White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GW J -- DHF

Facility

$472.16

Service Code	HCPCS C1769
Hospital Charge Code	80731706
Hospital Revenue Code	272
Min. Negotiated Rate	$42.49
Max. Negotiated Rate	$306.90
Rate for Payer: Aetna Commercial	$259.69
Rate for Payer: Amerigroup CHIP/Medicaid	$42.49
Rate for Payer: BCBS of TX Blue Advantage	$141.65
Rate for Payer: BCBS of TX Blue Essentials	$169.98
Rate for Payer: BCBS of TX PPO	$188.86
Rate for Payer: Cash Price	$415.50
Rate for Payer: Multiplan Auto	$306.90
Rate for Payer: Multiplan Commercial	$306.90
Rate for Payer: Multiplan Workers Comp	$306.90
Rate for Payer: Scott and White EPO/PPO	$236.08
Rate for Payer: Superior Health Plan EPO	$64.21

GW J -- DHF

Facility

$472.16

Service Code	HCPCS C1769
Hospital Charge Code	80731706
Hospital Revenue Code	272
Rate for Payer: Cash Price	$415.50

GW PTCA CHOICE 182/300 -- DHF

Facility

$348.56

Service Code	HCPCS C1769
Hospital Charge Code	82412107
Hospital Revenue Code	272
Min. Negotiated Rate	$31.37
Max. Negotiated Rate	$226.56
Rate for Payer: Aetna Commercial	$191.71
Rate for Payer: Amerigroup CHIP/Medicaid	$31.37
Rate for Payer: BCBS of TX Blue Advantage	$104.57
Rate for Payer: BCBS of TX Blue Essentials	$125.48
Rate for Payer: BCBS of TX PPO	$139.42
Rate for Payer: Cash Price	$306.73
Rate for Payer: Multiplan Auto	$226.56
Rate for Payer: Multiplan Commercial	$226.56
Rate for Payer: Multiplan Workers Comp	$226.56
Rate for Payer: Scott and White EPO/PPO	$174.28
Rate for Payer: Superior Health Plan EPO	$47.40

GW PTCA CHOICE 182/300 -- DHF

Facility

$348.56

Service Code	HCPCS C1769
Hospital Charge Code	82412107
Hospital Revenue Code	272
Rate for Payer: Cash Price	$306.73

GW VERRATA 185CM 10185P

Facility

$5,879.30

Service Code	HCPCS C1769
Hospital Charge Code	80735061
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,173.78

GW VERRATA 185CM 10185P

Facility

$5,879.30

Service Code	HCPCS C1769
Hospital Charge Code	80735061
Hospital Revenue Code	272
Min. Negotiated Rate	$529.14
Max. Negotiated Rate	$3,821.54
Rate for Payer: Aetna Commercial	$3,233.62
Rate for Payer: Amerigroup CHIP/Medicaid	$529.14
Rate for Payer: BCBS of TX Blue Advantage	$1,763.79
Rate for Payer: BCBS of TX Blue Essentials	$2,116.55
Rate for Payer: BCBS of TX PPO	$2,351.72
Rate for Payer: Cash Price	$5,173.78
Rate for Payer: Multiplan Auto	$3,821.54
Rate for Payer: Multiplan Commercial	$3,821.54
Rate for Payer: Multiplan Workers Comp	$3,821.54
Rate for Payer: Scott and White EPO/PPO	$2,939.65
Rate for Payer: Superior Health Plan EPO	$799.58

Hallux rigidus correction

Facility

$15,074.51

Service Code	CPT 28291
Hospital Charge Code	36028291
Hospital Revenue Code	360
Min. Negotiated Rate	$144.31
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3,623.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
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	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicaid	$3,623.98
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina CHIP/Medicaid	$3,623.98
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
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	$3,623.98
Rate for Payer: Scott and White EPO/PPO	$144.31
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,623.98
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsop

Facility

$10,000.00

Service Code	CPT 28289
Hospital Charge Code	36028289
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

haloperidol 5 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1630
Hospital Charge Code	77602094
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

haloperidol 5 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1630
Hospital Charge Code	77602094
Hospital Revenue Code	636
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$5.76
Rate for Payer: BCBS of TX Blue Essentials	$6.91
Rate for Payer: BCBS of TX PPO	$7.66
Rate for Payer: Cash Price	$87.16
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

