White Rock Medical Center

All Charges

Charge

Type

Setting

Price

K30003010

Facility

$21,578.43

Service Code	HCPCS C1734
Hospital Charge Code	991199
Hospital Revenue Code	278
Min. Negotiated Rate	$5,394.61
Max. Negotiated Rate	$10,789.22
Rate for Payer: Cash Price	$14,673.33
Rate for Payer: Cigna Commercial	$5,394.61
Rate for Payer: Multiplan Auto	$10,789.22
Rate for Payer: Multiplan Commercial	$10,789.22
Rate for Payer: Multiplan Workers Comp	$10,789.22
Rate for Payer: Scott and White EPO/PPO	$10,789.22

K30003010

Facility

$21,578.43

Service Code	HCPCS C1734
Hospital Charge Code	991199
Hospital Revenue Code	278
Min. Negotiated Rate	$1,942.06
Max. Negotiated Rate	$15,536.47
Rate for Payer: Amerigroup CHIP/Medicaid	$1,942.06
Rate for Payer: BCBS of TX Blue Advantage	$6,473.53
Rate for Payer: BCBS of TX Blue Essentials	$7,768.23
Rate for Payer: BCBS of TX PPO	$8,631.37
Rate for Payer: Cash Price	$14,673.33
Rate for Payer: Cigna Medicaid	$15,536.47
Rate for Payer: Molina CHIP/Medicaid	$15,536.47
Rate for Payer: Multiplan Auto	$10,789.22
Rate for Payer: Multiplan Commercial	$10,789.22
Rate for Payer: Multiplan Workers Comp	$10,789.22
Rate for Payer: Parkland Medicaid	$15,536.47
Rate for Payer: Scott and White EPO/PPO	$10,789.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,536.47
Rate for Payer: Superior Health Plan EPO	$2,934.67

K30003010

Facility

$21,578.00

Service Code	HCPCS C1734
Hospital Charge Code	991040
Hospital Revenue Code	278
Min. Negotiated Rate	$5,394.50
Max. Negotiated Rate	$10,789.00
Rate for Payer: Cash Price	$14,673.04
Rate for Payer: Cigna Commercial	$5,394.50
Rate for Payer: Multiplan Auto	$10,789.00
Rate for Payer: Multiplan Commercial	$10,789.00
Rate for Payer: Multiplan Workers Comp	$10,789.00
Rate for Payer: Scott and White EPO/PPO	$10,789.00

K30003010

Facility

$21,578.00

Service Code	HCPCS C1734
Hospital Charge Code	991040
Hospital Revenue Code	278
Min. Negotiated Rate	$1,942.02
Max. Negotiated Rate	$15,536.16
Rate for Payer: Amerigroup CHIP/Medicaid	$1,942.02
Rate for Payer: BCBS of TX Blue Advantage	$6,473.40
Rate for Payer: BCBS of TX Blue Essentials	$7,768.08
Rate for Payer: BCBS of TX PPO	$8,631.20
Rate for Payer: Cash Price	$14,673.04
Rate for Payer: Cigna Medicaid	$15,536.16
Rate for Payer: Molina CHIP/Medicaid	$15,536.16
Rate for Payer: Multiplan Auto	$10,789.00
Rate for Payer: Multiplan Commercial	$10,789.00
Rate for Payer: Multiplan Workers Comp	$10,789.00
Rate for Payer: Parkland Medicaid	$15,536.16
Rate for Payer: Scott and White EPO/PPO	$10,789.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,536.16
Rate for Payer: Superior Health Plan EPO	$2,934.61

Karl Storz Laparoscopic Handle

Facility

$2,016.12

Hospital Charge Code	992738
Hospital Revenue Code	270
Min. Negotiated Rate	$181.45
Max. Negotiated Rate	$1,451.61
Rate for Payer: Amerigroup CHIP/Medicaid	$181.45
Rate for Payer: BCBS of TX Blue Advantage	$604.84
Rate for Payer: BCBS of TX Blue Essentials	$725.80
Rate for Payer: BCBS of TX PPO	$806.45
Rate for Payer: Cash Price	$1,370.96
Rate for Payer: Cigna Medicaid	$1,451.61
Rate for Payer: Molina CHIP/Medicaid	$1,451.61
Rate for Payer: Multiplan Auto	$1,310.48
Rate for Payer: Multiplan Commercial	$1,310.48
Rate for Payer: Multiplan Workers Comp	$1,310.48
Rate for Payer: Parkland Medicaid	$1,451.61
Rate for Payer: Scott and White EPO/PPO	$1,008.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,451.61
Rate for Payer: Superior Health Plan EPO	$274.19

