White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Graft rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)

Facility

$12,715.13

Service Code	HCPCS 21230
Hospital Charge Code	9900191
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,646.29

GRAFT STRATTICE 2025002 PER SQ CM

Facility

$175.00

Service Code	HCPCS Q4205
Hospital Charge Code	118460
Hospital Revenue Code	278
Min. Negotiated Rate	$43.75
Max. Negotiated Rate	$87.50
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$43.75
Rate for Payer: Multiplan Auto	$87.50
Rate for Payer: Multiplan Commercial	$87.50
Rate for Payer: Multiplan Workers Comp	$87.50
Rate for Payer: Scott and White EPO/PPO	$87.50

GRAFT STRATTICE 2025002 PER SQ CM

Facility

$175.00

Service Code	HCPCS Q4205
Hospital Charge Code	118460
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$264.25
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$14.83
Rate for Payer: BCBS of TX Blue Essentials	$17.80
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$126.00
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$126.00
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$87.50
Rate for Payer: Multiplan Commercial	$87.50
Rate for Payer: Multiplan Workers Comp	$87.50
Rate for Payer: Parkland Medicaid	$126.00
Rate for Payer: Scott and White EPO/PPO	$87.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

GRAFT TIS 6X16CM AMNIOFIX BIO

Facility

$20,672.00

Service Code	HCPCS Q4205
Hospital Charge Code	120840
Hospital Revenue Code	278
Min. Negotiated Rate	$5,168.00
Max. Negotiated Rate	$10,336.00
Rate for Payer: Cash Price	$14,056.96
Rate for Payer: Cigna Commercial	$5,168.00
Rate for Payer: Multiplan Auto	$10,336.00
Rate for Payer: Multiplan Commercial	$10,336.00
Rate for Payer: Multiplan Workers Comp	$10,336.00
Rate for Payer: Scott and White EPO/PPO	$10,336.00

GRAFT TIS 6X16CM AMNIOFIX BIO

Facility

$20,672.00

Service Code	HCPCS Q4205
Hospital Charge Code	120840
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$14,883.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1,860.48
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$14.83
Rate for Payer: BCBS of TX Blue Essentials	$17.80
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$14,056.96
Rate for Payer: Cash Price	$14,056.96
Rate for Payer: Cash Price	$14,056.96
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$14,883.84
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$14,883.84
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$10,336.00
Rate for Payer: Multiplan Commercial	$10,336.00
Rate for Payer: Multiplan Workers Comp	$10,336.00
Rate for Payer: Parkland Medicaid	$14,883.84
Rate for Payer: Scott and White EPO/PPO	$10,336.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,883.84
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

GRAFT VASC ARTEGRAFT -- DHF

Facility

$16,319.00

Service Code	HCPCS C1768
Hospital Charge Code	81421364
Hospital Revenue Code	278
Min. Negotiated Rate	$1,468.71
Max. Negotiated Rate	$11,749.68
Rate for Payer: Amerigroup CHIP/Medicaid	$1,468.71
Rate for Payer: BCBS of TX Blue Advantage	$4,895.70
Rate for Payer: BCBS of TX Blue Essentials	$5,874.84
Rate for Payer: BCBS of TX PPO	$6,527.60
Rate for Payer: Cash Price	$11,096.92
Rate for Payer: Cigna Medicaid	$11,749.68
Rate for Payer: Molina CHIP/Medicaid	$11,749.68
Rate for Payer: Multiplan Auto	$8,159.50
Rate for Payer: Multiplan Commercial	$8,159.50
Rate for Payer: Multiplan Workers Comp	$8,159.50
Rate for Payer: Parkland Medicaid	$11,749.68
Rate for Payer: Scott and White EPO/PPO	$8,159.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,749.68
Rate for Payer: Superior Health Plan EPO	$2,219.38

