White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OPWC Bone Biopsy Needle/Trocar, Superficial BCE

Facility

$2,714.00

Service Code	CPT 20220
Hospital Charge Code	8912542
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,388.32

OPWC Chemical Cauterization of Wound BCE

Facility

$410.00

Service Code	CPT 17250
Hospital Charge Code	8910543
Hospital Revenue Code	761
Rate for Payer: Cash Price	$360.80

OPWC Chemical Cauterization of Wound BCE

Facility

$410.00

Service Code	CPT 17250
Hospital Charge Code	8910543
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$225.50
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$36.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$360.80
Rate for Payer: Cash Price	$360.80
Rate for Payer: Cash Price	$360.80
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$266.50
Rate for Payer: Multiplan Commercial	$266.50
Rate for Payer: Multiplan Workers Comp	$266.50
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

OPWC Counsel Smoking Cessatn 3-10Min BCE

Facility

$53.00

Service Code	CPT 99406
Hospital Charge Code	8910544
Hospital Revenue Code	510
Rate for Payer: Cash Price	$46.64

OPWC Counsel Smoking Cessatn 3-10Min BCE

Facility

$53.00

Service Code	CPT 99406
Hospital Charge Code	8910544
Hospital Revenue Code	510
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$59.45
Rate for Payer: Aetna Commercial	$29.15
Rate for Payer: Aetna Medicare	$39.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.24
Rate for Payer: Amerigroup Medicare	$26.24
Rate for Payer: BCBS of TX Blue Advantage	$21.94
Rate for Payer: BCBS of TX Blue Essentials	$26.23
Rate for Payer: BCBS of TX Medicare	$26.24
Rate for Payer: BCBS of TX PPO	$29.26
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cigna Commercial	$59.45
Rate for Payer: Cigna Medicaid	$10.29
Rate for Payer: Cigna Medicare	$26.24
Rate for Payer: Employer Direct Commercial	$26.24
Rate for Payer: Humana Medicare/TRICARE	$26.24
Rate for Payer: Molina CHIP/Medicaid	$10.29
Rate for Payer: Molina Dual Medicare/Medicaid	$26.24
Rate for Payer: Molina Medicare	$26.24
Rate for Payer: Multiplan Auto	$34.45
Rate for Payer: Multiplan Commercial	$34.45
Rate for Payer: Multiplan Workers Comp	$34.45
Rate for Payer: Parkland Medicaid	$10.29
Rate for Payer: Scott and White EPO/PPO	$0.47
Rate for Payer: Scott and White Medicare	$26.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.29
Rate for Payer: Superior Health Plan EPO	$26.24
Rate for Payer: Superior Health Plan Medicare	$26.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.24
Rate for Payer: Universal American Medicare	$26.24
Rate for Payer: Wellcare Medicare	$26.24
Rate for Payer: Wellmed Medicare	$26.24

OPWC Debrid Bone <=20 BCE

Facility

$5,698.00

Service Code	CPT 11044
Hospital Charge Code	8912543
Hospital Revenue Code	761
Rate for Payer: Cash Price	$5,014.24

OPWC Debrid Bone <=20 BCE

Facility

$5,698.00

Service Code	CPT 11044
Hospital Charge Code	8912543
Hospital Revenue Code	761
Min. Negotiated Rate	$26.52
Max. Negotiated Rate	$3,703.70
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$512.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
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	$1,482.74
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$5,014.24
Rate for Payer: Cash Price	$5,014.24
Rate for Payer: Cash Price	$5,014.24
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$486.45
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$486.45
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
Rate for Payer: Multiplan Auto	$3,703.70
Rate for Payer: Multiplan Commercial	$3,703.70
Rate for Payer: Multiplan Workers Comp	$3,703.70
Rate for Payer: Parkland Medicaid	$486.45
Rate for Payer: Scott and White EPO/PPO	$26.52
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$486.45
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

OPWC Debrid Bone Ad 20 Sqcm BCE

Facility

$4,412.00

Service Code	CPT 11047
Hospital Charge Code	8912544
Hospital Revenue Code	761
Rate for Payer: Cash Price	$3,882.56

OPWC Debrid Bone Ad 20 Sqcm BCE

Facility

$4,412.00

Service Code	CPT 11047
Hospital Charge Code	8912544
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$2,867.80
Rate for Payer: Aetna Commercial	$2,426.60
Rate for Payer: Amerigroup CHIP/Medicaid	$397.08
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$3,882.56
Rate for Payer: Cash Price	$3,882.56
Rate for Payer: Multiplan Auto	$2,867.80
Rate for Payer: Multiplan Commercial	$2,867.80
Rate for Payer: Multiplan Workers Comp	$2,867.80
Rate for Payer: Scott and White EPO/PPO	$2,206.00
Rate for Payer: Superior Health Plan EPO	$600.03

