White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SYSTEM, SPLINTING ONE STEP FIBERGLASS & FOAM 3X12 -- DHF

Facility

$258.92

Hospital Charge Code	81035008
Hospital Revenue Code	270
Min. Negotiated Rate	$23.30
Max. Negotiated Rate	$168.30
Rate for Payer: Aetna Commercial	$142.41
Rate for Payer: Amerigroup CHIP/Medicaid	$23.30
Rate for Payer: BCBS of TX Blue Advantage	$77.68
Rate for Payer: BCBS of TX Blue Essentials	$93.21
Rate for Payer: BCBS of TX PPO	$103.57
Rate for Payer: Cash Price	$227.85
Rate for Payer: Multiplan Auto	$168.30
Rate for Payer: Multiplan Commercial	$168.30
Rate for Payer: Multiplan Workers Comp	$168.30
Rate for Payer: Scott and White EPO/PPO	$129.46
Rate for Payer: Superior Health Plan EPO	$35.21

SYSTEM, SPLINTING ONE STEP FIBERGLASS & FOAM 3X12 -- DHF

Facility

$258.92

Hospital Charge Code	81035008
Hospital Revenue Code	270
Rate for Payer: Cash Price	$227.85

SYSTEM, SUTURE ENDOSCOPIC OVERSTITCH -- DHF

Facility

$4,838.12

Hospital Charge Code	82499013
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,257.55

SYSTEM, SUTURE ENDOSCOPIC OVERSTITCH -- DHF

Facility

$4,838.12

Hospital Charge Code	82499013
Hospital Revenue Code	272
Min. Negotiated Rate	$435.43
Max. Negotiated Rate	$3,144.78
Rate for Payer: Aetna Commercial	$2,660.97
Rate for Payer: Amerigroup CHIP/Medicaid	$435.43
Rate for Payer: BCBS of TX Blue Advantage	$1,451.44
Rate for Payer: BCBS of TX Blue Essentials	$1,741.72
Rate for Payer: BCBS of TX PPO	$1,935.25
Rate for Payer: Cash Price	$4,257.55
Rate for Payer: Multiplan Auto	$3,144.78
Rate for Payer: Multiplan Commercial	$3,144.78
Rate for Payer: Multiplan Workers Comp	$3,144.78
Rate for Payer: Scott and White EPO/PPO	$2,419.06
Rate for Payer: Superior Health Plan EPO	$657.98

SYSTEM THROM SOLENT DISTA

Facility

$15,147.53

Service Code	HCPCS C1757
Hospital Charge Code	135989
Hospital Revenue Code	278
Min. Negotiated Rate	$1,363.28
Max. Negotiated Rate	$7,573.76
Rate for Payer: Aetna Commercial	$4,544.26
Rate for Payer: Amerigroup CHIP/Medicaid	$1,363.28
Rate for Payer: BCBS of TX Blue Advantage	$4,544.26
Rate for Payer: BCBS of TX Blue Essentials	$5,453.11
Rate for Payer: BCBS of TX PPO	$6,059.01
Rate for Payer: Cash Price	$13,329.83
Rate for Payer: Multiplan Auto	$7,573.76
Rate for Payer: Multiplan Commercial	$7,573.76
Rate for Payer: Multiplan Workers Comp	$7,573.76
Rate for Payer: Scott and White EPO/PPO	$7,573.76
Rate for Payer: Superior Health Plan EPO	$2,060.06

SYSTEM THROM SOLENT DISTA

Facility

$15,147.53

Service Code	HCPCS C1757
Hospital Charge Code	135989
Hospital Revenue Code	278
Min. Negotiated Rate	$3,786.88
Max. Negotiated Rate	$7,573.76
Rate for Payer: Aetna Commercial	$4,544.26
Rate for Payer: Cash Price	$13,329.83
Rate for Payer: Cigna Commercial	$3,786.88
Rate for Payer: Multiplan Auto	$7,573.76
Rate for Payer: Multiplan Commercial	$7,573.76
Rate for Payer: Multiplan Workers Comp	$7,573.76
Rate for Payer: Scott and White EPO/PPO	$7,573.76

