White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WC Trim Nails Any Number BCE

Facility

$191.00

Service Code	CPT 11719
Hospital Charge Code	7150238
Hospital Revenue Code	761
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$138.63
Rate for Payer: Aetna Commercial	$105.05
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$17.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$91.87
Rate for Payer: BCBS of TX Blue Essentials	$110.02
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$138.63
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Scott and White EPO/PPO	$1.00
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

WC Trim Nails Any Number BCE

Facility

$191.00

Service Code	CPT 11719
Hospital Charge Code	7150238
Hospital Revenue Code	761
Rate for Payer: Cash Price	$168.08

WC Unna Boot BCE

Facility

$530.00

Service Code	CPT 29580 50
Hospital Charge Code	7150794
Hospital Revenue Code	761
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$344.50
Rate for Payer: Aetna Commercial	$291.50
Rate for Payer: Aetna Medicare	$216.15
Rate for Payer: Amerigroup CHIP/Medicaid	$47.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$144.10
Rate for Payer: Amerigroup Medicare	$144.10
Rate for Payer: BCBS of TX Blue Advantage	$70.51
Rate for Payer: BCBS of TX Blue Essentials	$84.44
Rate for Payer: BCBS of TX Medicare	$144.10
Rate for Payer: BCBS of TX PPO	$106.39
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cigna Commercial	$326.44
Rate for Payer: Cigna Medicaid	$35.16
Rate for Payer: Cigna Medicare	$144.10
Rate for Payer: Employer Direct Commercial	$144.10
Rate for Payer: Humana Medicare/TRICARE	$144.10
Rate for Payer: Molina CHIP/Medicaid	$35.16
Rate for Payer: Molina Dual Medicare/Medicaid	$144.10
Rate for Payer: Molina Medicare	$144.10
Rate for Payer: Multiplan Auto	$344.50
Rate for Payer: Multiplan Commercial	$344.50
Rate for Payer: Multiplan Workers Comp	$344.50
Rate for Payer: Parkland Medicaid	$35.16
Rate for Payer: Scott and White EPO/PPO	$2.58
Rate for Payer: Scott and White Medicare	$144.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.16
Rate for Payer: Superior Health Plan EPO	$144.10
Rate for Payer: Superior Health Plan Medicare	$144.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$144.10
Rate for Payer: Universal American Medicare	$144.10
Rate for Payer: Wellcare Medicare	$144.10
Rate for Payer: Wellmed Medicare	$144.10

WC Unna Boot BCE

Facility

$530.00

Service Code	CPT 29580 50
Hospital Charge Code	7150794
Hospital Revenue Code	761
Rate for Payer: Cash Price	$466.40

Weak D

Facility

$129.00

Service Code	CPT 86885
Hospital Charge Code	2402915
Hospital Revenue Code	300
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$353.86
Rate for Payer: Aetna Commercial	$6.00
Rate for Payer: Aetna Medicare	$234.32
Rate for Payer: Amerigroup CHIP/Medicaid	$2.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.21
Rate for Payer: Amerigroup Medicare	$156.21
Rate for Payer: BCBS of TX Blue Advantage	$236.78
Rate for Payer: BCBS of TX Blue Essentials	$284.13
Rate for Payer: BCBS of TX Medicare	$156.21
Rate for Payer: BCBS of TX PPO	$317.14
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cigna Commercial	$353.86
Rate for Payer: Cigna Medicaid	$5.72
Rate for Payer: Cigna Medicare	$156.21
Rate for Payer: Employer Direct Commercial	$156.21
Rate for Payer: Humana Medicare/TRICARE	$156.21
Rate for Payer: Molina CHIP/Medicaid	$5.72
Rate for Payer: Molina Dual Medicare/Medicaid	$156.21
Rate for Payer: Molina Medicare	$156.21
Rate for Payer: Multiplan Auto	$83.85
Rate for Payer: Multiplan Commercial	$83.85
Rate for Payer: Multiplan Workers Comp	$83.85
Rate for Payer: Parkland Medicaid	$5.72
Rate for Payer: Scott and White EPO/PPO	$7.15
Rate for Payer: Scott and White Medicare	$156.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.72
Rate for Payer: Superior Health Plan EPO	$156.21
Rate for Payer: Superior Health Plan Medicare	$156.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.21
Rate for Payer: Universal American Medicare	$156.21
Rate for Payer: Wellcare Medicare	$156.21
Rate for Payer: Wellmed Medicare	$156.21

