White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$68,487.40

Service Code	MSDRG 574
Min. Negotiated Rate	$26,194.74
Max. Negotiated Rate	$68,487.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,202.06
Rate for Payer: Amerigroup Medicare	$30,202.06
Rate for Payer: BCBS of TX Medicare	$30,202.06
Rate for Payer: Cigna Commercial	$44,711.63
Rate for Payer: Cigna Medicare	$30,202.06
Rate for Payer: Employer Direct Commercial	$30,202.06
Rate for Payer: Humana Medicare/TRICARE	$30,202.06
Rate for Payer: Molina Dual Medicare/Medicaid	$30,202.06
Rate for Payer: Molina Medicare	$30,202.06
Rate for Payer: Multiplan Auto	$68,487.40
Rate for Payer: Multiplan Commercial	$68,487.40
Rate for Payer: Multiplan Workers Comp	$68,487.40
Rate for Payer: Scott and White EPO/PPO	$31,540.25
Rate for Payer: Scott and White Medicare	$30,202.06
Rate for Payer: Superior Health Plan EPO	$30,202.06
Rate for Payer: Superior Health Plan Medicare	$30,202.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,202.06
Rate for Payer: Universal American Medicare	$30,202.06
Rate for Payer: Wellcare Medicare	$30,202.06
Rate for Payer: Wellmed Medicare	$30,202.06

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$111,539.50

Service Code	MSDRG 573
Min. Negotiated Rate	$45,162.90
Max. Negotiated Rate	$111,539.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$52,775.46
Rate for Payer: Amerigroup Medicare	$52,775.46
Rate for Payer: BCBS of TX Medicare	$52,775.46
Rate for Payer: Cigna Commercial	$84,382.03
Rate for Payer: Cigna Medicare	$52,775.46
Rate for Payer: Employer Direct Commercial	$52,775.46
Rate for Payer: Humana Medicare/TRICARE	$52,775.46
Rate for Payer: Molina Dual Medicare/Medicaid	$52,775.46
Rate for Payer: Molina Medicare	$52,775.46
Rate for Payer: Multiplan Auto	$111,539.50
Rate for Payer: Multiplan Commercial	$111,539.50
Rate for Payer: Multiplan Workers Comp	$111,539.50
Rate for Payer: Scott and White EPO/PPO	$51,366.88
Rate for Payer: Scott and White Medicare	$52,775.46
Rate for Payer: Superior Health Plan EPO	$52,775.46
Rate for Payer: Superior Health Plan Medicare	$52,775.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$52,775.46
Rate for Payer: Universal American Medicare	$52,775.46
Rate for Payer: Wellcare Medicare	$52,775.46
Rate for Payer: Wellmed Medicare	$52,775.46

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$38,942.40

Service Code	MSDRG 575
Min. Negotiated Rate	$15,123.96
Max. Negotiated Rate	$38,942.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,930.35
Rate for Payer: Amerigroup Medicare	$17,930.35
Rate for Payer: BCBS of TX Medicare	$17,930.35
Rate for Payer: Cigna Commercial	$21,040.77
Rate for Payer: Cigna Medicare	$17,930.35
Rate for Payer: Employer Direct Commercial	$17,930.35
Rate for Payer: Humana Medicare/TRICARE	$17,930.35
Rate for Payer: Molina Dual Medicare/Medicaid	$17,930.35
Rate for Payer: Molina Medicare	$17,930.35
Rate for Payer: Multiplan Auto	$38,942.40
Rate for Payer: Multiplan Commercial	$38,942.40
Rate for Payer: Multiplan Workers Comp	$38,942.40
Rate for Payer: Scott and White EPO/PPO	$17,934.00
Rate for Payer: Scott and White Medicare	$17,930.35
Rate for Payer: Superior Health Plan EPO	$17,930.35
Rate for Payer: Superior Health Plan Medicare	$17,930.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,930.35
Rate for Payer: Universal American Medicare	$17,930.35
Rate for Payer: Wellcare Medicare	$17,930.35
Rate for Payer: Wellmed Medicare	$17,930.35

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W MCC

Facility

$111,539.50

Service Code	MSDRG 573
Min. Negotiated Rate	$45,162.90
Max. Negotiated Rate	$111,539.50
Rate for Payer: BCBS of TX Blue Advantage	$45,162.90
Rate for Payer: BCBS of TX Blue Essentials	$54,190.23
Rate for Payer: BCBS of TX PPO	$60,213.70

