White Rock Medical Center

All Charges

Charge

Type

Setting

Price

85025 CBC W/AUTOMATED DIFFERENTIAL

Facility

$387.00

Service Code	HCPCS 85025
Hospital Charge Code	1600386
Hospital Revenue Code	305
Rate for Payer: Cash Price	$263.16

85025 CBC W/AUTOMATED DIFFERENTIAL

Facility

$387.00

Service Code	HCPCS 85025
Hospital Charge Code	1600386
Hospital Revenue Code	305
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$278.64
Rate for Payer: Amerigroup CHIP/Medicaid	$3.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.77
Rate for Payer: Amerigroup Medicare	$7.77
Rate for Payer: BCBS of TX Blue Advantage	$116.10
Rate for Payer: BCBS of TX Blue Essentials	$139.32
Rate for Payer: BCBS of TX Medicare	$7.77
Rate for Payer: BCBS of TX PPO	$154.80
Rate for Payer: Cash Price	$263.16
Rate for Payer: Cash Price	$263.16
Rate for Payer: Cigna Medicaid	$278.64
Rate for Payer: Cigna Medicare	$7.77
Rate for Payer: Employer Direct Commercial	$7.77
Rate for Payer: Humana Medicare/TRICARE	$7.77
Rate for Payer: Molina CHIP/Medicaid	$278.64
Rate for Payer: Molina Dual Medicare/Medicaid	$7.77
Rate for Payer: Molina Medicare	$7.77
Rate for Payer: Multiplan Auto	$251.55
Rate for Payer: Multiplan Commercial	$251.55
Rate for Payer: Multiplan Workers Comp	$251.55
Rate for Payer: Parkland Medicaid	$278.64
Rate for Payer: Scott and White EPO/PPO	$9.71
Rate for Payer: Scott and White Medicare	$7.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$278.64
Rate for Payer: Superior Health Plan EPO	$7.77
Rate for Payer: Superior Health Plan Medicare	$7.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.77
Rate for Payer: Universal American Medicare	$7.77
Rate for Payer: Wellcare Medicare	$7.77
Rate for Payer: Wellmed Medicare	$7.77

85041 BLOOD COUNT RED BLOOD CELL

Facility

$24.93

Service Code	HCPCS 85041
Hospital Charge Code	1605799
Hospital Revenue Code	305
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$17.95
Rate for Payer: Amerigroup CHIP/Medicaid	$1.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.02
Rate for Payer: Amerigroup Medicare	$3.02
Rate for Payer: BCBS of TX Blue Advantage	$7.48
Rate for Payer: BCBS of TX Blue Essentials	$8.97
Rate for Payer: BCBS of TX Medicare	$3.02
Rate for Payer: BCBS of TX PPO	$9.97
Rate for Payer: Cash Price	$16.95
Rate for Payer: Cash Price	$16.95
Rate for Payer: Cigna Medicaid	$17.95
Rate for Payer: Cigna Medicare	$3.02
Rate for Payer: Employer Direct Commercial	$3.02
Rate for Payer: Humana Medicare/TRICARE	$3.02
Rate for Payer: Molina CHIP/Medicaid	$17.95
Rate for Payer: Molina Dual Medicare/Medicaid	$3.02
Rate for Payer: Molina Medicare	$3.02
Rate for Payer: Multiplan Auto	$16.20
Rate for Payer: Multiplan Commercial	$16.20
Rate for Payer: Multiplan Workers Comp	$16.20
Rate for Payer: Parkland Medicaid	$17.95
Rate for Payer: Scott and White EPO/PPO	$3.77
Rate for Payer: Scott and White Medicare	$3.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.95
Rate for Payer: Superior Health Plan EPO	$3.02
Rate for Payer: Superior Health Plan Medicare	$3.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.02
Rate for Payer: Universal American Medicare	$3.02
Rate for Payer: Wellcare Medicare	$3.02
Rate for Payer: Wellmed Medicare	$3.02

85041 BLOOD COUNT RED BLOOD CELL

Facility

$24.93

Service Code	HCPCS 85041
Hospital Charge Code	1605799
Hospital Revenue Code	305
Rate for Payer: Cash Price	$16.95

