White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Factor II Activity SO

Facility

$173.00

Service Code	HCPCS 85210
Hospital Charge Code	1709187
Hospital Revenue Code	305
Rate for Payer: Cash Price	$117.64

Factor II Activity SO

Facility

$173.00

Service Code	HCPCS 85210
Hospital Charge Code	1709187
Hospital Revenue Code	305
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$124.56
Rate for Payer: Amerigroup CHIP/Medicaid	$5.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.98
Rate for Payer: Amerigroup Medicare	$12.98
Rate for Payer: BCBS of TX Blue Advantage	$51.90
Rate for Payer: BCBS of TX Blue Essentials	$62.28
Rate for Payer: BCBS of TX Medicare	$12.98
Rate for Payer: BCBS of TX PPO	$69.20
Rate for Payer: Cash Price	$117.64
Rate for Payer: Cash Price	$117.64
Rate for Payer: Cigna Medicaid	$124.56
Rate for Payer: Cigna Medicare	$12.98
Rate for Payer: Employer Direct Commercial	$12.98
Rate for Payer: Humana Medicare/TRICARE	$12.98
Rate for Payer: Molina CHIP/Medicaid	$124.56
Rate for Payer: Molina Dual Medicare/Medicaid	$12.98
Rate for Payer: Molina Medicare	$12.98
Rate for Payer: Multiplan Auto	$112.45
Rate for Payer: Multiplan Commercial	$112.45
Rate for Payer: Multiplan Workers Comp	$112.45
Rate for Payer: Parkland Medicaid	$124.56
Rate for Payer: Scott and White EPO/PPO	$16.23
Rate for Payer: Scott and White Medicare	$12.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$124.56
Rate for Payer: Superior Health Plan EPO	$12.98
Rate for Payer: Superior Health Plan Medicare	$12.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.98
Rate for Payer: Universal American Medicare	$12.98
Rate for Payer: Wellcare Medicare	$12.98
Rate for Payer: Wellmed Medicare	$12.98

Factor II, DNA Analysis SO

Facility

$297.00

Service Code	HCPCS 81240
Hospital Charge Code	1740953
Hospital Revenue Code	310
Min. Negotiated Rate	$25.62
Max. Negotiated Rate	$213.84
Rate for Payer: Amerigroup CHIP/Medicaid	$25.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$65.69
Rate for Payer: Amerigroup Medicare	$65.69
Rate for Payer: BCBS of TX Blue Advantage	$89.10
Rate for Payer: BCBS of TX Blue Essentials	$106.92
Rate for Payer: BCBS of TX Medicare	$65.69
Rate for Payer: BCBS of TX PPO	$118.80
Rate for Payer: Cash Price	$201.96
Rate for Payer: Cash Price	$201.96
Rate for Payer: Cigna Medicaid	$213.84
Rate for Payer: Cigna Medicare	$65.69
Rate for Payer: Employer Direct Commercial	$65.69
Rate for Payer: Humana Medicare/TRICARE	$65.69
Rate for Payer: Molina CHIP/Medicaid	$213.84
Rate for Payer: Molina Dual Medicare/Medicaid	$65.69
Rate for Payer: Molina Medicare	$65.69
Rate for Payer: Multiplan Auto	$193.05
Rate for Payer: Multiplan Commercial	$193.05
Rate for Payer: Multiplan Workers Comp	$193.05
Rate for Payer: Parkland Medicaid	$213.84
Rate for Payer: Scott and White EPO/PPO	$82.11
Rate for Payer: Scott and White Medicare	$65.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$213.84
Rate for Payer: Superior Health Plan EPO	$65.69
Rate for Payer: Superior Health Plan Medicare	$65.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$65.69
Rate for Payer: Universal American Medicare	$65.69
Rate for Payer: Wellcare Medicare	$65.69
Rate for Payer: Wellmed Medicare	$65.69