GRAFT VASC ARTEGRAFT -- DHF

Facility

$16,319.00

Service Code	HCPCS C1768
Hospital Charge Code	81421364
Hospital Revenue Code	278
Min. Negotiated Rate	$4,079.75
Max. Negotiated Rate	$8,159.50
Rate for Payer: Cash Price	$11,096.92
Rate for Payer: Cigna Commercial	$4,079.75
Rate for Payer: Multiplan Auto	$8,159.50
Rate for Payer: Multiplan Commercial	$8,159.50
Rate for Payer: Multiplan Workers Comp	$8,159.50
Rate for Payer: Scott and White EPO/PPO	$8,159.50

GRAFT VASCULAR ALL COLLAGEN 6MM X 15CMSeptal defect implant system, intracardiac

Facility

$7,825.30

Service Code	HCPCS C1817
Hospital Charge Code	131728
Hospital Revenue Code	275
Min. Negotiated Rate	$1,956.33
Max. Negotiated Rate	$3,912.65
Rate for Payer: Cash Price	$5,321.20
Rate for Payer: Cigna Commercial	$1,956.33
Rate for Payer: Multiplan Auto	$3,912.65
Rate for Payer: Multiplan Commercial	$3,912.65
Rate for Payer: Multiplan Workers Comp	$3,912.65
Rate for Payer: Scott and White EPO/PPO	$3,912.65

GRAFT VASCULAR ALL COLLAGEN 6MM X 15CMSeptal defect implant system, intracardiac

Facility

$7,825.30

Service Code	HCPCS C1817
Hospital Charge Code	131728
Hospital Revenue Code	275
Min. Negotiated Rate	$704.28
Max. Negotiated Rate	$5,634.22
Rate for Payer: Amerigroup CHIP/Medicaid	$704.28
Rate for Payer: BCBS of TX Blue Advantage	$2,347.59
Rate for Payer: BCBS of TX Blue Essentials	$2,817.11
Rate for Payer: BCBS of TX PPO	$3,130.12
Rate for Payer: Cash Price	$5,321.20
Rate for Payer: Cigna Medicaid	$5,634.22
Rate for Payer: Molina CHIP/Medicaid	$5,634.22
Rate for Payer: Multiplan Auto	$3,912.65
Rate for Payer: Multiplan Commercial	$3,912.65
Rate for Payer: Multiplan Workers Comp	$3,912.65
Rate for Payer: Parkland Medicaid	$5,634.22
Rate for Payer: Scott and White EPO/PPO	$3,912.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,634.22
Rate for Payer: Superior Health Plan EPO	$1,064.24

GRAFT VASCULAR ALL COLLAGEN 7MM X 40CM-44CM

Facility

$9,302.46

Service Code	HCPCS C1768
Hospital Charge Code	81410151
Hospital Revenue Code	278
Min. Negotiated Rate	$2,325.61
Max. Negotiated Rate	$4,651.23
Rate for Payer: Cash Price	$6,325.67
Rate for Payer: Cigna Commercial	$2,325.61
Rate for Payer: Multiplan Auto	$4,651.23
Rate for Payer: Multiplan Commercial	$4,651.23
Rate for Payer: Multiplan Workers Comp	$4,651.23
Rate for Payer: Scott and White EPO/PPO	$4,651.23

GRAFT VASCULAR ALL COLLAGEN 7MM X 40CM-44CM

Facility

$9,302.46

Service Code	HCPCS C1768
Hospital Charge Code	992741
Hospital Revenue Code	278
Min. Negotiated Rate	$2,325.61
Max. Negotiated Rate	$4,651.23
Rate for Payer: Cash Price	$6,325.67
Rate for Payer: Cigna Commercial	$2,325.61
Rate for Payer: Multiplan Auto	$4,651.23
Rate for Payer: Multiplan Commercial	$4,651.23
Rate for Payer: Multiplan Workers Comp	$4,651.23
Rate for Payer: Scott and White EPO/PPO	$4,651.23

