White Rock Medical Center

All Charges

Charge

Type

Setting

Price

83735 MAGNESIUM

Facility

$234.00

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

83883 NEPHELOMETRY EA ANALYTE NES

Facility

$185.00

Service Code	HCPCS 83883
Hospital Charge Code	1706530
Hospital Revenue Code	301
Min. Negotiated Rate	$5.30
Max. Negotiated Rate	$133.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.60
Rate for Payer: Amerigroup Medicare	$13.60
Rate for Payer: BCBS of TX Blue Advantage	$55.50
Rate for Payer: BCBS of TX Blue Essentials	$66.60
Rate for Payer: BCBS of TX Medicare	$13.60
Rate for Payer: BCBS of TX PPO	$74.00
Rate for Payer: Cash Price	$125.80
Rate for Payer: Cash Price	$125.80
Rate for Payer: Cigna Medicaid	$133.20
Rate for Payer: Cigna Medicare	$13.60
Rate for Payer: Employer Direct Commercial	$13.60
Rate for Payer: Humana Medicare/TRICARE	$13.60
Rate for Payer: Molina CHIP/Medicaid	$133.20
Rate for Payer: Molina Dual Medicare/Medicaid	$13.60
Rate for Payer: Molina Medicare	$13.60
Rate for Payer: Multiplan Auto	$120.25
Rate for Payer: Multiplan Commercial	$120.25
Rate for Payer: Multiplan Workers Comp	$120.25
Rate for Payer: Parkland Medicaid	$133.20
Rate for Payer: Scott and White EPO/PPO	$17.00
Rate for Payer: Scott and White Medicare	$13.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.20
Rate for Payer: Superior Health Plan EPO	$13.60
Rate for Payer: Superior Health Plan Medicare	$13.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.60
Rate for Payer: Universal American Medicare	$13.60
Rate for Payer: Wellcare Medicare	$13.60
Rate for Payer: Wellmed Medicare	$13.60

83883 NEPHELOMETRY EA ANALYTE NES

Facility

$185.00

Service Code	HCPCS 83883
Hospital Charge Code	1706530
Hospital Revenue Code	301
Rate for Payer: Cash Price	$125.80

83935 OSMOLALITY URINE

Facility

$272.00

Service Code	HCPCS 83935
Hospital Charge Code	1602564
Hospital Revenue Code	301
Rate for Payer: Cash Price	$184.96

83935 OSMOLALITY URINE

Facility

$272.00

Service Code	HCPCS 83935
Hospital Charge Code	1602564
Hospital Revenue Code	301
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$195.84
Rate for Payer: Amerigroup CHIP/Medicaid	$2.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.82
Rate for Payer: Amerigroup Medicare	$6.82
Rate for Payer: BCBS of TX Blue Advantage	$81.60
Rate for Payer: BCBS of TX Blue Essentials	$97.92
Rate for Payer: BCBS of TX Medicare	$6.82
Rate for Payer: BCBS of TX PPO	$108.80
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cigna Medicaid	$195.84
Rate for Payer: Cigna Medicare	$6.82
Rate for Payer: Employer Direct Commercial	$6.82
Rate for Payer: Humana Medicare/TRICARE	$6.82
Rate for Payer: Molina CHIP/Medicaid	$195.84
Rate for Payer: Molina Dual Medicare/Medicaid	$6.82
Rate for Payer: Molina Medicare	$6.82
Rate for Payer: Multiplan Auto	$176.80
Rate for Payer: Multiplan Commercial	$176.80
Rate for Payer: Multiplan Workers Comp	$176.80
Rate for Payer: Parkland Medicaid	$195.84
Rate for Payer: Scott and White EPO/PPO	$8.53
Rate for Payer: Scott and White Medicare	$6.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.84
Rate for Payer: Superior Health Plan EPO	$6.82
Rate for Payer: Superior Health Plan Medicare	$6.82
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.82
Rate for Payer: Universal American Medicare	$6.82
Rate for Payer: Wellcare Medicare	$6.82
Rate for Payer: Wellmed Medicare	$6.82

83945 OXALATE

Facility

$129.00

Service Code	HCPCS 83945
Hospital Charge Code	1702133
Hospital Revenue Code	301
Rate for Payer: Cash Price	$87.72

