White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CT Orbits Sella w/ + w/o Contrast

Facility

$5,435.00

Service Code	HCPCS 70482
Hospital Charge Code	3800372
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,913.20
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,695.80
Rate for Payer: Cash Price	$3,695.80
Rate for Payer: Cash Price	$3,695.80
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,913.20
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$3,913.20
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$3,532.75
Rate for Payer: Multiplan Commercial	$3,532.75
Rate for Payer: Multiplan Workers Comp	$3,532.75
Rate for Payer: Parkland Medicaid	$3,913.20
Rate for Payer: Scott and White EPO/PPO	$267.23
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,913.20
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Pelvis w/ Contrast

Facility

$4,538.00

Service Code	HCPCS 72193
Hospital Charge Code	3800265
Hospital Revenue Code	352
Rate for Payer: Cash Price	$3,085.84

CT Pelvis w/ Contrast

Facility

$4,538.00

Service Code	HCPCS 72193
Hospital Charge Code	3800265
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,267.36
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,085.84
Rate for Payer: Cash Price	$3,085.84
Rate for Payer: Cash Price	$3,085.84
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,267.36
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$3,267.36
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$2,949.70
Rate for Payer: Multiplan Commercial	$2,949.70
Rate for Payer: Multiplan Workers Comp	$2,949.70
Rate for Payer: Parkland Medicaid	$3,267.36
Rate for Payer: Scott and White EPO/PPO	$290.34
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,267.36
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Pelvis w/o Contrast

Facility

$3,778.00

Service Code	HCPCS 72192
Hospital Charge Code	5052192
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$2,720.16
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$2,569.04
Rate for Payer: Cash Price	$2,569.04
Rate for Payer: Cash Price	$2,569.04
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$2,720.16
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$2,720.16
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$2,455.70
Rate for Payer: Multiplan Commercial	$2,455.70
Rate for Payer: Multiplan Workers Comp	$2,455.70
Rate for Payer: Parkland Medicaid	$2,720.16
Rate for Payer: Scott and White EPO/PPO	$168.39
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,720.16
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

CT Pelvis w/o Contrast

Facility

$3,778.00

Service Code	HCPCS 72192
Hospital Charge Code	5052192
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,569.04

CT Pelvis w/ + w/o Contrast

Facility

$4,765.00

Service Code	HCPCS 72194
Hospital Charge Code	3800190
Hospital Revenue Code	352
Rate for Payer: Cash Price	$3,240.20

CT Pelvis w/ + w/o Contrast

Facility

$4,765.00

Service Code	HCPCS 72194
Hospital Charge Code	3800190
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,430.80
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,240.20
Rate for Payer: Cash Price	$3,240.20
Rate for Payer: Cash Price	$3,240.20
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,430.80
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$3,430.80
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$3,097.25
Rate for Payer: Multiplan Commercial	$3,097.25
Rate for Payer: Multiplan Workers Comp	$3,097.25
Rate for Payer: Parkland Medicaid	$3,430.80
Rate for Payer: Scott and White EPO/PPO	$320.44
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,430.80
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Sacroplasty Bilat 2 or more needles

Facility

$21,024.00

Service Code	HCPCS 0201T
Hospital Charge Code	4612011
Hospital Revenue Code	360
Rate for Payer: Cash Price	$14,296.32

CT Sacroplasty Bilat 2 or more needles

Facility

$21,024.00

Service Code	HCPCS 0201T
Hospital Charge Code	5052898
Hospital Revenue Code	360
Min. Negotiated Rate	$1,892.16
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,892.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$14,296.32
Rate for Payer: Cash Price	$14,296.32
Rate for Payer: Cash Price	$14,296.32
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$15,137.28
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$15,137.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$15,137.28
Rate for Payer: Scott and White EPO/PPO	$10,512.00
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,137.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