85097 AP Bill Bone Marrow Smear Interp

Facility

$314.00

Service Code	HCPCS 85097
Hospital Charge Code	4305097
Hospital Revenue Code	305
Rate for Payer: Cash Price	$213.52

85097 AP Bill Bone Marrow Smear Interp

Facility

$314.00

Service Code	HCPCS 85097
Hospital Charge Code	4305097
Hospital Revenue Code	305
Min. Negotiated Rate	$19.99
Max. Negotiated Rate	$1,710.82
Rate for Payer: Amerigroup CHIP/Medicaid	$19.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$809.35
Rate for Payer: Amerigroup Medicare	$809.35
Rate for Payer: BCBS of TX Blue Advantage	$94.20
Rate for Payer: BCBS of TX Blue Essentials	$113.04
Rate for Payer: BCBS of TX Medicare	$809.35
Rate for Payer: BCBS of TX PPO	$125.60
Rate for Payer: Cash Price	$213.52
Rate for Payer: Cash Price	$213.52
Rate for Payer: Cash Price	$213.52
Rate for Payer: Cigna Commercial	$1,710.82
Rate for Payer: Cigna Medicaid	$226.08
Rate for Payer: Cigna Medicare	$809.35
Rate for Payer: Employer Direct Commercial	$809.35
Rate for Payer: Humana Medicare/TRICARE	$809.35
Rate for Payer: Molina CHIP/Medicaid	$226.08
Rate for Payer: Molina Dual Medicare/Medicaid	$809.35
Rate for Payer: Molina Medicare	$809.35
Rate for Payer: Multiplan Auto	$204.10
Rate for Payer: Multiplan Commercial	$204.10
Rate for Payer: Multiplan Workers Comp	$204.10
Rate for Payer: Parkland Medicaid	$226.08
Rate for Payer: Scott and White EPO/PPO	$58.00
Rate for Payer: Scott and White Medicare	$809.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$226.08
Rate for Payer: Superior Health Plan EPO	$809.35
Rate for Payer: Superior Health Plan Medicare	$809.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$809.35
Rate for Payer: Universal American Medicare	$809.35
Rate for Payer: Wellcare Medicare	$809.35
Rate for Payer: Wellmed Medicare	$809.35

85613 RUSSELL VIPER VENOM TIME DILUTED

Facility

$150.00

Service Code	HCPCS 85613
Hospital Charge Code	1708353
Hospital Revenue Code	305
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$108.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.58
Rate for Payer: Amerigroup Medicare	$9.58
Rate for Payer: BCBS of TX Blue Advantage	$45.00
Rate for Payer: BCBS of TX Blue Essentials	$54.00
Rate for Payer: BCBS of TX Medicare	$9.58
Rate for Payer: BCBS of TX PPO	$60.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cigna Medicaid	$108.00
Rate for Payer: Cigna Medicare	$9.58
Rate for Payer: Employer Direct Commercial	$9.58
Rate for Payer: Humana Medicare/TRICARE	$9.58
Rate for Payer: Molina CHIP/Medicaid	$108.00
Rate for Payer: Molina Dual Medicare/Medicaid	$9.58
Rate for Payer: Molina Medicare	$9.58
Rate for Payer: Multiplan Auto	$97.50
Rate for Payer: Multiplan Commercial	$97.50
Rate for Payer: Multiplan Workers Comp	$97.50
Rate for Payer: Parkland Medicaid	$108.00
Rate for Payer: Scott and White EPO/PPO	$11.97
Rate for Payer: Scott and White Medicare	$9.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.00
Rate for Payer: Superior Health Plan EPO	$9.58
Rate for Payer: Superior Health Plan Medicare	$9.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.58
Rate for Payer: Universal American Medicare	$9.58
Rate for Payer: Wellcare Medicare	$9.58
Rate for Payer: Wellmed Medicare	$9.58

85613 RUSSELL VIPER VENOM TIME DILUTED

Facility

$150.00

Service Code	HCPCS 85613
Hospital Charge Code	1708353
Hospital Revenue Code	305
Rate for Payer: Cash Price	$102.00