Factor II, DNA Analysis SO

Facility

$297.00

Service Code	HCPCS 81240
Hospital Charge Code	1740953
Hospital Revenue Code	310
Rate for Payer: Cash Price	$201.96

Factor IX Activity SO

Facility

$168.00

Service Code	HCPCS 85250
Hospital Charge Code	1701051
Hospital Revenue Code	305
Rate for Payer: Cash Price	$114.24

Factor IX Activity SO

Facility

$168.00

Service Code	HCPCS 85250
Hospital Charge Code	1701051
Hospital Revenue Code	305
Min. Negotiated Rate	$7.43
Max. Negotiated Rate	$120.96
Rate for Payer: Amerigroup CHIP/Medicaid	$7.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.04
Rate for Payer: Amerigroup Medicare	$19.04
Rate for Payer: BCBS of TX Blue Advantage	$50.40
Rate for Payer: BCBS of TX Blue Essentials	$60.48
Rate for Payer: BCBS of TX Medicare	$19.04
Rate for Payer: BCBS of TX PPO	$67.20
Rate for Payer: Cash Price	$114.24
Rate for Payer: Cash Price	$114.24
Rate for Payer: Cigna Medicaid	$120.96
Rate for Payer: Cigna Medicare	$19.04
Rate for Payer: Employer Direct Commercial	$19.04
Rate for Payer: Humana Medicare/TRICARE	$19.04
Rate for Payer: Molina CHIP/Medicaid	$120.96
Rate for Payer: Molina Dual Medicare/Medicaid	$19.04
Rate for Payer: Molina Medicare	$19.04
Rate for Payer: Multiplan Auto	$109.20
Rate for Payer: Multiplan Commercial	$109.20
Rate for Payer: Multiplan Workers Comp	$109.20
Rate for Payer: Parkland Medicaid	$120.96
Rate for Payer: Scott and White EPO/PPO	$23.80
Rate for Payer: Scott and White Medicare	$19.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.96
Rate for Payer: Superior Health Plan EPO	$19.04
Rate for Payer: Superior Health Plan Medicare	$19.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.04
Rate for Payer: Universal American Medicare	$19.04
Rate for Payer: Wellcare Medicare	$19.04
Rate for Payer: Wellmed Medicare	$19.04

Factor V Activity SO

Facility

$261.00

Service Code	HCPCS 85220
Hospital Charge Code	1703396
Hospital Revenue Code	305
Rate for Payer: Cash Price	$177.48

Factor V Activity SO

Facility

$261.00

Service Code	HCPCS 85220
Hospital Charge Code	1703396
Hospital Revenue Code	305
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$187.92
Rate for Payer: Amerigroup CHIP/Medicaid	$6.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.65
Rate for Payer: Amerigroup Medicare	$17.65
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	$17.65
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	$17.65
Rate for Payer: Employer Direct Commercial	$17.65
Rate for Payer: Humana Medicare/TRICARE	$17.65
Rate for Payer: Molina CHIP/Medicaid	$187.92
Rate for Payer: Molina Dual Medicare/Medicaid	$17.65
Rate for Payer: Molina Medicare	$17.65
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	$22.06
Rate for Payer: Scott and White Medicare	$17.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$187.92
Rate for Payer: Superior Health Plan EPO	$17.65
Rate for Payer: Superior Health Plan Medicare	$17.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.65
Rate for Payer: Universal American Medicare	$17.65
Rate for Payer: Wellcare Medicare	$17.65
Rate for Payer: Wellmed Medicare	$17.65

Factor VII Activity SO

Facility

$301.00

Service Code	HCPCS 85230
Hospital Charge Code	1701036
Hospital Revenue Code	305
Rate for Payer: Cash Price	$204.68

