White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ligasure blunt tip

Facility

$2,604.82

Hospital Charge Code	992685
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,771.28

ligasure blunt tip

Facility

$2,604.82

Hospital Charge Code	992685
Hospital Revenue Code	272
Min. Negotiated Rate	$234.43
Max. Negotiated Rate	$1,875.47
Rate for Payer: Amerigroup CHIP/Medicaid	$234.43
Rate for Payer: BCBS of TX Blue Advantage	$781.45
Rate for Payer: BCBS of TX Blue Essentials	$937.74
Rate for Payer: BCBS of TX PPO	$1,041.93
Rate for Payer: Cash Price	$1,771.28
Rate for Payer: Cigna Medicaid	$1,875.47
Rate for Payer: Molina CHIP/Medicaid	$1,875.47
Rate for Payer: Multiplan Auto	$1,693.13
Rate for Payer: Multiplan Commercial	$1,693.13
Rate for Payer: Multiplan Workers Comp	$1,693.13
Rate for Payer: Parkland Medicaid	$1,875.47
Rate for Payer: Scott and White EPO/PPO	$1,302.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,875.47
Rate for Payer: Superior Health Plan EPO	$354.26

LIGASURE, BLUNT TIP, 44CM

Facility

$2,717.55

Hospital Charge Code	992810
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,847.93

LIGASURE, BLUNT TIP, 44CM

Facility

$2,717.55

Hospital Charge Code	992810
Hospital Revenue Code	272
Min. Negotiated Rate	$244.58
Max. Negotiated Rate	$1,956.64
Rate for Payer: Amerigroup CHIP/Medicaid	$244.58
Rate for Payer: BCBS of TX Blue Advantage	$815.26
Rate for Payer: BCBS of TX Blue Essentials	$978.32
Rate for Payer: BCBS of TX PPO	$1,087.02
Rate for Payer: Cash Price	$1,847.93
Rate for Payer: Cigna Medicaid	$1,956.64
Rate for Payer: Molina CHIP/Medicaid	$1,956.64
Rate for Payer: Multiplan Auto	$1,766.41
Rate for Payer: Multiplan Commercial	$1,766.41
Rate for Payer: Multiplan Workers Comp	$1,766.41
Rate for Payer: Parkland Medicaid	$1,956.64
Rate for Payer: Scott and White EPO/PPO	$1,358.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,956.64
Rate for Payer: Superior Health Plan EPO	$369.59

LIGASURE IMPACT

Facility

$2,512.89

Hospital Charge Code	992688
Hospital Revenue Code	272
Min. Negotiated Rate	$226.16
Max. Negotiated Rate	$1,809.28
Rate for Payer: Amerigroup CHIP/Medicaid	$226.16
Rate for Payer: BCBS of TX Blue Advantage	$753.87
Rate for Payer: BCBS of TX Blue Essentials	$904.64
Rate for Payer: BCBS of TX PPO	$1,005.16
Rate for Payer: Cash Price	$1,708.77
Rate for Payer: Cigna Medicaid	$1,809.28
Rate for Payer: Molina CHIP/Medicaid	$1,809.28
Rate for Payer: Multiplan Auto	$1,633.38
Rate for Payer: Multiplan Commercial	$1,633.38
Rate for Payer: Multiplan Workers Comp	$1,633.38
Rate for Payer: Parkland Medicaid	$1,809.28
Rate for Payer: Scott and White EPO/PPO	$1,256.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,809.28
Rate for Payer: Superior Health Plan EPO	$341.75

LIGASURE IMPACT

Facility

$2,512.89

Hospital Charge Code	992688
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,708.77

LIGASURE MARYLAND 44CM

Facility

$2,758.05

Hospital Charge Code	992687
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,875.47

LIGASURE MARYLAND 44CM

Facility

$2,758.05

Hospital Charge Code	992687
Hospital Revenue Code	272
Min. Negotiated Rate	$248.22
Max. Negotiated Rate	$1,985.80
Rate for Payer: Amerigroup CHIP/Medicaid	$248.22
Rate for Payer: BCBS of TX Blue Advantage	$827.41
Rate for Payer: BCBS of TX Blue Essentials	$992.90
Rate for Payer: BCBS of TX PPO	$1,103.22
Rate for Payer: Cash Price	$1,875.47
Rate for Payer: Cigna Medicaid	$1,985.80
Rate for Payer: Molina CHIP/Medicaid	$1,985.80
Rate for Payer: Multiplan Auto	$1,792.73
Rate for Payer: Multiplan Commercial	$1,792.73
Rate for Payer: Multiplan Workers Comp	$1,792.73
Rate for Payer: Parkland Medicaid	$1,985.80
Rate for Payer: Scott and White EPO/PPO	$1,379.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,985.80
Rate for Payer: Superior Health Plan EPO	$375.09

