White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WC Avlsn Plte, Smpl, Sngl BCE

Facility

$476.00

Service Code	CPT 11730
Hospital Charge Code	7150776
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$261.80
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$42.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$418.88
Rate for Payer: Cash Price	$418.88
Rate for Payer: Cash Price	$418.88
Rate for Payer: Cigna Commercial	$414.75
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 Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$309.40
Rate for Payer: Multiplan Commercial	$309.40
Rate for Payer: Multiplan Workers Comp	$309.40
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 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

WC Avlsn Plte, Smpl, Sngl BCE

Facility

$476.00

Service Code	CPT 11730
Hospital Charge Code	7150776
Hospital Revenue Code	761
Rate for Payer: Cash Price	$418.88

WC Biopsy Bone Open BCE

Facility

$4,752.00

Service Code	CPT 20240
Hospital Charge Code	7150911
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,181.76

WC Biopsy Bone Open BCE

Facility

$4,752.00

Service Code	CPT 20240
Hospital Charge Code	7150911
Hospital Revenue Code	361
Min. Negotiated Rate	$57.32
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$3,898.02
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,598.68
Rate for Payer: Amerigroup Medicare	$2,598.68
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,598.68
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cash Price	$4,181.76
Rate for Payer: Cash Price	$4,181.76
Rate for Payer: Cigna Commercial	$5,886.75
Rate for Payer: Cigna Medicaid	$815.20
Rate for Payer: Cigna Medicare	$2,598.68
Rate for Payer: Employer Direct Commercial	$2,598.68
Rate for Payer: Humana Medicare/TRICARE	$2,598.68
Rate for Payer: Molina CHIP/Medicaid	$815.20
Rate for Payer: Molina Dual Medicare/Medicaid	$2,598.68
Rate for Payer: Molina Medicare	$2,598.68
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	$815.20
Rate for Payer: Scott and White EPO/PPO	$57.32
Rate for Payer: Scott and White Medicare	$2,598.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$815.20
Rate for Payer: Superior Health Plan EPO	$2,598.68
Rate for Payer: Superior Health Plan Medicare	$2,598.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,598.68
Rate for Payer: Universal American Medicare	$2,598.68
Rate for Payer: Wellcare Medicare	$2,598.68
Rate for Payer: Wellmed Medicare	$2,598.68

WC BONE BIOPSY NEEDLE/TROCAR DEEP BCE

Facility

$2,948.00

Service Code	CPT 20225
Hospital Charge Code	8178355
Hospital Revenue Code	361
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
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	$1,482.74
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$2,594.24
Rate for Payer: Cash Price	$2,594.24
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$486.45
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$486.45
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
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	$486.45
Rate for Payer: Scott and White EPO/PPO	$32.70
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$486.45
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

WC BONE BIOPSY NEEDLE/TROCAR DEEP BCE

Facility

$2,948.00

Service Code	CPT 20225
Hospital Charge Code	8178355
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,594.24

WC Bone Biopsy Needle/Trocar, Superficial BCE

Facility

$2,714.00

Service Code	CPT 20220
Hospital Charge Code	7150910
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,388.32

WC Bone Biopsy Needle/Trocar, Superficial BCE

Facility

$2,714.00

Service Code	CPT 20220
Hospital Charge Code	7150910
Hospital Revenue Code	361
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
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	$1,482.74
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$2,388.32
Rate for Payer: Cash Price	$2,388.32
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$486.45
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$486.45
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
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	$486.45
Rate for Payer: Scott and White EPO/PPO	$32.70
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$486.45
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

WC Chemical Cauterization of Wound BCE

Facility

$410.00

Service Code	CPT 17250
Hospital Charge Code	7150345
Hospital Revenue Code	761
Rate for Payer: Cash Price	$360.80

WC Chemical Cauterization of Wound BCE

Facility

$410.00

Service Code	CPT 17250
Hospital Charge Code	7150345
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$225.50
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$36.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$360.80
Rate for Payer: Cash Price	$360.80
Rate for Payer: Cash Price	$360.80
Rate for Payer: Cigna Commercial	$414.75
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 Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$266.50
Rate for Payer: Multiplan Commercial	$266.50
Rate for Payer: Multiplan Workers Comp	$266.50
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 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