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC

Facility

$38,942.40

Service Code	MSDRG 575
Min. Negotiated Rate	$15,123.96
Max. Negotiated Rate	$38,942.40
Rate for Payer: BCBS of TX Blue Advantage	$15,123.96
Rate for Payer: BCBS of TX Blue Essentials	$18,146.99
Rate for Payer: BCBS of TX PPO	$20,164.11

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$35,807.40

Service Code	MSDRG 623
Min. Negotiated Rate	$16,490.25
Max. Negotiated Rate	$35,807.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,907.63
Rate for Payer: Amerigroup Medicare	$17,907.63
Rate for Payer: BCBS of TX Medicare	$17,907.63
Rate for Payer: Cigna Commercial	$23,105.43
Rate for Payer: Cigna Medicare	$17,907.63
Rate for Payer: Employer Direct Commercial	$17,907.63
Rate for Payer: Humana Medicare/TRICARE	$17,907.63
Rate for Payer: Molina Dual Medicare/Medicaid	$17,907.63
Rate for Payer: Molina Medicare	$17,907.63
Rate for Payer: Multiplan Auto	$35,807.40
Rate for Payer: Multiplan Commercial	$35,807.40
Rate for Payer: Multiplan Workers Comp	$35,807.40
Rate for Payer: Scott and White EPO/PPO	$16,490.25
Rate for Payer: Scott and White Medicare	$17,907.63
Rate for Payer: Superior Health Plan EPO	$17,907.63
Rate for Payer: Superior Health Plan Medicare	$17,907.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,907.63
Rate for Payer: Universal American Medicare	$17,907.63
Rate for Payer: Wellcare Medicare	$17,907.63
Rate for Payer: Wellmed Medicare	$17,907.63

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$68,800.90

Service Code	MSDRG 622
Min. Negotiated Rate	$30,845.56
Max. Negotiated Rate	$68,800.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,845.56
Rate for Payer: Amerigroup Medicare	$30,845.56
Rate for Payer: BCBS of TX Medicare	$30,845.56
Rate for Payer: Cigna Commercial	$45,842.50
Rate for Payer: Cigna Medicare	$30,845.56
Rate for Payer: Employer Direct Commercial	$30,845.56
Rate for Payer: Humana Medicare/TRICARE	$30,845.56
Rate for Payer: Molina Dual Medicare/Medicaid	$30,845.56
Rate for Payer: Molina Medicare	$30,845.56
Rate for Payer: Multiplan Auto	$68,800.90
Rate for Payer: Multiplan Commercial	$68,800.90
Rate for Payer: Multiplan Workers Comp	$68,800.90
Rate for Payer: Scott and White EPO/PPO	$31,684.62
Rate for Payer: Scott and White Medicare	$30,845.56
Rate for Payer: Superior Health Plan EPO	$30,845.56
Rate for Payer: Superior Health Plan Medicare	$30,845.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,845.56
Rate for Payer: Universal American Medicare	$30,845.56
Rate for Payer: Wellcare Medicare	$30,845.56
Rate for Payer: Wellmed Medicare	$30,845.56

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$18,791.00

Service Code	MSDRG 624
Min. Negotiated Rate	$8,653.75
Max. Negotiated Rate	$18,791.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,935.29
Rate for Payer: Amerigroup Medicare	$13,935.29
Rate for Payer: BCBS of TX Medicare	$13,935.29
Rate for Payer: Cigna Commercial	$16,124.47
Rate for Payer: Cigna Medicare	$13,935.29
Rate for Payer: Employer Direct Commercial	$13,935.29
Rate for Payer: Humana Medicare/TRICARE	$13,935.29
Rate for Payer: Molina Dual Medicare/Medicaid	$13,935.29
Rate for Payer: Molina Medicare	$13,935.29
Rate for Payer: Multiplan Auto	$18,791.00
Rate for Payer: Multiplan Commercial	$18,791.00
Rate for Payer: Multiplan Workers Comp	$18,791.00
Rate for Payer: Scott and White EPO/PPO	$8,653.75
Rate for Payer: Scott and White Medicare	$13,935.29
Rate for Payer: Superior Health Plan EPO	$13,935.29
Rate for Payer: Superior Health Plan Medicare	$13,935.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,935.29
Rate for Payer: Universal American Medicare	$13,935.29
Rate for Payer: Wellcare Medicare	$13,935.29
Rate for Payer: Wellmed Medicare	$13,935.29

