White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SUTURE, MONODERM CLR 3-0 3.5X3.5CML DE12 NDL ABSRB -- DHF

Facility

$115.36

Hospital Charge Code	81943656
Hospital Revenue Code	272
Min. Negotiated Rate	$10.38
Max. Negotiated Rate	$83.06
Rate for Payer: Amerigroup CHIP/Medicaid	$10.38
Rate for Payer: BCBS of TX Blue Advantage	$34.61
Rate for Payer: BCBS of TX Blue Essentials	$41.53
Rate for Payer: BCBS of TX PPO	$46.14
Rate for Payer: Cash Price	$78.44
Rate for Payer: Cigna Medicaid	$83.06
Rate for Payer: Molina CHIP/Medicaid	$83.06
Rate for Payer: Multiplan Auto	$74.98
Rate for Payer: Multiplan Commercial	$74.98
Rate for Payer: Multiplan Workers Comp	$74.98
Rate for Payer: Parkland Medicaid	$83.06
Rate for Payer: Scott and White EPO/PPO	$57.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83.06
Rate for Payer: Superior Health Plan EPO	$15.69

SUTURE, MONODERM CLR 3-0 3.5X3.5CML DE12 NDL ABSRB -- DHF

Facility

$115.36

Hospital Charge Code	81943656
Hospital Revenue Code	272
Rate for Payer: Cash Price	$78.44

SUTURE, MONODERM CLR 3-0 7 X 7CML DE12 NDL ABSRB -- DHF

Facility

$124.04

Hospital Charge Code	81943557
Hospital Revenue Code	272
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$89.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: BCBS of TX Blue Advantage	$37.21
Rate for Payer: BCBS of TX Blue Essentials	$44.65
Rate for Payer: BCBS of TX PPO	$49.62
Rate for Payer: Cash Price	$84.35
Rate for Payer: Cigna Medicaid	$89.31
Rate for Payer: Molina CHIP/Medicaid	$89.31
Rate for Payer: Multiplan Auto	$80.63
Rate for Payer: Multiplan Commercial	$80.63
Rate for Payer: Multiplan Workers Comp	$80.63
Rate for Payer: Parkland Medicaid	$89.31
Rate for Payer: Scott and White EPO/PPO	$62.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.31
Rate for Payer: Superior Health Plan EPO	$16.87

SUTURE, MONODERM CLR 3-0 7 X 7CML DE12 NDL ABSRB -- DHF

Facility

$124.04

Hospital Charge Code	81943557
Hospital Revenue Code	272
Rate for Payer: Cash Price	$84.35

SUTURE, NUROLON, BLACK, 0, 8-18, MO-7

Facility

$84.97

Hospital Charge Code	993796
Hospital Revenue Code	272
Rate for Payer: Cash Price	$57.78

SUTURE, NUROLON, BLACK, 0, 8-18, MO-7

Facility

$84.97

Hospital Charge Code	993796
Hospital Revenue Code	272
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$61.18
Rate for Payer: Amerigroup CHIP/Medicaid	$7.65
Rate for Payer: BCBS of TX Blue Advantage	$25.49
Rate for Payer: BCBS of TX Blue Essentials	$30.59
Rate for Payer: BCBS of TX PPO	$33.99
Rate for Payer: Cash Price	$57.78
Rate for Payer: Cigna Medicaid	$61.18
Rate for Payer: Molina CHIP/Medicaid	$61.18
Rate for Payer: Multiplan Auto	$55.23
Rate for Payer: Multiplan Commercial	$55.23
Rate for Payer: Multiplan Workers Comp	$55.23
Rate for Payer: Parkland Medicaid	$61.18
Rate for Payer: Scott and White EPO/PPO	$42.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$61.18
Rate for Payer: Superior Health Plan EPO	$11.56

SUTURE, NUROLON BLK BR 0 CLSR 8-18' CR MO-7 COMPRT -- DHF

Facility

$642.60

Hospital Charge Code	8194155
Hospital Revenue Code	272
Rate for Payer: Cash Price	$436.97