Karl Storz Laparoscopic Handle

Facility

$2,016.12

Hospital Charge Code	992738
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,370.96

KB36AA

Facility

$1,144.58

Hospital Charge Code	99011
Hospital Revenue Code	272
Rate for Payer: Cash Price	$778.31

KB36AA

Facility

$1,144.58

Hospital Charge Code	99011
Hospital Revenue Code	272
Min. Negotiated Rate	$103.01
Max. Negotiated Rate	$824.10
Rate for Payer: Amerigroup CHIP/Medicaid	$103.01
Rate for Payer: BCBS of TX Blue Advantage	$343.37
Rate for Payer: BCBS of TX Blue Essentials	$412.05
Rate for Payer: BCBS of TX PPO	$457.83
Rate for Payer: Cash Price	$778.31
Rate for Payer: Cigna Medicaid	$824.10
Rate for Payer: Molina CHIP/Medicaid	$824.10
Rate for Payer: Multiplan Auto	$743.98
Rate for Payer: Multiplan Commercial	$743.98
Rate for Payer: Multiplan Workers Comp	$743.98
Rate for Payer: Parkland Medicaid	$824.10
Rate for Payer: Scott and White EPO/PPO	$572.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$824.10
Rate for Payer: Superior Health Plan EPO	$155.66

kerecis micrograft omega3 19cm ea sq/cm

Facility

$333.00

Service Code	HCPCS Q4158
Hospital Charge Code	8672532
Hospital Revenue Code	278
Min. Negotiated Rate	$29.97
Max. Negotiated Rate	$264.25
Rate for Payer: Amerigroup CHIP/Medicaid	$29.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$99.90
Rate for Payer: BCBS of TX Blue Essentials	$119.88
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$133.20
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$239.76
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	$239.76
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$166.50
Rate for Payer: Multiplan Commercial	$166.50
Rate for Payer: Multiplan Workers Comp	$166.50
Rate for Payer: Parkland Medicaid	$239.76
Rate for Payer: Scott and White EPO/PPO	$166.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$239.76
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

kerecis micrograft omega3 19cm ea sq/cm

Facility

$333.00

Service Code	HCPCS Q4158
Hospital Charge Code	8672532
Hospital Revenue Code	278
Min. Negotiated Rate	$83.25
Max. Negotiated Rate	$166.50
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cigna Commercial	$83.25
Rate for Payer: Multiplan Auto	$166.50
Rate for Payer: Multiplan Commercial	$166.50
Rate for Payer: Multiplan Workers Comp	$166.50
Rate for Payer: Scott and White EPO/PPO	$166.50

kerecis omega3 1.75x1.75 50200s00b0d per sq cm

Facility

$828.00

Service Code	HCPCS Q4158
Hospital Charge Code	8638509
Hospital Revenue Code	278
Min. Negotiated Rate	$207.00
Max. Negotiated Rate	$414.00
Rate for Payer: Cash Price	$563.04
Rate for Payer: Cigna Commercial	$207.00
Rate for Payer: Multiplan Auto	$414.00
Rate for Payer: Multiplan Commercial	$414.00
Rate for Payer: Multiplan Workers Comp	$414.00
Rate for Payer: Scott and White EPO/PPO	$414.00

kerecis omega3 1.75x1.75 50200s00b0d per sq cm

Facility

$828.00

Service Code	HCPCS Q4158
Hospital Charge Code	8638509
Hospital Revenue Code	278
Min. Negotiated Rate	$74.52
Max. Negotiated Rate	$596.16
Rate for Payer: Amerigroup CHIP/Medicaid	$74.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$248.40
Rate for Payer: BCBS of TX Blue Essentials	$298.08
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$331.20
Rate for Payer: Cash Price	$563.04
Rate for Payer: Cash Price	$563.04
Rate for Payer: Cash Price	$563.04
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$596.16
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	$596.16
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$414.00
Rate for Payer: Multiplan Commercial	$414.00
Rate for Payer: Multiplan Workers Comp	$414.00
Rate for Payer: Parkland Medicaid	$596.16
Rate for Payer: Scott and White EPO/PPO	$414.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$596.16
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

kerecis omega3 1.75x1.75 (bx) 50200s00b2d sq cm

Facility

$411.00

Service Code	HCPCS Q4158
Hospital Charge Code	8640532
Hospital Revenue Code	278
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$295.92
Rate for Payer: Amerigroup CHIP/Medicaid	$36.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$123.30
Rate for Payer: BCBS of TX Blue Essentials	$147.96
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$164.40
Rate for Payer: Cash Price	$279.48
Rate for Payer: Cash Price	$279.48
Rate for Payer: Cash Price	$279.48
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$295.92
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	$295.92
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$205.50
Rate for Payer: Multiplan Commercial	$205.50
Rate for Payer: Multiplan Workers Comp	$205.50
Rate for Payer: Parkland Medicaid	$295.92
Rate for Payer: Scott and White EPO/PPO	$205.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$295.92
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

