White Rock Medical Center

All Charges

Charge

Type

Setting

Price

AORTOGRAPHY ABD SERIALOGRAPHY

Facility

$4,645.00

Service Code	CPT 75625
Hospital Charge Code	2302644
Hospital Revenue Code	320
Min. Negotiated Rate	$52.13
Max. Negotiated Rate	$6,603.56
Rate for Payer: Aetna Commercial	$69.93
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$126.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Amerigroup Medicare	$2,915.10
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX Medicare	$2,915.10
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$4,087.60
Rate for Payer: Cash Price	$4,087.60
Rate for Payer: Cash Price	$4,087.60
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$126.30
Rate for Payer: Cigna Medicare	$2,915.10
Rate for Payer: Employer Direct Commercial	$2,915.10
Rate for Payer: Humana Medicare/TRICARE	$2,915.10
Rate for Payer: Molina CHIP/Medicaid	$126.30
Rate for Payer: Molina Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Molina Medicare	$2,915.10
Rate for Payer: Multiplan Auto	$3,019.25
Rate for Payer: Multiplan Commercial	$3,019.25
Rate for Payer: Multiplan Workers Comp	$3,019.25
Rate for Payer: Parkland Medicaid	$126.30
Rate for Payer: Scott and White EPO/PPO	$52.13
Rate for Payer: Scott and White Medicare	$2,915.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.30
Rate for Payer: Superior Health Plan EPO	$2,915.10
Rate for Payer: Superior Health Plan Medicare	$2,915.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Universal American Medicare	$2,915.10
Rate for Payer: Wellcare Medicare	$2,915.10
Rate for Payer: Wellmed Medicare	$2,915.10

AORTOGRAPHY ABD SERIALOGRAPHY

Facility

$4,645.00

Service Code	CPT 75625
Hospital Charge Code	2302644
Hospital Revenue Code	320
Rate for Payer: Cash Price	$4,087.60

AORTOGRAPHY THORACIC

Facility

$4,382.00

Service Code	CPT 75605
Hospital Charge Code	2320273
Hospital Revenue Code	320
Rate for Payer: Cash Price	$3,856.16

AORTOGRAPHY THORACIC

Facility

$4,382.00

Service Code	CPT 75605
Hospital Charge Code	2320273
Hospital Revenue Code	320
Min. Negotiated Rate	$78.22
Max. Negotiated Rate	$11,384.78
Rate for Payer: Aetna Commercial	$78.22
Rate for Payer: Aetna Medicare	$7,538.62
Rate for Payer: Amerigroup CHIP/Medicaid	$120.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,025.75
Rate for Payer: Amerigroup Medicare	$5,025.75
Rate for Payer: BCBS of TX Blue Advantage	$7,583.71
Rate for Payer: BCBS of TX Blue Essentials	$9,100.46
Rate for Payer: BCBS of TX Medicare	$5,025.75
Rate for Payer: BCBS of TX PPO	$10,157.58
Rate for Payer: Cash Price	$3,856.16
Rate for Payer: Cash Price	$3,856.16
Rate for Payer: Cash Price	$3,856.16
Rate for Payer: Cigna Commercial	$11,384.78
Rate for Payer: Cigna Medicaid	$120.63
Rate for Payer: Cigna Medicare	$5,025.75
Rate for Payer: Employer Direct Commercial	$5,025.75
Rate for Payer: Humana Medicare/TRICARE	$5,025.75
Rate for Payer: Molina CHIP/Medicaid	$120.63
Rate for Payer: Molina Dual Medicare/Medicaid	$5,025.75
Rate for Payer: Molina Medicare	$5,025.75
Rate for Payer: Multiplan Auto	$2,848.30
Rate for Payer: Multiplan Commercial	$2,848.30
Rate for Payer: Multiplan Workers Comp	$2,848.30
Rate for Payer: Parkland Medicaid	$120.63
Rate for Payer: Scott and White EPO/PPO	$89.88
Rate for Payer: Scott and White Medicare	$5,025.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.63
Rate for Payer: Superior Health Plan EPO	$5,025.75
Rate for Payer: Superior Health Plan Medicare	$5,025.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,025.75
Rate for Payer: Universal American Medicare	$5,025.75
Rate for Payer: Wellcare Medicare	$5,025.75
Rate for Payer: Wellmed Medicare	$5,025.75