SUTURE, NUROLON BLK BR 0 CLSR 8-18' CR MO-7 COMPRT -- DHF

Facility

$642.60

Hospital Charge Code	8194155
Hospital Revenue Code	272
Min. Negotiated Rate	$57.83
Max. Negotiated Rate	$462.67
Rate for Payer: Amerigroup CHIP/Medicaid	$57.83
Rate for Payer: BCBS of TX Blue Advantage	$192.78
Rate for Payer: BCBS of TX Blue Essentials	$231.34
Rate for Payer: BCBS of TX PPO	$257.04
Rate for Payer: Cash Price	$436.97
Rate for Payer: Cigna Medicaid	$462.67
Rate for Payer: Molina CHIP/Medicaid	$462.67
Rate for Payer: Multiplan Auto	$417.69
Rate for Payer: Multiplan Commercial	$417.69
Rate for Payer: Multiplan Workers Comp	$417.69
Rate for Payer: Parkland Medicaid	$462.67
Rate for Payer: Scott and White EPO/PPO	$321.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$462.67
Rate for Payer: Superior Health Plan EPO	$87.39

SUTURE NYL ETH 2-0 PS 18IN MFL BLK NABS

Facility

$11.09

Hospital Charge Code	121521
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7.54

SUTURE NYL ETH 2-0 PS 18IN MFL BLK NABS

Facility

$11.09

Hospital Charge Code	121521
Hospital Revenue Code	272
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$7.98
Rate for Payer: Amerigroup CHIP/Medicaid	$1.00
Rate for Payer: BCBS of TX Blue Advantage	$3.33
Rate for Payer: BCBS of TX Blue Essentials	$3.99
Rate for Payer: BCBS of TX PPO	$4.44
Rate for Payer: Cash Price	$7.54
Rate for Payer: Cigna Medicaid	$7.98
Rate for Payer: Molina CHIP/Medicaid	$7.98
Rate for Payer: Multiplan Auto	$7.21
Rate for Payer: Multiplan Commercial	$7.21
Rate for Payer: Multiplan Workers Comp	$7.21
Rate for Payer: Parkland Medicaid	$7.98
Rate for Payer: Scott and White EPO/PPO	$5.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.98
Rate for Payer: Superior Health Plan EPO	$1.51

Suture of 1 nerve; hand or foot, common sensory nerve

Facility

$13,882.71

Service Code	CPT 64834
Hospital Charge Code	36064834
Hospital Revenue Code	360
Min. Negotiated Rate	$1,996.58
Max. Negotiated Rate	$13,882.71
Rate for Payer: Amerigroup CHIP/Medicaid	$1,996.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Amerigroup Medicare	$3,431.72
Rate for Payer: BCBS of TX Blue Advantage	$9,200.05
Rate for Payer: BCBS of TX Blue Essentials	$11,018.02
Rate for Payer: BCBS of TX Medicare	$3,431.72
Rate for Payer: BCBS of TX PPO	$13,882.71
Rate for Payer: Cigna Commercial	$7,254.03
Rate for Payer: Cigna Medicare	$3,431.72
Rate for Payer: Employer Direct Commercial	$3,431.72
Rate for Payer: Humana Medicare/TRICARE	$3,431.72
Rate for Payer: Molina Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Molina Medicare	$3,431.72
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	$11,270.57
Rate for Payer: Scott and White Medicare	$3,431.72
Rate for Payer: Superior Health Plan EPO	$3,431.72
Rate for Payer: Superior Health Plan Medicare	$3,431.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Universal American Medicare	$3,431.72
Rate for Payer: Wellcare Medicare	$3,431.72
Rate for Payer: Wellmed Medicare	$3,431.72

Suture of 1 nerve; hand or foot, common sensory nerve

Facility

$17,471.85

Service Code	HCPCS 64834
Hospital Charge Code	9900851
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,880.86

Suture of 1 nerve; hand or foot, common sensory nerve

Facility

$17,471.85

Service Code	HCPCS 64834
Hospital Charge Code	9900851
Hospital Revenue Code	360
Min. Negotiated Rate	$1,996.58
Max. Negotiated Rate	$13,882.71
Rate for Payer: Amerigroup CHIP/Medicaid	$1,996.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Amerigroup Medicare	$3,431.72
Rate for Payer: BCBS of TX Blue Advantage	$9,200.05
Rate for Payer: BCBS of TX Blue Essentials	$11,018.02
Rate for Payer: BCBS of TX Medicare	$3,431.72
Rate for Payer: BCBS of TX PPO	$13,882.71
Rate for Payer: Cash Price	$11,880.86
Rate for Payer: Cash Price	$11,880.86
Rate for Payer: Cash Price	$11,880.86
Rate for Payer: Cigna Commercial	$7,254.03
Rate for Payer: Cigna Medicaid	$12,579.73
Rate for Payer: Cigna Medicare	$3,431.72
Rate for Payer: Employer Direct Commercial	$3,431.72
Rate for Payer: Humana Medicare/TRICARE	$3,431.72
Rate for Payer: Molina CHIP/Medicaid	$12,579.73
Rate for Payer: Molina Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Molina Medicare	$3,431.72
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	$12,579.73
Rate for Payer: Scott and White EPO/PPO	$11,270.57
Rate for Payer: Scott and White Medicare	$3,431.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,579.73
Rate for Payer: Superior Health Plan EPO	$3,431.72
Rate for Payer: Superior Health Plan Medicare	$3,431.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Universal American Medicare	$3,431.72
Rate for Payer: Wellcare Medicare	$3,431.72
Rate for Payer: Wellmed Medicare	$3,431.72

