White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Inf for Therapy, Prophylaxis, Dx Initial up to 1 Hour 96368

Facility

$149.00

Service Code	CPT 96368
Hospital Charge Code	1500362
Hospital Revenue Code	260
Min. Negotiated Rate	$13.41
Max. Negotiated Rate	$96.85
Rate for Payer: Aetna Commercial	$81.95
Rate for Payer: Amerigroup CHIP/Medicaid	$13.41
Rate for Payer: BCBS of TX Blue Advantage	$36.99
Rate for Payer: BCBS of TX Blue Essentials	$44.22
Rate for Payer: BCBS of TX PPO	$49.32
Rate for Payer: Cash Price	$131.12
Rate for Payer: Cash Price	$131.12
Rate for Payer: Multiplan Auto	$96.85
Rate for Payer: Multiplan Commercial	$96.85
Rate for Payer: Multiplan Workers Comp	$96.85
Rate for Payer: Scott and White EPO/PPO	$24.29
Rate for Payer: Superior Health Plan EPO	$20.26

Inf for Therapy, Prophylaxis or Dx Each Addl Hour 96366

Facility

$153.00

Service Code	CPT 96366
Hospital Charge Code	1500347
Hospital Revenue Code	260
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$99.45
Rate for Payer: Aetna Commercial	$84.15
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$38.25
Rate for Payer: BCBS of TX Blue Essentials	$45.72
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$50.99
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Scott and White EPO/PPO	$25.11
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

Inf for Therapy, Prophylaxis or Dx Each Addl Hour 96366

Facility

$153.00

Service Code	CPT 96366
Hospital Charge Code	1500347
Hospital Revenue Code	260
Rate for Payer: Cash Price	$134.64

Inf for Tx Prophylaxis Dx Addl Seq Infusion New Drug 96367

Facility

$175.00

Service Code	CPT 96367
Hospital Charge Code	7003627
Hospital Revenue Code	260
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$55.18
Rate for Payer: BCBS of TX Blue Essentials	$65.96
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$73.57
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Scott and White EPO/PPO	$35.01
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

Inf for Tx Prophylaxis Dx Addl Seq Infusion New Drug 96367

Facility

$175.00

Service Code	CPT 96367
Hospital Charge Code	7003627
Hospital Revenue Code	260
Rate for Payer: Cash Price	$154.00

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$21,633.49

Service Code	MSDRG 727
Min. Negotiated Rate	$11,843.06
Max. Negotiated Rate	$21,633.49
Rate for Payer: Aetna Commercial	$18,236.25
Rate for Payer: Aetna Medicare	$21,633.49
Rate for Payer: BCBS of TX Blue Advantage	$11,843.06
Rate for Payer: BCBS of TX Blue Essentials	$14,838.72
Rate for Payer: BCBS of TX PPO	$16,488.11
Rate for Payer: Cigna Commercial	$20,878.48

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC

Facility

$12,846.52

Service Code	MSDRG 728
Min. Negotiated Rate	$6,947.08
Max. Negotiated Rate	$12,846.52
Rate for Payer: Aetna Commercial	$9,001.12
Rate for Payer: Aetna Medicare	$12,846.52
Rate for Payer: BCBS of TX Blue Advantage	$6,947.08
Rate for Payer: BCBS of TX Blue Essentials	$8,166.46
Rate for Payer: BCBS of TX PPO	$9,074.19
Rate for Payer: Cigna Commercial	$10,305.29

INFLAMMATORY BOWEL DISEASE WITH CC

Facility

$14,682.25

Service Code	MSDRG 386
Min. Negotiated Rate	$8,344.58
Max. Negotiated Rate	$14,682.25
Rate for Payer: Aetna Commercial	$10,930.50
Rate for Payer: Aetna Medicare	$14,682.25
Rate for Payer: BCBS of TX Blue Advantage	$8,344.58
Rate for Payer: BCBS of TX Blue Essentials	$10,113.65
Rate for Payer: BCBS of TX PPO	$11,237.83
Rate for Payer: Cigna Commercial	$12,514.21

INFLAMMATORY BOWEL DISEASE WITH MCC

Facility

$21,054.40

Service Code	MSDRG 385
Min. Negotiated Rate	$14,023.16
Max. Negotiated Rate	$21,054.40
Rate for Payer: Aetna Commercial	$17,627.62
Rate for Payer: Aetna Medicare	$21,054.40
Rate for Payer: BCBS of TX Blue Advantage	$14,023.16
Rate for Payer: BCBS of TX Blue Essentials	$17,520.63
Rate for Payer: BCBS of TX PPO	$19,468.12
Rate for Payer: Cigna Commercial	$20,181.67

INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC

Facility

$11,604.85

Service Code	MSDRG 387
Min. Negotiated Rate	$6,382.92
Max. Negotiated Rate	$11,604.85
Rate for Payer: Aetna Commercial	$7,696.12
Rate for Payer: Aetna Medicare	$11,604.85
Rate for Payer: BCBS of TX Blue Advantage	$6,382.92
Rate for Payer: BCBS of TX Blue Essentials	$7,189.25
Rate for Payer: BCBS of TX PPO	$7,988.36
Rate for Payer: Cigna Commercial	$8,811.21

INFL SYR W/GAUGE -- DHF

Facility

$149.03

Hospital Charge Code	80325111
Hospital Revenue Code	272
Min. Negotiated Rate	$13.41
Max. Negotiated Rate	$96.87
Rate for Payer: Aetna Commercial	$81.97
Rate for Payer: Amerigroup CHIP/Medicaid	$13.41
Rate for Payer: BCBS of TX Blue Advantage	$44.71
Rate for Payer: BCBS of TX Blue Essentials	$53.65
Rate for Payer: BCBS of TX PPO	$59.61
Rate for Payer: Cash Price	$131.15
Rate for Payer: Multiplan Auto	$96.87
Rate for Payer: Multiplan Commercial	$96.87
Rate for Payer: Multiplan Workers Comp	$96.87
Rate for Payer: Scott and White EPO/PPO	$74.52
Rate for Payer: Superior Health Plan EPO	$20.27

INFL SYR W/GAUGE -- DHF

Facility

$149.03

Hospital Charge Code	80325111
Hospital Revenue Code	272
Rate for Payer: Cash Price	$131.15

Influenza A and B Antigens BCE

Facility

$172.00

Service Code	CPT 87804
Hospital Charge Code	1640072
Hospital Revenue Code	306
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$111.80
Rate for Payer: Aetna Commercial	$17.38
Rate for Payer: Aetna Medicare	$24.82
Rate for Payer: Amerigroup CHIP/Medicaid	$6.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.55
Rate for Payer: Amerigroup Medicare	$16.55
Rate for Payer: BCBS of TX Blue Advantage	$27.31
Rate for Payer: BCBS of TX Blue Essentials	$32.77
Rate for Payer: BCBS of TX Medicare	$16.55
Rate for Payer: BCBS of TX PPO	$36.58
Rate for Payer: Cash Price	$151.36
Rate for Payer: Cash Price	$151.36
Rate for Payer: Cigna Medicaid	$16.55
Rate for Payer: Cigna Medicare	$16.55
Rate for Payer: Employer Direct Commercial	$16.55
Rate for Payer: Humana Medicare/TRICARE	$16.55
Rate for Payer: Molina CHIP/Medicaid	$16.55
Rate for Payer: Molina Dual Medicare/Medicaid	$16.55
Rate for Payer: Molina Medicare	$16.55
Rate for Payer: Multiplan Auto	$111.80
Rate for Payer: Multiplan Commercial	$111.80
Rate for Payer: Multiplan Workers Comp	$111.80
Rate for Payer: Parkland Medicaid	$16.55
Rate for Payer: Scott and White EPO/PPO	$20.69
Rate for Payer: Scott and White Medicare	$16.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.55
Rate for Payer: Superior Health Plan EPO	$16.55
Rate for Payer: Superior Health Plan Medicare	$16.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.55
Rate for Payer: Universal American Medicare	$16.55
Rate for Payer: Wellcare Medicare	$16.55
Rate for Payer: Wellmed Medicare	$16.55

Influenza A and B by RNA

Facility

$304.00

Service Code	CPT 87502
Hospital Charge Code	1630030
Hospital Revenue Code	300
Min. Negotiated Rate	$37.36
Max. Negotiated Rate	$211.72
Rate for Payer: Aetna Commercial	$100.59
Rate for Payer: Aetna Medicare	$143.70
Rate for Payer: Amerigroup CHIP/Medicaid	$37.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$95.80
Rate for Payer: Amerigroup Medicare	$95.80
Rate for Payer: BCBS of TX Blue Advantage	$158.07
Rate for Payer: BCBS of TX Blue Essentials	$189.68
Rate for Payer: BCBS of TX Medicare	$95.80
Rate for Payer: BCBS of TX PPO	$211.72
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cigna Medicaid	$95.80
Rate for Payer: Cigna Medicare	$95.80
Rate for Payer: Employer Direct Commercial	$95.80
Rate for Payer: Humana Medicare/TRICARE	$95.80
Rate for Payer: Molina CHIP/Medicaid	$95.80
Rate for Payer: Molina Dual Medicare/Medicaid	$95.80
Rate for Payer: Molina Medicare	$95.80
Rate for Payer: Multiplan Auto	$197.60
Rate for Payer: Multiplan Commercial	$197.60
Rate for Payer: Multiplan Workers Comp	$197.60
Rate for Payer: Parkland Medicaid	$95.80
Rate for Payer: Scott and White EPO/PPO	$119.75
Rate for Payer: Scott and White Medicare	$95.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$95.80
Rate for Payer: Superior Health Plan EPO	$95.80
Rate for Payer: Superior Health Plan Medicare	$95.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$95.80
Rate for Payer: Universal American Medicare	$95.80
Rate for Payer: Wellcare Medicare	$95.80
Rate for Payer: Wellmed Medicare	$95.80

