White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$1,373.51
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	$1,373.51
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

$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	$755.48
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 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	$755.48
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 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	$1,362.60
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

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 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, 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	$755.48
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	$755.48
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
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 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 Subcutan Each Add 20 sq cm

Facility

$1,020.00

Service Code	HCPCS 11045
Hospital Charge Code	7150795
Hospital Revenue Code	360
Rate for Payer: Cash Price	$693.60

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

DECELL PLACENTAL MEMBRANE 2X3 CM PAC06M

Facility

$938.00

Service Code	HCPCS Q4205
Hospital Charge Code	146033
Hospital Revenue Code	278
Min. Negotiated Rate	$234.50
Max. Negotiated Rate	$469.00
Rate for Payer: Cash Price	$637.84
Rate for Payer: Cigna Commercial	$234.50
Rate for Payer: Multiplan Auto	$469.00
Rate for Payer: Multiplan Commercial	$469.00
Rate for Payer: Multiplan Workers Comp	$469.00
Rate for Payer: Scott and White EPO/PPO	$469.00

DECELL PLACENTAL MEMBRANE 2X3 CM PAC06M

Facility

$938.00

Service Code	HCPCS Q4205
Hospital Charge Code	146033
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$675.36
Rate for Payer: Amerigroup CHIP/Medicaid	$84.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$14.83
Rate for Payer: BCBS of TX Blue Essentials	$17.80
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$637.84
Rate for Payer: Cash Price	$637.84
Rate for Payer: Cash Price	$637.84
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$675.36
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$675.36
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$469.00
Rate for Payer: Multiplan Commercial	$469.00
Rate for Payer: Multiplan Workers Comp	$469.00
Rate for Payer: Parkland Medicaid	$675.36
Rate for Payer: Scott and White EPO/PPO	$469.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$675.36
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

DECELL PLACENTAL MEMBRANE 3X4

Facility

$744.00

Service Code	HCPCS Q4205
Hospital Charge Code	145560
Hospital Revenue Code	278
Min. Negotiated Rate	$186.00
Max. Negotiated Rate	$372.00
Rate for Payer: Cash Price	$505.92
Rate for Payer: Cigna Commercial	$186.00
Rate for Payer: Multiplan Auto	$372.00
Rate for Payer: Multiplan Commercial	$372.00
Rate for Payer: Multiplan Workers Comp	$372.00
Rate for Payer: Scott and White EPO/PPO	$372.00

DECELL PLACENTAL MEMBRANE 3X4

Facility

$744.00

Service Code	HCPCS Q4205
Hospital Charge Code	145560
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$535.68
Rate for Payer: Amerigroup CHIP/Medicaid	$66.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$14.83
Rate for Payer: BCBS of TX Blue Essentials	$17.80
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$505.92
Rate for Payer: Cash Price	$505.92
Rate for Payer: Cash Price	$505.92
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$535.68
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$535.68
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$372.00
Rate for Payer: Multiplan Commercial	$372.00
Rate for Payer: Multiplan Workers Comp	$372.00
Rate for Payer: Parkland Medicaid	$535.68
Rate for Payer: Scott and White EPO/PPO	$372.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$535.68
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

DECELLULARIZED DERMIS 4X4 0.5-1MM THICK

Facility

$458.00

Service Code	HCPCS C1734
Hospital Charge Code	145561
Hospital Revenue Code	278
Min. Negotiated Rate	$114.50
Max. Negotiated Rate	$229.00
Rate for Payer: Cash Price	$311.44
Rate for Payer: Cigna Commercial	$114.50
Rate for Payer: Multiplan Auto	$229.00
Rate for Payer: Multiplan Commercial	$229.00
Rate for Payer: Multiplan Workers Comp	$229.00
Rate for Payer: Scott and White EPO/PPO	$229.00

