White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy

Facility

$46,200.00

Service Code	HCPCS 43845
Hospital Charge Code	993997
Hospital Revenue Code	360
Rate for Payer: Cash Price	$31,416.00

Gastrin, Serum SO

Facility

$167.00

Service Code	HCPCS 82941
Hospital Charge Code	1701374
Hospital Revenue Code	301
Rate for Payer: Cash Price	$113.56

Gastrin, Serum SO

Facility

$167.00

Service Code	HCPCS 82941
Hospital Charge Code	1701374
Hospital Revenue Code	301
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$120.24
Rate for Payer: Amerigroup CHIP/Medicaid	$6.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.63
Rate for Payer: Amerigroup Medicare	$17.63
Rate for Payer: BCBS of TX Blue Advantage	$50.10
Rate for Payer: BCBS of TX Blue Essentials	$60.12
Rate for Payer: BCBS of TX Medicare	$17.63
Rate for Payer: BCBS of TX PPO	$66.80
Rate for Payer: Cash Price	$113.56
Rate for Payer: Cash Price	$113.56
Rate for Payer: Cigna Medicaid	$120.24
Rate for Payer: Cigna Medicare	$17.63
Rate for Payer: Employer Direct Commercial	$17.63
Rate for Payer: Humana Medicare/TRICARE	$17.63
Rate for Payer: Molina CHIP/Medicaid	$120.24
Rate for Payer: Molina Dual Medicare/Medicaid	$17.63
Rate for Payer: Molina Medicare	$17.63
Rate for Payer: Multiplan Auto	$108.55
Rate for Payer: Multiplan Commercial	$108.55
Rate for Payer: Multiplan Workers Comp	$108.55
Rate for Payer: Parkland Medicaid	$120.24
Rate for Payer: Scott and White EPO/PPO	$22.04
Rate for Payer: Scott and White Medicare	$17.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.24
Rate for Payer: Superior Health Plan EPO	$17.63
Rate for Payer: Superior Health Plan Medicare	$17.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.63
Rate for Payer: Universal American Medicare	$17.63
Rate for Payer: Wellcare Medicare	$17.63
Rate for Payer: Wellmed Medicare	$17.63

Gastrocnemius recession (eg, Strayer procedure)

Facility

$19,812.80

Service Code	HCPCS 27687
Hospital Charge Code	9900437
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,472.70

Gastrocnemius recession (eg, Strayer procedure)

Facility

$19,812.80

Service Code	HCPCS 27687
Hospital Charge Code	9900437
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$14,265.22
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	$13,472.70
Rate for Payer: Cash Price	$13,472.70
Rate for Payer: Cash Price	$13,472.70
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$14,265.22
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	$14,265.22
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	$14,265.22
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,265.22
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

Gastrocnemius recession (eg, Strayer procedure)

Facility

$10,000.00

Service Code	CPT 27687
Hospital Charge Code	36027687
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	$6,080.78
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

GASTROINTESTINAL HEMORRHAGE WITH CC

Facility

$18,633.30

Service Code	MSDRG 378
Min. Negotiated Rate	$8,516.58
Max. Negotiated Rate	$18,633.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,947.66
Rate for Payer: Amerigroup Medicare	$11,947.66
Rate for Payer: BCBS of TX Medicare	$11,947.66
Rate for Payer: Cigna Commercial	$12,631.42
Rate for Payer: Cigna Medicare	$11,947.66
Rate for Payer: Employer Direct Commercial	$11,947.66
Rate for Payer: Humana Medicare/TRICARE	$11,947.66
Rate for Payer: Molina Dual Medicare/Medicaid	$11,947.66
Rate for Payer: Molina Medicare	$11,947.66
Rate for Payer: Multiplan Auto	$18,633.30
Rate for Payer: Multiplan Commercial	$18,633.30
Rate for Payer: Multiplan Workers Comp	$18,633.30
Rate for Payer: Scott and White EPO/PPO	$8,581.12
Rate for Payer: Scott and White Medicare	$11,947.66
Rate for Payer: Superior Health Plan EPO	$11,947.66
Rate for Payer: Superior Health Plan Medicare	$11,947.66
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,947.66
Rate for Payer: Universal American Medicare	$11,947.66
Rate for Payer: Wellcare Medicare	$11,947.66
Rate for Payer: Wellmed Medicare	$11,947.66

