White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Factor II Activity SO

Facility

$173.00

Service Code	CPT 85210
Hospital Charge Code	1709187
Hospital Revenue Code	305
Rate for Payer: Cash Price	$152.24

Factor II Activity SO

Facility

$173.00

Service Code	CPT 85210
Hospital Charge Code	1709187
Hospital Revenue Code	305
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$112.45
Rate for Payer: Aetna Commercial	$13.63
Rate for Payer: Aetna Medicare	$19.47
Rate for Payer: Amerigroup CHIP/Medicaid	$5.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.98
Rate for Payer: Amerigroup Medicare	$12.98
Rate for Payer: BCBS of TX Blue Advantage	$21.42
Rate for Payer: BCBS of TX Blue Essentials	$25.70
Rate for Payer: BCBS of TX Medicare	$12.98
Rate for Payer: BCBS of TX PPO	$28.69
Rate for Payer: Cash Price	$152.24
Rate for Payer: Cash Price	$152.24
Rate for Payer: Cigna Medicaid	$12.98
Rate for Payer: Cigna Medicare	$12.98
Rate for Payer: Employer Direct Commercial	$12.98
Rate for Payer: Humana Medicare/TRICARE	$12.98
Rate for Payer: Molina CHIP/Medicaid	$12.98
Rate for Payer: Molina Dual Medicare/Medicaid	$12.98
Rate for Payer: Molina Medicare	$12.98
Rate for Payer: Multiplan Auto	$112.45
Rate for Payer: Multiplan Commercial	$112.45
Rate for Payer: Multiplan Workers Comp	$112.45
Rate for Payer: Parkland Medicaid	$12.98
Rate for Payer: Scott and White EPO/PPO	$16.22
Rate for Payer: Scott and White Medicare	$12.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.98
Rate for Payer: Superior Health Plan EPO	$12.98
Rate for Payer: Superior Health Plan Medicare	$12.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.98
Rate for Payer: Universal American Medicare	$12.98
Rate for Payer: Wellcare Medicare	$12.98
Rate for Payer: Wellmed Medicare	$12.98

Factor II, DNA Analysis SO

Facility

$297.00

Service Code	CPT 81240
Hospital Charge Code	1740953
Hospital Revenue Code	310
Rate for Payer: Cash Price	$261.36

Factor II, DNA Analysis SO

Facility

$297.00

Service Code	CPT 81240
Hospital Charge Code	1740953
Hospital Revenue Code	310
Min. Negotiated Rate	$25.62
Max. Negotiated Rate	$193.05
Rate for Payer: Aetna Commercial	$68.97
Rate for Payer: Aetna Medicare	$98.54
Rate for Payer: Amerigroup CHIP/Medicaid	$25.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$65.69
Rate for Payer: Amerigroup Medicare	$65.69
Rate for Payer: BCBS of TX Blue Advantage	$108.39
Rate for Payer: BCBS of TX Blue Essentials	$130.07
Rate for Payer: BCBS of TX Medicare	$65.69
Rate for Payer: BCBS of TX PPO	$145.17
Rate for Payer: Cash Price	$261.36
Rate for Payer: Cash Price	$261.36
Rate for Payer: Cigna Medicaid	$65.69
Rate for Payer: Cigna Medicare	$65.69
Rate for Payer: Employer Direct Commercial	$65.69
Rate for Payer: Humana Medicare/TRICARE	$65.69
Rate for Payer: Molina CHIP/Medicaid	$65.69
Rate for Payer: Molina Dual Medicare/Medicaid	$65.69
Rate for Payer: Molina Medicare	$65.69
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	$65.69
Rate for Payer: Scott and White EPO/PPO	$82.11
Rate for Payer: Scott and White Medicare	$65.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.69
Rate for Payer: Superior Health Plan EPO	$65.69
Rate for Payer: Superior Health Plan Medicare	$65.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$65.69
Rate for Payer: Universal American Medicare	$65.69
Rate for Payer: Wellcare Medicare	$65.69
Rate for Payer: Wellmed Medicare	$65.69

