White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BG URINE DRN -- DHF

Facility

$90.80

Hospital Charge Code	80410558
Hospital Revenue Code	272
Min. Negotiated Rate	$8.17
Max. Negotiated Rate	$65.38
Rate for Payer: Amerigroup CHIP/Medicaid	$8.17
Rate for Payer: BCBS of TX Blue Advantage	$27.24
Rate for Payer: BCBS of TX Blue Essentials	$32.69
Rate for Payer: BCBS of TX PPO	$36.32
Rate for Payer: Cash Price	$61.74
Rate for Payer: Cigna Medicaid	$65.38
Rate for Payer: Molina CHIP/Medicaid	$65.38
Rate for Payer: Multiplan Auto	$59.02
Rate for Payer: Multiplan Commercial	$59.02
Rate for Payer: Multiplan Workers Comp	$59.02
Rate for Payer: Parkland Medicaid	$65.38
Rate for Payer: Scott and White EPO/PPO	$45.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.38
Rate for Payer: Superior Health Plan EPO	$12.35

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC

Facility

$101,851.40

Service Code	MSDRG 461
Min. Negotiated Rate	$38,549.50
Max. Negotiated Rate	$101,851.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$45,238.29
Rate for Payer: Amerigroup Medicare	$45,238.29
Rate for Payer: BCBS of TX Medicare	$45,238.29
Rate for Payer: Cigna Commercial	$69,044.53
Rate for Payer: Cigna Medicare	$45,238.29
Rate for Payer: Employer Direct Commercial	$45,238.29
Rate for Payer: Humana Medicare/TRICARE	$45,238.29
Rate for Payer: Molina Dual Medicare/Medicaid	$45,238.29
Rate for Payer: Molina Medicare	$45,238.29
Rate for Payer: Multiplan Auto	$101,851.40
Rate for Payer: Multiplan Commercial	$101,851.40
Rate for Payer: Multiplan Workers Comp	$101,851.40
Rate for Payer: Scott and White EPO/PPO	$46,905.25
Rate for Payer: Scott and White Medicare	$45,238.29
Rate for Payer: Superior Health Plan EPO	$45,238.29
Rate for Payer: Superior Health Plan Medicare	$45,238.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$45,238.29
Rate for Payer: Universal American Medicare	$45,238.29
Rate for Payer: Wellcare Medicare	$45,238.29
Rate for Payer: Wellmed Medicare	$45,238.29

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC

Facility

$50,540.00

Service Code	MSDRG 462
Min. Negotiated Rate	$23,275.00
Max. Negotiated Rate	$50,540.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24,255.29
Rate for Payer: Amerigroup Medicare	$24,255.29
Rate for Payer: BCBS of TX Medicare	$24,255.29
Rate for Payer: Cigna Commercial	$34,260.80
Rate for Payer: Cigna Medicare	$24,255.29
Rate for Payer: Employer Direct Commercial	$24,255.29
Rate for Payer: Humana Medicare/TRICARE	$24,255.29
Rate for Payer: Molina Dual Medicare/Medicaid	$24,255.29
Rate for Payer: Molina Medicare	$24,255.29
Rate for Payer: Multiplan Auto	$50,540.00
Rate for Payer: Multiplan Commercial	$50,540.00
Rate for Payer: Multiplan Workers Comp	$50,540.00
Rate for Payer: Scott and White EPO/PPO	$23,275.00
Rate for Payer: Scott and White Medicare	$24,255.29
Rate for Payer: Superior Health Plan EPO	$24,255.29
Rate for Payer: Superior Health Plan Medicare	$24,255.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$24,255.29
Rate for Payer: Universal American Medicare	$24,255.29
Rate for Payer: Wellcare Medicare	$24,255.29
Rate for Payer: Wellmed Medicare	$24,255.29

BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W MCC

Facility

$101,851.40

Service Code	MSDRG 461
Min. Negotiated Rate	$38,549.50
Max. Negotiated Rate	$101,851.40
Rate for Payer: BCBS of TX Blue Advantage	$38,549.50
Rate for Payer: BCBS of TX Blue Essentials	$46,254.92
Rate for Payer: BCBS of TX PPO	$51,396.35

BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC

Facility

$50,540.00

Service Code	MSDRG 462
Min. Negotiated Rate	$23,275.00
Max. Negotiated Rate	$50,540.00
Rate for Payer: BCBS of TX Blue Advantage	$27,469.26
Rate for Payer: BCBS of TX Blue Essentials	$32,959.92
Rate for Payer: BCBS of TX PPO	$36,623.55