85660 SICKLING OF RBC REDUCTION

Facility

$120.00

Service Code	HCPCS 85660
Hospital Charge Code	1600568
Hospital Revenue Code	305
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$86.40
Rate for Payer: Amerigroup CHIP/Medicaid	$2.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.51
Rate for Payer: Amerigroup Medicare	$5.51
Rate for Payer: BCBS of TX Blue Advantage	$36.00
Rate for Payer: BCBS of TX Blue Essentials	$43.20
Rate for Payer: BCBS of TX Medicare	$5.51
Rate for Payer: BCBS of TX PPO	$48.00
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna Medicaid	$86.40
Rate for Payer: Cigna Medicare	$5.51
Rate for Payer: Employer Direct Commercial	$5.51
Rate for Payer: Humana Medicare/TRICARE	$5.51
Rate for Payer: Molina CHIP/Medicaid	$86.40
Rate for Payer: Molina Dual Medicare/Medicaid	$5.51
Rate for Payer: Molina Medicare	$5.51
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Parkland Medicaid	$86.40
Rate for Payer: Scott and White EPO/PPO	$6.89
Rate for Payer: Scott and White Medicare	$5.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.40
Rate for Payer: Superior Health Plan EPO	$5.51
Rate for Payer: Superior Health Plan Medicare	$5.51
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.51
Rate for Payer: Universal American Medicare	$5.51
Rate for Payer: Wellcare Medicare	$5.51
Rate for Payer: Wellmed Medicare	$5.51

85660 SICKLING OF RBC REDUCTION

Facility

$120.00

Service Code	HCPCS 85660
Hospital Charge Code	1600568
Hospital Revenue Code	305
Rate for Payer: Cash Price	$81.60

85670 THROMBIN TIME PLASMA

Facility

$84.00

Service Code	HCPCS 85670
Hospital Charge Code	1600659
Hospital Revenue Code	305
Rate for Payer: Cash Price	$57.12

85670 THROMBIN TIME PLASMA

Facility

$84.00

Service Code	HCPCS 85670
Hospital Charge Code	1600659
Hospital Revenue Code	305
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$60.48
Rate for Payer: Amerigroup CHIP/Medicaid	$2.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.77
Rate for Payer: Amerigroup Medicare	$5.77
Rate for Payer: BCBS of TX Blue Advantage	$25.20
Rate for Payer: BCBS of TX Blue Essentials	$30.24
Rate for Payer: BCBS of TX Medicare	$5.77
Rate for Payer: BCBS of TX PPO	$33.60
Rate for Payer: Cash Price	$57.12
Rate for Payer: Cash Price	$57.12
Rate for Payer: Cigna Medicaid	$60.48
Rate for Payer: Cigna Medicare	$5.77
Rate for Payer: Employer Direct Commercial	$5.77
Rate for Payer: Humana Medicare/TRICARE	$5.77
Rate for Payer: Molina CHIP/Medicaid	$60.48
Rate for Payer: Molina Dual Medicare/Medicaid	$5.77
Rate for Payer: Molina Medicare	$5.77
Rate for Payer: Multiplan Auto	$54.60
Rate for Payer: Multiplan Commercial	$54.60
Rate for Payer: Multiplan Workers Comp	$54.60
Rate for Payer: Parkland Medicaid	$60.48
Rate for Payer: Scott and White EPO/PPO	$7.21
Rate for Payer: Scott and White Medicare	$5.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60.48
Rate for Payer: Superior Health Plan EPO	$5.77
Rate for Payer: Superior Health Plan Medicare	$5.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.77
Rate for Payer: Universal American Medicare	$5.77
Rate for Payer: Wellcare Medicare	$5.77
Rate for Payer: Wellmed Medicare	$5.77

