White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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 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 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	$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	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	$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 6X10 MESHED

Facility

$518.00

Service Code	HCPCS Q4152
Hospital Charge Code	146030
Hospital Revenue Code	278
Min. Negotiated Rate	$46.62
Max. Negotiated Rate	$372.96
Rate for Payer: Amerigroup CHIP/Medicaid	$46.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$155.40
Rate for Payer: BCBS of TX Blue Essentials	$186.48
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$207.20
Rate for Payer: Cash Price	$352.24
Rate for Payer: Cash Price	$352.24
Rate for Payer: Cash Price	$352.24
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$372.96
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	$372.96
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$259.00
Rate for Payer: Multiplan Commercial	$259.00
Rate for Payer: Multiplan Workers Comp	$259.00
Rate for Payer: Parkland Medicaid	$372.96
Rate for Payer: Scott and White EPO/PPO	$259.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$372.96
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 6X10 MESHED

Facility

$518.00

Service Code	HCPCS Q4152
Hospital Charge Code	146030
Hospital Revenue Code	278
Min. Negotiated Rate	$129.50
Max. Negotiated Rate	$259.00
Rate for Payer: Cash Price	$352.24
Rate for Payer: Cigna Commercial	$129.50
Rate for Payer: Multiplan Auto	$259.00
Rate for Payer: Multiplan Commercial	$259.00
Rate for Payer: Multiplan Workers Comp	$259.00
Rate for Payer: Scott and White EPO/PPO	$259.00

Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment

Facility

$12,978.44

Service Code	HCPCS 27602
Hospital Charge Code	994118
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,825.34

Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment

Facility

$12,978.44

Service Code	HCPCS 27602
Hospital Charge Code	994118
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$8,825.34
Rate for Payer: Cash Price	$8,825.34
Rate for Payer: Cash Price	$8,825.34
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$9,344.48
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$9,344.48
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$9,344.48
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,344.48
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Decompression fasciotomy, leg; anterior and/or lateral compartments only

Facility

$10,000.00

Service Code	CPT 27600
Hospital Charge Code	36027600
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Decompression fasciotomy, leg; anterior and/or lateral compartments only

Facility

$11,569.12

Service Code	HCPCS 27600
Hospital Charge Code	9900416
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,867.00

Decompression fasciotomy, leg; anterior and/or lateral compartments only

Facility

$11,569.12

Service Code	HCPCS 27600
Hospital Charge Code	9900416
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$7,867.00
Rate for Payer: Cash Price	$7,867.00
Rate for Payer: Cash Price	$7,867.00
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,329.77
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$8,329.77
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$8,329.77
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,329.77
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Decompression of tibia nerve

Facility

$10,000.00

Service Code	CPT 28035
Hospital Charge Code	36028035
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Decompression of tibia nerve

Facility

$10,526.34

Service Code	HCPCS 28035
Hospital Charge Code	9900461
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,157.91

Decompression of tibia nerve

Facility

$10,526.34

Service Code	HCPCS 28035
Hospital Charge Code	9900461
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$7,578.96
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$7,578.96
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$7,578.96
Rate for Payer: Scott and White EPO/PPO	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,578.96
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

DECTECTOR CO2 PEDI

Facility

$29.56

Hospital Charge Code	131479
Hospital Revenue Code	270
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$21.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2.66
Rate for Payer: BCBS of TX Blue Advantage	$8.87
Rate for Payer: BCBS of TX Blue Essentials	$10.64
Rate for Payer: BCBS of TX PPO	$11.82
Rate for Payer: Cash Price	$20.10
Rate for Payer: Cigna Medicaid	$21.28
Rate for Payer: Molina CHIP/Medicaid	$21.28
Rate for Payer: Multiplan Auto	$19.21
Rate for Payer: Multiplan Commercial	$19.21
Rate for Payer: Multiplan Workers Comp	$19.21
Rate for Payer: Parkland Medicaid	$21.28
Rate for Payer: Scott and White EPO/PPO	$14.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.28
Rate for Payer: Superior Health Plan EPO	$4.02

DECTECTOR CO2 PEDI

Facility

$29.56

Hospital Charge Code	131479
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.10

DEEP VEIN THROMBOPHLEBITIS W CC/MCC

Facility

$21,935.50

Service Code	MSDRG 294
Min. Negotiated Rate	$9,982.88
Max. Negotiated Rate	$21,935.50
Rate for Payer: BCBS of TX Blue Advantage	$9,982.88
Rate for Payer: BCBS of TX Blue Essentials	$11,978.30
Rate for Payer: BCBS of TX PPO	$13,309.73

DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC

Facility

$21,935.50

Service Code	MSDRG 294
Min. Negotiated Rate	$9,982.88
Max. Negotiated Rate	$21,935.50
Rate for Payer: Multiplan Auto	$21,935.50
Rate for Payer: Multiplan Commercial	$21,935.50
Rate for Payer: Multiplan Workers Comp	$21,935.50
Rate for Payer: Scott and White EPO/PPO	$10,101.88

Know your out-of-pocket cost for care.

All Charges