White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DIABETES W/O CC/MCC

Facility

$11,415.20

Service Code	MSDRG 639
Min. Negotiated Rate	$5,257.00
Max. Negotiated Rate	$11,415.20
Rate for Payer: BCBS of TX Blue Advantage	$5,434.34
Rate for Payer: BCBS of TX Blue Essentials	$6,520.58
Rate for Payer: BCBS of TX PPO	$7,245.37

Diagnostic bone marrow aspiration(s)

Facility

$10,000.00

Service Code	CPT 38220
Hospital Charge Code	36038220
Hospital Revenue Code	360
Min. Negotiated Rate	$92.74
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$92.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$204.31
Rate for Payer: BCBS of TX Blue Essentials	$244.68
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$308.30
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Diagnostic bone marrow aspiration(s)

Facility

$6,331.50

Service Code	HCPCS 38220
Hospital Charge Code	9900635
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,305.42

Diagnostic bone marrow aspiration(s)

Facility

$6,331.50

Service Code	HCPCS 38220
Hospital Charge Code	9900635
Hospital Revenue Code	360
Min. Negotiated Rate	$92.74
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$92.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$204.31
Rate for Payer: BCBS of TX Blue Essentials	$244.68
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$308.30
Rate for Payer: Cash Price	$4,305.42
Rate for Payer: Cash Price	$4,305.42
Rate for Payer: Cash Price	$4,305.42
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,558.68
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$4,558.68
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$4,558.68
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,558.68
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

DIALYSIS CIRCUIT EMBOLJ

Facility

$10,870.00

Service Code	HCPCS 36909
Hospital Charge Code	2351108
Hospital Revenue Code	360
Min. Negotiated Rate	$978.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$978.30
Rate for Payer: BCBS of TX Blue Advantage	$3,261.00
Rate for Payer: BCBS of TX Blue Essentials	$3,913.20
Rate for Payer: BCBS of TX PPO	$4,348.00
Rate for Payer: Cash Price	$7,391.60
Rate for Payer: Cash Price	$7,391.60
Rate for Payer: Cigna Medicaid	$7,826.40
Rate for Payer: Molina CHIP/Medicaid	$7,826.40
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	$7,826.40
Rate for Payer: Scott and White EPO/PPO	$5,435.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,826.40
Rate for Payer: Superior Health Plan EPO	$1,478.32

DIALYSIS CIRCUIT EMBOLJ

Facility

$10,870.00

Service Code	HCPCS 36909
Hospital Charge Code	2351108
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,391.60

Dialysis Treatment Charge -> IP Hemodialysis Treatment Complete

Facility

$4,750.00

Hospital Charge Code	800011
Hospital Revenue Code	801
Min. Negotiated Rate	$427.50
Max. Negotiated Rate	$3,420.00
Rate for Payer: Amerigroup CHIP/Medicaid	$427.50
Rate for Payer: BCBS of TX Blue Advantage	$1,425.00
Rate for Payer: BCBS of TX Blue Essentials	$1,710.00
Rate for Payer: BCBS of TX PPO	$1,900.00
Rate for Payer: Cash Price	$3,230.00
Rate for Payer: Cigna Medicaid	$3,420.00
Rate for Payer: Molina CHIP/Medicaid	$3,420.00
Rate for Payer: Multiplan Auto	$3,087.50
Rate for Payer: Multiplan Commercial	$3,087.50
Rate for Payer: Multiplan Workers Comp	$3,087.50
Rate for Payer: Parkland Medicaid	$3,420.00
Rate for Payer: Scott and White EPO/PPO	$2,375.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,420.00
Rate for Payer: Superior Health Plan EPO	$646.00

Dialysis Treatment Charge -> IP Hemodialysis Treatment Complete

Facility

$4,750.00

Hospital Charge Code	800011
Hospital Revenue Code	801
Rate for Payer: Cash Price	$3,230.00

Dialysis Treatment Charge -> OP Hemodialysis Treatment Complete

Facility

$2,811.00

Service Code	HCPCS 90935
Hospital Charge Code	800029
Hospital Revenue Code	829
Rate for Payer: Cash Price	$1,911.48

