White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Esophagoscopy, rigid, transoral diagnostic, including collection of specimen(s) by brushing or wash

Facility

$10,000.00

Service Code	CPT 43191
Hospital Charge Code	36043191
Hospital Revenue Code	360
Min. Negotiated Rate	$38.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,610.33
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Amerigroup Medicare	$1,740.22
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,740.22
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cigna Commercial	$3,942.10
Rate for Payer: Cigna Medicaid	$564.97
Rate for Payer: Cigna Medicare	$1,740.22
Rate for Payer: Employer Direct Commercial	$1,740.22
Rate for Payer: Humana Medicare/TRICARE	$1,740.22
Rate for Payer: Molina CHIP/Medicaid	$564.97
Rate for Payer: Molina Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Molina Medicare	$1,740.22
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	$564.97
Rate for Payer: Scott and White EPO/PPO	$38.38
Rate for Payer: Scott and White Medicare	$1,740.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.97
Rate for Payer: Superior Health Plan EPO	$1,740.22
Rate for Payer: Superior Health Plan Medicare	$1,740.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Universal American Medicare	$1,740.22
Rate for Payer: Wellcare Medicare	$1,740.22
Rate for Payer: Wellmed Medicare	$1,740.22

ESTA PATIENT CLINIC VISIT LEVEL 1

Facility

$113.00

Service Code	CPT 99211
Hospital Charge Code	7000060
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$73.45
Rate for Payer: Aetna Commercial	$62.15
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$16.30
Rate for Payer: BCBS of TX Blue Essentials	$19.49
Rate for Payer: BCBS of TX PPO	$21.74
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cigna Medicaid	$12.41
Rate for Payer: Molina CHIP/Medicaid	$12.41
Rate for Payer: Multiplan Auto	$73.45
Rate for Payer: Multiplan Commercial	$73.45
Rate for Payer: Multiplan Workers Comp	$73.45
Rate for Payer: Parkland Medicaid	$12.41
Rate for Payer: Scott and White EPO/PPO	$56.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.41

ESTA PATIENT CLINIC VISIT LEVEL 1

Facility

$113.00

Service Code	CPT 99211
Hospital Charge Code	7000060
Hospital Revenue Code	510
Rate for Payer: Cash Price	$99.44

ESTA PATIENT CLINIC VISIT LEVEL 2

Facility

$174.00

Service Code	CPT 99212
Hospital Charge Code	7000078
Hospital Revenue Code	510
Rate for Payer: Cash Price	$153.12

ESTA PATIENT CLINIC VISIT LEVEL 2

Facility

$174.00

Service Code	CPT 99212
Hospital Charge Code	7000078
Hospital Revenue Code	510
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$113.10
Rate for Payer: Aetna Commercial	$95.70
Rate for Payer: Amerigroup CHIP/Medicaid	$15.66
Rate for Payer: BCBS of TX Blue Advantage	$45.15
Rate for Payer: BCBS of TX Blue Essentials	$53.98
Rate for Payer: BCBS of TX PPO	$60.20
Rate for Payer: Cash Price	$153.12
Rate for Payer: Cash Price	$153.12
Rate for Payer: Cigna Medicaid	$20.78
Rate for Payer: Molina CHIP/Medicaid	$20.78
Rate for Payer: Multiplan Auto	$113.10
Rate for Payer: Multiplan Commercial	$113.10
Rate for Payer: Multiplan Workers Comp	$113.10
Rate for Payer: Parkland Medicaid	$20.78
Rate for Payer: Scott and White EPO/PPO	$87.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.78

ESTA PATIENT CLINIC VISIT LEVEL 3

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	7000086
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$137.15
Rate for Payer: Aetna Commercial	$116.05
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$90.31
Rate for Payer: BCBS of TX Blue Essentials	$107.95
Rate for Payer: BCBS of TX PPO	$120.41
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cigna Medicaid	$31.23
Rate for Payer: Molina CHIP/Medicaid	$31.23
Rate for Payer: Multiplan Auto	$137.15
Rate for Payer: Multiplan Commercial	$137.15
Rate for Payer: Multiplan Workers Comp	$137.15
Rate for Payer: Parkland Medicaid	$31.23
Rate for Payer: Scott and White EPO/PPO	$105.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.23

