White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MSK NASAL CPAP -- DHF

Facility

$75.16

Hospital Charge Code	82056979
Hospital Revenue Code	271
Rate for Payer: Cash Price	$51.11

.Mtb AST Confirm 182691 SO

Facility

$147.00

Service Code	HCPCS 87190
Hospital Charge Code	1700035
Hospital Revenue Code	300
Rate for Payer: Cash Price	$99.96

.Mtb AST Confirm 182691 SO

Facility

$147.00

Service Code	HCPCS 87190
Hospital Charge Code	1700035
Hospital Revenue Code	300
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$105.84
Rate for Payer: Amerigroup CHIP/Medicaid	$2.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.31
Rate for Payer: Amerigroup Medicare	$7.31
Rate for Payer: BCBS of TX Blue Advantage	$44.10
Rate for Payer: BCBS of TX Blue Essentials	$52.92
Rate for Payer: BCBS of TX Medicare	$7.31
Rate for Payer: BCBS of TX PPO	$58.80
Rate for Payer: Cash Price	$99.96
Rate for Payer: Cash Price	$99.96
Rate for Payer: Cigna Medicaid	$105.84
Rate for Payer: Cigna Medicare	$7.31
Rate for Payer: Employer Direct Commercial	$7.31
Rate for Payer: Humana Medicare/TRICARE	$7.31
Rate for Payer: Molina CHIP/Medicaid	$105.84
Rate for Payer: Molina Dual Medicare/Medicaid	$7.31
Rate for Payer: Molina Medicare	$7.31
Rate for Payer: Multiplan Auto	$95.55
Rate for Payer: Multiplan Commercial	$95.55
Rate for Payer: Multiplan Workers Comp	$95.55
Rate for Payer: Parkland Medicaid	$105.84
Rate for Payer: Scott and White EPO/PPO	$9.14
Rate for Payer: Scott and White Medicare	$7.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$105.84
Rate for Payer: Superior Health Plan EPO	$7.31
Rate for Payer: Superior Health Plan Medicare	$7.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.31
Rate for Payer: Universal American Medicare	$7.31
Rate for Payer: Wellcare Medicare	$7.31
Rate for Payer: Wellmed Medicare	$7.31

.Mtb Susceptibility Broth 182579 SO

Facility

$182.00

Service Code	HCPCS 87188
Hospital Charge Code	1700034
Hospital Revenue Code	300
Rate for Payer: Cash Price	$123.76

.Mtb Susceptibility Broth 182579 SO

Facility

$182.00

Service Code	HCPCS 87188
Hospital Charge Code	1700034
Hospital Revenue Code	300
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$131.04
Rate for Payer: Amerigroup CHIP/Medicaid	$2.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.64
Rate for Payer: Amerigroup Medicare	$6.64
Rate for Payer: BCBS of TX Blue Advantage	$54.60
Rate for Payer: BCBS of TX Blue Essentials	$65.52
Rate for Payer: BCBS of TX Medicare	$6.64
Rate for Payer: BCBS of TX PPO	$72.80
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cigna Medicaid	$131.04
Rate for Payer: Cigna Medicare	$6.64
Rate for Payer: Employer Direct Commercial	$6.64
Rate for Payer: Humana Medicare/TRICARE	$6.64
Rate for Payer: Molina CHIP/Medicaid	$131.04
Rate for Payer: Molina Dual Medicare/Medicaid	$6.64
Rate for Payer: Molina Medicare	$6.64
Rate for Payer: Multiplan Auto	$118.30
Rate for Payer: Multiplan Commercial	$118.30
Rate for Payer: Multiplan Workers Comp	$118.30
Rate for Payer: Parkland Medicaid	$131.04
Rate for Payer: Scott and White EPO/PPO	$8.30
Rate for Payer: Scott and White Medicare	$6.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.04
Rate for Payer: Superior Health Plan EPO	$6.64
Rate for Payer: Superior Health Plan Medicare	$6.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.64
Rate for Payer: Universal American Medicare	$6.64
Rate for Payer: Wellcare Medicare	$6.64
Rate for Payer: Wellmed Medicare	$6.64

MUC 4.3MM CANN ENDMILL CHARLOTTE F&A SYSTEM

Facility

$1,520.90

Hospital Charge Code	993528
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,034.21