WC Counsel Smoking Cessatn 3-10Min BCE

Facility

$53.00

Service Code	CPT 99406
Hospital Charge Code	7150781
Hospital Revenue Code	510
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$59.45
Rate for Payer: Aetna Commercial	$29.15
Rate for Payer: Aetna Medicare	$39.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.24
Rate for Payer: Amerigroup Medicare	$26.24
Rate for Payer: BCBS of TX Blue Advantage	$21.94
Rate for Payer: BCBS of TX Blue Essentials	$26.23
Rate for Payer: BCBS of TX Medicare	$26.24
Rate for Payer: BCBS of TX PPO	$29.26
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cigna Commercial	$59.45
Rate for Payer: Cigna Medicaid	$10.29
Rate for Payer: Cigna Medicare	$26.24
Rate for Payer: Employer Direct Commercial	$26.24
Rate for Payer: Humana Medicare/TRICARE	$26.24
Rate for Payer: Molina CHIP/Medicaid	$10.29
Rate for Payer: Molina Dual Medicare/Medicaid	$26.24
Rate for Payer: Molina Medicare	$26.24
Rate for Payer: Multiplan Auto	$34.45
Rate for Payer: Multiplan Commercial	$34.45
Rate for Payer: Multiplan Workers Comp	$34.45
Rate for Payer: Parkland Medicaid	$10.29
Rate for Payer: Scott and White EPO/PPO	$0.47
Rate for Payer: Scott and White Medicare	$26.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.29
Rate for Payer: Superior Health Plan EPO	$26.24
Rate for Payer: Superior Health Plan Medicare	$26.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.24
Rate for Payer: Universal American Medicare	$26.24
Rate for Payer: Wellcare Medicare	$26.24
Rate for Payer: Wellmed Medicare	$26.24

WC Counsel Smoking Cessatn 3-10Min BCE

Facility

$53.00

Service Code	CPT 99406
Hospital Charge Code	7150781
Hospital Revenue Code	510
Rate for Payer: Cash Price	$46.64

WC Debrid Bone <=20 BCE

Facility

$5,698.00

Service Code	CPT 11044
Hospital Charge Code	7150188
Hospital Revenue Code	761
Min. Negotiated Rate	$26.52
Max. Negotiated Rate	$3,703.70
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$512.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
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	$1,482.74
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$5,014.24
Rate for Payer: Cash Price	$5,014.24
Rate for Payer: Cash Price	$5,014.24
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$486.45
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$486.45
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
Rate for Payer: Multiplan Auto	$3,703.70
Rate for Payer: Multiplan Commercial	$3,703.70
Rate for Payer: Multiplan Workers Comp	$3,703.70
Rate for Payer: Parkland Medicaid	$486.45
Rate for Payer: Scott and White EPO/PPO	$26.52
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$486.45
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

WC Debrid Bone <=20 BCE

Facility

$5,698.00

Service Code	CPT 11044
Hospital Charge Code	7150188
Hospital Revenue Code	761
Rate for Payer: Cash Price	$5,014.24

WC Debrid Bone Ad 20 Sqcm BCE

Facility

$4,412.00

Service Code	CPT 11047
Hospital Charge Code	7150797
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$2,867.80
Rate for Payer: Aetna Commercial	$2,426.60
Rate for Payer: Amerigroup CHIP/Medicaid	$397.08
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	$3,882.56
Rate for Payer: Cash Price	$3,882.56
Rate for Payer: Multiplan Auto	$2,867.80
Rate for Payer: Multiplan Commercial	$2,867.80
Rate for Payer: Multiplan Workers Comp	$2,867.80
Rate for Payer: Scott and White EPO/PPO	$2,206.00
Rate for Payer: Superior Health Plan EPO	$600.03

WC Debrid Bone Ad 20 Sqcm BCE

Facility

$4,412.00

Service Code	CPT 11047
Hospital Charge Code	7150797
Hospital Revenue Code	761
Rate for Payer: Cash Price	$3,882.56

WC Debrid Mus/Fsc Ad 20 Sqcm BCE

Facility

$2,026.00

Service Code	CPT 11046
Hospital Charge Code	7150796
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$1,316.90
Rate for Payer: Aetna Commercial	$1,114.30
Rate for Payer: Amerigroup CHIP/Medicaid	$182.34
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	$1,782.88
Rate for Payer: Cash Price	$1,782.88
Rate for Payer: Multiplan Auto	$1,316.90
Rate for Payer: Multiplan Commercial	$1,316.90
Rate for Payer: Multiplan Workers Comp	$1,316.90
Rate for Payer: Scott and White EPO/PPO	$1,013.00
Rate for Payer: Superior Health Plan EPO	$275.54

WC Debrid Mus/Fsc Ad 20 Sqcm BCE

Facility

$2,026.00

Service Code	CPT 11046
Hospital Charge Code	7150796
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,782.88

WC Debrid Mus/Fsc Tiss <=20 BCE

Facility

$2,376.00

Service Code	CPT 11043
Hospital Charge Code	7150170
Hospital Revenue Code	761
Rate for Payer: Cash Price	$2,090.88

