White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

Facility

$10,000.00

Service Code	CPT 37765
Hospital Charge Code	36037765
Hospital Revenue Code	360
Min. Negotiated Rate	$194.90
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$194.90
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	$414.06
Rate for Payer: BCBS of TX Blue Essentials	$495.88
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$624.81
Rate for Payer: Cigna Commercial	$6,704.76
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 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: Scott and White EPO/PPO	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
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

Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

Facility

$14,618.15

Service Code	HCPCS 37765
Hospital Charge Code	9900633
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,940.34

Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

Facility

$14,618.15

Service Code	HCPCS 36475
Hospital Charge Code	9900627
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,940.34

Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

Facility

$14,618.15

Service Code	HCPCS 37765
Hospital Charge Code	9900633
Hospital Revenue Code	360
Min. Negotiated Rate	$194.90
Max. Negotiated Rate	$10,525.07
Rate for Payer: Amerigroup CHIP/Medicaid	$194.90
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	$414.06
Rate for Payer: BCBS of TX Blue Essentials	$495.88
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$624.81
Rate for Payer: Cash Price	$9,940.34
Rate for Payer: Cash Price	$9,940.34
Rate for Payer: Cash Price	$9,940.34
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$10,525.07
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	$10,525.07
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	$10,525.07
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	$10,525.07
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

Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

Facility

$10,000.00

Service Code	CPT 36475
Hospital Charge Code	36036475
Hospital Revenue Code	360
Min. Negotiated Rate	$1,118.22
Max. Negotiated Rate	$10,000.00
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: Cigna Commercial	$6,704.76
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 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: Scott and White EPO/PPO	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
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

Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

Facility

$14,618.15

Service Code	HCPCS 36475
Hospital Charge Code	9900627
Hospital Revenue Code	360
Min. Negotiated Rate	$1,118.22
Max. Negotiated Rate	$10,525.07
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	$9,940.34
Rate for Payer: Cash Price	$9,940.34
Rate for Payer: Cash Price	$9,940.34
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$10,525.07
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	$10,525.07
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	$10,525.07
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	$10,525.07
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

Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions

Facility

$11,915.88

Service Code	HCPCS 37766
Hospital Charge Code	9900634
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,102.80

Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions

Facility

$11,915.88

Service Code	HCPCS 37766
Hospital Charge Code	9900634
Hospital Revenue Code	360
Min. Negotiated Rate	$212.90
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$212.90
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	$456.24
Rate for Payer: BCBS of TX Blue Essentials	$546.40
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$688.46
Rate for Payer: Cash Price	$8,102.80
Rate for Payer: Cash Price	$8,102.80
Rate for Payer: Cash Price	$8,102.80
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$8,579.43
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	$8,579.43
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	$8,579.43
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	$8,579.43
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

Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions

Facility

$10,000.00

Service Code	CPT 37766
Hospital Charge Code	36037766
Hospital Revenue Code	360
Min. Negotiated Rate	$212.90
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$212.90
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	$456.24
Rate for Payer: BCBS of TX Blue Essentials	$546.40
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$688.46
Rate for Payer: Cigna Commercial	$6,704.76
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 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: Scott and White EPO/PPO	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
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

ST ADM BLOOD/PMP -- DHF

Facility

$152.70

Hospital Charge Code	54200365
Hospital Revenue Code	270
Rate for Payer: Cash Price	$103.84

ST ADM BLOOD/PMP -- DHF

Facility

$152.70

Hospital Charge Code	54200365
Hospital Revenue Code	270
Min. Negotiated Rate	$13.74
Max. Negotiated Rate	$109.94
Rate for Payer: Amerigroup CHIP/Medicaid	$13.74
Rate for Payer: BCBS of TX Blue Advantage	$45.81
Rate for Payer: BCBS of TX Blue Essentials	$54.97
Rate for Payer: BCBS of TX PPO	$61.08
Rate for Payer: Cash Price	$103.84
Rate for Payer: Cigna Medicaid	$109.94
Rate for Payer: Molina CHIP/Medicaid	$109.94
Rate for Payer: Multiplan Auto	$99.25
Rate for Payer: Multiplan Commercial	$99.25
Rate for Payer: Multiplan Workers Comp	$99.25
Rate for Payer: Parkland Medicaid	$109.94
Rate for Payer: Scott and White EPO/PPO	$76.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.94
Rate for Payer: Superior Health Plan EPO	$20.77

ST AMBU -- DHF

Facility

$85.35

Hospital Charge Code	82070004
Hospital Revenue Code	270
Rate for Payer: Cash Price	$58.04

ST AMBU -- DHF

Facility

$85.35

Hospital Charge Code	82070004
Hospital Revenue Code	270
Min. Negotiated Rate	$7.68
Max. Negotiated Rate	$61.45
Rate for Payer: Amerigroup CHIP/Medicaid	$7.68
Rate for Payer: BCBS of TX Blue Advantage	$25.61
Rate for Payer: BCBS of TX Blue Essentials	$30.73
Rate for Payer: BCBS of TX PPO	$34.14
Rate for Payer: Cash Price	$58.04
Rate for Payer: Cigna Medicaid	$61.45
Rate for Payer: Molina CHIP/Medicaid	$61.45
Rate for Payer: Multiplan Auto	$55.48
Rate for Payer: Multiplan Commercial	$55.48
Rate for Payer: Multiplan Workers Comp	$55.48
Rate for Payer: Parkland Medicaid	$61.45
Rate for Payer: Scott and White EPO/PPO	$42.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$61.45
Rate for Payer: Superior Health Plan EPO	$11.61

