White Rock Medical Center

All Charges

Charge

Type

Setting

Price

LORazepam 2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2060
Hospital Charge Code	77671729
Hospital Revenue Code	636
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.54
Rate for Payer: BCBS of TX Blue Essentials	$0.64
Rate for Payer: BCBS of TX PPO	$0.71
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

LORazepam 2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2060
Hospital Charge Code	77671729
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

LORazepam 2 mg Tab

Facility

$9.15

Service Code	HCPCS J3490
Hospital Charge Code	77671674
Hospital Revenue Code	250
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$5.95
Rate for Payer: Amerigroup CHIP/Medicaid	$0.82
Rate for Payer: BCBS of TX Blue Advantage	$2.74
Rate for Payer: BCBS of TX Blue Essentials	$3.29
Rate for Payer: BCBS of TX PPO	$3.66
Rate for Payer: Cash Price	$6.22
Rate for Payer: Multiplan Auto	$5.95
Rate for Payer: Multiplan Commercial	$5.95
Rate for Payer: Multiplan Workers Comp	$5.95
Rate for Payer: Scott and White EPO/PPO	$4.58
Rate for Payer: Superior Health Plan EPO	$1.24

LORazepam 2 mg Tab

Facility

$9.15

Service Code	HCPCS J3490
Hospital Charge Code	77671674
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.22

LORazepam 4 mg/mL Inj

Facility

$128.17

Service Code	HCPCS J2060
Hospital Charge Code	77672008
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

LORazepam 4 mg/mL Inj

Facility

$128.17

Service Code	HCPCS J2060
Hospital Charge Code	77672008
Hospital Revenue Code	636
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.54
Rate for Payer: BCBS of TX Blue Essentials	$0.64
Rate for Payer: BCBS of TX PPO	$0.71
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

losartan 50 mg Tab

Facility

$9.85

Service Code	HCPCS J3490
Hospital Charge Code	77672285
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.70

losartan 50 mg Tab

Facility

$9.85

Service Code	HCPCS J3490
Hospital Charge Code	77672285
Hospital Revenue Code	250
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$6.40
Rate for Payer: Amerigroup CHIP/Medicaid	$0.89
Rate for Payer: BCBS of TX Blue Advantage	$2.96
Rate for Payer: BCBS of TX Blue Essentials	$3.55
Rate for Payer: BCBS of TX PPO	$3.94
Rate for Payer: Cash Price	$6.70
Rate for Payer: Multiplan Auto	$6.40
Rate for Payer: Multiplan Commercial	$6.40
Rate for Payer: Multiplan Workers Comp	$6.40
Rate for Payer: Scott and White EPO/PPO	$4.92
Rate for Payer: Superior Health Plan EPO	$1.34

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC

Facility

$45,632.30

Service Code	MSDRG 493
Min. Negotiated Rate	$18,375.62
Max. Negotiated Rate	$45,632.30
Rate for Payer: Aetna Commercial	$27,019.12
Rate for Payer: Aetna Medicare	$29,990.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,993.46
Rate for Payer: Amerigroup Medicare	$19,993.46
Rate for Payer: BCBS of TX Blue Advantage	$18,375.62
Rate for Payer: BCBS of TX Blue Essentials	$23,177.51
Rate for Payer: BCBS of TX Medicare	$19,993.46
Rate for Payer: BCBS of TX PPO	$25,753.78
Rate for Payer: Cigna Commercial	$30,933.90
Rate for Payer: Cigna Medicare	$19,993.46
Rate for Payer: Employer Direct Commercial	$19,993.46
Rate for Payer: Humana Medicare/TRICARE	$19,993.46
Rate for Payer: Molina Dual Medicare/Medicaid	$19,993.46
Rate for Payer: Molina Medicare	$19,993.46
Rate for Payer: Multiplan Auto	$45,632.30
Rate for Payer: Multiplan Commercial	$45,632.30
Rate for Payer: Multiplan Workers Comp	$45,632.30
Rate for Payer: Scott and White EPO/PPO	$21,014.88
Rate for Payer: Scott and White Medicare	$19,993.46
Rate for Payer: Superior Health Plan EPO	$19,993.46
Rate for Payer: Superior Health Plan Medicare	$19,993.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,993.46
Rate for Payer: Universal American Medicare	$19,993.46
Rate for Payer: Wellcare Medicare	$19,993.46
Rate for Payer: Wellmed Medicare	$19,993.46