Suture of 1 nerve; median motor thenar

Facility

$17,471.85

Service Code	HCPCS 64835
Hospital Charge Code	9900852
Hospital Revenue Code	360
Min. Negotiated Rate	$1,996.58
Max. Negotiated Rate	$13,882.71
Rate for Payer: Amerigroup CHIP/Medicaid	$1,996.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Amerigroup Medicare	$3,431.72
Rate for Payer: BCBS of TX Blue Advantage	$9,200.05
Rate for Payer: BCBS of TX Blue Essentials	$11,018.02
Rate for Payer: BCBS of TX Medicare	$3,431.72
Rate for Payer: BCBS of TX PPO	$13,882.71
Rate for Payer: Cash Price	$11,880.86
Rate for Payer: Cash Price	$11,880.86
Rate for Payer: Cash Price	$11,880.86
Rate for Payer: Cigna Commercial	$7,254.03
Rate for Payer: Cigna Medicaid	$12,579.73
Rate for Payer: Cigna Medicare	$3,431.72
Rate for Payer: Employer Direct Commercial	$3,431.72
Rate for Payer: Humana Medicare/TRICARE	$3,431.72
Rate for Payer: Molina CHIP/Medicaid	$12,579.73
Rate for Payer: Molina Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Molina Medicare	$3,431.72
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	$12,579.73
Rate for Payer: Scott and White EPO/PPO	$11,270.57
Rate for Payer: Scott and White Medicare	$3,431.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,579.73
Rate for Payer: Superior Health Plan EPO	$3,431.72
Rate for Payer: Superior Health Plan Medicare	$3,431.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Universal American Medicare	$3,431.72
Rate for Payer: Wellcare Medicare	$3,431.72
Rate for Payer: Wellmed Medicare	$3,431.72

Suture of 1 nerve; median motor thenar

Facility

$13,882.71

Service Code	CPT 64835
Hospital Charge Code	36064835
Hospital Revenue Code	360
Min. Negotiated Rate	$1,996.58
Max. Negotiated Rate	$13,882.71
Rate for Payer: Amerigroup CHIP/Medicaid	$1,996.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Amerigroup Medicare	$3,431.72
Rate for Payer: BCBS of TX Blue Advantage	$9,200.05
Rate for Payer: BCBS of TX Blue Essentials	$11,018.02
Rate for Payer: BCBS of TX Medicare	$3,431.72
Rate for Payer: BCBS of TX PPO	$13,882.71
Rate for Payer: Cigna Commercial	$7,254.03
Rate for Payer: Cigna Medicare	$3,431.72
Rate for Payer: Employer Direct Commercial	$3,431.72
Rate for Payer: Humana Medicare/TRICARE	$3,431.72
Rate for Payer: Molina Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Molina Medicare	$3,431.72
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	$11,270.57
Rate for Payer: Scott and White Medicare	$3,431.72
Rate for Payer: Superior Health Plan EPO	$3,431.72
Rate for Payer: Superior Health Plan Medicare	$3,431.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Universal American Medicare	$3,431.72
Rate for Payer: Wellcare Medicare	$3,431.72
Rate for Payer: Wellmed Medicare	$3,431.72

Suture of 1 nerve; median motor thenar

Facility

$17,471.85

Service Code	HCPCS 64835
Hospital Charge Code	9900852
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,880.86

