White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DDPB3D4 ICD COBALT DR MRI

Facility

$78,313.00

Service Code	HCPCS C1721
Hospital Charge Code	9395003
Hospital Revenue Code	278
Min. Negotiated Rate	$7,048.17
Max. Negotiated Rate	$56,385.36
Rate for Payer: Amerigroup CHIP/Medicaid	$7,048.17
Rate for Payer: BCBS of TX Blue Advantage	$23,493.90
Rate for Payer: BCBS of TX Blue Essentials	$28,192.68
Rate for Payer: BCBS of TX PPO	$31,325.20
Rate for Payer: Cash Price	$53,252.84
Rate for Payer: Cigna Medicaid	$56,385.36
Rate for Payer: Molina CHIP/Medicaid	$56,385.36
Rate for Payer: Multiplan Auto	$39,156.50
Rate for Payer: Multiplan Commercial	$39,156.50
Rate for Payer: Multiplan Workers Comp	$39,156.50
Rate for Payer: Parkland Medicaid	$56,385.36
Rate for Payer: Scott and White EPO/PPO	$39,156.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56,385.36
Rate for Payer: Superior Health Plan EPO	$10,650.57

Debride Bone Each Additional 20 Sq cm

Facility

$4,412.00

Service Code	HCPCS 11047
Hospital Charge Code	7150797
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,000.16

Debride Bone Each Additional 20 Sq cm

Facility

$4,412.00

Service Code	HCPCS 11047
Hospital Charge Code	7150797
Hospital Revenue Code	361
Min. Negotiated Rate	$397.08
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$397.08
Rate for Payer: BCBS of TX Blue Advantage	$1,323.60
Rate for Payer: BCBS of TX Blue Essentials	$1,588.32
Rate for Payer: BCBS of TX PPO	$1,764.80
Rate for Payer: Cash Price	$3,000.16
Rate for Payer: Cash Price	$3,000.16
Rate for Payer: Cigna Medicaid	$3,176.64
Rate for Payer: Molina CHIP/Medicaid	$3,176.64
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	$3,176.64
Rate for Payer: Scott and White EPO/PPO	$2,206.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,176.64
Rate for Payer: Superior Health Plan EPO	$600.03

Debride Bone First 20 Sq cm or Less

Facility

$6,480.96

Service Code	HCPCS 11044
Hospital Charge Code	9900084
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,407.05

Debride Bone First 20 Sq cm or Less

Facility

$6,480.96

Service Code	HCPCS 11044
Hospital Charge Code	9900084
Hospital Revenue Code	360
Min. Negotiated Rate	$566.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$566.62
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	$4,407.05
Rate for Payer: Cash Price	$4,407.05
Rate for Payer: Cash Price	$4,407.05
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,666.29
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	$4,666.29
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	$4,666.29
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	$4,666.29
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

Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if perform

Facility

$6,480.96

Service Code	HCPCS 11044
Hospital Charge Code	8912543
Hospital Revenue Code	360
Min. Negotiated Rate	$566.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$566.62
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	$4,407.05
Rate for Payer: Cash Price	$4,407.05
Rate for Payer: Cash Price	$4,407.05
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,666.29
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	$4,666.29
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	$4,666.29
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	$4,666.29
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

Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if perform

Facility

$6,480.96

Service Code	HCPCS 11044
Hospital Charge Code	8912543
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,407.05

Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if perform

Facility

$10,000.00

Service Code	CPT 11044
Hospital Charge Code	36011044
Hospital Revenue Code	360
Min. Negotiated Rate	$566.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$566.62
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

Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone

Facility

$16,590.07

Service Code	HCPCS 11012
Hospital Charge Code	9900081
Hospital Revenue Code	360
Min. Negotiated Rate	$815.20
Max. Negotiated Rate	$11,944.85
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	$11,281.25
Rate for Payer: Cash Price	$11,281.25
Rate for Payer: Cash Price	$11,281.25
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicaid	$11,944.85
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	$11,944.85
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	$11,944.85
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	$11,944.85
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

Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone

Facility

$16,590.07

Service Code	HCPCS 11012
Hospital Charge Code	9900081
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,281.25

Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed

Facility

$4,383.94

Service Code	HCPCS 11043
Hospital Charge Code	9900083
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,981.08

Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed

Facility

$10,000.00

Service Code	CPT 11043
Hospital Charge Code	36011043
Hospital Revenue Code	360
Min. Negotiated Rate	$262.63
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
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	$1,062.60
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed

Facility

$4,383.94

Service Code	HCPCS 11043
Hospital Charge Code	9900083
Hospital Revenue Code	360
Min. Negotiated Rate	$262.63
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,981.08
Rate for Payer: Cash Price	$2,981.08
Rate for Payer: Cash Price	$2,981.08
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$3,156.44
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina CHIP/Medicaid	$3,156.44
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
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	$3,156.44
Rate for Payer: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,156.44
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

Debridement of extensive eczematous or infected skin up to 10% of body surface

Facility

$1,099.00

Service Code	HCPCS 11000
Hospital Charge Code	9900078
Hospital Revenue Code	360
Rate for Payer: Cash Price	$747.32