CT Sacroplasty Bilat 2 or more needles

Facility

$21,024.00

Service Code	HCPCS 0201T
Hospital Charge Code	5052898
Hospital Revenue Code	360
Rate for Payer: Cash Price	$14,296.32

CT Sacroplasty Bilat 2 or more needles

Facility

$21,024.00

Service Code	HCPCS 0201T
Hospital Charge Code	4612011
Hospital Revenue Code	360
Min. Negotiated Rate	$1,892.16
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,892.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$14,296.32
Rate for Payer: Cash Price	$14,296.32
Rate for Payer: Cash Price	$14,296.32
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$15,137.28
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$15,137.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$15,137.28
Rate for Payer: Scott and White EPO/PPO	$10,512.00
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,137.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

CT Sacroplasty Unilat 1 or more needles

Facility

$14,016.00

Service Code	HCPCS 0200T
Hospital Charge Code	4610200
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,530.88

CT Sacroplasty Unilat 1 or more needles

Facility

$14,016.00

Service Code	HCPCS 0200T
Hospital Charge Code	4610200
Hospital Revenue Code	360
Min. Negotiated Rate	$1,261.44
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,261.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$9,530.88
Rate for Payer: Cash Price	$9,530.88
Rate for Payer: Cash Price	$9,530.88
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$10,091.52
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$10,091.52
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$10,091.52
Rate for Payer: Scott and White EPO/PPO	$7,008.00
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,091.52
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

CT Shoulder w/ Contrast Left

Facility

$3,312.00

Service Code	HCPCS 73201 LT
Hospital Charge Code	3800281
Hospital Revenue Code	352
Min. Negotiated Rate	$206.49
Max. Negotiated Rate	$2,384.64
Rate for Payer: Amerigroup CHIP/Medicaid	$206.49
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$2,252.16
Rate for Payer: Cash Price	$2,252.16
Rate for Payer: Cash Price	$2,252.16
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$2,384.64
Rate for Payer: Molina CHIP/Medicaid	$2,384.64
Rate for Payer: Multiplan Auto	$2,152.80
Rate for Payer: Multiplan Commercial	$2,152.80
Rate for Payer: Multiplan Workers Comp	$2,152.80
Rate for Payer: Parkland Medicaid	$2,384.64
Rate for Payer: Scott and White EPO/PPO	$1,656.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,384.64
Rate for Payer: Superior Health Plan EPO	$450.43

CT Shoulder w/ Contrast Left

Facility

$3,312.00

Service Code	HCPCS 73201 LT
Hospital Charge Code	3800281
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,252.16

CT Shoulder w/ Contrast Right

Facility

$3,312.00

Service Code	HCPCS 73201 RT
Hospital Charge Code	3801842
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,252.16

CT Shoulder w/ Contrast Right

Facility

$3,312.00

Service Code	HCPCS 73201 RT
Hospital Charge Code	3801842
Hospital Revenue Code	352
Min. Negotiated Rate	$206.49
Max. Negotiated Rate	$2,384.64
Rate for Payer: Amerigroup CHIP/Medicaid	$206.49
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$2,252.16
Rate for Payer: Cash Price	$2,252.16
Rate for Payer: Cash Price	$2,252.16
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$2,384.64
Rate for Payer: Molina CHIP/Medicaid	$2,384.64
Rate for Payer: Multiplan Auto	$2,152.80
Rate for Payer: Multiplan Commercial	$2,152.80
Rate for Payer: Multiplan Workers Comp	$2,152.80
Rate for Payer: Parkland Medicaid	$2,384.64
Rate for Payer: Scott and White EPO/PPO	$1,656.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,384.64
Rate for Payer: Superior Health Plan EPO	$450.43