GRAFT VASCULAR ALL COLLAGEN 7MM X 40CM-44CM

Facility

$9,302.46

Service Code	HCPCS C1768
Hospital Charge Code	992741
Hospital Revenue Code	278
Min. Negotiated Rate	$837.22
Max. Negotiated Rate	$6,697.77
Rate for Payer: Amerigroup CHIP/Medicaid	$837.22
Rate for Payer: BCBS of TX Blue Advantage	$2,790.74
Rate for Payer: BCBS of TX Blue Essentials	$3,348.89
Rate for Payer: BCBS of TX PPO	$3,720.98
Rate for Payer: Cash Price	$6,325.67
Rate for Payer: Cigna Medicaid	$6,697.77
Rate for Payer: Molina CHIP/Medicaid	$6,697.77
Rate for Payer: Multiplan Auto	$4,651.23
Rate for Payer: Multiplan Commercial	$4,651.23
Rate for Payer: Multiplan Workers Comp	$4,651.23
Rate for Payer: Parkland Medicaid	$6,697.77
Rate for Payer: Scott and White EPO/PPO	$4,651.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,697.77
Rate for Payer: Superior Health Plan EPO	$1,265.13

GRAFT VASCULAR ALL COLLAGEN 7MM X 40CM-44CM

Facility

$9,302.46

Service Code	HCPCS C1768
Hospital Charge Code	81410151
Hospital Revenue Code	278
Min. Negotiated Rate	$837.22
Max. Negotiated Rate	$6,697.77
Rate for Payer: Amerigroup CHIP/Medicaid	$837.22
Rate for Payer: BCBS of TX Blue Advantage	$2,790.74
Rate for Payer: BCBS of TX Blue Essentials	$3,348.89
Rate for Payer: BCBS of TX PPO	$3,720.98
Rate for Payer: Cash Price	$6,325.67
Rate for Payer: Cigna Medicaid	$6,697.77
Rate for Payer: Molina CHIP/Medicaid	$6,697.77
Rate for Payer: Multiplan Auto	$4,651.23
Rate for Payer: Multiplan Commercial	$4,651.23
Rate for Payer: Multiplan Workers Comp	$4,651.23
Rate for Payer: Parkland Medicaid	$6,697.77
Rate for Payer: Scott and White EPO/PPO	$4,651.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,697.77
Rate for Payer: Superior Health Plan EPO	$1,265.13

GRAFT VASCULAR ALL COLLAGEN 8MM X 15CM

Facility

$13,887.86

Service Code	HCPCS C1768
Hospital Charge Code	992740
Hospital Revenue Code	278
Min. Negotiated Rate	$1,249.91
Max. Negotiated Rate	$9,999.26
Rate for Payer: Amerigroup CHIP/Medicaid	$1,249.91
Rate for Payer: BCBS of TX Blue Advantage	$4,166.36
Rate for Payer: BCBS of TX Blue Essentials	$4,999.63
Rate for Payer: BCBS of TX PPO	$5,555.14
Rate for Payer: Cash Price	$9,443.74
Rate for Payer: Cigna Medicaid	$9,999.26
Rate for Payer: Molina CHIP/Medicaid	$9,999.26
Rate for Payer: Multiplan Auto	$6,943.93
Rate for Payer: Multiplan Commercial	$6,943.93
Rate for Payer: Multiplan Workers Comp	$6,943.93
Rate for Payer: Parkland Medicaid	$9,999.26
Rate for Payer: Scott and White EPO/PPO	$6,943.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,999.26
Rate for Payer: Superior Health Plan EPO	$1,888.75

GRAFT VASCULAR ALL COLLAGEN 8MM X 15CM

Facility

$13,887.86

Service Code	HCPCS C1768
Hospital Charge Code	992740
Hospital Revenue Code	278
Min. Negotiated Rate	$3,471.97
Max. Negotiated Rate	$6,943.93
Rate for Payer: Cash Price	$9,443.74
Rate for Payer: Cigna Commercial	$3,471.97
Rate for Payer: Multiplan Auto	$6,943.93
Rate for Payer: Multiplan Commercial	$6,943.93
Rate for Payer: Multiplan Workers Comp	$6,943.93
Rate for Payer: Scott and White EPO/PPO	$6,943.93

