White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Gonorrhea PCR BCE

Facility

$245.00

Service Code	CPT 87591
Hospital Charge Code	4107592
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$159.25
Rate for Payer: Aetna Commercial	$36.84
Rate for Payer: Aetna Medicare	$52.64
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$57.90
Rate for Payer: BCBS of TX Blue Essentials	$69.48
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$77.55
Rate for Payer: Cash Price	$215.60
Rate for Payer: Cash Price	$215.60
Rate for Payer: Cigna Medicaid	$35.09
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$35.09
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$159.25
Rate for Payer: Multiplan Commercial	$159.25
Rate for Payer: Multiplan Workers Comp	$159.25
Rate for Payer: Parkland Medicaid	$35.09
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.09
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

GORE EXCLUDER AAA ENDOPOSTHEISI 14.5 X 12

Facility

$31,204.82

Service Code	HCPCS C1768
Hospital Charge Code	145407
Hospital Revenue Code	278
Min. Negotiated Rate	$2,808.43
Max. Negotiated Rate	$15,602.41
Rate for Payer: Aetna Commercial	$9,361.45
Rate for Payer: Amerigroup CHIP/Medicaid	$2,808.43
Rate for Payer: BCBS of TX Blue Advantage	$9,361.45
Rate for Payer: BCBS of TX Blue Essentials	$11,233.74
Rate for Payer: BCBS of TX PPO	$12,481.93
Rate for Payer: Cash Price	$27,460.24
Rate for Payer: Multiplan Auto	$15,602.41
Rate for Payer: Multiplan Commercial	$15,602.41
Rate for Payer: Multiplan Workers Comp	$15,602.41
Rate for Payer: Scott and White EPO/PPO	$15,602.41
Rate for Payer: Superior Health Plan EPO	$4,243.86

GORE EXCLUDER AAA ENDOPOSTHEISI 14.5 X 12

Facility

$31,204.82

Service Code	HCPCS C1768
Hospital Charge Code	145407
Hospital Revenue Code	278
Min. Negotiated Rate	$7,801.20
Max. Negotiated Rate	$15,602.41
Rate for Payer: Aetna Commercial	$9,361.45
Rate for Payer: Cash Price	$27,460.24
Rate for Payer: Cigna Commercial	$7,801.20
Rate for Payer: Multiplan Auto	$15,602.41
Rate for Payer: Multiplan Commercial	$15,602.41
Rate for Payer: Multiplan Workers Comp	$15,602.41
Rate for Payer: Scott and White EPO/PPO	$15,602.41

GORE EXCLUDER AAA ENDOPROSTHESIS 14.5X14

Facility

$31,204.82

Service Code	HCPCS C1768
Hospital Charge Code	119871
Hospital Revenue Code	278
Min. Negotiated Rate	$7,801.20
Max. Negotiated Rate	$15,602.41
Rate for Payer: Aetna Commercial	$9,361.45
Rate for Payer: Cash Price	$27,460.24
Rate for Payer: Cigna Commercial	$7,801.20
Rate for Payer: Multiplan Auto	$15,602.41
Rate for Payer: Multiplan Commercial	$15,602.41
Rate for Payer: Multiplan Workers Comp	$15,602.41
Rate for Payer: Scott and White EPO/PPO	$15,602.41

GORE EXCLUDER AAA ENDOPROSTHESIS 14.5X14

Facility

$31,204.82

Service Code	HCPCS C1768
Hospital Charge Code	119871
Hospital Revenue Code	278
Min. Negotiated Rate	$2,808.43
Max. Negotiated Rate	$15,602.41
Rate for Payer: Aetna Commercial	$9,361.45
Rate for Payer: Amerigroup CHIP/Medicaid	$2,808.43
Rate for Payer: BCBS of TX Blue Advantage	$9,361.45
Rate for Payer: BCBS of TX Blue Essentials	$11,233.74
Rate for Payer: BCBS of TX PPO	$12,481.93
Rate for Payer: Cash Price	$27,460.24
Rate for Payer: Multiplan Auto	$15,602.41
Rate for Payer: Multiplan Commercial	$15,602.41
Rate for Payer: Multiplan Workers Comp	$15,602.41
Rate for Payer: Scott and White EPO/PPO	$15,602.41
Rate for Payer: Superior Health Plan EPO	$4,243.86