SKIN GRAFTS FOR INJURIES W CC/MCC

Facility

$67,486.10

Service Code	MSDRG 904
Min. Negotiated Rate	$27,743.60
Max. Negotiated Rate	$67,486.10
Rate for Payer: BCBS of TX Blue Advantage	$27,743.60
Rate for Payer: BCBS of TX Blue Essentials	$33,289.09
Rate for Payer: BCBS of TX PPO	$36,989.32

SKIN GRAFTS FOR INJURIES WITH CC/MCC

Facility

$67,486.10

Service Code	MSDRG 904
Min. Negotiated Rate	$27,743.60
Max. Negotiated Rate	$67,486.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$31,680.32
Rate for Payer: Amerigroup Medicare	$31,680.32
Rate for Payer: BCBS of TX Medicare	$31,680.32
Rate for Payer: Cigna Commercial	$47,309.53
Rate for Payer: Cigna Medicare	$31,680.32
Rate for Payer: Employer Direct Commercial	$31,680.32
Rate for Payer: Humana Medicare/TRICARE	$31,680.32
Rate for Payer: Molina Dual Medicare/Medicaid	$31,680.32
Rate for Payer: Molina Medicare	$31,680.32
Rate for Payer: Multiplan Auto	$67,486.10
Rate for Payer: Multiplan Commercial	$67,486.10
Rate for Payer: Multiplan Workers Comp	$67,486.10
Rate for Payer: Scott and White EPO/PPO	$31,079.12
Rate for Payer: Scott and White Medicare	$31,680.32
Rate for Payer: Superior Health Plan EPO	$31,680.32
Rate for Payer: Superior Health Plan Medicare	$31,680.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$31,680.32
Rate for Payer: Universal American Medicare	$31,680.32
Rate for Payer: Wellcare Medicare	$31,680.32
Rate for Payer: Wellmed Medicare	$31,680.32

SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC

Facility

$29,638.10

Service Code	MSDRG 905
Min. Negotiated Rate	$13,649.12
Max. Negotiated Rate	$29,638.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,631.95
Rate for Payer: Amerigroup Medicare	$15,631.95
Rate for Payer: BCBS of TX Medicare	$15,631.95
Rate for Payer: Cigna Commercial	$18,441.58
Rate for Payer: Cigna Medicare	$15,631.95
Rate for Payer: Employer Direct Commercial	$15,631.95
Rate for Payer: Humana Medicare/TRICARE	$15,631.95
Rate for Payer: Molina Dual Medicare/Medicaid	$15,631.95
Rate for Payer: Molina Medicare	$15,631.95
Rate for Payer: Multiplan Auto	$29,638.10
Rate for Payer: Multiplan Commercial	$29,638.10
Rate for Payer: Multiplan Workers Comp	$29,638.10
Rate for Payer: Scott and White EPO/PPO	$13,649.12
Rate for Payer: Scott and White Medicare	$15,631.95
Rate for Payer: Superior Health Plan EPO	$15,631.95
Rate for Payer: Superior Health Plan Medicare	$15,631.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,631.95
Rate for Payer: Universal American Medicare	$15,631.95
Rate for Payer: Wellcare Medicare	$15,631.95
Rate for Payer: Wellmed Medicare	$15,631.95

SKIN GRAFTS FOR INJURIES W/O CC/MCC

Facility

$29,638.10

Service Code	MSDRG 905
Min. Negotiated Rate	$13,649.12
Max. Negotiated Rate	$29,638.10
Rate for Payer: BCBS of TX Blue Advantage	$15,215.12
Rate for Payer: BCBS of TX Blue Essentials	$18,256.37
Rate for Payer: BCBS of TX PPO	$20,285.65

SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC

Facility

$35,807.40

Service Code	MSDRG 623
Min. Negotiated Rate	$16,490.25
Max. Negotiated Rate	$35,807.40
Rate for Payer: BCBS of TX Blue Advantage	$16,539.52
Rate for Payer: BCBS of TX Blue Essentials	$19,845.50
Rate for Payer: BCBS of TX PPO	$22,051.41

SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W MCC

Facility

$68,800.90

Service Code	MSDRG 622
Min. Negotiated Rate	$30,845.56
Max. Negotiated Rate	$68,800.90
Rate for Payer: BCBS of TX Blue Advantage	$32,662.80
Rate for Payer: BCBS of TX Blue Essentials	$39,191.56
Rate for Payer: BCBS of TX PPO	$43,547.87

SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W/O CC/MCC

Facility

$18,791.00

Service Code	MSDRG 624
Min. Negotiated Rate	$8,653.75
Max. Negotiated Rate	$18,791.00
Rate for Payer: BCBS of TX Blue Advantage	$11,145.60
Rate for Payer: BCBS of TX Blue Essentials	$13,373.42
Rate for Payer: BCBS of TX PPO	$14,859.94

Skin Sub Graft Face/Neck/Nk/Fh/G First 25 Sq cm

Facility

$7,316.92

Service Code	HCPCS 15275
Hospital Charge Code	7150814
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,975.51

Skin Sub Graft Face/Neck/Nk/Fh/G First 25 Sq cm

Facility

$7,316.92

Service Code	HCPCS 15275
Hospital Charge Code	7150814
Hospital Revenue Code	361
Min. Negotiated Rate	$71.16
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$71.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$5,268.18
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	$5,268.18
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	$5,268.18
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,268.18
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

Skin Sub Grft Trk/Arm/Leg Ch 1st 100sqcm

Facility

$6,927.00

Service Code	HCPCS 15273
Hospital Charge Code	7150812
Hospital Revenue Code	361
Min. Negotiated Rate	$1,565.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,565.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cash Price	$4,710.36
Rate for Payer: Cash Price	$4,710.36
Rate for Payer: Cash Price	$4,710.36
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$4,987.44
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$4,987.44
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$4,987.44
Rate for Payer: Scott and White EPO/PPO	$6,069.94
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,987.44
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Skin Sub Grft Trk/Arm/Leg Ch 1st 100sqcm

Facility

$6,927.00

Service Code	HCPCS 15273
Hospital Charge Code	7150812
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,710.36

Skin Sub Grft Trk/Arm/Leg Ch 1st 25 sqcm

Facility

$10,292.16

Service Code	HCPCS 15271
Hospital Charge Code	7150810
Hospital Revenue Code	361
Min. Negotiated Rate	$742.44
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$784.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$6,998.67
Rate for Payer: Cash Price	$6,998.67
Rate for Payer: Cash Price	$6,998.67
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$7,410.36
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	$7,410.36
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	$7,410.36
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,410.36
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

Skin Sub Grft Trk/Arm/Leg Ch 1st 25 sqcm

Facility

$10,292.16

Service Code	HCPCS 15271
Hospital Charge Code	7150810
Hospital Revenue Code	361
Rate for Payer: Cash Price	$6,998.67

Skin Sub Grft Trk/Arm/Leg Ch ad 25 sqcm

Facility

$977.00

Service Code	HCPCS 15272
Hospital Charge Code	7150811
Hospital Revenue Code	361
Rate for Payer: Cash Price	$664.36

Skin Sub Grft Trk/Arm/Leg Ch ad 25 sqcm

Facility

$977.00

Service Code	HCPCS 15272
Hospital Charge Code	7150811
Hospital Revenue Code	361
Min. Negotiated Rate	$87.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$87.93
Rate for Payer: BCBS of TX Blue Advantage	$293.10
Rate for Payer: BCBS of TX Blue Essentials	$351.72
Rate for Payer: BCBS of TX PPO	$390.80
Rate for Payer: Cash Price	$664.36
Rate for Payer: Cash Price	$664.36
Rate for Payer: Cigna Medicaid	$703.44
Rate for Payer: Molina CHIP/Medicaid	$703.44
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	$703.44
Rate for Payer: Scott and White EPO/PPO	$488.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$703.44
Rate for Payer: Superior Health Plan EPO	$132.87

Skin Sub Grft Trnk/Arm/Leg Ch ad 100sqcm

Facility

$3,438.00

Service Code	HCPCS 15274
Hospital Charge Code	7150813
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,337.84

Skin Sub Grft Trnk/Arm/Leg Ch ad 100sqcm

Facility

$3,438.00

Service Code	HCPCS 15274
Hospital Charge Code	7150813
Hospital Revenue Code	361
Min. Negotiated Rate	$309.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$309.42
Rate for Payer: BCBS of TX Blue Advantage	$1,031.40
Rate for Payer: BCBS of TX Blue Essentials	$1,237.68
Rate for Payer: BCBS of TX PPO	$1,375.20
Rate for Payer: Cash Price	$2,337.84
Rate for Payer: Cash Price	$2,337.84
Rate for Payer: Cigna Medicaid	$2,475.36
Rate for Payer: Molina CHIP/Medicaid	$2,475.36
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	$2,475.36
Rate for Payer: Scott and White EPO/PPO	$1,719.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,475.36
Rate for Payer: Superior Health Plan EPO	$467.57

Know your out-of-pocket cost for care.

All Charges