White Rock Medical Center

All Charges

Charge

Type

Setting

Price

82131 AMINO ACIDS SGL QUANT EA SPECIMEN

Facility

$245.00

Service Code	HCPCS 82131
Hospital Charge Code	1705995
Hospital Revenue Code	301
Rate for Payer: Cash Price	$166.60

82131 AMINO ACIDS SGL QUANT EA SPECIMEN

Facility

$245.00

Service Code	HCPCS 82131
Hospital Charge Code	1705995
Hospital Revenue Code	301
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$176.40
Rate for Payer: Amerigroup CHIP/Medicaid	$8.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22.98
Rate for Payer: Amerigroup Medicare	$22.98
Rate for Payer: BCBS of TX Blue Advantage	$73.50
Rate for Payer: BCBS of TX Blue Essentials	$88.20
Rate for Payer: BCBS of TX Medicare	$22.98
Rate for Payer: BCBS of TX PPO	$98.00
Rate for Payer: Cash Price	$166.60
Rate for Payer: Cash Price	$166.60
Rate for Payer: Cigna Medicaid	$176.40
Rate for Payer: Cigna Medicare	$22.98
Rate for Payer: Employer Direct Commercial	$22.98
Rate for Payer: Humana Medicare/TRICARE	$22.98
Rate for Payer: Molina CHIP/Medicaid	$176.40
Rate for Payer: Molina Dual Medicare/Medicaid	$22.98
Rate for Payer: Molina Medicare	$22.98
Rate for Payer: Multiplan Auto	$159.25
Rate for Payer: Multiplan Commercial	$159.25
Rate for Payer: Multiplan Workers Comp	$159.25
Rate for Payer: Parkland Medicaid	$176.40
Rate for Payer: Scott and White EPO/PPO	$28.73
Rate for Payer: Scott and White Medicare	$22.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$176.40
Rate for Payer: Superior Health Plan EPO	$22.98
Rate for Payer: Superior Health Plan Medicare	$22.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$22.98
Rate for Payer: Universal American Medicare	$22.98
Rate for Payer: Wellcare Medicare	$22.98
Rate for Payer: Wellmed Medicare	$22.98

82140 AMMONIA

Facility

$316.00

Service Code	HCPCS 82140
Hospital Charge Code	1601616
Hospital Revenue Code	301
Rate for Payer: Cash Price	$214.88

82140 AMMONIA

Facility

$316.00

Service Code	HCPCS 82140
Hospital Charge Code	1601616
Hospital Revenue Code	301
Min. Negotiated Rate	$5.68
Max. Negotiated Rate	$227.52
Rate for Payer: Amerigroup CHIP/Medicaid	$5.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.57
Rate for Payer: Amerigroup Medicare	$14.57
Rate for Payer: BCBS of TX Blue Advantage	$94.80
Rate for Payer: BCBS of TX Blue Essentials	$113.76
Rate for Payer: BCBS of TX Medicare	$14.57
Rate for Payer: BCBS of TX PPO	$126.40
Rate for Payer: Cash Price	$214.88
Rate for Payer: Cash Price	$214.88
Rate for Payer: Cigna Medicaid	$227.52
Rate for Payer: Cigna Medicare	$14.57
Rate for Payer: Employer Direct Commercial	$14.57
Rate for Payer: Humana Medicare/TRICARE	$14.57
Rate for Payer: Molina CHIP/Medicaid	$227.52
Rate for Payer: Molina Dual Medicare/Medicaid	$14.57
Rate for Payer: Molina Medicare	$14.57
Rate for Payer: Multiplan Auto	$205.40
Rate for Payer: Multiplan Commercial	$205.40
Rate for Payer: Multiplan Workers Comp	$205.40
Rate for Payer: Parkland Medicaid	$227.52
Rate for Payer: Scott and White EPO/PPO	$18.21
Rate for Payer: Scott and White Medicare	$14.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$227.52
Rate for Payer: Superior Health Plan EPO	$14.57
Rate for Payer: Superior Health Plan Medicare	$14.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.57
Rate for Payer: Universal American Medicare	$14.57
Rate for Payer: Wellcare Medicare	$14.57
Rate for Payer: Wellmed Medicare	$14.57

82172 APOLIPOPROTEIN EACH

Facility

$106.00

Service Code	HCPCS 82172
Hospital Charge Code	1601418
Hospital Revenue Code	301
Rate for Payer: Cash Price	$72.08