LigaSure Maryland Jaw Laparoscopic Sealer/Divider with Nano-

Facility

$3,405.00

Hospital Charge Code	993690
Hospital Revenue Code	270
Min. Negotiated Rate	$306.45
Max. Negotiated Rate	$2,451.60
Rate for Payer: Amerigroup CHIP/Medicaid	$306.45
Rate for Payer: BCBS of TX Blue Advantage	$1,021.50
Rate for Payer: BCBS of TX Blue Essentials	$1,225.80
Rate for Payer: BCBS of TX PPO	$1,362.00
Rate for Payer: Cash Price	$2,315.40
Rate for Payer: Cigna Medicaid	$2,451.60
Rate for Payer: Molina CHIP/Medicaid	$2,451.60
Rate for Payer: Multiplan Auto	$2,213.25
Rate for Payer: Multiplan Commercial	$2,213.25
Rate for Payer: Multiplan Workers Comp	$2,213.25
Rate for Payer: Parkland Medicaid	$2,451.60
Rate for Payer: Scott and White EPO/PPO	$1,702.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,451.60
Rate for Payer: Superior Health Plan EPO	$463.08

LigaSure Maryland Jaw Laparoscopic Sealer/Divider with Nano-

Facility

$3,405.00

Hospital Charge Code	993690
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2,315.40

Ligation and division and complete stripping of long or short saphenous veins with radical excision

Facility

$14,618.15

Service Code	HCPCS 37735
Hospital Charge Code	9900631
Hospital Revenue Code	360
Min. Negotiated Rate	$1,118.22
Max. Negotiated Rate	$10,525.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$9,940.34
Rate for Payer: Cash Price	$9,940.34
Rate for Payer: Cash Price	$9,940.34
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$10,525.07
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$10,525.07
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$10,525.07
Rate for Payer: Scott and White EPO/PPO	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,525.07
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

Ligation and division and complete stripping of long or short saphenous veins with radical excision

Facility

$10,000.00

Service Code	CPT 37735
Hospital Charge Code	36037735
Hospital Revenue Code	360
Min. Negotiated Rate	$1,118.22
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

Ligation and division and complete stripping of long or short saphenous veins with radical excision

Facility

$14,618.15

Service Code	HCPCS 37735
Hospital Charge Code	9900631
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,940.34

LIGATION INF VENACAVA

Facility

$19,220.00

Service Code	HCPCS 37619
Hospital Charge Code	4617619
Hospital Revenue Code	361
Rate for Payer: Cash Price	$13,069.60

LIGATION INF VENACAVA

Facility

$19,220.00

Service Code	HCPCS 37619
Hospital Charge Code	4617619
Hospital Revenue Code	361
Min. Negotiated Rate	$1,729.80
Max. Negotiated Rate	$13,838.40
Rate for Payer: Amerigroup CHIP/Medicaid	$1,729.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Amerigroup Medicare	$5,589.84
Rate for Payer: BCBS of TX Blue Advantage	$7,675.64
Rate for Payer: BCBS of TX Blue Essentials	$9,192.38
Rate for Payer: BCBS of TX Medicare	$5,589.84
Rate for Payer: BCBS of TX PPO	$11,582.40
Rate for Payer: Cash Price	$13,069.60
Rate for Payer: Cash Price	$13,069.60
Rate for Payer: Cash Price	$13,069.60
Rate for Payer: Cigna Commercial	$11,815.91
Rate for Payer: Cigna Medicaid	$13,838.40
Rate for Payer: Cigna Medicare	$5,589.84
Rate for Payer: Employer Direct Commercial	$5,589.84
Rate for Payer: Humana Medicare/TRICARE	$5,589.84
Rate for Payer: Molina CHIP/Medicaid	$13,838.40
Rate for Payer: Molina Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Molina Medicare	$5,589.84
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	$13,838.40
Rate for Payer: Scott and White EPO/PPO	$9,297.64
Rate for Payer: Scott and White Medicare	$5,589.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,838.40
Rate for Payer: Superior Health Plan EPO	$5,589.84
Rate for Payer: Superior Health Plan Medicare	$5,589.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Universal American Medicare	$5,589.84
Rate for Payer: Wellcare Medicare	$5,589.84
Rate for Payer: Wellmed Medicare	$5,589.84

Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 l

Facility

$11,915.88

Service Code	HCPCS 37761
Hospital Charge Code	9900632
Hospital Revenue Code	360
Min. Negotiated Rate	$968.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$968.45
Rate for Payer: BCBS of TX Blue Essentials	$1,159.82
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$1,461.37
Rate for Payer: Cash Price	$8,102.80
Rate for Payer: Cash Price	$8,102.80
Rate for Payer: Cash Price	$8,102.80
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$8,579.43
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$8,579.43
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$8,579.43
Rate for Payer: Scott and White EPO/PPO	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,579.43
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 l

Facility

$10,000.00

Service Code	CPT 37761
Hospital Charge Code	36037761
Hospital Revenue Code	360
Min. Negotiated Rate	$968.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$968.45
Rate for Payer: BCBS of TX Blue Essentials	$1,159.82
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$1,461.37
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 l

Facility

$11,915.88

Service Code	HCPCS 37761
Hospital Charge Code	9900632
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,102.80

Ligation or banding of angioaccess arteriovenous fistula

Facility

$12,148.04

Service Code	HCPCS 37607
Hospital Charge Code	990935
Hospital Revenue Code	360
Min. Negotiated Rate	$1,118.22
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$8,260.67
Rate for Payer: Cash Price	$8,260.67
Rate for Payer: Cash Price	$8,260.67
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$8,746.59
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$8,746.59
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$8,746.59
Rate for Payer: Scott and White EPO/PPO	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,746.59
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

Ligation or banding of angioaccess arteriovenous fistula

Facility

$12,148.04

Service Code	HCPCS 37607
Hospital Charge Code	990935
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,260.67

Ligation or biopsy, temporal artery

Facility

$6,179.00

Service Code	HCPCS 37609
Hospital Charge Code	991400
Hospital Revenue Code	360
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
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	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$4,201.72
Rate for Payer: Cash Price	$4,201.72
Rate for Payer: Cash Price	$4,201.72
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,448.88
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$4,448.88
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$4,448.88
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,448.88
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Ligation or biopsy, temporal artery

Facility

$6,179.00

Service Code	HCPCS 37609
Hospital Charge Code	991400
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,201.72

LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$72,279.80

Service Code	MSDRG 956
Min. Negotiated Rate	$32,339.20
Max. Negotiated Rate	$72,279.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$32,339.20
Rate for Payer: Amerigroup Medicare	$32,339.20
Rate for Payer: BCBS of TX Medicare	$32,339.20
Rate for Payer: Cigna Commercial	$48,467.44
Rate for Payer: Cigna Medicare	$32,339.20
Rate for Payer: Employer Direct Commercial	$32,339.20
Rate for Payer: Humana Medicare/TRICARE	$32,339.20
Rate for Payer: Molina Dual Medicare/Medicaid	$32,339.20
Rate for Payer: Molina Medicare	$32,339.20
Rate for Payer: Multiplan Auto	$72,279.80
Rate for Payer: Multiplan Commercial	$72,279.80
Rate for Payer: Multiplan Workers Comp	$72,279.80
Rate for Payer: Scott and White EPO/PPO	$33,286.75
Rate for Payer: Scott and White Medicare	$32,339.20
Rate for Payer: Superior Health Plan EPO	$32,339.20
Rate for Payer: Superior Health Plan Medicare	$32,339.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$32,339.20
Rate for Payer: Universal American Medicare	$32,339.20
Rate for Payer: Wellcare Medicare	$32,339.20
Rate for Payer: Wellmed Medicare	$32,339.20

LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$72,279.80

Service Code	MSDRG 956
Min. Negotiated Rate	$32,339.20
Max. Negotiated Rate	$72,279.80
Rate for Payer: BCBS of TX Blue Advantage	$32,540.68
Rate for Payer: BCBS of TX Blue Essentials	$39,045.03
Rate for Payer: BCBS of TX PPO	$43,385.05

LINE BOOT DERMAPROX

Facility

$1,235.61

Hospital Charge Code	145900
Hospital Revenue Code	272
Rate for Payer: Cash Price	$840.21

Know your out-of-pocket cost for care.

All Charges