White Rock Medical Center

All Charges

Charge

Type

Setting

Price

86359 T-CELL TOTAL COUNT

Facility

$191.79

Service Code	HCPCS 86359
Hospital Charge Code	1702950
Hospital Revenue Code	302
Min. Negotiated Rate	$14.71
Max. Negotiated Rate	$138.09
Rate for Payer: Amerigroup CHIP/Medicaid	$14.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37.73
Rate for Payer: Amerigroup Medicare	$37.73
Rate for Payer: BCBS of TX Blue Advantage	$57.54
Rate for Payer: BCBS of TX Blue Essentials	$69.04
Rate for Payer: BCBS of TX Medicare	$37.73
Rate for Payer: BCBS of TX PPO	$76.72
Rate for Payer: Cash Price	$130.42
Rate for Payer: Cash Price	$130.42
Rate for Payer: Cigna Medicaid	$138.09
Rate for Payer: Cigna Medicare	$37.73
Rate for Payer: Employer Direct Commercial	$37.73
Rate for Payer: Humana Medicare/TRICARE	$37.73
Rate for Payer: Molina CHIP/Medicaid	$138.09
Rate for Payer: Molina Dual Medicare/Medicaid	$37.73
Rate for Payer: Molina Medicare	$37.73
Rate for Payer: Multiplan Auto	$124.66
Rate for Payer: Multiplan Commercial	$124.66
Rate for Payer: Multiplan Workers Comp	$124.66
Rate for Payer: Parkland Medicaid	$138.09
Rate for Payer: Scott and White EPO/PPO	$47.16
Rate for Payer: Scott and White Medicare	$37.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$138.09
Rate for Payer: Superior Health Plan EPO	$37.73
Rate for Payer: Superior Health Plan Medicare	$37.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$37.73
Rate for Payer: Universal American Medicare	$37.73
Rate for Payer: Wellcare Medicare	$37.73
Rate for Payer: Wellmed Medicare	$37.73

86592 SYPHILIS TEST QUALITATIVE

Facility

$164.00

Service Code	HCPCS 86592
Hospital Charge Code	1605450
Hospital Revenue Code	302
Rate for Payer: Cash Price	$111.52

86592 SYPHILIS TEST QUALITATIVE

Facility

$164.00

Service Code	HCPCS 86592
Hospital Charge Code	1605450
Hospital Revenue Code	302
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$118.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.27
Rate for Payer: Amerigroup Medicare	$4.27
Rate for Payer: BCBS of TX Blue Advantage	$49.20
Rate for Payer: BCBS of TX Blue Essentials	$59.04
Rate for Payer: BCBS of TX Medicare	$4.27
Rate for Payer: BCBS of TX PPO	$65.60
Rate for Payer: Cash Price	$111.52
Rate for Payer: Cash Price	$111.52
Rate for Payer: Cigna Medicaid	$118.08
Rate for Payer: Cigna Medicare	$4.27
Rate for Payer: Employer Direct Commercial	$4.27
Rate for Payer: Humana Medicare/TRICARE	$4.27
Rate for Payer: Molina CHIP/Medicaid	$118.08
Rate for Payer: Molina Dual Medicare/Medicaid	$4.27
Rate for Payer: Molina Medicare	$4.27
Rate for Payer: Multiplan Auto	$106.60
Rate for Payer: Multiplan Commercial	$106.60
Rate for Payer: Multiplan Workers Comp	$106.60
Rate for Payer: Parkland Medicaid	$118.08
Rate for Payer: Scott and White EPO/PPO	$5.34
Rate for Payer: Scott and White Medicare	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.08
Rate for Payer: Superior Health Plan EPO	$4.27
Rate for Payer: Superior Health Plan Medicare	$4.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.27
Rate for Payer: Universal American Medicare	$4.27
Rate for Payer: Wellcare Medicare	$4.27
Rate for Payer: Wellmed Medicare	$4.27