GRAFT VIAGRAFT 5.0CC

Facility

$13,554.00

Service Code	HCPCS Q4205
Hospital Charge Code	8504495
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$9,758.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,219.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$14.83
Rate for Payer: BCBS of TX Blue Essentials	$17.80
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$9,216.72
Rate for Payer: Cash Price	$9,216.72
Rate for Payer: Cash Price	$9,216.72
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$9,758.88
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$9,758.88
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$6,777.00
Rate for Payer: Multiplan Commercial	$6,777.00
Rate for Payer: Multiplan Workers Comp	$6,777.00
Rate for Payer: Parkland Medicaid	$9,758.88
Rate for Payer: Scott and White EPO/PPO	$6,777.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,758.88
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

GRAFT VIAGRAFT 5.0CC

Facility

$13,554.00

Service Code	HCPCS Q4205
Hospital Charge Code	8504495
Hospital Revenue Code	278
Min. Negotiated Rate	$3,388.50
Max. Negotiated Rate	$6,777.00
Rate for Payer: Cash Price	$9,216.72
Rate for Payer: Cigna Commercial	$3,388.50
Rate for Payer: Multiplan Auto	$6,777.00
Rate for Payer: Multiplan Commercial	$6,777.00
Rate for Payer: Multiplan Workers Comp	$6,777.00
Rate for Payer: Scott and White EPO/PPO	$6,777.00

Gram negative identification (Vitek)

Facility

$238.00

Service Code	HCPCS 87077
Hospital Charge Code	4108707
Hospital Revenue Code	306
Rate for Payer: Cash Price	$161.84

Gram negative identification (Vitek)

Facility

$238.00

Service Code	HCPCS 87077
Hospital Charge Code	4108707
Hospital Revenue Code	306
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$171.36
Rate for Payer: Amerigroup CHIP/Medicaid	$3.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.08
Rate for Payer: Amerigroup Medicare	$8.08
Rate for Payer: BCBS of TX Blue Advantage	$71.40
Rate for Payer: BCBS of TX Blue Essentials	$85.68
Rate for Payer: BCBS of TX Medicare	$8.08
Rate for Payer: BCBS of TX PPO	$95.20
Rate for Payer: Cash Price	$161.84
Rate for Payer: Cash Price	$161.84
Rate for Payer: Cigna Medicaid	$171.36
Rate for Payer: Cigna Medicare	$8.08
Rate for Payer: Employer Direct Commercial	$8.08
Rate for Payer: Humana Medicare/TRICARE	$8.08
Rate for Payer: Molina CHIP/Medicaid	$171.36
Rate for Payer: Molina Dual Medicare/Medicaid	$8.08
Rate for Payer: Molina Medicare	$8.08
Rate for Payer: Multiplan Auto	$154.70
Rate for Payer: Multiplan Commercial	$154.70
Rate for Payer: Multiplan Workers Comp	$154.70
Rate for Payer: Parkland Medicaid	$171.36
Rate for Payer: Scott and White EPO/PPO	$10.10
Rate for Payer: Scott and White Medicare	$8.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$171.36
Rate for Payer: Superior Health Plan EPO	$8.08
Rate for Payer: Superior Health Plan Medicare	$8.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.08
Rate for Payer: Universal American Medicare	$8.08
Rate for Payer: Wellcare Medicare	$8.08
Rate for Payer: Wellmed Medicare	$8.08

Gram negative identification (Vitek)

Facility

$238.00

Service Code	HCPCS 87077
Hospital Charge Code	297662
Hospital Revenue Code	306
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$171.36
Rate for Payer: Amerigroup CHIP/Medicaid	$3.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.08
Rate for Payer: Amerigroup Medicare	$8.08
Rate for Payer: BCBS of TX Blue Advantage	$71.40
Rate for Payer: BCBS of TX Blue Essentials	$85.68
Rate for Payer: BCBS of TX Medicare	$8.08
Rate for Payer: BCBS of TX PPO	$95.20
Rate for Payer: Cash Price	$161.84
Rate for Payer: Cash Price	$161.84
Rate for Payer: Cigna Medicaid	$171.36
Rate for Payer: Cigna Medicare	$8.08
Rate for Payer: Employer Direct Commercial	$8.08
Rate for Payer: Humana Medicare/TRICARE	$8.08
Rate for Payer: Molina CHIP/Medicaid	$171.36
Rate for Payer: Molina Dual Medicare/Medicaid	$8.08
Rate for Payer: Molina Medicare	$8.08
Rate for Payer: Multiplan Auto	$154.70
Rate for Payer: Multiplan Commercial	$154.70
Rate for Payer: Multiplan Workers Comp	$154.70
Rate for Payer: Parkland Medicaid	$171.36
Rate for Payer: Scott and White EPO/PPO	$10.10
Rate for Payer: Scott and White Medicare	$8.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$171.36
Rate for Payer: Superior Health Plan EPO	$8.08
Rate for Payer: Superior Health Plan Medicare	$8.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.08
Rate for Payer: Universal American Medicare	$8.08
Rate for Payer: Wellcare Medicare	$8.08
Rate for Payer: Wellmed Medicare	$8.08