OPWC Debrid Mus/Fsc Ad 20 Sqcm BCE

Facility

$2,026.00

Service Code	CPT 11046
Hospital Charge Code	8914540
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,782.88

OPWC Debrid Mus/Fsc Ad 20 Sqcm BCE

Facility

$2,026.00

Service Code	CPT 11046
Hospital Charge Code	8914540
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$1,316.90
Rate for Payer: Aetna Commercial	$1,114.30
Rate for Payer: Amerigroup CHIP/Medicaid	$182.34
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$1,782.88
Rate for Payer: Cash Price	$1,782.88
Rate for Payer: Multiplan Auto	$1,316.90
Rate for Payer: Multiplan Commercial	$1,316.90
Rate for Payer: Multiplan Workers Comp	$1,316.90
Rate for Payer: Scott and White EPO/PPO	$1,013.00
Rate for Payer: Superior Health Plan EPO	$275.54

OPWC Debrid Mus/Fsc Tiss <=20 BCE

Facility

$2,376.00

Service Code	CPT 11043
Hospital Charge Code	8910546
Hospital Revenue Code	761
Rate for Payer: Cash Price	$2,090.88

OPWC Debrid Mus/Fsc Tiss <=20 BCE

Facility

$2,376.00

Service Code	CPT 11043
Hospital Charge Code	8910546
Hospital Revenue Code	761
Min. Negotiated Rate	$10.27
Max. Negotiated Rate	$1,544.40
Rate for Payer: Aetna Commercial	$1,306.80
Rate for Payer: Aetna Medicare	$861.57
Rate for Payer: Amerigroup CHIP/Medicaid	$213.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$574.38
Rate for Payer: Amerigroup Medicare	$574.38
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	$574.38
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,090.88
Rate for Payer: Cash Price	$2,090.88
Rate for Payer: Cash Price	$2,090.88
Rate for Payer: Cigna Commercial	$1,301.14
Rate for Payer: Cigna Medicaid	$216.80
Rate for Payer: Cigna Medicare	$574.38
Rate for Payer: Employer Direct Commercial	$574.38
Rate for Payer: Humana Medicare/TRICARE	$574.38
Rate for Payer: Molina CHIP/Medicaid	$216.80
Rate for Payer: Molina Dual Medicare/Medicaid	$574.38
Rate for Payer: Molina Medicare	$574.38
Rate for Payer: Multiplan Auto	$1,544.40
Rate for Payer: Multiplan Commercial	$1,544.40
Rate for Payer: Multiplan Workers Comp	$1,544.40
Rate for Payer: Parkland Medicaid	$216.80
Rate for Payer: Scott and White EPO/PPO	$10.27
Rate for Payer: Scott and White Medicare	$574.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.80
Rate for Payer: Superior Health Plan EPO	$574.38
Rate for Payer: Superior Health Plan Medicare	$574.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$574.38
Rate for Payer: Universal American Medicare	$574.38
Rate for Payer: Wellcare Medicare	$574.38
Rate for Payer: Wellmed Medicare	$574.38

OPWC Debrid Skin/Sq Tiss <=20 BCE

Facility

$1,546.00

Service Code	CPT 11042
Hospital Charge Code	8914541
Hospital Revenue Code	761
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$1,004.90
Rate for Payer: Aetna Commercial	$850.30
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$139.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
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	$364.67
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,360.48
Rate for Payer: Cash Price	$1,360.48
Rate for Payer: Cash Price	$1,360.48
Rate for Payer: Cigna Commercial	$826.08
Rate for Payer: Cigna Medicaid	$143.08
Rate for Payer: Cigna Medicare	$364.67
Rate for Payer: Employer Direct Commercial	$364.67
Rate for Payer: Humana Medicare/TRICARE	$364.67
Rate for Payer: Molina CHIP/Medicaid	$143.08
Rate for Payer: Molina Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$1,004.90
Rate for Payer: Multiplan Commercial	$1,004.90
Rate for Payer: Multiplan Workers Comp	$1,004.90
Rate for Payer: Parkland Medicaid	$143.08
Rate for Payer: Scott and White EPO/PPO	$6.52
Rate for Payer: Scott and White Medicare	$364.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.08
Rate for Payer: Superior Health Plan EPO	$364.67
Rate for Payer: Superior Health Plan Medicare	$364.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.67
Rate for Payer: Universal American Medicare	$364.67
Rate for Payer: Wellcare Medicare	$364.67
Rate for Payer: Wellmed Medicare	$364.67

OPWC Debrid Skin/Sq Tiss <=20 BCE

Facility

$1,546.00

Service Code	CPT 11042
Hospital Charge Code	8914541
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,360.48

