White Rock Medical Center

All Charges

Charge

Type

Setting

Price

END CAP T2 SUPER CONDYLAR NAIL

Facility

$1,205.30

Service Code	HCPCS C1713
Hospital Charge Code	140511
Hospital Revenue Code	278
Min. Negotiated Rate	$301.32
Max. Negotiated Rate	$602.65
Rate for Payer: Aetna Commercial	$361.59
Rate for Payer: Cash Price	$1,060.66
Rate for Payer: Cigna Commercial	$301.32
Rate for Payer: Multiplan Auto	$602.65
Rate for Payer: Multiplan Commercial	$602.65
Rate for Payer: Multiplan Workers Comp	$602.65
Rate for Payer: Scott and White EPO/PPO	$602.65

ENDO CATCH/SAC -- DHF

Facility

$1,541.75

Hospital Charge Code	80811110
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,356.74

ENDO CATCH/SAC -- DHF

Facility

$1,541.75

Hospital Charge Code	80811110
Hospital Revenue Code	272
Min. Negotiated Rate	$138.76
Max. Negotiated Rate	$1,002.14
Rate for Payer: Aetna Commercial	$847.96
Rate for Payer: Amerigroup CHIP/Medicaid	$138.76
Rate for Payer: BCBS of TX Blue Advantage	$462.52
Rate for Payer: BCBS of TX Blue Essentials	$555.03
Rate for Payer: BCBS of TX PPO	$616.70
Rate for Payer: Cash Price	$1,356.74
Rate for Payer: Multiplan Auto	$1,002.14
Rate for Payer: Multiplan Commercial	$1,002.14
Rate for Payer: Multiplan Workers Comp	$1,002.14
Rate for Payer: Scott and White EPO/PPO	$770.88
Rate for Payer: Superior Health Plan EPO	$209.68

ENDOCLOSE -- DHF

Facility

$356.09

Hospital Charge Code	80811177
Hospital Revenue Code	272
Min. Negotiated Rate	$32.05
Max. Negotiated Rate	$231.46
Rate for Payer: Aetna Commercial	$195.85
Rate for Payer: Amerigroup CHIP/Medicaid	$32.05
Rate for Payer: BCBS of TX Blue Advantage	$106.83
Rate for Payer: BCBS of TX Blue Essentials	$128.19
Rate for Payer: BCBS of TX PPO	$142.44
Rate for Payer: Cash Price	$313.36
Rate for Payer: Multiplan Auto	$231.46
Rate for Payer: Multiplan Commercial	$231.46
Rate for Payer: Multiplan Workers Comp	$231.46
Rate for Payer: Scott and White EPO/PPO	$178.04
Rate for Payer: Superior Health Plan EPO	$48.43

ENDOCLOSE -- DHF

Facility

$356.09

Hospital Charge Code	80811177
Hospital Revenue Code	272
Rate for Payer: Cash Price	$313.36

ENDOCRINE DISORDERS WITH CC

Facility

$20,172.30

Service Code	MSDRG 644
Min. Negotiated Rate	$8,574.20
Max. Negotiated Rate	$20,172.30
Rate for Payer: Aetna Commercial	$11,944.12
Rate for Payer: Aetna Medicare	$15,646.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,431.14
Rate for Payer: Amerigroup Medicare	$10,431.14
Rate for Payer: BCBS of TX Blue Advantage	$8,574.20
Rate for Payer: BCBS of TX Blue Essentials	$10,447.99
Rate for Payer: BCBS of TX Medicare	$10,431.14
Rate for Payer: BCBS of TX PPO	$11,609.32
Rate for Payer: Cigna Commercial	$13,674.70
Rate for Payer: Cigna Medicare	$10,431.14
Rate for Payer: Employer Direct Commercial	$10,431.14
Rate for Payer: Humana Medicare/TRICARE	$10,431.14
Rate for Payer: Molina Dual Medicare/Medicaid	$10,431.14
Rate for Payer: Molina Medicare	$10,431.14
Rate for Payer: Multiplan Auto	$20,172.30
Rate for Payer: Multiplan Commercial	$20,172.30
Rate for Payer: Multiplan Workers Comp	$20,172.30
Rate for Payer: Scott and White EPO/PPO	$9,289.88
Rate for Payer: Scott and White Medicare	$10,431.14
Rate for Payer: Superior Health Plan EPO	$10,431.14
Rate for Payer: Superior Health Plan Medicare	$10,431.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,431.14
Rate for Payer: Universal American Medicare	$10,431.14
Rate for Payer: Wellcare Medicare	$10,431.14
Rate for Payer: Wellmed Medicare	$10,431.14

