White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OPWC Strapping Una Boot Rt BCE

Facility

$993.50

Service Code	HCPCS 29580
Hospital Charge Code	8912558
Hospital Revenue Code	361
Min. Negotiated Rate	$33.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$33.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
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	$163.24
Rate for Payer: BCBS of TX PPO	$106.39
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	$301.99
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

OPWC Strapping Una Boot Rt BCE

Facility

$993.50

Service Code	HCPCS 29580
Hospital Charge Code	7150831
Hospital Revenue Code	361
Min. Negotiated Rate	$33.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$33.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
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	$163.24
Rate for Payer: BCBS of TX PPO	$106.39
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	$301.99
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

OPWC Strapping Una Boot Rt BCE

Facility

$993.50

Service Code	HCPCS 29580
Hospital Charge Code	7150831
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OPWC Tangntl Bx Skin Ea Sep/Addl BCE

Facility

$399.00

Service Code	HCPCS 11103
Hospital Charge Code	8914561
Hospital Revenue Code	361
Rate for Payer: Cash Price	$271.32

OPWC Tangntl Bx Skin Ea Sep/Addl BCE

Facility

$399.00

Service Code	HCPCS 11103
Hospital Charge Code	8914561
Hospital Revenue Code	361
Min. Negotiated Rate	$35.91
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$35.91
Rate for Payer: BCBS of TX Blue Advantage	$119.70
Rate for Payer: BCBS of TX Blue Essentials	$143.64
Rate for Payer: BCBS of TX PPO	$159.60
Rate for Payer: Cash Price	$271.32
Rate for Payer: Cash Price	$271.32
Rate for Payer: Cigna Medicaid	$287.28
Rate for Payer: Molina CHIP/Medicaid	$287.28
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	$287.28
Rate for Payer: Scott and White EPO/PPO	$199.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$287.28
Rate for Payer: Superior Health Plan EPO	$54.26

OPWC Tangntl Bx Skin Single Les BCE

Facility

$715.00

Service Code	HCPCS 11102
Hospital Charge Code	8912559
Hospital Revenue Code	361
Rate for Payer: Cash Price	$486.20

OPWC Tangntl Bx Skin Single Les BCE

Facility

$715.00

Service Code	HCPCS 11102
Hospital Charge Code	8912559
Hospital Revenue Code	361
Min. Negotiated Rate	$64.23
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$64.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
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	$408.37
Rate for Payer: BCBS of TX PPO	$190.99
Rate for Payer: Cash Price	$486.20
Rate for Payer: Cash Price	$486.20
Rate for Payer: Cash Price	$486.20
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$514.80
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$514.80
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$514.80
Rate for Payer: Scott and White EPO/PPO	$755.48
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$514.80
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

OPWC Tobacco Counsel >10Min Symtomatic BCE

Facility

$97.00

Service Code	HCPCS 99407
Hospital Charge Code	7150782
Hospital Revenue Code	761
Min. Negotiated Rate	$8.73
Max. Negotiated Rate	$79.55
Rate for Payer: Amerigroup CHIP/Medicaid	$8.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37.64
Rate for Payer: Amerigroup Medicare	$37.64
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 Medicare	$37.64
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cigna Commercial	$79.55
Rate for Payer: Cigna Medicaid	$69.84
Rate for Payer: Cigna Medicare	$37.64
Rate for Payer: Employer Direct Commercial	$37.64
Rate for Payer: Humana Medicare/TRICARE	$37.64
Rate for Payer: Molina CHIP/Medicaid	$69.84
Rate for Payer: Molina Dual Medicare/Medicaid	$37.64
Rate for Payer: Molina Medicare	$37.64
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$69.84
Rate for Payer: Scott and White EPO/PPO	$48.50
Rate for Payer: Scott and White Medicare	$37.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.84
Rate for Payer: Superior Health Plan EPO	$37.64
Rate for Payer: Superior Health Plan Medicare	$37.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$37.64
Rate for Payer: Universal American Medicare	$37.64
Rate for Payer: Wellcare Medicare	$37.64
Rate for Payer: Wellmed Medicare	$37.64