Bile Acids, Fractionated LCMS SO

Facility

$314.00

Service Code	HCPCS 82542
Hospital Charge Code	1708155
Hospital Revenue Code	301
Min. Negotiated Rate	$9.40
Max. Negotiated Rate	$226.08
Rate for Payer: Amerigroup CHIP/Medicaid	$9.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24.09
Rate for Payer: Amerigroup Medicare	$24.09
Rate for Payer: BCBS of TX Blue Advantage	$94.20
Rate for Payer: BCBS of TX Blue Essentials	$113.04
Rate for Payer: BCBS of TX Medicare	$24.09
Rate for Payer: BCBS of TX PPO	$125.60
Rate for Payer: Cash Price	$213.52
Rate for Payer: Cash Price	$213.52
Rate for Payer: Cigna Medicaid	$226.08
Rate for Payer: Cigna Medicare	$24.09
Rate for Payer: Employer Direct Commercial	$24.09
Rate for Payer: Humana Medicare/TRICARE	$24.09
Rate for Payer: Molina CHIP/Medicaid	$226.08
Rate for Payer: Molina Dual Medicare/Medicaid	$24.09
Rate for Payer: Molina Medicare	$24.09
Rate for Payer: Multiplan Auto	$204.10
Rate for Payer: Multiplan Commercial	$204.10
Rate for Payer: Multiplan Workers Comp	$204.10
Rate for Payer: Parkland Medicaid	$226.08
Rate for Payer: Scott and White EPO/PPO	$30.11
Rate for Payer: Scott and White Medicare	$24.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$226.08
Rate for Payer: Superior Health Plan EPO	$24.09
Rate for Payer: Superior Health Plan Medicare	$24.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$24.09
Rate for Payer: Universal American Medicare	$24.09
Rate for Payer: Wellcare Medicare	$24.09
Rate for Payer: Wellmed Medicare	$24.09

Bile Acids, Fractionated LCMS SO

Facility

$314.00

Service Code	HCPCS 82542
Hospital Charge Code	1708155
Hospital Revenue Code	301
Rate for Payer: Cash Price	$213.52

Bile Acids SO

Facility

$161.00

Service Code	HCPCS 82239
Hospital Charge Code	1706159
Hospital Revenue Code	301
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$115.92
Rate for Payer: Amerigroup CHIP/Medicaid	$6.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.12
Rate for Payer: Amerigroup Medicare	$17.12
Rate for Payer: BCBS of TX Blue Advantage	$48.30
Rate for Payer: BCBS of TX Blue Essentials	$57.96
Rate for Payer: BCBS of TX Medicare	$17.12
Rate for Payer: BCBS of TX PPO	$64.40
Rate for Payer: Cash Price	$109.48
Rate for Payer: Cash Price	$109.48
Rate for Payer: Cigna Medicaid	$115.92
Rate for Payer: Cigna Medicare	$17.12
Rate for Payer: Employer Direct Commercial	$17.12
Rate for Payer: Humana Medicare/TRICARE	$17.12
Rate for Payer: Molina CHIP/Medicaid	$115.92
Rate for Payer: Molina Dual Medicare/Medicaid	$17.12
Rate for Payer: Molina Medicare	$17.12
Rate for Payer: Multiplan Auto	$104.65
Rate for Payer: Multiplan Commercial	$104.65
Rate for Payer: Multiplan Workers Comp	$104.65
Rate for Payer: Parkland Medicaid	$115.92
Rate for Payer: Scott and White EPO/PPO	$21.40
Rate for Payer: Scott and White Medicare	$17.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.92
Rate for Payer: Superior Health Plan EPO	$17.12
Rate for Payer: Superior Health Plan Medicare	$17.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.12
Rate for Payer: Universal American Medicare	$17.12
Rate for Payer: Wellcare Medicare	$17.12
Rate for Payer: Wellmed Medicare	$17.12

Bile Acids SO

Facility

$161.00

Service Code	HCPCS 82239
Hospital Charge Code	1706159
Hospital Revenue Code	301
Rate for Payer: Cash Price	$109.48