Weak D

Facility

$129.00

Service Code	CPT 86885
Hospital Charge Code	2402915
Hospital Revenue Code	300
Rate for Payer: Cash Price	$113.52

WEDGE COMFORT GLIDE -- DHF

Facility

$144.71

Hospital Charge Code	80399017
Hospital Revenue Code	270
Rate for Payer: Cash Price	$127.34

WEDGE COMFORT GLIDE -- DHF

Facility

$144.71

Hospital Charge Code	80399017
Hospital Revenue Code	270
Min. Negotiated Rate	$13.02
Max. Negotiated Rate	$94.06
Rate for Payer: Aetna Commercial	$79.59
Rate for Payer: Amerigroup CHIP/Medicaid	$13.02
Rate for Payer: BCBS of TX Blue Advantage	$43.41
Rate for Payer: BCBS of TX Blue Essentials	$52.10
Rate for Payer: BCBS of TX PPO	$57.88
Rate for Payer: Cash Price	$127.34
Rate for Payer: Multiplan Auto	$94.06
Rate for Payer: Multiplan Commercial	$94.06
Rate for Payer: Multiplan Workers Comp	$94.06
Rate for Payer: Scott and White EPO/PPO	$72.36
Rate for Payer: Superior Health Plan EPO	$19.68

Wedge excision of skin of nail fold (eg, for ingrown toenail)

Facility

$10,000.00

Service Code	CPT 11765
Hospital Charge Code	36011765
Hospital Revenue Code	360
Min. Negotiated Rate	$8.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$547.00
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: Cigna Commercial	$826.08
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 Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
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	$8.04
Rate for Payer: Scott and White Medicare	$364.67
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

WEDGE POSITIONING UNIVERSAL 24X11X8.5

Facility

$58.54

Hospital Charge Code	145202
Hospital Revenue Code	270
Min. Negotiated Rate	$5.27
Max. Negotiated Rate	$38.05
Rate for Payer: Aetna Commercial	$32.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.27
Rate for Payer: BCBS of TX Blue Advantage	$17.56
Rate for Payer: BCBS of TX Blue Essentials	$21.07
Rate for Payer: BCBS of TX PPO	$23.42
Rate for Payer: Cash Price	$51.52
Rate for Payer: Multiplan Auto	$38.05
Rate for Payer: Multiplan Commercial	$38.05
Rate for Payer: Multiplan Workers Comp	$38.05
Rate for Payer: Scott and White EPO/PPO	$29.27
Rate for Payer: Superior Health Plan EPO	$7.96

WEDGE POSITIONING UNIVERSAL 24X11X8.5

Facility

$58.54

Hospital Charge Code	145202
Hospital Revenue Code	270
Rate for Payer: Cash Price	$51.52

West Nile Virus Ab, CSF SO

Facility

$166.00

Service Code	CPT 86788
Hospital Charge Code	1720002
Hospital Revenue Code	302
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$107.90
Rate for Payer: Aetna Commercial	$17.69
Rate for Payer: Aetna Medicare	$25.28
Rate for Payer: Amerigroup CHIP/Medicaid	$6.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.85
Rate for Payer: Amerigroup Medicare	$16.85
Rate for Payer: BCBS of TX Blue Advantage	$27.80
Rate for Payer: BCBS of TX Blue Essentials	$33.36
Rate for Payer: BCBS of TX Medicare	$16.85
Rate for Payer: BCBS of TX PPO	$37.24
Rate for Payer: Cash Price	$146.08
Rate for Payer: Cash Price	$146.08
Rate for Payer: Cigna Medicaid	$16.85
Rate for Payer: Cigna Medicare	$16.85
Rate for Payer: Employer Direct Commercial	$16.85
Rate for Payer: Humana Medicare/TRICARE	$16.85
Rate for Payer: Molina CHIP/Medicaid	$16.85
Rate for Payer: Molina Dual Medicare/Medicaid	$16.85
Rate for Payer: Molina Medicare	$16.85
Rate for Payer: Multiplan Auto	$107.90
Rate for Payer: Multiplan Commercial	$107.90
Rate for Payer: Multiplan Workers Comp	$107.90
Rate for Payer: Parkland Medicaid	$16.85
Rate for Payer: Scott and White EPO/PPO	$21.06
Rate for Payer: Scott and White Medicare	$16.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.85
Rate for Payer: Superior Health Plan EPO	$16.85
Rate for Payer: Superior Health Plan Medicare	$16.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.85
Rate for Payer: Universal American Medicare	$16.85
Rate for Payer: Wellcare Medicare	$16.85
Rate for Payer: Wellmed Medicare	$16.85