WC Debrid Mus/Fsc Tiss <=20 BCE

Facility

$2,376.00

Service Code	CPT 11043
Hospital Charge Code	7150170
Hospital Revenue Code	761
Min. Negotiated Rate	$10.27
Max. Negotiated Rate	$1,544.40
Rate for Payer: Aetna Commercial	$1,306.80
Rate for Payer: Aetna Medicare	$861.57
Rate for Payer: Amerigroup CHIP/Medicaid	$213.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$574.38
Rate for Payer: Amerigroup Medicare	$574.38
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$574.38
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,090.88
Rate for Payer: Cash Price	$2,090.88
Rate for Payer: Cash Price	$2,090.88
Rate for Payer: Cigna Commercial	$1,301.14
Rate for Payer: Cigna Medicaid	$216.80
Rate for Payer: Cigna Medicare	$574.38
Rate for Payer: Employer Direct Commercial	$574.38
Rate for Payer: Humana Medicare/TRICARE	$574.38
Rate for Payer: Molina CHIP/Medicaid	$216.80
Rate for Payer: Molina Dual Medicare/Medicaid	$574.38
Rate for Payer: Molina Medicare	$574.38
Rate for Payer: Multiplan Auto	$1,544.40
Rate for Payer: Multiplan Commercial	$1,544.40
Rate for Payer: Multiplan Workers Comp	$1,544.40
Rate for Payer: Parkland Medicaid	$216.80
Rate for Payer: Scott and White EPO/PPO	$10.27
Rate for Payer: Scott and White Medicare	$574.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.80
Rate for Payer: Superior Health Plan EPO	$574.38
Rate for Payer: Superior Health Plan Medicare	$574.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$574.38
Rate for Payer: Universal American Medicare	$574.38
Rate for Payer: Wellcare Medicare	$574.38
Rate for Payer: Wellmed Medicare	$574.38

WC Debrid Skin/Sq Tiss <=20 BCE

Facility

$1,546.00

Service Code	CPT 11042
Hospital Charge Code	7150162
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,360.48

WC Debrid Skin/Sq Tiss <=20 BCE

Facility

$1,546.00

Service Code	CPT 11042
Hospital Charge Code	7150162
Hospital Revenue Code	761
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$1,004.90
Rate for Payer: Aetna Commercial	$850.30
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$139.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,360.48
Rate for Payer: Cash Price	$1,360.48
Rate for Payer: Cash Price	$1,360.48
Rate for Payer: Cigna Commercial	$826.08
Rate for Payer: Cigna Medicaid	$143.08
Rate for Payer: Cigna Medicare	$364.67
Rate for Payer: Employer Direct Commercial	$364.67
Rate for Payer: Humana Medicare/TRICARE	$364.67
Rate for Payer: Molina CHIP/Medicaid	$143.08
Rate for Payer: Molina Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$1,004.90
Rate for Payer: Multiplan Commercial	$1,004.90
Rate for Payer: Multiplan Workers Comp	$1,004.90
Rate for Payer: Parkland Medicaid	$143.08
Rate for Payer: Scott and White EPO/PPO	$6.52
Rate for Payer: Scott and White Medicare	$364.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.08
Rate for Payer: Superior Health Plan EPO	$364.67
Rate for Payer: Superior Health Plan Medicare	$364.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.67
Rate for Payer: Universal American Medicare	$364.67
Rate for Payer: Wellcare Medicare	$364.67
Rate for Payer: Wellmed Medicare	$364.67

WC Debrid Sq Tiss Ad 20 Sqcm BCE

Facility

$1,020.00

Service Code	CPT 11045
Hospital Charge Code	7150795
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$663.00
Rate for Payer: Aetna Commercial	$561.00
Rate for Payer: Amerigroup CHIP/Medicaid	$91.80
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	$897.60
Rate for Payer: Cash Price	$897.60
Rate for Payer: Multiplan Auto	$663.00
Rate for Payer: Multiplan Commercial	$663.00
Rate for Payer: Multiplan Workers Comp	$663.00
Rate for Payer: Scott and White EPO/PPO	$510.00
Rate for Payer: Superior Health Plan EPO	$138.72

WC Debrid Sq Tiss Ad 20 Sqcm BCE

Facility

$1,020.00

Service Code	CPT 11045
Hospital Charge Code	7150795
Hospital Revenue Code	761
Rate for Payer: Cash Price	$897.60

WC Dressing/Debridement Burns, Small BCE

Facility

$413.00

Service Code	CPT 16020
Hospital Charge Code	7150819
Hospital Revenue Code	761
Rate for Payer: Cash Price	$363.44

Know your out-of-pocket cost for care.

All Charges