate for Payer: Wellmed Medicare	$12,897.19

Osteotomy radius AND ulna

Facility

$16,200.00

Service Code	HCPCS 25365
Hospital Charge Code	9900291
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,016.00

Osteotomy radius AND ulna

Facility

$29,989.79

Service Code	CPT 25365
Hospital Charge Code	36025365
Hospital Revenue Code	360
Min. Negotiated Rate	$4,811.02
Max. Negotiated Rate	$29,989.79
Rate for Payer: Amerigroup CHIP/Medicaid	$4,811.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Amerigroup Medicare	$12,897.19
Rate for Payer: BCBS of TX Blue Advantage	$19,874.19
Rate for Payer: BCBS of TX Blue Essentials	$23,801.42
Rate for Payer: BCBS of TX Medicare	$12,897.19
Rate for Payer: BCBS of TX PPO	$29,989.79
Rate for Payer: Cigna Commercial	$27,262.32
Rate for Payer: Cigna Medicare	$12,897.19
Rate for Payer: Employer Direct Commercial	$12,897.19
Rate for Payer: Humana Medicare/TRICARE	$12,897.19
Rate for Payer: Molina Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Molina Medicare	$12,897.19
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	$23,859.80
Rate for Payer: Scott and White Medicare	$12,897.19
Rate for Payer: Superior Health Plan EPO	$12,897.19
Rate for Payer: Superior Health Plan Medicare	$12,897.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Universal American Medicare	$12,897.19
Rate for Payer: Wellcare Medicare	$12,897.19
Rate for Payer: Wellmed Medicare	$12,897.19

Osteotomy, radius; distal third

Facility

$18,794.85

Service Code	HCPCS 25350
Hospital Charge Code	9900290
Hospital Revenue Code	360
Min. Negotiated Rate	$3,385.99
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,385.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$13,532.29
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$13,532.29
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$13,532.29
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,532.29
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Osteotomy, radius; distal third

Facility

$15,408.22

Service Code	CPT 25350
Hospital Charge Code	36025350
Hospital Revenue Code	360
Min. Negotiated Rate	$3,385.99
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,385.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Osteotomy, radius; distal third

Facility

$18,794.85

Service Code	HCPCS 25350
Hospital Charge Code	9900290
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,780.50

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