Factor IX Activity SO

Facility

$168.00

Service Code	CPT 85250
Hospital Charge Code	1701051
Hospital Revenue Code	305
Min. Negotiated Rate	$7.43
Max. Negotiated Rate	$109.20
Rate for Payer: Aetna Commercial	$19.98
Rate for Payer: Aetna Medicare	$28.56
Rate for Payer: Amerigroup CHIP/Medicaid	$7.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.04
Rate for Payer: Amerigroup Medicare	$19.04
Rate for Payer: BCBS of TX Blue Advantage	$31.42
Rate for Payer: BCBS of TX Blue Essentials	$37.70
Rate for Payer: BCBS of TX Medicare	$19.04
Rate for Payer: BCBS of TX PPO	$42.08
Rate for Payer: Cash Price	$147.84
Rate for Payer: Cash Price	$147.84
Rate for Payer: Cigna Medicaid	$19.04
Rate for Payer: Cigna Medicare	$19.04
Rate for Payer: Employer Direct Commercial	$19.04
Rate for Payer: Humana Medicare/TRICARE	$19.04
Rate for Payer: Molina CHIP/Medicaid	$19.04
Rate for Payer: Molina Dual Medicare/Medicaid	$19.04
Rate for Payer: Molina Medicare	$19.04
Rate for Payer: Multiplan Auto	$109.20
Rate for Payer: Multiplan Commercial	$109.20
Rate for Payer: Multiplan Workers Comp	$109.20
Rate for Payer: Parkland Medicaid	$19.04
Rate for Payer: Scott and White EPO/PPO	$23.80
Rate for Payer: Scott and White Medicare	$19.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.04
Rate for Payer: Superior Health Plan EPO	$19.04
Rate for Payer: Superior Health Plan Medicare	$19.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.04
Rate for Payer: Universal American Medicare	$19.04
Rate for Payer: Wellcare Medicare	$19.04
Rate for Payer: Wellmed Medicare	$19.04

Factor IX Activity SO

Facility

$168.00

Service Code	CPT 85250
Hospital Charge Code	1701051
Hospital Revenue Code	305
Rate for Payer: Cash Price	$147.84

Factor V Activity SO

Facility

$61.00

Service Code	CPT 85220
Hospital Charge Code	1703396
Hospital Revenue Code	305
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$39.65
Rate for Payer: Aetna Commercial	$18.53
Rate for Payer: Aetna Medicare	$26.48
Rate for Payer: Amerigroup CHIP/Medicaid	$6.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.65
Rate for Payer: Amerigroup Medicare	$17.65
Rate for Payer: BCBS of TX Blue Advantage	$29.12
Rate for Payer: BCBS of TX Blue Essentials	$34.95
Rate for Payer: BCBS of TX Medicare	$17.65
Rate for Payer: BCBS of TX PPO	$39.01
Rate for Payer: Cash Price	$53.68
Rate for Payer: Cash Price	$53.68
Rate for Payer: Cigna Medicaid	$17.65
Rate for Payer: Cigna Medicare	$17.65
Rate for Payer: Employer Direct Commercial	$17.65
Rate for Payer: Humana Medicare/TRICARE	$17.65
Rate for Payer: Molina CHIP/Medicaid	$17.65
Rate for Payer: Molina Dual Medicare/Medicaid	$17.65
Rate for Payer: Molina Medicare	$17.65
Rate for Payer: Multiplan Auto	$39.65
Rate for Payer: Multiplan Commercial	$39.65
Rate for Payer: Multiplan Workers Comp	$39.65
Rate for Payer: Parkland Medicaid	$17.65
Rate for Payer: Scott and White EPO/PPO	$22.06
Rate for Payer: Scott and White Medicare	$17.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.65
Rate for Payer: Superior Health Plan EPO	$17.65
Rate for Payer: Superior Health Plan Medicare	$17.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.65
Rate for Payer: Universal American Medicare	$17.65
Rate for Payer: Wellcare Medicare	$17.65
Rate for Payer: Wellmed Medicare	$17.65

Factor V Activity SO

Facility

$61.00

Service Code	CPT 85220
Hospital Charge Code	1703396
Hospital Revenue Code	305
Rate for Payer: Cash Price	$53.68

Factor VII Activity SO

Facility

$301.00

Service Code	CPT 85230
Hospital Charge Code	1701036
Hospital Revenue Code	305
Rate for Payer: Cash Price	$264.88