kerecis omega3 1.75x1.75 (bx) 50200s00b2d sq cm

Facility

$411.00

Service Code	HCPCS Q4158
Hospital Charge Code	8640532
Hospital Revenue Code	278
Min. Negotiated Rate	$102.75
Max. Negotiated Rate	$205.50
Rate for Payer: Cash Price	$279.48
Rate for Payer: Cigna Commercial	$102.75
Rate for Payer: Multiplan Auto	$205.50
Rate for Payer: Multiplan Commercial	$205.50
Rate for Payer: Multiplan Workers Comp	$205.50
Rate for Payer: Scott and White EPO/PPO	$205.50

kerecis omega 3 3x3.5 50200s01b0d per sq cm

Facility

$415.00

Service Code	HCPCS Q4158
Hospital Charge Code	8640519
Hospital Revenue Code	278
Min. Negotiated Rate	$103.75
Max. Negotiated Rate	$207.50
Rate for Payer: Cash Price	$282.20
Rate for Payer: Cigna Commercial	$103.75
Rate for Payer: Multiplan Auto	$207.50
Rate for Payer: Multiplan Commercial	$207.50
Rate for Payer: Multiplan Workers Comp	$207.50
Rate for Payer: Scott and White EPO/PPO	$207.50

kerecis omega 3 3x3.5 50200s01b0d per sq cm

Facility

$415.00

Service Code	HCPCS Q4158
Hospital Charge Code	8640519
Hospital Revenue Code	278
Min. Negotiated Rate	$37.35
Max. Negotiated Rate	$298.80
Rate for Payer: Amerigroup CHIP/Medicaid	$37.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$124.50
Rate for Payer: BCBS of TX Blue Essentials	$149.40
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$166.00
Rate for Payer: Cash Price	$282.20
Rate for Payer: Cash Price	$282.20
Rate for Payer: Cash Price	$282.20
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$298.80
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	$298.80
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$207.50
Rate for Payer: Multiplan Commercial	$207.50
Rate for Payer: Multiplan Workers Comp	$207.50
Rate for Payer: Parkland Medicaid	$298.80
Rate for Payer: Scott and White EPO/PPO	$207.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$298.80
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

kerecis omega3 3x3.5cm-50200s01b2d

Facility

$256.00

Service Code	HCPCS Q4158
Hospital Charge Code	8630553
Hospital Revenue Code	278
Min. Negotiated Rate	$23.04
Max. Negotiated Rate	$264.25
Rate for Payer: Amerigroup CHIP/Medicaid	$23.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$76.80
Rate for Payer: BCBS of TX Blue Essentials	$92.16
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$102.40
Rate for Payer: Cash Price	$174.08
Rate for Payer: Cash Price	$174.08
Rate for Payer: Cash Price	$174.08
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$184.32
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	$184.32
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$128.00
Rate for Payer: Multiplan Commercial	$128.00
Rate for Payer: Multiplan Workers Comp	$128.00
Rate for Payer: Parkland Medicaid	$184.32
Rate for Payer: Scott and White EPO/PPO	$128.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$184.32
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

kerecis omega3 3x3.5cm-50200s01b2d

Facility

$256.00

Service Code	HCPCS Q4158
Hospital Charge Code	8630553
Hospital Revenue Code	278
Min. Negotiated Rate	$64.00
Max. Negotiated Rate	$128.00
Rate for Payer: Cash Price	$174.08
Rate for Payer: Cigna Commercial	$64.00
Rate for Payer: Multiplan Auto	$128.00
Rate for Payer: Multiplan Commercial	$128.00
Rate for Payer: Multiplan Workers Comp	$128.00
Rate for Payer: Scott and White EPO/PPO	$128.00

kerecis omega 3 3x7cm 50200s02b2d per sq cm

Facility

$252.00

Service Code	HCPCS Q4158
Hospital Charge Code	40299018
Hospital Revenue Code	278
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$126.00
Rate for Payer: Cash Price	$171.36
Rate for Payer: Cigna Commercial	$63.00
Rate for Payer: Multiplan Auto	$126.00
Rate for Payer: Multiplan Commercial	$126.00
Rate for Payer: Multiplan Workers Comp	$126.00
Rate for Payer: Scott and White EPO/PPO	$126.00