ESTA PATIENT CLINIC VISIT LEVEL 3

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	7000086
Hospital Revenue Code	510
Rate for Payer: Cash Price	$185.68

ESTA PATIENT CLINIC VISIT LEVEL 4

Facility

$390.00

Service Code	CPT 99214
Hospital Charge Code	7000094
Hospital Revenue Code	510
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$253.50
Rate for Payer: Aetna Commercial	$214.50
Rate for Payer: Amerigroup CHIP/Medicaid	$35.10
Rate for Payer: BCBS of TX Blue Advantage	$139.22
Rate for Payer: BCBS of TX Blue Essentials	$166.42
Rate for Payer: BCBS of TX PPO	$185.62
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cigna Medicaid	$43.87
Rate for Payer: Molina CHIP/Medicaid	$43.87
Rate for Payer: Multiplan Auto	$253.50
Rate for Payer: Multiplan Commercial	$253.50
Rate for Payer: Multiplan Workers Comp	$253.50
Rate for Payer: Parkland Medicaid	$43.87
Rate for Payer: Scott and White EPO/PPO	$195.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.87

ESTA PATIENT CLINIC VISIT LEVEL 4

Facility

$390.00

Service Code	CPT 99214
Hospital Charge Code	7000094
Hospital Revenue Code	510
Rate for Payer: Cash Price	$343.20

ESTA PATIENT CLINIC VISIT LEVEL 5

Facility

$426.00

Service Code	CPT 99215
Hospital Charge Code	7000102
Hospital Revenue Code	510
Rate for Payer: Cash Price	$374.88

ESTA PATIENT CLINIC VISIT LEVEL 5

Facility

$426.00

Service Code	CPT 99215
Hospital Charge Code	7000102
Hospital Revenue Code	510
Min. Negotiated Rate	$38.34
Max. Negotiated Rate	$276.90
Rate for Payer: Aetna Commercial	$234.30
Rate for Payer: Amerigroup CHIP/Medicaid	$38.34
Rate for Payer: BCBS of TX Blue Advantage	$196.27
Rate for Payer: BCBS of TX Blue Essentials	$234.62
Rate for Payer: BCBS of TX PPO	$261.70
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cigna Medicaid	$67.53
Rate for Payer: Molina CHIP/Medicaid	$67.53
Rate for Payer: Multiplan Auto	$276.90
Rate for Payer: Multiplan Commercial	$276.90
Rate for Payer: Multiplan Workers Comp	$276.90
Rate for Payer: Parkland Medicaid	$67.53
Rate for Payer: Scott and White EPO/PPO	$213.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.53

EST PT Wound Visit Level 1 (0-15 Min)

Facility

$113.00

Service Code	CPT 99211
Hospital Charge Code	7150493
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$73.45
Rate for Payer: Aetna Commercial	$62.15
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$16.30
Rate for Payer: BCBS of TX Blue Essentials	$19.49
Rate for Payer: BCBS of TX PPO	$21.74
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cigna Medicaid	$12.41
Rate for Payer: Molina CHIP/Medicaid	$12.41
Rate for Payer: Multiplan Auto	$73.45
Rate for Payer: Multiplan Commercial	$73.45
Rate for Payer: Multiplan Workers Comp	$73.45
Rate for Payer: Parkland Medicaid	$12.41
Rate for Payer: Scott and White EPO/PPO	$56.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.41

EST PT Wound Visit Level 2 (16-30 Min)