apixaban 2.5 mg Tab

Facility

$31.85

Service Code	HCPCS J3490
Hospital Charge Code	77380440
Hospital Revenue Code	636
Min. Negotiated Rate	$2.87
Max. Negotiated Rate	$20.70
Rate for Payer: Amerigroup CHIP/Medicaid	$2.87
Rate for Payer: BCBS of TX Blue Advantage	$9.56
Rate for Payer: BCBS of TX Blue Essentials	$11.47
Rate for Payer: BCBS of TX PPO	$12.74
Rate for Payer: Cash Price	$21.66
Rate for Payer: Multiplan Auto	$20.70
Rate for Payer: Multiplan Commercial	$20.70
Rate for Payer: Multiplan Workers Comp	$20.70
Rate for Payer: Scott and White EPO/PPO	$15.92
Rate for Payer: Superior Health Plan EPO	$4.33

apixaban 2.5 mg Tab

Facility

$31.85

Service Code	HCPCS J3490
Hospital Charge Code	77380440
Hospital Revenue Code	636
Min. Negotiated Rate	$7.96
Max. Negotiated Rate	$15.92
Rate for Payer: Cash Price	$21.66
Rate for Payer: Cigna Commercial	$7.96
Rate for Payer: Scott and White EPO/PPO	$15.92

apixaban 5 mg Tab

Facility

$31.85

Service Code	HCPCS J3490
Hospital Charge Code	77380489
Hospital Revenue Code	636
Min. Negotiated Rate	$2.87
Max. Negotiated Rate	$20.70
Rate for Payer: Amerigroup CHIP/Medicaid	$2.87
Rate for Payer: BCBS of TX Blue Advantage	$9.56
Rate for Payer: BCBS of TX Blue Essentials	$11.47
Rate for Payer: BCBS of TX PPO	$12.74
Rate for Payer: Cash Price	$21.66
Rate for Payer: Multiplan Auto	$20.70
Rate for Payer: Multiplan Commercial	$20.70
Rate for Payer: Multiplan Workers Comp	$20.70
Rate for Payer: Scott and White EPO/PPO	$15.92
Rate for Payer: Superior Health Plan EPO	$4.33

apixaban 5 mg Tab

Facility

$31.85

Service Code	HCPCS J3490
Hospital Charge Code	77380489
Hospital Revenue Code	636
Min. Negotiated Rate	$7.96
Max. Negotiated Rate	$15.92
Rate for Payer: Cash Price	$21.66
Rate for Payer: Cigna Commercial	$7.96
Rate for Payer: Scott and White EPO/PPO	$15.92

APLIGRAF PER SQ CM

Facility

$271.58

Service Code	HCPCS Q4101
Hospital Charge Code	82404518
Hospital Revenue Code	278
Min. Negotiated Rate	$24.44
Max. Negotiated Rate	$135.79
Rate for Payer: Aetna Commercial	$81.47
Rate for Payer: Amerigroup CHIP/Medicaid	$24.44
Rate for Payer: BCBS of TX Blue Advantage	$81.47
Rate for Payer: BCBS of TX Blue Essentials	$97.77
Rate for Payer: BCBS of TX PPO	$108.63
Rate for Payer: Cash Price	$238.99
Rate for Payer: Multiplan Auto	$135.79
Rate for Payer: Multiplan Commercial	$135.79
Rate for Payer: Multiplan Workers Comp	$135.79
Rate for Payer: Scott and White EPO/PPO	$135.79
Rate for Payer: Superior Health Plan EPO	$36.93

APLIGRAF PER SQ CM

Facility

$271.58

Service Code	HCPCS Q4101
Hospital Charge Code	82404518
Hospital Revenue Code	278
Min. Negotiated Rate	$67.90
Max. Negotiated Rate	$135.79
Rate for Payer: Aetna Commercial	$81.47
Rate for Payer: Cash Price	$238.99
Rate for Payer: Cigna Commercial	$67.90
Rate for Payer: Multiplan Auto	$135.79
Rate for Payer: Multiplan Commercial	$135.79
Rate for Payer: Multiplan Workers Comp	$135.79
Rate for Payer: Scott and White EPO/PPO	$135.79

