White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Nursemaid Elbow Child w/ Manipulation

Facility

$777.00

Service Code	CPT 24640
Hospital Charge Code	8398504
Hospital Revenue Code	450
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$505.05
Rate for Payer: Aetna Commercial	$427.35
Rate for Payer: Aetna Medicare	$323.50
Rate for Payer: Amerigroup CHIP/Medicaid	$69.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$215.67
Rate for Payer: Amerigroup Medicare	$215.67
Rate for Payer: BCBS of TX Blue Advantage	$93.42
Rate for Payer: BCBS of TX Blue Essentials	$111.88
Rate for Payer: BCBS of TX Medicare	$215.67
Rate for Payer: BCBS of TX PPO	$140.97
Rate for Payer: Cash Price	$683.76
Rate for Payer: Cash Price	$683.76
Rate for Payer: Cash Price	$683.76
Rate for Payer: Cigna Commercial	$488.55
Rate for Payer: Cigna Medicaid	$49.00
Rate for Payer: Cigna Medicare	$215.67
Rate for Payer: Employer Direct Commercial	$215.67
Rate for Payer: Humana Medicare/TRICARE	$215.67
Rate for Payer: Molina CHIP/Medicaid	$49.00
Rate for Payer: Molina Dual Medicare/Medicaid	$215.67
Rate for Payer: Molina Medicare	$215.67
Rate for Payer: Multiplan Auto	$505.05
Rate for Payer: Multiplan Commercial	$505.05
Rate for Payer: Multiplan Workers Comp	$505.05
Rate for Payer: Parkland Medicaid	$49.00
Rate for Payer: Scott and White EPO/PPO	$3.86
Rate for Payer: Scott and White Medicare	$215.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.00
Rate for Payer: Superior Health Plan EPO	$215.67
Rate for Payer: Superior Health Plan Medicare	$215.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$215.67
Rate for Payer: Universal American Medicare	$215.67
Rate for Payer: Wellcare Medicare	$215.67
Rate for Payer: Wellmed Medicare	$215.67

NuSwab Vaginitis Plus (VG+) SO

Facility

$298.00

Service Code	CPT 87491
Hospital Charge Code	1709682
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$193.70
Rate for Payer: Aetna Commercial	$36.84
Rate for Payer: Aetna Medicare	$52.64
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$57.90
Rate for Payer: BCBS of TX Blue Essentials	$69.48
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$77.55
Rate for Payer: Cash Price	$262.24
Rate for Payer: Cash Price	$262.24
Rate for Payer: Cigna Medicaid	$35.09
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$35.09
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$193.70
Rate for Payer: Multiplan Commercial	$193.70
Rate for Payer: Multiplan Workers Comp	$193.70
Rate for Payer: Parkland Medicaid	$35.09
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.09
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

NuSwab Vaginitis Plus (VG+) SO

Facility

$298.00

Service Code	CPT 87491
Hospital Charge Code	1709682
Hospital Revenue Code	306
Rate for Payer: Cash Price	$262.24

nystatin 100,000 units/g Cream 15 g

Facility

$29.90

Service Code	HCPCS J3490
Hospital Charge Code	77730258
Hospital Revenue Code	250
Rate for Payer: Cash Price	$20.33

nystatin 100,000 units/g Cream 15 g

Facility

$29.90

Service Code	HCPCS J3490
Hospital Charge Code	77730258
Hospital Revenue Code	250
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$19.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2.69
Rate for Payer: BCBS of TX Blue Advantage	$8.97
Rate for Payer: BCBS of TX Blue Essentials	$10.76
Rate for Payer: BCBS of TX PPO	$11.96
Rate for Payer: Cash Price	$20.33
Rate for Payer: Multiplan Auto	$19.44
Rate for Payer: Multiplan Commercial	$19.44
Rate for Payer: Multiplan Workers Comp	$19.44
Rate for Payer: Scott and White EPO/PPO	$14.95
Rate for Payer: Superior Health Plan EPO	$4.07