82172 APOLIPOPROTEIN EACH

Facility

$106.00

Service Code	HCPCS 82172
Hospital Charge Code	1601418
Hospital Revenue Code	301
Min. Negotiated Rate	$8.23
Max. Negotiated Rate	$76.32
Rate for Payer: Amerigroup CHIP/Medicaid	$8.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.09
Rate for Payer: Amerigroup Medicare	$21.09
Rate for Payer: BCBS of TX Blue Advantage	$31.80
Rate for Payer: BCBS of TX Blue Essentials	$38.16
Rate for Payer: BCBS of TX Medicare	$21.09
Rate for Payer: BCBS of TX PPO	$42.40
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Medicaid	$76.32
Rate for Payer: Cigna Medicare	$21.09
Rate for Payer: Employer Direct Commercial	$21.09
Rate for Payer: Humana Medicare/TRICARE	$21.09
Rate for Payer: Molina CHIP/Medicaid	$76.32
Rate for Payer: Molina Dual Medicare/Medicaid	$21.09
Rate for Payer: Molina Medicare	$21.09
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$76.32
Rate for Payer: Scott and White EPO/PPO	$26.36
Rate for Payer: Scott and White Medicare	$21.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.32
Rate for Payer: Superior Health Plan EPO	$21.09
Rate for Payer: Superior Health Plan Medicare	$21.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.09
Rate for Payer: Universal American Medicare	$21.09
Rate for Payer: Wellcare Medicare	$21.09
Rate for Payer: Wellmed Medicare	$21.09

82340 CALCIUM URINE QUANT TIMED SPECIMEN

Facility

$213.00

Service Code	HCPCS 82340
Hospital Charge Code	1601269
Hospital Revenue Code	301
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$153.36
Rate for Payer: Amerigroup CHIP/Medicaid	$2.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.03
Rate for Payer: Amerigroup Medicare	$6.03
Rate for Payer: BCBS of TX Blue Advantage	$63.90
Rate for Payer: BCBS of TX Blue Essentials	$76.68
Rate for Payer: BCBS of TX Medicare	$6.03
Rate for Payer: BCBS of TX PPO	$85.20
Rate for Payer: Cash Price	$144.84
Rate for Payer: Cash Price	$144.84
Rate for Payer: Cigna Medicaid	$153.36
Rate for Payer: Cigna Medicare	$6.03
Rate for Payer: Employer Direct Commercial	$6.03
Rate for Payer: Humana Medicare/TRICARE	$6.03
Rate for Payer: Molina CHIP/Medicaid	$153.36
Rate for Payer: Molina Dual Medicare/Medicaid	$6.03
Rate for Payer: Molina Medicare	$6.03
Rate for Payer: Multiplan Auto	$138.45
Rate for Payer: Multiplan Commercial	$138.45
Rate for Payer: Multiplan Workers Comp	$138.45
Rate for Payer: Parkland Medicaid	$153.36
Rate for Payer: Scott and White EPO/PPO	$7.54
Rate for Payer: Scott and White Medicare	$6.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$153.36
Rate for Payer: Superior Health Plan EPO	$6.03
Rate for Payer: Superior Health Plan Medicare	$6.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.03
Rate for Payer: Universal American Medicare	$6.03
Rate for Payer: Wellcare Medicare	$6.03
Rate for Payer: Wellmed Medicare	$6.03

82340 CALCIUM URINE QUANT TIMED SPECIMEN

Facility

$213.00

Service Code	HCPCS 82340
Hospital Charge Code	1601269
Hospital Revenue Code	301
Rate for Payer: Cash Price	$144.84

82507 CITRATE

Facility

$109.00

Service Code	HCPCS 82507
Hospital Charge Code	1700050
Hospital Revenue Code	300
Rate for Payer: Cash Price	$74.12