Factor VII Activity SO

Facility

$301.00

Service Code	HCPCS 85230
Hospital Charge Code	1701036
Hospital Revenue Code	305
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$216.72
Rate for Payer: Amerigroup CHIP/Medicaid	$6.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.90
Rate for Payer: Amerigroup Medicare	$17.90
Rate for Payer: BCBS of TX Blue Advantage	$90.30
Rate for Payer: BCBS of TX Blue Essentials	$108.36
Rate for Payer: BCBS of TX Medicare	$17.90
Rate for Payer: BCBS of TX PPO	$120.40
Rate for Payer: Cash Price	$204.68
Rate for Payer: Cash Price	$204.68
Rate for Payer: Cigna Medicaid	$216.72
Rate for Payer: Cigna Medicare	$17.90
Rate for Payer: Employer Direct Commercial	$17.90
Rate for Payer: Humana Medicare/TRICARE	$17.90
Rate for Payer: Molina CHIP/Medicaid	$216.72
Rate for Payer: Molina Dual Medicare/Medicaid	$17.90
Rate for Payer: Molina Medicare	$17.90
Rate for Payer: Multiplan Auto	$195.65
Rate for Payer: Multiplan Commercial	$195.65
Rate for Payer: Multiplan Workers Comp	$195.65
Rate for Payer: Parkland Medicaid	$216.72
Rate for Payer: Scott and White EPO/PPO	$22.38
Rate for Payer: Scott and White Medicare	$17.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.72
Rate for Payer: Superior Health Plan EPO	$17.90
Rate for Payer: Superior Health Plan Medicare	$17.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.90
Rate for Payer: Universal American Medicare	$17.90
Rate for Payer: Wellcare Medicare	$17.90
Rate for Payer: Wellmed Medicare	$17.90

Factor VIII Activity SO

Facility

$118.00

Service Code	HCPCS 85240
Hospital Charge Code	1706977
Hospital Revenue Code	305
Rate for Payer: Cash Price	$80.24

Factor VIII Activity SO

Facility

$118.00

Service Code	HCPCS 85240
Hospital Charge Code	1706977
Hospital Revenue Code	305
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$84.96
Rate for Payer: Amerigroup CHIP/Medicaid	$6.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.90
Rate for Payer: Amerigroup Medicare	$17.90
Rate for Payer: BCBS of TX Blue Advantage	$35.40
Rate for Payer: BCBS of TX Blue Essentials	$42.48
Rate for Payer: BCBS of TX Medicare	$17.90
Rate for Payer: BCBS of TX PPO	$47.20
Rate for Payer: Cash Price	$80.24
Rate for Payer: Cash Price	$80.24
Rate for Payer: Cigna Medicaid	$84.96
Rate for Payer: Cigna Medicare	$17.90
Rate for Payer: Employer Direct Commercial	$17.90
Rate for Payer: Humana Medicare/TRICARE	$17.90
Rate for Payer: Molina CHIP/Medicaid	$84.96
Rate for Payer: Molina Dual Medicare/Medicaid	$17.90
Rate for Payer: Molina Medicare	$17.90
Rate for Payer: Multiplan Auto	$76.70
Rate for Payer: Multiplan Commercial	$76.70
Rate for Payer: Multiplan Workers Comp	$76.70
Rate for Payer: Parkland Medicaid	$84.96
Rate for Payer: Scott and White EPO/PPO	$22.38
Rate for Payer: Scott and White Medicare	$17.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.96
Rate for Payer: Superior Health Plan EPO	$17.90
Rate for Payer: Superior Health Plan Medicare	$17.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.90
Rate for Payer: Universal American Medicare	$17.90
Rate for Payer: Wellcare Medicare	$17.90
Rate for Payer: Wellmed Medicare	$17.90

Factor V Leiden Mutation SO

Facility

$286.00

Service Code	HCPCS 81241
Hospital Charge Code	1740951
Hospital Revenue Code	310
Rate for Payer: Cash Price	$194.48