85732 THROMBOPLASTIN TIME SUBSTITUTION

Facility

$95.00

Service Code	HCPCS 85732
Hospital Charge Code	1600337
Hospital Revenue Code	305
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$68.40
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.47
Rate for Payer: Amerigroup Medicare	$6.47
Rate for Payer: BCBS of TX Blue Advantage	$28.50
Rate for Payer: BCBS of TX Blue Essentials	$34.20
Rate for Payer: BCBS of TX Medicare	$6.47
Rate for Payer: BCBS of TX PPO	$38.00
Rate for Payer: Cash Price	$64.60
Rate for Payer: Cash Price	$64.60
Rate for Payer: Cigna Medicaid	$68.40
Rate for Payer: Cigna Medicare	$6.47
Rate for Payer: Employer Direct Commercial	$6.47
Rate for Payer: Humana Medicare/TRICARE	$6.47
Rate for Payer: Molina CHIP/Medicaid	$68.40
Rate for Payer: Molina Dual Medicare/Medicaid	$6.47
Rate for Payer: Molina Medicare	$6.47
Rate for Payer: Multiplan Auto	$61.75
Rate for Payer: Multiplan Commercial	$61.75
Rate for Payer: Multiplan Workers Comp	$61.75
Rate for Payer: Parkland Medicaid	$68.40
Rate for Payer: Scott and White EPO/PPO	$8.09
Rate for Payer: Scott and White Medicare	$6.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$68.40
Rate for Payer: Superior Health Plan EPO	$6.47
Rate for Payer: Superior Health Plan Medicare	$6.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.47
Rate for Payer: Universal American Medicare	$6.47
Rate for Payer: Wellcare Medicare	$6.47
Rate for Payer: Wellmed Medicare	$6.47

85732 THROMBOPLASTIN TIME SUBSTITUTION

Facility

$95.00

Service Code	HCPCS 85732
Hospital Charge Code	1600337
Hospital Revenue Code	305
Rate for Payer: Cash Price	$64.60

86038 ANTINUCLEAR ANTIBODIES (ANA)

Facility

$338.00

Service Code	HCPCS 86038
Hospital Charge Code	1605393
Hospital Revenue Code	302
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$243.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.09
Rate for Payer: Amerigroup Medicare	$12.09
Rate for Payer: BCBS of TX Blue Advantage	$101.40
Rate for Payer: BCBS of TX Blue Essentials	$121.68
Rate for Payer: BCBS of TX Medicare	$12.09
Rate for Payer: BCBS of TX PPO	$135.20
Rate for Payer: Cash Price	$229.84
Rate for Payer: Cash Price	$229.84
Rate for Payer: Cigna Medicaid	$243.36
Rate for Payer: Cigna Medicare	$12.09
Rate for Payer: Employer Direct Commercial	$12.09
Rate for Payer: Humana Medicare/TRICARE	$12.09
Rate for Payer: Molina CHIP/Medicaid	$243.36
Rate for Payer: Molina Dual Medicare/Medicaid	$12.09
Rate for Payer: Molina Medicare	$12.09
Rate for Payer: Multiplan Auto	$219.70
Rate for Payer: Multiplan Commercial	$219.70
Rate for Payer: Multiplan Workers Comp	$219.70
Rate for Payer: Parkland Medicaid	$243.36
Rate for Payer: Scott and White EPO/PPO	$15.11
Rate for Payer: Scott and White Medicare	$12.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$243.36
Rate for Payer: Superior Health Plan EPO	$12.09
Rate for Payer: Superior Health Plan Medicare	$12.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.09
Rate for Payer: Universal American Medicare	$12.09
Rate for Payer: Wellcare Medicare	$12.09
Rate for Payer: Wellmed Medicare	$12.09

86038 ANTINUCLEAR ANTIBODIES (ANA)

Facility

$338.00

Service Code	HCPCS 86038
Hospital Charge Code	1605393
Hospital Revenue Code	302
Rate for Payer: Cash Price	$229.84