Factor VII Activity SO

Facility

$301.00

Service Code	CPT 85230
Hospital Charge Code	1701036
Hospital Revenue Code	305
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$195.65
Rate for Payer: Aetna Commercial	$18.80
Rate for Payer: Aetna Medicare	$26.85
Rate for Payer: Amerigroup CHIP/Medicaid	$6.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.90
Rate for Payer: Amerigroup Medicare	$17.90
Rate for Payer: BCBS of TX Blue Advantage	$29.54
Rate for Payer: BCBS of TX Blue Essentials	$35.44
Rate for Payer: BCBS of TX Medicare	$17.90
Rate for Payer: BCBS of TX PPO	$39.56
Rate for Payer: Cash Price	$264.88
Rate for Payer: Cash Price	$264.88
Rate for Payer: Cigna Medicaid	$17.90
Rate for Payer: Cigna Medicare	$17.90
Rate for Payer: Employer Direct Commercial	$17.90
Rate for Payer: Humana Medicare/TRICARE	$17.90
Rate for Payer: Molina CHIP/Medicaid	$17.90
Rate for Payer: Molina Dual Medicare/Medicaid	$17.90
Rate for Payer: Molina Medicare	$17.90
Rate for Payer: Multiplan Auto	$195.65
Rate for Payer: Multiplan Commercial	$195.65
Rate for Payer: Multiplan Workers Comp	$195.65
Rate for Payer: Parkland Medicaid	$17.90
Rate for Payer: Scott and White EPO/PPO	$22.38
Rate for Payer: Scott and White Medicare	$17.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.90
Rate for Payer: Superior Health Plan EPO	$17.90
Rate for Payer: Superior Health Plan Medicare	$17.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.90
Rate for Payer: Universal American Medicare	$17.90
Rate for Payer: Wellcare Medicare	$17.90
Rate for Payer: Wellmed Medicare	$17.90

Factor VIII Activity SO

Facility

$118.00

Service Code	CPT 85240
Hospital Charge Code	1706977
Hospital Revenue Code	305
Rate for Payer: Cash Price	$103.84

Factor VIII Activity SO

Facility

$118.00

Service Code	CPT 85240
Hospital Charge Code	1706977
Hospital Revenue Code	305
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$76.70
Rate for Payer: Aetna Commercial	$18.80
Rate for Payer: Aetna Medicare	$26.85
Rate for Payer: Amerigroup CHIP/Medicaid	$6.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.90
Rate for Payer: Amerigroup Medicare	$17.90
Rate for Payer: BCBS of TX Blue Advantage	$29.54
Rate for Payer: BCBS of TX Blue Essentials	$35.44
Rate for Payer: BCBS of TX Medicare	$17.90
Rate for Payer: BCBS of TX PPO	$39.56
Rate for Payer: Cash Price	$103.84
Rate for Payer: Cash Price	$103.84
Rate for Payer: Cigna Medicaid	$17.90
Rate for Payer: Cigna Medicare	$17.90
Rate for Payer: Employer Direct Commercial	$17.90
Rate for Payer: Humana Medicare/TRICARE	$17.90
Rate for Payer: Molina CHIP/Medicaid	$17.90
Rate for Payer: Molina Dual Medicare/Medicaid	$17.90
Rate for Payer: Molina Medicare	$17.90
Rate for Payer: Multiplan Auto	$76.70
Rate for Payer: Multiplan Commercial	$76.70
Rate for Payer: Multiplan Workers Comp	$76.70
Rate for Payer: Parkland Medicaid	$17.90
Rate for Payer: Scott and White EPO/PPO	$22.38
Rate for Payer: Scott and White Medicare	$17.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.90
Rate for Payer: Superior Health Plan EPO	$17.90
Rate for Payer: Superior Health Plan Medicare	$17.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.90
Rate for Payer: Universal American Medicare	$17.90
Rate for Payer: Wellcare Medicare	$17.90
Rate for Payer: Wellmed Medicare	$17.90

Factor V Leiden Mutation SO

Facility

$286.00

Service Code	CPT 81241
Hospital Charge Code	1740951
Hospital Revenue Code	310
Rate for Payer: Cash Price	$251.68

