White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Destruction by neurolytic agent pudendal nerve

Facility

$8,551.07

Service Code	HCPCS 64630
Hospital Charge Code	9900827
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,814.73

Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ova

Facility

$10,000.00

Service Code	CPT 64610
Hospital Charge Code	36064610
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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: Scott and White EPO/PPO	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ova

Facility

$10,526.34

Service Code	HCPCS 64610
Hospital Charge Code	9900820
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,157.91

Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ova

Facility

$10,526.34

Service Code	HCPCS 64610
Hospital Charge Code	9900820
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$7,578.96
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$7,578.96
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$7,578.96
Rate for Payer: Scott and White EPO/PPO	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,578.96
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Destruction by neurolytic agent, trigeminal nerve supraorbital, infraorbital, mental, or inferior a

Facility

$2,467.38

Service Code	HCPCS 64600
Hospital Charge Code	9900819
Hospital Revenue Code	360
Min. Negotiated Rate	$340.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$340.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$888.50
Rate for Payer: Amerigroup Medicare	$888.50
Rate for Payer: BCBS of TX Blue Advantage	$1,356.12
Rate for Payer: BCBS of TX Blue Essentials	$1,624.10
Rate for Payer: BCBS of TX Medicare	$888.50
Rate for Payer: BCBS of TX PPO	$2,046.37
Rate for Payer: Cash Price	$1,677.82
Rate for Payer: Cash Price	$1,677.82
Rate for Payer: Cash Price	$1,677.82
Rate for Payer: Cigna Commercial	$1,878.13
Rate for Payer: Cigna Medicaid	$1,776.51
Rate for Payer: Cigna Medicare	$888.50
Rate for Payer: Employer Direct Commercial	$888.50
Rate for Payer: Humana Medicare/TRICARE	$888.50
Rate for Payer: Molina CHIP/Medicaid	$1,776.51
Rate for Payer: Molina Dual Medicare/Medicaid	$888.50
Rate for Payer: Molina Medicare	$888.50
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	$1,776.51
Rate for Payer: Scott and White EPO/PPO	$1,542.14
Rate for Payer: Scott and White Medicare	$888.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,776.51
Rate for Payer: Superior Health Plan EPO	$888.50
Rate for Payer: Superior Health Plan Medicare	$888.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$888.50
Rate for Payer: Universal American Medicare	$888.50
Rate for Payer: Wellcare Medicare	$888.50
Rate for Payer: Wellmed Medicare	$888.50

Destruction by neurolytic agent, trigeminal nerve supraorbital, infraorbital, mental, or inferior a

Facility

$10,000.00

Service Code	CPT 64600
Hospital Charge Code	36064600
Hospital Revenue Code	360
Min. Negotiated Rate	$340.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$340.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$888.50
Rate for Payer: Amerigroup Medicare	$888.50
Rate for Payer: BCBS of TX Blue Advantage	$1,356.12
Rate for Payer: BCBS of TX Blue Essentials	$1,624.10
Rate for Payer: BCBS of TX Medicare	$888.50
Rate for Payer: BCBS of TX PPO	$2,046.37
Rate for Payer: Cigna Commercial	$1,878.13
Rate for Payer: Cigna Medicare	$888.50
Rate for Payer: Employer Direct Commercial	$888.50
Rate for Payer: Humana Medicare/TRICARE	$888.50
Rate for Payer: Molina Dual Medicare/Medicaid	$888.50
Rate for Payer: Molina Medicare	$888.50
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: Scott and White EPO/PPO	$1,542.14
Rate for Payer: Scott and White Medicare	$888.50
Rate for Payer: Superior Health Plan EPO	$888.50
Rate for Payer: Superior Health Plan Medicare	$888.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$888.50
Rate for Payer: Universal American Medicare	$888.50
Rate for Payer: Wellcare Medicare	$888.50
Rate for Payer: Wellmed Medicare	$888.50

Destruction by neurolytic agent, trigeminal nerve supraorbital, infraorbital, mental, or inferior a

Facility

$2,467.38

Service Code	HCPCS 64600
Hospital Charge Code	9900819
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,677.82

Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus

Facility

$10,000.00

Service Code	CPT 64680
Hospital Charge Code	36064680
Hospital Revenue Code	360
Min. Negotiated Rate	$340.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$340.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$888.50
Rate for Payer: Amerigroup Medicare	$888.50
Rate for Payer: BCBS of TX Blue Advantage	$1,356.12
Rate for Payer: BCBS of TX Blue Essentials	$1,624.10
Rate for Payer: BCBS of TX Medicare	$888.50
Rate for Payer: BCBS of TX PPO	$2,046.37
Rate for Payer: Cigna Commercial	$1,878.13
Rate for Payer: Cigna Medicare	$888.50
Rate for Payer: Employer Direct Commercial	$888.50
Rate for Payer: Humana Medicare/TRICARE	$888.50
Rate for Payer: Molina Dual Medicare/Medicaid	$888.50
Rate for Payer: Molina Medicare	$888.50
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: Scott and White EPO/PPO	$1,542.14
Rate for Payer: Scott and White Medicare	$888.50
Rate for Payer: Superior Health Plan EPO	$888.50
Rate for Payer: Superior Health Plan Medicare	$888.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$888.50
Rate for Payer: Universal American Medicare	$888.50
Rate for Payer: Wellcare Medicare	$888.50
Rate for Payer: Wellmed Medicare	$888.50

Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus

Facility

$6,579.68

Service Code	HCPCS 64680
Hospital Charge Code	9900835
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,474.18

Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus

Facility

$6,579.68

Service Code	HCPCS 64680
Hospital Charge Code	9900835
Hospital Revenue Code	360
Min. Negotiated Rate	$340.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$340.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$888.50
Rate for Payer: Amerigroup Medicare	$888.50
Rate for Payer: BCBS of TX Blue Advantage	$1,356.12
Rate for Payer: BCBS of TX Blue Essentials	$1,624.10
Rate for Payer: BCBS of TX Medicare	$888.50
Rate for Payer: BCBS of TX PPO	$2,046.37
Rate for Payer: Cash Price	$4,474.18
Rate for Payer: Cash Price	$4,474.18
Rate for Payer: Cash Price	$4,474.18
Rate for Payer: Cigna Commercial	$1,878.13
Rate for Payer: Cigna Medicaid	$4,737.37
Rate for Payer: Cigna Medicare	$888.50
Rate for Payer: Employer Direct Commercial	$888.50
Rate for Payer: Humana Medicare/TRICARE	$888.50
Rate for Payer: Molina CHIP/Medicaid	$4,737.37
Rate for Payer: Molina Dual Medicare/Medicaid	$888.50
Rate for Payer: Molina Medicare	$888.50
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	$4,737.37
Rate for Payer: Scott and White EPO/PPO	$1,542.14
Rate for Payer: Scott and White Medicare	$888.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,737.37
Rate for Payer: Superior Health Plan EPO	$888.50
Rate for Payer: Superior Health Plan Medicare	$888.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$888.50
Rate for Payer: Universal American Medicare	$888.50
Rate for Payer: Wellcare Medicare	$888.50
Rate for Payer: Wellmed Medicare	$888.50

Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus

Facility

$2,467.38

Service Code	HCPCS 64681
Hospital Charge Code	9900836
Hospital Revenue Code	360
Min. Negotiated Rate	$340.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$340.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$888.50
Rate for Payer: Amerigroup Medicare	$888.50
Rate for Payer: BCBS of TX Blue Advantage	$1,356.12
Rate for Payer: BCBS of TX Blue Essentials	$1,624.10
Rate for Payer: BCBS of TX Medicare	$888.50
Rate for Payer: BCBS of TX PPO	$2,046.37
Rate for Payer: Cash Price	$1,677.82
Rate for Payer: Cash Price	$1,677.82
Rate for Payer: Cash Price	$1,677.82
Rate for Payer: Cigna Commercial	$1,878.13
Rate for Payer: Cigna Medicaid	$1,776.51
Rate for Payer: Cigna Medicare	$888.50
Rate for Payer: Employer Direct Commercial	$888.50
Rate for Payer: Humana Medicare/TRICARE	$888.50
Rate for Payer: Molina CHIP/Medicaid	$1,776.51
Rate for Payer: Molina Dual Medicare/Medicaid	$888.50
Rate for Payer: Molina Medicare	$888.50
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	$1,776.51
Rate for Payer: Scott and White EPO/PPO	$1,542.14
Rate for Payer: Scott and White Medicare	$888.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,776.51
Rate for Payer: Superior Health Plan EPO	$888.50
Rate for Payer: Superior Health Plan Medicare	$888.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$888.50
Rate for Payer: Universal American Medicare	$888.50
Rate for Payer: Wellcare Medicare	$888.50
Rate for Payer: Wellmed Medicare	$888.50

Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus

Facility

$10,000.00

Service Code	CPT 64681
Hospital Charge Code	36064681
Hospital Revenue Code	360
Min. Negotiated Rate	$340.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$340.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$888.50
Rate for Payer: Amerigroup Medicare	$888.50
Rate for Payer: BCBS of TX Blue Advantage	$1,356.12
Rate for Payer: BCBS of TX Blue Essentials	$1,624.10
Rate for Payer: BCBS of TX Medicare	$888.50
Rate for Payer: BCBS of TX PPO	$2,046.37
Rate for Payer: Cigna Commercial	$1,878.13
Rate for Payer: Cigna Medicare	$888.50
Rate for Payer: Employer Direct Commercial	$888.50
Rate for Payer: Humana Medicare/TRICARE	$888.50
Rate for Payer: Molina Dual Medicare/Medicaid	$888.50
Rate for Payer: Molina Medicare	$888.50
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: Scott and White EPO/PPO	$1,542.14
Rate for Payer: Scott and White Medicare	$888.50
Rate for Payer: Superior Health Plan EPO	$888.50
Rate for Payer: Superior Health Plan Medicare	$888.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$888.50
Rate for Payer: Universal American Medicare	$888.50
Rate for Payer: Wellcare Medicare	$888.50
Rate for Payer: Wellmed Medicare	$888.50

Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus

Facility

$2,467.38

Service Code	HCPCS 64681
Hospital Charge Code	9900836
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,677.82

DETERGENT CA II SIEMENS 45ML

Facility

$267.86

Hospital Charge Code	993825
Hospital Revenue Code	270
Rate for Payer: Cash Price	$182.14

DETERGENT CA II SIEMENS 45ML

Facility

$267.86

Hospital Charge Code	993825
Hospital Revenue Code	270
Min. Negotiated Rate	$24.11
Max. Negotiated Rate	$192.86
Rate for Payer: Amerigroup CHIP/Medicaid	$24.11
Rate for Payer: BCBS of TX Blue Advantage	$80.36
Rate for Payer: BCBS of TX Blue Essentials	$96.43
Rate for Payer: BCBS of TX PPO	$107.14
Rate for Payer: Cash Price	$182.14
Rate for Payer: Cigna Medicaid	$192.86
Rate for Payer: Molina CHIP/Medicaid	$192.86
Rate for Payer: Multiplan Auto	$174.11
Rate for Payer: Multiplan Commercial	$174.11
Rate for Payer: Multiplan Workers Comp	$174.11
Rate for Payer: Parkland Medicaid	$192.86
Rate for Payer: Scott and White EPO/PPO	$133.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.86
Rate for Payer: Superior Health Plan EPO	$36.43

DETERGENT ENDOQUICK-ELITE 3BTLS/CA

Facility

$260.29

Hospital Charge Code	993933
Hospital Revenue Code	270
Rate for Payer: Cash Price	$177.00

DETERGENT ENDOQUICK-ELITE 3BTLS/CA

Facility

$260.29

Hospital Charge Code	993933
Hospital Revenue Code	270
Min. Negotiated Rate	$23.43
Max. Negotiated Rate	$187.41
Rate for Payer: Amerigroup CHIP/Medicaid	$23.43
Rate for Payer: BCBS of TX Blue Advantage	$78.09
Rate for Payer: BCBS of TX Blue Essentials	$93.70
Rate for Payer: BCBS of TX PPO	$104.12
Rate for Payer: Cash Price	$177.00
Rate for Payer: Cigna Medicaid	$187.41
Rate for Payer: Molina CHIP/Medicaid	$187.41
Rate for Payer: Multiplan Auto	$169.19
Rate for Payer: Multiplan Commercial	$169.19
Rate for Payer: Multiplan Workers Comp	$169.19
Rate for Payer: Parkland Medicaid	$187.41
Rate for Payer: Scott and White EPO/PPO	$130.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$187.41
Rate for Payer: Superior Health Plan EPO	$35.40

DETERGENT PROLYSTICA 2X CONCENTRATE NEUTRAL 1 GAL

Facility

$106.91

Hospital Charge Code	993194
Hospital Revenue Code	270
Rate for Payer: Cash Price	$72.70