APOLIPOPROTEIN EACH

Facility

$106.00

Service Code	CPT 82172
Hospital Charge Code	1601418
Hospital Revenue Code	301
Rate for Payer: Cash Price	$93.28

APOLIPOPROTEIN EACH

Facility

$106.00

Service Code	CPT 82172
Hospital Charge Code	1601418
Hospital Revenue Code	301
Min. Negotiated Rate	$8.23
Max. Negotiated Rate	$68.90
Rate for Payer: Aetna Commercial	$22.14
Rate for Payer: Aetna Medicare	$31.64
Rate for Payer: Amerigroup CHIP/Medicaid	$8.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.09
Rate for Payer: Amerigroup Medicare	$21.09
Rate for Payer: BCBS of TX Blue Advantage	$34.80
Rate for Payer: BCBS of TX Blue Essentials	$41.76
Rate for Payer: BCBS of TX Medicare	$21.09
Rate for Payer: BCBS of TX PPO	$46.61
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cigna Medicaid	$21.09
Rate for Payer: Cigna Medicare	$21.09
Rate for Payer: Employer Direct Commercial	$21.09
Rate for Payer: Humana Medicare/TRICARE	$21.09
Rate for Payer: Molina CHIP/Medicaid	$21.09
Rate for Payer: Molina Dual Medicare/Medicaid	$21.09
Rate for Payer: Molina Medicare	$21.09
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$21.09
Rate for Payer: Scott and White EPO/PPO	$26.36
Rate for Payer: Scott and White Medicare	$21.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.09
Rate for Payer: Superior Health Plan EPO	$21.09
Rate for Payer: Superior Health Plan Medicare	$21.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.09
Rate for Payer: Universal American Medicare	$21.09
Rate for Payer: Wellcare Medicare	$21.09
Rate for Payer: Wellmed Medicare	$21.09

APPENDIX PROCEDURES WITH CC

Facility

$28,752.70

Service Code	MSDRG 398
Min. Negotiated Rate	$13,241.38
Max. Negotiated Rate	$28,752.70
Rate for Payer: Aetna Commercial	$17,024.62
Rate for Payer: Aetna Medicare	$20,480.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,653.78
Rate for Payer: Amerigroup Medicare	$13,653.78
Rate for Payer: BCBS of TX Medicare	$13,653.78
Rate for Payer: Cigna Commercial	$19,491.30
Rate for Payer: Cigna Medicare	$13,653.78
Rate for Payer: Employer Direct Commercial	$13,653.78
Rate for Payer: Humana Medicare/TRICARE	$13,653.78
Rate for Payer: Molina Dual Medicare/Medicaid	$13,653.78
Rate for Payer: Molina Medicare	$13,653.78
Rate for Payer: Multiplan Auto	$28,752.70
Rate for Payer: Multiplan Commercial	$28,752.70
Rate for Payer: Multiplan Workers Comp	$28,752.70
Rate for Payer: Scott and White EPO/PPO	$13,241.38
Rate for Payer: Scott and White Medicare	$13,653.78
Rate for Payer: Superior Health Plan EPO	$13,653.78
Rate for Payer: Superior Health Plan Medicare	$13,653.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,653.78
Rate for Payer: Universal American Medicare	$13,653.78
Rate for Payer: Wellcare Medicare	$13,653.78
Rate for Payer: Wellmed Medicare	$13,653.78