GASTROINTESTINAL HEMORRHAGE WITH MCC

Facility

$34,732.00

Service Code	MSDRG 377
Min. Negotiated Rate	$15,383.68
Max. Negotiated Rate	$34,732.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,157.54
Rate for Payer: Amerigroup Medicare	$18,157.54
Rate for Payer: BCBS of TX Medicare	$18,157.54
Rate for Payer: Cigna Commercial	$23,544.64
Rate for Payer: Cigna Medicare	$18,157.54
Rate for Payer: Employer Direct Commercial	$18,157.54
Rate for Payer: Humana Medicare/TRICARE	$18,157.54
Rate for Payer: Molina Dual Medicare/Medicaid	$18,157.54
Rate for Payer: Molina Medicare	$18,157.54
Rate for Payer: Multiplan Auto	$34,732.00
Rate for Payer: Multiplan Commercial	$34,732.00
Rate for Payer: Multiplan Workers Comp	$34,732.00
Rate for Payer: Scott and White EPO/PPO	$15,995.00
Rate for Payer: Scott and White Medicare	$18,157.54
Rate for Payer: Superior Health Plan EPO	$18,157.54
Rate for Payer: Superior Health Plan Medicare	$18,157.54
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,157.54
Rate for Payer: Universal American Medicare	$18,157.54
Rate for Payer: Wellcare Medicare	$18,157.54
Rate for Payer: Wellmed Medicare	$18,157.54

GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC

Facility

$11,977.60

Service Code	MSDRG 379
Min. Negotiated Rate	$5,516.00
Max. Negotiated Rate	$11,977.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,380.30
Rate for Payer: Amerigroup Medicare	$9,380.30
Rate for Payer: BCBS of TX Medicare	$9,380.30
Rate for Payer: Cigna Commercial	$8,119.55
Rate for Payer: Cigna Medicare	$9,380.30
Rate for Payer: Employer Direct Commercial	$9,380.30
Rate for Payer: Humana Medicare/TRICARE	$9,380.30
Rate for Payer: Molina Dual Medicare/Medicaid	$9,380.30
Rate for Payer: Molina Medicare	$9,380.30
Rate for Payer: Multiplan Auto	$11,977.60
Rate for Payer: Multiplan Commercial	$11,977.60
Rate for Payer: Multiplan Workers Comp	$11,977.60
Rate for Payer: Scott and White EPO/PPO	$5,516.00
Rate for Payer: Scott and White Medicare	$9,380.30
Rate for Payer: Superior Health Plan EPO	$9,380.30
Rate for Payer: Superior Health Plan Medicare	$9,380.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,380.30
Rate for Payer: Universal American Medicare	$9,380.30
Rate for Payer: Wellcare Medicare	$9,380.30
Rate for Payer: Wellmed Medicare	$9,380.30

GASTROINTESTINAL OBSTRUCTION WITH CC

Facility

$15,006.20

Service Code	MSDRG 389
Min. Negotiated Rate	$6,910.75
Max. Negotiated Rate	$15,006.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,548.55
Rate for Payer: Amerigroup Medicare	$10,548.55
Rate for Payer: BCBS of TX Medicare	$10,548.55
Rate for Payer: Cigna Commercial	$10,172.62
Rate for Payer: Cigna Medicare	$10,548.55
Rate for Payer: Employer Direct Commercial	$10,548.55
Rate for Payer: Humana Medicare/TRICARE	$10,548.55
Rate for Payer: Molina Dual Medicare/Medicaid	$10,548.55
Rate for Payer: Molina Medicare	$10,548.55
Rate for Payer: Multiplan Auto	$15,006.20
Rate for Payer: Multiplan Commercial	$15,006.20
Rate for Payer: Multiplan Workers Comp	$15,006.20
Rate for Payer: Scott and White EPO/PPO	$6,910.75
Rate for Payer: Scott and White Medicare	$10,548.55
Rate for Payer: Superior Health Plan EPO	$10,548.55
Rate for Payer: Superior Health Plan Medicare	$10,548.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,548.55
Rate for Payer: Universal American Medicare	$10,548.55
Rate for Payer: Wellcare Medicare	$10,548.55
Rate for Payer: Wellmed Medicare	$10,548.55

GASTROINTESTINAL OBSTRUCTION WITH MCC

Facility

$28,059.20

Service Code	MSDRG 388
Min. Negotiated Rate	$12,922.00
Max. Negotiated Rate	$28,059.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,583.59
Rate for Payer: Amerigroup Medicare	$15,583.59
Rate for Payer: BCBS of TX Medicare	$15,583.59
Rate for Payer: Cigna Commercial	$19,021.18
Rate for Payer: Cigna Medicare	$15,583.59
Rate for Payer: Employer Direct Commercial	$15,583.59
Rate for Payer: Humana Medicare/TRICARE	$15,583.59
Rate for Payer: Molina Dual Medicare/Medicaid	$15,583.59
Rate for Payer: Molina Medicare	$15,583.59
Rate for Payer: Multiplan Auto	$28,059.20
Rate for Payer: Multiplan Commercial	$28,059.20
Rate for Payer: Multiplan Workers Comp	$28,059.20
Rate for Payer: Scott and White EPO/PPO	$12,922.00
Rate for Payer: Scott and White Medicare	$15,583.59
Rate for Payer: Superior Health Plan EPO	$15,583.59
Rate for Payer: Superior Health Plan Medicare	$15,583.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,583.59
Rate for Payer: Universal American Medicare	$15,583.59
Rate for Payer: Wellcare Medicare	$15,583.59
Rate for Payer: Wellmed Medicare	$15,583.59

GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC

Facility

$10,336.00

Service Code	MSDRG 390
Min. Negotiated Rate	$4,760.00
Max. Negotiated Rate	$10,336.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,747.06
Rate for Payer: Amerigroup Medicare	$8,747.06
Rate for Payer: BCBS of TX Medicare	$8,747.06
Rate for Payer: Cigna Commercial	$7,006.72
Rate for Payer: Cigna Medicare	$8,747.06
Rate for Payer: Employer Direct Commercial	$8,747.06
Rate for Payer: Humana Medicare/TRICARE	$8,747.06
Rate for Payer: Molina Dual Medicare/Medicaid	$8,747.06
Rate for Payer: Molina Medicare	$8,747.06
Rate for Payer: Multiplan Auto	$10,336.00
Rate for Payer: Multiplan Commercial	$10,336.00
Rate for Payer: Multiplan Workers Comp	$10,336.00
Rate for Payer: Scott and White EPO/PPO	$4,760.00
Rate for Payer: Scott and White Medicare	$8,747.06
Rate for Payer: Superior Health Plan EPO	$8,747.06
Rate for Payer: Superior Health Plan Medicare	$8,747.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,747.06
Rate for Payer: Universal American Medicare	$8,747.06
Rate for Payer: Wellcare Medicare	$8,747.06
Rate for Payer: Wellmed Medicare	$8,747.06

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$7,312.56

Service Code	APR-DRG 2463
Min. Negotiated Rate	$6,894.54
Max. Negotiated Rate	$7,312.56
Rate for Payer: Amerigroup CHIP/Medicaid	$6,894.54
Rate for Payer: Cigna Medicaid	$6,894.54
Rate for Payer: Molina CHIP/Medicaid	$6,894.54
Rate for Payer: Parkland Medicaid	$6,894.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,312.56

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$79,257.22

Service Code	APR-DRG 2464
Min. Negotiated Rate	$74,726.48
Max. Negotiated Rate	$79,257.22
Rate for Payer: Amerigroup CHIP/Medicaid	$74,726.48
Rate for Payer: Cigna Medicaid	$74,726.48
Rate for Payer: Molina CHIP/Medicaid	$74,726.48
Rate for Payer: Parkland Medicaid	$74,726.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79,257.22

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$5,876.60

Service Code	APR-DRG 2461
Min. Negotiated Rate	$5,540.67
Max. Negotiated Rate	$5,876.60
Rate for Payer: Amerigroup CHIP/Medicaid	$5,540.67
Rate for Payer: Cigna Medicaid	$5,540.67
Rate for Payer: Molina CHIP/Medicaid	$5,540.67
Rate for Payer: Parkland Medicaid	$5,540.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,876.60

GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility

$6,594.77

Service Code	APR-DRG 2462
Min. Negotiated Rate	$6,217.78
Max. Negotiated Rate	$6,594.77
Rate for Payer: Amerigroup CHIP/Medicaid	$6,217.78
Rate for Payer: Cigna Medicaid	$6,217.78
Rate for Payer: Molina CHIP/Medicaid	$6,217.78
Rate for Payer: Parkland Medicaid	$6,217.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,594.77

Gastrojejunostomy

Facility

$14,044.40

Service Code	HCPCS 43820
Hospital Charge Code	9900691
Hospital Revenue Code	360
Min. Negotiated Rate	$1,264.00
Max. Negotiated Rate	$10,111.97
Rate for Payer: Amerigroup CHIP/Medicaid	$1,264.00
Rate for Payer: BCBS of TX Blue Advantage	$2,345.41
Rate for Payer: BCBS of TX Blue Essentials	$2,808.88
Rate for Payer: BCBS of TX PPO	$3,539.19
Rate for Payer: Cash Price	$9,550.19
Rate for Payer: Cash Price	$9,550.19
Rate for Payer: Cash Price	$9,550.19
Rate for Payer: Cigna Medicaid	$10,111.97
Rate for Payer: Molina CHIP/Medicaid	$10,111.97
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	$10,111.97
Rate for Payer: Scott and White EPO/PPO	$7,022.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,111.97
Rate for Payer: Superior Health Plan EPO	$1,910.04