nystatin 100,000 units/g Topical Powder 15 g

Facility

$69.50

Service Code	HCPCS J3490
Hospital Charge Code	77730521
Hospital Revenue Code	250
Min. Negotiated Rate	$6.26
Max. Negotiated Rate	$45.18
Rate for Payer: Amerigroup CHIP/Medicaid	$6.26
Rate for Payer: BCBS of TX Blue Advantage	$20.85
Rate for Payer: BCBS of TX Blue Essentials	$25.02
Rate for Payer: BCBS of TX PPO	$27.80
Rate for Payer: Cash Price	$47.26
Rate for Payer: Multiplan Auto	$45.18
Rate for Payer: Multiplan Commercial	$45.18
Rate for Payer: Multiplan Workers Comp	$45.18
Rate for Payer: Scott and White EPO/PPO	$34.75
Rate for Payer: Superior Health Plan EPO	$9.45

nystatin 100,000 units/g Topical Powder 15 g

Facility

$69.50

Service Code	HCPCS J3490
Hospital Charge Code	77730521
Hospital Revenue Code	250
Rate for Payer: Cash Price	$47.26

O2 Sat Meas

Facility

$943.00

Service Code	CPT 82805
Hospital Charge Code	4000519
Hospital Revenue Code	301
Min. Negotiated Rate	$30.72
Max. Negotiated Rate	$612.95
Rate for Payer: Aetna Commercial	$82.70
Rate for Payer: Aetna Medicare	$118.16
Rate for Payer: Amerigroup CHIP/Medicaid	$30.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$78.77
Rate for Payer: Amerigroup Medicare	$78.77
Rate for Payer: BCBS of TX Blue Advantage	$129.97
Rate for Payer: BCBS of TX Blue Essentials	$155.96
Rate for Payer: BCBS of TX Medicare	$78.77
Rate for Payer: BCBS of TX PPO	$174.08
Rate for Payer: Cash Price	$829.84
Rate for Payer: Cash Price	$829.84
Rate for Payer: Cigna Medicaid	$78.77
Rate for Payer: Cigna Medicare	$78.77
Rate for Payer: Employer Direct Commercial	$78.77
Rate for Payer: Humana Medicare/TRICARE	$78.77
Rate for Payer: Molina CHIP/Medicaid	$78.77
Rate for Payer: Molina Dual Medicare/Medicaid	$78.77
Rate for Payer: Molina Medicare	$78.77
Rate for Payer: Multiplan Auto	$612.95
Rate for Payer: Multiplan Commercial	$612.95
Rate for Payer: Multiplan Workers Comp	$612.95
Rate for Payer: Parkland Medicaid	$78.77
Rate for Payer: Scott and White EPO/PPO	$98.46
Rate for Payer: Scott and White Medicare	$78.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$78.77
Rate for Payer: Superior Health Plan EPO	$78.77
Rate for Payer: Superior Health Plan Medicare	$78.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$78.77
Rate for Payer: Universal American Medicare	$78.77
Rate for Payer: Wellcare Medicare	$78.77
Rate for Payer: Wellmed Medicare	$78.77

O2 Sat Meas

Facility

$320.00

Service Code	CPT 82810
Hospital Charge Code	4049206
Hospital Revenue Code	301
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$10.26
Rate for Payer: Aetna Medicare	$14.66
Rate for Payer: Amerigroup CHIP/Medicaid	$3.81
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.77
Rate for Payer: Amerigroup Medicare	$9.77
Rate for Payer: BCBS of TX Blue Advantage	$16.12
Rate for Payer: BCBS of TX Blue Essentials	$19.34
Rate for Payer: BCBS of TX Medicare	$9.77
Rate for Payer: BCBS of TX PPO	$21.59
Rate for Payer: Cash Price	$281.60
Rate for Payer: Cash Price	$281.60
Rate for Payer: Cigna Medicaid	$9.77
Rate for Payer: Cigna Medicare	$9.77
Rate for Payer: Employer Direct Commercial	$9.77
Rate for Payer: Humana Medicare/TRICARE	$9.77
Rate for Payer: Molina CHIP/Medicaid	$9.77
Rate for Payer: Molina Dual Medicare/Medicaid	$9.77
Rate for Payer: Molina Medicare	$9.77
Rate for Payer: Multiplan Auto	$208.00
Rate for Payer: Multiplan Commercial	$208.00
Rate for Payer: Multiplan Workers Comp	$208.00
Rate for Payer: Parkland Medicaid	$9.77
Rate for Payer: Scott and White EPO/PPO	$12.21
Rate for Payer: Scott and White Medicare	$9.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.77
Rate for Payer: Superior Health Plan EPO	$9.77
Rate for Payer: Superior Health Plan Medicare	$9.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.77
Rate for Payer: Universal American Medicare	$9.77
Rate for Payer: Wellcare Medicare	$9.77
Rate for Payer: Wellmed Medicare	$9.77

