White Rock Medical Center

All Charges

Charge

Type

Setting

Price

QUICK-CROSS, .014 150 cm (518-065-B)

Facility

$4,540.00

Hospital Charge Code	993122
Hospital Revenue Code	270
Min. Negotiated Rate	$408.60
Max. Negotiated Rate	$3,268.80
Rate for Payer: Amerigroup CHIP/Medicaid	$408.60
Rate for Payer: BCBS of TX Blue Advantage	$1,362.00
Rate for Payer: BCBS of TX Blue Essentials	$1,634.40
Rate for Payer: BCBS of TX PPO	$1,816.00
Rate for Payer: Cash Price	$3,087.20
Rate for Payer: Cigna Medicaid	$3,268.80
Rate for Payer: Molina CHIP/Medicaid	$3,268.80
Rate for Payer: Multiplan Auto	$2,951.00
Rate for Payer: Multiplan Commercial	$2,951.00
Rate for Payer: Multiplan Workers Comp	$2,951.00
Rate for Payer: Parkland Medicaid	$3,268.80
Rate for Payer: Scott and White EPO/PPO	$2,270.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,268.80
Rate for Payer: Superior Health Plan EPO	$617.44

QUICK-CROSS, .014 150 cm (518-065-B)

Facility

$4,540.00

Hospital Charge Code	993122
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3,087.20

QUICK-CROSS, .035 135 cm (518-037-B)

Facility

$4,540.00

Hospital Charge Code	993123
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3,087.20

QUICK-CROSS, .035 135 cm (518-037-B)

Facility

$4,540.00

Hospital Charge Code	993123
Hospital Revenue Code	270
Min. Negotiated Rate	$408.60
Max. Negotiated Rate	$3,268.80
Rate for Payer: Amerigroup CHIP/Medicaid	$408.60
Rate for Payer: BCBS of TX Blue Advantage	$1,362.00
Rate for Payer: BCBS of TX Blue Essentials	$1,634.40
Rate for Payer: BCBS of TX PPO	$1,816.00
Rate for Payer: Cash Price	$3,087.20
Rate for Payer: Cigna Medicaid	$3,268.80
Rate for Payer: Molina CHIP/Medicaid	$3,268.80
Rate for Payer: Multiplan Auto	$2,951.00
Rate for Payer: Multiplan Commercial	$2,951.00
Rate for Payer: Multiplan Workers Comp	$2,951.00
Rate for Payer: Parkland Medicaid	$3,268.80
Rate for Payer: Scott and White EPO/PPO	$2,270.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,268.80
Rate for Payer: Superior Health Plan EPO	$617.44

QUICK-CROSS, .035 90 cm (518-036-B)

Facility

$4,540.00

Hospital Charge Code	993121
Hospital Revenue Code	270
Min. Negotiated Rate	$408.60
Max. Negotiated Rate	$3,268.80
Rate for Payer: Amerigroup CHIP/Medicaid	$408.60
Rate for Payer: BCBS of TX Blue Advantage	$1,362.00
Rate for Payer: BCBS of TX Blue Essentials	$1,634.40
Rate for Payer: BCBS of TX PPO	$1,816.00
Rate for Payer: Cash Price	$3,087.20
Rate for Payer: Cigna Medicaid	$3,268.80
Rate for Payer: Molina CHIP/Medicaid	$3,268.80
Rate for Payer: Multiplan Auto	$2,951.00
Rate for Payer: Multiplan Commercial	$2,951.00
Rate for Payer: Multiplan Workers Comp	$2,951.00
Rate for Payer: Parkland Medicaid	$3,268.80
Rate for Payer: Scott and White EPO/PPO	$2,270.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,268.80
Rate for Payer: Superior Health Plan EPO	$617.44

QUICK-CROSS, .035 90 cm (518-036-B)

Facility

$4,540.00

Hospital Charge Code	993121
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3,087.20

QUICK-VAC MIXING BOWL SINGLE

Facility

$431.30

Hospital Charge Code	144807
Hospital Revenue Code	270
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$310.54
Rate for Payer: Amerigroup CHIP/Medicaid	$38.82
Rate for Payer: BCBS of TX Blue Advantage	$129.39
Rate for Payer: BCBS of TX Blue Essentials	$155.27
Rate for Payer: BCBS of TX PPO	$172.52
Rate for Payer: Cash Price	$293.28
Rate for Payer: Cigna Medicaid	$310.54
Rate for Payer: Molina CHIP/Medicaid	$310.54
Rate for Payer: Multiplan Auto	$280.35
Rate for Payer: Multiplan Commercial	$280.35
Rate for Payer: Multiplan Workers Comp	$280.35
Rate for Payer: Parkland Medicaid	$310.54
Rate for Payer: Scott and White EPO/PPO	$215.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$310.54
Rate for Payer: Superior Health Plan EPO	$58.66

QUICK-VAC MIXING BOWL SINGLE

Facility

$431.30

Hospital Charge Code	144807
Hospital Revenue Code	270
Rate for Payer: Cash Price	$293.28

QuickVue SARS Antigen Test Kit CLIA Waived

Facility

$787.89

Hospital Charge Code	992712
Hospital Revenue Code	270
Rate for Payer: Cash Price	$535.77