ENDOCRINE DISORDERS WITH MCC

Facility

$31,256.90

Service Code	MSDRG 643
Min. Negotiated Rate	$13,484.80
Max. Negotiated Rate	$31,256.90
Rate for Payer: Aetna Commercial	$18,507.38
Rate for Payer: Aetna Medicare	$21,891.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,594.31
Rate for Payer: Amerigroup Medicare	$14,594.31
Rate for Payer: BCBS of TX Blue Advantage	$13,484.80
Rate for Payer: BCBS of TX Blue Essentials	$16,862.28
Rate for Payer: BCBS of TX Medicare	$14,594.31
Rate for Payer: BCBS of TX PPO	$18,736.59
Rate for Payer: Cigna Commercial	$21,188.89
Rate for Payer: Cigna Medicare	$14,594.31
Rate for Payer: Employer Direct Commercial	$14,594.31
Rate for Payer: Humana Medicare/TRICARE	$14,594.31
Rate for Payer: Molina Dual Medicare/Medicaid	$14,594.31
Rate for Payer: Molina Medicare	$14,594.31
Rate for Payer: Multiplan Auto	$31,256.90
Rate for Payer: Multiplan Commercial	$31,256.90
Rate for Payer: Multiplan Workers Comp	$31,256.90
Rate for Payer: Scott and White EPO/PPO	$14,394.62
Rate for Payer: Scott and White Medicare	$14,594.31
Rate for Payer: Superior Health Plan EPO	$14,594.31
Rate for Payer: Superior Health Plan Medicare	$14,594.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,594.31
Rate for Payer: Universal American Medicare	$14,594.31
Rate for Payer: Wellcare Medicare	$14,594.31
Rate for Payer: Wellmed Medicare	$14,594.31

ENDOCRINE DISORDERS WITHOUT CC/MCC

Facility

$14,457.10

Service Code	MSDRG 645
Min. Negotiated Rate	$6,277.14
Max. Negotiated Rate	$14,457.10
Rate for Payer: Aetna Commercial	$8,560.12
Rate for Payer: Aetna Medicare	$12,426.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,284.61
Rate for Payer: Amerigroup Medicare	$8,284.61
Rate for Payer: BCBS of TX Blue Advantage	$6,277.14
Rate for Payer: BCBS of TX Blue Essentials	$7,665.99
Rate for Payer: BCBS of TX Medicare	$8,284.61
Rate for Payer: BCBS of TX PPO	$8,518.09
Rate for Payer: Cigna Commercial	$9,800.39
Rate for Payer: Cigna Medicare	$8,284.61
Rate for Payer: Employer Direct Commercial	$8,284.61
Rate for Payer: Humana Medicare/TRICARE	$8,284.61
Rate for Payer: Molina Dual Medicare/Medicaid	$8,284.61
Rate for Payer: Molina Medicare	$8,284.61
Rate for Payer: Multiplan Auto	$14,457.10
Rate for Payer: Multiplan Commercial	$14,457.10
Rate for Payer: Multiplan Workers Comp	$14,457.10
Rate for Payer: Scott and White EPO/PPO	$6,657.88
Rate for Payer: Scott and White Medicare	$8,284.61
Rate for Payer: Superior Health Plan EPO	$8,284.61
Rate for Payer: Superior Health Plan Medicare	$8,284.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,284.61
Rate for Payer: Universal American Medicare	$8,284.61
Rate for Payer: Wellcare Medicare	$8,284.61
Rate for Payer: Wellmed Medicare	$8,284.61