OPWC Tobacco Counsel >10Min Symtomatic BCE

Facility

$97.00

Service Code	HCPCS 99407
Hospital Charge Code	7150782
Hospital Revenue Code	761
Rate for Payer: Cash Price	$65.96

OPWC Tobacco Counsel >10Min Symtomatic BCE

Facility

$97.00

Service Code	HCPCS 99407
Hospital Charge Code	8910577
Hospital Revenue Code	761
Rate for Payer: Cash Price	$65.96

OPWC Tobacco Counsel >10Min Symtomatic BCE

Facility

$97.00

Service Code	HCPCS 99407
Hospital Charge Code	8910577
Hospital Revenue Code	761
Min. Negotiated Rate	$8.73
Max. Negotiated Rate	$79.55
Rate for Payer: Amerigroup CHIP/Medicaid	$8.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37.64
Rate for Payer: Amerigroup Medicare	$37.64
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 Medicare	$37.64
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cigna Commercial	$79.55
Rate for Payer: Cigna Medicaid	$69.84
Rate for Payer: Cigna Medicare	$37.64
Rate for Payer: Employer Direct Commercial	$37.64
Rate for Payer: Humana Medicare/TRICARE	$37.64
Rate for Payer: Molina CHIP/Medicaid	$69.84
Rate for Payer: Molina Dual Medicare/Medicaid	$37.64
Rate for Payer: Molina Medicare	$37.64
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$69.84
Rate for Payer: Scott and White EPO/PPO	$48.50
Rate for Payer: Scott and White Medicare	$37.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.84
Rate for Payer: Superior Health Plan EPO	$37.64
Rate for Payer: Superior Health Plan Medicare	$37.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$37.64
Rate for Payer: Universal American Medicare	$37.64
Rate for Payer: Wellcare Medicare	$37.64
Rate for Payer: Wellmed Medicare	$37.64

OPWC Trim Nails Any Number BCE

Facility

$993.50

Service Code	HCPCS 11719
Hospital Charge Code	8910578
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OPWC Trim Nails Any Number BCE

Facility

$993.50

Service Code	HCPCS 11719
Hospital Charge Code	8910578
Hospital Revenue Code	361
Min. Negotiated Rate	$59.26
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$89.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
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	$59.26
Rate for Payer: BCBS of TX PPO	$138.63
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	$125.27
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
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	$109.63
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

OPWC Unna Boot Bilateral BCE

Facility

$993.50

Service Code	HCPCS 29580
Hospital Charge Code	8910579
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OPWC Unna Boot Bilateral BCE

Facility

$993.50

Service Code	HCPCS 29580
Hospital Charge Code	8910579
Hospital Revenue Code	361
Min. Negotiated Rate	$33.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$33.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
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	$163.24
Rate for Payer: BCBS of TX PPO	$106.39
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	$301.99
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

OR01293

Facility

$24,909.63

Service Code	HCPCS C1734
Hospital Charge Code	991126
Hospital Revenue Code	278
Min. Negotiated Rate	$6,227.41
Max. Negotiated Rate	$12,454.82
Rate for Payer: Cash Price	$16,938.55
Rate for Payer: Cigna Commercial	$6,227.41
Rate for Payer: Multiplan Auto	$12,454.82
Rate for Payer: Multiplan Commercial	$12,454.82
Rate for Payer: Multiplan Workers Comp	$12,454.82
Rate for Payer: Scott and White EPO/PPO	$12,454.82