86593 SYPHILIS TEST QUANTITATIVE

Facility

$185.00

Service Code	HCPCS 86593
Hospital Charge Code	1605468
Hospital Revenue Code	302
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$133.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.40
Rate for Payer: Amerigroup Medicare	$4.40
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	$4.40
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	$4.40
Rate for Payer: Employer Direct Commercial	$4.40
Rate for Payer: Humana Medicare/TRICARE	$4.40
Rate for Payer: Molina CHIP/Medicaid	$133.20
Rate for Payer: Molina Dual Medicare/Medicaid	$4.40
Rate for Payer: Molina Medicare	$4.40
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	$5.50
Rate for Payer: Scott and White Medicare	$4.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.20
Rate for Payer: Superior Health Plan EPO	$4.40
Rate for Payer: Superior Health Plan Medicare	$4.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.40
Rate for Payer: Universal American Medicare	$4.40
Rate for Payer: Wellcare Medicare	$4.40
Rate for Payer: Wellmed Medicare	$4.40

86593 SYPHILIS TEST QUANTITATIVE

Facility

$185.00

Service Code	HCPCS 86593
Hospital Charge Code	1605468
Hospital Revenue Code	302
Rate for Payer: Cash Price	$125.80

86602 ACTINOMYCES ANTIBODY

Facility

$74.00

Service Code	HCPCS 86602
Hospital Charge Code	1740729
Hospital Revenue Code	302
Rate for Payer: Cash Price	$50.32

86602 ACTINOMYCES ANTIBODY

Facility

$74.00

Service Code	HCPCS 86602
Hospital Charge Code	1740729
Hospital Revenue Code	302
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$53.28
Rate for Payer: Amerigroup CHIP/Medicaid	$3.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.18
Rate for Payer: Amerigroup Medicare	$10.18
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	$10.18
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	$10.18
Rate for Payer: Employer Direct Commercial	$10.18
Rate for Payer: Humana Medicare/TRICARE	$10.18
Rate for Payer: Molina CHIP/Medicaid	$53.28
Rate for Payer: Molina Dual Medicare/Medicaid	$10.18
Rate for Payer: Molina Medicare	$10.18
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	$12.72
Rate for Payer: Scott and White Medicare	$10.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53.28
Rate for Payer: Superior Health Plan EPO	$10.18
Rate for Payer: Superior Health Plan Medicare	$10.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.18
Rate for Payer: Universal American Medicare	$10.18
Rate for Payer: Wellcare Medicare	$10.18
Rate for Payer: Wellmed Medicare	$10.18

86606 ANTIBODY ASPERGILLUS

Facility

$203.00

Service Code	HCPCS 86606
Hospital Charge Code	1706894
Hospital Revenue Code	302
Rate for Payer: Cash Price	$138.04

86606 ANTIBODY ASPERGILLUS

Facility

$203.00

Service Code	HCPCS 86606
Hospital Charge Code	1706894
Hospital Revenue Code	302
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$146.16
Rate for Payer: Amerigroup CHIP/Medicaid	$5.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.05
Rate for Payer: Amerigroup Medicare	$15.05
Rate for Payer: BCBS of TX Blue Advantage	$60.90
Rate for Payer: BCBS of TX Blue Essentials	$73.08
Rate for Payer: BCBS of TX Medicare	$15.05
Rate for Payer: BCBS of TX PPO	$81.20
Rate for Payer: Cash Price	$138.04
Rate for Payer: Cash Price	$138.04
Rate for Payer: Cigna Medicaid	$146.16
Rate for Payer: Cigna Medicare	$15.05
Rate for Payer: Employer Direct Commercial	$15.05
Rate for Payer: Humana Medicare/TRICARE	$15.05
Rate for Payer: Molina CHIP/Medicaid	$146.16
Rate for Payer: Molina Dual Medicare/Medicaid	$15.05
Rate for Payer: Molina Medicare	$15.05
Rate for Payer: Multiplan Auto	$131.95
Rate for Payer: Multiplan Commercial	$131.95
Rate for Payer: Multiplan Workers Comp	$131.95
Rate for Payer: Parkland Medicaid	$146.16
Rate for Payer: Scott and White EPO/PPO	$18.81
Rate for Payer: Scott and White Medicare	$15.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$146.16
Rate for Payer: Superior Health Plan EPO	$15.05
Rate for Payer: Superior Health Plan Medicare	$15.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.05
Rate for Payer: Universal American Medicare	$15.05
Rate for Payer: Wellcare Medicare	$15.05
Rate for Payer: Wellmed Medicare	$15.05