SYS THROMB SOLENT PROXI -- DHF

Facility

$12,411.20

Service Code	HCPCS C1757
Hospital Charge Code	81787467
Hospital Revenue Code	278
Min. Negotiated Rate	$1,117.01
Max. Negotiated Rate	$6,205.60
Rate for Payer: Aetna Commercial	$3,723.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,117.01
Rate for Payer: BCBS of TX Blue Advantage	$3,723.36
Rate for Payer: BCBS of TX Blue Essentials	$4,468.03
Rate for Payer: BCBS of TX PPO	$4,964.48
Rate for Payer: Cash Price	$10,921.86
Rate for Payer: Multiplan Auto	$6,205.60
Rate for Payer: Multiplan Commercial	$6,205.60
Rate for Payer: Multiplan Workers Comp	$6,205.60
Rate for Payer: Scott and White EPO/PPO	$6,205.60
Rate for Payer: Superior Health Plan EPO	$1,687.92

SYS THROMB SOLENT PROXI -- DHF

Facility

$12,411.20

Service Code	HCPCS C1757
Hospital Charge Code	81787467
Hospital Revenue Code	278
Min. Negotiated Rate	$3,102.80
Max. Negotiated Rate	$6,205.60
Rate for Payer: Aetna Commercial	$3,723.36
Rate for Payer: Cash Price	$10,921.86
Rate for Payer: Cigna Commercial	$3,102.80
Rate for Payer: Multiplan Auto	$6,205.60
Rate for Payer: Multiplan Commercial	$6,205.60
Rate for Payer: Multiplan Workers Comp	$6,205.60
Rate for Payer: Scott and White EPO/PPO	$6,205.60

T3 Free

Facility

$453.00

Service Code	CPT 84481
Hospital Charge Code	1703008
Hospital Revenue Code	301
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$294.45
Rate for Payer: Aetna Commercial	$17.78
Rate for Payer: Aetna Medicare	$25.41
Rate for Payer: Amerigroup CHIP/Medicaid	$6.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.94
Rate for Payer: Amerigroup Medicare	$16.94
Rate for Payer: BCBS of TX Blue Advantage	$27.95
Rate for Payer: BCBS of TX Blue Essentials	$33.54
Rate for Payer: BCBS of TX Medicare	$16.94
Rate for Payer: BCBS of TX PPO	$37.44
Rate for Payer: Cash Price	$398.64
Rate for Payer: Cash Price	$398.64
Rate for Payer: Cigna Medicaid	$16.94
Rate for Payer: Cigna Medicare	$16.94
Rate for Payer: Employer Direct Commercial	$16.94
Rate for Payer: Humana Medicare/TRICARE	$16.94
Rate for Payer: Molina CHIP/Medicaid	$16.94
Rate for Payer: Molina Dual Medicare/Medicaid	$16.94
Rate for Payer: Molina Medicare	$16.94
Rate for Payer: Multiplan Auto	$294.45
Rate for Payer: Multiplan Commercial	$294.45
Rate for Payer: Multiplan Workers Comp	$294.45
Rate for Payer: Parkland Medicaid	$16.94
Rate for Payer: Scott and White EPO/PPO	$21.18
Rate for Payer: Scott and White Medicare	$16.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.94
Rate for Payer: Superior Health Plan EPO	$16.94
Rate for Payer: Superior Health Plan Medicare	$16.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.94
Rate for Payer: Universal American Medicare	$16.94
Rate for Payer: Wellcare Medicare	$16.94
Rate for Payer: Wellmed Medicare	$16.94

T3 Total

Facility

$400.00

Service Code	CPT 84480
Hospital Charge Code	1602309
Hospital Revenue Code	301
Min. Negotiated Rate	$5.53
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$14.89
Rate for Payer: Aetna Medicare	$21.27
Rate for Payer: Amerigroup CHIP/Medicaid	$5.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.18
Rate for Payer: Amerigroup Medicare	$14.18
Rate for Payer: BCBS of TX Blue Advantage	$23.40
Rate for Payer: BCBS of TX Blue Essentials	$28.08
Rate for Payer: BCBS of TX Medicare	$14.18
Rate for Payer: BCBS of TX PPO	$31.34
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cigna Medicaid	$14.18
Rate for Payer: Cigna Medicare	$14.18
Rate for Payer: Employer Direct Commercial	$14.18
Rate for Payer: Humana Medicare/TRICARE	$14.18
Rate for Payer: Molina CHIP/Medicaid	$14.18
Rate for Payer: Molina Dual Medicare/Medicaid	$14.18
Rate for Payer: Molina Medicare	$14.18
Rate for Payer: Multiplan Auto	$260.00
Rate for Payer: Multiplan Commercial	$260.00
Rate for Payer: Multiplan Workers Comp	$260.00
Rate for Payer: Parkland Medicaid	$14.18
Rate for Payer: Scott and White EPO/PPO	$17.72
Rate for Payer: Scott and White Medicare	$14.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.18
Rate for Payer: Superior Health Plan EPO	$14.18
Rate for Payer: Superior Health Plan Medicare	$14.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.18
Rate for Payer: Universal American Medicare	$14.18
Rate for Payer: Wellcare Medicare	$14.18
Rate for Payer: Wellmed Medicare	$14.18