DETERGENT PROLYSTICA 2X CONCENTRATE NEUTRAL 1 GAL

Facility

$106.91

Hospital Charge Code	993194
Hospital Revenue Code	270
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$76.98
Rate for Payer: Amerigroup CHIP/Medicaid	$9.62
Rate for Payer: BCBS of TX Blue Advantage	$32.07
Rate for Payer: BCBS of TX Blue Essentials	$38.49
Rate for Payer: BCBS of TX PPO	$42.76
Rate for Payer: Cash Price	$72.70
Rate for Payer: Cigna Medicaid	$76.98
Rate for Payer: Molina CHIP/Medicaid	$76.98
Rate for Payer: Multiplan Auto	$69.49
Rate for Payer: Multiplan Commercial	$69.49
Rate for Payer: Multiplan Workers Comp	$69.49
Rate for Payer: Parkland Medicaid	$76.98
Rate for Payer: Scott and White EPO/PPO	$53.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.98
Rate for Payer: Superior Health Plan EPO	$14.54

DETERGENT, PROLYSTICA 2X CONC NEUTRAL GAL

Facility

$109.85

Hospital Charge Code	993019
Hospital Revenue Code	270
Min. Negotiated Rate	$9.89
Max. Negotiated Rate	$79.09
Rate for Payer: Amerigroup CHIP/Medicaid	$9.89
Rate for Payer: BCBS of TX Blue Advantage	$32.95
Rate for Payer: BCBS of TX Blue Essentials	$39.55
Rate for Payer: BCBS of TX PPO	$43.94
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Medicaid	$79.09
Rate for Payer: Molina CHIP/Medicaid	$79.09
Rate for Payer: Multiplan Auto	$71.40
Rate for Payer: Multiplan Commercial	$71.40
Rate for Payer: Multiplan Workers Comp	$71.40
Rate for Payer: Parkland Medicaid	$79.09
Rate for Payer: Scott and White EPO/PPO	$54.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.09
Rate for Payer: Superior Health Plan EPO	$14.94

DETERGENT, PROLYSTICA 2X CONC NEUTRAL GAL

Facility

$109.85

Hospital Charge Code	993019
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.70

DETERGENT, PROLYSTICA, ULTRA, NEUTRAL, 2 X 5L

Facility

$600.71

Hospital Charge Code	993815
Hospital Revenue Code	270
Min. Negotiated Rate	$54.06
Max. Negotiated Rate	$432.51
Rate for Payer: Amerigroup CHIP/Medicaid	$54.06
Rate for Payer: BCBS of TX Blue Advantage	$180.21
Rate for Payer: BCBS of TX Blue Essentials	$216.26
Rate for Payer: BCBS of TX PPO	$240.28
Rate for Payer: Cash Price	$408.48
Rate for Payer: Cigna Medicaid	$432.51
Rate for Payer: Molina CHIP/Medicaid	$432.51
Rate for Payer: Multiplan Auto	$390.46
Rate for Payer: Multiplan Commercial	$390.46
Rate for Payer: Multiplan Workers Comp	$390.46
Rate for Payer: Parkland Medicaid	$432.51
Rate for Payer: Scott and White EPO/PPO	$300.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$432.51
Rate for Payer: Superior Health Plan EPO	$81.70

DETERGENT, PROLYSTICA, ULTRA, NEUTRAL, 2 X 5L

Facility

$600.71

Hospital Charge Code	993815
Hospital Revenue Code	270
Rate for Payer: Cash Price	$408.48

DETERGENT, PROLYSTICA, ULTRA, NTRL, 10LTR

Facility

$1,201.42

Hospital Charge Code	993020
Hospital Revenue Code	272
Min. Negotiated Rate	$108.13
Max. Negotiated Rate	$865.02
Rate for Payer: Amerigroup CHIP/Medicaid	$108.13
Rate for Payer: BCBS of TX Blue Advantage	$360.43
Rate for Payer: BCBS of TX Blue Essentials	$432.51
Rate for Payer: BCBS of TX PPO	$480.57
Rate for Payer: Cash Price	$816.97
Rate for Payer: Cigna Medicaid	$865.02
Rate for Payer: Molina CHIP/Medicaid	$865.02
Rate for Payer: Multiplan Auto	$780.92
Rate for Payer: Multiplan Commercial	$780.92
Rate for Payer: Multiplan Workers Comp	$780.92
Rate for Payer: Parkland Medicaid	$865.02
Rate for Payer: Scott and White EPO/PPO	$600.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$865.02
Rate for Payer: Superior Health Plan EPO	$163.39

DETERGENT, PROLYSTICA, ULTRA, NTRL, 10LTR

Facility

$1,201.42

Hospital Charge Code	993020
Hospital Revenue Code	272
Rate for Payer: Cash Price	$816.97

Know your out-of-pocket cost for care.

All Charges