OPWC Debrid Sq Tiss Ad 20 Sqcm BCE

Facility

$1,020.00

Service Code	CPT 11045
Hospital Charge Code	8910547
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$663.00
Rate for Payer: Aetna Commercial	$561.00
Rate for Payer: Amerigroup CHIP/Medicaid	$91.80
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$897.60
Rate for Payer: Cash Price	$897.60
Rate for Payer: Multiplan Auto	$663.00
Rate for Payer: Multiplan Commercial	$663.00
Rate for Payer: Multiplan Workers Comp	$663.00
Rate for Payer: Scott and White EPO/PPO	$510.00
Rate for Payer: Superior Health Plan EPO	$138.72

OPWC Debrid Sq Tiss Ad 20 Sqcm BCE

Facility

$1,020.00

Service Code	CPT 11045
Hospital Charge Code	8910547
Hospital Revenue Code	761
Rate for Payer: Cash Price	$897.60

OPWC Dressing/Debridement Burns, Small BCE

Facility

$413.00

Service Code	CPT 16020
Hospital Charge Code	8912545
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$227.15
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$37.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$363.44
Rate for Payer: Cash Price	$363.44
Rate for Payer: Cash Price	$363.44
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$44.31
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina CHIP/Medicaid	$44.31
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$268.45
Rate for Payer: Multiplan Commercial	$268.45
Rate for Payer: Multiplan Workers Comp	$268.45
Rate for Payer: Parkland Medicaid	$44.31
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.31
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

OPWC Dressing/Debridement Burns, Small BCE

Facility

$413.00

Service Code	CPT 16020
Hospital Charge Code	8912545
Hospital Revenue Code	761
Rate for Payer: Cash Price	$363.44

OPWC Duplex Scan Extremity Veins Complete Bilateral BCE

Facility

$2,850.00

Service Code	CPT 93970
Hospital Charge Code	8910548
Hospital Revenue Code	921
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$1,852.50
Rate for Payer: Aetna Commercial	$315.95
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$256.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$224.10
Rate for Payer: Amerigroup Medicare	$224.10
Rate for Payer: BCBS of TX Blue Advantage	$284.70
Rate for Payer: BCBS of TX Blue Essentials	$340.33
Rate for Payer: BCBS of TX Medicare	$224.10
Rate for Payer: BCBS of TX PPO	$379.60
Rate for Payer: Cash Price	$2,508.00
Rate for Payer: Cash Price	$2,508.00
Rate for Payer: Cash Price	$2,508.00
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$188.79
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Employer Direct Commercial	$224.10
Rate for Payer: Humana Medicare/TRICARE	$224.10
Rate for Payer: Molina CHIP/Medicaid	$188.79
Rate for Payer: Molina Dual Medicare/Medicaid	$224.10
Rate for Payer: Molina Medicare	$224.10
Rate for Payer: Multiplan Auto	$1,852.50
Rate for Payer: Multiplan Commercial	$1,852.50
Rate for Payer: Multiplan Workers Comp	$1,852.50
Rate for Payer: Parkland Medicaid	$188.79
Rate for Payer: Scott and White EPO/PPO	$4.01
Rate for Payer: Scott and White Medicare	$224.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$188.79
Rate for Payer: Superior Health Plan EPO	$224.10
Rate for Payer: Superior Health Plan Medicare	$224.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$224.10
Rate for Payer: Universal American Medicare	$224.10
Rate for Payer: Wellcare Medicare	$224.10
Rate for Payer: Wellmed Medicare	$224.10

OPWC Duplex Scan Extremity Veins Complete Bilateral BCE

Facility

$2,850.00

Service Code	CPT 93970
Hospital Charge Code	8910548
Hospital Revenue Code	921
Rate for Payer: Cash Price	$2,508.00

OPWC Epdrml Atgrft,Face/Nk/Hf BCE

Facility

$5,070.00

Service Code	CPT 15115
Hospital Charge Code	8912547
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,461.60

OPWC Epdrml Atgrft,Face/Nk/Hf BCE

Facility

$5,070.00

Service Code	CPT 15115
Hospital Charge Code	8912547
Hospital Revenue Code	361
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: Cash Price	$4,461.60
Rate for Payer: Cash Price	$4,461.60
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

OPWC Epi Auto Trnk/Arms/Legs ea/add 100 sqcm BCE

Facility

$5,206.00

Service Code	CPT 15111
Hospital Charge Code	8914543
Hospital Revenue Code	361
Min. Negotiated Rate	$468.54
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,863.30
Rate for Payer: Amerigroup CHIP/Medicaid	$468.54
Rate for Payer: Cash Price	$4,581.28
Rate for Payer: Cash Price	$4,581.28
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	$2,603.00
Rate for Payer: Superior Health Plan EPO	$708.02

OPWC Epi Auto Trnk/Arms/Legs ea/add 100 sqcm BCE

Facility

$5,206.00

Service Code	CPT 15111
Hospital Charge Code	8914543
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,581.28

Know your out-of-pocket cost for care.

All Charges