82507 CITRATE

Facility

$109.00

Service Code	HCPCS 82507
Hospital Charge Code	1700050
Hospital Revenue Code	300
Min. Negotiated Rate	$10.84
Max. Negotiated Rate	$78.48
Rate for Payer: Amerigroup CHIP/Medicaid	$10.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.80
Rate for Payer: Amerigroup Medicare	$27.80
Rate for Payer: BCBS of TX Blue Advantage	$32.70
Rate for Payer: BCBS of TX Blue Essentials	$39.24
Rate for Payer: BCBS of TX Medicare	$27.80
Rate for Payer: BCBS of TX PPO	$43.60
Rate for Payer: Cash Price	$74.12
Rate for Payer: Cash Price	$74.12
Rate for Payer: Cigna Medicaid	$78.48
Rate for Payer: Cigna Medicare	$27.80
Rate for Payer: Employer Direct Commercial	$27.80
Rate for Payer: Humana Medicare/TRICARE	$27.80
Rate for Payer: Molina CHIP/Medicaid	$78.48
Rate for Payer: Molina Dual Medicare/Medicaid	$27.80
Rate for Payer: Molina Medicare	$27.80
Rate for Payer: Multiplan Auto	$70.85
Rate for Payer: Multiplan Commercial	$70.85
Rate for Payer: Multiplan Workers Comp	$70.85
Rate for Payer: Parkland Medicaid	$78.48
Rate for Payer: Scott and White EPO/PPO	$34.75
Rate for Payer: Scott and White Medicare	$27.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$78.48
Rate for Payer: Superior Health Plan EPO	$27.80
Rate for Payer: Superior Health Plan Medicare	$27.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.80
Rate for Payer: Universal American Medicare	$27.80
Rate for Payer: Wellcare Medicare	$27.80
Rate for Payer: Wellmed Medicare	$27.80

82570 CREATININE OTHER SOURCE

Facility

$96.00

Service Code	HCPCS 82570
Hospital Charge Code	1601152
Hospital Revenue Code	301
Rate for Payer: Cash Price	$65.28

82570 CREATININE OTHER SOURCE

Facility

$96.00

Service Code	HCPCS 82570
Hospital Charge Code	1601152
Hospital Revenue Code	301
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$69.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$28.80
Rate for Payer: BCBS of TX Blue Essentials	$34.56
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$38.40
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cigna Medicaid	$69.12
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$69.12
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$62.40
Rate for Payer: Multiplan Commercial	$62.40
Rate for Payer: Multiplan Workers Comp	$62.40
Rate for Payer: Parkland Medicaid	$69.12
Rate for Payer: Scott and White EPO/PPO	$6.47
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.12
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

82784 GAMMAGLOBULIN;IGA,IGD,IGG,IGM EACH

Facility

$199.00

Service Code	HCPCS 82784
Hospital Charge Code	1602069
Hospital Revenue Code	301
Min. Negotiated Rate	$3.63
Max. Negotiated Rate	$143.28
Rate for Payer: Amerigroup CHIP/Medicaid	$3.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.30
Rate for Payer: Amerigroup Medicare	$9.30
Rate for Payer: BCBS of TX Blue Advantage	$59.70
Rate for Payer: BCBS of TX Blue Essentials	$71.64
Rate for Payer: BCBS of TX Medicare	$9.30
Rate for Payer: BCBS of TX PPO	$79.60
Rate for Payer: Cash Price	$135.32
Rate for Payer: Cash Price	$135.32
Rate for Payer: Cigna Medicaid	$143.28
Rate for Payer: Cigna Medicare	$9.30
Rate for Payer: Employer Direct Commercial	$9.30
Rate for Payer: Humana Medicare/TRICARE	$9.30
Rate for Payer: Molina CHIP/Medicaid	$143.28
Rate for Payer: Molina Dual Medicare/Medicaid	$9.30
Rate for Payer: Molina Medicare	$9.30
Rate for Payer: Multiplan Auto	$129.35
Rate for Payer: Multiplan Commercial	$129.35
Rate for Payer: Multiplan Workers Comp	$129.35
Rate for Payer: Parkland Medicaid	$143.28
Rate for Payer: Scott and White EPO/PPO	$11.62
Rate for Payer: Scott and White Medicare	$9.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.28
Rate for Payer: Superior Health Plan EPO	$9.30
Rate for Payer: Superior Health Plan Medicare	$9.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.30
Rate for Payer: Universal American Medicare	$9.30
Rate for Payer: Wellcare Medicare	$9.30
Rate for Payer: Wellmed Medicare	$9.30

82784 GAMMAGLOBULIN;IGA,IGD,IGG,IGM EACH

Facility

$199.00

Service Code	HCPCS 82784
Hospital Charge Code	1602069
Hospital Revenue Code	301
Rate for Payer: Cash Price	$135.32

