White Rock Medical Center

All Charges

Charge

Type

Setting

Price

APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$20,761.30

Service Code	MSDRG 343
Min. Negotiated Rate	$9,333.58
Max. Negotiated Rate	$20,761.30
Rate for Payer: Multiplan Auto	$20,761.30
Rate for Payer: Multiplan Commercial	$20,761.30
Rate for Payer: Multiplan Workers Comp	$20,761.30
Rate for Payer: Scott and White EPO/PPO	$9,561.12

APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC

Facility

$27,610.80

Service Code	MSDRG 342
Min. Negotiated Rate	$12,201.68
Max. Negotiated Rate	$27,610.80
Rate for Payer: BCBS of TX Blue Advantage	$12,201.68
Rate for Payer: BCBS of TX Blue Essentials	$14,640.60
Rate for Payer: BCBS of TX PPO	$16,267.96

APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W MCC

Facility

$42,921.00

Service Code	MSDRG 341
Min. Negotiated Rate	$19,646.70
Max. Negotiated Rate	$42,921.00
Rate for Payer: BCBS of TX Blue Advantage	$19,646.70
Rate for Payer: BCBS of TX Blue Essentials	$23,573.76
Rate for Payer: BCBS of TX PPO	$26,194.08

APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC

Facility

$20,761.30

Service Code	MSDRG 343
Min. Negotiated Rate	$9,333.58
Max. Negotiated Rate	$20,761.30
Rate for Payer: BCBS of TX Blue Advantage	$9,333.58
Rate for Payer: BCBS of TX Blue Essentials	$11,199.21
Rate for Payer: BCBS of TX PPO	$12,444.05

APPENDIX PROCEDURES WITH CC

Facility

$19,495.17

Service Code	MSDRG 398
Min. Negotiated Rate	$15,853.30
Max. Negotiated Rate	$19,495.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,853.30
Rate for Payer: Amerigroup Medicare	$15,853.30
Rate for Payer: BCBS of TX Medicare	$15,853.30
Rate for Payer: Cigna Commercial	$19,495.17
Rate for Payer: Cigna Medicare	$15,853.30
Rate for Payer: Employer Direct Commercial	$15,853.30
Rate for Payer: Humana Medicare/TRICARE	$15,853.30
Rate for Payer: Molina Dual Medicare/Medicaid	$15,853.30
Rate for Payer: Molina Medicare	$15,853.30
Rate for Payer: Scott and White Medicare	$15,853.30
Rate for Payer: Superior Health Plan EPO	$15,853.30
Rate for Payer: Superior Health Plan Medicare	$15,853.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,853.30
Rate for Payer: Universal American Medicare	$15,853.30
Rate for Payer: Wellcare Medicare	$15,853.30
Rate for Payer: Wellmed Medicare	$15,853.30

APPENDIX PROCEDURES WITH MCC

Facility

$30,846.31

Service Code	MSDRG 397
Min. Negotiated Rate	$22,312.37
Max. Negotiated Rate	$30,846.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,312.37
Rate for Payer: Amerigroup Medicare	$22,312.37
Rate for Payer: BCBS of TX Medicare	$22,312.37
Rate for Payer: Cigna Commercial	$30,846.31
Rate for Payer: Cigna Medicare	$22,312.37
Rate for Payer: Employer Direct Commercial	$22,312.37
Rate for Payer: Humana Medicare/TRICARE	$22,312.37
Rate for Payer: Molina Dual Medicare/Medicaid	$22,312.37
Rate for Payer: Molina Medicare	$22,312.37
Rate for Payer: Scott and White Medicare	$22,312.37
Rate for Payer: Superior Health Plan EPO	$22,312.37
Rate for Payer: Superior Health Plan Medicare	$22,312.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,312.37
Rate for Payer: Universal American Medicare	$22,312.37
Rate for Payer: Wellcare Medicare	$22,312.37
Rate for Payer: Wellmed Medicare	$22,312.37