Facility

$174.00

Service Code	CPT 99212
Hospital Charge Code	7150501
Hospital Revenue Code	510
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$113.10
Rate for Payer: Aetna Commercial	$95.70
Rate for Payer: Amerigroup CHIP/Medicaid	$15.66
Rate for Payer: BCBS of TX Blue Advantage	$45.15
Rate for Payer: BCBS of TX Blue Essentials	$53.98
Rate for Payer: BCBS of TX PPO	$60.20
Rate for Payer: Cash Price	$153.12
Rate for Payer: Cash Price	$153.12
Rate for Payer: Cigna Medicaid	$20.78
Rate for Payer: Molina CHIP/Medicaid	$20.78
Rate for Payer: Multiplan Auto	$113.10
Rate for Payer: Multiplan Commercial	$113.10
Rate for Payer: Multiplan Workers Comp	$113.10
Rate for Payer: Parkland Medicaid	$20.78
Rate for Payer: Scott and White EPO/PPO	$87.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.78

EST PT Wound Visit Level 3 (31-45 Min)

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	7150519
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$137.15
Rate for Payer: Aetna Commercial	$116.05
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$90.31
Rate for Payer: BCBS of TX Blue Essentials	$107.95
Rate for Payer: BCBS of TX PPO	$120.41
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cigna Medicaid	$31.23
Rate for Payer: Molina CHIP/Medicaid	$31.23
Rate for Payer: Multiplan Auto	$137.15
Rate for Payer: Multiplan Commercial	$137.15
Rate for Payer: Multiplan Workers Comp	$137.15
Rate for Payer: Parkland Medicaid	$31.23
Rate for Payer: Scott and White EPO/PPO	$105.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.23

EST PT Wound Visit Level 4 (46-60 Min)

Facility

$390.00

Service Code	CPT 99214
Hospital Charge Code	7150527
Hospital Revenue Code	510
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$253.50
Rate for Payer: Aetna Commercial	$214.50
Rate for Payer: Amerigroup CHIP/Medicaid	$35.10
Rate for Payer: BCBS of TX Blue Advantage	$139.22
Rate for Payer: BCBS of TX Blue Essentials	$166.42
Rate for Payer: BCBS of TX PPO	$185.62
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cigna Medicaid	$43.87
Rate for Payer: Molina CHIP/Medicaid	$43.87
Rate for Payer: Multiplan Auto	$253.50
Rate for Payer: Multiplan Commercial	$253.50
Rate for Payer: Multiplan Workers Comp	$253.50
Rate for Payer: Parkland Medicaid	$43.87
Rate for Payer: Scott and White EPO/PPO	$195.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.87

EST PT Wound Visit Level 5 (60+ Min)

Facility

$426.00

Service Code	CPT 99215
Hospital Charge Code	7150535
Hospital Revenue Code	510
Min. Negotiated Rate	$38.34
Max. Negotiated Rate	$276.90
Rate for Payer: Aetna Commercial	$234.30
Rate for Payer: Amerigroup CHIP/Medicaid	$38.34
Rate for Payer: BCBS of TX Blue Advantage	$196.27
Rate for Payer: BCBS of TX Blue Essentials	$234.62
Rate for Payer: BCBS of TX PPO	$261.70
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cigna Medicaid	$67.53
Rate for Payer: Molina CHIP/Medicaid	$67.53
Rate for Payer: Multiplan Auto	$276.90
Rate for Payer: Multiplan Commercial	$276.90
Rate for Payer: Multiplan Workers Comp	$276.90
Rate for Payer: Parkland Medicaid	$67.53
Rate for Payer: Scott and White EPO/PPO	$213.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.53

