White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC

Facility

$28,705.20

Service Code	MSDRG 583
Min. Negotiated Rate	$11,851.66
Max. Negotiated Rate	$28,705.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,398.25
Rate for Payer: Amerigroup Medicare	$17,398.25
Rate for Payer: BCBS of TX Medicare	$17,398.25
Rate for Payer: Cigna Commercial	$22,210.27
Rate for Payer: Cigna Medicare	$17,398.25
Rate for Payer: Employer Direct Commercial	$17,398.25
Rate for Payer: Humana Medicare/TRICARE	$17,398.25
Rate for Payer: Molina Dual Medicare/Medicaid	$17,398.25
Rate for Payer: Molina Medicare	$17,398.25
Rate for Payer: Multiplan Auto	$28,705.20
Rate for Payer: Multiplan Commercial	$28,705.20
Rate for Payer: Multiplan Workers Comp	$28,705.20
Rate for Payer: Scott and White EPO/PPO	$13,219.50
Rate for Payer: Scott and White Medicare	$17,398.25
Rate for Payer: Superior Health Plan EPO	$17,398.25
Rate for Payer: Superior Health Plan Medicare	$17,398.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,398.25
Rate for Payer: Universal American Medicare	$17,398.25
Rate for Payer: Wellcare Medicare	$17,398.25
Rate for Payer: Wellmed Medicare	$17,398.25

MASTECTOMY FOR MALIGNANCY W/O CC/MCC

Facility

$28,705.20

Service Code	MSDRG 583
Min. Negotiated Rate	$11,851.66
Max. Negotiated Rate	$28,705.20
Rate for Payer: BCBS of TX Blue Advantage	$11,851.66
Rate for Payer: BCBS of TX Blue Essentials	$14,220.61
Rate for Payer: BCBS of TX PPO	$15,801.29

Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)

Facility

$13,655.82

Service Code	HCPCS 19301
Hospital Charge Code	9900154
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,285.96

Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)

Facility

$10,000.00

Service Code	CPT 19301
Hospital Charge Code	36019301
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Amerigroup Medicare	$3,933.28
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,933.28
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cigna Commercial	$8,314.23
Rate for Payer: Cigna Medicare	$3,933.28
Rate for Payer: Employer Direct Commercial	$3,933.28
Rate for Payer: Humana Medicare/TRICARE	$3,933.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Molina Medicare	$3,933.28
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	$6,449.12
Rate for Payer: Scott and White Medicare	$3,933.28
Rate for Payer: Superior Health Plan EPO	$3,933.28
Rate for Payer: Superior Health Plan Medicare	$3,933.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Universal American Medicare	$3,933.28
Rate for Payer: Wellcare Medicare	$3,933.28
Rate for Payer: Wellmed Medicare	$3,933.28

Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)

Facility

$13,655.82

Service Code	HCPCS 19301
Hospital Charge Code	9900154
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Amerigroup Medicare	$3,933.28
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,933.28
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cash Price	$9,285.96
Rate for Payer: Cash Price	$9,285.96
Rate for Payer: Cash Price	$9,285.96
Rate for Payer: Cigna Commercial	$8,314.23
Rate for Payer: Cigna Medicaid	$9,832.19
Rate for Payer: Cigna Medicare	$3,933.28
Rate for Payer: Employer Direct Commercial	$3,933.28
Rate for Payer: Humana Medicare/TRICARE	$3,933.28
Rate for Payer: Molina CHIP/Medicaid	$9,832.19
Rate for Payer: Molina Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Molina Medicare	$3,933.28
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: Parkland Medicaid	$9,832.19
Rate for Payer: Scott and White EPO/PPO	$6,449.12
Rate for Payer: Scott and White Medicare	$3,933.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,832.19
Rate for Payer: Superior Health Plan EPO	$3,933.28
Rate for Payer: Superior Health Plan Medicare	$3,933.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Universal American Medicare	$3,933.28
Rate for Payer: Wellcare Medicare	$3,933.28
Rate for Payer: Wellmed Medicare	$3,933.28