Suture of 1 nerve; ulnar motor

Facility

$13,882.71

Service Code	CPT 64836
Hospital Charge Code	36064836
Hospital Revenue Code	360
Min. Negotiated Rate	$1,996.58
Max. Negotiated Rate	$13,882.71
Rate for Payer: Amerigroup CHIP/Medicaid	$1,996.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Amerigroup Medicare	$3,431.72
Rate for Payer: BCBS of TX Blue Advantage	$9,200.05
Rate for Payer: BCBS of TX Blue Essentials	$11,018.02
Rate for Payer: BCBS of TX Medicare	$3,431.72
Rate for Payer: BCBS of TX PPO	$13,882.71
Rate for Payer: Cigna Commercial	$7,254.03
Rate for Payer: Cigna Medicare	$3,431.72
Rate for Payer: Employer Direct Commercial	$3,431.72
Rate for Payer: Humana Medicare/TRICARE	$3,431.72
Rate for Payer: Molina Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Molina Medicare	$3,431.72
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	$11,270.57
Rate for Payer: Scott and White Medicare	$3,431.72
Rate for Payer: Superior Health Plan EPO	$3,431.72
Rate for Payer: Superior Health Plan Medicare	$3,431.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Universal American Medicare	$3,431.72
Rate for Payer: Wellcare Medicare	$3,431.72
Rate for Payer: Wellmed Medicare	$3,431.72

Suture of 1 nerve; ulnar motor

Facility

$23,295.80

Service Code	HCPCS 64836
Hospital Charge Code	9900853
Hospital Revenue Code	360
Min. Negotiated Rate	$1,996.58
Max. Negotiated Rate	$16,772.98
Rate for Payer: Amerigroup CHIP/Medicaid	$1,996.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Amerigroup Medicare	$3,431.72
Rate for Payer: BCBS of TX Blue Advantage	$9,200.05
Rate for Payer: BCBS of TX Blue Essentials	$11,018.02
Rate for Payer: BCBS of TX Medicare	$3,431.72
Rate for Payer: BCBS of TX PPO	$13,882.71
Rate for Payer: Cash Price	$15,841.14
Rate for Payer: Cash Price	$15,841.14
Rate for Payer: Cash Price	$15,841.14
Rate for Payer: Cigna Commercial	$7,254.03
Rate for Payer: Cigna Medicaid	$16,772.98
Rate for Payer: Cigna Medicare	$3,431.72
Rate for Payer: Employer Direct Commercial	$3,431.72
Rate for Payer: Humana Medicare/TRICARE	$3,431.72
Rate for Payer: Molina CHIP/Medicaid	$16,772.98
Rate for Payer: Molina Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Molina Medicare	$3,431.72
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	$16,772.98
Rate for Payer: Scott and White EPO/PPO	$11,270.57
Rate for Payer: Scott and White Medicare	$3,431.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,772.98
Rate for Payer: Superior Health Plan EPO	$3,431.72
Rate for Payer: Superior Health Plan Medicare	$3,431.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,431.72
Rate for Payer: Universal American Medicare	$3,431.72
Rate for Payer: Wellcare Medicare	$3,431.72
Rate for Payer: Wellmed Medicare	$3,431.72

Suture of 1 nerve; ulnar motor

Facility

$23,295.80

Service Code	HCPCS 64836
Hospital Charge Code	9900853
Hospital Revenue Code	360
Rate for Payer: Cash Price	$15,841.14

Suture of digital nerve, hand or foot

Facility

$14,035.12

Service Code	HCPCS 64831
Hospital Charge Code	9900850
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,105.29
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cash Price	$9,543.88
Rate for Payer: Cash Price	$9,543.88
Rate for Payer: Cash Price	$9,543.88
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$10,105.29
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$10,105.29
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$10,105.29
Rate for Payer: Scott and White EPO/PPO	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,105.29
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Suture of digital nerve, hand or foot

Facility

$10,000.00

Service Code	CPT 64831
Hospital Charge Code	36064831
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Suture of digital nerve, hand or foot

Facility

$14,035.12

Service Code	HCPCS 64831
Hospital Charge Code	9900850
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,543.88

Suture of infrapatellar tendon; primary

Facility

$18,794.85

Service Code	HCPCS 27380
Hospital Charge Code	9900400
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: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$13,532.29
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	$13,532.29
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	$13,532.29
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	$13,532.29
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

Suture of infrapatellar tendon; primary

Facility

$15,408.22

Service Code	CPT 27380
Hospital Charge Code	36027380
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

Suture of infrapatellar tendon; primary

Facility

$18,794.85

Service Code	HCPCS 27380
Hospital Charge Code	9900400
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,780.50

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