kerecis omega 3 3x7cm 50200s02b2d per sq cm

Facility

$252.00

Service Code	HCPCS Q4158
Hospital Charge Code	40299018
Hospital Revenue Code	278
Min. Negotiated Rate	$22.68
Max. Negotiated Rate	$264.25
Rate for Payer: Amerigroup CHIP/Medicaid	$22.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$75.60
Rate for Payer: BCBS of TX Blue Essentials	$90.72
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$100.80
Rate for Payer: Cash Price	$171.36
Rate for Payer: Cash Price	$171.36
Rate for Payer: Cash Price	$171.36
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$181.44
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	$181.44
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$126.00
Rate for Payer: Multiplan Commercial	$126.00
Rate for Payer: Multiplan Workers Comp	$126.00
Rate for Payer: Parkland Medicaid	$181.44
Rate for Payer: Scott and White EPO/PPO	$126.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$181.44
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

kerecis omega3 3x7cm(ea) 50200s02b0d sq cm

Facility

$347.00

Service Code	HCPCS Q4158
Hospital Charge Code	8640520
Hospital Revenue Code	278
Min. Negotiated Rate	$31.23
Max. Negotiated Rate	$264.25
Rate for Payer: Amerigroup CHIP/Medicaid	$31.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$104.10
Rate for Payer: BCBS of TX Blue Essentials	$124.92
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$138.80
Rate for Payer: Cash Price	$235.96
Rate for Payer: Cash Price	$235.96
Rate for Payer: Cash Price	$235.96
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$249.84
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	$249.84
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$173.50
Rate for Payer: Multiplan Commercial	$173.50
Rate for Payer: Multiplan Workers Comp	$173.50
Rate for Payer: Parkland Medicaid	$249.84
Rate for Payer: Scott and White EPO/PPO	$173.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$249.84
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

kerecis omega3 3x7cm(ea) 50200s02b0d sq cm

Facility

$347.00

Service Code	HCPCS Q4158
Hospital Charge Code	8640520
Hospital Revenue Code	278
Min. Negotiated Rate	$86.75
Max. Negotiated Rate	$173.50
Rate for Payer: Cash Price	$235.96
Rate for Payer: Cigna Commercial	$86.75
Rate for Payer: Multiplan Auto	$173.50
Rate for Payer: Multiplan Commercial	$173.50
Rate for Payer: Multiplan Workers Comp	$173.50
Rate for Payer: Scott and White EPO/PPO	$173.50

kerecis omega 3 7x10 50200s03bod per sq cm

Facility

$275.00

Service Code	HCPCS Q4158
Hospital Charge Code	8638508
Hospital Revenue Code	278
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$264.25
Rate for Payer: Amerigroup CHIP/Medicaid	$24.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$82.50
Rate for Payer: BCBS of TX Blue Essentials	$99.00
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$110.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$198.00
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	$198.00
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$137.50
Rate for Payer: Multiplan Commercial	$137.50
Rate for Payer: Multiplan Workers Comp	$137.50
Rate for Payer: Parkland Medicaid	$198.00
Rate for Payer: Scott and White EPO/PPO	$137.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$198.00
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

kerecis omega 3 7x10 50200s03bod per sq cm

Facility

$275.00

Service Code	HCPCS Q4158
Hospital Charge Code	8638508
Hospital Revenue Code	278
Min. Negotiated Rate	$68.75
Max. Negotiated Rate	$137.50
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cigna Commercial	$68.75
Rate for Payer: Multiplan Auto	$137.50
Rate for Payer: Multiplan Commercial	$137.50
Rate for Payer: Multiplan Workers Comp	$137.50
Rate for Payer: Scott and White EPO/PPO	$137.50

kerecis omega3 7x20 (ea) per sq cm

Facility

$323.00

Service Code	HCPCS Q4158
Hospital Charge Code	8630552
Hospital Revenue Code	278
Min. Negotiated Rate	$29.07
Max. Negotiated Rate	$264.25
Rate for Payer: Amerigroup CHIP/Medicaid	$29.07
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$96.90
Rate for Payer: BCBS of TX Blue Essentials	$116.28
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$129.20
Rate for Payer: Cash Price	$219.64
Rate for Payer: Cash Price	$219.64
Rate for Payer: Cash Price	$219.64
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$232.56
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	$232.56
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$161.50
Rate for Payer: Multiplan Commercial	$161.50
Rate for Payer: Multiplan Workers Comp	$161.50
Rate for Payer: Parkland Medicaid	$232.56
Rate for Payer: Scott and White EPO/PPO	$161.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$232.56
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

Know your out-of-pocket cost for care.

All Charges