83945 OXALATE

Facility

$129.00

Service Code	HCPCS 83945
Hospital Charge Code	1702133
Hospital Revenue Code	301
Min. Negotiated Rate	$5.64
Max. Negotiated Rate	$92.88
Rate for Payer: Amerigroup CHIP/Medicaid	$5.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.45
Rate for Payer: Amerigroup Medicare	$14.45
Rate for Payer: BCBS of TX Blue Advantage	$38.70
Rate for Payer: BCBS of TX Blue Essentials	$46.44
Rate for Payer: BCBS of TX Medicare	$14.45
Rate for Payer: BCBS of TX PPO	$51.60
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cigna Medicaid	$92.88
Rate for Payer: Cigna Medicare	$14.45
Rate for Payer: Employer Direct Commercial	$14.45
Rate for Payer: Humana Medicare/TRICARE	$14.45
Rate for Payer: Molina CHIP/Medicaid	$92.88
Rate for Payer: Molina Dual Medicare/Medicaid	$14.45
Rate for Payer: Molina Medicare	$14.45
Rate for Payer: Multiplan Auto	$83.85
Rate for Payer: Multiplan Commercial	$83.85
Rate for Payer: Multiplan Workers Comp	$83.85
Rate for Payer: Parkland Medicaid	$92.88
Rate for Payer: Scott and White EPO/PPO	$18.06
Rate for Payer: Scott and White Medicare	$14.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.88
Rate for Payer: Superior Health Plan EPO	$14.45
Rate for Payer: Superior Health Plan Medicare	$14.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.45
Rate for Payer: Universal American Medicare	$14.45
Rate for Payer: Wellcare Medicare	$14.45
Rate for Payer: Wellmed Medicare	$14.45

84105 PHOSPHORUS URINE

Facility

$74.00

Service Code	HCPCS 84105
Hospital Charge Code	1700160
Hospital Revenue Code	301
Rate for Payer: Cash Price	$50.32

84105 PHOSPHORUS URINE

Facility

$74.00

Service Code	HCPCS 84105
Hospital Charge Code	1700160
Hospital Revenue Code	301
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$53.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.78
Rate for Payer: Amerigroup Medicare	$5.78
Rate for Payer: BCBS of TX Blue Advantage	$22.20
Rate for Payer: BCBS of TX Blue Essentials	$26.64
Rate for Payer: BCBS of TX Medicare	$5.78
Rate for Payer: BCBS of TX PPO	$29.60
Rate for Payer: Cash Price	$50.32
Rate for Payer: Cash Price	$50.32
Rate for Payer: Cigna Medicaid	$53.28
Rate for Payer: Cigna Medicare	$5.78
Rate for Payer: Employer Direct Commercial	$5.78
Rate for Payer: Humana Medicare/TRICARE	$5.78
Rate for Payer: Molina CHIP/Medicaid	$53.28
Rate for Payer: Molina Dual Medicare/Medicaid	$5.78
Rate for Payer: Molina Medicare	$5.78
Rate for Payer: Multiplan Auto	$48.10
Rate for Payer: Multiplan Commercial	$48.10
Rate for Payer: Multiplan Workers Comp	$48.10
Rate for Payer: Parkland Medicaid	$53.28
Rate for Payer: Scott and White EPO/PPO	$7.22
Rate for Payer: Scott and White Medicare	$5.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53.28
Rate for Payer: Superior Health Plan EPO	$5.78
Rate for Payer: Superior Health Plan Medicare	$5.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.78
Rate for Payer: Universal American Medicare	$5.78
Rate for Payer: Wellcare Medicare	$5.78
Rate for Payer: Wellmed Medicare	$5.78

84155 PROTEIN TOTAL EXCEPT REFRACTOMETRY

Facility

$199.00

Service Code	HCPCS 84155
Hospital Charge Code	1602226
Hospital Revenue Code	301
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$143.28
Rate for Payer: Amerigroup CHIP/Medicaid	$1.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.67
Rate for Payer: Amerigroup Medicare	$3.67
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	$3.67
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	$3.67
Rate for Payer: Employer Direct Commercial	$3.67
Rate for Payer: Humana Medicare/TRICARE	$3.67
Rate for Payer: Molina CHIP/Medicaid	$143.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3.67
Rate for Payer: Molina Medicare	$3.67
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	$4.59
Rate for Payer: Scott and White Medicare	$3.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.28
Rate for Payer: Superior Health Plan EPO	$3.67
Rate for Payer: Superior Health Plan Medicare	$3.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.67
Rate for Payer: Universal American Medicare	$3.67
Rate for Payer: Wellcare Medicare	$3.67
Rate for Payer: Wellmed Medicare	$3.67

84155 PROTEIN TOTAL EXCEPT REFRACTOMETRY

Facility

$199.00

Service Code	HCPCS 84155
Hospital Charge Code	1602226
Hospital Revenue Code	301
Rate for Payer: Cash Price	$135.32