86147 CARDIOLIPIN (PHOSPHOLIPID) AB EA LG

Facility

$110.00

Service Code	HCPCS 86147
Hospital Charge Code	1702406
Hospital Revenue Code	302
Min. Negotiated Rate	$9.93
Max. Negotiated Rate	$79.20
Rate for Payer: Amerigroup CHIP/Medicaid	$9.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25.45
Rate for Payer: Amerigroup Medicare	$25.45
Rate for Payer: BCBS of TX Blue Advantage	$33.00
Rate for Payer: BCBS of TX Blue Essentials	$39.60
Rate for Payer: BCBS of TX Medicare	$25.45
Rate for Payer: BCBS of TX PPO	$44.00
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cigna Medicaid	$79.20
Rate for Payer: Cigna Medicare	$25.45
Rate for Payer: Employer Direct Commercial	$25.45
Rate for Payer: Humana Medicare/TRICARE	$25.45
Rate for Payer: Molina CHIP/Medicaid	$79.20
Rate for Payer: Molina Dual Medicare/Medicaid	$25.45
Rate for Payer: Molina Medicare	$25.45
Rate for Payer: Multiplan Auto	$71.50
Rate for Payer: Multiplan Commercial	$71.50
Rate for Payer: Multiplan Workers Comp	$71.50
Rate for Payer: Parkland Medicaid	$79.20
Rate for Payer: Scott and White EPO/PPO	$31.81
Rate for Payer: Scott and White Medicare	$25.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$25.45
Rate for Payer: Superior Health Plan Medicare	$25.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$25.45
Rate for Payer: Universal American Medicare	$25.45
Rate for Payer: Wellcare Medicare	$25.45
Rate for Payer: Wellmed Medicare	$25.45

86147 CARDIOLIPIN (PHOSPHOLIPID) AB EA LG

Facility

$110.00

Service Code	HCPCS 86147
Hospital Charge Code	1702406
Hospital Revenue Code	302
Rate for Payer: Cash Price	$74.80

86235 EXTRACTABLE NUCL ANTIGN, AB TO, AM

Facility

$230.00

Service Code	HCPCS 86235
Hospital Charge Code	1701143
Hospital Revenue Code	302
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$165.60
Rate for Payer: Amerigroup CHIP/Medicaid	$6.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.93
Rate for Payer: Amerigroup Medicare	$17.93
Rate for Payer: BCBS of TX Blue Advantage	$69.00
Rate for Payer: BCBS of TX Blue Essentials	$82.80
Rate for Payer: BCBS of TX Medicare	$17.93
Rate for Payer: BCBS of TX PPO	$92.00
Rate for Payer: Cash Price	$156.40
Rate for Payer: Cash Price	$156.40
Rate for Payer: Cigna Medicaid	$165.60
Rate for Payer: Cigna Medicare	$17.93
Rate for Payer: Employer Direct Commercial	$17.93
Rate for Payer: Humana Medicare/TRICARE	$17.93
Rate for Payer: Molina CHIP/Medicaid	$165.60
Rate for Payer: Molina Dual Medicare/Medicaid	$17.93
Rate for Payer: Molina Medicare	$17.93
Rate for Payer: Multiplan Auto	$149.50
Rate for Payer: Multiplan Commercial	$149.50
Rate for Payer: Multiplan Workers Comp	$149.50
Rate for Payer: Parkland Medicaid	$165.60
Rate for Payer: Scott and White EPO/PPO	$22.41
Rate for Payer: Scott and White Medicare	$17.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$165.60
Rate for Payer: Superior Health Plan EPO	$17.93
Rate for Payer: Superior Health Plan Medicare	$17.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.93
Rate for Payer: Universal American Medicare	$17.93
Rate for Payer: Wellcare Medicare	$17.93
Rate for Payer: Wellmed Medicare	$17.93

86235 EXTRACTABLE NUCL ANTIGN, AB TO, AM

Facility

$230.00

Service Code	HCPCS 86235
Hospital Charge Code	1701143
Hospital Revenue Code	302
Rate for Payer: Cash Price	$156.40