DECELLULARIZED DERMIS 4X4 0.5-1MM THICK

Facility

$458.00

Service Code	HCPCS C1734
Hospital Charge Code	145561
Hospital Revenue Code	278
Min. Negotiated Rate	$41.22
Max. Negotiated Rate	$329.76
Rate for Payer: Amerigroup CHIP/Medicaid	$41.22
Rate for Payer: BCBS of TX Blue Advantage	$137.40
Rate for Payer: BCBS of TX Blue Essentials	$164.88
Rate for Payer: BCBS of TX PPO	$183.20
Rate for Payer: Cash Price	$311.44
Rate for Payer: Cigna Medicaid	$329.76
Rate for Payer: Molina CHIP/Medicaid	$329.76
Rate for Payer: Multiplan Auto	$229.00
Rate for Payer: Multiplan Commercial	$229.00
Rate for Payer: Multiplan Workers Comp	$229.00
Rate for Payer: Parkland Medicaid	$329.76
Rate for Payer: Scott and White EPO/PPO	$229.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$329.76
Rate for Payer: Superior Health Plan EPO	$62.29

DECELLULARIZED DERMIS 5X7 MESHED

Facility

$469.00

Service Code	HCPCS Q4152
Hospital Charge Code	146032
Hospital Revenue Code	278
Min. Negotiated Rate	$117.25
Max. Negotiated Rate	$234.50
Rate for Payer: Cash Price	$318.92
Rate for Payer: Cigna Commercial	$117.25
Rate for Payer: Multiplan Auto	$234.50
Rate for Payer: Multiplan Commercial	$234.50
Rate for Payer: Multiplan Workers Comp	$234.50
Rate for Payer: Scott and White EPO/PPO	$234.50

DECELLULARIZED DERMIS 5X7 MESHED

Facility

$469.00

Service Code	HCPCS Q4152
Hospital Charge Code	146031
Hospital Revenue Code	278
Min. Negotiated Rate	$42.21
Max. Negotiated Rate	$337.68
Rate for Payer: Amerigroup CHIP/Medicaid	$42.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$140.70
Rate for Payer: BCBS of TX Blue Essentials	$168.84
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$187.60
Rate for Payer: Cash Price	$318.92
Rate for Payer: Cash Price	$318.92
Rate for Payer: Cash Price	$318.92
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$337.68
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$337.68
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$234.50
Rate for Payer: Multiplan Commercial	$234.50
Rate for Payer: Multiplan Workers Comp	$234.50
Rate for Payer: Parkland Medicaid	$337.68
Rate for Payer: Scott and White EPO/PPO	$234.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$337.68
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

DECELLULARIZED DERMIS 5X7 MESHED

Facility

$469.00

Service Code	HCPCS Q4152
Hospital Charge Code	146032
Hospital Revenue Code	278
Min. Negotiated Rate	$42.21
Max. Negotiated Rate	$337.68
Rate for Payer: Amerigroup CHIP/Medicaid	$42.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$140.70
Rate for Payer: BCBS of TX Blue Essentials	$168.84
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$187.60
Rate for Payer: Cash Price	$318.92
Rate for Payer: Cash Price	$318.92
Rate for Payer: Cash Price	$318.92
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$337.68
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$337.68
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$234.50
Rate for Payer: Multiplan Commercial	$234.50
Rate for Payer: Multiplan Workers Comp	$234.50
Rate for Payer: Parkland Medicaid	$337.68
Rate for Payer: Scott and White EPO/PPO	$234.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$337.68
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

DECELLULARIZED DERMIS 5X7 MESHED

Facility

$469.00

Service Code	HCPCS Q4152
Hospital Charge Code	146031
Hospital Revenue Code	278
Min. Negotiated Rate	$117.25
Max. Negotiated Rate	$234.50
Rate for Payer: Cash Price	$318.92
Rate for Payer: Cigna Commercial	$117.25
Rate for Payer: Multiplan Auto	$234.50
Rate for Payer: Multiplan Commercial	$234.50
Rate for Payer: Multiplan Workers Comp	$234.50
Rate for Payer: Scott and White EPO/PPO	$234.50

Know your out-of-pocket cost for care.

All Charges