GORE EXCLUDER AAA ENDOPROSTHESIS 16X12

Facility

$30,590.36

Hospital Charge Code	8528498
Hospital Revenue Code	278
Min. Negotiated Rate	$7,647.59
Max. Negotiated Rate	$15,295.18
Rate for Payer: Aetna Commercial	$9,177.11
Rate for Payer: Cash Price	$26,919.52
Rate for Payer: Cigna Commercial	$7,647.59
Rate for Payer: Multiplan Auto	$15,295.18
Rate for Payer: Multiplan Commercial	$15,295.18
Rate for Payer: Multiplan Workers Comp	$15,295.18
Rate for Payer: Scott and White EPO/PPO	$15,295.18

GORE EXCLUDER AAA ENDOPROSTHESIS 16X12

Facility

$30,590.36

Hospital Charge Code	8528498
Hospital Revenue Code	278
Min. Negotiated Rate	$2,753.13
Max. Negotiated Rate	$15,295.18
Rate for Payer: Aetna Commercial	$9,177.11
Rate for Payer: Amerigroup CHIP/Medicaid	$2,753.13
Rate for Payer: BCBS of TX Blue Advantage	$9,177.11
Rate for Payer: BCBS of TX Blue Essentials	$11,012.53
Rate for Payer: BCBS of TX PPO	$12,236.14
Rate for Payer: Cash Price	$26,919.52
Rate for Payer: Multiplan Auto	$15,295.18
Rate for Payer: Multiplan Commercial	$15,295.18
Rate for Payer: Multiplan Workers Comp	$15,295.18
Rate for Payer: Scott and White EPO/PPO	$15,295.18
Rate for Payer: Superior Health Plan EPO	$4,160.29

GORE EXCLUDER AAA ENDOPROTHESIS 13X12X12

Facility

$73,144.58

Hospital Charge Code	8392455
Hospital Revenue Code	278
Min. Negotiated Rate	$18,286.14
Max. Negotiated Rate	$36,572.29
Rate for Payer: Aetna Commercial	$21,943.37
Rate for Payer: Cash Price	$64,367.23
Rate for Payer: Cigna Commercial	$18,286.14
Rate for Payer: Multiplan Auto	$36,572.29
Rate for Payer: Multiplan Commercial	$36,572.29
Rate for Payer: Multiplan Workers Comp	$36,572.29
Rate for Payer: Scott and White EPO/PPO	$36,572.29

GORE EXCLUDER AAA ENDOPROTHESIS 13X12X12

Facility

$73,144.58

Hospital Charge Code	8392455
Hospital Revenue Code	278
Min. Negotiated Rate	$6,583.01
Max. Negotiated Rate	$36,572.29
Rate for Payer: Aetna Commercial	$21,943.37
Rate for Payer: Amerigroup CHIP/Medicaid	$6,583.01
Rate for Payer: BCBS of TX Blue Advantage	$21,943.37
Rate for Payer: BCBS of TX Blue Essentials	$26,332.05
Rate for Payer: BCBS of TX PPO	$29,257.83
Rate for Payer: Cash Price	$64,367.23
Rate for Payer: Multiplan Auto	$36,572.29
Rate for Payer: Multiplan Commercial	$36,572.29
Rate for Payer: Multiplan Workers Comp	$36,572.29
Rate for Payer: Scott and White EPO/PPO	$36,572.29
Rate for Payer: Superior Health Plan EPO	$9,947.66

GORE EXCLUDER AAA ENDOPROTHESIS 16x11.15

Facility

$29,988.01

Hospital Charge Code	8392454
Hospital Revenue Code	278
Min. Negotiated Rate	$2,698.92
Max. Negotiated Rate	$14,994.00
Rate for Payer: Aetna Commercial	$8,996.40
Rate for Payer: Amerigroup CHIP/Medicaid	$2,698.92
Rate for Payer: BCBS of TX Blue Advantage	$8,996.40
Rate for Payer: BCBS of TX Blue Essentials	$10,795.68
Rate for Payer: BCBS of TX PPO	$11,995.20
Rate for Payer: Cash Price	$26,389.45
Rate for Payer: Multiplan Auto	$14,994.00
Rate for Payer: Multiplan Commercial	$14,994.00
Rate for Payer: Multiplan Workers Comp	$14,994.00
Rate for Payer: Scott and White EPO/PPO	$14,994.00
Rate for Payer: Superior Health Plan EPO	$4,078.37