Debridement of extensive eczematous or infected skin up to 10% of body surface

Facility

$1,099.00

Service Code	HCPCS 11000
Hospital Charge Code	9900078
Hospital Revenue Code	360
Min. Negotiated Rate	$28.98
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$28.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$57.26
Rate for Payer: BCBS of TX Blue Essentials	$68.58
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$86.41
Rate for Payer: Cash Price	$747.32
Rate for Payer: Cash Price	$747.32
Rate for Payer: Cash Price	$747.32
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$791.28
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$791.28
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$791.28
Rate for Payer: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$791.28
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

Debridement of extensive eczematous or infected skin up to 10% of body surface

Facility

$10,000.00

Service Code	CPT 11000
Hospital Charge Code	36011000
Hospital Revenue Code	360
Min. Negotiated Rate	$28.98
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$28.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$57.26
Rate for Payer: BCBS of TX Blue Essentials	$68.58
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$86.41
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$1,062.60
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection a

Facility

$4,062.60

Service Code	HCPCS 11005
Hospital Charge Code	9900079
Hospital Revenue Code	360
Min. Negotiated Rate	$365.63
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$365.63
Rate for Payer: BCBS of TX Blue Advantage	$1,362.60
Rate for Payer: BCBS of TX Blue Essentials	$1,631.86
Rate for Payer: BCBS of TX PPO	$2,056.14
Rate for Payer: Cash Price	$2,762.57
Rate for Payer: Cash Price	$2,762.57
Rate for Payer: Cash Price	$2,762.57
Rate for Payer: Cigna Medicaid	$2,925.07
Rate for Payer: Molina CHIP/Medicaid	$2,925.07
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	$2,925.07
Rate for Payer: Scott and White EPO/PPO	$2,031.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,925.07
Rate for Payer: Superior Health Plan EPO	$552.51

Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection a

Facility

$10,000.00

Service Code	CPT 11005
Hospital Charge Code	36011005
Hospital Revenue Code	360
Min. Negotiated Rate	$930.06
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$1,362.60
Rate for Payer: BCBS of TX Blue Essentials	$1,631.86
Rate for Payer: BCBS of TX PPO	$2,056.14
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	$930.06

Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection a

Facility

$4,062.60

Service Code	HCPCS 11005
Hospital Charge Code	9900079
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,762.57

Debridement, subcutaneous tissue (includes epidermis and dermis, if performed) first 20 sq cm or le

Facility

$1,546.00

Service Code	HCPCS 11042
Hospital Charge Code	9900082
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,051.28

Debridement, subcutaneous tissue (includes epidermis and dermis, if performed) first 20 sq cm or le

Facility

$1,546.00

Service Code	HCPCS 11042
Hospital Charge Code	9900082
Hospital Revenue Code	360
Min. Negotiated Rate	$171.51
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$171.51
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,051.28
Rate for Payer: Cash Price	$1,051.28
Rate for Payer: Cash Price	$1,051.28
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,113.12
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$1,113.12
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$1,113.12
Rate for Payer: Scott and White EPO/PPO	$674.64
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,113.12
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

Debridement, subcutaneous tissue (includes epidermis and dermis, if performed) first 20 sq cm or le

Facility

$10,000.00

Service Code	CPT 11042
Hospital Charge Code	36011042
Hospital Revenue Code	360
Min. Negotiated Rate	$171.51
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$171.51
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$674.64
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

Debride Muscle/Fascia Each Additional 20 Sq cm

Facility

$2,026.00

Service Code	HCPCS 11046
Hospital Charge Code	7150796
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,377.68

Debride Muscle/Fascia Each Additional 20 Sq cm

Facility

$2,026.00

Service Code	HCPCS 11046
Hospital Charge Code	7150796
Hospital Revenue Code	361
Min. Negotiated Rate	$182.34
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$182.34
Rate for Payer: BCBS of TX Blue Advantage	$607.80
Rate for Payer: BCBS of TX Blue Essentials	$729.36
Rate for Payer: BCBS of TX PPO	$810.40
Rate for Payer: Cash Price	$1,377.68
Rate for Payer: Cash Price	$1,377.68
Rate for Payer: Cigna Medicaid	$1,458.72
Rate for Payer: Molina CHIP/Medicaid	$1,458.72
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	$1,458.72
Rate for Payer: Scott and White EPO/PPO	$1,013.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,458.72
Rate for Payer: Superior Health Plan EPO	$275.54

Debride Subcutan Each Add 20 sq cm

Facility

$1,020.00

Service Code	HCPCS 11045
Hospital Charge Code	7150795
Hospital Revenue Code	360
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$91.80
Rate for Payer: BCBS of TX Blue Advantage	$306.00
Rate for Payer: BCBS of TX Blue Essentials	$367.20
Rate for Payer: BCBS of TX PPO	$408.00
Rate for Payer: Cash Price	$693.60
Rate for Payer: Cash Price	$693.60
Rate for Payer: Cigna Medicaid	$734.40
Rate for Payer: Molina CHIP/Medicaid	$734.40
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	$734.40
Rate for Payer: Scott and White EPO/PPO	$510.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$734.40
Rate for Payer: Superior Health Plan EPO	$138.72

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