White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Remote Physiologic Monitoring -> 20+ Minutes of Monitoring 99457

Facility

$183.00

Service Code	HCPCS 99457
Hospital Charge Code	6019908
Hospital Revenue Code	510
Rate for Payer: Cash Price	$124.44

Remote Physiologic Monitoring -> 20+ Minutes of Monitoring 99457

Facility

$183.00

Service Code	HCPCS 99457
Hospital Charge Code	6019908
Hospital Revenue Code	510
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$131.76
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: BCBS of TX Blue Advantage	$54.90
Rate for Payer: BCBS of TX Blue Essentials	$65.88
Rate for Payer: BCBS of TX PPO	$73.20
Rate for Payer: Cash Price	$124.44
Rate for Payer: Cash Price	$124.44
Rate for Payer: Cigna Medicaid	$131.76
Rate for Payer: Molina CHIP/Medicaid	$131.76
Rate for Payer: Multiplan Auto	$118.95
Rate for Payer: Multiplan Commercial	$118.95
Rate for Payer: Multiplan Workers Comp	$118.95
Rate for Payer: Parkland Medicaid	$131.76
Rate for Payer: Scott and White EPO/PPO	$36.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.76

Remote Physiologic Monitoring -> Initial Setup 99453

Facility

$570.00

Service Code	HCPCS 99453
Hospital Charge Code	6019906
Hospital Revenue Code	510
Min. Negotiated Rate	$24.62
Max. Negotiated Rate	$410.40
Rate for Payer: Amerigroup CHIP/Medicaid	$51.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.74
Rate for Payer: Amerigroup Medicare	$133.74
Rate for Payer: BCBS of TX Blue Advantage	$171.00
Rate for Payer: BCBS of TX Blue Essentials	$205.20
Rate for Payer: BCBS of TX Medicare	$133.74
Rate for Payer: BCBS of TX PPO	$228.00
Rate for Payer: Cash Price	$387.60
Rate for Payer: Cash Price	$387.60
Rate for Payer: Cash Price	$387.60
Rate for Payer: Cigna Commercial	$282.70
Rate for Payer: Cigna Medicaid	$410.40
Rate for Payer: Cigna Medicare	$133.74
Rate for Payer: Employer Direct Commercial	$133.74
Rate for Payer: Humana Medicare/TRICARE	$133.74
Rate for Payer: Molina CHIP/Medicaid	$410.40
Rate for Payer: Molina Dual Medicare/Medicaid	$133.74
Rate for Payer: Molina Medicare	$133.74
Rate for Payer: Multiplan Auto	$370.50
Rate for Payer: Multiplan Commercial	$370.50
Rate for Payer: Multiplan Workers Comp	$370.50
Rate for Payer: Parkland Medicaid	$410.40
Rate for Payer: Scott and White EPO/PPO	$24.62
Rate for Payer: Scott and White Medicare	$133.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$410.40
Rate for Payer: Superior Health Plan EPO	$133.74
Rate for Payer: Superior Health Plan Medicare	$133.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.74
Rate for Payer: Universal American Medicare	$133.74
Rate for Payer: Wellcare Medicare	$133.74
Rate for Payer: Wellmed Medicare	$133.74

Remote Physiologic Monitoring -> Initial Setup 99453

Facility

$570.00

Service Code	HCPCS 99453
Hospital Charge Code	6019906
Hospital Revenue Code	510
Rate for Payer: Cash Price	$387.60

Removal Filter Vena Cava

Facility

$12,172.50

Service Code	HCPCS 37193
Hospital Charge Code	8184149
Hospital Revenue Code	481
Rate for Payer: Cash Price	$8,277.30

Removal Filter Vena Cava

Facility

$12,172.50

Service Code	HCPCS 37193
Hospital Charge Code	8184149
Hospital Revenue Code	481
Min. Negotiated Rate	$411.40
Max. Negotiated Rate	$8,764.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1,095.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$8,277.30
Rate for Payer: Cash Price	$8,277.30
Rate for Payer: Cash Price	$8,277.30
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$8,764.20
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$8,764.20
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
Rate for Payer: Multiplan Auto	$7,912.12
Rate for Payer: Multiplan Commercial	$7,912.12
Rate for Payer: Multiplan Workers Comp	$7,912.12
Rate for Payer: Parkland Medicaid	$8,764.20
Rate for Payer: Scott and White EPO/PPO	$411.40
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,764.20
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