QuickVue SARS Antigen Test Kit CLIA Waived

Facility

$787.89

Hospital Charge Code	992712
Hospital Revenue Code	270
Min. Negotiated Rate	$70.91
Max. Negotiated Rate	$567.28
Rate for Payer: Amerigroup CHIP/Medicaid	$70.91
Rate for Payer: BCBS of TX Blue Advantage	$236.37
Rate for Payer: BCBS of TX Blue Essentials	$283.64
Rate for Payer: BCBS of TX PPO	$315.16
Rate for Payer: Cash Price	$535.77
Rate for Payer: Cigna Medicaid	$567.28
Rate for Payer: Molina CHIP/Medicaid	$567.28
Rate for Payer: Multiplan Auto	$512.13
Rate for Payer: Multiplan Commercial	$512.13
Rate for Payer: Multiplan Workers Comp	$512.13
Rate for Payer: Parkland Medicaid	$567.28
Rate for Payer: Scott and White EPO/PPO	$393.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$567.28
Rate for Payer: Superior Health Plan EPO	$107.15

racepinephrine 2.25% Sol UD

Facility

$8.15

Service Code	HCPCS J7699
Hospital Charge Code	78744463
Hospital Revenue Code	636
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$4.08
Rate for Payer: Cash Price	$5.54
Rate for Payer: Cigna Commercial	$2.04
Rate for Payer: Scott and White EPO/PPO	$4.08

racepinephrine 2.25% Sol UD

Facility

$8.15

Service Code	HCPCS J7699
Hospital Charge Code	78744463
Hospital Revenue Code	636
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$5.87
Rate for Payer: Amerigroup CHIP/Medicaid	$0.73
Rate for Payer: BCBS of TX Blue Advantage	$2.44
Rate for Payer: BCBS of TX Blue Essentials	$2.93
Rate for Payer: BCBS of TX PPO	$3.26
Rate for Payer: Cash Price	$5.54
Rate for Payer: Cigna Medicaid	$5.87
Rate for Payer: Molina CHIP/Medicaid	$5.87
Rate for Payer: Multiplan Auto	$5.30
Rate for Payer: Multiplan Commercial	$5.30
Rate for Payer: Multiplan Workers Comp	$5.30
Rate for Payer: Parkland Medicaid	$5.87
Rate for Payer: Scott and White EPO/PPO	$4.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.87
Rate for Payer: Superior Health Plan EPO	$1.11

Radial styloidectomy (separate procedure)

Facility

$14,640.00

Service Code	HCPCS 25230
Hospital Charge Code	9900279
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,540.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$9,955.20
Rate for Payer: Cash Price	$9,955.20
Rate for Payer: Cash Price	$9,955.20
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$10,540.80
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$10,540.80
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$10,540.80
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,540.80
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Radial styloidectomy (separate procedure)

Facility

$10,000.00

Service Code	CPT 25230
Hospital Charge Code	36025230
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Radial styloidectomy (separate procedure)

Facility

$14,640.00

Service Code	HCPCS 25230
Hospital Charge Code	9900279
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,955.20

Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus,

Facility

$10,000.00

Service Code	CPT 25115
Hospital Charge Code	36025115
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus,

Facility

$6,961.75

Service Code	HCPCS 25115
Hospital Charge Code	9900272
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,733.99

Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus,

Facility

$6,961.75

Service Code	HCPCS 25115
Hospital Charge Code	9900272
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cash Price	$4,733.99
Rate for Payer: Cash Price	$4,733.99
Rate for Payer: Cash Price	$4,733.99
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$5,012.46
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina CHIP/Medicaid	$5,012.46
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$5,012.46
Rate for Payer: Scott and White EPO/PPO	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,012.46
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, T

Facility

$13,479.00

Service Code	HCPCS 25116
Hospital Charge Code	9900273
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$9,165.72
Rate for Payer: Cash Price	$9,165.72
Rate for Payer: Cash Price	$9,165.72
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$9,704.88
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$9,704.88
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$9,704.88
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,704.88
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, T

Facility

$13,479.00

Service Code	HCPCS 25116
Hospital Charge Code	9900273
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,165.72

Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, T

Facility

$10,000.00

Service Code	CPT 25116
Hospital Charge Code	36025116
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (se

Facility

$15,408.22

Service Code	CPT 24149
Hospital Charge Code	36024149
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (se

Facility

$23,096.00

Service Code	HCPCS 24149
Hospital Charge Code	9900244
Hospital Revenue Code	360
Rate for Payer: Cash Price	$15,705.28

Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (se

Facility

$23,096.00

Service Code	HCPCS 24149
Hospital Charge Code	9900244
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$16,629.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$15,705.28
Rate for Payer: Cash Price	$15,705.28
Rate for Payer: Cash Price	$15,705.28
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$16,629.12
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$16,629.12
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$16,629.12
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,629.12
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area 3 cm or greater

Facility

$18,960.08

Service Code	HCPCS 25078
Hospital Charge Code	9900268
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,892.85

Know your out-of-pocket cost for care.

All Charges