White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 SO

Facility

$161.00

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

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

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

$40,496.60

Service Code	MSDRG 409
Min. Negotiated Rate	$18,649.75
Max. Negotiated Rate	$40,496.60
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	$40,496.60
Rate for Payer: Multiplan Commercial	$40,496.60
Rate for Payer: Multiplan Workers Comp	$40,496.60
Rate for Payer: Scott and White EPO/PPO	$18,649.75
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

$69,720.50

Service Code	MSDRG 408
Min. Negotiated Rate	$30,892.46
Max. Negotiated Rate	$69,720.50
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	$69,720.50
Rate for Payer: Multiplan Commercial	$69,720.50
Rate for Payer: Multiplan Workers Comp	$69,720.50
Rate for Payer: Scott and White EPO/PPO	$32,108.12
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

$32,256.30

Service Code	MSDRG 410
Min. Negotiated Rate	$14,212.36
Max. Negotiated Rate	$32,256.30
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	$32,256.30
Rate for Payer: Multiplan Commercial	$32,256.30
Rate for Payer: Multiplan Workers Comp	$32,256.30
Rate for Payer: Scott and White EPO/PPO	$14,854.88
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

$40,496.60

Service Code	MSDRG 409
Min. Negotiated Rate	$18,649.75
Max. Negotiated Rate	$40,496.60
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

$69,720.50

Service Code	MSDRG 408
Min. Negotiated Rate	$30,892.46
Max. Negotiated Rate	$69,720.50
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

$32,256.30

Service Code	MSDRG 410
Min. Negotiated Rate	$14,212.36
Max. Negotiated Rate	$32,256.30
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
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 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 Indirect Neonate

Facility

$190.00

Service Code	HCPCS 82247
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

Bili Indirect Neonate

Facility

$190.00

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

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	$83.91
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

Bill Only BB Antibody Elution

Facility

$297.00

Service Code	HCPCS 86860
Hospital Charge Code	2403095
Hospital Revenue Code	302
Min. Negotiated Rate	$26.73
Max. Negotiated Rate	$361.78
Rate for Payer: Amerigroup CHIP/Medicaid	$26.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$171.15
Rate for Payer: Amerigroup Medicare	$171.15
Rate for Payer: BCBS of TX Blue Advantage	$89.10
Rate for Payer: BCBS of TX Blue Essentials	$106.92
Rate for Payer: BCBS of TX Medicare	$171.15
Rate for Payer: BCBS of TX PPO	$118.80
Rate for Payer: Cash Price	$201.96
Rate for Payer: Cash Price	$201.96
Rate for Payer: Cash Price	$201.96
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$213.84
Rate for Payer: Cigna Medicare	$171.15
Rate for Payer: Employer Direct Commercial	$171.15
Rate for Payer: Humana Medicare/TRICARE	$171.15
Rate for Payer: Molina CHIP/Medicaid	$213.84
Rate for Payer: Molina Dual Medicare/Medicaid	$171.15
Rate for Payer: Molina Medicare	$171.15
Rate for Payer: Multiplan Auto	$193.05
Rate for Payer: Multiplan Commercial	$193.05
Rate for Payer: Multiplan Workers Comp	$193.05
Rate for Payer: Parkland Medicaid	$213.84
Rate for Payer: Scott and White EPO/PPO	$234.31
Rate for Payer: Scott and White Medicare	$171.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$213.84
Rate for Payer: Superior Health Plan EPO	$171.15
Rate for Payer: Superior Health Plan Medicare	$171.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$171.15
Rate for Payer: Universal American Medicare	$171.15
Rate for Payer: Wellcare Medicare	$171.15
Rate for Payer: Wellmed Medicare	$171.15

Bill Only BB Antibody Elution

Facility

$297.00

Service Code	HCPCS 86860
Hospital Charge Code	2403095
Hospital Revenue Code	302
Rate for Payer: Cash Price	$201.96

