White Rock Medical Center

All Charges

Charge

Type

Setting

Price

UNITE 'AB Bone Cement

Facility

$5,180.72

Service Code	HCPCS C1734
Hospital Charge Code	992264
Hospital Revenue Code	278
Min. Negotiated Rate	$1,295.18
Max. Negotiated Rate	$2,590.36
Rate for Payer: Cash Price	$3,522.89
Rate for Payer: Cigna Commercial	$1,295.18
Rate for Payer: Multiplan Auto	$2,590.36
Rate for Payer: Multiplan Commercial	$2,590.36
Rate for Payer: Multiplan Workers Comp	$2,590.36
Rate for Payer: Scott and White EPO/PPO	$2,590.36

UNITE 'AB Bone Cement

Facility

$5,180.72

Service Code	HCPCS C1734
Hospital Charge Code	992264
Hospital Revenue Code	278
Min. Negotiated Rate	$466.26
Max. Negotiated Rate	$3,730.12
Rate for Payer: Amerigroup CHIP/Medicaid	$466.26
Rate for Payer: BCBS of TX Blue Advantage	$1,554.22
Rate for Payer: BCBS of TX Blue Essentials	$1,865.06
Rate for Payer: BCBS of TX PPO	$2,072.29
Rate for Payer: Cash Price	$3,522.89
Rate for Payer: Cigna Medicaid	$3,730.12
Rate for Payer: Molina CHIP/Medicaid	$3,730.12
Rate for Payer: Multiplan Auto	$2,590.36
Rate for Payer: Multiplan Commercial	$2,590.36
Rate for Payer: Multiplan Workers Comp	$2,590.36
Rate for Payer: Parkland Medicaid	$3,730.12
Rate for Payer: Scott and White EPO/PPO	$2,590.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,730.12
Rate for Payer: Superior Health Plan EPO	$704.58

Universal Pack I without Gowns

Facility

$52.93

Hospital Charge Code	992783
Hospital Revenue Code	272
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$38.11
Rate for Payer: Amerigroup CHIP/Medicaid	$4.76
Rate for Payer: BCBS of TX Blue Advantage	$15.88
Rate for Payer: BCBS of TX Blue Essentials	$19.05
Rate for Payer: BCBS of TX PPO	$21.17
Rate for Payer: Cash Price	$35.99
Rate for Payer: Cigna Medicaid	$38.11
Rate for Payer: Molina CHIP/Medicaid	$38.11
Rate for Payer: Multiplan Auto	$34.40
Rate for Payer: Multiplan Commercial	$34.40
Rate for Payer: Multiplan Workers Comp	$34.40
Rate for Payer: Parkland Medicaid	$38.11
Rate for Payer: Scott and White EPO/PPO	$26.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.11
Rate for Payer: Superior Health Plan EPO	$7.20

Universal Pack I without Gowns

Facility

$52.93

Hospital Charge Code	992783
Hospital Revenue Code	272
Rate for Payer: Cash Price	$35.99

UNIV SLITTER -- DHF

Facility

$77.00

Hospital Charge Code	82438805
Hospital Revenue Code	272
Min. Negotiated Rate	$6.93
Max. Negotiated Rate	$55.44
Rate for Payer: Amerigroup CHIP/Medicaid	$6.93
Rate for Payer: BCBS of TX Blue Advantage	$23.10
Rate for Payer: BCBS of TX Blue Essentials	$27.72
Rate for Payer: BCBS of TX PPO	$30.80
Rate for Payer: Cash Price	$52.36
Rate for Payer: Cigna Medicaid	$55.44
Rate for Payer: Molina CHIP/Medicaid	$55.44
Rate for Payer: Multiplan Auto	$50.05
Rate for Payer: Multiplan Commercial	$50.05
Rate for Payer: Multiplan Workers Comp	$50.05
Rate for Payer: Parkland Medicaid	$55.44
Rate for Payer: Scott and White EPO/PPO	$38.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$55.44
Rate for Payer: Superior Health Plan EPO	$10.47