Removal foreign body from external auditory canal; with general anesthesia

Facility

$8,997.30

Service Code	HCPCS 69205
Hospital Charge Code	9900883
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,118.16

Removal foreign body from external auditory canal; with general anesthesia

Facility

$10,000.00

Service Code	CPT 69205
Hospital Charge Code	36069205
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	$2,743.07
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

Removal foreign body from external auditory canal; with general anesthesia

Facility

$8,997.30

Service Code	HCPCS 69205
Hospital Charge Code	9900883
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	$6,118.16
Rate for Payer: Cash Price	$6,118.16
Rate for Payer: Cash Price	$6,118.16
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$6,478.06
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	$6,478.06
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	$6,478.06
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,478.06
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

REMOVAL IAB CATHETER

Facility

$3,723.00

Service Code	HCPCS 33968
Hospital Charge Code	2330001
Hospital Revenue Code	480
Rate for Payer: Cash Price	$2,531.64

REMOVAL IAB CATHETER

Facility

$3,723.00

Service Code	HCPCS 33968
Hospital Charge Code	2330001
Hospital Revenue Code	480
Min. Negotiated Rate	$40.16
Max. Negotiated Rate	$2,680.56
Rate for Payer: Amerigroup CHIP/Medicaid	$335.07
Rate for Payer: BCBS of TX Blue Advantage	$58.98
Rate for Payer: BCBS of TX Blue Essentials	$70.64
Rate for Payer: BCBS of TX PPO	$89.01
Rate for Payer: Cash Price	$2,531.64
Rate for Payer: Cash Price	$2,531.64
Rate for Payer: Cigna Medicaid	$2,680.56
Rate for Payer: Molina CHIP/Medicaid	$2,680.56
Rate for Payer: Multiplan Auto	$2,419.95
Rate for Payer: Multiplan Commercial	$2,419.95
Rate for Payer: Multiplan Workers Comp	$2,419.95
Rate for Payer: Parkland Medicaid	$2,680.56
Rate for Payer: Scott and White EPO/PPO	$40.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,680.56
Rate for Payer: Superior Health Plan EPO	$506.33

Removal of ankle implant

Facility

$10,000.00

Service Code	CPT 27704
Hospital Charge Code	36027704
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	$5,476.44
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

Removal of ankle implant

Facility

$12,302.00

Service Code	HCPCS 27704
Hospital Charge Code	9900442
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,365.36

Removal of ankle implant

Facility

$12,302.00

Service Code	HCPCS 27704
Hospital Charge Code	9900442
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	$8,365.36
Rate for Payer: Cash Price	$8,365.36
Rate for Payer: Cash Price	$8,365.36
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,857.44
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	$8,857.44
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	$8,857.44
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,857.44
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

Removal of embedded foreign body from dentoalveolar structures; soft tissues

Facility

$4,734.77

Service Code	HCPCS 41805
Hospital Charge Code	9900649
Hospital Revenue Code	360
Min. Negotiated Rate	$220.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$220.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Amerigroup Medicare	$1,558.65
Rate for Payer: BCBS of TX Blue Advantage	$421.29
Rate for Payer: BCBS of TX Blue Essentials	$504.54
Rate for Payer: BCBS of TX Medicare	$1,558.65
Rate for Payer: BCBS of TX PPO	$635.72
Rate for Payer: Cash Price	$3,219.64
Rate for Payer: Cash Price	$3,219.64
Rate for Payer: Cash Price	$3,219.64
Rate for Payer: Cigna Commercial	$3,294.71
Rate for Payer: Cigna Medicaid	$3,409.03
Rate for Payer: Cigna Medicare	$1,558.65
Rate for Payer: Employer Direct Commercial	$1,558.65
Rate for Payer: Humana Medicare/TRICARE	$1,558.65
Rate for Payer: Molina CHIP/Medicaid	$3,409.03
Rate for Payer: Molina Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Molina Medicare	$1,558.65
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$3,409.03
Rate for Payer: Scott and White EPO/PPO	$2,580.23
Rate for Payer: Scott and White Medicare	$1,558.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,409.03
Rate for Payer: Superior Health Plan EPO	$1,558.65
Rate for Payer: Superior Health Plan Medicare	$1,558.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Universal American Medicare	$1,558.65
Rate for Payer: Wellcare Medicare	$1,558.65
Rate for Payer: Wellmed Medicare	$1,558.65