HANDLE, STAPLER EXTRA LARGE ENDO GIA -- DHF

Facility

$2,582.77

Hospital Charge Code	81911356
Hospital Revenue Code	272
Min. Negotiated Rate	$232.45
Max. Negotiated Rate	$1,678.80
Rate for Payer: Aetna Commercial	$1,420.52
Rate for Payer: Amerigroup CHIP/Medicaid	$232.45
Rate for Payer: BCBS of TX Blue Advantage	$774.83
Rate for Payer: BCBS of TX Blue Essentials	$929.80
Rate for Payer: BCBS of TX PPO	$1,033.11
Rate for Payer: Cash Price	$2,272.84
Rate for Payer: Multiplan Auto	$1,678.80
Rate for Payer: Multiplan Commercial	$1,678.80
Rate for Payer: Multiplan Workers Comp	$1,678.80
Rate for Payer: Scott and White EPO/PPO	$1,291.38
Rate for Payer: Superior Health Plan EPO	$351.26

HANDLE, STAPLER EXTRA LARGE ENDO GIA -- DHF

Facility

$2,582.77

Hospital Charge Code	81911356
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,272.84

HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC

Facility

$30,799.00

Service Code	MSDRG 513
Min. Negotiated Rate	$12,906.88
Max. Negotiated Rate	$30,799.00
Rate for Payer: Aetna Commercial	$18,236.25
Rate for Payer: Aetna Medicare	$21,633.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,422.33
Rate for Payer: Amerigroup Medicare	$14,422.33
Rate for Payer: BCBS of TX Blue Advantage	$12,906.88
Rate for Payer: BCBS of TX Blue Essentials	$16,919.03
Rate for Payer: BCBS of TX Medicare	$14,422.33
Rate for Payer: BCBS of TX PPO	$18,799.65
Rate for Payer: Cigna Commercial	$20,878.48
Rate for Payer: Cigna Medicare	$14,422.33
Rate for Payer: Employer Direct Commercial	$14,422.33
Rate for Payer: Humana Medicare/TRICARE	$14,422.33
Rate for Payer: Molina Dual Medicare/Medicaid	$14,422.33
Rate for Payer: Molina Medicare	$14,422.33
Rate for Payer: Multiplan Auto	$30,799.00
Rate for Payer: Multiplan Commercial	$30,799.00
Rate for Payer: Multiplan Workers Comp	$30,799.00
Rate for Payer: Scott and White EPO/PPO	$14,183.75
Rate for Payer: Scott and White Medicare	$14,422.33
Rate for Payer: Superior Health Plan EPO	$14,422.33
Rate for Payer: Superior Health Plan Medicare	$14,422.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,422.33
Rate for Payer: Universal American Medicare	$14,422.33
Rate for Payer: Wellcare Medicare	$14,422.33
Rate for Payer: Wellmed Medicare	$14,422.33

HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$19,788.50

Service Code	MSDRG 514
Min. Negotiated Rate	$8,358.34
Max. Negotiated Rate	$19,788.50
Rate for Payer: Aetna Commercial	$11,716.88
Rate for Payer: Aetna Medicare	$15,430.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,286.98
Rate for Payer: Amerigroup Medicare	$10,286.98
Rate for Payer: BCBS of TX Blue Advantage	$8,358.34
Rate for Payer: BCBS of TX Blue Essentials	$10,316.94
Rate for Payer: BCBS of TX Medicare	$10,286.98
Rate for Payer: BCBS of TX PPO	$11,463.71
Rate for Payer: Cigna Commercial	$13,414.52
Rate for Payer: Cigna Medicare	$10,286.98
Rate for Payer: Employer Direct Commercial	$10,286.98
Rate for Payer: Humana Medicare/TRICARE	$10,286.98
Rate for Payer: Molina Dual Medicare/Medicaid	$10,286.98
Rate for Payer: Molina Medicare	$10,286.98
Rate for Payer: Multiplan Auto	$19,788.50
Rate for Payer: Multiplan Commercial	$19,788.50
Rate for Payer: Multiplan Workers Comp	$19,788.50
Rate for Payer: Scott and White EPO/PPO	$9,113.12
Rate for Payer: Scott and White Medicare	$10,286.98
Rate for Payer: Superior Health Plan EPO	$10,286.98
Rate for Payer: Superior Health Plan Medicare	$10,286.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,286.98
Rate for Payer: Universal American Medicare	$10,286.98
Rate for Payer: Wellcare Medicare	$10,286.98
Rate for Payer: Wellmed Medicare	$10,286.98