GORE EXCLUDER AAA ENDOPROTHESIS 16x11.15

Facility

$29,988.01

Hospital Charge Code	8392454
Hospital Revenue Code	278
Min. Negotiated Rate	$7,497.00
Max. Negotiated Rate	$14,994.00
Rate for Payer: Aetna Commercial	$8,996.40
Rate for Payer: Cash Price	$26,389.45
Rate for Payer: Cigna Commercial	$7,497.00
Rate for Payer: Multiplan Auto	$14,994.00
Rate for Payer: Multiplan Commercial	$14,994.00
Rate for Payer: Multiplan Workers Comp	$14,994.00
Rate for Payer: Scott and White EPO/PPO	$14,994.00

GORE EXCLUDER AAA ENDOPROTHESIS 16x95

Facility

$29,988.01

Hospital Charge Code	8392453
Hospital Revenue Code	278
Min. Negotiated Rate	$2,698.92
Max. Negotiated Rate	$14,994.00
Rate for Payer: Aetna Commercial	$8,996.40
Rate for Payer: Amerigroup CHIP/Medicaid	$2,698.92
Rate for Payer: BCBS of TX Blue Advantage	$8,996.40
Rate for Payer: BCBS of TX Blue Essentials	$10,795.68
Rate for Payer: BCBS of TX PPO	$11,995.20
Rate for Payer: Cash Price	$26,389.45
Rate for Payer: Multiplan Auto	$14,994.00
Rate for Payer: Multiplan Commercial	$14,994.00
Rate for Payer: Multiplan Workers Comp	$14,994.00
Rate for Payer: Scott and White EPO/PPO	$14,994.00
Rate for Payer: Superior Health Plan EPO	$4,078.37

GORE EXCLUDER AAA ENDOPROTHESIS 16x95

Facility

$29,988.01

Hospital Charge Code	8392453
Hospital Revenue Code	278
Min. Negotiated Rate	$7,497.00
Max. Negotiated Rate	$14,994.00
Rate for Payer: Aetna Commercial	$8,996.40
Rate for Payer: Cash Price	$26,389.45
Rate for Payer: Cigna Commercial	$7,497.00
Rate for Payer: Multiplan Auto	$14,994.00
Rate for Payer: Multiplan Commercial	$14,994.00
Rate for Payer: Multiplan Workers Comp	$14,994.00
Rate for Payer: Scott and White EPO/PPO	$14,994.00

GORE EXCLUDER ENDOPROSTHESIS CXT261412

Facility

$87,855.42

Service Code	HCPCS C1768
Hospital Charge Code	145406
Hospital Revenue Code	278
Min. Negotiated Rate	$7,906.99
Max. Negotiated Rate	$43,927.71
Rate for Payer: Aetna Commercial	$26,356.63
Rate for Payer: Amerigroup CHIP/Medicaid	$7,906.99
Rate for Payer: BCBS of TX Blue Advantage	$26,356.63
Rate for Payer: BCBS of TX Blue Essentials	$31,627.95
Rate for Payer: BCBS of TX PPO	$35,142.17
Rate for Payer: Cash Price	$77,312.77
Rate for Payer: Multiplan Auto	$43,927.71
Rate for Payer: Multiplan Commercial	$43,927.71
Rate for Payer: Multiplan Workers Comp	$43,927.71
Rate for Payer: Scott and White EPO/PPO	$43,927.71
Rate for Payer: Superior Health Plan EPO	$11,948.34

GORE EXCLUDER ENDOPROSTHESIS CXT261412

Facility

$87,855.42

Service Code	HCPCS C1768
Hospital Charge Code	145406
Hospital Revenue Code	278
Min. Negotiated Rate	$21,963.86
Max. Negotiated Rate	$43,927.71
Rate for Payer: Aetna Commercial	$26,356.63
Rate for Payer: Cash Price	$77,312.77
Rate for Payer: Cigna Commercial	$21,963.86
Rate for Payer: Multiplan Auto	$43,927.71
Rate for Payer: Multiplan Commercial	$43,927.71
Rate for Payer: Multiplan Workers Comp	$43,927.71
Rate for Payer: Scott and White EPO/PPO	$43,927.71

GORE EXDLUDER AAA ENDOPROSTHESIS 35X14.5

Facility

$54,383.25

Hospital Charge Code	8532467
Hospital Revenue Code	278
Min. Negotiated Rate	$13,595.81
Max. Negotiated Rate	$27,191.62
Rate for Payer: Aetna Commercial	$16,314.98
Rate for Payer: Cash Price	$47,857.26
Rate for Payer: Cigna Commercial	$13,595.81
Rate for Payer: Multiplan Auto	$27,191.62
Rate for Payer: Multiplan Commercial	$27,191.62
Rate for Payer: Multiplan Workers Comp	$27,191.62
Rate for Payer: Scott and White EPO/PPO	$27,191.62