BILIARY DIL W/WO STENT

Facility

$2,655.00

Service Code	HCPCS 74363
Hospital Charge Code	4614363
Hospital Revenue Code	320
Min. Negotiated Rate	$72.55
Max. Negotiated Rate	$1,911.60
Rate for Payer: Amerigroup CHIP/Medicaid	$238.95
Rate for Payer: BCBS of TX Blue Advantage	$72.55
Rate for Payer: BCBS of TX Blue Essentials	$87.06
Rate for Payer: BCBS of TX PPO	$97.17
Rate for Payer: Cash Price	$1,805.40
Rate for Payer: Cash Price	$1,805.40
Rate for Payer: Cigna Medicaid	$1,911.60
Rate for Payer: Molina CHIP/Medicaid	$1,911.60
Rate for Payer: Multiplan Auto	$1,725.75
Rate for Payer: Multiplan Commercial	$1,725.75
Rate for Payer: Multiplan Workers Comp	$1,725.75
Rate for Payer: Parkland Medicaid	$1,911.60
Rate for Payer: Scott and White EPO/PPO	$1,327.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,911.60
Rate for Payer: Superior Health Plan EPO	$361.08

BILIARY DIL W/WO STENT

Facility

$2,655.00

Service Code	HCPCS 74363
Hospital Charge Code	4614363
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,805.40

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC

Facility

$41,368.70

Service Code	MSDRG 409
Min. Negotiated Rate	$19,051.38
Max. Negotiated Rate	$41,368.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,717.57
Rate for Payer: Amerigroup Medicare	$20,717.57
Rate for Payer: BCBS of TX Medicare	$20,717.57
Rate for Payer: Cigna Commercial	$28,043.62
Rate for Payer: Cigna Medicare	$20,717.57
Rate for Payer: Employer Direct Commercial	$20,717.57
Rate for Payer: Humana Medicare/TRICARE	$20,717.57
Rate for Payer: Molina Dual Medicare/Medicaid	$20,717.57
Rate for Payer: Molina Medicare	$20,717.57
Rate for Payer: Multiplan Auto	$41,368.70
Rate for Payer: Multiplan Commercial	$41,368.70
Rate for Payer: Multiplan Workers Comp	$41,368.70
Rate for Payer: Scott and White EPO/PPO	$19,051.38
Rate for Payer: Scott and White Medicare	$20,717.57
Rate for Payer: Superior Health Plan EPO	$20,717.57
Rate for Payer: Superior Health Plan Medicare	$20,717.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,717.57
Rate for Payer: Universal American Medicare	$20,717.57
Rate for Payer: Wellcare Medicare	$20,717.57
Rate for Payer: Wellmed Medicare	$20,717.57

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC

Facility

$67,746.40

Service Code	MSDRG 408
Min. Negotiated Rate	$30,892.46
Max. Negotiated Rate	$67,746.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,892.46
Rate for Payer: Amerigroup Medicare	$30,892.46
Rate for Payer: BCBS of TX Medicare	$30,892.46
Rate for Payer: Cigna Commercial	$45,924.93
Rate for Payer: Cigna Medicare	$30,892.46
Rate for Payer: Employer Direct Commercial	$30,892.46
Rate for Payer: Humana Medicare/TRICARE	$30,892.46
Rate for Payer: Molina Dual Medicare/Medicaid	$30,892.46
Rate for Payer: Molina Medicare	$30,892.46
Rate for Payer: Multiplan Auto	$67,746.40
Rate for Payer: Multiplan Commercial	$67,746.40
Rate for Payer: Multiplan Workers Comp	$67,746.40
Rate for Payer: Scott and White EPO/PPO	$31,199.00
Rate for Payer: Scott and White Medicare	$30,892.46
Rate for Payer: Superior Health Plan EPO	$30,892.46
Rate for Payer: Superior Health Plan Medicare	$30,892.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,892.46
Rate for Payer: Universal American Medicare	$30,892.46
Rate for Payer: Wellcare Medicare	$30,892.46
Rate for Payer: Wellmed Medicare	$30,892.46