Factor V Leiden Mutation SO

Facility

$286.00

Service Code	HCPCS 81241
Hospital Charge Code	1740951
Hospital Revenue Code	310
Min. Negotiated Rate	$28.61
Max. Negotiated Rate	$205.92
Rate for Payer: Amerigroup CHIP/Medicaid	$28.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$73.37
Rate for Payer: Amerigroup Medicare	$73.37
Rate for Payer: BCBS of TX Blue Advantage	$85.80
Rate for Payer: BCBS of TX Blue Essentials	$102.96
Rate for Payer: BCBS of TX Medicare	$73.37
Rate for Payer: BCBS of TX PPO	$114.40
Rate for Payer: Cash Price	$194.48
Rate for Payer: Cash Price	$194.48
Rate for Payer: Cigna Medicaid	$205.92
Rate for Payer: Cigna Medicare	$73.37
Rate for Payer: Employer Direct Commercial	$73.37
Rate for Payer: Humana Medicare/TRICARE	$73.37
Rate for Payer: Molina CHIP/Medicaid	$205.92
Rate for Payer: Molina Dual Medicare/Medicaid	$73.37
Rate for Payer: Molina Medicare	$73.37
Rate for Payer: Multiplan Auto	$185.90
Rate for Payer: Multiplan Commercial	$185.90
Rate for Payer: Multiplan Workers Comp	$185.90
Rate for Payer: Parkland Medicaid	$205.92
Rate for Payer: Scott and White EPO/PPO	$91.71
Rate for Payer: Scott and White Medicare	$73.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$205.92
Rate for Payer: Superior Health Plan EPO	$73.37
Rate for Payer: Superior Health Plan Medicare	$73.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$73.37
Rate for Payer: Universal American Medicare	$73.37
Rate for Payer: Wellcare Medicare	$73.37
Rate for Payer: Wellmed Medicare	$73.37

Factor X Activity SO

Facility

$161.00

Service Code	HCPCS 85260
Hospital Charge Code	1703883
Hospital Revenue Code	305
Rate for Payer: Cash Price	$109.48

Factor X Activity SO

Facility

$161.00

Service Code	HCPCS 85260
Hospital Charge Code	1703883
Hospital Revenue Code	305
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$115.92
Rate for Payer: Amerigroup CHIP/Medicaid	$6.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.90
Rate for Payer: Amerigroup Medicare	$17.90
Rate for Payer: BCBS of TX Blue Advantage	$48.30
Rate for Payer: BCBS of TX Blue Essentials	$57.96
Rate for Payer: BCBS of TX Medicare	$17.90
Rate for Payer: BCBS of TX PPO	$64.40
Rate for Payer: Cash Price	$109.48
Rate for Payer: Cash Price	$109.48
Rate for Payer: Cigna Medicaid	$115.92
Rate for Payer: Cigna Medicare	$17.90
Rate for Payer: Employer Direct Commercial	$17.90
Rate for Payer: Humana Medicare/TRICARE	$17.90
Rate for Payer: Molina CHIP/Medicaid	$115.92
Rate for Payer: Molina Dual Medicare/Medicaid	$17.90
Rate for Payer: Molina Medicare	$17.90
Rate for Payer: Multiplan Auto	$104.65
Rate for Payer: Multiplan Commercial	$104.65
Rate for Payer: Multiplan Workers Comp	$104.65
Rate for Payer: Parkland Medicaid	$115.92
Rate for Payer: Scott and White EPO/PPO	$22.38
Rate for Payer: Scott and White Medicare	$17.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.92
Rate for Payer: Superior Health Plan EPO	$17.90
Rate for Payer: Superior Health Plan Medicare	$17.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.90
Rate for Payer: Universal American Medicare	$17.90
Rate for Payer: Wellcare Medicare	$17.90
Rate for Payer: Wellmed Medicare	$17.90