O2 Uptake CO2 Output 94681

Facility

$843.00

Service Code	CPT 94681
Hospital Charge Code	5504681
Hospital Revenue Code	460
Rate for Payer: Cash Price	$741.84

O2 Uptake CO2 Output 94681

Facility

$843.00

Service Code	CPT 94681
Hospital Charge Code	5504681
Hospital Revenue Code	460
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$650.28
Rate for Payer: Aetna Commercial	$463.65
Rate for Payer: Aetna Medicare	$430.59
Rate for Payer: Amerigroup CHIP/Medicaid	$75.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$287.06
Rate for Payer: Amerigroup Medicare	$287.06
Rate for Payer: BCBS of TX Blue Advantage	$440.39
Rate for Payer: BCBS of TX Blue Essentials	$526.45
Rate for Payer: BCBS of TX Medicare	$287.06
Rate for Payer: BCBS of TX PPO	$587.19
Rate for Payer: Cash Price	$741.84
Rate for Payer: Cash Price	$741.84
Rate for Payer: Cash Price	$741.84
Rate for Payer: Cigna Commercial	$650.28
Rate for Payer: Cigna Medicare	$287.06
Rate for Payer: Employer Direct Commercial	$287.06
Rate for Payer: Humana Medicare/TRICARE	$287.06
Rate for Payer: Molina Dual Medicare/Medicaid	$287.06
Rate for Payer: Molina Medicare	$287.06
Rate for Payer: Multiplan Auto	$547.95
Rate for Payer: Multiplan Commercial	$547.95
Rate for Payer: Multiplan Workers Comp	$547.95
Rate for Payer: Scott and White EPO/PPO	$5.13
Rate for Payer: Scott and White Medicare	$287.06
Rate for Payer: Superior Health Plan EPO	$287.06
Rate for Payer: Superior Health Plan Medicare	$287.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$287.06
Rate for Payer: Universal American Medicare	$287.06
Rate for Payer: Wellcare Medicare	$287.06
Rate for Payer: Wellmed Medicare	$287.06

obtuator bladeless long opticl 8mm

Facility

$136.20

Hospital Charge Code	8692538
Hospital Revenue Code	272
Rate for Payer: Cash Price	$119.86

obtuator bladeless long opticl 8mm

Facility

$136.20

Hospital Charge Code	8692538
Hospital Revenue Code	272
Min. Negotiated Rate	$12.26
Max. Negotiated Rate	$88.53
Rate for Payer: Aetna Commercial	$74.91
Rate for Payer: Amerigroup CHIP/Medicaid	$12.26
Rate for Payer: BCBS of TX Blue Advantage	$40.86
Rate for Payer: BCBS of TX Blue Essentials	$49.03
Rate for Payer: BCBS of TX PPO	$54.48
Rate for Payer: Cash Price	$119.86
Rate for Payer: Multiplan Auto	$88.53
Rate for Payer: Multiplan Commercial	$88.53
Rate for Payer: Multiplan Workers Comp	$88.53
Rate for Payer: Scott and White EPO/PPO	$68.10
Rate for Payer: Superior Health Plan EPO	$18.52

obturator bladelss opticle 8mm

Facility

$81.72

Hospital Charge Code	8694516
Hospital Revenue Code	272
Rate for Payer: Cash Price	$71.91

obturator bladelss opticle 8mm

Facility

$81.72

Hospital Charge Code	8694516
Hospital Revenue Code	272
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$53.12
Rate for Payer: Aetna Commercial	$44.95
Rate for Payer: Amerigroup CHIP/Medicaid	$7.35
Rate for Payer: BCBS of TX Blue Advantage	$24.52
Rate for Payer: BCBS of TX Blue Essentials	$29.42
Rate for Payer: BCBS of TX PPO	$32.69
Rate for Payer: Cash Price	$71.91
Rate for Payer: Multiplan Auto	$53.12
Rate for Payer: Multiplan Commercial	$53.12
Rate for Payer: Multiplan Workers Comp	$53.12
Rate for Payer: Scott and White EPO/PPO	$40.86
Rate for Payer: Superior Health Plan EPO	$11.11