Dialysis Treatment Charge -> OP Hemodialysis Treatment Complete

Facility

$2,811.00

Service Code	HCPCS 90935
Hospital Charge Code	800029
Hospital Revenue Code	829
Min. Negotiated Rate	$86.31
Max. Negotiated Rate	$2,023.92
Rate for Payer: Amerigroup CHIP/Medicaid	$252.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$689.44
Rate for Payer: Amerigroup Medicare	$689.44
Rate for Payer: BCBS of TX Blue Advantage	$843.30
Rate for Payer: BCBS of TX Blue Essentials	$1,011.96
Rate for Payer: BCBS of TX Medicare	$689.44
Rate for Payer: BCBS of TX PPO	$1,124.40
Rate for Payer: Cash Price	$1,911.48
Rate for Payer: Cash Price	$1,911.48
Rate for Payer: Cash Price	$1,911.48
Rate for Payer: Cigna Commercial	$1,457.36
Rate for Payer: Cigna Medicaid	$2,023.92
Rate for Payer: Cigna Medicare	$689.44
Rate for Payer: Employer Direct Commercial	$689.44
Rate for Payer: Humana Medicare/TRICARE	$689.44
Rate for Payer: Molina CHIP/Medicaid	$2,023.92
Rate for Payer: Molina Dual Medicare/Medicaid	$689.44
Rate for Payer: Molina Medicare	$689.44
Rate for Payer: Multiplan Auto	$1,827.15
Rate for Payer: Multiplan Commercial	$1,827.15
Rate for Payer: Multiplan Workers Comp	$1,827.15
Rate for Payer: Parkland Medicaid	$2,023.92
Rate for Payer: Scott and White EPO/PPO	$86.31
Rate for Payer: Scott and White Medicare	$689.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,023.92
Rate for Payer: Superior Health Plan EPO	$689.44
Rate for Payer: Superior Health Plan Medicare	$689.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$689.44
Rate for Payer: Universal American Medicare	$689.44
Rate for Payer: Wellcare Medicare	$689.44
Rate for Payer: Wellmed Medicare	$689.44

Dialysis Treatment Charge -> Peritoneal Dialysis Treatment Complete

Facility

$5,866.00

Service Code	HCPCS 90945
Hospital Charge Code	810001
Hospital Revenue Code	804
Rate for Payer: Cash Price	$3,988.88

Dialysis Treatment Charge -> Peritoneal Dialysis Treatment Complete

Facility

$5,866.00

Service Code	HCPCS 90945
Hospital Charge Code	810001
Hospital Revenue Code	804
Min. Negotiated Rate	$104.41
Max. Negotiated Rate	$4,223.52
Rate for Payer: Amerigroup CHIP/Medicaid	$527.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$419.16
Rate for Payer: Amerigroup Medicare	$419.16
Rate for Payer: BCBS of TX Blue Advantage	$1,759.80
Rate for Payer: BCBS of TX Blue Essentials	$2,111.76
Rate for Payer: BCBS of TX Medicare	$419.16
Rate for Payer: BCBS of TX PPO	$2,346.40
Rate for Payer: Cash Price	$3,988.88
Rate for Payer: Cash Price	$3,988.88
Rate for Payer: Cash Price	$3,988.88
Rate for Payer: Cigna Commercial	$886.05
Rate for Payer: Cigna Medicaid	$4,223.52
Rate for Payer: Cigna Medicare	$419.16
Rate for Payer: Employer Direct Commercial	$419.16
Rate for Payer: Humana Medicare/TRICARE	$419.16
Rate for Payer: Molina CHIP/Medicaid	$4,223.52
Rate for Payer: Molina Dual Medicare/Medicaid	$419.16
Rate for Payer: Molina Medicare	$419.16
Rate for Payer: Multiplan Auto	$3,812.90
Rate for Payer: Multiplan Commercial	$3,812.90
Rate for Payer: Multiplan Workers Comp	$3,812.90
Rate for Payer: Parkland Medicaid	$4,223.52
Rate for Payer: Scott and White EPO/PPO	$104.41
Rate for Payer: Scott and White Medicare	$419.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,223.52
Rate for Payer: Superior Health Plan EPO	$419.16
Rate for Payer: Superior Health Plan Medicare	$419.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$419.16
Rate for Payer: Universal American Medicare	$419.16
Rate for Payer: Wellcare Medicare	$419.16
Rate for Payer: Wellmed Medicare	$419.16