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC

Facility

$65,779.90

Service Code	MSDRG 492
Min. Negotiated Rate	$27,560.53
Max. Negotiated Rate	$65,779.90
Rate for Payer: Aetna Commercial	$38,948.62
Rate for Payer: Aetna Medicare	$41,340.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27,560.53
Rate for Payer: Amerigroup Medicare	$27,560.53
Rate for Payer: BCBS of TX Blue Advantage	$27,644.70
Rate for Payer: BCBS of TX Blue Essentials	$34,986.57
Rate for Payer: BCBS of TX Medicare	$27,560.53
Rate for Payer: BCBS of TX PPO	$38,875.47
Rate for Payer: Cigna Commercial	$44,591.85
Rate for Payer: Cigna Medicare	$27,560.53
Rate for Payer: Employer Direct Commercial	$27,560.53
Rate for Payer: Humana Medicare/TRICARE	$27,560.53
Rate for Payer: Molina Dual Medicare/Medicaid	$27,560.53
Rate for Payer: Molina Medicare	$27,560.53
Rate for Payer: Multiplan Auto	$65,779.90
Rate for Payer: Multiplan Commercial	$65,779.90
Rate for Payer: Multiplan Workers Comp	$65,779.90
Rate for Payer: Scott and White EPO/PPO	$30,293.38
Rate for Payer: Scott and White Medicare	$27,560.53
Rate for Payer: Superior Health Plan EPO	$27,560.53
Rate for Payer: Superior Health Plan Medicare	$27,560.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$27,560.53
Rate for Payer: Universal American Medicare	$27,560.53
Rate for Payer: Wellcare Medicare	$27,560.53
Rate for Payer: Wellmed Medicare	$27,560.53

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC

Facility

$35,514.80

Service Code	MSDRG 494
Min. Negotiated Rate	$14,036.06
Max. Negotiated Rate	$35,514.80
Rate for Payer: Aetna Commercial	$21,028.50
Rate for Payer: Aetna Medicare	$24,290.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,193.50
Rate for Payer: Amerigroup Medicare	$16,193.50
Rate for Payer: BCBS of TX Blue Advantage	$14,036.06
Rate for Payer: BCBS of TX Blue Essentials	$18,098.49
Rate for Payer: BCBS of TX Medicare	$16,193.50
Rate for Payer: BCBS of TX PPO	$20,110.22
Rate for Payer: Cigna Commercial	$24,075.30
Rate for Payer: Cigna Medicare	$16,193.50
Rate for Payer: Employer Direct Commercial	$16,193.50
Rate for Payer: Humana Medicare/TRICARE	$16,193.50
Rate for Payer: Molina Dual Medicare/Medicaid	$16,193.50
Rate for Payer: Molina Medicare	$16,193.50
Rate for Payer: Multiplan Auto	$35,514.80
Rate for Payer: Multiplan Commercial	$35,514.80
Rate for Payer: Multiplan Workers Comp	$35,514.80
Rate for Payer: Scott and White EPO/PPO	$16,355.50
Rate for Payer: Scott and White Medicare	$16,193.50
Rate for Payer: Superior Health Plan EPO	$16,193.50
Rate for Payer: Superior Health Plan Medicare	$16,193.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,193.50
Rate for Payer: Universal American Medicare	$16,193.50
Rate for Payer: Wellcare Medicare	$16,193.50
Rate for Payer: Wellmed Medicare	$16,193.50

Lumbar Puncture Procedure Time

Facility

$1,261.00

Service Code	CPT 62270
Hospital Charge Code	315358
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,109.68

Lumbar Puncture Procedure Time

Facility

$1,261.00

Service Code	CPT 62270
Hospital Charge Code	315358
Hospital Revenue Code	361
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$948.68
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$632.45
Rate for Payer: Amerigroup Medicare	$632.45
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$632.45
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$1,109.68
Rate for Payer: Cash Price	$1,109.68
Rate for Payer: Cigna Commercial	$1,432.68
Rate for Payer: Cigna Medicaid	$262.86
Rate for Payer: Cigna Medicare	$632.45
Rate for Payer: Employer Direct Commercial	$632.45
Rate for Payer: Humana Medicare/TRICARE	$632.45
Rate for Payer: Molina CHIP/Medicaid	$262.86
Rate for Payer: Molina Dual Medicare/Medicaid	$632.45
Rate for Payer: Molina Medicare	$632.45
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$262.86
Rate for Payer: Scott and White EPO/PPO	$13.95
Rate for Payer: Scott and White Medicare	$632.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.86
Rate for Payer: Superior Health Plan EPO	$632.45
Rate for Payer: Superior Health Plan Medicare	$632.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$632.45
Rate for Payer: Universal American Medicare	$632.45
Rate for Payer: Wellcare Medicare	$632.45
Rate for Payer: Wellmed Medicare	$632.45