ESTRADIOL

Facility

$194.00

Service Code	CPT 82670
Hospital Charge Code	1603364
Hospital Revenue Code	301
Min. Negotiated Rate	$10.90
Max. Negotiated Rate	$126.10
Rate for Payer: Aetna Commercial	$29.33
Rate for Payer: Aetna Medicare	$41.91
Rate for Payer: Amerigroup CHIP/Medicaid	$10.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.94
Rate for Payer: Amerigroup Medicare	$27.94
Rate for Payer: BCBS of TX Blue Advantage	$46.10
Rate for Payer: BCBS of TX Blue Essentials	$55.32
Rate for Payer: BCBS of TX Medicare	$27.94
Rate for Payer: BCBS of TX PPO	$61.75
Rate for Payer: Cash Price	$170.72
Rate for Payer: Cash Price	$170.72
Rate for Payer: Cigna Medicaid	$27.94
Rate for Payer: Cigna Medicare	$27.94
Rate for Payer: Employer Direct Commercial	$27.94
Rate for Payer: Humana Medicare/TRICARE	$27.94
Rate for Payer: Molina CHIP/Medicaid	$27.94
Rate for Payer: Molina Dual Medicare/Medicaid	$27.94
Rate for Payer: Molina Medicare	$27.94
Rate for Payer: Multiplan Auto	$126.10
Rate for Payer: Multiplan Commercial	$126.10
Rate for Payer: Multiplan Workers Comp	$126.10
Rate for Payer: Parkland Medicaid	$27.94
Rate for Payer: Scott and White EPO/PPO	$34.92
Rate for Payer: Scott and White Medicare	$27.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.94
Rate for Payer: Superior Health Plan EPO	$27.94
Rate for Payer: Superior Health Plan Medicare	$27.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.94
Rate for Payer: Universal American Medicare	$27.94
Rate for Payer: Wellcare Medicare	$27.94
Rate for Payer: Wellmed Medicare	$27.94

Estradiol, Sensitive SO

Facility

$194.00

Service Code	CPT 82670
Hospital Charge Code	1603364
Hospital Revenue Code	301
Rate for Payer: Cash Price	$170.72

Estradiol, Sensitive SO

Facility

$194.00

Service Code	CPT 82670
Hospital Charge Code	1603364
Hospital Revenue Code	301
Min. Negotiated Rate	$10.90
Max. Negotiated Rate	$126.10
Rate for Payer: Aetna Commercial	$29.33
Rate for Payer: Aetna Medicare	$41.91
Rate for Payer: Amerigroup CHIP/Medicaid	$10.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.94
Rate for Payer: Amerigroup Medicare	$27.94
Rate for Payer: BCBS of TX Blue Advantage	$46.10
Rate for Payer: BCBS of TX Blue Essentials	$55.32
Rate for Payer: BCBS of TX Medicare	$27.94
Rate for Payer: BCBS of TX PPO	$61.75
Rate for Payer: Cash Price	$170.72
Rate for Payer: Cash Price	$170.72
Rate for Payer: Cigna Medicaid	$27.94
Rate for Payer: Cigna Medicare	$27.94
Rate for Payer: Employer Direct Commercial	$27.94
Rate for Payer: Humana Medicare/TRICARE	$27.94
Rate for Payer: Molina CHIP/Medicaid	$27.94
Rate for Payer: Molina Dual Medicare/Medicaid	$27.94
Rate for Payer: Molina Medicare	$27.94
Rate for Payer: Multiplan Auto	$126.10
Rate for Payer: Multiplan Commercial	$126.10
Rate for Payer: Multiplan Workers Comp	$126.10
Rate for Payer: Parkland Medicaid	$27.94
Rate for Payer: Scott and White EPO/PPO	$34.92
Rate for Payer: Scott and White Medicare	$27.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.94
Rate for Payer: Superior Health Plan EPO	$27.94
Rate for Payer: Superior Health Plan Medicare	$27.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.94
Rate for Payer: Universal American Medicare	$27.94
Rate for Payer: Wellcare Medicare	$27.94
Rate for Payer: Wellmed Medicare	$27.94