Dialysis Treatment Charge -> TPE Complete

Facility

$3,926.00

Service Code	HCPCS 36514
Hospital Charge Code	810005
Hospital Revenue Code	940
Min. Negotiated Rate	$112.85
Max. Negotiated Rate	$3,335.52
Rate for Payer: Amerigroup CHIP/Medicaid	$353.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Amerigroup Medicare	$1,564.52
Rate for Payer: BCBS of TX Blue Advantage	$2,210.45
Rate for Payer: BCBS of TX Blue Essentials	$2,647.24
Rate for Payer: BCBS of TX Medicare	$1,564.52
Rate for Payer: BCBS of TX PPO	$3,335.52
Rate for Payer: Cash Price	$2,669.68
Rate for Payer: Cash Price	$2,669.68
Rate for Payer: Cash Price	$2,669.68
Rate for Payer: Cigna Commercial	$3,307.12
Rate for Payer: Cigna Medicaid	$2,826.72
Rate for Payer: Cigna Medicare	$1,564.52
Rate for Payer: Employer Direct Commercial	$1,564.52
Rate for Payer: Humana Medicare/TRICARE	$1,564.52
Rate for Payer: Molina CHIP/Medicaid	$2,826.72
Rate for Payer: Molina Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Molina Medicare	$1,564.52
Rate for Payer: Multiplan Auto	$2,551.90
Rate for Payer: Multiplan Commercial	$2,551.90
Rate for Payer: Multiplan Workers Comp	$2,551.90
Rate for Payer: Parkland Medicaid	$2,826.72
Rate for Payer: Scott and White EPO/PPO	$112.85
Rate for Payer: Scott and White Medicare	$1,564.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,826.72
Rate for Payer: Superior Health Plan EPO	$1,564.52
Rate for Payer: Superior Health Plan Medicare	$1,564.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Universal American Medicare	$1,564.52
Rate for Payer: Wellcare Medicare	$1,564.52
Rate for Payer: Wellmed Medicare	$1,564.52

Dialysis Treatment Charge -> TPE Complete

Facility

$3,926.00

Service Code	HCPCS 36514
Hospital Charge Code	810005
Hospital Revenue Code	940
Rate for Payer: Cash Price	$2,669.68

Dialysis Treatment Charge -> Unscheduled Dial ESR PT

Facility

$2,811.00

Hospital Charge Code	5600257
Hospital Revenue Code	820
Min. Negotiated Rate	$252.99
Max. Negotiated Rate	$2,023.92
Rate for Payer: Amerigroup CHIP/Medicaid	$252.99
Rate for Payer: BCBS of TX Blue Advantage	$843.30
Rate for Payer: BCBS of TX Blue Essentials	$1,011.96
Rate for Payer: BCBS of TX PPO	$1,124.40
Rate for Payer: Cash Price	$1,911.48
Rate for Payer: Cigna Medicaid	$2,023.92
Rate for Payer: Molina CHIP/Medicaid	$2,023.92
Rate for Payer: Multiplan Auto	$1,827.15
Rate for Payer: Multiplan Commercial	$1,827.15
Rate for Payer: Multiplan Workers Comp	$1,827.15
Rate for Payer: Parkland Medicaid	$2,023.92
Rate for Payer: Scott and White EPO/PPO	$1,405.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,023.92
Rate for Payer: Superior Health Plan EPO	$382.30

Dialysis Treatment Charge -> Unscheduled Dial ESR PT

Facility

$2,811.00

Hospital Charge Code	5600257
Hospital Revenue Code	820
Rate for Payer: Cash Price	$1,911.48