T3 Uptake

Facility

$199.00

Service Code	CPT 84479
Hospital Charge Code	1602267
Hospital Revenue Code	301
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$129.35
Rate for Payer: Aetna Commercial	$6.79
Rate for Payer: Aetna Medicare	$9.70
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.47
Rate for Payer: Amerigroup Medicare	$6.47
Rate for Payer: BCBS of TX Blue Advantage	$10.68
Rate for Payer: BCBS of TX Blue Essentials	$12.81
Rate for Payer: BCBS of TX Medicare	$6.47
Rate for Payer: BCBS of TX PPO	$14.30
Rate for Payer: Cash Price	$175.12
Rate for Payer: Cash Price	$175.12
Rate for Payer: Cigna Medicaid	$6.47
Rate for Payer: Cigna Medicare	$6.47
Rate for Payer: Employer Direct Commercial	$6.47
Rate for Payer: Humana Medicare/TRICARE	$6.47
Rate for Payer: Molina CHIP/Medicaid	$6.47
Rate for Payer: Molina Dual Medicare/Medicaid	$6.47
Rate for Payer: Molina Medicare	$6.47
Rate for Payer: Multiplan Auto	$129.35
Rate for Payer: Multiplan Commercial	$129.35
Rate for Payer: Multiplan Workers Comp	$129.35
Rate for Payer: Parkland Medicaid	$6.47
Rate for Payer: Scott and White EPO/PPO	$8.09
Rate for Payer: Scott and White Medicare	$6.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.47
Rate for Payer: Superior Health Plan EPO	$6.47
Rate for Payer: Superior Health Plan Medicare	$6.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.47
Rate for Payer: Universal American Medicare	$6.47
Rate for Payer: Wellcare Medicare	$6.47
Rate for Payer: Wellmed Medicare	$6.47

T3 Uptake

Facility

$199.00

Service Code	CPT 84479
Hospital Charge Code	4104250
Hospital Revenue Code	301
Rate for Payer: Cash Price	$175.12

T3 Uptake

Facility

$199.00

Service Code	CPT 84479
Hospital Charge Code	4104250
Hospital Revenue Code	301
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$129.35
Rate for Payer: Aetna Commercial	$6.79
Rate for Payer: Aetna Medicare	$9.70
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.47
Rate for Payer: Amerigroup Medicare	$6.47
Rate for Payer: BCBS of TX Blue Advantage	$10.68
Rate for Payer: BCBS of TX Blue Essentials	$12.81
Rate for Payer: BCBS of TX Medicare	$6.47
Rate for Payer: BCBS of TX PPO	$14.30
Rate for Payer: Cash Price	$175.12
Rate for Payer: Cash Price	$175.12
Rate for Payer: Cigna Medicaid	$6.47
Rate for Payer: Cigna Medicare	$6.47
Rate for Payer: Employer Direct Commercial	$6.47
Rate for Payer: Humana Medicare/TRICARE	$6.47
Rate for Payer: Molina CHIP/Medicaid	$6.47
Rate for Payer: Molina Dual Medicare/Medicaid	$6.47
Rate for Payer: Molina Medicare	$6.47
Rate for Payer: Multiplan Auto	$129.35
Rate for Payer: Multiplan Commercial	$129.35
Rate for Payer: Multiplan Workers Comp	$129.35
Rate for Payer: Parkland Medicaid	$6.47
Rate for Payer: Scott and White EPO/PPO	$8.09
Rate for Payer: Scott and White Medicare	$6.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.47
Rate for Payer: Superior Health Plan EPO	$6.47
Rate for Payer: Superior Health Plan Medicare	$6.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.47
Rate for Payer: Universal American Medicare	$6.47
Rate for Payer: Wellcare Medicare	$6.47
Rate for Payer: Wellmed Medicare	$6.47