84156 PROTEIN TOT EXCEPT REFRACT URINE

Facility

$160.00

Service Code	HCPCS 84156
Hospital Charge Code	1605823
Hospital Revenue Code	301
Rate for Payer: Cash Price	$108.80

84156 PROTEIN TOT EXCEPT REFRACT URINE

Facility

$160.00

Service Code	HCPCS 84156
Hospital Charge Code	1605823
Hospital Revenue Code	301
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$115.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.67
Rate for Payer: Amerigroup Medicare	$3.67
Rate for Payer: BCBS of TX Blue Advantage	$48.00
Rate for Payer: BCBS of TX Blue Essentials	$57.60
Rate for Payer: BCBS of TX Medicare	$3.67
Rate for Payer: BCBS of TX PPO	$64.00
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cigna Medicaid	$115.20
Rate for Payer: Cigna Medicare	$3.67
Rate for Payer: Employer Direct Commercial	$3.67
Rate for Payer: Humana Medicare/TRICARE	$3.67
Rate for Payer: Molina CHIP/Medicaid	$115.20
Rate for Payer: Molina Dual Medicare/Medicaid	$3.67
Rate for Payer: Molina Medicare	$3.67
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Parkland Medicaid	$115.20
Rate for Payer: Scott and White EPO/PPO	$4.59
Rate for Payer: Scott and White Medicare	$3.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.20
Rate for Payer: Superior Health Plan EPO	$3.67
Rate for Payer: Superior Health Plan Medicare	$3.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.67
Rate for Payer: Universal American Medicare	$3.67
Rate for Payer: Wellcare Medicare	$3.67
Rate for Payer: Wellmed Medicare	$3.67

84165 PROTEIN ELECTROPHORETIC FRACTNATION

Facility

$441.00

Service Code	HCPCS 84165
Hospital Charge Code	1601814
Hospital Revenue Code	301
Min. Negotiated Rate	$4.19
Max. Negotiated Rate	$317.52
Rate for Payer: Amerigroup CHIP/Medicaid	$4.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.74
Rate for Payer: Amerigroup Medicare	$10.74
Rate for Payer: BCBS of TX Blue Advantage	$132.30
Rate for Payer: BCBS of TX Blue Essentials	$158.76
Rate for Payer: BCBS of TX Medicare	$10.74
Rate for Payer: BCBS of TX PPO	$176.40
Rate for Payer: Cash Price	$299.88
Rate for Payer: Cash Price	$299.88
Rate for Payer: Cigna Medicaid	$317.52
Rate for Payer: Cigna Medicare	$10.74
Rate for Payer: Employer Direct Commercial	$10.74
Rate for Payer: Humana Medicare/TRICARE	$10.74
Rate for Payer: Molina CHIP/Medicaid	$317.52
Rate for Payer: Molina Dual Medicare/Medicaid	$10.74
Rate for Payer: Molina Medicare	$10.74
Rate for Payer: Multiplan Auto	$286.65
Rate for Payer: Multiplan Commercial	$286.65
Rate for Payer: Multiplan Workers Comp	$286.65
Rate for Payer: Parkland Medicaid	$317.52
Rate for Payer: Scott and White EPO/PPO	$13.43
Rate for Payer: Scott and White Medicare	$10.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$317.52
Rate for Payer: Superior Health Plan EPO	$10.74
Rate for Payer: Superior Health Plan Medicare	$10.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.74
Rate for Payer: Universal American Medicare	$10.74
Rate for Payer: Wellcare Medicare	$10.74
Rate for Payer: Wellmed Medicare	$10.74

84165 PROTEIN ELECTROPHORETIC FRACTNATION

Facility

$441.00

Service Code	HCPCS 84165
Hospital Charge Code	1601814
Hospital Revenue Code	301
Rate for Payer: Cash Price	$299.88

84166 PROTEIN ELECTROPHOREC FRAC & QUAL

Facility

$485.00

Service Code	HCPCS 84166
Hospital Charge Code	1611805
Hospital Revenue Code	301
Rate for Payer: Cash Price	$329.80

