White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Repair blood vessel- hand, finger- major

Facility

$17,169.96

Service Code	HCPCS 35207
Hospital Charge Code	9900623
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,675.57

Repair blood vessel- hand, finger- major

Facility

$17,169.96

Service Code	HCPCS 35207
Hospital Charge Code	9900623
Hospital Revenue Code	360
Min. Negotiated Rate	$1,118.22
Max. Negotiated Rate	$12,362.37
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$11,675.57
Rate for Payer: Cash Price	$11,675.57
Rate for Payer: Cash Price	$11,675.57
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$12,362.37
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$12,362.37
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$12,362.37
Rate for Payer: Scott and White EPO/PPO	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,362.37
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

Repair, complex, eyelids, nose, ears and/or lips 1.1 cm to 2.5 cm

Facility

$3,145.02

Service Code	HCPCS 13151
Hospital Charge Code	9900115
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,138.61

Repair, complex, eyelids, nose, ears and/or lips 1.1 cm to 2.5 cm

Facility

$3,145.02

Service Code	HCPCS 13151
Hospital Charge Code	9900115
Hospital Revenue Code	360
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$216.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
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	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,138.61
Rate for Payer: Cash Price	$2,138.61
Rate for Payer: Cash Price	$2,138.61
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$2,264.41
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina CHIP/Medicaid	$2,264.41
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
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	$2,264.41
Rate for Payer: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,264.41
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

Repair, complex, eyelids, nose, ears and/or lips 1.1 cm to 2.5 cm

Facility

$10,000.00

Service Code	CPT 13151
Hospital Charge Code	36013151
Hospital Revenue Code	360
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$216.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
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	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
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	$1,062.60
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm

Facility

$1,519.68

Service Code	HCPCS 13131
Hospital Charge Code	990970
Hospital Revenue Code	360
Min. Negotiated Rate	$143.08
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$143.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
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	$408.37
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,033.38
Rate for Payer: Cash Price	$1,033.38
Rate for Payer: Cash Price	$1,033.38
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,094.17
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	$1,094.17
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	$1,094.17
Rate for Payer: Scott and White EPO/PPO	$674.64
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,094.17
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

Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm

Facility

$1,519.68

Service Code	HCPCS 13131
Hospital Charge Code	990970
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,033.38

Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm

Facility

$10,000.00

Service Code	CPT 13132
Hospital Charge Code	36013132
Hospital Revenue Code	360
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$216.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
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	$408.37
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cigna Commercial	$863.21
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 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: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$408.37
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

Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm

Facility

$3,145.02

Service Code	HCPCS 13132
Hospital Charge Code	9900114
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,138.61

Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm

Facility

$3,145.02

Service Code	HCPCS 13132
Hospital Charge Code	9900114
Hospital Revenue Code	360
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$216.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
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	$408.37
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,138.61
Rate for Payer: Cash Price	$2,138.61
Rate for Payer: Cash Price	$2,138.61
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$2,264.41
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	$2,264.41
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	$2,264.41
Rate for Payer: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,264.41
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

Repair, complex, scalp, arms, and/or legs 1.1 cm to 2.5 cm

Facility

$10,000.00

Service Code	CPT 13120
Hospital Charge Code	36013120
Hospital Revenue Code	360
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$216.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
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	$408.37
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cigna Commercial	$863.21
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 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: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$408.37
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

Repair, complex, scalp, arms, and/or legs 1.1 cm to 2.5 cm

Facility

$3,664.00

Service Code	HCPCS 13120
Hospital Charge Code	9900111
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,491.52

Repair, complex, scalp, arms, and/or legs 1.1 cm to 2.5 cm

Facility

$3,664.00

Service Code	HCPCS 13120
Hospital Charge Code	9900111
Hospital Revenue Code	360
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$216.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
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	$408.37
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,491.52
Rate for Payer: Cash Price	$2,491.52
Rate for Payer: Cash Price	$2,491.52
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$2,638.08
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	$2,638.08
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	$2,638.08
Rate for Payer: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,638.08
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

Repair, complex, scalp, arms, and/or legs 2.6 cm to 7.5 cm

Facility

$3,145.02

Service Code	HCPCS 13121
Hospital Charge Code	9900112
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,138.61