Influenza A and B by RNA

Facility

$304.00

Service Code	CPT 87502
Hospital Charge Code	1630030
Hospital Revenue Code	300
Rate for Payer: Cash Price	$267.52

Influenza A Antigen

Facility

$172.00

Service Code	CPT 87804
Hospital Charge Code	1640072
Hospital Revenue Code	306
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$111.80
Rate for Payer: Aetna Commercial	$17.38
Rate for Payer: Aetna Medicare	$24.82
Rate for Payer: Amerigroup CHIP/Medicaid	$6.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.55
Rate for Payer: Amerigroup Medicare	$16.55
Rate for Payer: BCBS of TX Blue Advantage	$27.31
Rate for Payer: BCBS of TX Blue Essentials	$32.77
Rate for Payer: BCBS of TX Medicare	$16.55
Rate for Payer: BCBS of TX PPO	$36.58
Rate for Payer: Cash Price	$151.36
Rate for Payer: Cash Price	$151.36
Rate for Payer: Cigna Medicaid	$16.55
Rate for Payer: Cigna Medicare	$16.55
Rate for Payer: Employer Direct Commercial	$16.55
Rate for Payer: Humana Medicare/TRICARE	$16.55
Rate for Payer: Molina CHIP/Medicaid	$16.55
Rate for Payer: Molina Dual Medicare/Medicaid	$16.55
Rate for Payer: Molina Medicare	$16.55
Rate for Payer: Multiplan Auto	$111.80
Rate for Payer: Multiplan Commercial	$111.80
Rate for Payer: Multiplan Workers Comp	$111.80
Rate for Payer: Parkland Medicaid	$16.55
Rate for Payer: Scott and White EPO/PPO	$20.69
Rate for Payer: Scott and White Medicare	$16.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.55
Rate for Payer: Superior Health Plan EPO	$16.55
Rate for Payer: Superior Health Plan Medicare	$16.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.55
Rate for Payer: Universal American Medicare	$16.55
Rate for Payer: Wellcare Medicare	$16.55
Rate for Payer: Wellmed Medicare	$16.55

Influenza A/B Ab, Quant SO

Facility

$176.00

Service Code	CPT 86710
Hospital Charge Code	1705953
Hospital Revenue Code	302
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$114.40
Rate for Payer: Aetna Commercial	$14.23
Rate for Payer: Aetna Medicare	$20.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.55
Rate for Payer: Amerigroup Medicare	$13.55
Rate for Payer: BCBS of TX Blue Advantage	$22.36
Rate for Payer: BCBS of TX Blue Essentials	$26.83
Rate for Payer: BCBS of TX Medicare	$13.55
Rate for Payer: BCBS of TX PPO	$29.95
Rate for Payer: Cash Price	$154.88
Rate for Payer: Cash Price	$154.88
Rate for Payer: Cigna Medicaid	$13.55
Rate for Payer: Cigna Medicare	$13.55
Rate for Payer: Employer Direct Commercial	$13.55
Rate for Payer: Humana Medicare/TRICARE	$13.55
Rate for Payer: Molina CHIP/Medicaid	$13.55
Rate for Payer: Molina Dual Medicare/Medicaid	$13.55
Rate for Payer: Molina Medicare	$13.55
Rate for Payer: Multiplan Auto	$114.40
Rate for Payer: Multiplan Commercial	$114.40
Rate for Payer: Multiplan Workers Comp	$114.40
Rate for Payer: Parkland Medicaid	$13.55
Rate for Payer: Scott and White EPO/PPO	$16.94
Rate for Payer: Scott and White Medicare	$13.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.55
Rate for Payer: Superior Health Plan EPO	$13.55
Rate for Payer: Superior Health Plan Medicare	$13.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.55
Rate for Payer: Universal American Medicare	$13.55
Rate for Payer: Wellcare Medicare	$13.55
Rate for Payer: Wellmed Medicare	$13.55

Influenza A/B Ab, Quant SO

Facility

$176.00

Service Code	CPT 86710
Hospital Charge Code	1705953
Hospital Revenue Code	302
Rate for Payer: Cash Price	$154.88

Influenza B Antigen

Facility

$172.00

Service Code	CPT 87804
Hospital Charge Code	1640072
Hospital Revenue Code	306
Rate for Payer: Cash Price	$151.36

