White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Universal Pack I without Gowns

Facility

$52.93

Hospital Charge Code	992783
Hospital Revenue Code	272
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$38.11
Rate for Payer: Amerigroup CHIP/Medicaid	$4.76
Rate for Payer: BCBS of TX Blue Advantage	$15.88
Rate for Payer: BCBS of TX Blue Essentials	$19.05
Rate for Payer: BCBS of TX PPO	$21.17
Rate for Payer: Cash Price	$35.99
Rate for Payer: Cigna Medicaid	$38.11
Rate for Payer: Molina CHIP/Medicaid	$38.11
Rate for Payer: Multiplan Auto	$34.40
Rate for Payer: Multiplan Commercial	$34.40
Rate for Payer: Multiplan Workers Comp	$34.40
Rate for Payer: Parkland Medicaid	$38.11
Rate for Payer: Scott and White EPO/PPO	$26.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.11
Rate for Payer: Superior Health Plan EPO	$7.20

UNIV SLITTER -- DHF

Facility

$77.00

Hospital Charge Code	82438805
Hospital Revenue Code	272
Rate for Payer: Cash Price	$52.36

UNIV SLITTER -- DHF

Facility

$77.00

Hospital Charge Code	82438805
Hospital Revenue Code	272
Min. Negotiated Rate	$6.93
Max. Negotiated Rate	$55.44
Rate for Payer: Amerigroup CHIP/Medicaid	$6.93
Rate for Payer: BCBS of TX Blue Advantage	$23.10
Rate for Payer: BCBS of TX Blue Essentials	$27.72
Rate for Payer: BCBS of TX PPO	$30.80
Rate for Payer: Cash Price	$52.36
Rate for Payer: Cigna Medicaid	$55.44
Rate for Payer: Molina CHIP/Medicaid	$55.44
Rate for Payer: Multiplan Auto	$50.05
Rate for Payer: Multiplan Commercial	$50.05
Rate for Payer: Multiplan Workers Comp	$50.05
Rate for Payer: Parkland Medicaid	$55.44
Rate for Payer: Scott and White EPO/PPO	$38.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$55.44
Rate for Payer: Superior Health Plan EPO	$10.47

UNKNOWN DESCRIPTION

Facility

$336.89

Hospital Charge Code	992998
Hospital Revenue Code	270
Rate for Payer: Cash Price	$229.09

UNKNOWN DESCRIPTION

Facility

$336.89

Hospital Charge Code	992998
Hospital Revenue Code	270
Min. Negotiated Rate	$30.32
Max. Negotiated Rate	$242.56
Rate for Payer: Amerigroup CHIP/Medicaid	$30.32
Rate for Payer: BCBS of TX Blue Advantage	$101.07
Rate for Payer: BCBS of TX Blue Essentials	$121.28
Rate for Payer: BCBS of TX PPO	$134.76
Rate for Payer: Cash Price	$229.09
Rate for Payer: Cigna Medicaid	$242.56
Rate for Payer: Molina CHIP/Medicaid	$242.56
Rate for Payer: Multiplan Auto	$218.98
Rate for Payer: Multiplan Commercial	$218.98
Rate for Payer: Multiplan Workers Comp	$218.98
Rate for Payer: Parkland Medicaid	$242.56
Rate for Payer: Scott and White EPO/PPO	$168.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$242.56
Rate for Payer: Superior Health Plan EPO	$45.82

Unlisted laparoscopy procedure, stomach

Facility

$20,241.76

Service Code	HCPCS 43659
Hospital Charge Code	9900687
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,764.40

Unlisted laparoscopy procedure, stomach

Facility

$12,837.39

Service Code	CPT 43659
Hospital Charge Code	36043659
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Unlisted laparoscopy procedure, stomach

Facility

$20,241.76

Service Code	HCPCS 43659
Hospital Charge Code	9900687
Hospital Revenue Code	360
Min. Negotiated Rate	$1,821.76
Max. Negotiated Rate	$14,574.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,821.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$13,764.40
Rate for Payer: Cash Price	$13,764.40
Rate for Payer: Cash Price	$13,764.40
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$14,574.07
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$14,574.07
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$14,574.07
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,574.07
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Unlisted laps px intestine