86617 LYME ANTIBODIES WESTERN BLOT

Facility

$183.26

Service Code	HCPCS 86617
Hospital Charge Code	1708866
Hospital Revenue Code	300
Rate for Payer: Cash Price	$124.62

86617 LYME ANTIBODIES WESTERN BLOT

Facility

$183.26

Service Code	HCPCS 86617
Hospital Charge Code	1708866
Hospital Revenue Code	300
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$131.95
Rate for Payer: Amerigroup CHIP/Medicaid	$6.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.49
Rate for Payer: Amerigroup Medicare	$15.49
Rate for Payer: BCBS of TX Blue Advantage	$54.98
Rate for Payer: BCBS of TX Blue Essentials	$65.97
Rate for Payer: BCBS of TX Medicare	$15.49
Rate for Payer: BCBS of TX PPO	$73.30
Rate for Payer: Cash Price	$124.62
Rate for Payer: Cash Price	$124.62
Rate for Payer: Cigna Medicaid	$131.95
Rate for Payer: Cigna Medicare	$15.49
Rate for Payer: Employer Direct Commercial	$15.49
Rate for Payer: Humana Medicare/TRICARE	$15.49
Rate for Payer: Molina CHIP/Medicaid	$131.95
Rate for Payer: Molina Dual Medicare/Medicaid	$15.49
Rate for Payer: Molina Medicare	$15.49
Rate for Payer: Multiplan Auto	$119.12
Rate for Payer: Multiplan Commercial	$119.12
Rate for Payer: Multiplan Workers Comp	$119.12
Rate for Payer: Parkland Medicaid	$131.95
Rate for Payer: Scott and White EPO/PPO	$19.36
Rate for Payer: Scott and White Medicare	$15.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.95
Rate for Payer: Superior Health Plan EPO	$15.49
Rate for Payer: Superior Health Plan Medicare	$15.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.49
Rate for Payer: Universal American Medicare	$15.49
Rate for Payer: Wellcare Medicare	$15.49
Rate for Payer: Wellmed Medicare	$15.49

86618 ANTIBODY BORRELIA BURGDORFERI LYME

Facility

$261.00

Service Code	HCPCS 86618
Hospital Charge Code	1704709
Hospital Revenue Code	302
Rate for Payer: Cash Price	$177.48

86618 ANTIBODY BORRELIA BURGDORFERI LYME

Facility

$261.00

Service Code	HCPCS 86618
Hospital Charge Code	1704709
Hospital Revenue Code	302
Min. Negotiated Rate	$6.64
Max. Negotiated Rate	$187.92
Rate for Payer: Amerigroup CHIP/Medicaid	$6.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.03
Rate for Payer: Amerigroup Medicare	$17.03
Rate for Payer: BCBS of TX Blue Advantage	$78.30
Rate for Payer: BCBS of TX Blue Essentials	$93.96
Rate for Payer: BCBS of TX Medicare	$17.03
Rate for Payer: BCBS of TX PPO	$104.40
Rate for Payer: Cash Price	$177.48
Rate for Payer: Cash Price	$177.48
Rate for Payer: Cigna Medicaid	$187.92
Rate for Payer: Cigna Medicare	$17.03
Rate for Payer: Employer Direct Commercial	$17.03
Rate for Payer: Humana Medicare/TRICARE	$17.03
Rate for Payer: Molina CHIP/Medicaid	$187.92
Rate for Payer: Molina Dual Medicare/Medicaid	$17.03
Rate for Payer: Molina Medicare	$17.03
Rate for Payer: Multiplan Auto	$169.65
Rate for Payer: Multiplan Commercial	$169.65
Rate for Payer: Multiplan Workers Comp	$169.65
Rate for Payer: Parkland Medicaid	$187.92
Rate for Payer: Scott and White EPO/PPO	$21.29
Rate for Payer: Scott and White Medicare	$17.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$187.92
Rate for Payer: Superior Health Plan EPO	$17.03
Rate for Payer: Superior Health Plan Medicare	$17.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.03
Rate for Payer: Universal American Medicare	$17.03
Rate for Payer: Wellcare Medicare	$17.03
Rate for Payer: Wellmed Medicare	$17.03