LUNG TRANSPLANT

Facility

$233,061.60

Service Code	MSDRG 007
Min. Negotiated Rate	$83,362.38
Max. Negotiated Rate	$233,061.60
Rate for Payer: Aetna Commercial	$137,997.00
Rate for Payer: Aetna Medicare	$135,582.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$90,388.56
Rate for Payer: Amerigroup Medicare	$90,388.56
Rate for Payer: BCBS of TX Blue Advantage	$83,362.38
Rate for Payer: BCBS of TX Blue Essentials	$109,907.67
Rate for Payer: BCBS of TX Medicare	$90,388.56
Rate for Payer: BCBS of TX PPO	$122,124.37
Rate for Payer: Cigna Commercial	$157,991.23
Rate for Payer: Cigna Medicare	$90,388.56
Rate for Payer: Employer Direct Commercial	$90,388.56
Rate for Payer: Molina Dual Medicare/Medicaid	$90,388.56
Rate for Payer: Molina Medicare	$90,388.56
Rate for Payer: Multiplan Auto	$233,061.60
Rate for Payer: Multiplan Commercial	$233,061.60
Rate for Payer: Multiplan Workers Comp	$233,061.60
Rate for Payer: Scott and White EPO/PPO	$107,331.00
Rate for Payer: Scott and White Medicare	$90,388.56
Rate for Payer: Superior Health Plan EPO	$90,388.56
Rate for Payer: Superior Health Plan Medicare	$90,388.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$90,388.56
Rate for Payer: Universal American Medicare	$90,388.56
Rate for Payer: Wellcare Medicare	$90,388.56
Rate for Payer: Wellmed Medicare	$90,388.56

Lupus Anticoagulant Reflex SO

Facility

$150.00

Service Code	CPT 85613
Hospital Charge Code	1708353
Hospital Revenue Code	305
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$97.50
Rate for Payer: Aetna Commercial	$10.06
Rate for Payer: Aetna Medicare	$14.37
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	$15.81
Rate for Payer: BCBS of TX Blue Essentials	$18.97
Rate for Payer: BCBS of TX Medicare	$9.58
Rate for Payer: BCBS of TX PPO	$21.17
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cigna Medicaid	$9.58
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	$9.58
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	$9.58
Rate for Payer: Scott and White EPO/PPO	$11.98
Rate for Payer: Scott and White Medicare	$9.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.58
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

Lupus Anticoagulant Reflex SO

Facility

$150.00

Service Code	CPT 85613
Hospital Charge Code	1708353
Hospital Revenue Code	305
Rate for Payer: Cash Price	$132.00

Luteinizing Hormone(LH), S SO

Facility

$248.00

Service Code	CPT 83002
Hospital Charge Code	1602135
Hospital Revenue Code	301
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$161.20
Rate for Payer: Aetna Commercial	$19.44
Rate for Payer: Aetna Medicare	$27.78
Rate for Payer: Amerigroup CHIP/Medicaid	$7.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.52
Rate for Payer: Amerigroup Medicare	$18.52
Rate for Payer: BCBS of TX Blue Advantage	$30.56
Rate for Payer: BCBS of TX Blue Essentials	$36.67
Rate for Payer: BCBS of TX Medicare	$18.52
Rate for Payer: BCBS of TX PPO	$40.93
Rate for Payer: Cash Price	$218.24
Rate for Payer: Cash Price	$218.24
Rate for Payer: Cigna Medicaid	$18.52
Rate for Payer: Cigna Medicare	$18.52
Rate for Payer: Employer Direct Commercial	$18.52
Rate for Payer: Humana Medicare/TRICARE	$18.52
Rate for Payer: Molina CHIP/Medicaid	$18.52
Rate for Payer: Molina Dual Medicare/Medicaid	$18.52
Rate for Payer: Molina Medicare	$18.52
Rate for Payer: Multiplan Auto	$161.20
Rate for Payer: Multiplan Commercial	$161.20
Rate for Payer: Multiplan Workers Comp	$161.20
Rate for Payer: Parkland Medicaid	$18.52
Rate for Payer: Scott and White EPO/PPO	$23.15
Rate for Payer: Scott and White Medicare	$18.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.52
Rate for Payer: Superior Health Plan EPO	$18.52
Rate for Payer: Superior Health Plan Medicare	$18.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.52
Rate for Payer: Universal American Medicare	$18.52
Rate for Payer: Wellcare Medicare	$18.52
Rate for Payer: Wellmed Medicare	$18.52