West Nile Virus Ab, CSF SO

Facility

$166.00

Service Code	CPT 86788
Hospital Charge Code	1720002
Hospital Revenue Code	302
Rate for Payer: Cash Price	$146.08

WEST NILE VIRUS AB IGM

Facility

$166.00

Service Code	CPT 86788
Hospital Charge Code	1720002
Hospital Revenue Code	302
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$107.90
Rate for Payer: Aetna Commercial	$17.69
Rate for Payer: Aetna Medicare	$25.28
Rate for Payer: Amerigroup CHIP/Medicaid	$6.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.85
Rate for Payer: Amerigroup Medicare	$16.85
Rate for Payer: BCBS of TX Blue Advantage	$27.80
Rate for Payer: BCBS of TX Blue Essentials	$33.36
Rate for Payer: BCBS of TX Medicare	$16.85
Rate for Payer: BCBS of TX PPO	$37.24
Rate for Payer: Cash Price	$146.08
Rate for Payer: Cash Price	$146.08
Rate for Payer: Cigna Medicaid	$16.85
Rate for Payer: Cigna Medicare	$16.85
Rate for Payer: Employer Direct Commercial	$16.85
Rate for Payer: Humana Medicare/TRICARE	$16.85
Rate for Payer: Molina CHIP/Medicaid	$16.85
Rate for Payer: Molina Dual Medicare/Medicaid	$16.85
Rate for Payer: Molina Medicare	$16.85
Rate for Payer: Multiplan Auto	$107.90
Rate for Payer: Multiplan Commercial	$107.90
Rate for Payer: Multiplan Workers Comp	$107.90
Rate for Payer: Parkland Medicaid	$16.85
Rate for Payer: Scott and White EPO/PPO	$21.06
Rate for Payer: Scott and White Medicare	$16.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.85
Rate for Payer: Superior Health Plan EPO	$16.85
Rate for Payer: Superior Health Plan Medicare	$16.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.85
Rate for Payer: Universal American Medicare	$16.85
Rate for Payer: Wellcare Medicare	$16.85
Rate for Payer: Wellmed Medicare	$16.85

West Nile Virus Ab,Serum SO

Facility

$139.00

Service Code	CPT 86789
Hospital Charge Code	1720010
Hospital Revenue Code	302
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$90.35
Rate for Payer: Aetna Commercial	$15.10
Rate for Payer: Aetna Medicare	$21.58
Rate for Payer: Amerigroup CHIP/Medicaid	$5.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.39
Rate for Payer: Amerigroup Medicare	$14.39
Rate for Payer: BCBS of TX Blue Advantage	$23.74
Rate for Payer: BCBS of TX Blue Essentials	$28.49
Rate for Payer: BCBS of TX Medicare	$14.39
Rate for Payer: BCBS of TX PPO	$31.80
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cigna Medicaid	$14.39
Rate for Payer: Cigna Medicare	$14.39
Rate for Payer: Employer Direct Commercial	$14.39
Rate for Payer: Humana Medicare/TRICARE	$14.39
Rate for Payer: Molina CHIP/Medicaid	$14.39
Rate for Payer: Molina Dual Medicare/Medicaid	$14.39
Rate for Payer: Molina Medicare	$14.39
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Parkland Medicaid	$14.39
Rate for Payer: Scott and White EPO/PPO	$17.99
Rate for Payer: Scott and White Medicare	$14.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.39
Rate for Payer: Superior Health Plan EPO	$14.39
Rate for Payer: Superior Health Plan Medicare	$14.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.39
Rate for Payer: Universal American Medicare	$14.39
Rate for Payer: Wellcare Medicare	$14.39
Rate for Payer: Wellmed Medicare	$14.39