MASTECTOMY PROCEDURES

Facility

$17,361.26

Service Code	APR-DRG 3624
Min. Negotiated Rate	$16,368.80
Max. Negotiated Rate	$17,361.26
Rate for Payer: Amerigroup CHIP/Medicaid	$16,368.80
Rate for Payer: Cigna Medicaid	$16,368.80
Rate for Payer: Molina CHIP/Medicaid	$16,368.80
Rate for Payer: Parkland Medicaid	$16,368.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,361.26

MASTECTOMY PROCEDURES

Facility

$11,071.63

Service Code	APR-DRG 3623
Min. Negotiated Rate	$10,438.72
Max. Negotiated Rate	$11,071.63
Rate for Payer: Amerigroup CHIP/Medicaid	$10,438.72
Rate for Payer: Cigna Medicaid	$10,438.72
Rate for Payer: Molina CHIP/Medicaid	$10,438.72
Rate for Payer: Parkland Medicaid	$10,438.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,071.63

MASTECTOMY PROCEDURES

Facility

$6,721.89

Service Code	APR-DRG 3621
Min. Negotiated Rate	$6,337.63
Max. Negotiated Rate	$6,721.89
Rate for Payer: Amerigroup CHIP/Medicaid	$6,337.63
Rate for Payer: Cigna Medicaid	$6,337.63
Rate for Payer: Molina CHIP/Medicaid	$6,337.63
Rate for Payer: Parkland Medicaid	$6,337.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,721.89

MASTECTOMY PROCEDURES

Facility

$10,883.79

Service Code	APR-DRG 3622
Min. Negotiated Rate	$10,261.62
Max. Negotiated Rate	$10,883.79
Rate for Payer: Amerigroup CHIP/Medicaid	$10,261.62
Rate for Payer: Cigna Medicaid	$10,261.62
Rate for Payer: Molina CHIP/Medicaid	$10,261.62
Rate for Payer: Parkland Medicaid	$10,261.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,883.79

Mastopexy

Facility

$23,772.60

Service Code	HCPCS 19316
Hospital Charge Code	9900155
Hospital Revenue Code	360
Rate for Payer: Cash Price	$16,165.37

Mastopexy

Facility

$14,100.07

Service Code	CPT 19316
Hospital Charge Code	36019316
Hospital Revenue Code	360
Min. Negotiated Rate	$1,845.21
Max. Negotiated Rate	$14,100.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,845.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Amerigroup Medicare	$6,670.43
Rate for Payer: BCBS of TX Blue Advantage	$8,746.27
Rate for Payer: BCBS of TX Blue Essentials	$10,474.58
Rate for Payer: BCBS of TX Medicare	$6,670.43
Rate for Payer: BCBS of TX PPO	$13,197.97
Rate for Payer: Cigna Commercial	$14,100.07
Rate for Payer: Cigna Medicare	$6,670.43
Rate for Payer: Employer Direct Commercial	$6,670.43
Rate for Payer: Humana Medicare/TRICARE	$6,670.43
Rate for Payer: Molina Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Molina Medicare	$6,670.43
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	$11,033.10
Rate for Payer: Scott and White Medicare	$6,670.43
Rate for Payer: Superior Health Plan EPO	$6,670.43
Rate for Payer: Superior Health Plan Medicare	$6,670.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Universal American Medicare	$6,670.43
Rate for Payer: Wellcare Medicare	$6,670.43
Rate for Payer: Wellmed Medicare	$6,670.43