GORE EXDLUDER AAA ENDOPROSTHESIS 35X14.5

Facility

$54,383.25

Hospital Charge Code	8532467
Hospital Revenue Code	278
Min. Negotiated Rate	$4,894.49
Max. Negotiated Rate	$27,191.62
Rate for Payer: Aetna Commercial	$16,314.98
Rate for Payer: Amerigroup CHIP/Medicaid	$4,894.49
Rate for Payer: BCBS of TX Blue Advantage	$16,314.98
Rate for Payer: BCBS of TX Blue Essentials	$19,577.97
Rate for Payer: BCBS of TX PPO	$21,753.30
Rate for Payer: Cash Price	$47,857.26
Rate for Payer: Multiplan Auto	$27,191.62
Rate for Payer: Multiplan Commercial	$27,191.62
Rate for Payer: Multiplan Workers Comp	$27,191.62
Rate for Payer: Scott and White EPO/PPO	$27,191.62
Rate for Payer: Superior Health Plan EPO	$7,396.12

GORE EXLUDER AAA ENDOPROTHESIS 20X10

Facility

$30,590.36

Hospital Charge Code	8532468
Hospital Revenue Code	272
Rate for Payer: Cash Price	$26,919.52

GORE EXLUDER AAA ENDOPROTHESIS 20X10

Facility

$30,590.36

Hospital Charge Code	8532468
Hospital Revenue Code	272
Min. Negotiated Rate	$2,753.13
Max. Negotiated Rate	$19,883.73
Rate for Payer: Aetna Commercial	$16,824.70
Rate for Payer: Amerigroup CHIP/Medicaid	$2,753.13
Rate for Payer: BCBS of TX Blue Advantage	$9,177.11
Rate for Payer: BCBS of TX Blue Essentials	$11,012.53
Rate for Payer: BCBS of TX PPO	$12,236.14
Rate for Payer: Cash Price	$26,919.52
Rate for Payer: Multiplan Auto	$19,883.73
Rate for Payer: Multiplan Commercial	$19,883.73
Rate for Payer: Multiplan Workers Comp	$19,883.73
Rate for Payer: Scott and White EPO/PPO	$15,295.18
Rate for Payer: Superior Health Plan EPO	$4,160.29

gore propaten axillo bifemoral

Facility

$22,536.14

Service Code	HCPCS C1768
Hospital Charge Code	8660508
Hospital Revenue Code	278
Min. Negotiated Rate	$2,028.25
Max. Negotiated Rate	$11,268.07
Rate for Payer: Aetna Commercial	$6,760.84
Rate for Payer: Amerigroup CHIP/Medicaid	$2,028.25
Rate for Payer: BCBS of TX Blue Advantage	$6,760.84
Rate for Payer: BCBS of TX Blue Essentials	$8,113.01
Rate for Payer: BCBS of TX PPO	$9,014.46
Rate for Payer: Cash Price	$19,831.80
Rate for Payer: Multiplan Auto	$11,268.07
Rate for Payer: Multiplan Commercial	$11,268.07
Rate for Payer: Multiplan Workers Comp	$11,268.07
Rate for Payer: Scott and White EPO/PPO	$11,268.07
Rate for Payer: Superior Health Plan EPO	$3,064.92

gore propaten axillo bifemoral

Facility

$22,536.14

Service Code	HCPCS C1768
Hospital Charge Code	8660508
Hospital Revenue Code	278
Min. Negotiated Rate	$5,634.04
Max. Negotiated Rate	$11,268.07
Rate for Payer: Aetna Commercial	$6,760.84
Rate for Payer: Cash Price	$19,831.80
Rate for Payer: Cigna Commercial	$5,634.04
Rate for Payer: Multiplan Auto	$11,268.07
Rate for Payer: Multiplan Commercial	$11,268.07
Rate for Payer: Multiplan Workers Comp	$11,268.07
Rate for Payer: Scott and White EPO/PPO	$11,268.07