HANDPIECE, VESSEL SEALER FRONT GRIP 5MMX 45CM -- DHF

Facility

$2,043.00

Hospital Charge Code	81748345
Hospital Revenue Code	272
Min. Negotiated Rate	$183.87
Max. Negotiated Rate	$1,327.95
Rate for Payer: Aetna Commercial	$1,123.65
Rate for Payer: Amerigroup CHIP/Medicaid	$183.87
Rate for Payer: BCBS of TX Blue Advantage	$612.90
Rate for Payer: BCBS of TX Blue Essentials	$735.48
Rate for Payer: BCBS of TX PPO	$817.20
Rate for Payer: Cash Price	$1,797.84
Rate for Payer: Multiplan Auto	$1,327.95
Rate for Payer: Multiplan Commercial	$1,327.95
Rate for Payer: Multiplan Workers Comp	$1,327.95
Rate for Payer: Scott and White EPO/PPO	$1,021.50
Rate for Payer: Superior Health Plan EPO	$277.85

HANDPIECE, VESSEL SEALER OPEN FINE JAW 9CM SCISSOR -- DHF

Facility

$2,043.00

Hospital Charge Code	81748345
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,797.84

HANDPIECE, VESSEL SEALER OPEN FINE JAW 9CM SCISSOR -- DHF

Facility

$2,043.00

Hospital Charge Code	81748345
Hospital Revenue Code	272
Min. Negotiated Rate	$183.87
Max. Negotiated Rate	$1,327.95
Rate for Payer: Aetna Commercial	$1,123.65
Rate for Payer: Amerigroup CHIP/Medicaid	$183.87
Rate for Payer: BCBS of TX Blue Advantage	$612.90
Rate for Payer: BCBS of TX Blue Essentials	$735.48
Rate for Payer: BCBS of TX PPO	$817.20
Rate for Payer: Cash Price	$1,797.84
Rate for Payer: Multiplan Auto	$1,327.95
Rate for Payer: Multiplan Commercial	$1,327.95
Rate for Payer: Multiplan Workers Comp	$1,327.95
Rate for Payer: Scott and White EPO/PPO	$1,021.50
Rate for Payer: Superior Health Plan EPO	$277.85

HAND PROCEDURES FOR INJURIES

Facility

$35,750.40

Service Code	MSDRG 906
Min. Negotiated Rate	$12,931.82
Max. Negotiated Rate	$35,750.40
Rate for Payer: Aetna Commercial	$21,168.00
Rate for Payer: Aetna Medicare	$24,423.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,282.00
Rate for Payer: Amerigroup Medicare	$16,282.00
Rate for Payer: BCBS of TX Blue Advantage	$12,931.82
Rate for Payer: BCBS of TX Blue Essentials	$19,019.98
Rate for Payer: BCBS of TX Medicare	$16,282.00
Rate for Payer: BCBS of TX PPO	$21,134.13
Rate for Payer: Cigna Commercial	$24,235.01
Rate for Payer: Cigna Medicare	$16,282.00
Rate for Payer: Employer Direct Commercial	$16,282.00
Rate for Payer: Humana Medicare/TRICARE	$16,282.00
Rate for Payer: Molina Dual Medicare/Medicaid	$16,282.00
Rate for Payer: Molina Medicare	$16,282.00
Rate for Payer: Multiplan Auto	$35,750.40
Rate for Payer: Multiplan Commercial	$35,750.40
Rate for Payer: Multiplan Workers Comp	$35,750.40
Rate for Payer: Scott and White EPO/PPO	$16,464.00
Rate for Payer: Scott and White Medicare	$16,282.00
Rate for Payer: Superior Health Plan EPO	$16,282.00
Rate for Payer: Superior Health Plan Medicare	$16,282.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,282.00
Rate for Payer: Universal American Medicare	$16,282.00
Rate for Payer: Wellcare Medicare	$16,282.00
Rate for Payer: Wellmed Medicare	$16,282.00