Removal of embedded foreign body from dentoalveolar structures; soft tissues

Facility

$4,734.77

Service Code	HCPCS 41805
Hospital Charge Code	9900649
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,219.64

Removal of embedded foreign body from dentoalveolar structures; soft tissues

Facility

$10,000.00

Service Code	CPT 41805
Hospital Charge Code	36041805
Hospital Revenue Code	360
Min. Negotiated Rate	$220.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$220.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Amerigroup Medicare	$1,558.65
Rate for Payer: BCBS of TX Blue Advantage	$421.29
Rate for Payer: BCBS of TX Blue Essentials	$504.54
Rate for Payer: BCBS of TX Medicare	$1,558.65
Rate for Payer: BCBS of TX PPO	$635.72
Rate for Payer: Cigna Commercial	$3,294.71
Rate for Payer: Cigna Medicare	$1,558.65
Rate for Payer: Employer Direct Commercial	$1,558.65
Rate for Payer: Humana Medicare/TRICARE	$1,558.65
Rate for Payer: Molina Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Molina Medicare	$1,558.65
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$2,580.23
Rate for Payer: Scott and White Medicare	$1,558.65
Rate for Payer: Superior Health Plan EPO	$1,558.65
Rate for Payer: Superior Health Plan Medicare	$1,558.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Universal American Medicare	$1,558.65
Rate for Payer: Wellcare Medicare	$1,558.65
Rate for Payer: Wellmed Medicare	$1,558.65

Removal of embedded foreign body, vestibule of mouth; complicated

Facility

$10,000.00

Service Code	CPT 40808
Hospital Charge Code	36040808
Hospital Revenue Code	360
Min. Negotiated Rate	$107.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$107.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$541.79
Rate for Payer: Amerigroup Medicare	$541.79
Rate for Payer: BCBS of TX Blue Advantage	$203.71
Rate for Payer: BCBS of TX Blue Essentials	$243.96
Rate for Payer: BCBS of TX Medicare	$541.79
Rate for Payer: BCBS of TX PPO	$307.39
Rate for Payer: Cigna Commercial	$1,145.24
Rate for Payer: Cigna Medicare	$541.79
Rate for Payer: Employer Direct Commercial	$541.79
Rate for Payer: Humana Medicare/TRICARE	$541.79
Rate for Payer: Molina Dual Medicare/Medicaid	$541.79
Rate for Payer: Molina Medicare	$541.79
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	$930.90
Rate for Payer: Scott and White Medicare	$541.79
Rate for Payer: Superior Health Plan EPO	$541.79
Rate for Payer: Superior Health Plan Medicare	$541.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$541.79
Rate for Payer: Universal American Medicare	$541.79
Rate for Payer: Wellcare Medicare	$541.79
Rate for Payer: Wellmed Medicare	$541.79

Removal of embedded foreign body, vestibule of mouth; complicated

Facility

$10,000.00

Service Code	CPT 40805
Hospital Charge Code	36040805
Hospital Revenue Code	360
Min. Negotiated Rate	$150.61
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$150.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$541.79
Rate for Payer: Amerigroup Medicare	$541.79
Rate for Payer: BCBS of TX Blue Advantage	$328.47
Rate for Payer: BCBS of TX Blue Essentials	$393.38
Rate for Payer: BCBS of TX Medicare	$541.79
Rate for Payer: BCBS of TX PPO	$495.66
Rate for Payer: Cigna Commercial	$1,145.24
Rate for Payer: Cigna Medicare	$541.79
Rate for Payer: Employer Direct Commercial	$541.79
Rate for Payer: Humana Medicare/TRICARE	$541.79
Rate for Payer: Molina Dual Medicare/Medicaid	$541.79
Rate for Payer: Molina Medicare	$541.79
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	$930.90
Rate for Payer: Scott and White Medicare	$541.79
Rate for Payer: Superior Health Plan EPO	$541.79
Rate for Payer: Superior Health Plan Medicare	$541.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$541.79
Rate for Payer: Universal American Medicare	$541.79
Rate for Payer: Wellcare Medicare	$541.79
Rate for Payer: Wellmed Medicare	$541.79