West Nile Virus Ab,Serum SO

Facility

$139.00

Service Code	CPT 86789
Hospital Charge Code	1720010
Hospital Revenue Code	302
Rate for Payer: Cash Price	$122.32

WEST NILE VIRUS ANTIBODY

Facility

$139.00

Service Code	CPT 86789
Hospital Charge Code	1720010
Hospital Revenue Code	302
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$90.35
Rate for Payer: Aetna Commercial	$15.10
Rate for Payer: Aetna Medicare	$21.58
Rate for Payer: Amerigroup CHIP/Medicaid	$5.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.39
Rate for Payer: Amerigroup Medicare	$14.39
Rate for Payer: BCBS of TX Blue Advantage	$23.74
Rate for Payer: BCBS of TX Blue Essentials	$28.49
Rate for Payer: BCBS of TX Medicare	$14.39
Rate for Payer: BCBS of TX PPO	$31.80
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cigna Medicaid	$14.39
Rate for Payer: Cigna Medicare	$14.39
Rate for Payer: Employer Direct Commercial	$14.39
Rate for Payer: Humana Medicare/TRICARE	$14.39
Rate for Payer: Molina CHIP/Medicaid	$14.39
Rate for Payer: Molina Dual Medicare/Medicaid	$14.39
Rate for Payer: Molina Medicare	$14.39
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Parkland Medicaid	$14.39
Rate for Payer: Scott and White EPO/PPO	$17.99
Rate for Payer: Scott and White Medicare	$14.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.39
Rate for Payer: Superior Health Plan EPO	$14.39
Rate for Payer: Superior Health Plan Medicare	$14.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.39
Rate for Payer: Universal American Medicare	$14.39
Rate for Payer: Wellcare Medicare	$14.39
Rate for Payer: Wellmed Medicare	$14.39

Wet Prep

Facility

$98.00

Service Code	CPT 87210
Hospital Charge Code	4107210
Hospital Revenue Code	306
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$63.70
Rate for Payer: Aetna Commercial	$6.11
Rate for Payer: Aetna Medicare	$8.73
Rate for Payer: Amerigroup CHIP/Medicaid	$2.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.82
Rate for Payer: Amerigroup Medicare	$5.82
Rate for Payer: BCBS of TX Blue Advantage	$9.60
Rate for Payer: BCBS of TX Blue Essentials	$11.52
Rate for Payer: BCBS of TX Medicare	$5.82
Rate for Payer: BCBS of TX PPO	$12.86
Rate for Payer: Cash Price	$86.24
Rate for Payer: Cash Price	$86.24
Rate for Payer: Cigna Medicaid	$5.82
Rate for Payer: Cigna Medicare	$5.82
Rate for Payer: Employer Direct Commercial	$5.82
Rate for Payer: Humana Medicare/TRICARE	$5.82
Rate for Payer: Molina CHIP/Medicaid	$5.82
Rate for Payer: Molina Dual Medicare/Medicaid	$5.82
Rate for Payer: Molina Medicare	$5.82
Rate for Payer: Multiplan Auto	$63.70
Rate for Payer: Multiplan Commercial	$63.70
Rate for Payer: Multiplan Workers Comp	$63.70
Rate for Payer: Parkland Medicaid	$5.82
Rate for Payer: Scott and White EPO/PPO	$7.28
Rate for Payer: Scott and White Medicare	$5.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.82
Rate for Payer: Superior Health Plan EPO	$5.82
Rate for Payer: Superior Health Plan Medicare	$5.82
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.82
Rate for Payer: Universal American Medicare	$5.82
Rate for Payer: Wellcare Medicare	$5.82
Rate for Payer: Wellmed Medicare	$5.82

Wet Prep

Facility

$98.00

Service Code	CPT 87210
Hospital Charge Code	4107210
Hospital Revenue Code	306
Rate for Payer: Cash Price	$86.24

WIRE GUIDEPINCAL -- DHF

Facility

$654.62

Service Code	HCPCS C1769
Hospital Charge Code	81370900
Hospital Revenue Code	278
Min. Negotiated Rate	$58.92
Max. Negotiated Rate	$327.31
Rate for Payer: Aetna Commercial	$196.39
Rate for Payer: Amerigroup CHIP/Medicaid	$58.92
Rate for Payer: BCBS of TX Blue Advantage	$196.39
Rate for Payer: BCBS of TX Blue Essentials	$235.66
Rate for Payer: BCBS of TX PPO	$261.85
Rate for Payer: Cash Price	$576.07
Rate for Payer: Multiplan Auto	$327.31
Rate for Payer: Multiplan Commercial	$327.31
Rate for Payer: Multiplan Workers Comp	$327.31
Rate for Payer: Scott and White EPO/PPO	$327.31
Rate for Payer: Superior Health Plan EPO	$89.03