HAPTOGLOBIN QUANTITATIVE

Facility

$278.00

Service Code	CPT 83010
Hospital Charge Code	1702364
Hospital Revenue Code	301
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$180.70
Rate for Payer: Aetna Commercial	$13.21
Rate for Payer: Aetna Medicare	$18.87
Rate for Payer: Amerigroup CHIP/Medicaid	$4.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.58
Rate for Payer: Amerigroup Medicare	$12.58
Rate for Payer: BCBS of TX Blue Advantage	$20.76
Rate for Payer: BCBS of TX Blue Essentials	$24.91
Rate for Payer: BCBS of TX Medicare	$12.58
Rate for Payer: BCBS of TX PPO	$27.80
Rate for Payer: Cash Price	$244.64
Rate for Payer: Cash Price	$244.64
Rate for Payer: Cigna Medicaid	$12.58
Rate for Payer: Cigna Medicare	$12.58
Rate for Payer: Employer Direct Commercial	$12.58
Rate for Payer: Humana Medicare/TRICARE	$12.58
Rate for Payer: Molina CHIP/Medicaid	$12.58
Rate for Payer: Molina Dual Medicare/Medicaid	$12.58
Rate for Payer: Molina Medicare	$12.58
Rate for Payer: Multiplan Auto	$180.70
Rate for Payer: Multiplan Commercial	$180.70
Rate for Payer: Multiplan Workers Comp	$180.70
Rate for Payer: Parkland Medicaid	$12.58
Rate for Payer: Scott and White EPO/PPO	$15.72
Rate for Payer: Scott and White Medicare	$12.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.58
Rate for Payer: Superior Health Plan EPO	$12.58
Rate for Payer: Superior Health Plan Medicare	$12.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.58
Rate for Payer: Universal American Medicare	$12.58
Rate for Payer: Wellcare Medicare	$12.58
Rate for Payer: Wellmed Medicare	$12.58

Haptoglobin SO

Facility

$278.00

Service Code	CPT 83010
Hospital Charge Code	1702364
Hospital Revenue Code	301
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$180.70
Rate for Payer: Aetna Commercial	$13.21
Rate for Payer: Aetna Medicare	$18.87
Rate for Payer: Amerigroup CHIP/Medicaid	$4.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.58
Rate for Payer: Amerigroup Medicare	$12.58
Rate for Payer: BCBS of TX Blue Advantage	$20.76
Rate for Payer: BCBS of TX Blue Essentials	$24.91
Rate for Payer: BCBS of TX Medicare	$12.58
Rate for Payer: BCBS of TX PPO	$27.80
Rate for Payer: Cash Price	$244.64
Rate for Payer: Cash Price	$244.64
Rate for Payer: Cigna Medicaid	$12.58
Rate for Payer: Cigna Medicare	$12.58
Rate for Payer: Employer Direct Commercial	$12.58
Rate for Payer: Humana Medicare/TRICARE	$12.58
Rate for Payer: Molina CHIP/Medicaid	$12.58
Rate for Payer: Molina Dual Medicare/Medicaid	$12.58
Rate for Payer: Molina Medicare	$12.58
Rate for Payer: Multiplan Auto	$180.70
Rate for Payer: Multiplan Commercial	$180.70
Rate for Payer: Multiplan Workers Comp	$180.70
Rate for Payer: Parkland Medicaid	$12.58
Rate for Payer: Scott and White EPO/PPO	$15.72
Rate for Payer: Scott and White Medicare	$12.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.58
Rate for Payer: Superior Health Plan EPO	$12.58
Rate for Payer: Superior Health Plan Medicare	$12.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.58
Rate for Payer: Universal American Medicare	$12.58
Rate for Payer: Wellcare Medicare	$12.58
Rate for Payer: Wellmed Medicare	$12.58

Haptoglobin SO

Facility

$278.00

Service Code	CPT 83010
Hospital Charge Code	1702364
Hospital Revenue Code	301
Rate for Payer: Cash Price	$244.64