82787 IMMUNOGLOBULIN SUB CL G1,2,3OR 4 EA

Facility

$50.00

Service Code	HCPCS 82787
Hospital Charge Code	1703925
Hospital Revenue Code	301
Rate for Payer: Cash Price	$34.00

82787 IMMUNOGLOBULIN SUB CL G1,2,3OR 4 EA

Facility

$50.00

Service Code	HCPCS 82787
Hospital Charge Code	1703925
Hospital Revenue Code	301
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$36.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.02
Rate for Payer: Amerigroup Medicare	$8.02
Rate for Payer: BCBS of TX Blue Advantage	$15.00
Rate for Payer: BCBS of TX Blue Essentials	$18.00
Rate for Payer: BCBS of TX Medicare	$8.02
Rate for Payer: BCBS of TX PPO	$20.00
Rate for Payer: Cash Price	$34.00
Rate for Payer: Cash Price	$34.00
Rate for Payer: Cigna Medicaid	$36.00
Rate for Payer: Cigna Medicare	$8.02
Rate for Payer: Employer Direct Commercial	$8.02
Rate for Payer: Humana Medicare/TRICARE	$8.02
Rate for Payer: Molina CHIP/Medicaid	$36.00
Rate for Payer: Molina Dual Medicare/Medicaid	$8.02
Rate for Payer: Molina Medicare	$8.02
Rate for Payer: Multiplan Auto	$32.50
Rate for Payer: Multiplan Commercial	$32.50
Rate for Payer: Multiplan Workers Comp	$32.50
Rate for Payer: Parkland Medicaid	$36.00
Rate for Payer: Scott and White EPO/PPO	$10.03
Rate for Payer: Scott and White Medicare	$8.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.00
Rate for Payer: Superior Health Plan EPO	$8.02
Rate for Payer: Superior Health Plan Medicare	$8.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.02
Rate for Payer: Universal American Medicare	$8.02
Rate for Payer: Wellcare Medicare	$8.02
Rate for Payer: Wellmed Medicare	$8.02

83002 GONADOTROPIN LUTEINIZING HORMONE LH

Facility

$248.00

Service Code	HCPCS 83002
Hospital Charge Code	1602135
Hospital Revenue Code	301
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$178.56
Rate for Payer: Amerigroup CHIP/Medicaid	$7.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.52
Rate for Payer: Amerigroup Medicare	$18.52
Rate for Payer: BCBS of TX Blue Advantage	$74.40
Rate for Payer: BCBS of TX Blue Essentials	$89.28
Rate for Payer: BCBS of TX Medicare	$18.52
Rate for Payer: BCBS of TX PPO	$99.20
Rate for Payer: Cash Price	$168.64
Rate for Payer: Cash Price	$168.64
Rate for Payer: Cigna Medicaid	$178.56
Rate for Payer: Cigna Medicare	$18.52
Rate for Payer: Employer Direct Commercial	$18.52
Rate for Payer: Humana Medicare/TRICARE	$18.52
Rate for Payer: Molina CHIP/Medicaid	$178.56
Rate for Payer: Molina Dual Medicare/Medicaid	$18.52
Rate for Payer: Molina Medicare	$18.52
Rate for Payer: Multiplan Auto	$161.20
Rate for Payer: Multiplan Commercial	$161.20
Rate for Payer: Multiplan Workers Comp	$161.20
Rate for Payer: Parkland Medicaid	$178.56
Rate for Payer: Scott and White EPO/PPO	$23.15
Rate for Payer: Scott and White Medicare	$18.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$178.56
Rate for Payer: Superior Health Plan EPO	$18.52
Rate for Payer: Superior Health Plan Medicare	$18.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.52
Rate for Payer: Universal American Medicare	$18.52
Rate for Payer: Wellcare Medicare	$18.52
Rate for Payer: Wellmed Medicare	$18.52

83002 GONADOTROPIN LUTEINIZING HORMONE LH

Facility

$248.00

Service Code	HCPCS 83002
Hospital Charge Code	1602135
Hospital Revenue Code	301
Rate for Payer: Cash Price	$168.64

83010 HAPTOGLOBIN QUANTITATIVE

Facility

$278.00

Service Code	HCPCS 83010
Hospital Charge Code	1702364
Hospital Revenue Code	301
Rate for Payer: Cash Price	$189.04