Gram negative identification (Vitek)

Facility

$238.00

Service Code	HCPCS 87077
Hospital Charge Code	297662
Hospital Revenue Code	306
Rate for Payer: Cash Price	$161.84

Gram positive identification (Vitek)

Facility

$238.00

Service Code	HCPCS 87077
Hospital Charge Code	297663
Hospital Revenue Code	306
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$171.36
Rate for Payer: Amerigroup CHIP/Medicaid	$3.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.08
Rate for Payer: Amerigroup Medicare	$8.08
Rate for Payer: BCBS of TX Blue Advantage	$71.40
Rate for Payer: BCBS of TX Blue Essentials	$85.68
Rate for Payer: BCBS of TX Medicare	$8.08
Rate for Payer: BCBS of TX PPO	$95.20
Rate for Payer: Cash Price	$161.84
Rate for Payer: Cash Price	$161.84
Rate for Payer: Cigna Medicaid	$171.36
Rate for Payer: Cigna Medicare	$8.08
Rate for Payer: Employer Direct Commercial	$8.08
Rate for Payer: Humana Medicare/TRICARE	$8.08
Rate for Payer: Molina CHIP/Medicaid	$171.36
Rate for Payer: Molina Dual Medicare/Medicaid	$8.08
Rate for Payer: Molina Medicare	$8.08
Rate for Payer: Multiplan Auto	$154.70
Rate for Payer: Multiplan Commercial	$154.70
Rate for Payer: Multiplan Workers Comp	$154.70
Rate for Payer: Parkland Medicaid	$171.36
Rate for Payer: Scott and White EPO/PPO	$10.10
Rate for Payer: Scott and White Medicare	$8.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$171.36
Rate for Payer: Superior Health Plan EPO	$8.08
Rate for Payer: Superior Health Plan Medicare	$8.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.08
Rate for Payer: Universal American Medicare	$8.08
Rate for Payer: Wellcare Medicare	$8.08
Rate for Payer: Wellmed Medicare	$8.08

Gram positive identification (Vitek)

Facility

$238.00

Service Code	HCPCS 87077
Hospital Charge Code	297663
Hospital Revenue Code	306
Rate for Payer: Cash Price	$161.84

Gram Stain Body Fluid

Facility

$138.00

Service Code	HCPCS 87205
Hospital Charge Code	1604206
Hospital Revenue Code	306
Rate for Payer: Cash Price	$93.84

Gram Stain Body Fluid

Facility

$138.00

Service Code	HCPCS 87205
Hospital Charge Code	1604206
Hospital Revenue Code	306
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$99.36
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	$41.40
Rate for Payer: BCBS of TX Blue Essentials	$49.68
Rate for Payer: BCBS of TX Medicare	$4.27
Rate for Payer: BCBS of TX PPO	$55.20
Rate for Payer: Cash Price	$93.84
Rate for Payer: Cash Price	$93.84
Rate for Payer: Cigna Medicaid	$99.36
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	$99.36
Rate for Payer: Molina Dual Medicare/Medicaid	$4.27
Rate for Payer: Molina Medicare	$4.27
Rate for Payer: Multiplan Auto	$89.70
Rate for Payer: Multiplan Commercial	$89.70
Rate for Payer: Multiplan Workers Comp	$89.70
Rate for Payer: Parkland Medicaid	$99.36
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	$99.36
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

Know your out-of-pocket cost for care.

All Charges