MUC 4.3MM CANN ENDMILL CHARLOTTE F&A SYSTEM

Facility

$1,520.90

Hospital Charge Code	993528
Hospital Revenue Code	270
Min. Negotiated Rate	$136.88
Max. Negotiated Rate	$1,095.05
Rate for Payer: Amerigroup CHIP/Medicaid	$136.88
Rate for Payer: BCBS of TX Blue Advantage	$456.27
Rate for Payer: BCBS of TX Blue Essentials	$547.52
Rate for Payer: BCBS of TX PPO	$608.36
Rate for Payer: Cash Price	$1,034.21
Rate for Payer: Cigna Medicaid	$1,095.05
Rate for Payer: Molina CHIP/Medicaid	$1,095.05
Rate for Payer: Multiplan Auto	$988.59
Rate for Payer: Multiplan Commercial	$988.59
Rate for Payer: Multiplan Workers Comp	$988.59
Rate for Payer: Parkland Medicaid	$1,095.05
Rate for Payer: Scott and White EPO/PPO	$760.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,095.05
Rate for Payer: Superior Health Plan EPO	$206.84

MUC SCREW 3.0 X 28MM CHARLOTTE F&A SYSTEM

Facility

$2,233.13

Service Code	HCPCS C1713
Hospital Charge Code	992291
Hospital Revenue Code	278
Min. Negotiated Rate	$558.28
Max. Negotiated Rate	$1,116.57
Rate for Payer: Cash Price	$1,518.53
Rate for Payer: Cigna Commercial	$558.28
Rate for Payer: Multiplan Auto	$1,116.57
Rate for Payer: Multiplan Commercial	$1,116.57
Rate for Payer: Multiplan Workers Comp	$1,116.57
Rate for Payer: Scott and White EPO/PPO	$1,116.57

MUC SCREW 3.0 X 28MM CHARLOTTE F&A SYSTEM

Facility

$2,233.13

Service Code	HCPCS C1713
Hospital Charge Code	992291
Hospital Revenue Code	278
Min. Negotiated Rate	$200.98
Max. Negotiated Rate	$1,607.85
Rate for Payer: Amerigroup CHIP/Medicaid	$200.98
Rate for Payer: BCBS of TX Blue Advantage	$669.94
Rate for Payer: BCBS of TX Blue Essentials	$803.93
Rate for Payer: BCBS of TX PPO	$893.25
Rate for Payer: Cash Price	$1,518.53
Rate for Payer: Cigna Medicaid	$1,607.85
Rate for Payer: Molina CHIP/Medicaid	$1,607.85
Rate for Payer: Multiplan Auto	$1,116.57
Rate for Payer: Multiplan Commercial	$1,116.57
Rate for Payer: Multiplan Workers Comp	$1,116.57
Rate for Payer: Parkland Medicaid	$1,607.85
Rate for Payer: Scott and White EPO/PPO	$1,116.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,607.85
Rate for Payer: Superior Health Plan EPO	$303.71

MUC SCREW 4.3 MM X 36 MM LONG CHARLOTTE F&A SYSTEM

Facility

$2,743.37

Service Code	HCPCS C1713
Hospital Charge Code	993136
Hospital Revenue Code	278
Min. Negotiated Rate	$246.90
Max. Negotiated Rate	$1,975.23
Rate for Payer: Amerigroup CHIP/Medicaid	$246.90
Rate for Payer: BCBS of TX Blue Advantage	$823.01
Rate for Payer: BCBS of TX Blue Essentials	$987.61
Rate for Payer: BCBS of TX PPO	$1,097.35
Rate for Payer: Cash Price	$1,865.49
Rate for Payer: Cigna Medicaid	$1,975.23
Rate for Payer: Molina CHIP/Medicaid	$1,975.23
Rate for Payer: Multiplan Auto	$1,371.68
Rate for Payer: Multiplan Commercial	$1,371.68
Rate for Payer: Multiplan Workers Comp	$1,371.68
Rate for Payer: Parkland Medicaid	$1,975.23
Rate for Payer: Scott and White EPO/PPO	$1,371.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,975.23
Rate for Payer: Superior Health Plan EPO	$373.10