UNIV SLITTER -- DHF

Facility

$77.00

Hospital Charge Code	82438805
Hospital Revenue Code	272
Rate for Payer: Cash Price	$52.36

UNKNOWN DESCRIPTION

Facility

$336.89

Hospital Charge Code	992998
Hospital Revenue Code	270
Min. Negotiated Rate	$30.32
Max. Negotiated Rate	$242.56
Rate for Payer: Amerigroup CHIP/Medicaid	$30.32
Rate for Payer: BCBS of TX Blue Advantage	$101.07
Rate for Payer: BCBS of TX Blue Essentials	$121.28
Rate for Payer: BCBS of TX PPO	$134.76
Rate for Payer: Cash Price	$229.09
Rate for Payer: Cigna Medicaid	$242.56
Rate for Payer: Molina CHIP/Medicaid	$242.56
Rate for Payer: Multiplan Auto	$218.98
Rate for Payer: Multiplan Commercial	$218.98
Rate for Payer: Multiplan Workers Comp	$218.98
Rate for Payer: Parkland Medicaid	$242.56
Rate for Payer: Scott and White EPO/PPO	$168.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$242.56
Rate for Payer: Superior Health Plan EPO	$45.82

UNKNOWN DESCRIPTION

Facility

$336.89

Hospital Charge Code	992998
Hospital Revenue Code	270
Rate for Payer: Cash Price	$229.09

Unlisted laparoscopy procedure, stomach

Facility

$12,837.39

Service Code	CPT 43659
Hospital Charge Code	36043659
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$11,235.20
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Unlisted laps px intestine

Facility

$12,837.39

Service Code	CPT 44238
Hospital Charge Code	36044238
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$11,235.20
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Unlisted procedure, abdomen, peritoneum and omentum

Facility

$10,000.00

Service Code	CPT 49999
Hospital Charge Code	36049999
Hospital Revenue Code	360
Min. Negotiated Rate	$911.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$911.12
Rate for Payer: Amerigroup Medicare	$911.12
Rate for Payer: BCBS of TX Blue Advantage	$1,312.49
Rate for Payer: BCBS of TX Blue Essentials	$1,571.84
Rate for Payer: BCBS of TX Medicare	$911.12
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicare	$911.12
Rate for Payer: Employer Direct Commercial	$911.12
Rate for Payer: Humana Medicare/TRICARE	$911.12
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
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	$1,685.57
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan EPO	$911.12
Rate for Payer: Superior Health Plan Medicare	$911.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$911.12
Rate for Payer: Universal American Medicare	$911.12
Rate for Payer: Wellcare Medicare	$911.12
Rate for Payer: Wellmed Medicare	$911.12

Unlisted procedure, arthroscopy

Facility

$10,000.00

Service Code	CPT 29999
Hospital Charge Code	36029999
Hospital Revenue Code	360
Min. Negotiated Rate	$247.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
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	$458.41
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

Unlisted procedure, foot or toes

Facility

$10,000.00

Service Code	CPT 28899
Hospital Charge Code	36028899
Hospital Revenue Code	360
Min. Negotiated Rate	$247.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
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	$458.41
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

Unlisted procedure, leg or ankle

Facility

$10,000.00

Service Code	CPT 27899
Hospital Charge Code	36027899
Hospital Revenue Code	360
Min. Negotiated Rate	$247.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
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	$458.41
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

Unlisted procedure, middle ear

Facility

$10,000.00

Service Code	CPT 69799
Hospital Charge Code	36069799
Hospital Revenue Code	360
Min. Negotiated Rate	$237.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$237.93
Rate for Payer: Amerigroup Medicare	$237.93
Rate for Payer: BCBS of TX Blue Advantage	$340.08
Rate for Payer: BCBS of TX Blue Essentials	$407.28
Rate for Payer: BCBS of TX Medicare	$237.93
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicare	$237.93
Rate for Payer: Employer Direct Commercial	$237.93
Rate for Payer: Humana Medicare/TRICARE	$237.93
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
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	$440.17
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan EPO	$237.93
Rate for Payer: Superior Health Plan Medicare	$237.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$237.93
Rate for Payer: Universal American Medicare	$237.93
Rate for Payer: Wellcare Medicare	$237.93
Rate for Payer: Wellmed Medicare	$237.93