ENDOMYSIAL AB IGA

Facility

$215.00

Service Code	CPT 83516
Hospital Charge Code	1706019
Hospital Revenue Code	301
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$139.75
Rate for Payer: Aetna Commercial	$12.11
Rate for Payer: Aetna Medicare	$17.30
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.53
Rate for Payer: Amerigroup Medicare	$11.53
Rate for Payer: BCBS of TX Blue Advantage	$19.02
Rate for Payer: BCBS of TX Blue Essentials	$22.83
Rate for Payer: BCBS of TX Medicare	$11.53
Rate for Payer: BCBS of TX PPO	$25.48
Rate for Payer: Cash Price	$189.20
Rate for Payer: Cash Price	$189.20
Rate for Payer: Cigna Medicaid	$11.53
Rate for Payer: Cigna Medicare	$11.53
Rate for Payer: Employer Direct Commercial	$11.53
Rate for Payer: Humana Medicare/TRICARE	$11.53
Rate for Payer: Molina CHIP/Medicaid	$11.53
Rate for Payer: Molina Dual Medicare/Medicaid	$11.53
Rate for Payer: Molina Medicare	$11.53
Rate for Payer: Multiplan Auto	$139.75
Rate for Payer: Multiplan Commercial	$139.75
Rate for Payer: Multiplan Workers Comp	$139.75
Rate for Payer: Parkland Medicaid	$11.53
Rate for Payer: Scott and White EPO/PPO	$14.41
Rate for Payer: Scott and White Medicare	$11.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.53
Rate for Payer: Superior Health Plan EPO	$11.53
Rate for Payer: Superior Health Plan Medicare	$11.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.53
Rate for Payer: Universal American Medicare	$11.53
Rate for Payer: Wellcare Medicare	$11.53
Rate for Payer: Wellmed Medicare	$11.53

Endomysial Antibody IgA SO

Facility

$372.00

Service Code	CPT 86231
Hospital Charge Code	1707074
Hospital Revenue Code	302
Rate for Payer: Cash Price	$327.36

Endomysial Antibody IgA SO

Facility

$372.00

Service Code	CPT 86231
Hospital Charge Code	1707074
Hospital Revenue Code	302
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$241.80
Rate for Payer: Aetna Commercial	$12.69
Rate for Payer: Aetna Medicare	$18.14
Rate for Payer: Amerigroup CHIP/Medicaid	$4.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.09
Rate for Payer: Amerigroup Medicare	$12.09
Rate for Payer: BCBS of TX Blue Advantage	$19.95
Rate for Payer: BCBS of TX Blue Essentials	$23.94
Rate for Payer: BCBS of TX Medicare	$12.09
Rate for Payer: BCBS of TX PPO	$26.72
Rate for Payer: Cash Price	$327.36
Rate for Payer: Cash Price	$327.36
Rate for Payer: Cigna Medicaid	$12.09
Rate for Payer: Cigna Medicare	$12.09
Rate for Payer: Employer Direct Commercial	$12.09
Rate for Payer: Humana Medicare/TRICARE	$12.09
Rate for Payer: Molina CHIP/Medicaid	$12.09
Rate for Payer: Molina Dual Medicare/Medicaid	$12.09
Rate for Payer: Molina Medicare	$12.09
Rate for Payer: Multiplan Auto	$241.80
Rate for Payer: Multiplan Commercial	$241.80
Rate for Payer: Multiplan Workers Comp	$241.80
Rate for Payer: Parkland Medicaid	$12.09
Rate for Payer: Scott and White EPO/PPO	$15.11
Rate for Payer: Scott and White Medicare	$12.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.09
Rate for Payer: Superior Health Plan EPO	$12.09
Rate for Payer: Superior Health Plan Medicare	$12.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.09
Rate for Payer: Universal American Medicare	$12.09
Rate for Payer: Wellcare Medicare	$12.09
Rate for Payer: Wellmed Medicare	$12.09

Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, f

Facility

$15,074.51

Service Code	CPT 62380
Hospital Charge Code	36062380
Hospital Revenue Code	360
Min. Negotiated Rate	$144.31
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
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	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicaid	$2,398.52
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina CHIP/Medicaid	$2,398.52
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
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	$2,398.52
Rate for Payer: Scott and White EPO/PPO	$144.31
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,398.52
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

Endoscopic plantar fasciotomy

Facility

$10,000.00

Service Code	CPT 29893
Hospital Charge Code	36029893
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
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	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Endoscopy, wrist, surgical, with release of transverse carpal ligament

Facility

$10,000.00

Service Code	CPT 29848
Hospital Charge Code	36029848
Hospital Revenue Code	360
Min. Negotiated Rate	$32.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$2,204.79
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,469.86
Rate for Payer: Amerigroup Medicare	$1,469.86
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,469.86
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cigna Commercial	$3,329.66
Rate for Payer: Cigna Medicaid	$593.04
Rate for Payer: Cigna Medicare	$1,469.86
Rate for Payer: Employer Direct Commercial	$1,469.86
Rate for Payer: Humana Medicare/TRICARE	$1,469.86
Rate for Payer: Molina CHIP/Medicaid	$593.04
Rate for Payer: Molina Dual Medicare/Medicaid	$1,469.86
Rate for Payer: Molina Medicare	$1,469.86
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	$593.04
Rate for Payer: Scott and White EPO/PPO	$32.42
Rate for Payer: Scott and White Medicare	$1,469.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$593.04
Rate for Payer: Superior Health Plan EPO	$1,469.86
Rate for Payer: Superior Health Plan Medicare	$1,469.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,469.86
Rate for Payer: Universal American Medicare	$1,469.86
Rate for Payer: Wellcare Medicare	$1,469.86
Rate for Payer: Wellmed Medicare	$1,469.86

ENDOSTITCH POLYSORB 3-0 170071

Facility

$98.43

Hospital Charge Code	116428
Hospital Revenue Code	272
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$63.98
Rate for Payer: Aetna Commercial	$54.14
Rate for Payer: Amerigroup CHIP/Medicaid	$8.86
Rate for Payer: BCBS of TX Blue Advantage	$29.53
Rate for Payer: BCBS of TX Blue Essentials	$35.43
Rate for Payer: BCBS of TX PPO	$39.37
Rate for Payer: Cash Price	$86.62
Rate for Payer: Multiplan Auto	$63.98
Rate for Payer: Multiplan Commercial	$63.98
Rate for Payer: Multiplan Workers Comp	$63.98
Rate for Payer: Scott and White EPO/PPO	$49.22
Rate for Payer: Superior Health Plan EPO	$13.39

ENDOSTITCH POLYSORB 3-0 170071

Facility

$98.43

Hospital Charge Code	116428
Hospital Revenue Code	272
Rate for Payer: Cash Price	$86.62

ENDOSTITCH POLYSORB O 170052

Facility

$96.43

Hospital Charge Code	116426
Hospital Revenue Code	272
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$62.68
Rate for Payer: Aetna Commercial	$53.04
Rate for Payer: Amerigroup CHIP/Medicaid	$8.68
Rate for Payer: BCBS of TX Blue Advantage	$28.93
Rate for Payer: BCBS of TX Blue Essentials	$34.71
Rate for Payer: BCBS of TX PPO	$38.57
Rate for Payer: Cash Price	$84.86
Rate for Payer: Multiplan Auto	$62.68
Rate for Payer: Multiplan Commercial	$62.68
Rate for Payer: Multiplan Workers Comp	$62.68
Rate for Payer: Scott and White EPO/PPO	$48.22
Rate for Payer: Superior Health Plan EPO	$13.11

ENDOSTITCH POLYSORB O 170052

Facility

$96.43

Hospital Charge Code	116426
Hospital Revenue Code	272
Rate for Payer: Cash Price	$84.86