Influenza B Antigen

Facility

$172.00

Service Code	CPT 87804
Hospital Charge Code	1640072
Hospital Revenue Code	306
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$111.80
Rate for Payer: Aetna Commercial	$17.38
Rate for Payer: Aetna Medicare	$24.82
Rate for Payer: Amerigroup CHIP/Medicaid	$6.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.55
Rate for Payer: Amerigroup Medicare	$16.55
Rate for Payer: BCBS of TX Blue Advantage	$27.31
Rate for Payer: BCBS of TX Blue Essentials	$32.77
Rate for Payer: BCBS of TX Medicare	$16.55
Rate for Payer: BCBS of TX PPO	$36.58
Rate for Payer: Cash Price	$151.36
Rate for Payer: Cash Price	$151.36
Rate for Payer: Cigna Medicaid	$16.55
Rate for Payer: Cigna Medicare	$16.55
Rate for Payer: Employer Direct Commercial	$16.55
Rate for Payer: Humana Medicare/TRICARE	$16.55
Rate for Payer: Molina CHIP/Medicaid	$16.55
Rate for Payer: Molina Dual Medicare/Medicaid	$16.55
Rate for Payer: Molina Medicare	$16.55
Rate for Payer: Multiplan Auto	$111.80
Rate for Payer: Multiplan Commercial	$111.80
Rate for Payer: Multiplan Workers Comp	$111.80
Rate for Payer: Parkland Medicaid	$16.55
Rate for Payer: Scott and White EPO/PPO	$20.69
Rate for Payer: Scott and White Medicare	$16.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.55
Rate for Payer: Superior Health Plan EPO	$16.55
Rate for Payer: Superior Health Plan Medicare	$16.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.55
Rate for Payer: Universal American Medicare	$16.55
Rate for Payer: Wellcare Medicare	$16.55
Rate for Payer: Wellmed Medicare	$16.55

Inf Tx Chemo Inf 1 hr Single/Initial Drug 96413 BCE

Facility

$555.00

Service Code	CPT 96413
Hospital Charge Code	1500271
Hospital Revenue Code	335
Rate for Payer: Cash Price	$488.40

Inf Tx Chemo Inf 1 hr Single/Initial Drug 96413 BCE

Facility

$555.00

Service Code	CPT 96413
Hospital Charge Code	1500271
Hospital Revenue Code	335
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$701.61
Rate for Payer: Aetna Commercial	$170.74
Rate for Payer: Aetna Medicare	$464.60
Rate for Payer: Amerigroup CHIP/Medicaid	$49.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$309.73
Rate for Payer: Amerigroup Medicare	$309.73
Rate for Payer: BCBS of TX Blue Advantage	$248.96
Rate for Payer: BCBS of TX Blue Essentials	$297.61
Rate for Payer: BCBS of TX Medicare	$309.73
Rate for Payer: BCBS of TX PPO	$331.95
Rate for Payer: Cash Price	$488.40
Rate for Payer: Cash Price	$488.40
Rate for Payer: Cash Price	$488.40
Rate for Payer: Cigna Commercial	$701.61
Rate for Payer: Cigna Medicare	$309.73
Rate for Payer: Employer Direct Commercial	$309.73
Rate for Payer: Humana Medicare/TRICARE	$309.73
Rate for Payer: Molina Dual Medicare/Medicaid	$309.73
Rate for Payer: Molina Medicare	$309.73
Rate for Payer: Multiplan Auto	$360.75
Rate for Payer: Multiplan Commercial	$360.75
Rate for Payer: Multiplan Workers Comp	$360.75
Rate for Payer: Scott and White EPO/PPO	$159.60
Rate for Payer: Scott and White Medicare	$309.73
Rate for Payer: Superior Health Plan EPO	$309.73
Rate for Payer: Superior Health Plan Medicare	$309.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$309.73
Rate for Payer: Universal American Medicare	$309.73
Rate for Payer: Wellcare Medicare	$309.73
Rate for Payer: Wellmed Medicare	$309.73

Inf Tx Chemo Infusion Each Additional Hr 96415 BCE

Facility

$124.00

Service Code	CPT 96415
Hospital Charge Code	1500289
Hospital Revenue Code	335
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$36.22
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$53.92
Rate for Payer: BCBS of TX Blue Essentials	$64.46
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$71.90
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Scott and White EPO/PPO	$34.14
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

Inf Tx Chemo Infusion Each Additional Hr 96415 BCE

Facility

$124.00

Service Code	CPT 96415
Hospital Charge Code	1500289
Hospital Revenue Code	335
Rate for Payer: Cash Price	$109.12

Inf Tx Proph Diag Ea Addl IVP Drug 96375 BCE

Facility

$330.00

Service Code	CPT 96375
Hospital Charge Code	6290775
Hospital Revenue Code	260
Rate for Payer: Cash Price	$290.40

Know your out-of-pocket cost for care.

All Charges