Gastrojejunostomy

Facility

$10,000.00

Service Code	CPT 43820
Hospital Charge Code	36043820
Hospital Revenue Code	360
Min. Negotiated Rate	$2,345.41
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$2,345.41
Rate for Payer: BCBS of TX Blue Essentials	$2,808.88
Rate for Payer: BCBS of TX PPO	$3,539.19
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

Gastrojejunostomy

Facility

$14,044.40

Service Code	HCPCS 43820
Hospital Charge Code	9900691
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,550.19

Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury

Facility

$64,200.00

Service Code	HCPCS 43840
Hospital Charge Code	994087
Hospital Revenue Code	360
Min. Negotiated Rate	$2,373.70
Max. Negotiated Rate	$46,224.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,778.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,873.04
Rate for Payer: Amerigroup Medicare	$3,873.04
Rate for Payer: BCBS of TX Blue Advantage	$2,373.70
Rate for Payer: BCBS of TX Blue Essentials	$2,842.76
Rate for Payer: BCBS of TX Medicare	$3,873.04
Rate for Payer: BCBS of TX PPO	$3,581.88
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cigna Commercial	$8,186.91
Rate for Payer: Cigna Medicaid	$46,224.00
Rate for Payer: Cigna Medicare	$3,873.04
Rate for Payer: Employer Direct Commercial	$3,873.04
Rate for Payer: Humana Medicare/TRICARE	$3,873.04
Rate for Payer: Molina CHIP/Medicaid	$46,224.00
Rate for Payer: Molina Dual Medicare/Medicaid	$3,873.04
Rate for Payer: Molina Medicare	$3,873.04
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	$46,224.00
Rate for Payer: Scott and White EPO/PPO	$7,165.12
Rate for Payer: Scott and White Medicare	$3,873.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,224.00
Rate for Payer: Superior Health Plan EPO	$3,873.04
Rate for Payer: Superior Health Plan Medicare	$3,873.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,873.04
Rate for Payer: Universal American Medicare	$3,873.04
Rate for Payer: Wellcare Medicare	$3,873.04
Rate for Payer: Wellmed Medicare	$3,873.04

Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury

Facility

$64,200.00

Service Code	HCPCS 43840
Hospital Charge Code	994087
Hospital Revenue Code	360
Rate for Payer: Cash Price	$43,656.00

GAUZE, NW, DELUXE, 2'X2', 4PLY, NS, LF

Facility

$0.05

Hospital Charge Code	992962
Hospital Revenue Code	270
Max. Negotiated Rate	$0.04
Rate for Payer: Amerigroup CHIP/Medicaid	$0.00
Rate for Payer: BCBS of TX Blue Advantage	$0.02
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna Medicaid	$0.04
Rate for Payer: Molina CHIP/Medicaid	$0.04
Rate for Payer: Multiplan Auto	$0.03
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: Multiplan Workers Comp	$0.03
Rate for Payer: Parkland Medicaid	$0.04
Rate for Payer: Scott and White EPO/PPO	$0.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.04
Rate for Payer: Superior Health Plan EPO	$0.01

GAUZE, NW, DELUXE, 2'X2', 4PLY, NS, LF

Facility

$0.05

Hospital Charge Code	992962
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.03

GAUZE, PACKING IODOFORM 1/2'X 5YD STERILE -- DHF

Facility

$247.86

Hospital Charge Code	80247307
Hospital Revenue Code	270
Min. Negotiated Rate	$22.31
Max. Negotiated Rate	$178.46
Rate for Payer: Amerigroup CHIP/Medicaid	$22.31
Rate for Payer: BCBS of TX Blue Advantage	$74.36
Rate for Payer: BCBS of TX Blue Essentials	$89.23
Rate for Payer: BCBS of TX PPO	$99.14
Rate for Payer: Cash Price	$168.54
Rate for Payer: Cigna Medicaid	$178.46
Rate for Payer: Molina CHIP/Medicaid	$178.46
Rate for Payer: Multiplan Auto	$161.11
Rate for Payer: Multiplan Commercial	$161.11
Rate for Payer: Multiplan Workers Comp	$161.11
Rate for Payer: Parkland Medicaid	$178.46
Rate for Payer: Scott and White EPO/PPO	$123.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$178.46
Rate for Payer: Superior Health Plan EPO	$33.71

GAUZE, PACKING IODOFORM 1/2'X 5YD STERILE -- DHF

Facility

$247.86

Hospital Charge Code	80247307
Hospital Revenue Code	270
Rate for Payer: Cash Price	$168.54

Know your out-of-pocket cost for care.

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