MUC SCREW 4.3 MM X 36 MM LONG CHARLOTTE F&A SYSTEM

Facility

$2,743.37

Service Code	HCPCS C1713
Hospital Charge Code	993136
Hospital Revenue Code	278
Min. Negotiated Rate	$685.84
Max. Negotiated Rate	$1,371.68
Rate for Payer: Cash Price	$1,865.49
Rate for Payer: Cigna Commercial	$685.84
Rate for Payer: Multiplan Auto	$1,371.68
Rate for Payer: Multiplan Commercial	$1,371.68
Rate for Payer: Multiplan Workers Comp	$1,371.68
Rate for Payer: Scott and White EPO/PPO	$1,371.68

MUC SCREW 4.3 MM X 50 MM LONG CHARLOTTE F&A SYSTEM

Facility

$2,743.37

Service Code	HCPCS C1713
Hospital Charge Code	993137
Hospital Revenue Code	278
Min. Negotiated Rate	$685.84
Max. Negotiated Rate	$1,371.68
Rate for Payer: Cash Price	$1,865.49
Rate for Payer: Cigna Commercial	$685.84
Rate for Payer: Multiplan Auto	$1,371.68
Rate for Payer: Multiplan Commercial	$1,371.68
Rate for Payer: Multiplan Workers Comp	$1,371.68
Rate for Payer: Scott and White EPO/PPO	$1,371.68

MUC SCREW 4.3 MM X 50 MM LONG CHARLOTTE F&A SYSTEM

Facility

$2,743.37

Service Code	HCPCS C1713
Hospital Charge Code	993137
Hospital Revenue Code	278
Min. Negotiated Rate	$246.90
Max. Negotiated Rate	$1,975.23
Rate for Payer: Amerigroup CHIP/Medicaid	$246.90
Rate for Payer: BCBS of TX Blue Advantage	$823.01
Rate for Payer: BCBS of TX Blue Essentials	$987.61
Rate for Payer: BCBS of TX PPO	$1,097.35
Rate for Payer: Cash Price	$1,865.49
Rate for Payer: Cigna Medicaid	$1,975.23
Rate for Payer: Molina CHIP/Medicaid	$1,975.23
Rate for Payer: Multiplan Auto	$1,371.68
Rate for Payer: Multiplan Commercial	$1,371.68
Rate for Payer: Multiplan Workers Comp	$1,371.68
Rate for Payer: Parkland Medicaid	$1,975.23
Rate for Payer: Scott and White EPO/PPO	$1,371.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,975.23
Rate for Payer: Superior Health Plan EPO	$373.10

MUC SCREW 4.3MM X 55MM LONG CHARLOTTE F&A SYSTEM

Facility

$2,743.37

Service Code	HCPCS C1713
Hospital Charge Code	992374
Hospital Revenue Code	278
Min. Negotiated Rate	$685.84
Max. Negotiated Rate	$1,371.68
Rate for Payer: Cash Price	$1,865.49
Rate for Payer: Cigna Commercial	$685.84
Rate for Payer: Multiplan Auto	$1,371.68
Rate for Payer: Multiplan Commercial	$1,371.68
Rate for Payer: Multiplan Workers Comp	$1,371.68
Rate for Payer: Scott and White EPO/PPO	$1,371.68

MUC SCREW 4.3MM X 55MM LONG CHARLOTTE F&A SYSTEM

Facility

$2,743.37

Service Code	HCPCS C1713
Hospital Charge Code	992374
Hospital Revenue Code	278
Min. Negotiated Rate	$246.90
Max. Negotiated Rate	$1,975.23
Rate for Payer: Amerigroup CHIP/Medicaid	$246.90
Rate for Payer: BCBS of TX Blue Advantage	$823.01
Rate for Payer: BCBS of TX Blue Essentials	$987.61
Rate for Payer: BCBS of TX PPO	$1,097.35
Rate for Payer: Cash Price	$1,865.49
Rate for Payer: Cigna Medicaid	$1,975.23
Rate for Payer: Molina CHIP/Medicaid	$1,975.23
Rate for Payer: Multiplan Auto	$1,371.68
Rate for Payer: Multiplan Commercial	$1,371.68
Rate for Payer: Multiplan Workers Comp	$1,371.68
Rate for Payer: Parkland Medicaid	$1,975.23
Rate for Payer: Scott and White EPO/PPO	$1,371.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,975.23
Rate for Payer: Superior Health Plan EPO	$373.10

MUE 1 - Percutaneous implantation of neurostimulator electrode array; cranial nerve