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$30,166.30

Service Code	MSDRG 410
Min. Negotiated Rate	$13,892.38
Max. Negotiated Rate	$30,166.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,396.37
Rate for Payer: Amerigroup Medicare	$16,396.37
Rate for Payer: BCBS of TX Medicare	$16,396.37
Rate for Payer: Cigna Commercial	$20,449.58
Rate for Payer: Cigna Medicare	$16,396.37
Rate for Payer: Employer Direct Commercial	$16,396.37
Rate for Payer: Humana Medicare/TRICARE	$16,396.37
Rate for Payer: Molina Dual Medicare/Medicaid	$16,396.37
Rate for Payer: Molina Medicare	$16,396.37
Rate for Payer: Multiplan Auto	$30,166.30
Rate for Payer: Multiplan Commercial	$30,166.30
Rate for Payer: Multiplan Workers Comp	$30,166.30
Rate for Payer: Scott and White EPO/PPO	$13,892.38
Rate for Payer: Scott and White Medicare	$16,396.37
Rate for Payer: Superior Health Plan EPO	$16,396.37
Rate for Payer: Superior Health Plan Medicare	$16,396.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,396.37
Rate for Payer: Universal American Medicare	$16,396.37
Rate for Payer: Wellcare Medicare	$16,396.37
Rate for Payer: Wellmed Medicare	$16,396.37

BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC

Facility

$41,368.70

Service Code	MSDRG 409
Min. Negotiated Rate	$19,051.38
Max. Negotiated Rate	$41,368.70
Rate for Payer: BCBS of TX Blue Advantage	$19,975.22
Rate for Payer: BCBS of TX Blue Essentials	$23,967.94
Rate for Payer: BCBS of TX PPO	$26,632.08

BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W MCC

Facility

$67,746.40

Service Code	MSDRG 408
Min. Negotiated Rate	$30,892.46
Max. Negotiated Rate	$67,746.40
Rate for Payer: BCBS of TX Blue Advantage	$34,799.90
Rate for Payer: BCBS of TX Blue Essentials	$41,755.83
Rate for Payer: BCBS of TX PPO	$46,397.17

BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC

Facility

$30,166.30

Service Code	MSDRG 410
Min. Negotiated Rate	$13,892.38
Max. Negotiated Rate	$30,166.30
Rate for Payer: BCBS of TX Blue Advantage	$14,212.36
Rate for Payer: BCBS of TX Blue Essentials	$17,053.18
Rate for Payer: BCBS of TX PPO	$18,948.71

Bili Direct Neonate

Facility

$178.00

Service Code	HCPCS 82248
Hospital Charge Code	1600907
Hospital Revenue Code	301
Rate for Payer: Cash Price	$121.04

Bili Direct Neonate

Facility

$178.00

Service Code	HCPCS 82248
Hospital Charge Code	1600907
Hospital Revenue Code	301
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$128.16
Rate for Payer: Amerigroup CHIP/Medicaid	$1.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.02
Rate for Payer: Amerigroup Medicare	$5.02
Rate for Payer: BCBS of TX Blue Advantage	$53.40
Rate for Payer: BCBS of TX Blue Essentials	$64.08
Rate for Payer: BCBS of TX Medicare	$5.02
Rate for Payer: BCBS of TX PPO	$71.20
Rate for Payer: Cash Price	$121.04
Rate for Payer: Cash Price	$121.04
Rate for Payer: Cigna Medicaid	$128.16
Rate for Payer: Cigna Medicare	$5.02
Rate for Payer: Employer Direct Commercial	$5.02
Rate for Payer: Humana Medicare/TRICARE	$5.02
Rate for Payer: Molina CHIP/Medicaid	$128.16
Rate for Payer: Molina Dual Medicare/Medicaid	$5.02
Rate for Payer: Molina Medicare	$5.02
Rate for Payer: Multiplan Auto	$115.70
Rate for Payer: Multiplan Commercial	$115.70
Rate for Payer: Multiplan Workers Comp	$115.70
Rate for Payer: Parkland Medicaid	$128.16
Rate for Payer: Scott and White EPO/PPO	$6.28
Rate for Payer: Scott and White Medicare	$5.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$128.16
Rate for Payer: Superior Health Plan EPO	$5.02
Rate for Payer: Superior Health Plan Medicare	$5.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.02
Rate for Payer: Universal American Medicare	$5.02
Rate for Payer: Wellcare Medicare	$5.02
Rate for Payer: Wellmed Medicare	$5.02

Bili Indirect Neonate

Facility

$190.00

Service Code	HCPCS 82247 QW
Hospital Charge Code	1602408
Hospital Revenue Code	301
Rate for Payer: Cash Price	$129.20