Facility

$12,837.39

Service Code	CPT 44238
Hospital Charge Code	36044238
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Unlisted procedure, abdomen, peritoneum and omentum

Facility

$4,425.75

Service Code	HCPCS 49999
Hospital Charge Code	9900730
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,009.51

Unlisted procedure, abdomen, peritoneum and omentum

Facility

$4,425.75

Service Code	HCPCS 49999
Hospital Charge Code	9900730
Hospital Revenue Code	360
Min. Negotiated Rate	$911.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$911.12
Rate for Payer: Amerigroup Medicare	$911.12
Rate for Payer: BCBS of TX Blue Advantage	$1,312.49
Rate for Payer: BCBS of TX Blue Essentials	$1,571.84
Rate for Payer: BCBS of TX Medicare	$911.12
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cash Price	$3,009.51
Rate for Payer: Cash Price	$3,009.51
Rate for Payer: Cash Price	$3,009.51
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicaid	$3,186.54
Rate for Payer: Cigna Medicare	$911.12
Rate for Payer: Employer Direct Commercial	$911.12
Rate for Payer: Humana Medicare/TRICARE	$911.12
Rate for Payer: Molina CHIP/Medicaid	$3,186.54
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
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	$3,186.54
Rate for Payer: Scott and White EPO/PPO	$1,533.69
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,186.54
Rate for Payer: Superior Health Plan EPO	$911.12
Rate for Payer: Superior Health Plan Medicare	$911.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$911.12
Rate for Payer: Universal American Medicare	$911.12
Rate for Payer: Wellcare Medicare	$911.12
Rate for Payer: Wellmed Medicare	$911.12

Unlisted procedure, abdomen, peritoneum and omentum

Facility

$10,000.00

Service Code	CPT 49999
Hospital Charge Code	36049999
Hospital Revenue Code	360
Min. Negotiated Rate	$911.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$911.12
Rate for Payer: Amerigroup Medicare	$911.12
Rate for Payer: BCBS of TX Blue Advantage	$1,312.49
Rate for Payer: BCBS of TX Blue Essentials	$1,571.84
Rate for Payer: BCBS of TX Medicare	$911.12
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicare	$911.12
Rate for Payer: Employer Direct Commercial	$911.12
Rate for Payer: Humana Medicare/TRICARE	$911.12
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
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	$1,533.69
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan EPO	$911.12
Rate for Payer: Superior Health Plan Medicare	$911.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$911.12
Rate for Payer: Universal American Medicare	$911.12
Rate for Payer: Wellcare Medicare	$911.12
Rate for Payer: Wellmed Medicare	$911.12

Unlisted procedure, arthroscopy

Facility

$10,000.00

Service Code	CPT 29999
Hospital Charge Code	36029999
Hospital Revenue Code	360
Min. Negotiated Rate	$247.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
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	$398.99
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

Unlisted procedure, arthroscopy

Facility

$621.03

Service Code	HCPCS 29999
Hospital Charge Code	9900590
Hospital Revenue Code	360
Min. Negotiated Rate	$247.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$422.30
Rate for Payer: Cash Price	$422.30
Rate for Payer: Cash Price	$422.30
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$447.14
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$447.14
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
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	$447.14
Rate for Payer: Scott and White EPO/PPO	$398.99
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$447.14
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

Unlisted procedure, arthroscopy

Facility

$621.03

Service Code	HCPCS 29999
Hospital Charge Code	9900590
Hospital Revenue Code	360
Rate for Payer: Cash Price	$422.30

Unlisted procedure, foot or toes

Facility

$1,237.14

Service Code	HCPCS 28899
Hospital Charge Code	9900537
Hospital Revenue Code	360
Rate for Payer: Cash Price	$841.26