86256 FLURESCENT NONINFECT ANTI,TITER

Facility

$207.00

Service Code	HCPCS 86256
Hospital Charge Code	1700285
Hospital Revenue Code	302
Min. Negotiated Rate	$4.70
Max. Negotiated Rate	$149.04
Rate for Payer: Amerigroup CHIP/Medicaid	$4.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.05
Rate for Payer: Amerigroup Medicare	$12.05
Rate for Payer: BCBS of TX Blue Advantage	$62.10
Rate for Payer: BCBS of TX Blue Essentials	$74.52
Rate for Payer: BCBS of TX Medicare	$12.05
Rate for Payer: BCBS of TX PPO	$82.80
Rate for Payer: Cash Price	$140.76
Rate for Payer: Cash Price	$140.76
Rate for Payer: Cigna Medicaid	$149.04
Rate for Payer: Cigna Medicare	$12.05
Rate for Payer: Employer Direct Commercial	$12.05
Rate for Payer: Humana Medicare/TRICARE	$12.05
Rate for Payer: Molina CHIP/Medicaid	$149.04
Rate for Payer: Molina Dual Medicare/Medicaid	$12.05
Rate for Payer: Molina Medicare	$12.05
Rate for Payer: Multiplan Auto	$134.55
Rate for Payer: Multiplan Commercial	$134.55
Rate for Payer: Multiplan Workers Comp	$134.55
Rate for Payer: Parkland Medicaid	$149.04
Rate for Payer: Scott and White EPO/PPO	$15.06
Rate for Payer: Scott and White Medicare	$12.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$149.04
Rate for Payer: Superior Health Plan EPO	$12.05
Rate for Payer: Superior Health Plan Medicare	$12.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.05
Rate for Payer: Universal American Medicare	$12.05
Rate for Payer: Wellcare Medicare	$12.05
Rate for Payer: Wellmed Medicare	$12.05

86256 FLURESCENT NONINFECT ANTI,TITER

Facility

$207.00

Service Code	HCPCS 86256
Hospital Charge Code	1700285
Hospital Revenue Code	302
Rate for Payer: Cash Price	$140.76

86335 IMMUNOFIXATION ELECTRO OTHER FLUIDS

Facility

$457.00

Service Code	HCPCS 86335
Hospital Charge Code	1605849
Hospital Revenue Code	302
Min. Negotiated Rate	$11.45
Max. Negotiated Rate	$329.04
Rate for Payer: Amerigroup CHIP/Medicaid	$11.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29.35
Rate for Payer: Amerigroup Medicare	$29.35
Rate for Payer: BCBS of TX Blue Advantage	$137.10
Rate for Payer: BCBS of TX Blue Essentials	$164.52
Rate for Payer: BCBS of TX Medicare	$29.35
Rate for Payer: BCBS of TX PPO	$182.80
Rate for Payer: Cash Price	$310.76
Rate for Payer: Cash Price	$310.76
Rate for Payer: Cigna Medicaid	$329.04
Rate for Payer: Cigna Medicare	$29.35
Rate for Payer: Employer Direct Commercial	$29.35
Rate for Payer: Humana Medicare/TRICARE	$29.35
Rate for Payer: Molina CHIP/Medicaid	$329.04
Rate for Payer: Molina Dual Medicare/Medicaid	$29.35
Rate for Payer: Molina Medicare	$29.35
Rate for Payer: Multiplan Auto	$297.05
Rate for Payer: Multiplan Commercial	$297.05
Rate for Payer: Multiplan Workers Comp	$297.05
Rate for Payer: Parkland Medicaid	$329.04
Rate for Payer: Scott and White EPO/PPO	$36.69
Rate for Payer: Scott and White Medicare	$29.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$329.04
Rate for Payer: Superior Health Plan EPO	$29.35
Rate for Payer: Superior Health Plan Medicare	$29.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$29.35
Rate for Payer: Universal American Medicare	$29.35
Rate for Payer: Wellcare Medicare	$29.35
Rate for Payer: Wellmed Medicare	$29.35

86335 IMMUNOFIXATION ELECTRO OTHER FLUIDS

Facility

$457.00

Service Code	HCPCS 86335
Hospital Charge Code	1605849
Hospital Revenue Code	302
Rate for Payer: Cash Price	$310.76

86359 T-CELL TOTAL COUNT

Facility

$191.79

Service Code	HCPCS 86359
Hospital Charge Code	1702950
Hospital Revenue Code	302
Rate for Payer: Cash Price	$130.42

Know your out-of-pocket cost for care.

All Charges