Mastopexy

Facility

$23,772.60

Service Code	HCPCS 19316
Hospital Charge Code	9900155
Hospital Revenue Code	360
Min. Negotiated Rate	$1,845.21
Max. Negotiated Rate	$17,116.27
Rate for Payer: Amerigroup CHIP/Medicaid	$1,845.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Amerigroup Medicare	$6,670.43
Rate for Payer: BCBS of TX Blue Advantage	$8,746.27
Rate for Payer: BCBS of TX Blue Essentials	$10,474.58
Rate for Payer: BCBS of TX Medicare	$6,670.43
Rate for Payer: BCBS of TX PPO	$13,197.97
Rate for Payer: Cash Price	$16,165.37
Rate for Payer: Cash Price	$16,165.37
Rate for Payer: Cash Price	$16,165.37
Rate for Payer: Cigna Commercial	$14,100.07
Rate for Payer: Cigna Medicaid	$17,116.27
Rate for Payer: Cigna Medicare	$6,670.43
Rate for Payer: Employer Direct Commercial	$6,670.43
Rate for Payer: Humana Medicare/TRICARE	$6,670.43
Rate for Payer: Molina CHIP/Medicaid	$17,116.27
Rate for Payer: Molina Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Molina Medicare	$6,670.43
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	$17,116.27
Rate for Payer: Scott and White EPO/PPO	$11,033.10
Rate for Payer: Scott and White Medicare	$6,670.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,116.27
Rate for Payer: Superior Health Plan EPO	$6,670.43
Rate for Payer: Superior Health Plan Medicare	$6,670.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Universal American Medicare	$6,670.43
Rate for Payer: Wellcare Medicare	$6,670.43
Rate for Payer: Wellmed Medicare	$6,670.43

Mastotomy with exploration or drainage of abscess, deep

Facility

$5,747.96

Service Code	HCPCS 19020
Hospital Charge Code	8914619
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	$3,908.61
Rate for Payer: Cash Price	$3,908.61
Rate for Payer: Cash Price	$3,908.61
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,138.53
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	$4,138.53
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	$4,138.53
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	$4,138.53
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

Mastotomy with exploration or drainage of abscess, deep

Facility

$5,747.96

Service Code	HCPCS 19020
Hospital Charge Code	8914619
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,908.61

Mastotomy with exploration or drainage of abscess, deep

Facility

$10,000.00

Service Code	CPT 19020
Hospital Charge Code	36019020
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: Cigna Commercial	$3,507.10
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 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: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
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

Mastotomy with exploration or drainage of abscess, deep

Facility

$5,747.96

Service Code	HCPCS 19020
Hospital Charge Code	9900152
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	$3,908.61
Rate for Payer: Cash Price	$3,908.61
Rate for Payer: Cash Price	$3,908.61
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,138.53
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	$4,138.53
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	$4,138.53
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	$4,138.53
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

Mastotomy with exploration or drainage of abscess, deep

Facility

$5,747.96

Service Code	HCPCS 19020
Hospital Charge Code	9900152
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,908.61

MATERIAL, STAPLE LINE BIO USS INDO GIAII 60-3.5 -- DHF

Facility

$755.15

Hospital Charge Code	81911604
Hospital Revenue Code	272
Rate for Payer: Cash Price	$513.50

MATERIAL, STAPLE LINE BIO USS INDO GIAII 60-3.5 -- DHF

Facility

$755.15

Hospital Charge Code	81911604
Hospital Revenue Code	272
Min. Negotiated Rate	$67.96
Max. Negotiated Rate	$543.71
Rate for Payer: Amerigroup CHIP/Medicaid	$67.96
Rate for Payer: BCBS of TX Blue Advantage	$226.54
Rate for Payer: BCBS of TX Blue Essentials	$271.85
Rate for Payer: BCBS of TX PPO	$302.06
Rate for Payer: Cash Price	$513.50
Rate for Payer: Cigna Medicaid	$543.71
Rate for Payer: Molina CHIP/Medicaid	$543.71
Rate for Payer: Multiplan Auto	$490.85
Rate for Payer: Multiplan Commercial	$490.85
Rate for Payer: Multiplan Workers Comp	$490.85
Rate for Payer: Parkland Medicaid	$543.71
Rate for Payer: Scott and White EPO/PPO	$377.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$543.71
Rate for Payer: Superior Health Plan EPO	$102.70