Unlisted procedure, foot or toes

Facility

$1,237.14

Service Code	HCPCS 28899
Hospital Charge Code	9900537
Hospital Revenue Code	360
Min. Negotiated Rate	$247.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$841.26
Rate for Payer: Cash Price	$841.26
Rate for Payer: Cash Price	$841.26
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$890.74
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$890.74
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
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	$890.74
Rate for Payer: Scott and White EPO/PPO	$398.99
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$890.74
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

Unlisted procedure, foot or toes

Facility

$10,000.00

Service Code	CPT 28899
Hospital Charge Code	36028899
Hospital Revenue Code	360
Min. Negotiated Rate	$247.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
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	$398.99
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

Unlisted procedure, leg or ankle

Facility

$9,906.40

Service Code	HCPCS 27899
Hospital Charge Code	9900454
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,736.35

Unlisted procedure, leg or ankle

Facility

$9,906.40

Service Code	HCPCS 27899
Hospital Charge Code	9900454
Hospital Revenue Code	360
Min. Negotiated Rate	$247.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
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	$523.79
Rate for Payer: Cigna Medicaid	$7,132.61
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$7,132.61
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
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	$7,132.61
Rate for Payer: Scott and White EPO/PPO	$398.99
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,132.61
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

Unlisted procedure, leg or ankle

Facility

$10,000.00

Service Code	CPT 27899
Hospital Charge Code	36027899
Hospital Revenue Code	360
Min. Negotiated Rate	$247.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
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	$398.99
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

Unlisted procedure, middle ear

Facility

$4,221.28

Service Code	HCPCS 69799
Hospital Charge Code	9900897
Hospital Revenue Code	360
Min. Negotiated Rate	$237.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$237.93
Rate for Payer: Amerigroup Medicare	$237.93
Rate for Payer: BCBS of TX Blue Advantage	$340.08
Rate for Payer: BCBS of TX Blue Essentials	$407.28
Rate for Payer: BCBS of TX Medicare	$237.93
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cash Price	$2,870.47
Rate for Payer: Cash Price	$2,870.47
Rate for Payer: Cash Price	$2,870.47
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$3,039.32
Rate for Payer: Cigna Medicare	$237.93
Rate for Payer: Employer Direct Commercial	$237.93
Rate for Payer: Humana Medicare/TRICARE	$237.93
Rate for Payer: Molina CHIP/Medicaid	$3,039.32
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
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	$3,039.32
Rate for Payer: Scott and White EPO/PPO	$413.27
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,039.32
Rate for Payer: Superior Health Plan EPO	$237.93
Rate for Payer: Superior Health Plan Medicare	$237.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$237.93
Rate for Payer: Universal American Medicare	$237.93
Rate for Payer: Wellcare Medicare	$237.93
Rate for Payer: Wellmed Medicare	$237.93

Unlisted procedure, middle ear

Facility

$4,221.28

Service Code	HCPCS 69799
Hospital Charge Code	9900897
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,870.47

Unlisted procedure, middle ear

Facility

$10,000.00

Service Code	CPT 69799
Hospital Charge Code	36069799
Hospital Revenue Code	360
Min. Negotiated Rate	$237.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$237.93
Rate for Payer: Amerigroup Medicare	$237.93
Rate for Payer: BCBS of TX Blue Advantage	$340.08
Rate for Payer: BCBS of TX Blue Essentials	$407.28
Rate for Payer: BCBS of TX Medicare	$237.93
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicare	$237.93
Rate for Payer: Employer Direct Commercial	$237.93
Rate for Payer: Humana Medicare/TRICARE	$237.93
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
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	$413.27
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan EPO	$237.93
Rate for Payer: Superior Health Plan Medicare	$237.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$237.93
Rate for Payer: Universal American Medicare	$237.93
Rate for Payer: Wellcare Medicare	$237.93
Rate for Payer: Wellmed Medicare	$237.93

Unlisted procedure, nervous system

Facility

$1,567.02

Service Code	HCPCS 64999
Hospital Charge Code	9900857
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,065.57

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