86645 ANTIBODY CYTOMEGALOVIRUS IGM

Facility

$414.00

Service Code	HCPCS 86645
Hospital Charge Code	1702596
Hospital Revenue Code	302
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$298.08
Rate for Payer: Amerigroup CHIP/Medicaid	$6.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.85
Rate for Payer: Amerigroup Medicare	$16.85
Rate for Payer: BCBS of TX Blue Advantage	$124.20
Rate for Payer: BCBS of TX Blue Essentials	$149.04
Rate for Payer: BCBS of TX Medicare	$16.85
Rate for Payer: BCBS of TX PPO	$165.60
Rate for Payer: Cash Price	$281.52
Rate for Payer: Cash Price	$281.52
Rate for Payer: Cigna Medicaid	$298.08
Rate for Payer: Cigna Medicare	$16.85
Rate for Payer: Employer Direct Commercial	$16.85
Rate for Payer: Humana Medicare/TRICARE	$16.85
Rate for Payer: Molina CHIP/Medicaid	$298.08
Rate for Payer: Molina Dual Medicare/Medicaid	$16.85
Rate for Payer: Molina Medicare	$16.85
Rate for Payer: Multiplan Auto	$269.10
Rate for Payer: Multiplan Commercial	$269.10
Rate for Payer: Multiplan Workers Comp	$269.10
Rate for Payer: Parkland Medicaid	$298.08
Rate for Payer: Scott and White EPO/PPO	$21.06
Rate for Payer: Scott and White Medicare	$16.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$298.08
Rate for Payer: Superior Health Plan EPO	$16.85
Rate for Payer: Superior Health Plan Medicare	$16.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.85
Rate for Payer: Universal American Medicare	$16.85
Rate for Payer: Wellcare Medicare	$16.85
Rate for Payer: Wellmed Medicare	$16.85

86645 ANTIBODY CYTOMEGALOVIRUS IGM

Facility

$414.00

Service Code	HCPCS 86645
Hospital Charge Code	1702596
Hospital Revenue Code	302
Rate for Payer: Cash Price	$281.52

86665 ANTIBODY EPSTEIIN BARR VIRUS VCA

Facility

$164.00

Service Code	HCPCS 86665
Hospital Charge Code	1702232
Hospital Revenue Code	302
Min. Negotiated Rate	$7.07
Max. Negotiated Rate	$118.08
Rate for Payer: Amerigroup CHIP/Medicaid	$7.07
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.14
Rate for Payer: Amerigroup Medicare	$18.14
Rate for Payer: BCBS of TX Blue Advantage	$49.20
Rate for Payer: BCBS of TX Blue Essentials	$59.04
Rate for Payer: BCBS of TX Medicare	$18.14
Rate for Payer: BCBS of TX PPO	$65.60
Rate for Payer: Cash Price	$111.52
Rate for Payer: Cash Price	$111.52
Rate for Payer: Cigna Medicaid	$118.08
Rate for Payer: Cigna Medicare	$18.14
Rate for Payer: Employer Direct Commercial	$18.14
Rate for Payer: Humana Medicare/TRICARE	$18.14
Rate for Payer: Molina CHIP/Medicaid	$118.08
Rate for Payer: Molina Dual Medicare/Medicaid	$18.14
Rate for Payer: Molina Medicare	$18.14
Rate for Payer: Multiplan Auto	$106.60
Rate for Payer: Multiplan Commercial	$106.60
Rate for Payer: Multiplan Workers Comp	$106.60
Rate for Payer: Parkland Medicaid	$118.08
Rate for Payer: Scott and White EPO/PPO	$22.68
Rate for Payer: Scott and White Medicare	$18.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.08
Rate for Payer: Superior Health Plan EPO	$18.14
Rate for Payer: Superior Health Plan Medicare	$18.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.14
Rate for Payer: Universal American Medicare	$18.14
Rate for Payer: Wellcare Medicare	$18.14
Rate for Payer: Wellmed Medicare	$18.14

86665 ANTIBODY EPSTEIIN BARR VIRUS VCA

Facility

$164.00

Service Code	HCPCS 86665
Hospital Charge Code	1702232
Hospital Revenue Code	302
Rate for Payer: Cash Price	$111.52