Removal of embedded foreign body, vestibule of mouth; complicated

Facility

$1,583.26

Service Code	HCPCS 40805
Hospital Charge Code	9900641
Hospital Revenue Code	360
Min. Negotiated Rate	$150.61
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$150.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$541.79
Rate for Payer: Amerigroup Medicare	$541.79
Rate for Payer: BCBS of TX Blue Advantage	$328.47
Rate for Payer: BCBS of TX Blue Essentials	$393.38
Rate for Payer: BCBS of TX Medicare	$541.79
Rate for Payer: BCBS of TX PPO	$495.66
Rate for Payer: Cash Price	$1,076.62
Rate for Payer: Cash Price	$1,076.62
Rate for Payer: Cash Price	$1,076.62
Rate for Payer: Cigna Commercial	$1,145.24
Rate for Payer: Cigna Medicaid	$1,139.95
Rate for Payer: Cigna Medicare	$541.79
Rate for Payer: Employer Direct Commercial	$541.79
Rate for Payer: Humana Medicare/TRICARE	$541.79
Rate for Payer: Molina CHIP/Medicaid	$1,139.95
Rate for Payer: Molina Dual Medicare/Medicaid	$541.79
Rate for Payer: Molina Medicare	$541.79
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	$1,139.95
Rate for Payer: Scott and White EPO/PPO	$930.90
Rate for Payer: Scott and White Medicare	$541.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,139.95
Rate for Payer: Superior Health Plan EPO	$541.79
Rate for Payer: Superior Health Plan Medicare	$541.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$541.79
Rate for Payer: Universal American Medicare	$541.79
Rate for Payer: Wellcare Medicare	$541.79
Rate for Payer: Wellmed Medicare	$541.79

Removal of embedded foreign body, vestibule of mouth; complicated

Facility

$1,583.26

Service Code	HCPCS 40808
Hospital Charge Code	9900642
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,076.62

Removal of embedded foreign body, vestibule of mouth; complicated

Facility

$1,583.26

Service Code	HCPCS 40808
Hospital Charge Code	9900642
Hospital Revenue Code	360
Min. Negotiated Rate	$107.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$107.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$541.79
Rate for Payer: Amerigroup Medicare	$541.79
Rate for Payer: BCBS of TX Blue Advantage	$203.71
Rate for Payer: BCBS of TX Blue Essentials	$243.96
Rate for Payer: BCBS of TX Medicare	$541.79
Rate for Payer: BCBS of TX PPO	$307.39
Rate for Payer: Cash Price	$1,076.62
Rate for Payer: Cash Price	$1,076.62
Rate for Payer: Cash Price	$1,076.62
Rate for Payer: Cigna Commercial	$1,145.24
Rate for Payer: Cigna Medicaid	$1,139.95
Rate for Payer: Cigna Medicare	$541.79
Rate for Payer: Employer Direct Commercial	$541.79
Rate for Payer: Humana Medicare/TRICARE	$541.79
Rate for Payer: Molina CHIP/Medicaid	$1,139.95
Rate for Payer: Molina Dual Medicare/Medicaid	$541.79
Rate for Payer: Molina Medicare	$541.79
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	$1,139.95
Rate for Payer: Scott and White EPO/PPO	$930.90
Rate for Payer: Scott and White Medicare	$541.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,139.95
Rate for Payer: Superior Health Plan EPO	$541.79
Rate for Payer: Superior Health Plan Medicare	$541.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$541.79
Rate for Payer: Universal American Medicare	$541.79
Rate for Payer: Wellcare Medicare	$541.79
Rate for Payer: Wellmed Medicare	$541.79

Removal of embedded foreign body, vestibule of mouth; complicated

Facility

$1,583.26

Service Code	HCPCS 40805
Hospital Charge Code	9900641
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,076.62

Removal of foreign body, deep, thigh region or knee area

Facility

$15,499.50

Service Code	HCPCS 27372
Hospital Charge Code	9900399
Hospital Revenue Code	360
Min. Negotiated Rate	$815.20
Max. Negotiated Rate	$11,159.64
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	$10,539.66
Rate for Payer: Cash Price	$10,539.66
Rate for Payer: Cash Price	$10,539.66
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicaid	$11,159.64
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	$11,159.64
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	$11,159.64
Rate for Payer: Scott and White EPO/PPO	$4,807.56
Rate for Payer: Scott and White Medicare	$2,917.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,159.64
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

Removal of foreign body, deep, thigh region or knee area

Facility

$15,499.50

Service Code	HCPCS 27372
Hospital Charge Code	9900399
Hospital Revenue Code	360
Rate for Payer: Cash Price	$10,539.66

Know your out-of-pocket cost for care.

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