OR01293

Facility

$24,909.63

Service Code	HCPCS C1734
Hospital Charge Code	991126
Hospital Revenue Code	278
Min. Negotiated Rate	$2,241.87
Max. Negotiated Rate	$17,934.93
Rate for Payer: Amerigroup CHIP/Medicaid	$2,241.87
Rate for Payer: BCBS of TX Blue Advantage	$7,472.89
Rate for Payer: BCBS of TX Blue Essentials	$8,967.47
Rate for Payer: BCBS of TX PPO	$9,963.85
Rate for Payer: Cash Price	$16,938.55
Rate for Payer: Cigna Medicaid	$17,934.93
Rate for Payer: Molina CHIP/Medicaid	$17,934.93
Rate for Payer: Multiplan Auto	$12,454.82
Rate for Payer: Multiplan Commercial	$12,454.82
Rate for Payer: Multiplan Workers Comp	$12,454.82
Rate for Payer: Parkland Medicaid	$17,934.93
Rate for Payer: Scott and White EPO/PPO	$12,454.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,934.93
Rate for Payer: Superior Health Plan EPO	$3,387.71

OR01529

Facility

$5,180.72

Service Code	HCPCS C1734
Hospital Charge Code	991124
Hospital Revenue Code	278
Min. Negotiated Rate	$466.26
Max. Negotiated Rate	$3,730.12
Rate for Payer: Amerigroup CHIP/Medicaid	$466.26
Rate for Payer: BCBS of TX Blue Advantage	$1,554.22
Rate for Payer: BCBS of TX Blue Essentials	$1,865.06
Rate for Payer: BCBS of TX PPO	$2,072.29
Rate for Payer: Cash Price	$3,522.89
Rate for Payer: Cigna Medicaid	$3,730.12
Rate for Payer: Molina CHIP/Medicaid	$3,730.12
Rate for Payer: Multiplan Auto	$2,590.36
Rate for Payer: Multiplan Commercial	$2,590.36
Rate for Payer: Multiplan Workers Comp	$2,590.36
Rate for Payer: Parkland Medicaid	$3,730.12
Rate for Payer: Scott and White EPO/PPO	$2,590.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,730.12
Rate for Payer: Superior Health Plan EPO	$704.58

OR01529

Facility

$5,180.72

Service Code	HCPCS C1734
Hospital Charge Code	991124
Hospital Revenue Code	278
Min. Negotiated Rate	$1,295.18
Max. Negotiated Rate	$2,590.36
Rate for Payer: Cash Price	$3,522.89
Rate for Payer: Cigna Commercial	$1,295.18
Rate for Payer: Multiplan Auto	$2,590.36
Rate for Payer: Multiplan Commercial	$2,590.36
Rate for Payer: Multiplan Workers Comp	$2,590.36
Rate for Payer: Scott and White EPO/PPO	$2,590.36

OR01677

Facility

$34,910.64

Service Code	HCPCS C1734
Hospital Charge Code	991125
Hospital Revenue Code	278
Min. Negotiated Rate	$3,141.96
Max. Negotiated Rate	$25,135.66
Rate for Payer: Amerigroup CHIP/Medicaid	$3,141.96
Rate for Payer: BCBS of TX Blue Advantage	$10,473.19
Rate for Payer: BCBS of TX Blue Essentials	$12,567.83
Rate for Payer: BCBS of TX PPO	$13,964.26
Rate for Payer: Cash Price	$23,739.24
Rate for Payer: Cigna Medicaid	$25,135.66
Rate for Payer: Molina CHIP/Medicaid	$25,135.66
Rate for Payer: Multiplan Auto	$17,455.32
Rate for Payer: Multiplan Commercial	$17,455.32
Rate for Payer: Multiplan Workers Comp	$17,455.32
Rate for Payer: Parkland Medicaid	$25,135.66
Rate for Payer: Scott and White EPO/PPO	$17,455.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,135.66
Rate for Payer: Superior Health Plan EPO	$4,747.85

OR01677

Facility

$34,910.64

Service Code	HCPCS C1734
Hospital Charge Code	991125
Hospital Revenue Code	278
Min. Negotiated Rate	$8,727.66
Max. Negotiated Rate	$17,455.32
Rate for Payer: Cash Price	$23,739.24
Rate for Payer: Cigna Commercial	$8,727.66
Rate for Payer: Multiplan Auto	$17,455.32
Rate for Payer: Multiplan Commercial	$17,455.32
Rate for Payer: Multiplan Workers Comp	$17,455.32
Rate for Payer: Scott and White EPO/PPO	$17,455.32