APPENDIX PROCEDURES WITH MCC

Facility

$42,685.40

Service Code	MSDRG 397
Min. Negotiated Rate	$18,886.65
Max. Negotiated Rate	$42,685.40
Rate for Payer: Aetna Commercial	$25,274.25
Rate for Payer: Aetna Medicare	$28,329.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,886.65
Rate for Payer: Amerigroup Medicare	$18,886.65
Rate for Payer: BCBS of TX Medicare	$18,886.65
Rate for Payer: Cigna Commercial	$28,936.21
Rate for Payer: Cigna Medicare	$18,886.65
Rate for Payer: Employer Direct Commercial	$18,886.65
Rate for Payer: Humana Medicare/TRICARE	$18,886.65
Rate for Payer: Molina Dual Medicare/Medicaid	$18,886.65
Rate for Payer: Molina Medicare	$18,886.65
Rate for Payer: Multiplan Auto	$42,685.40
Rate for Payer: Multiplan Commercial	$42,685.40
Rate for Payer: Multiplan Workers Comp	$42,685.40
Rate for Payer: Scott and White EPO/PPO	$19,657.75
Rate for Payer: Scott and White Medicare	$18,886.65
Rate for Payer: Superior Health Plan EPO	$18,886.65
Rate for Payer: Superior Health Plan Medicare	$18,886.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,886.65
Rate for Payer: Universal American Medicare	$18,886.65
Rate for Payer: Wellcare Medicare	$18,886.65
Rate for Payer: Wellmed Medicare	$18,886.65

APPENDIX PROCEDURES WITHOUT CC/MCC

Facility

$21,148.90

Service Code	MSDRG 399
Min. Negotiated Rate	$9,739.62
Max. Negotiated Rate	$21,148.90
Rate for Payer: Aetna Commercial	$12,522.38
Rate for Payer: Aetna Medicare	$16,196.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,797.92
Rate for Payer: Amerigroup Medicare	$10,797.92
Rate for Payer: BCBS of TX Medicare	$10,797.92
Rate for Payer: Cigna Commercial	$14,336.73
Rate for Payer: Cigna Medicare	$10,797.92
Rate for Payer: Employer Direct Commercial	$10,797.92
Rate for Payer: Humana Medicare/TRICARE	$10,797.92
Rate for Payer: Molina Dual Medicare/Medicaid	$10,797.92
Rate for Payer: Molina Medicare	$10,797.92
Rate for Payer: Multiplan Auto	$21,148.90
Rate for Payer: Multiplan Commercial	$21,148.90
Rate for Payer: Multiplan Workers Comp	$21,148.90
Rate for Payer: Scott and White EPO/PPO	$9,739.62
Rate for Payer: Scott and White Medicare	$10,797.92
Rate for Payer: Superior Health Plan EPO	$10,797.92
Rate for Payer: Superior Health Plan Medicare	$10,797.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,797.92
Rate for Payer: Universal American Medicare	$10,797.92
Rate for Payer: Wellcare Medicare	$10,797.92
Rate for Payer: Wellmed Medicare	$10,797.92

Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation syst

Facility

$29,989.79

Service Code	CPT 20692
Hospital Charge Code	36020692
Hospital Revenue Code	360
Min. Negotiated Rate	$265.49
Max. Negotiated Rate	$29,989.79
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$18,054.70
Rate for Payer: Amerigroup CHIP/Medicaid	$7,448.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,036.47
Rate for Payer: Amerigroup Medicare	$12,036.47
Rate for Payer: BCBS of TX Blue Advantage	$19,874.19
Rate for Payer: BCBS of TX Blue Essentials	$23,801.42
Rate for Payer: BCBS of TX Medicare	$12,036.47
Rate for Payer: BCBS of TX PPO	$29,989.79
Rate for Payer: Cigna Commercial	$27,266.10
Rate for Payer: Cigna Medicaid	$7,448.53
Rate for Payer: Cigna Medicare	$12,036.47
Rate for Payer: Employer Direct Commercial	$12,036.47
Rate for Payer: Humana Medicare/TRICARE	$12,036.47
Rate for Payer: Molina CHIP/Medicaid	$7,448.53
Rate for Payer: Molina Dual Medicare/Medicaid	$12,036.47
Rate for Payer: Molina Medicare	$12,036.47
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	$7,448.53
Rate for Payer: Scott and White EPO/PPO	$265.49
Rate for Payer: Scott and White Medicare	$12,036.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,448.53
Rate for Payer: Superior Health Plan EPO	$12,036.47
Rate for Payer: Superior Health Plan Medicare	$12,036.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,036.47
Rate for Payer: Universal American Medicare	$12,036.47
Rate for Payer: Wellcare Medicare	$12,036.47
Rate for Payer: Wellmed Medicare	$12,036.47

Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system

Facility

$15,074.51

Service Code	CPT 20690
Hospital Charge Code	36020690
Hospital Revenue Code	360
Min. Negotiated Rate	$144.31
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3,422.19
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	$3,422.19
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	$3,422.19
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	$3,422.19
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	$3,422.19
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

Application of short arm splint (forearm to hand) static

Facility

$10,000.00

Service Code	CPT 29125
Hospital Charge Code	36029125
Hospital Revenue Code	360
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$175.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$116.82
Rate for Payer: Amerigroup Medicare	$116.82
Rate for Payer: BCBS of TX Blue Advantage	$182.08
Rate for Payer: BCBS of TX Blue Essentials	$218.06
Rate for Payer: BCBS of TX Medicare	$116.82
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cigna Commercial	$264.63
Rate for Payer: Cigna Medicare	$116.82
Rate for Payer: Employer Direct Commercial	$116.82
Rate for Payer: Humana Medicare/TRICARE	$116.82
Rate for Payer: Molina Dual Medicare/Medicaid	$116.82
Rate for Payer: Molina Medicare	$116.82
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	$2.58
Rate for Payer: Scott and White Medicare	$116.82
Rate for Payer: Superior Health Plan EPO	$116.82
Rate for Payer: Superior Health Plan Medicare	$116.82
Rate for Payer: Universal American Dual Medicare/Medicaid	$116.82
Rate for Payer: Universal American Medicare	$116.82
Rate for Payer: Wellcare Medicare	$116.82
Rate for Payer: Wellmed Medicare	$116.82

Application of short leg splint (calf to foot)

Facility

$10,000.00

Service Code	CPT 29515
Hospital Charge Code	36029515
Hospital Revenue Code	360
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$216.15
Rate for Payer: Amerigroup CHIP/Medicaid	$34.33
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$144.10
Rate for Payer: Amerigroup Medicare	$144.10
Rate for Payer: BCBS of TX Blue Advantage	$70.51
Rate for Payer: BCBS of TX Blue Essentials	$84.44
Rate for Payer: BCBS of TX Medicare	$144.10
Rate for Payer: BCBS of TX PPO	$106.39
Rate for Payer: Cigna Commercial	$326.44
Rate for Payer: Cigna Medicaid	$34.33
Rate for Payer: Cigna Medicare	$144.10
Rate for Payer: Employer Direct Commercial	$144.10
Rate for Payer: Humana Medicare/TRICARE	$144.10
Rate for Payer: Molina CHIP/Medicaid	$34.33
Rate for Payer: Molina Dual Medicare/Medicaid	$144.10
Rate for Payer: Molina Medicare	$144.10
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	$34.33
Rate for Payer: Scott and White EPO/PPO	$3.18
Rate for Payer: Scott and White Medicare	$144.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.33
Rate for Payer: Superior Health Plan EPO	$144.10
Rate for Payer: Superior Health Plan Medicare	$144.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$144.10
Rate for Payer: Universal American Medicare	$144.10
Rate for Payer: Wellcare Medicare	$144.10
Rate for Payer: Wellmed Medicare	$144.10

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,

Facility

$10,000.00

Service Code	CPT 15275
Hospital Charge Code	36015275
Hospital Revenue Code	360
Min. Negotiated Rate	$36.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,501.68
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Amerigroup Medicare	$1,667.79
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$1,667.79
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$3,778.02
Rate for Payer: Cigna Medicaid	$709.01
Rate for Payer: Cigna Medicare	$1,667.79
Rate for Payer: Employer Direct Commercial	$1,667.79
Rate for Payer: Humana Medicare/TRICARE	$1,667.79
Rate for Payer: Molina CHIP/Medicaid	$709.01
Rate for Payer: Molina Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Molina Medicare	$1,667.79
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	$709.01
Rate for Payer: Scott and White EPO/PPO	$36.79
Rate for Payer: Scott and White Medicare	$1,667.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$709.01
Rate for Payer: Superior Health Plan EPO	$1,667.79
Rate for Payer: Superior Health Plan Medicare	$1,667.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Universal American Medicare	$1,667.79
Rate for Payer: Wellcare Medicare	$1,667.79
Rate for Payer: Wellmed Medicare	$1,667.79