Factor V Leiden Mutation SO

Facility

$286.00

Service Code	CPT 81241
Hospital Charge Code	1740951
Hospital Revenue Code	310
Min. Negotiated Rate	$28.61
Max. Negotiated Rate	$185.90
Rate for Payer: Aetna Commercial	$77.04
Rate for Payer: Aetna Medicare	$110.06
Rate for Payer: Amerigroup CHIP/Medicaid	$28.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$73.37
Rate for Payer: Amerigroup Medicare	$73.37
Rate for Payer: BCBS of TX Blue Advantage	$121.06
Rate for Payer: BCBS of TX Blue Essentials	$145.27
Rate for Payer: BCBS of TX Medicare	$73.37
Rate for Payer: BCBS of TX PPO	$162.15
Rate for Payer: Cash Price	$251.68
Rate for Payer: Cash Price	$251.68
Rate for Payer: Cigna Medicaid	$73.37
Rate for Payer: Cigna Medicare	$73.37
Rate for Payer: Employer Direct Commercial	$73.37
Rate for Payer: Humana Medicare/TRICARE	$73.37
Rate for Payer: Molina CHIP/Medicaid	$73.37
Rate for Payer: Molina Dual Medicare/Medicaid	$73.37
Rate for Payer: Molina Medicare	$73.37
Rate for Payer: Multiplan Auto	$185.90
Rate for Payer: Multiplan Commercial	$185.90
Rate for Payer: Multiplan Workers Comp	$185.90
Rate for Payer: Parkland Medicaid	$73.37
Rate for Payer: Scott and White EPO/PPO	$91.71
Rate for Payer: Scott and White Medicare	$73.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$73.37
Rate for Payer: Superior Health Plan EPO	$73.37
Rate for Payer: Superior Health Plan Medicare	$73.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$73.37
Rate for Payer: Universal American Medicare	$73.37
Rate for Payer: Wellcare Medicare	$73.37
Rate for Payer: Wellmed Medicare	$73.37

Factor X Activity SO

Facility

$161.00

Service Code	CPT 85260
Hospital Charge Code	1703883
Hospital Revenue Code	305
Rate for Payer: Cash Price	$141.68

Factor X Activity SO

Facility

$161.00

Service Code	CPT 85260
Hospital Charge Code	1703883
Hospital Revenue Code	305
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$104.65
Rate for Payer: Aetna Commercial	$18.80
Rate for Payer: Aetna Medicare	$26.85
Rate for Payer: Amerigroup CHIP/Medicaid	$6.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.90
Rate for Payer: Amerigroup Medicare	$17.90
Rate for Payer: BCBS of TX Blue Advantage	$29.54
Rate for Payer: BCBS of TX Blue Essentials	$35.44
Rate for Payer: BCBS of TX Medicare	$17.90
Rate for Payer: BCBS of TX PPO	$39.56
Rate for Payer: Cash Price	$141.68
Rate for Payer: Cash Price	$141.68
Rate for Payer: Cigna Medicaid	$17.90
Rate for Payer: Cigna Medicare	$17.90
Rate for Payer: Employer Direct Commercial	$17.90
Rate for Payer: Humana Medicare/TRICARE	$17.90
Rate for Payer: Molina CHIP/Medicaid	$17.90
Rate for Payer: Molina Dual Medicare/Medicaid	$17.90
Rate for Payer: Molina Medicare	$17.90
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	$17.90
Rate for Payer: Scott and White EPO/PPO	$22.38
Rate for Payer: Scott and White Medicare	$17.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.90
Rate for Payer: Superior Health Plan EPO	$17.90
Rate for Payer: Superior Health Plan Medicare	$17.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.90
Rate for Payer: Universal American Medicare	$17.90
Rate for Payer: Wellcare Medicare	$17.90
Rate for Payer: Wellmed Medicare	$17.90

Factor XI Activity SO

Facility

$284.00

Service Code	CPT 85270
Hospital Charge Code	1706365
Hospital Revenue Code	305
Rate for Payer: Cash Price	$249.92