Factor XI Activity SO

Facility

$284.00

Service Code	HCPCS 85270
Hospital Charge Code	1706365
Hospital Revenue Code	305
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$204.48
Rate for Payer: Amerigroup CHIP/Medicaid	$6.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.90
Rate for Payer: Amerigroup Medicare	$17.90
Rate for Payer: BCBS of TX Blue Advantage	$85.20
Rate for Payer: BCBS of TX Blue Essentials	$102.24
Rate for Payer: BCBS of TX Medicare	$17.90
Rate for Payer: BCBS of TX PPO	$113.60
Rate for Payer: Cash Price	$193.12
Rate for Payer: Cash Price	$193.12
Rate for Payer: Cigna Medicaid	$204.48
Rate for Payer: Cigna Medicare	$17.90
Rate for Payer: Employer Direct Commercial	$17.90
Rate for Payer: Humana Medicare/TRICARE	$17.90
Rate for Payer: Molina CHIP/Medicaid	$204.48
Rate for Payer: Molina Dual Medicare/Medicaid	$17.90
Rate for Payer: Molina Medicare	$17.90
Rate for Payer: Multiplan Auto	$184.60
Rate for Payer: Multiplan Commercial	$184.60
Rate for Payer: Multiplan Workers Comp	$184.60
Rate for Payer: Parkland Medicaid	$204.48
Rate for Payer: Scott and White EPO/PPO	$22.38
Rate for Payer: Scott and White Medicare	$17.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$204.48
Rate for Payer: Superior Health Plan EPO	$17.90
Rate for Payer: Superior Health Plan Medicare	$17.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.90
Rate for Payer: Universal American Medicare	$17.90
Rate for Payer: Wellcare Medicare	$17.90
Rate for Payer: Wellmed Medicare	$17.90

Factor XI Activity SO

Facility

$284.00

Service Code	HCPCS 85270
Hospital Charge Code	1706365
Hospital Revenue Code	305
Rate for Payer: Cash Price	$193.12

Factor XII Activity SO

Facility

$306.00

Service Code	HCPCS 85280
Hospital Charge Code	1706373
Hospital Revenue Code	305
Min. Negotiated Rate	$7.55
Max. Negotiated Rate	$220.32
Rate for Payer: Amerigroup CHIP/Medicaid	$7.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.35
Rate for Payer: Amerigroup Medicare	$19.35
Rate for Payer: BCBS of TX Blue Advantage	$91.80
Rate for Payer: BCBS of TX Blue Essentials	$110.16
Rate for Payer: BCBS of TX Medicare	$19.35
Rate for Payer: BCBS of TX PPO	$122.40
Rate for Payer: Cash Price	$208.08
Rate for Payer: Cash Price	$208.08
Rate for Payer: Cigna Medicaid	$220.32
Rate for Payer: Cigna Medicare	$19.35
Rate for Payer: Employer Direct Commercial	$19.35
Rate for Payer: Humana Medicare/TRICARE	$19.35
Rate for Payer: Molina CHIP/Medicaid	$220.32
Rate for Payer: Molina Dual Medicare/Medicaid	$19.35
Rate for Payer: Molina Medicare	$19.35
Rate for Payer: Multiplan Auto	$198.90
Rate for Payer: Multiplan Commercial	$198.90
Rate for Payer: Multiplan Workers Comp	$198.90
Rate for Payer: Parkland Medicaid	$220.32
Rate for Payer: Scott and White EPO/PPO	$24.19
Rate for Payer: Scott and White Medicare	$19.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$220.32
Rate for Payer: Superior Health Plan EPO	$19.35
Rate for Payer: Superior Health Plan Medicare	$19.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.35
Rate for Payer: Universal American Medicare	$19.35
Rate for Payer: Wellcare Medicare	$19.35
Rate for Payer: Wellmed Medicare	$19.35

Factor XII Activity SO

Facility

$306.00

Service Code	HCPCS 85280
Hospital Charge Code	1706373
Hospital Revenue Code	305
Rate for Payer: Cash Price	$208.08

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J1308
Hospital Charge Code	77561660
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J1308
Hospital Charge Code	77561660
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	7445530
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	7445530
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

famotidine 20 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78433747
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Know your out-of-pocket cost for care.

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