T3 Uptake SO

Facility

$199.00

Service Code	CPT 84479
Hospital Charge Code	1602267
Hospital Revenue Code	301
Rate for Payer: Cash Price	$175.12

T3 Uptake SO

Facility

$199.00

Service Code	CPT 84479
Hospital Charge Code	1602267
Hospital Revenue Code	301
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$129.35
Rate for Payer: Aetna Commercial	$6.79
Rate for Payer: Aetna Medicare	$9.70
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.47
Rate for Payer: Amerigroup Medicare	$6.47
Rate for Payer: BCBS of TX Blue Advantage	$10.68
Rate for Payer: BCBS of TX Blue Essentials	$12.81
Rate for Payer: BCBS of TX Medicare	$6.47
Rate for Payer: BCBS of TX PPO	$14.30
Rate for Payer: Cash Price	$175.12
Rate for Payer: Cash Price	$175.12
Rate for Payer: Cigna Medicaid	$6.47
Rate for Payer: Cigna Medicare	$6.47
Rate for Payer: Employer Direct Commercial	$6.47
Rate for Payer: Humana Medicare/TRICARE	$6.47
Rate for Payer: Molina CHIP/Medicaid	$6.47
Rate for Payer: Molina Dual Medicare/Medicaid	$6.47
Rate for Payer: Molina Medicare	$6.47
Rate for Payer: Multiplan Auto	$129.35
Rate for Payer: Multiplan Commercial	$129.35
Rate for Payer: Multiplan Workers Comp	$129.35
Rate for Payer: Parkland Medicaid	$6.47
Rate for Payer: Scott and White EPO/PPO	$8.09
Rate for Payer: Scott and White Medicare	$6.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.47
Rate for Payer: Superior Health Plan EPO	$6.47
Rate for Payer: Superior Health Plan Medicare	$6.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.47
Rate for Payer: Universal American Medicare	$6.47
Rate for Payer: Wellcare Medicare	$6.47
Rate for Payer: Wellmed Medicare	$6.47

T4 Total

Facility

$256.00

Service Code	CPT 84436
Hospital Charge Code	1602283
Hospital Revenue Code	301
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$166.40
Rate for Payer: Aetna Commercial	$7.21
Rate for Payer: Aetna Medicare	$10.30
Rate for Payer: Amerigroup CHIP/Medicaid	$2.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.87
Rate for Payer: Amerigroup Medicare	$6.87
Rate for Payer: BCBS of TX Blue Advantage	$11.34
Rate for Payer: BCBS of TX Blue Essentials	$13.60
Rate for Payer: BCBS of TX Medicare	$6.87
Rate for Payer: BCBS of TX PPO	$15.18
Rate for Payer: Cash Price	$225.28
Rate for Payer: Cash Price	$225.28
Rate for Payer: Cigna Medicaid	$6.87
Rate for Payer: Cigna Medicare	$6.87
Rate for Payer: Employer Direct Commercial	$6.87
Rate for Payer: Humana Medicare/TRICARE	$6.87
Rate for Payer: Molina CHIP/Medicaid	$6.87
Rate for Payer: Molina Dual Medicare/Medicaid	$6.87
Rate for Payer: Molina Medicare	$6.87
Rate for Payer: Multiplan Auto	$166.40
Rate for Payer: Multiplan Commercial	$166.40
Rate for Payer: Multiplan Workers Comp	$166.40
Rate for Payer: Parkland Medicaid	$6.87
Rate for Payer: Scott and White EPO/PPO	$8.59
Rate for Payer: Scott and White Medicare	$6.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.87
Rate for Payer: Superior Health Plan EPO	$6.87
Rate for Payer: Superior Health Plan Medicare	$6.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.87
Rate for Payer: Universal American Medicare	$6.87
Rate for Payer: Wellcare Medicare	$6.87
Rate for Payer: Wellmed Medicare	$6.87

T4 Total

Facility

$256.00

Service Code	CPT 84436
Hospital Charge Code	1602283
Hospital Revenue Code	301
Rate for Payer: Cash Price	$225.28

Tack endovascluar implant

Facility

$12,018.07

Service Code	HCPCS C1876
Hospital Charge Code	8684542
Hospital Revenue Code	278
Min. Negotiated Rate	$3,004.52
Max. Negotiated Rate	$6,009.04
Rate for Payer: Aetna Commercial	$3,605.42
Rate for Payer: Cash Price	$10,575.90
Rate for Payer: Cigna Commercial	$3,004.52
Rate for Payer: Multiplan Auto	$6,009.04
Rate for Payer: Multiplan Commercial	$6,009.04
Rate for Payer: Multiplan Workers Comp	$6,009.04
Rate for Payer: Scott and White EPO/PPO	$6,009.04