84166 PROTEIN ELECTROPHOREC FRAC & QUAL

Facility

$485.00

Service Code	HCPCS 84166
Hospital Charge Code	1611805
Hospital Revenue Code	301
Min. Negotiated Rate	$6.95
Max. Negotiated Rate	$349.20
Rate for Payer: Amerigroup CHIP/Medicaid	$6.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.83
Rate for Payer: Amerigroup Medicare	$17.83
Rate for Payer: BCBS of TX Blue Advantage	$145.50
Rate for Payer: BCBS of TX Blue Essentials	$174.60
Rate for Payer: BCBS of TX Medicare	$17.83
Rate for Payer: BCBS of TX PPO	$194.00
Rate for Payer: Cash Price	$329.80
Rate for Payer: Cash Price	$329.80
Rate for Payer: Cigna Medicaid	$349.20
Rate for Payer: Cigna Medicare	$17.83
Rate for Payer: Employer Direct Commercial	$17.83
Rate for Payer: Humana Medicare/TRICARE	$17.83
Rate for Payer: Molina CHIP/Medicaid	$349.20
Rate for Payer: Molina Dual Medicare/Medicaid	$17.83
Rate for Payer: Molina Medicare	$17.83
Rate for Payer: Multiplan Auto	$315.25
Rate for Payer: Multiplan Commercial	$315.25
Rate for Payer: Multiplan Workers Comp	$315.25
Rate for Payer: Parkland Medicaid	$349.20
Rate for Payer: Scott and White EPO/PPO	$22.29
Rate for Payer: Scott and White Medicare	$17.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$349.20
Rate for Payer: Superior Health Plan EPO	$17.83
Rate for Payer: Superior Health Plan Medicare	$17.83
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.83
Rate for Payer: Universal American Medicare	$17.83
Rate for Payer: Wellcare Medicare	$17.83
Rate for Payer: Wellmed Medicare	$17.83

84392 SULFATE URINE

Facility

$52.00

Service Code	HCPCS 84392
Hospital Charge Code	1740927
Hospital Revenue Code	301
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$37.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.49
Rate for Payer: Amerigroup Medicare	$5.49
Rate for Payer: BCBS of TX Blue Advantage	$15.60
Rate for Payer: BCBS of TX Blue Essentials	$18.72
Rate for Payer: BCBS of TX Medicare	$5.49
Rate for Payer: BCBS of TX PPO	$20.80
Rate for Payer: Cash Price	$35.36
Rate for Payer: Cash Price	$35.36
Rate for Payer: Cigna Medicaid	$37.44
Rate for Payer: Cigna Medicare	$5.49
Rate for Payer: Employer Direct Commercial	$5.49
Rate for Payer: Humana Medicare/TRICARE	$5.49
Rate for Payer: Molina CHIP/Medicaid	$37.44
Rate for Payer: Molina Dual Medicare/Medicaid	$5.49
Rate for Payer: Molina Medicare	$5.49
Rate for Payer: Multiplan Auto	$33.80
Rate for Payer: Multiplan Commercial	$33.80
Rate for Payer: Multiplan Workers Comp	$33.80
Rate for Payer: Parkland Medicaid	$37.44
Rate for Payer: Scott and White EPO/PPO	$6.86
Rate for Payer: Scott and White Medicare	$5.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.44
Rate for Payer: Superior Health Plan EPO	$5.49
Rate for Payer: Superior Health Plan Medicare	$5.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.49
Rate for Payer: Universal American Medicare	$5.49
Rate for Payer: Wellcare Medicare	$5.49
Rate for Payer: Wellmed Medicare	$5.49

84392 SULFATE URINE

Facility

$52.00

Service Code	HCPCS 84392
Hospital Charge Code	1740927
Hospital Revenue Code	301
Rate for Payer: Cash Price	$35.36

84560 URIC ACID OTHER SOURCE

Facility

$134.00

Service Code	HCPCS 84560
Hospital Charge Code	1602630
Hospital Revenue Code	301
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$96.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.08
Rate for Payer: Amerigroup Medicare	$5.08
Rate for Payer: BCBS of TX Blue Advantage	$40.20
Rate for Payer: BCBS of TX Blue Essentials	$48.24
Rate for Payer: BCBS of TX Medicare	$5.08
Rate for Payer: BCBS of TX PPO	$53.60
Rate for Payer: Cash Price	$91.12
Rate for Payer: Cash Price	$91.12
Rate for Payer: Cigna Medicaid	$96.48
Rate for Payer: Cigna Medicare	$5.08
Rate for Payer: Employer Direct Commercial	$5.08
Rate for Payer: Humana Medicare/TRICARE	$5.08
Rate for Payer: Molina CHIP/Medicaid	$96.48
Rate for Payer: Molina Dual Medicare/Medicaid	$5.08
Rate for Payer: Molina Medicare	$5.08
Rate for Payer: Multiplan Auto	$87.10
Rate for Payer: Multiplan Commercial	$87.10
Rate for Payer: Multiplan Workers Comp	$87.10
Rate for Payer: Parkland Medicaid	$96.48
Rate for Payer: Scott and White EPO/PPO	$6.35
Rate for Payer: Scott and White Medicare	$5.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.48
Rate for Payer: Superior Health Plan EPO	$5.08
Rate for Payer: Superior Health Plan Medicare	$5.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.08
Rate for Payer: Universal American Medicare	$5.08
Rate for Payer: Wellcare Medicare	$5.08
Rate for Payer: Wellmed Medicare	$5.08