Unlisted procedure, nervous system

Facility

$10,000.00

Service Code	CPT 64999
Hospital Charge Code	36064999
Hospital Revenue Code	360
Min. Negotiated Rate	$308.35
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.35
Rate for Payer: Amerigroup Medicare	$308.35
Rate for Payer: BCBS of TX Blue Advantage	$437.16
Rate for Payer: BCBS of TX Blue Essentials	$523.54
Rate for Payer: BCBS of TX Medicare	$308.35
Rate for Payer: BCBS of TX PPO	$659.66
Rate for Payer: Cigna Commercial	$651.79
Rate for Payer: Cigna Medicare	$308.35
Rate for Payer: Employer Direct Commercial	$308.35
Rate for Payer: Humana Medicare/TRICARE	$308.35
Rate for Payer: Molina Dual Medicare/Medicaid	$308.35
Rate for Payer: Molina Medicare	$308.35
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	$570.45
Rate for Payer: Scott and White Medicare	$308.35
Rate for Payer: Superior Health Plan EPO	$308.35
Rate for Payer: Superior Health Plan Medicare	$308.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.35
Rate for Payer: Universal American Medicare	$308.35
Rate for Payer: Wellcare Medicare	$308.35
Rate for Payer: Wellmed Medicare	$308.35

Unlisted procedure, pelvis or hip joint

Facility

$10,000.00

Service Code	CPT 27299
Hospital Charge Code	36027299
Hospital Revenue Code	360
Min. Negotiated Rate	$247.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
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	$458.41
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

Unlisted procedure, skin, mucous membrane and subcutaneous tissue

Facility

$10,000.00

Service Code	CPT 17999
Hospital Charge Code	36017999
Hospital Revenue Code	360
Min. Negotiated Rate	$201.55
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
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	$372.87
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

Unlisted procedure, small intestine - Graham Patch

Facility

$10,000.00

Service Code	CPT 44799
Hospital Charge Code	36044799
Hospital Revenue Code	360
Min. Negotiated Rate	$911.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$911.12
Rate for Payer: Amerigroup Medicare	$911.12
Rate for Payer: BCBS of TX Blue Advantage	$1,312.49
Rate for Payer: BCBS of TX Blue Essentials	$1,571.84
Rate for Payer: BCBS of TX Medicare	$911.12
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicare	$911.12
Rate for Payer: Employer Direct Commercial	$911.12
Rate for Payer: Humana Medicare/TRICARE	$911.12
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
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	$1,685.57
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan EPO	$911.12
Rate for Payer: Superior Health Plan Medicare	$911.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$911.12
Rate for Payer: Universal American Medicare	$911.12
Rate for Payer: Wellcare Medicare	$911.12
Rate for Payer: Wellmed Medicare	$911.12

Unlisted procedure, stomach

Facility

$10,000.00

Service Code	CPT 43999
Hospital Charge Code	36043999
Hospital Revenue Code	360
Min. Negotiated Rate	$911.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$911.12
Rate for Payer: Amerigroup Medicare	$911.12
Rate for Payer: BCBS of TX Blue Advantage	$1,312.49
Rate for Payer: BCBS of TX Blue Essentials	$1,571.84
Rate for Payer: BCBS of TX Medicare	$911.12
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicare	$911.12
Rate for Payer: Employer Direct Commercial	$911.12
Rate for Payer: Humana Medicare/TRICARE	$911.12
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
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	$1,685.57
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan EPO	$911.12
Rate for Payer: Superior Health Plan Medicare	$911.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$911.12
Rate for Payer: Universal American Medicare	$911.12
Rate for Payer: Wellcare Medicare	$911.12
Rate for Payer: Wellmed Medicare	$911.12