Bili Indirect Neonate

Facility

$190.00

Service Code	HCPCS 82247 QW
Hospital Charge Code	1602408
Hospital Revenue Code	301
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$136.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.02
Rate for Payer: Amerigroup Medicare	$5.02
Rate for Payer: BCBS of TX Blue Advantage	$57.00
Rate for Payer: BCBS of TX Blue Essentials	$68.40
Rate for Payer: BCBS of TX Medicare	$5.02
Rate for Payer: BCBS of TX PPO	$76.00
Rate for Payer: Cash Price	$129.20
Rate for Payer: Cash Price	$129.20
Rate for Payer: Cigna Medicaid	$136.80
Rate for Payer: Cigna Medicare	$5.02
Rate for Payer: Employer Direct Commercial	$5.02
Rate for Payer: Humana Medicare/TRICARE	$5.02
Rate for Payer: Molina CHIP/Medicaid	$136.80
Rate for Payer: Molina Dual Medicare/Medicaid	$5.02
Rate for Payer: Molina Medicare	$5.02
Rate for Payer: Multiplan Auto	$123.50
Rate for Payer: Multiplan Commercial	$123.50
Rate for Payer: Multiplan Workers Comp	$123.50
Rate for Payer: Parkland Medicaid	$136.80
Rate for Payer: Scott and White EPO/PPO	$6.28
Rate for Payer: Scott and White Medicare	$5.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$136.80
Rate for Payer: Superior Health Plan EPO	$5.02
Rate for Payer: Superior Health Plan Medicare	$5.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.02
Rate for Payer: Universal American Medicare	$5.02
Rate for Payer: Wellcare Medicare	$5.02
Rate for Payer: Wellmed Medicare	$5.02

Bill Only BB Ab ID Each Absorption

Facility

$350.00

Service Code	HCPCS 86978
Hospital Charge Code	2403616
Hospital Revenue Code	302
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$252.00
Rate for Payer: Amerigroup CHIP/Medicaid	$31.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$105.00
Rate for Payer: BCBS of TX Blue Essentials	$126.00
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$140.00
Rate for Payer: Cash Price	$238.00
Rate for Payer: Cash Price	$238.00
Rate for Payer: Cash Price	$238.00
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$252.00
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$252.00
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
Rate for Payer: Multiplan Auto	$227.50
Rate for Payer: Multiplan Commercial	$227.50
Rate for Payer: Multiplan Workers Comp	$227.50
Rate for Payer: Parkland Medicaid	$252.00
Rate for Payer: Scott and White EPO/PPO	$175.00
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$252.00
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

Bill Only BB Ab ID Each Absorption

Facility

$350.00

Service Code	HCPCS 86978
Hospital Charge Code	2403616
Hospital Revenue Code	302
Rate for Payer: Cash Price	$238.00

Bill Only BB ABO Type

Facility

$152.00

Service Code	HCPCS 86900
Hospital Charge Code	2400406
Hospital Revenue Code	302
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$282.53
Rate for Payer: Amerigroup CHIP/Medicaid	$1.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.99
Rate for Payer: Amerigroup Medicare	$2.99
Rate for Payer: BCBS of TX Blue Advantage	$45.60
Rate for Payer: BCBS of TX Blue Essentials	$54.72
Rate for Payer: BCBS of TX Medicare	$2.99
Rate for Payer: BCBS of TX PPO	$60.80
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$109.44
Rate for Payer: Cigna Medicare	$2.99
Rate for Payer: Employer Direct Commercial	$2.99
Rate for Payer: Humana Medicare/TRICARE	$2.99
Rate for Payer: Molina CHIP/Medicaid	$109.44
Rate for Payer: Molina Dual Medicare/Medicaid	$2.99
Rate for Payer: Molina Medicare	$2.99
Rate for Payer: Multiplan Auto	$98.80
Rate for Payer: Multiplan Commercial	$98.80
Rate for Payer: Multiplan Workers Comp	$98.80
Rate for Payer: Parkland Medicaid	$109.44
Rate for Payer: Scott and White EPO/PPO	$3.74
Rate for Payer: Scott and White Medicare	$2.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.44
Rate for Payer: Superior Health Plan EPO	$2.99
Rate for Payer: Superior Health Plan Medicare	$2.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.99
Rate for Payer: Universal American Medicare	$2.99
Rate for Payer: Wellcare Medicare	$2.99
Rate for Payer: Wellmed Medicare	$2.99

Bill Only BB ABO Type

Facility

$152.00

Service Code	HCPCS 86900
Hospital Charge Code	2400406
Hospital Revenue Code	302
Rate for Payer: Cash Price	$103.36

Know your out-of-pocket cost for care.

All Charges