ENDOSTITCH SOFSILK 2-0 170004

Facility

$271.54

Hospital Charge Code	116425
Hospital Revenue Code	272
Min. Negotiated Rate	$24.44
Max. Negotiated Rate	$176.50
Rate for Payer: Aetna Commercial	$149.35
Rate for Payer: Amerigroup CHIP/Medicaid	$24.44
Rate for Payer: BCBS of TX Blue Advantage	$81.46
Rate for Payer: BCBS of TX Blue Essentials	$97.75
Rate for Payer: BCBS of TX PPO	$108.62
Rate for Payer: Cash Price	$238.96
Rate for Payer: Multiplan Auto	$176.50
Rate for Payer: Multiplan Commercial	$176.50
Rate for Payer: Multiplan Workers Comp	$176.50
Rate for Payer: Scott and White EPO/PPO	$135.77
Rate for Payer: Superior Health Plan EPO	$36.93

ENDOSTITCH SOFSILK 2-0 170004

Facility

$271.54

Hospital Charge Code	116425
Hospital Revenue Code	272
Rate for Payer: Cash Price	$238.96

ENDOSTITCH SURGIDAC 2-0 173023

Facility

$98.43

Hospital Charge Code	122478
Hospital Revenue Code	272
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$63.98
Rate for Payer: Aetna Commercial	$54.14
Rate for Payer: Amerigroup CHIP/Medicaid	$8.86
Rate for Payer: BCBS of TX Blue Advantage	$29.53
Rate for Payer: BCBS of TX Blue Essentials	$35.43
Rate for Payer: BCBS of TX PPO	$39.37
Rate for Payer: Cash Price	$86.62
Rate for Payer: Multiplan Auto	$63.98
Rate for Payer: Multiplan Commercial	$63.98
Rate for Payer: Multiplan Workers Comp	$63.98
Rate for Payer: Scott and White EPO/PPO	$49.22
Rate for Payer: Superior Health Plan EPO	$13.39

ENDOSTITCH SURGIDAC 2-0 173023

Facility

$98.43

Hospital Charge Code	122478
Hospital Revenue Code	272
Rate for Payer: Cash Price	$86.62

ENDOSTITCH SURGIDAC O 173024

Facility

$96.43

Hospital Charge Code	122479
Hospital Revenue Code	272
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$62.68
Rate for Payer: Aetna Commercial	$53.04
Rate for Payer: Amerigroup CHIP/Medicaid	$8.68
Rate for Payer: BCBS of TX Blue Advantage	$28.93
Rate for Payer: BCBS of TX Blue Essentials	$34.71
Rate for Payer: BCBS of TX PPO	$38.57
Rate for Payer: Cash Price	$84.86
Rate for Payer: Multiplan Auto	$62.68
Rate for Payer: Multiplan Commercial	$62.68
Rate for Payer: Multiplan Workers Comp	$62.68
Rate for Payer: Scott and White EPO/PPO	$48.22
Rate for Payer: Superior Health Plan EPO	$13.11

ENDOSTITCH SURGIDAC O 173024

Facility

$96.43

Hospital Charge Code	122479
Hospital Revenue Code	272
Rate for Payer: Cash Price	$84.86

ENDOSTITCH SUTURE DEVICE

Facility

$1,955.55

Hospital Charge Code	8538527
Hospital Revenue Code	272
Min. Negotiated Rate	$176.00
Max. Negotiated Rate	$1,271.11
Rate for Payer: Aetna Commercial	$1,075.55
Rate for Payer: Amerigroup CHIP/Medicaid	$176.00
Rate for Payer: BCBS of TX Blue Advantage	$586.66
Rate for Payer: BCBS of TX Blue Essentials	$704.00
Rate for Payer: BCBS of TX PPO	$782.22
Rate for Payer: Cash Price	$1,720.88
Rate for Payer: Multiplan Auto	$1,271.11
Rate for Payer: Multiplan Commercial	$1,271.11
Rate for Payer: Multiplan Workers Comp	$1,271.11
Rate for Payer: Scott and White EPO/PPO	$977.78
Rate for Payer: Superior Health Plan EPO	$265.95

Know your out-of-pocket cost for care.

All Charges