86677 ANTIBODY HELICOBACTER PYLORI

Facility

$216.00

Service Code	HCPCS 86677
Hospital Charge Code	1604990
Hospital Revenue Code	302
Rate for Payer: Cash Price	$146.88

86677 ANTIBODY HELICOBACTER PYLORI

Facility

$216.00

Service Code	HCPCS 86677
Hospital Charge Code	1604990
Hospital Revenue Code	302
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$155.52
Rate for Payer: Amerigroup CHIP/Medicaid	$6.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.85
Rate for Payer: Amerigroup Medicare	$16.85
Rate for Payer: BCBS of TX Blue Advantage	$64.80
Rate for Payer: BCBS of TX Blue Essentials	$77.76
Rate for Payer: BCBS of TX Medicare	$16.85
Rate for Payer: BCBS of TX PPO	$86.40
Rate for Payer: Cash Price	$146.88
Rate for Payer: Cash Price	$146.88
Rate for Payer: Cigna Medicaid	$155.52
Rate for Payer: Cigna Medicare	$16.85
Rate for Payer: Employer Direct Commercial	$16.85
Rate for Payer: Humana Medicare/TRICARE	$16.85
Rate for Payer: Molina CHIP/Medicaid	$155.52
Rate for Payer: Molina Dual Medicare/Medicaid	$16.85
Rate for Payer: Molina Medicare	$16.85
Rate for Payer: Multiplan Auto	$140.40
Rate for Payer: Multiplan Commercial	$140.40
Rate for Payer: Multiplan Workers Comp	$140.40
Rate for Payer: Parkland Medicaid	$155.52
Rate for Payer: Scott and White EPO/PPO	$21.06
Rate for Payer: Scott and White Medicare	$16.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$155.52
Rate for Payer: Superior Health Plan EPO	$16.85
Rate for Payer: Superior Health Plan Medicare	$16.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.85
Rate for Payer: Universal American Medicare	$16.85
Rate for Payer: Wellcare Medicare	$16.85
Rate for Payer: Wellmed Medicare	$16.85

86687 ANTIBODY; HTLV-I

Facility

$117.00

Service Code	HCPCS 86687
Hospital Charge Code	1700037
Hospital Revenue Code	300
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$84.24
Rate for Payer: Amerigroup CHIP/Medicaid	$3.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.09
Rate for Payer: Amerigroup Medicare	$9.09
Rate for Payer: BCBS of TX Blue Advantage	$35.10
Rate for Payer: BCBS of TX Blue Essentials	$42.12
Rate for Payer: BCBS of TX Medicare	$9.09
Rate for Payer: BCBS of TX PPO	$46.80
Rate for Payer: Cash Price	$79.56
Rate for Payer: Cash Price	$79.56
Rate for Payer: Cigna Medicaid	$84.24
Rate for Payer: Cigna Medicare	$9.09
Rate for Payer: Employer Direct Commercial	$9.09
Rate for Payer: Humana Medicare/TRICARE	$9.09
Rate for Payer: Molina CHIP/Medicaid	$84.24
Rate for Payer: Molina Dual Medicare/Medicaid	$9.09
Rate for Payer: Molina Medicare	$9.09
Rate for Payer: Multiplan Auto	$76.05
Rate for Payer: Multiplan Commercial	$76.05
Rate for Payer: Multiplan Workers Comp	$76.05
Rate for Payer: Parkland Medicaid	$84.24
Rate for Payer: Scott and White EPO/PPO	$11.36
Rate for Payer: Scott and White Medicare	$9.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.24
Rate for Payer: Superior Health Plan EPO	$9.09
Rate for Payer: Superior Health Plan Medicare	$9.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.09
Rate for Payer: Universal American Medicare	$9.09
Rate for Payer: Wellcare Medicare	$9.09
Rate for Payer: Wellmed Medicare	$9.09

86687 ANTIBODY; HTLV-I

Facility

$117.00

Service Code	HCPCS 86687
Hospital Charge Code	1700037
Hospital Revenue Code	300
Rate for Payer: Cash Price	$79.56