HBsAg Screen SO

Facility

$242.00

Service Code	CPT 87340
Hospital Charge Code	1700150
Hospital Revenue Code	300
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$157.30
Rate for Payer: Aetna Commercial	$10.85
Rate for Payer: Aetna Medicare	$15.50
Rate for Payer: Amerigroup CHIP/Medicaid	$4.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.33
Rate for Payer: Amerigroup Medicare	$10.33
Rate for Payer: BCBS of TX Blue Advantage	$17.04
Rate for Payer: BCBS of TX Blue Essentials	$20.45
Rate for Payer: BCBS of TX Medicare	$10.33
Rate for Payer: BCBS of TX PPO	$22.83
Rate for Payer: Cash Price	$212.96
Rate for Payer: Cash Price	$212.96
Rate for Payer: Cigna Medicaid	$10.33
Rate for Payer: Cigna Medicare	$10.33
Rate for Payer: Employer Direct Commercial	$10.33
Rate for Payer: Humana Medicare/TRICARE	$10.33
Rate for Payer: Molina CHIP/Medicaid	$10.33
Rate for Payer: Molina Dual Medicare/Medicaid	$10.33
Rate for Payer: Molina Medicare	$10.33
Rate for Payer: Multiplan Auto	$157.30
Rate for Payer: Multiplan Commercial	$157.30
Rate for Payer: Multiplan Workers Comp	$157.30
Rate for Payer: Parkland Medicaid	$10.33
Rate for Payer: Scott and White EPO/PPO	$12.91
Rate for Payer: Scott and White Medicare	$10.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.33
Rate for Payer: Superior Health Plan EPO	$10.33
Rate for Payer: Superior Health Plan Medicare	$10.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.33
Rate for Payer: Universal American Medicare	$10.33
Rate for Payer: Wellcare Medicare	$10.33
Rate for Payer: Wellmed Medicare	$10.33

HBsAg Screen SO

Facility

$242.00

Service Code	CPT 87340
Hospital Charge Code	1700150
Hospital Revenue Code	300
Rate for Payer: Cash Price	$212.96

HBV Core Ab, IgG/IgM Diff SO

Facility

$326.00

Service Code	CPT 86705
Hospital Charge Code	1600873
Hospital Revenue Code	302
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$211.90
Rate for Payer: Aetna Commercial	$12.36
Rate for Payer: Aetna Medicare	$17.66
Rate for Payer: Amerigroup CHIP/Medicaid	$4.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.77
Rate for Payer: Amerigroup Medicare	$11.77
Rate for Payer: BCBS of TX Blue Advantage	$19.42
Rate for Payer: BCBS of TX Blue Essentials	$23.30
Rate for Payer: BCBS of TX Medicare	$11.77
Rate for Payer: BCBS of TX PPO	$26.01
Rate for Payer: Cash Price	$286.88
Rate for Payer: Cash Price	$286.88
Rate for Payer: Cigna Medicaid	$11.77
Rate for Payer: Cigna Medicare	$11.77
Rate for Payer: Employer Direct Commercial	$11.77
Rate for Payer: Humana Medicare/TRICARE	$11.77
Rate for Payer: Molina CHIP/Medicaid	$11.77
Rate for Payer: Molina Dual Medicare/Medicaid	$11.77
Rate for Payer: Molina Medicare	$11.77
Rate for Payer: Multiplan Auto	$211.90
Rate for Payer: Multiplan Commercial	$211.90
Rate for Payer: Multiplan Workers Comp	$211.90
Rate for Payer: Parkland Medicaid	$11.77
Rate for Payer: Scott and White EPO/PPO	$14.71
Rate for Payer: Scott and White Medicare	$11.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.77
Rate for Payer: Superior Health Plan EPO	$11.77
Rate for Payer: Superior Health Plan Medicare	$11.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.77
Rate for Payer: Universal American Medicare	$11.77
Rate for Payer: Wellcare Medicare	$11.77
Rate for Payer: Wellmed Medicare	$11.77

HCG Qualitative Serum

Facility

$237.00

Service Code	CPT 84703
Hospital Charge Code	1602580
Hospital Revenue Code	301
Rate for Payer: Cash Price	$208.56

Know your out-of-pocket cost for care.

All Charges