Graft derma-fat-fascia

Facility

$10,000.00

Service Code	CPT 15770
Hospital Charge Code	36015770
Hospital Revenue Code	360
Min. Negotiated Rate	$72.37
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,921.58
Rate for Payer: Amerigroup CHIP/Medicaid	$1,457.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Amerigroup Medicare	$3,281.05
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,281.05
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cigna Commercial	$7,432.53
Rate for Payer: Cigna Medicaid	$1,457.62
Rate for Payer: Cigna Medicare	$3,281.05
Rate for Payer: Employer Direct Commercial	$3,281.05
Rate for Payer: Humana Medicare/TRICARE	$3,281.05
Rate for Payer: Molina CHIP/Medicaid	$1,457.62
Rate for Payer: Molina Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Molina Medicare	$3,281.05
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	$1,457.62
Rate for Payer: Scott and White EPO/PPO	$72.37
Rate for Payer: Scott and White Medicare	$3,281.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,457.62
Rate for Payer: Superior Health Plan EPO	$3,281.05
Rate for Payer: Superior Health Plan Medicare	$3,281.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Universal American Medicare	$3,281.05
Rate for Payer: Wellcare Medicare	$3,281.05
Rate for Payer: Wellmed Medicare	$3,281.05

Graft ear cartilage, autogenous, to nose or ear (includes obtaining graft)

Facility

$12,223.34

Service Code	CPT 21235
Hospital Charge Code	36021235
Hospital Revenue Code	360
Min. Negotiated Rate	$118.13
Max. Negotiated Rate	$12,223.34
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$8,033.61
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Amerigroup Medicare	$5,355.74
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	$5,355.74
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,132.30
Rate for Payer: Cigna Medicaid	$1,954.22
Rate for Payer: Cigna Medicare	$5,355.74
Rate for Payer: Employer Direct Commercial	$5,355.74
Rate for Payer: Humana Medicare/TRICARE	$5,355.74
Rate for Payer: Molina CHIP/Medicaid	$1,954.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Molina Medicare	$5,355.74
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	$1,954.22
Rate for Payer: Scott and White EPO/PPO	$118.13
Rate for Payer: Scott and White Medicare	$5,355.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.22
Rate for Payer: Superior Health Plan EPO	$5,355.74
Rate for Payer: Superior Health Plan Medicare	$5,355.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Universal American Medicare	$5,355.74
Rate for Payer: Wellcare Medicare	$5,355.74
Rate for Payer: Wellmed Medicare	$5,355.74

Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or

Facility

$10,000.00

Service Code	CPT 15771
Hospital Charge Code	36015771
Hospital Revenue Code	360
Min. Negotiated Rate	$72.37
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,921.58
Rate for Payer: Amerigroup CHIP/Medicaid	$1,457.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Amerigroup Medicare	$3,281.05
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,281.05
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cigna Commercial	$7,432.53
Rate for Payer: Cigna Medicaid	$1,457.62
Rate for Payer: Cigna Medicare	$3,281.05
Rate for Payer: Employer Direct Commercial	$3,281.05
Rate for Payer: Humana Medicare/TRICARE	$3,281.05
Rate for Payer: Molina CHIP/Medicaid	$1,457.62
Rate for Payer: Molina Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Molina Medicare	$3,281.05
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	$1,457.62
Rate for Payer: Scott and White EPO/PPO	$72.37
Rate for Payer: Scott and White Medicare	$3,281.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,457.62
Rate for Payer: Superior Health Plan EPO	$3,281.05
Rate for Payer: Superior Health Plan Medicare	$3,281.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Universal American Medicare	$3,281.05
Rate for Payer: Wellcare Medicare	$3,281.05
Rate for Payer: Wellmed Medicare	$3,281.05

Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)

Facility

$10,000.00

Service Code	CPT 15769
Hospital Charge Code	36015769
Hospital Revenue Code	360
Min. Negotiated Rate	$72.37
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,921.58
Rate for Payer: Amerigroup CHIP/Medicaid	$1,457.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Amerigroup Medicare	$3,281.05
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,281.05
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cigna Commercial	$7,432.53
Rate for Payer: Cigna Medicaid	$1,457.62
Rate for Payer: Cigna Medicare	$3,281.05
Rate for Payer: Employer Direct Commercial	$3,281.05
Rate for Payer: Humana Medicare/TRICARE	$3,281.05
Rate for Payer: Molina CHIP/Medicaid	$1,457.62
Rate for Payer: Molina Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Molina Medicare	$3,281.05
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	$1,457.62
Rate for Payer: Scott and White EPO/PPO	$72.37
Rate for Payer: Scott and White Medicare	$3,281.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,457.62
Rate for Payer: Superior Health Plan EPO	$3,281.05
Rate for Payer: Superior Health Plan Medicare	$3,281.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Universal American Medicare	$3,281.05
Rate for Payer: Wellcare Medicare	$3,281.05
Rate for Payer: Wellmed Medicare	$3,281.05

Know your out-of-pocket cost for care.

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