Repair, complex, scalp, arms, and/or legs 2.6 cm to 7.5 cm

Facility

$3,145.02

Service Code	HCPCS 13121
Hospital Charge Code	9900112
Hospital Revenue Code	360
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$216.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
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	$408.37
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,138.61
Rate for Payer: Cash Price	$2,138.61
Rate for Payer: Cash Price	$2,138.61
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$2,264.41
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	$2,264.41
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	$2,264.41
Rate for Payer: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,264.41
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

Repair, complex, scalp, arms, and/or legs 2.6 cm to 7.5 cm

Facility

$10,000.00

Service Code	CPT 13121
Hospital Charge Code	36013121
Hospital Revenue Code	360
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$216.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
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	$408.37
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cigna Commercial	$863.21
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 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: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$408.37
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

Repair, complex, scalp, arms, and/or legs each additional 5 cm or less (List separately in addition

Facility

$1,077.72

Service Code	HCPCS 13122
Hospital Charge Code	9900113
Hospital Revenue Code	360
Rate for Payer: Cash Price	$732.85

Repair, complex, scalp, arms, and/or legs each additional 5 cm or less (List separately in addition

Facility

$1,077.72

Service Code	HCPCS 13122
Hospital Charge Code	9900113
Hospital Revenue Code	360
Min. Negotiated Rate	$96.99
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$96.99
Rate for Payer: BCBS of TX Blue Advantage	$323.32
Rate for Payer: BCBS of TX Blue Essentials	$387.98
Rate for Payer: BCBS of TX PPO	$431.09
Rate for Payer: Cash Price	$732.85
Rate for Payer: Cash Price	$732.85
Rate for Payer: Cigna Medicaid	$775.96
Rate for Payer: Molina CHIP/Medicaid	$775.96
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	$775.96
Rate for Payer: Scott and White EPO/PPO	$538.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$775.96
Rate for Payer: Superior Health Plan EPO	$146.57

Repair, complex, scalp, arms, and/or legs each additional 5 cm or less (List separately in addition

Facility

$10,000.00

Service Code	CPT 13122
Hospital Charge Code	36013122
Hospital Revenue Code	360
Min. Negotiated Rate	$100.05
Max. Negotiated Rate	$10,000.00
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	$100.05

Repair, complex, trunk; 1.1 cm to 2.5 cm

Facility

$1,832.00

Service Code	HCPCS 13100
Hospital Charge Code	9900108
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,245.76

Repair, complex, trunk; 1.1 cm to 2.5 cm

Facility

$1,832.00

Service Code	HCPCS 13100
Hospital Charge Code	9900108
Hospital Revenue Code	360
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$216.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
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	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$1,245.76
Rate for Payer: Cash Price	$1,245.76
Rate for Payer: Cash Price	$1,245.76
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$1,319.04
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina CHIP/Medicaid	$1,319.04
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
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	$1,319.04
Rate for Payer: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,319.04
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

Repair, complex, trunk 2.6 cm to 7.5 cm

Facility

$5,496.03

Service Code	HCPCS 13101
Hospital Charge Code	9900109
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,737.30

Repair, complex, trunk 2.6 cm to 7.5 cm

Facility

$10,000.00

Service Code	CPT 13101
Hospital Charge Code	36013101
Hospital Revenue Code	360
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$216.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
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	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
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	$1,062.60
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

Repair, complex, trunk 2.6 cm to 7.5 cm

Facility

$5,496.03

Service Code	HCPCS 13101
Hospital Charge Code	9900109
Hospital Revenue Code	360
Min. Negotiated Rate	$216.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$216.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
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	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$3,737.30
Rate for Payer: Cash Price	$3,737.30
Rate for Payer: Cash Price	$3,737.30
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$3,957.14
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina CHIP/Medicaid	$3,957.14
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
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	$3,957.14
Rate for Payer: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,957.14
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

Repair, complex, trunk each additional 5 cm or less (List separately in addition to code for primar

Facility

$10,000.00

Service Code	CPT 13102
Hospital Charge Code	36013102
Hospital Revenue Code	360
Min. Negotiated Rate	$86.92
Max. Negotiated Rate	$10,000.00
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	$86.92

Know your out-of-pocket cost for care.

All Charges