APPENDIX PROCEDURES WITHOUT CC/MCC

Facility

$14,743.74

Service Code	MSDRG 399
Min. Negotiated Rate	$13,149.62
Max. Negotiated Rate	$14,743.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,149.62
Rate for Payer: Amerigroup Medicare	$13,149.62
Rate for Payer: BCBS of TX Medicare	$13,149.62
Rate for Payer: Cigna Commercial	$14,743.74
Rate for Payer: Cigna Medicare	$13,149.62
Rate for Payer: Employer Direct Commercial	$13,149.62
Rate for Payer: Humana Medicare/TRICARE	$13,149.62
Rate for Payer: Molina Dual Medicare/Medicaid	$13,149.62
Rate for Payer: Molina Medicare	$13,149.62
Rate for Payer: Scott and White Medicare	$13,149.62
Rate for Payer: Superior Health Plan EPO	$13,149.62
Rate for Payer: Superior Health Plan Medicare	$13,149.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,149.62
Rate for Payer: Universal American Medicare	$13,149.62
Rate for Payer: Wellcare Medicare	$13,149.62
Rate for Payer: Wellmed Medicare	$13,149.62

Application of a modality to 1 or more areas; infrared

Facility

$41.00

Service Code	HCPCS 97026
Hospital Charge Code	9385000
Hospital Revenue Code	420
Rate for Payer: Cash Price	$27.88

Application of a modality to 1 or more areas; infrared

Facility

$41.00

Service Code	HCPCS 97026
Hospital Charge Code	9385000
Hospital Revenue Code	420
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.69
Rate for Payer: BCBS of TX Blue Advantage	$12.30
Rate for Payer: BCBS of TX Blue Essentials	$14.76
Rate for Payer: BCBS of TX PPO	$16.40
Rate for Payer: Cash Price	$27.88
Rate for Payer: Cash Price	$27.88
Rate for Payer: Cash Price	$27.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$29.52
Rate for Payer: Molina CHIP/Medicaid	$29.52
Rate for Payer: Multiplan Auto	$26.65
Rate for Payer: Multiplan Commercial	$26.65
Rate for Payer: Multiplan Workers Comp	$26.65
Rate for Payer: Parkland Medicaid	$29.52
Rate for Payer: Scott and White EPO/PPO	$8.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.52
Rate for Payer: Superior Health Plan EPO	$5.58

Application of a modality to 1 or more areas; vasopneumatic devices

Facility

$50.00

Hospital Charge Code	9385001
Hospital Revenue Code	420
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: BCBS of TX Blue Advantage	$15.00
Rate for Payer: BCBS of TX Blue Essentials	$18.00
Rate for Payer: BCBS of TX PPO	$20.00
Rate for Payer: Cash Price	$34.00
Rate for Payer: Cash Price	$34.00
Rate for Payer: Cash Price	$34.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$36.00
Rate for Payer: Molina CHIP/Medicaid	$36.00
Rate for Payer: Multiplan Auto	$32.50
Rate for Payer: Multiplan Commercial	$32.50
Rate for Payer: Multiplan Workers Comp	$32.50
Rate for Payer: Parkland Medicaid	$36.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.00
Rate for Payer: Superior Health Plan EPO	$6.80

Application of a modality to 1 or more areas; vasopneumatic devices

Facility

$50.00

Hospital Charge Code	9385001
Hospital Revenue Code	420
Rate for Payer: Cash Price	$34.00

Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation syst

Facility

$29,989.79

Service Code	CPT 20692
Hospital Charge Code	36020692
Hospital Revenue Code	360
Min. Negotiated Rate	$7,448.53
Max. Negotiated Rate	$29,989.79
Rate for Payer: Amerigroup CHIP/Medicaid	$7,448.53
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	$22,267.47
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

Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation syst

Facility

$73,888.56

Service Code	HCPCS 20692
Hospital Charge Code	9900182
Hospital Revenue Code	360
Min. Negotiated Rate	$7,448.53
Max. Negotiated Rate	$53,199.76
Rate for Payer: Amerigroup CHIP/Medicaid	$7,448.53
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	$22,267.47
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

Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation syst

Facility

$73,888.56

Service Code	HCPCS 20692
Hospital Charge Code	9900182
Hospital Revenue Code	360
Rate for Payer: Cash Price	$50,244.22

Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system

Facility

$15,408.22

Service Code	CPT 20690
Hospital Charge Code	36020690
Hospital Revenue Code	360
Min. Negotiated Rate	$3,422.19
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,422.19
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	$12,104.03
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

Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system

Facility

$15,662.38

Service Code	HCPCS 20690
Hospital Charge Code	9900181
Hospital Revenue Code	360
Rate for Payer: Cash Price	$10,650.42

Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system

Facility

$15,662.38

Service Code	HCPCS 20690
Hospital Charge Code	9900181
Hospital Revenue Code	360
Min. Negotiated Rate	$3,422.19
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,422.19
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	$10,650.42
Rate for Payer: Cash Price	$10,650.42
Rate for Payer: Cash Price	$10,650.42
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$11,276.91
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	$11,276.91
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	$11,276.91
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,276.91
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

Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

Facility

$5,812.02

Service Code	HCPCS 21110
Hospital Charge Code	990962
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,952.17

Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

Facility

$5,812.02

Service Code	HCPCS 21110
Hospital Charge Code	990962
Hospital Revenue Code	360
Min. Negotiated Rate	$420.64
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$420.64
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	$896.12
Rate for Payer: BCBS of TX Blue Essentials	$1,073.20
Rate for Payer: BCBS of TX Medicare	$1,558.65
Rate for Payer: BCBS of TX PPO	$1,352.23
Rate for Payer: Cash Price	$3,952.17
Rate for Payer: Cash Price	$3,952.17
Rate for Payer: Cash Price	$3,952.17
Rate for Payer: Cigna Commercial	$3,294.71
Rate for Payer: Cigna Medicaid	$4,184.65
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	$4,184.65
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: Parkland Medicaid	$4,184.65
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	$4,184.65
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

Application of short arm splint (forearm to hand) static

Facility

$1,140.00

Service Code	HCPCS 29125
Hospital Charge Code	9900538
Hospital Revenue Code	360
Min. Negotiated Rate	$102.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$102.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$182.08
Rate for Payer: BCBS of TX Blue Essentials	$218.06
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cash Price	$775.20
Rate for Payer: Cash Price	$775.20
Rate for Payer: Cash Price	$775.20
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$820.80
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$820.80
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
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	$820.80
Rate for Payer: Scott and White EPO/PPO	$216.12
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$820.80
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

Application of short arm splint (forearm to hand) static

Facility

$1,140.00

Service Code	HCPCS 29125
Hospital Charge Code	9900538
Hospital Revenue Code	360
Rate for Payer: Cash Price	$775.20

Application of short arm splint (forearm to hand) static

Facility

$10,000.00

Service Code	CPT 29125
Hospital Charge Code	36029125
Hospital Revenue Code	360
Min. Negotiated Rate	$133.65
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$182.08
Rate for Payer: BCBS of TX Blue Essentials	$218.06
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
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	$216.12
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

Application of short leg cast (below knee to toes); walking or ambulatory type

Facility

$739.14

Service Code	HCPCS 29425
Hospital Charge Code	9900539
Hospital Revenue Code	360
Rate for Payer: Cash Price	$502.62

Application of short leg cast (below knee to toes); walking or ambulatory type

Facility

$739.14

Service Code	HCPCS 29425
Hospital Charge Code	9900539
Hospital Revenue Code	360
Min. Negotiated Rate	$35.99
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$35.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$75.93
Rate for Payer: BCBS of TX Blue Essentials	$90.94
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$114.58
Rate for Payer: Cash Price	$502.62
Rate for Payer: Cash Price	$502.62
Rate for Payer: Cash Price	$502.62
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$532.18
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$532.18
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
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	$532.18
Rate for Payer: Scott and White EPO/PPO	$454.38
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$532.18
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

Application of short leg splint (calf to foot)

Facility

$635.31

Service Code	HCPCS 29515
Hospital Charge Code	9900541
Hospital Revenue Code	360
Rate for Payer: Cash Price	$432.01

Know your out-of-pocket cost for care.

All Charges