Bill Only BB Antibody Screen RBC

Facility

$253.00

Service Code	HCPCS 86850
Hospital Charge Code	2403137
Hospital Revenue Code	302
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$182.16
Rate for Payer: Amerigroup CHIP/Medicaid	$3.81
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.77
Rate for Payer: Amerigroup Medicare	$9.77
Rate for Payer: BCBS of TX Blue Advantage	$75.90
Rate for Payer: BCBS of TX Blue Essentials	$91.08
Rate for Payer: BCBS of TX Medicare	$9.77
Rate for Payer: BCBS of TX PPO	$101.20
Rate for Payer: Cash Price	$172.04
Rate for Payer: Cash Price	$172.04
Rate for Payer: Cash Price	$172.04
Rate for Payer: Cigna Commercial	$110.66
Rate for Payer: Cigna Medicaid	$182.16
Rate for Payer: Cigna Medicare	$9.77
Rate for Payer: Employer Direct Commercial	$9.77
Rate for Payer: Humana Medicare/TRICARE	$9.77
Rate for Payer: Molina CHIP/Medicaid	$182.16
Rate for Payer: Molina Dual Medicare/Medicaid	$9.77
Rate for Payer: Molina Medicare	$9.77
Rate for Payer: Multiplan Auto	$164.45
Rate for Payer: Multiplan Commercial	$164.45
Rate for Payer: Multiplan Workers Comp	$164.45
Rate for Payer: Parkland Medicaid	$182.16
Rate for Payer: Scott and White EPO/PPO	$12.21
Rate for Payer: Scott and White Medicare	$9.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$182.16
Rate for Payer: Superior Health Plan EPO	$9.77
Rate for Payer: Superior Health Plan Medicare	$9.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.77
Rate for Payer: Universal American Medicare	$9.77
Rate for Payer: Wellcare Medicare	$9.77
Rate for Payer: Wellmed Medicare	$9.77

Bill Only BB Antibody Screen RBC

Facility

$253.00

Service Code	HCPCS 86850
Hospital Charge Code	2403137
Hospital Revenue Code	302
Rate for Payer: Cash Price	$172.04

Bill Only BB Autologous Fee

Facility

$557.00

Service Code	HCPCS 86890
Hospital Charge Code	4206891
Hospital Revenue Code	390
Rate for Payer: Cash Price	$378.76

Bill Only BB Autologous Fee

Facility

$557.00

Service Code	HCPCS 86890
Hospital Charge Code	4206891
Hospital Revenue Code	390
Min. Negotiated Rate	$50.13
Max. Negotiated Rate	$401.04
Rate for Payer: Amerigroup CHIP/Medicaid	$50.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$171.15
Rate for Payer: Amerigroup Medicare	$171.15
Rate for Payer: BCBS of TX Blue Advantage	$167.10
Rate for Payer: BCBS of TX Blue Essentials	$200.52
Rate for Payer: BCBS of TX Medicare	$171.15
Rate for Payer: BCBS of TX PPO	$222.80
Rate for Payer: Cash Price	$378.76
Rate for Payer: Cash Price	$378.76
Rate for Payer: Cash Price	$378.76
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$401.04
Rate for Payer: Cigna Medicare	$171.15
Rate for Payer: Employer Direct Commercial	$171.15
Rate for Payer: Humana Medicare/TRICARE	$171.15
Rate for Payer: Molina CHIP/Medicaid	$401.04
Rate for Payer: Molina Dual Medicare/Medicaid	$171.15
Rate for Payer: Molina Medicare	$171.15
Rate for Payer: Multiplan Auto	$362.05
Rate for Payer: Multiplan Commercial	$362.05
Rate for Payer: Multiplan Workers Comp	$362.05
Rate for Payer: Parkland Medicaid	$401.04
Rate for Payer: Scott and White EPO/PPO	$278.50
Rate for Payer: Scott and White Medicare	$171.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$401.04
Rate for Payer: Superior Health Plan EPO	$171.15
Rate for Payer: Superior Health Plan Medicare	$171.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$171.15
Rate for Payer: Universal American Medicare	$171.15
Rate for Payer: Wellcare Medicare	$171.15
Rate for Payer: Wellmed Medicare	$171.15

Know your out-of-pocket cost for care.

All Charges