Factor XI Activity SO

Facility

$284.00

Service Code	CPT 85270
Hospital Charge Code	1706365
Hospital Revenue Code	305
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$184.60
Rate for Payer: Aetna Commercial	$18.80
Rate for Payer: Aetna Medicare	$26.85
Rate for Payer: Amerigroup CHIP/Medicaid	$6.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.90
Rate for Payer: Amerigroup Medicare	$17.90
Rate for Payer: BCBS of TX Blue Advantage	$29.54
Rate for Payer: BCBS of TX Blue Essentials	$35.44
Rate for Payer: BCBS of TX Medicare	$17.90
Rate for Payer: BCBS of TX PPO	$39.56
Rate for Payer: Cash Price	$249.92
Rate for Payer: Cash Price	$249.92
Rate for Payer: Cigna Medicaid	$17.90
Rate for Payer: Cigna Medicare	$17.90
Rate for Payer: Employer Direct Commercial	$17.90
Rate for Payer: Humana Medicare/TRICARE	$17.90
Rate for Payer: Molina CHIP/Medicaid	$17.90
Rate for Payer: Molina Dual Medicare/Medicaid	$17.90
Rate for Payer: Molina Medicare	$17.90
Rate for Payer: Multiplan Auto	$184.60
Rate for Payer: Multiplan Commercial	$184.60
Rate for Payer: Multiplan Workers Comp	$184.60
Rate for Payer: Parkland Medicaid	$17.90
Rate for Payer: Scott and White EPO/PPO	$22.38
Rate for Payer: Scott and White Medicare	$17.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.90
Rate for Payer: Superior Health Plan EPO	$17.90
Rate for Payer: Superior Health Plan Medicare	$17.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.90
Rate for Payer: Universal American Medicare	$17.90
Rate for Payer: Wellcare Medicare	$17.90
Rate for Payer: Wellmed Medicare	$17.90

Factor XII Activity SO

Facility

$306.00

Service Code	CPT 85280
Hospital Charge Code	1706373
Hospital Revenue Code	305
Min. Negotiated Rate	$7.55
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna Commercial	$20.32
Rate for Payer: Aetna Medicare	$29.02
Rate for Payer: Amerigroup CHIP/Medicaid	$7.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.35
Rate for Payer: Amerigroup Medicare	$19.35
Rate for Payer: BCBS of TX Blue Advantage	$31.93
Rate for Payer: BCBS of TX Blue Essentials	$38.31
Rate for Payer: BCBS of TX Medicare	$19.35
Rate for Payer: BCBS of TX PPO	$42.76
Rate for Payer: Cash Price	$269.28
Rate for Payer: Cash Price	$269.28
Rate for Payer: Cigna Medicaid	$19.35
Rate for Payer: Cigna Medicare	$19.35
Rate for Payer: Employer Direct Commercial	$19.35
Rate for Payer: Humana Medicare/TRICARE	$19.35
Rate for Payer: Molina CHIP/Medicaid	$19.35
Rate for Payer: Molina Dual Medicare/Medicaid	$19.35
Rate for Payer: Molina Medicare	$19.35
Rate for Payer: Multiplan Auto	$198.90
Rate for Payer: Multiplan Commercial	$198.90
Rate for Payer: Multiplan Workers Comp	$198.90
Rate for Payer: Parkland Medicaid	$19.35
Rate for Payer: Scott and White EPO/PPO	$24.19
Rate for Payer: Scott and White Medicare	$19.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.35
Rate for Payer: Superior Health Plan EPO	$19.35
Rate for Payer: Superior Health Plan Medicare	$19.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.35
Rate for Payer: Universal American Medicare	$19.35
Rate for Payer: Wellcare Medicare	$19.35
Rate for Payer: Wellmed Medicare	$19.35

Factor XII Activity SO

Facility

$306.00

Service Code	CPT 85280
Hospital Charge Code	1706373
Hospital Revenue Code	305
Rate for Payer: Cash Price	$269.28

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS S0028
Hospital Charge Code	77561660
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS S0028
Hospital Charge Code	7445530
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS S0028
Hospital Charge Code	7445530
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS S0028
Hospital Charge Code	77561660
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

famotidine 20 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78433747
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

Know your out-of-pocket cost for care.

All Charges