Tack endovascluar implant

Facility

$12,018.07

Service Code	HCPCS C1876
Hospital Charge Code	8684542
Hospital Revenue Code	278
Min. Negotiated Rate	$1,081.63
Max. Negotiated Rate	$6,009.04
Rate for Payer: Aetna Commercial	$3,605.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,081.63
Rate for Payer: BCBS of TX Blue Advantage	$3,605.42
Rate for Payer: BCBS of TX Blue Essentials	$4,326.51
Rate for Payer: BCBS of TX PPO	$4,807.23
Rate for Payer: Cash Price	$10,575.90
Rate for Payer: Multiplan Auto	$6,009.04
Rate for Payer: Multiplan Commercial	$6,009.04
Rate for Payer: Multiplan Workers Comp	$6,009.04
Rate for Payer: Scott and White EPO/PPO	$6,009.04
Rate for Payer: Superior Health Plan EPO	$1,634.46

Tacrolimus (FK506), Blood SO

Facility

$681.00

Service Code	CPT 80197
Hospital Charge Code	1708973
Hospital Revenue Code	300
Rate for Payer: Cash Price	$599.28

Tacrolimus (FK506), Blood SO

Facility

$681.00

Service Code	CPT 80197
Hospital Charge Code	1708973
Hospital Revenue Code	300
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$442.65
Rate for Payer: Aetna Commercial	$14.42
Rate for Payer: Aetna Medicare	$20.60
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.73
Rate for Payer: Amerigroup Medicare	$13.73
Rate for Payer: BCBS of TX Blue Advantage	$22.65
Rate for Payer: BCBS of TX Blue Essentials	$27.19
Rate for Payer: BCBS of TX Medicare	$13.73
Rate for Payer: BCBS of TX PPO	$30.34
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cigna Medicaid	$13.73
Rate for Payer: Cigna Medicare	$13.73
Rate for Payer: Employer Direct Commercial	$13.73
Rate for Payer: Humana Medicare/TRICARE	$13.73
Rate for Payer: Molina CHIP/Medicaid	$13.73
Rate for Payer: Molina Dual Medicare/Medicaid	$13.73
Rate for Payer: Molina Medicare	$13.73
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Parkland Medicaid	$13.73
Rate for Payer: Scott and White EPO/PPO	$17.16
Rate for Payer: Scott and White Medicare	$13.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.73
Rate for Payer: Superior Health Plan EPO	$13.73
Rate for Payer: Superior Health Plan Medicare	$13.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.73
Rate for Payer: Universal American Medicare	$13.73
Rate for Payer: Wellcare Medicare	$13.73
Rate for Payer: Wellmed Medicare	$13.73

tamsulosin 0.4 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78407675
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

tamsulosin 0.4 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78407675
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

TANGNTL BX SKIN EA SEP/ADDL

Facility

$399.00

Service Code	CPT 11103
Hospital Charge Code	7150053
Hospital Revenue Code	761
Min. Negotiated Rate	$35.91
Max. Negotiated Rate	$259.35
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Amerigroup CHIP/Medicaid	$35.91
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	$351.12
Rate for Payer: Cash Price	$351.12
Rate for Payer: Multiplan Auto	$259.35
Rate for Payer: Multiplan Commercial	$259.35
Rate for Payer: Multiplan Workers Comp	$259.35
Rate for Payer: Scott and White EPO/PPO	$199.50
Rate for Payer: Superior Health Plan EPO	$54.26

TANGNTL BX SKIN SINGLE LES

Facility

$715.00

Service Code	CPT 11102
Hospital Charge Code	7150050
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$464.75
Rate for Payer: Aetna Commercial	$393.25
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$64.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$126.57
Rate for Payer: BCBS of TX Blue Essentials	$151.58
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$190.99
Rate for Payer: Cash Price	$629.20
Rate for Payer: Cash Price	$629.20
Rate for Payer: Cash Price	$629.20
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$64.23
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	$64.23
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$464.75
Rate for Payer: Multiplan Commercial	$464.75
Rate for Payer: Multiplan Workers Comp	$464.75
Rate for Payer: Parkland Medicaid	$64.23
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	$64.23
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

Know your out-of-pocket cost for care.

All Charges