Luteinizing Hormone(LH), S SO

Facility

$248.00

Service Code	CPT 83002
Hospital Charge Code	1602135
Hospital Revenue Code	301
Rate for Payer: Cash Price	$218.24

L VENTRIC PACING LEAD ADD-ON

Facility

$14,696.00

Service Code	CPT 33225
Hospital Charge Code	2303311
Hospital Revenue Code	481
Min. Negotiated Rate	$1,322.64
Max. Negotiated Rate	$10,300.00
Rate for Payer: Aetna Commercial	$10,300.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,322.64
Rate for Payer: Cash Price	$12,932.48
Rate for Payer: Cash Price	$12,932.48
Rate for Payer: Multiplan Auto	$9,552.40
Rate for Payer: Multiplan Commercial	$9,552.40
Rate for Payer: Multiplan Workers Comp	$9,552.40
Rate for Payer: Scott and White EPO/PPO	$7,348.00
Rate for Payer: Superior Health Plan EPO	$1,998.66

L VENTRIC PACING LEAD ADD-ON

Facility

$14,696.00

Service Code	CPT 33225
Hospital Charge Code	2303311
Hospital Revenue Code	481
Rate for Payer: Cash Price	$12,932.48

LYME ANTIBODIES WESTERN BLOT

Facility

$183.26

Service Code	CPT 86617
Hospital Charge Code	1708866
Hospital Revenue Code	300
Rate for Payer: Cash Price	$161.27

LYME ANTIBODIES WESTERN BLOT

Facility

$183.26

Service Code	CPT 86617
Hospital Charge Code	1708866
Hospital Revenue Code	300
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$119.12
Rate for Payer: Aetna Commercial	$16.26
Rate for Payer: Aetna Medicare	$23.24
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	$25.56
Rate for Payer: BCBS of TX Blue Essentials	$30.67
Rate for Payer: BCBS of TX Medicare	$15.49
Rate for Payer: BCBS of TX PPO	$34.23
Rate for Payer: Cash Price	$161.27
Rate for Payer: Cash Price	$161.27
Rate for Payer: Cigna Medicaid	$15.49
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	$15.49
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	$15.49
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	$15.49
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

Lyme Antibody/Line Blot Reflex SO

Facility

$261.00

Service Code	CPT 86618
Hospital Charge Code	1704709
Hospital Revenue Code	302
Min. Negotiated Rate	$6.64
Max. Negotiated Rate	$169.65
Rate for Payer: Aetna Commercial	$17.88
Rate for Payer: Aetna Medicare	$25.54
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	$28.10
Rate for Payer: BCBS of TX Blue Essentials	$33.72
Rate for Payer: BCBS of TX Medicare	$17.03
Rate for Payer: BCBS of TX PPO	$37.64
Rate for Payer: Cash Price	$229.68
Rate for Payer: Cash Price	$229.68
Rate for Payer: Cigna Medicaid	$17.03
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	$17.03
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	$17.03
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	$17.03
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

Lyme, Total Ab Test/Reflex SO

Facility

$261.00

Service Code	CPT 86618
Hospital Charge Code	1704709
Hospital Revenue Code	302
Min. Negotiated Rate	$6.64
Max. Negotiated Rate	$169.65
Rate for Payer: Aetna Commercial	$17.88
Rate for Payer: Aetna Medicare	$25.54
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	$28.10
Rate for Payer: BCBS of TX Blue Essentials	$33.72
Rate for Payer: BCBS of TX Medicare	$17.03
Rate for Payer: BCBS of TX PPO	$37.64
Rate for Payer: Cash Price	$229.68
Rate for Payer: Cash Price	$229.68
Rate for Payer: Cigna Medicaid	$17.03
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	$17.03
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	$17.03
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	$17.03
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

Lyme, Total Ab Test/Reflex SO

Facility

$261.00

Service Code	CPT 86618
Hospital Charge Code	1704709
Hospital Revenue Code	302
Rate for Payer: Cash Price	$229.68

Know your out-of-pocket cost for care.

All Charges