84560 URIC ACID OTHER SOURCE

Facility

$134.00

Service Code	HCPCS 84560
Hospital Charge Code	1602630
Hospital Revenue Code	301
Rate for Payer: Cash Price	$91.12

84588 VASOPRESSIN (ANTIDIURETIC HORMONE)

Facility

$289.63

Service Code	HCPCS 84588
Hospital Charge Code	1706217
Hospital Revenue Code	301
Rate for Payer: Cash Price	$196.95

84588 VASOPRESSIN (ANTIDIURETIC HORMONE)

Facility

$289.63

Service Code	HCPCS 84588
Hospital Charge Code	1706217
Hospital Revenue Code	301
Min. Negotiated Rate	$13.24
Max. Negotiated Rate	$208.53
Rate for Payer: Amerigroup CHIP/Medicaid	$13.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$33.94
Rate for Payer: Amerigroup Medicare	$33.94
Rate for Payer: BCBS of TX Blue Advantage	$86.89
Rate for Payer: BCBS of TX Blue Essentials	$104.27
Rate for Payer: BCBS of TX Medicare	$33.94
Rate for Payer: BCBS of TX PPO	$115.85
Rate for Payer: Cash Price	$196.95
Rate for Payer: Cash Price	$196.95
Rate for Payer: Cigna Medicaid	$208.53
Rate for Payer: Cigna Medicare	$33.94
Rate for Payer: Employer Direct Commercial	$33.94
Rate for Payer: Humana Medicare/TRICARE	$33.94
Rate for Payer: Molina CHIP/Medicaid	$208.53
Rate for Payer: Molina Dual Medicare/Medicaid	$33.94
Rate for Payer: Molina Medicare	$33.94
Rate for Payer: Multiplan Auto	$188.26
Rate for Payer: Multiplan Commercial	$188.26
Rate for Payer: Multiplan Workers Comp	$188.26
Rate for Payer: Parkland Medicaid	$208.53
Rate for Payer: Scott and White EPO/PPO	$42.42
Rate for Payer: Scott and White Medicare	$33.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$208.53
Rate for Payer: Superior Health Plan EPO	$33.94
Rate for Payer: Superior Health Plan Medicare	$33.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$33.94
Rate for Payer: Universal American Medicare	$33.94
Rate for Payer: Wellcare Medicare	$33.94
Rate for Payer: Wellmed Medicare	$33.94

85014 HEMATOCRIT

Facility

$97.00

Service Code	HCPCS 85014
Hospital Charge Code	1600493
Hospital Revenue Code	305
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$69.84
Rate for Payer: Amerigroup CHIP/Medicaid	$0.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.37
Rate for Payer: Amerigroup Medicare	$2.37
Rate for Payer: BCBS of TX Blue Advantage	$29.10
Rate for Payer: BCBS of TX Blue Essentials	$34.92
Rate for Payer: BCBS of TX Medicare	$2.37
Rate for Payer: BCBS of TX PPO	$38.80
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cigna Medicaid	$69.84
Rate for Payer: Cigna Medicare	$2.37
Rate for Payer: Employer Direct Commercial	$2.37
Rate for Payer: Humana Medicare/TRICARE	$2.37
Rate for Payer: Molina CHIP/Medicaid	$69.84
Rate for Payer: Molina Dual Medicare/Medicaid	$2.37
Rate for Payer: Molina Medicare	$2.37
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$69.84
Rate for Payer: Scott and White EPO/PPO	$2.96
Rate for Payer: Scott and White Medicare	$2.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.84
Rate for Payer: Superior Health Plan EPO	$2.37
Rate for Payer: Superior Health Plan Medicare	$2.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.37
Rate for Payer: Universal American Medicare	$2.37
Rate for Payer: Wellcare Medicare	$2.37
Rate for Payer: Wellmed Medicare	$2.37

85014 HEMATOCRIT

Facility

$97.00

Service Code	HCPCS 85014
Hospital Charge Code	1600493
Hospital Revenue Code	305
Rate for Payer: Cash Price	$65.96

Know your out-of-pocket cost for care.

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