Estradiol SO

Facility

$194.00

Service Code	CPT 82670
Hospital Charge Code	1603364
Hospital Revenue Code	301
Min. Negotiated Rate	$10.90
Max. Negotiated Rate	$126.10
Rate for Payer: Aetna Commercial	$29.33
Rate for Payer: Aetna Medicare	$41.91
Rate for Payer: Amerigroup CHIP/Medicaid	$10.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.94
Rate for Payer: Amerigroup Medicare	$27.94
Rate for Payer: BCBS of TX Blue Advantage	$46.10
Rate for Payer: BCBS of TX Blue Essentials	$55.32
Rate for Payer: BCBS of TX Medicare	$27.94
Rate for Payer: BCBS of TX PPO	$61.75
Rate for Payer: Cash Price	$170.72
Rate for Payer: Cash Price	$170.72
Rate for Payer: Cigna Medicaid	$27.94
Rate for Payer: Cigna Medicare	$27.94
Rate for Payer: Employer Direct Commercial	$27.94
Rate for Payer: Humana Medicare/TRICARE	$27.94
Rate for Payer: Molina CHIP/Medicaid	$27.94
Rate for Payer: Molina Dual Medicare/Medicaid	$27.94
Rate for Payer: Molina Medicare	$27.94
Rate for Payer: Multiplan Auto	$126.10
Rate for Payer: Multiplan Commercial	$126.10
Rate for Payer: Multiplan Workers Comp	$126.10
Rate for Payer: Parkland Medicaid	$27.94
Rate for Payer: Scott and White EPO/PPO	$34.92
Rate for Payer: Scott and White Medicare	$27.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.94
Rate for Payer: Superior Health Plan EPO	$27.94
Rate for Payer: Superior Health Plan Medicare	$27.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.94
Rate for Payer: Universal American Medicare	$27.94
Rate for Payer: Wellcare Medicare	$27.94
Rate for Payer: Wellmed Medicare	$27.94

Estrogens, Total SO

Facility

$246.00

Service Code	CPT 82672
Hospital Charge Code	1702000
Hospital Revenue Code	301
Rate for Payer: Cash Price	$216.48

Estrogens, Total SO

Facility

$246.00

Service Code	CPT 82672
Hospital Charge Code	1702000
Hospital Revenue Code	301
Min. Negotiated Rate	$8.46
Max. Negotiated Rate	$159.90
Rate for Payer: Aetna Commercial	$22.78
Rate for Payer: Aetna Medicare	$32.55
Rate for Payer: Amerigroup CHIP/Medicaid	$8.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.70
Rate for Payer: Amerigroup Medicare	$21.70
Rate for Payer: BCBS of TX Blue Advantage	$35.80
Rate for Payer: BCBS of TX Blue Essentials	$42.97
Rate for Payer: BCBS of TX Medicare	$21.70
Rate for Payer: BCBS of TX PPO	$47.96
Rate for Payer: Cash Price	$216.48
Rate for Payer: Cash Price	$216.48
Rate for Payer: Cigna Medicaid	$21.70
Rate for Payer: Cigna Medicare	$21.70
Rate for Payer: Employer Direct Commercial	$21.70
Rate for Payer: Humana Medicare/TRICARE	$21.70
Rate for Payer: Molina CHIP/Medicaid	$21.70
Rate for Payer: Molina Dual Medicare/Medicaid	$21.70
Rate for Payer: Molina Medicare	$21.70
Rate for Payer: Multiplan Auto	$159.90
Rate for Payer: Multiplan Commercial	$159.90
Rate for Payer: Multiplan Workers Comp	$159.90
Rate for Payer: Parkland Medicaid	$21.70
Rate for Payer: Scott and White EPO/PPO	$27.12
Rate for Payer: Scott and White Medicare	$21.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.70
Rate for Payer: Superior Health Plan EPO	$21.70
Rate for Payer: Superior Health Plan Medicare	$21.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.70
Rate for Payer: Universal American Medicare	$21.70
Rate for Payer: Wellcare Medicare	$21.70
Rate for Payer: Wellmed Medicare	$21.70

Ethanol, Urine SO

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640108
Hospital Revenue Code	300
Rate for Payer: Cash Price	$278.96

Ethanol, Urine SO

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640108
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$206.05
Rate for Payer: Aetna Commercial	$65.24
Rate for Payer: Aetna Medicare	$93.21
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$102.53
Rate for Payer: BCBS of TX Blue Essentials	$123.04
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$137.33
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cigna Medicaid	$62.14
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$62.14
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$62.14
Rate for Payer: Scott and White EPO/PPO	$77.68
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.14
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

Ethylene Glycol, Serum SO

Facility

$112.00

Service Code	CPT 82693
Hospital Charge Code	1707207
Hospital Revenue Code	301
Rate for Payer: Cash Price	$98.56

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