86695 ANTIBODY HERPES SIMPLEX TYPE 1

Facility

$98.00

Service Code	HCPCS 86695
Hospital Charge Code	1701226
Hospital Revenue Code	302
Min. Negotiated Rate	$5.14
Max. Negotiated Rate	$70.56
Rate for Payer: Amerigroup CHIP/Medicaid	$5.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.19
Rate for Payer: Amerigroup Medicare	$13.19
Rate for Payer: BCBS of TX Blue Advantage	$29.40
Rate for Payer: BCBS of TX Blue Essentials	$35.28
Rate for Payer: BCBS of TX Medicare	$13.19
Rate for Payer: BCBS of TX PPO	$39.20
Rate for Payer: Cash Price	$66.64
Rate for Payer: Cash Price	$66.64
Rate for Payer: Cigna Medicaid	$70.56
Rate for Payer: Cigna Medicare	$13.19
Rate for Payer: Employer Direct Commercial	$13.19
Rate for Payer: Humana Medicare/TRICARE	$13.19
Rate for Payer: Molina CHIP/Medicaid	$70.56
Rate for Payer: Molina Dual Medicare/Medicaid	$13.19
Rate for Payer: Molina Medicare	$13.19
Rate for Payer: Multiplan Auto	$63.70
Rate for Payer: Multiplan Commercial	$63.70
Rate for Payer: Multiplan Workers Comp	$63.70
Rate for Payer: Parkland Medicaid	$70.56
Rate for Payer: Scott and White EPO/PPO	$16.49
Rate for Payer: Scott and White Medicare	$13.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$70.56
Rate for Payer: Superior Health Plan EPO	$13.19
Rate for Payer: Superior Health Plan Medicare	$13.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.19
Rate for Payer: Universal American Medicare	$13.19
Rate for Payer: Wellcare Medicare	$13.19
Rate for Payer: Wellmed Medicare	$13.19

86695 ANTIBODY HERPES SIMPLEX TYPE 1

Facility

$98.00

Service Code	HCPCS 86695
Hospital Charge Code	1701226
Hospital Revenue Code	302
Rate for Payer: Cash Price	$66.64

86698 ANTIBODY HISTOPLASMA

Facility

$94.00

Service Code	HCPCS 86698
Hospital Charge Code	1704030
Hospital Revenue Code	302
Rate for Payer: Cash Price	$63.92

86698 ANTIBODY HISTOPLASMA

Facility

$94.00

Service Code	HCPCS 86698
Hospital Charge Code	1704030
Hospital Revenue Code	302
Min. Negotiated Rate	$5.38
Max. Negotiated Rate	$67.68
Rate for Payer: Amerigroup CHIP/Medicaid	$5.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.79
Rate for Payer: Amerigroup Medicare	$13.79
Rate for Payer: BCBS of TX Blue Advantage	$28.20
Rate for Payer: BCBS of TX Blue Essentials	$33.84
Rate for Payer: BCBS of TX Medicare	$13.79
Rate for Payer: BCBS of TX PPO	$37.60
Rate for Payer: Cash Price	$63.92
Rate for Payer: Cash Price	$63.92
Rate for Payer: Cigna Medicaid	$67.68
Rate for Payer: Cigna Medicare	$13.79
Rate for Payer: Employer Direct Commercial	$13.79
Rate for Payer: Humana Medicare/TRICARE	$13.79
Rate for Payer: Molina CHIP/Medicaid	$67.68
Rate for Payer: Molina Dual Medicare/Medicaid	$13.79
Rate for Payer: Molina Medicare	$13.79
Rate for Payer: Multiplan Auto	$61.10
Rate for Payer: Multiplan Commercial	$61.10
Rate for Payer: Multiplan Workers Comp	$61.10
Rate for Payer: Parkland Medicaid	$67.68
Rate for Payer: Scott and White EPO/PPO	$17.24
Rate for Payer: Scott and White Medicare	$13.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.68
Rate for Payer: Superior Health Plan EPO	$13.79
Rate for Payer: Superior Health Plan Medicare	$13.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.79
Rate for Payer: Universal American Medicare	$13.79
Rate for Payer: Wellcare Medicare	$13.79
Rate for Payer: Wellmed Medicare	$13.79

Know your out-of-pocket cost for care.

All Charges