*Unna Boot

Facility

$993.50

Service Code	HCPCS 29580
Hospital Charge Code	7150794
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

*Unna Boot

Facility

$993.50

Service Code	HCPCS 29580
Hospital Charge Code	7150794
Hospital Revenue Code	361
Min. Negotiated Rate	$33.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$33.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$70.51
Rate for Payer: BCBS of TX Blue Essentials	$84.44
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$106.39
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
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	$715.32
Rate for Payer: Scott and White EPO/PPO	$301.99
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

UNTHREADED GUIDE WIRE ?2.0mm x 150mm

Facility

$603.82

Hospital Charge Code	993365
Hospital Revenue Code	272
Min. Negotiated Rate	$54.34
Max. Negotiated Rate	$434.75
Rate for Payer: Amerigroup CHIP/Medicaid	$54.34
Rate for Payer: BCBS of TX Blue Advantage	$181.15
Rate for Payer: BCBS of TX Blue Essentials	$217.38
Rate for Payer: BCBS of TX PPO	$241.53
Rate for Payer: Cash Price	$410.60
Rate for Payer: Cigna Medicaid	$434.75
Rate for Payer: Molina CHIP/Medicaid	$434.75
Rate for Payer: Multiplan Auto	$392.48
Rate for Payer: Multiplan Commercial	$392.48
Rate for Payer: Multiplan Workers Comp	$392.48
Rate for Payer: Parkland Medicaid	$434.75
Rate for Payer: Scott and White EPO/PPO	$301.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$434.75
Rate for Payer: Superior Health Plan EPO	$82.12

UNTHREADED GUIDE WIRE ?2.0mm x 150mm

Facility

$603.82

Hospital Charge Code	993365
Hospital Revenue Code	272
Rate for Payer: Cash Price	$410.60

UPGRADE TO DUAL CHAMBER

Facility

$32,225.00

Service Code	HCPCS 33214
Hospital Charge Code	2302453
Hospital Revenue Code	481
Min. Negotiated Rate	$2,900.25
Max. Negotiated Rate	$25,834.89
Rate for Payer: Amerigroup CHIP/Medicaid	$2,900.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Amerigroup Medicare	$10,499.62
Rate for Payer: BCBS of TX Blue Advantage	$17,120.74
Rate for Payer: BCBS of TX Blue Essentials	$20,503.88
Rate for Payer: BCBS of TX Medicare	$10,499.62
Rate for Payer: BCBS of TX PPO	$25,834.89
Rate for Payer: Cash Price	$21,913.00
Rate for Payer: Cash Price	$21,913.00
Rate for Payer: Cash Price	$21,913.00
Rate for Payer: Cigna Commercial	$22,194.30
Rate for Payer: Cigna Medicaid	$23,202.00
Rate for Payer: Cigna Medicare	$10,499.62
Rate for Payer: Employer Direct Commercial	$10,499.62
Rate for Payer: Humana Medicare/TRICARE	$10,499.62
Rate for Payer: Molina CHIP/Medicaid	$23,202.00
Rate for Payer: Molina Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Molina Medicare	$10,499.62
Rate for Payer: Multiplan Auto	$20,946.25
Rate for Payer: Multiplan Commercial	$20,946.25
Rate for Payer: Multiplan Workers Comp	$20,946.25
Rate for Payer: Parkland Medicaid	$23,202.00
Rate for Payer: Scott and White EPO/PPO	$16,112.50
Rate for Payer: Scott and White Medicare	$10,499.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,202.00
Rate for Payer: Superior Health Plan EPO	$10,499.62
Rate for Payer: Superior Health Plan Medicare	$10,499.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Universal American Medicare	$10,499.62
Rate for Payer: Wellcare Medicare	$10,499.62
Rate for Payer: Wellmed Medicare	$10,499.62

Know your out-of-pocket cost for care.

All Charges