WIRE GUIDEPINCAL -- DHF

Facility

$654.62

Service Code	HCPCS C1769
Hospital Charge Code	81370900
Hospital Revenue Code	278
Min. Negotiated Rate	$163.66
Max. Negotiated Rate	$327.31
Rate for Payer: Aetna Commercial	$196.39
Rate for Payer: Cash Price	$576.07
Rate for Payer: Cigna Commercial	$163.66
Rate for Payer: Multiplan Auto	$327.31
Rate for Payer: Multiplan Commercial	$327.31
Rate for Payer: Multiplan Workers Comp	$327.31
Rate for Payer: Scott and White EPO/PPO	$327.31

WIRE KIRCHNER I

Facility

$361.44

Service Code	HCPCS C1769
Hospital Charge Code	8514469
Hospital Revenue Code	278
Min. Negotiated Rate	$32.53
Max. Negotiated Rate	$180.72
Rate for Payer: Aetna Commercial	$108.43
Rate for Payer: Amerigroup CHIP/Medicaid	$32.53
Rate for Payer: BCBS of TX Blue Advantage	$108.43
Rate for Payer: BCBS of TX Blue Essentials	$130.12
Rate for Payer: BCBS of TX PPO	$144.58
Rate for Payer: Cash Price	$318.07
Rate for Payer: Multiplan Auto	$180.72
Rate for Payer: Multiplan Commercial	$180.72
Rate for Payer: Multiplan Workers Comp	$180.72
Rate for Payer: Scott and White EPO/PPO	$180.72
Rate for Payer: Superior Health Plan EPO	$49.16

WIRE KIRCHNER I

Facility

$361.44

Service Code	HCPCS C1769
Hospital Charge Code	8514469
Hospital Revenue Code	278
Min. Negotiated Rate	$90.36
Max. Negotiated Rate	$180.72
Rate for Payer: Aetna Commercial	$108.43
Rate for Payer: Cash Price	$318.07
Rate for Payer: Cigna Commercial	$90.36
Rate for Payer: Multiplan Auto	$180.72
Rate for Payer: Multiplan Commercial	$180.72
Rate for Payer: Multiplan Workers Comp	$180.72
Rate for Payer: Scott and White EPO/PPO	$180.72

WIRE KIRCHNER II

Facility

$115.66

Service Code	HCPCS C1769
Hospital Charge Code	8514476
Hospital Revenue Code	278
Min. Negotiated Rate	$28.92
Max. Negotiated Rate	$57.83
Rate for Payer: Aetna Commercial	$34.70
Rate for Payer: Cash Price	$101.78
Rate for Payer: Cigna Commercial	$28.92
Rate for Payer: Multiplan Auto	$57.83
Rate for Payer: Multiplan Commercial	$57.83
Rate for Payer: Multiplan Workers Comp	$57.83
Rate for Payer: Scott and White EPO/PPO	$57.83

WIRE KIRCHNER II

Facility

$115.66

Service Code	HCPCS C1769
Hospital Charge Code	8514476
Hospital Revenue Code	278
Min. Negotiated Rate	$10.41
Max. Negotiated Rate	$57.83
Rate for Payer: Aetna Commercial	$34.70
Rate for Payer: Amerigroup CHIP/Medicaid	$10.41
Rate for Payer: BCBS of TX Blue Advantage	$34.70
Rate for Payer: BCBS of TX Blue Essentials	$41.64
Rate for Payer: BCBS of TX PPO	$46.26
Rate for Payer: Cash Price	$101.78
Rate for Payer: Multiplan Auto	$57.83
Rate for Payer: Multiplan Commercial	$57.83
Rate for Payer: Multiplan Workers Comp	$57.83
Rate for Payer: Scott and White EPO/PPO	$57.83
Rate for Payer: Superior Health Plan EPO	$15.73

Know your out-of-pocket cost for care.

All Charges