Facility

$47,810.36

Service Code	HCPCS 64553
Hospital Charge Code	9900811
Hospital Revenue Code	360
Rate for Payer: Cash Price	$32,511.04

MUE 1 - Percutaneous implantation of neurostimulator electrode array; cranial nerve

Facility

$47,810.36

Service Code	HCPCS 64553
Hospital Charge Code	9900811
Hospital Revenue Code	360
Min. Negotiated Rate	$7,950.18
Max. Negotiated Rate	$34,423.46
Rate for Payer: Amerigroup CHIP/Medicaid	$7,950.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Amerigroup Medicare	$11,193.47
Rate for Payer: BCBS of TX Blue Advantage	$10,332.51
Rate for Payer: BCBS of TX Blue Essentials	$12,374.26
Rate for Payer: BCBS of TX Medicare	$11,193.47
Rate for Payer: BCBS of TX PPO	$15,591.57
Rate for Payer: Cash Price	$32,511.04
Rate for Payer: Cash Price	$32,511.04
Rate for Payer: Cash Price	$32,511.04
Rate for Payer: Cigna Commercial	$23,660.97
Rate for Payer: Cigna Medicaid	$34,423.46
Rate for Payer: Cigna Medicare	$11,193.47
Rate for Payer: Employer Direct Commercial	$11,193.47
Rate for Payer: Humana Medicare/TRICARE	$11,193.47
Rate for Payer: Molina CHIP/Medicaid	$34,423.46
Rate for Payer: Molina Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Molina Medicare	$11,193.47
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	$34,423.46
Rate for Payer: Scott and White EPO/PPO	$23,047.24
Rate for Payer: Scott and White Medicare	$11,193.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34,423.46
Rate for Payer: Superior Health Plan EPO	$11,193.47
Rate for Payer: Superior Health Plan Medicare	$11,193.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Universal American Medicare	$11,193.47
Rate for Payer: Wellcare Medicare	$11,193.47
Rate for Payer: Wellmed Medicare	$11,193.47

MUE 1 - Percutaneous implantation of neurostimulator electrode array; cranial nerve

Facility

$23,660.97

Service Code	CPT 64553
Hospital Charge Code	36064553
Hospital Revenue Code	360
Min. Negotiated Rate	$7,950.18
Max. Negotiated Rate	$23,660.97
Rate for Payer: Amerigroup CHIP/Medicaid	$7,950.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Amerigroup Medicare	$11,193.47
Rate for Payer: BCBS of TX Blue Advantage	$10,332.51
Rate for Payer: BCBS of TX Blue Essentials	$12,374.26
Rate for Payer: BCBS of TX Medicare	$11,193.47
Rate for Payer: BCBS of TX PPO	$15,591.57
Rate for Payer: Cigna Commercial	$23,660.97
Rate for Payer: Cigna Medicare	$11,193.47
Rate for Payer: Employer Direct Commercial	$11,193.47
Rate for Payer: Humana Medicare/TRICARE	$11,193.47
Rate for Payer: Molina Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Molina Medicare	$11,193.47
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	$23,047.24
Rate for Payer: Scott and White Medicare	$11,193.47
Rate for Payer: Superior Health Plan EPO	$11,193.47
Rate for Payer: Superior Health Plan Medicare	$11,193.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Universal American Medicare	$11,193.47
Rate for Payer: Wellcare Medicare	$11,193.47
Rate for Payer: Wellmed Medicare	$11,193.47

MUE 2 - The incision for implantation of neurostimulator electrode array peripheral nerve (excludes

Facility

$48,584.14

Service Code	CPT 64575
Hospital Charge Code	36064575
Hospital Revenue Code	360
Min. Negotiated Rate	$8,186.92
Max. Negotiated Rate	$48,584.14
Rate for Payer: Amerigroup CHIP/Medicaid	$8,186.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Amerigroup Medicare	$11,193.47
Rate for Payer: BCBS of TX Blue Advantage	$32,196.63
Rate for Payer: BCBS of TX Blue Essentials	$38,558.84
Rate for Payer: BCBS of TX Medicare	$11,193.47
Rate for Payer: BCBS of TX PPO	$48,584.14
Rate for Payer: Cigna Commercial	$23,660.97
Rate for Payer: Cigna Medicare	$11,193.47
Rate for Payer: Employer Direct Commercial	$11,193.47
Rate for Payer: Humana Medicare/TRICARE	$11,193.47
Rate for Payer: Molina Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Molina Medicare	$11,193.47
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	$23,047.24
Rate for Payer: Scott and White Medicare	$11,193.47
Rate for Payer: Superior Health Plan EPO	$11,193.47
Rate for Payer: Superior Health Plan Medicare	$11,193.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Universal American Medicare	$11,193.47
Rate for Payer: Wellcare Medicare	$11,193.47
Rate for Payer: Wellmed Medicare	$11,193.47