Standard bore iv extension set with removable sure-lok needle free connector

Facility

$8.56

Hospital Charge Code	993454
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.82

Standard bore iv extension set with removable sure-lok needle free connector

Facility

$8.56

Hospital Charge Code	993454
Hospital Revenue Code	272
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$6.16
Rate for Payer: Amerigroup CHIP/Medicaid	$0.77
Rate for Payer: BCBS of TX Blue Advantage	$2.57
Rate for Payer: BCBS of TX Blue Essentials	$3.08
Rate for Payer: BCBS of TX PPO	$3.42
Rate for Payer: Cash Price	$5.82
Rate for Payer: Cigna Medicaid	$6.16
Rate for Payer: Molina CHIP/Medicaid	$6.16
Rate for Payer: Multiplan Auto	$5.56
Rate for Payer: Multiplan Commercial	$5.56
Rate for Payer: Multiplan Workers Comp	$5.56
Rate for Payer: Parkland Medicaid	$6.16
Rate for Payer: Scott and White EPO/PPO	$4.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.16
Rate for Payer: Superior Health Plan EPO	$1.16

Standard instant cold pack, 6'x 9'

Facility

$2.94

Hospital Charge Code	993720
Hospital Revenue Code	271
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$2.12
Rate for Payer: Amerigroup CHIP/Medicaid	$0.26
Rate for Payer: BCBS of TX Blue Advantage	$0.88
Rate for Payer: BCBS of TX Blue Essentials	$1.06
Rate for Payer: BCBS of TX PPO	$1.18
Rate for Payer: Cash Price	$2.00
Rate for Payer: Cigna Medicaid	$2.12
Rate for Payer: Molina CHIP/Medicaid	$2.12
Rate for Payer: Multiplan Auto	$1.91
Rate for Payer: Multiplan Commercial	$1.91
Rate for Payer: Multiplan Workers Comp	$1.91
Rate for Payer: Parkland Medicaid	$2.12
Rate for Payer: Scott and White EPO/PPO	$1.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.12
Rate for Payer: Superior Health Plan EPO	$0.40

Standard instant cold pack, 6'x 9'

Facility

$2.94

Hospital Charge Code	993720
Hospital Revenue Code	271
Rate for Payer: Cash Price	$2.00

Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of for

Facility

$12,570.48

Service Code	CPT 69660
Hospital Charge Code	36069660
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of for

Facility

$13,986.64

Service Code	HCPCS 69660
Hospital Charge Code	9900893
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cash Price	$9,510.92
Rate for Payer: Cash Price	$9,510.92
Rate for Payer: Cash Price	$9,510.92
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicaid	$10,070.38
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina CHIP/Medicaid	$10,070.38
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$10,070.38
Rate for Payer: Scott and White EPO/PPO	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,070.38
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of for

Facility

$13,986.64

Service Code	HCPCS 69660
Hospital Charge Code	9900893
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,510.92

Staph Latex

Facility

$144.00

Service Code	HCPCS 87147
Hospital Charge Code	4107148
Hospital Revenue Code	306
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$103.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$43.20
Rate for Payer: BCBS of TX Blue Essentials	$51.84
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$57.60
Rate for Payer: Cash Price	$97.92
Rate for Payer: Cash Price	$97.92
Rate for Payer: Cigna Medicaid	$103.68
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$103.68
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$93.60
Rate for Payer: Multiplan Commercial	$93.60
Rate for Payer: Multiplan Workers Comp	$93.60
Rate for Payer: Parkland Medicaid	$103.68
Rate for Payer: Scott and White EPO/PPO	$6.47
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$103.68
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

Staph Latex

Facility

$144.00

Service Code	HCPCS 87147
Hospital Charge Code	4107148
Hospital Revenue Code	306
Rate for Payer: Cash Price	$97.92

stapler

Facility

$363.20

Hospital Charge Code	992680
Hospital Revenue Code	272
Min. Negotiated Rate	$32.69
Max. Negotiated Rate	$261.50
Rate for Payer: Amerigroup CHIP/Medicaid	$32.69
Rate for Payer: BCBS of TX Blue Advantage	$108.96
Rate for Payer: BCBS of TX Blue Essentials	$130.75
Rate for Payer: BCBS of TX PPO	$145.28
Rate for Payer: Cash Price	$246.98
Rate for Payer: Cigna Medicaid	$261.50
Rate for Payer: Molina CHIP/Medicaid	$261.50
Rate for Payer: Multiplan Auto	$236.08
Rate for Payer: Multiplan Commercial	$236.08
Rate for Payer: Multiplan Workers Comp	$236.08
Rate for Payer: Parkland Medicaid	$261.50
Rate for Payer: Scott and White EPO/PPO	$181.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$261.50
Rate for Payer: Superior Health Plan EPO	$49.40

stapler

Facility

$363.20

Hospital Charge Code	992680
Hospital Revenue Code	272
Rate for Payer: Cash Price	$246.98

stapler contour curved cs40b blue

Facility

$1,435.50

Hospital Charge Code	8666510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$976.14

Know your out-of-pocket cost for care.

All Charges