CT Shoulder w/o Contrast Left

Facility

$1,788.00

Service Code	HCPCS 73200 LT
Hospital Charge Code	3800943
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$1,287.36
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$1,215.84
Rate for Payer: Cash Price	$1,215.84
Rate for Payer: Cash Price	$1,215.84
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$1,287.36
Rate for Payer: Molina CHIP/Medicaid	$1,287.36
Rate for Payer: Multiplan Auto	$1,162.20
Rate for Payer: Multiplan Commercial	$1,162.20
Rate for Payer: Multiplan Workers Comp	$1,162.20
Rate for Payer: Parkland Medicaid	$1,287.36
Rate for Payer: Scott and White EPO/PPO	$894.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,287.36
Rate for Payer: Superior Health Plan EPO	$243.17

CT Shoulder w/o Contrast Left

Facility

$1,788.00

Service Code	HCPCS 73200 LT
Hospital Charge Code	3800943
Hospital Revenue Code	352
Rate for Payer: Cash Price	$1,215.84

CT Shoulder w/o Contrast Right

Facility

$1,788.00

Service Code	HCPCS 73200 RT
Hospital Charge Code	3801834
Hospital Revenue Code	352
Rate for Payer: Cash Price	$1,215.84

CT Shoulder w/o Contrast Right

Facility

$1,788.00

Service Code	HCPCS 73200 RT
Hospital Charge Code	3801834
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$1,287.36
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$1,215.84
Rate for Payer: Cash Price	$1,215.84
Rate for Payer: Cash Price	$1,215.84
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$1,287.36
Rate for Payer: Molina CHIP/Medicaid	$1,287.36
Rate for Payer: Multiplan Auto	$1,162.20
Rate for Payer: Multiplan Commercial	$1,162.20
Rate for Payer: Multiplan Workers Comp	$1,162.20
Rate for Payer: Parkland Medicaid	$1,287.36
Rate for Payer: Scott and White EPO/PPO	$894.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,287.36
Rate for Payer: Superior Health Plan EPO	$243.17

CT Sinus w/ + w/o Contrast

Facility

$5,171.00

Service Code	HCPCS 70488
Hospital Charge Code	3840121
Hospital Revenue Code	351
Rate for Payer: Cash Price	$3,516.28

CT Sinus w/ + w/o Contrast

Facility

$5,171.00

Service Code	HCPCS 70488
Hospital Charge Code	3840121
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,723.12
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,516.28
Rate for Payer: Cash Price	$3,516.28
Rate for Payer: Cash Price	$3,516.28
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,723.12
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$3,723.12
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$3,361.15
Rate for Payer: Multiplan Commercial	$3,361.15
Rate for Payer: Multiplan Workers Comp	$3,361.15
Rate for Payer: Parkland Medicaid	$3,723.12
Rate for Payer: Scott and White EPO/PPO	$233.43
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,723.12
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

Ct-Smac With Cefixime and Tellurite, For E. Coli O157, 15 x 100 mm Plate

Facility

$8.71

Hospital Charge Code	993356
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.92

Ct-Smac With Cefixime and Tellurite, For E. Coli O157, 15 x 100 mm Plate

Facility

$8.71

Hospital Charge Code	993356
Hospital Revenue Code	272
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$6.27
Rate for Payer: Amerigroup CHIP/Medicaid	$0.78
Rate for Payer: BCBS of TX Blue Advantage	$2.61
Rate for Payer: BCBS of TX Blue Essentials	$3.14
Rate for Payer: BCBS of TX PPO	$3.48
Rate for Payer: Cash Price	$5.92
Rate for Payer: Cigna Medicaid	$6.27
Rate for Payer: Molina CHIP/Medicaid	$6.27
Rate for Payer: Multiplan Auto	$5.66
Rate for Payer: Multiplan Commercial	$5.66
Rate for Payer: Multiplan Workers Comp	$5.66
Rate for Payer: Parkland Medicaid	$6.27
Rate for Payer: Scott and White EPO/PPO	$4.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.27
Rate for Payer: Superior Health Plan EPO	$1.18

Know your out-of-pocket cost for care.

All Charges