ORBITAL PROCEDURES W CC/MCC

Facility

$44,670.90

Service Code	MSDRG 113
Min. Negotiated Rate	$19,803.22
Max. Negotiated Rate	$44,670.90
Rate for Payer: BCBS of TX Blue Advantage	$19,803.22
Rate for Payer: BCBS of TX Blue Essentials	$23,761.56
Rate for Payer: BCBS of TX PPO	$26,402.76

ORBITAL PROCEDURES WITH CC/MCC

Facility

$44,670.90

Service Code	MSDRG 113
Min. Negotiated Rate	$19,803.22
Max. Negotiated Rate	$44,670.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,991.36
Rate for Payer: Amerigroup Medicare	$21,991.36
Rate for Payer: BCBS of TX Medicare	$21,991.36
Rate for Payer: Cigna Commercial	$30,282.17
Rate for Payer: Cigna Medicare	$21,991.36
Rate for Payer: Employer Direct Commercial	$21,991.36
Rate for Payer: Humana Medicare/TRICARE	$21,991.36
Rate for Payer: Molina Dual Medicare/Medicaid	$21,991.36
Rate for Payer: Molina Medicare	$21,991.36
Rate for Payer: Multiplan Auto	$44,670.90
Rate for Payer: Multiplan Commercial	$44,670.90
Rate for Payer: Multiplan Workers Comp	$44,670.90
Rate for Payer: Scott and White EPO/PPO	$20,572.12
Rate for Payer: Scott and White Medicare	$21,991.36
Rate for Payer: Superior Health Plan EPO	$21,991.36
Rate for Payer: Superior Health Plan Medicare	$21,991.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,991.36
Rate for Payer: Universal American Medicare	$21,991.36
Rate for Payer: Wellcare Medicare	$21,991.36
Rate for Payer: Wellmed Medicare	$21,991.36

ORBITAL PROCEDURES WITHOUT CC/MCC

Facility

$25,707.00

Service Code	MSDRG 114
Min. Negotiated Rate	$10,793.86
Max. Negotiated Rate	$25,707.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,676.25
Rate for Payer: Amerigroup Medicare	$14,676.25
Rate for Payer: BCBS of TX Medicare	$14,676.25
Rate for Payer: Cigna Commercial	$17,426.64
Rate for Payer: Cigna Medicare	$14,676.25
Rate for Payer: Employer Direct Commercial	$14,676.25
Rate for Payer: Humana Medicare/TRICARE	$14,676.25
Rate for Payer: Molina Dual Medicare/Medicaid	$14,676.25
Rate for Payer: Molina Medicare	$14,676.25
Rate for Payer: Multiplan Auto	$25,707.00
Rate for Payer: Multiplan Commercial	$25,707.00
Rate for Payer: Multiplan Workers Comp	$25,707.00
Rate for Payer: Scott and White EPO/PPO	$11,838.75
Rate for Payer: Scott and White Medicare	$14,676.25
Rate for Payer: Superior Health Plan EPO	$14,676.25
Rate for Payer: Superior Health Plan Medicare	$14,676.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,676.25
Rate for Payer: Universal American Medicare	$14,676.25
Rate for Payer: Wellcare Medicare	$14,676.25
Rate for Payer: Wellmed Medicare	$14,676.25

ORBITAL PROCEDURES W/O CC/MCC

Facility

$25,707.00

Service Code	MSDRG 114
Min. Negotiated Rate	$10,793.86
Max. Negotiated Rate	$25,707.00
Rate for Payer: BCBS of TX Blue Advantage	$10,793.86
Rate for Payer: BCBS of TX Blue Essentials	$12,951.38
Rate for Payer: BCBS of TX PPO	$14,390.98

Know your out-of-pocket cost for care.

All Charges