MUE 2 - The incision for implantation of neurostimulator electrode array peripheral nerve (excludes

Facility

$38,558.84

Service Code	HCPCS 64575
Hospital Charge Code	9900814
Hospital Revenue Code	360
Rate for Payer: Cash Price	$26,220.01

MUE 2 - The incision for implantation of neurostimulator electrode array peripheral nerve (excludes

Facility

$38,558.84

Service Code	HCPCS 64575
Hospital Charge Code	9900814
Hospital Revenue Code	360
Min. Negotiated Rate	$8,186.92
Max. Negotiated Rate	$48,584.14
Rate for Payer: Amerigroup CHIP/Medicaid	$8,186.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Amerigroup Medicare	$11,193.47
Rate for Payer: BCBS of TX Blue Advantage	$32,196.63
Rate for Payer: BCBS of TX Blue Essentials	$38,558.84
Rate for Payer: BCBS of TX Medicare	$11,193.47
Rate for Payer: BCBS of TX PPO	$48,584.14
Rate for Payer: Cash Price	$26,220.01
Rate for Payer: Cash Price	$26,220.01
Rate for Payer: Cash Price	$26,220.01
Rate for Payer: Cigna Commercial	$23,660.97
Rate for Payer: Cigna Medicaid	$27,762.36
Rate for Payer: Cigna Medicare	$11,193.47
Rate for Payer: Employer Direct Commercial	$11,193.47
Rate for Payer: Humana Medicare/TRICARE	$11,193.47
Rate for Payer: Molina CHIP/Medicaid	$27,762.36
Rate for Payer: Molina Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Molina Medicare	$11,193.47
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	$27,762.36
Rate for Payer: Scott and White EPO/PPO	$23,047.24
Rate for Payer: Scott and White Medicare	$11,193.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,762.36
Rate for Payer: Superior Health Plan EPO	$11,193.47
Rate for Payer: Superior Health Plan Medicare	$11,193.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,193.47
Rate for Payer: Universal American Medicare	$11,193.47
Rate for Payer: Wellcare Medicare	$11,193.47
Rate for Payer: Wellmed Medicare	$11,193.47

MUG INSULTD 32OZ W/STRW CLR/BLU 40/CS

Facility

$8.83

Hospital Charge Code	993270
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.00

MUG INSULTD 32OZ W/STRW CLR/BLU 40/CS

Facility

$8.83

Hospital Charge Code	993270
Hospital Revenue Code	270
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$6.36
Rate for Payer: Amerigroup CHIP/Medicaid	$0.79
Rate for Payer: BCBS of TX Blue Advantage	$2.65
Rate for Payer: BCBS of TX Blue Essentials	$3.18
Rate for Payer: BCBS of TX PPO	$3.53
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cigna Medicaid	$6.36
Rate for Payer: Molina CHIP/Medicaid	$6.36
Rate for Payer: Multiplan Auto	$5.74
Rate for Payer: Multiplan Commercial	$5.74
Rate for Payer: Multiplan Workers Comp	$5.74
Rate for Payer: Parkland Medicaid	$6.36
Rate for Payer: Scott and White EPO/PPO	$4.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.36
Rate for Payer: Superior Health Plan EPO	$1.20

*Multilayer Compression Wrap -> Below the Knee Bilateral

Facility

$993.50

Service Code	HCPCS 29581
Hospital Charge Code	7150774
Hospital Revenue Code	361
Min. Negotiated Rate	$51.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$51.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$112.86
Rate for Payer: BCBS of TX Blue Essentials	$135.16
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$170.30
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
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	$715.32
Rate for Payer: Scott and White EPO/PPO	$266.58
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

*Multilayer Compression Wrap -> Below the Knee Bilateral

Facility

$993.50

Service Code	HCPCS 29581
Hospital Charge Code	7150774
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

Know your out-of-pocket cost for care.

All Charges