83010 HAPTOGLOBIN QUANTITATIVE

Facility

$278.00

Service Code	HCPCS 83010
Hospital Charge Code	1702364
Hospital Revenue Code	301
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$200.16
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	$83.40
Rate for Payer: BCBS of TX Blue Essentials	$100.08
Rate for Payer: BCBS of TX Medicare	$12.58
Rate for Payer: BCBS of TX PPO	$111.20
Rate for Payer: Cash Price	$189.04
Rate for Payer: Cash Price	$189.04
Rate for Payer: Cigna Medicaid	$200.16
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	$200.16
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	$200.16
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	$200.16
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

83519 IMMUNOASSAY ANALYTE QUANTITAVE

Facility

$309.00

Service Code	HCPCS 83519
Hospital Charge Code	1703461
Hospital Revenue Code	301
Rate for Payer: Cash Price	$210.12

83519 IMMUNOASSAY ANALYTE QUANTITAVE

Facility

$309.00

Service Code	HCPCS 83519
Hospital Charge Code	1703461
Hospital Revenue Code	301
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$7.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.40
Rate for Payer: Amerigroup Medicare	$18.40
Rate for Payer: BCBS of TX Blue Advantage	$92.70
Rate for Payer: BCBS of TX Blue Essentials	$111.24
Rate for Payer: BCBS of TX Medicare	$18.40
Rate for Payer: BCBS of TX PPO	$123.60
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cigna Medicaid	$222.48
Rate for Payer: Cigna Medicare	$18.40
Rate for Payer: Employer Direct Commercial	$18.40
Rate for Payer: Humana Medicare/TRICARE	$18.40
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$18.40
Rate for Payer: Molina Medicare	$18.40
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$222.48
Rate for Payer: Scott and White EPO/PPO	$23.00
Rate for Payer: Scott and White Medicare	$18.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$18.40
Rate for Payer: Superior Health Plan Medicare	$18.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.40
Rate for Payer: Universal American Medicare	$18.40
Rate for Payer: Wellcare Medicare	$18.40
Rate for Payer: Wellmed Medicare	$18.40

83520 IMMUNOASSAY QUANTITATIVE NOS

Facility

$222.00

Service Code	HCPCS 83520
Hospital Charge Code	1706332
Hospital Revenue Code	301
Rate for Payer: Cash Price	$150.96

83520 IMMUNOASSAY QUANTITATIVE NOS

Facility

$222.00

Service Code	HCPCS 83520
Hospital Charge Code	1706332
Hospital Revenue Code	301
Min. Negotiated Rate	$6.74
Max. Negotiated Rate	$159.84
Rate for Payer: Amerigroup CHIP/Medicaid	$6.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.27
Rate for Payer: Amerigroup Medicare	$17.27
Rate for Payer: BCBS of TX Blue Advantage	$66.60
Rate for Payer: BCBS of TX Blue Essentials	$79.92
Rate for Payer: BCBS of TX Medicare	$17.27
Rate for Payer: BCBS of TX PPO	$88.80
Rate for Payer: Cash Price	$150.96
Rate for Payer: Cash Price	$150.96
Rate for Payer: Cigna Medicaid	$159.84
Rate for Payer: Cigna Medicare	$17.27
Rate for Payer: Employer Direct Commercial	$17.27
Rate for Payer: Humana Medicare/TRICARE	$17.27
Rate for Payer: Molina CHIP/Medicaid	$159.84
Rate for Payer: Molina Dual Medicare/Medicaid	$17.27
Rate for Payer: Molina Medicare	$17.27
Rate for Payer: Multiplan Auto	$144.30
Rate for Payer: Multiplan Commercial	$144.30
Rate for Payer: Multiplan Workers Comp	$144.30
Rate for Payer: Parkland Medicaid	$159.84
Rate for Payer: Scott and White EPO/PPO	$21.59
Rate for Payer: Scott and White Medicare	$17.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$159.84
Rate for Payer: Superior Health Plan EPO	$17.27
Rate for Payer: Superior Health Plan Medicare	$17.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.27
Rate for Payer: Universal American Medicare	$17.27
Rate for Payer: Wellcare Medicare	$17.27
Rate for Payer: Wellmed Medicare	$17.27

83735 MAGNESIUM

Facility

$234.00

Service Code	HCPCS 83735
Hospital Charge Code	1602143
Hospital Revenue Code	301
Rate for Payer: Cash Price	$159.12

Know your out-of-pocket cost for care.

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