DIAMOND BACK CARTRIDGE CLASSIC DBP-CART-150CLA145

Facility

$11,350.00

Hospital Charge Code	144469
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7,718.00

DIAMOND BACK CARTRIDGE CLASSIC DBP-CART-150CLA145

Facility

$11,350.00

Hospital Charge Code	144469
Hospital Revenue Code	272
Min. Negotiated Rate	$1,021.50
Max. Negotiated Rate	$8,172.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,021.50
Rate for Payer: BCBS of TX Blue Advantage	$3,405.00
Rate for Payer: BCBS of TX Blue Essentials	$4,086.00
Rate for Payer: BCBS of TX PPO	$4,540.00
Rate for Payer: Cash Price	$7,718.00
Rate for Payer: Cigna Medicaid	$8,172.00
Rate for Payer: Molina CHIP/Medicaid	$8,172.00
Rate for Payer: Multiplan Auto	$7,377.50
Rate for Payer: Multiplan Commercial	$7,377.50
Rate for Payer: Multiplan Workers Comp	$7,377.50
Rate for Payer: Parkland Medicaid	$8,172.00
Rate for Payer: Scott and White EPO/PPO	$5,675.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,172.00
Rate for Payer: Superior Health Plan EPO	$1,543.60

DIAMOND BACK CARTRIDGE MICRO DBP-CART-125MIC145

Facility

$11,350.00

Hospital Charge Code	144468
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7,718.00

DIAMOND BACK CARTRIDGE MICRO DBP-CART-125MIC145

Facility

$11,350.00

Hospital Charge Code	144468
Hospital Revenue Code	272
Min. Negotiated Rate	$1,021.50
Max. Negotiated Rate	$8,172.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,021.50
Rate for Payer: BCBS of TX Blue Advantage	$3,405.00
Rate for Payer: BCBS of TX Blue Essentials	$4,086.00
Rate for Payer: BCBS of TX PPO	$4,540.00
Rate for Payer: Cash Price	$7,718.00
Rate for Payer: Cigna Medicaid	$8,172.00
Rate for Payer: Molina CHIP/Medicaid	$8,172.00
Rate for Payer: Multiplan Auto	$7,377.50
Rate for Payer: Multiplan Commercial	$7,377.50
Rate for Payer: Multiplan Workers Comp	$7,377.50
Rate for Payer: Parkland Medicaid	$8,172.00
Rate for Payer: Scott and White EPO/PPO	$5,675.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,172.00
Rate for Payer: Superior Health Plan EPO	$1,543.60

Diaphragmatic Hernia Repair with Mesh

Facility

$12,837.39

Service Code	CPT 49659
Hospital Charge Code	36049659
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Diaphragmatic Hernia Repair with Mesh

Facility

$10,327.10

Service Code	HCPCS 49659
Hospital Charge Code	9900729
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,022.43

Diaphragmatic Hernia Repair with Mesh

Facility

$10,327.10

Service Code	HCPCS 49659
Hospital Charge Code	9900729
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$7,022.43
Rate for Payer: Cash Price	$7,022.43
Rate for Payer: Cash Price	$7,022.43
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$7,435.51
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$7,435.51
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$7,435.51
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,435.51
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

Facility

$142.00

Service Code	HCPCS Q9963
Hospital Charge Code	77510372
Hospital Revenue Code	255
Rate for Payer: Cash Price	$96.56

diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

Facility

$142.00

Service Code	HCPCS Q9963
Hospital Charge Code	77510372
Hospital Revenue Code	255
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$102.24
Rate for Payer: Amerigroup CHIP/Medicaid	$12.78
Rate for Payer: BCBS of TX Blue Advantage	$0.28
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.37
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cigna Medicaid	$102.24
Rate for Payer: Molina CHIP/Medicaid	$102.24
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Parkland Medicaid	$102.24
Rate for Payer: Scott and White EPO/PPO	$0.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.24
Rate for Payer: Superior Health Plan EPO	$19.31

Know your out-of-pocket cost for care.

All Charges