MATRIX ALLODERM SELECT TISSUE 5 X 10 CM THIN 1.0 +/- 0.2

Facility

$14,940.00

Service Code	HCPCS Q4116
Hospital Charge Code	145965
Hospital Revenue Code	278
Min. Negotiated Rate	$125.01
Max. Negotiated Rate	$10,756.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,344.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$4,482.00
Rate for Payer: BCBS of TX Blue Essentials	$5,378.40
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$5,976.00
Rate for Payer: Cash Price	$10,159.20
Rate for Payer: Cash Price	$10,159.20
Rate for Payer: Cash Price	$10,159.20
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$10,756.80
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	$10,756.80
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$7,470.00
Rate for Payer: Multiplan Commercial	$7,470.00
Rate for Payer: Multiplan Workers Comp	$7,470.00
Rate for Payer: Parkland Medicaid	$10,756.80
Rate for Payer: Scott and White EPO/PPO	$7,470.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,756.80
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

MATRIX ALLODERM SELECT TISSUE 5 X 10 CM THIN 1.0 +/- 0.2

Facility

$14,940.00

Service Code	HCPCS Q4116
Hospital Charge Code	145965
Hospital Revenue Code	278
Min. Negotiated Rate	$3,735.00
Max. Negotiated Rate	$7,470.00
Rate for Payer: Cash Price	$10,159.20
Rate for Payer: Cigna Commercial	$3,735.00
Rate for Payer: Multiplan Auto	$7,470.00
Rate for Payer: Multiplan Commercial	$7,470.00
Rate for Payer: Multiplan Workers Comp	$7,470.00
Rate for Payer: Scott and White EPO/PPO	$7,470.00

Mayo stand cover, plastic, 23' sterile

Facility

$7.59

Hospital Charge Code	992791
Hospital Revenue Code	272
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$5.46
Rate for Payer: Amerigroup CHIP/Medicaid	$0.68
Rate for Payer: BCBS of TX Blue Advantage	$2.28
Rate for Payer: BCBS of TX Blue Essentials	$2.73
Rate for Payer: BCBS of TX PPO	$3.04
Rate for Payer: Cash Price	$5.16
Rate for Payer: Cigna Medicaid	$5.46
Rate for Payer: Molina CHIP/Medicaid	$5.46
Rate for Payer: Multiplan Auto	$4.93
Rate for Payer: Multiplan Commercial	$4.93
Rate for Payer: Multiplan Workers Comp	$4.93
Rate for Payer: Parkland Medicaid	$5.46
Rate for Payer: Scott and White EPO/PPO	$3.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.46
Rate for Payer: Superior Health Plan EPO	$1.03

Mayo stand cover, plastic, 23' sterile

Facility

$7.59

Hospital Charge Code	992791
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.16

MBO-CANISTER 1200CCGUARDIAN, W/LOCKINGLID

Facility

$7.76

Hospital Charge Code	993948
Hospital Revenue Code	271
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$5.59
Rate for Payer: Amerigroup CHIP/Medicaid	$0.70
Rate for Payer: BCBS of TX Blue Advantage	$2.33
Rate for Payer: BCBS of TX Blue Essentials	$2.79
Rate for Payer: BCBS of TX PPO	$3.10
Rate for Payer: Cash Price	$5.28
Rate for Payer: Cigna Medicaid	$5.59
Rate for Payer: Molina CHIP/Medicaid	$5.59
Rate for Payer: Multiplan Auto	$5.04
Rate for Payer: Multiplan Commercial	$5.04
Rate for Payer: Multiplan Workers Comp	$5.04
Rate for Payer: Parkland Medicaid	$5.59
Rate for Payer: Scott and White EPO/PPO	$3.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.59
Rate for Payer: Superior Health Plan EPO	$1.06

MBO-CANISTER 1200CCGUARDIAN, W/LOCKINGLID

Facility

$7.76

Hospital Charge Code	993948
Hospital Revenue Code	271
Rate for Payer: Cash Price	$5.28

Know your out-of-pocket cost for care.

All Charges