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,

Facility

$10,000.00

Service Code	CPT 15276
Hospital Charge Code	36015276
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
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

Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm

Facility

$10,000.00

Service Code	CPT 15271
Hospital Charge Code	36015271
Hospital Revenue Code	360
Min. Negotiated Rate	$36.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,501.68
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Amerigroup Medicare	$1,667.79
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$1,667.79
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$3,778.02
Rate for Payer: Cigna Medicaid	$709.01
Rate for Payer: Cigna Medicare	$1,667.79
Rate for Payer: Employer Direct Commercial	$1,667.79
Rate for Payer: Humana Medicare/TRICARE	$1,667.79
Rate for Payer: Molina CHIP/Medicaid	$709.01
Rate for Payer: Molina Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Molina Medicare	$1,667.79
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	$709.01
Rate for Payer: Scott and White EPO/PPO	$36.79
Rate for Payer: Scott and White Medicare	$1,667.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$709.01
Rate for Payer: Superior Health Plan EPO	$1,667.79
Rate for Payer: Superior Health Plan Medicare	$1,667.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Universal American Medicare	$1,667.79
Rate for Payer: Wellcare Medicare	$1,667.79
Rate for Payer: Wellmed Medicare	$1,667.79

APPLICATOR,EVICEL LAP AIRLESS SPRAY ACCESSORY -- DHF

Facility

$284.38

Hospital Charge Code	80385024
Hospital Revenue Code	272
Min. Negotiated Rate	$25.59
Max. Negotiated Rate	$184.85
Rate for Payer: Aetna Commercial	$156.41
Rate for Payer: Amerigroup CHIP/Medicaid	$25.59
Rate for Payer: BCBS of TX Blue Advantage	$85.31
Rate for Payer: BCBS of TX Blue Essentials	$102.38
Rate for Payer: BCBS of TX PPO	$113.75
Rate for Payer: Cash Price	$250.25
Rate for Payer: Multiplan Auto	$184.85
Rate for Payer: Multiplan Commercial	$184.85
Rate for Payer: Multiplan Workers Comp	$184.85
Rate for Payer: Scott and White EPO/PPO	$142.19
Rate for Payer: Superior Health Plan EPO	$38.68

APPLIER, CLIP ENDO MULTIPLE TITANIUM 11.5" 20 MED

Facility

$376.32

Hospital Charge Code	81941056
Hospital Revenue Code	272
Min. Negotiated Rate	$33.87
Max. Negotiated Rate	$244.61
Rate for Payer: Aetna Commercial	$206.98
Rate for Payer: Amerigroup CHIP/Medicaid	$33.87
Rate for Payer: BCBS of TX Blue Advantage	$112.90
Rate for Payer: BCBS of TX Blue Essentials	$135.48
Rate for Payer: BCBS of TX PPO	$150.53
Rate for Payer: Cash Price	$331.16
Rate for Payer: Multiplan Auto	$244.61
Rate for Payer: Multiplan Commercial	$244.61
Rate for Payer: Multiplan Workers Comp	$244.61
Rate for Payer: Scott and White EPO/PPO	$188.16
Rate for Payer: Superior Health Plan EPO	$51.18

APPLIER, CLIP ENDO MULTIPLE TITANIUM 9 3/8" 20 MED

Facility

$376.32

Hospital Charge Code	81941056
Hospital Revenue Code	272
Min. Negotiated Rate	$33.87
Max. Negotiated Rate	$244.61
Rate for Payer: Aetna Commercial	$206.98
Rate for Payer: Amerigroup CHIP/Medicaid	$33.87
Rate for Payer: BCBS of TX Blue Advantage	$112.90
Rate for Payer: BCBS of TX Blue Essentials	$135.48
Rate for Payer: BCBS of TX PPO	$150.53
Rate for Payer: Cash Price	$331.16
Rate for Payer: Multiplan Auto	$244.61
Rate for Payer: Multiplan Commercial	$244.61
Rate for Payer: Multiplan Workers Comp	$244.61
Rate for Payer: Scott and White EPO/PPO	$188.16
Rate for Payer: Superior Health Plan EPO	$51.18

Know your out-of-pocket cost for care.

All Charges