OCCLSN/EMBL CATH NON-CNS

Facility

$12,192.00

Service Code	CPT 61626
Hospital Charge Code	4617790
Hospital Revenue Code	361
Rate for Payer: Cash Price	$10,728.96

OCCLSN/EMBL CATH NON-CNS

Facility

$12,192.00

Service Code	CPT 61626
Hospital Charge Code	4617790
Hospital Revenue Code	361
Min. Negotiated Rate	$221.91
Max. Negotiated Rate	$24,969.37
Rate for Payer: Aetna Commercial	$8,755.00
Rate for Payer: Aetna Medicare	$15,091.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,097.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Amerigroup Medicare	$10,061.07
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$10,061.07
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$10,728.96
Rate for Payer: Cash Price	$10,728.96
Rate for Payer: Cash Price	$10,728.96
Rate for Payer: Cigna Commercial	$22,791.24
Rate for Payer: Cigna Medicare	$10,061.07
Rate for Payer: Employer Direct Commercial	$10,061.07
Rate for Payer: Humana Medicare/TRICARE	$10,061.07
Rate for Payer: Molina Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Molina Medicare	$10,061.07
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: Scott and White EPO/PPO	$221.91
Rate for Payer: Scott and White Medicare	$10,061.07
Rate for Payer: Superior Health Plan EPO	$10,061.07
Rate for Payer: Superior Health Plan Medicare	$10,061.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Universal American Medicare	$10,061.07
Rate for Payer: Wellcare Medicare	$10,061.07
Rate for Payer: Wellmed Medicare	$10,061.07

Occult Blood Gastric

Facility

$78.00

Service Code	CPT 82271
Hospital Charge Code	1630025
Hospital Revenue Code	301
Rate for Payer: Cash Price	$68.64

Occult Blood Gastric

Facility

$78.00

Service Code	CPT 82271
Hospital Charge Code	1630025
Hospital Revenue Code	301
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$50.70
Rate for Payer: Aetna Commercial	$5.58
Rate for Payer: Aetna Medicare	$7.98
Rate for Payer: Amerigroup CHIP/Medicaid	$2.07
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.32
Rate for Payer: Amerigroup Medicare	$5.32
Rate for Payer: BCBS of TX Blue Advantage	$8.78
Rate for Payer: BCBS of TX Blue Essentials	$10.53
Rate for Payer: BCBS of TX Medicare	$5.32
Rate for Payer: BCBS of TX PPO	$11.76
Rate for Payer: Cash Price	$68.64
Rate for Payer: Cash Price	$68.64
Rate for Payer: Cigna Medicaid	$5.32
Rate for Payer: Cigna Medicare	$5.32
Rate for Payer: Employer Direct Commercial	$5.32
Rate for Payer: Humana Medicare/TRICARE	$5.32
Rate for Payer: Molina CHIP/Medicaid	$5.32
Rate for Payer: Molina Dual Medicare/Medicaid	$5.32
Rate for Payer: Molina Medicare	$5.32
Rate for Payer: Multiplan Auto	$50.70
Rate for Payer: Multiplan Commercial	$50.70
Rate for Payer: Multiplan Workers Comp	$50.70
Rate for Payer: Parkland Medicaid	$5.32
Rate for Payer: Scott and White EPO/PPO	$6.65
Rate for Payer: Scott and White Medicare	$5.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.32
Rate for Payer: Superior Health Plan EPO	$5.32
Rate for Payer: Superior Health Plan Medicare	$5.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.32
Rate for Payer: Universal American Medicare	$5.32
Rate for Payer: Wellcare Medicare	$5.32
Rate for Payer: Wellmed Medicare	$5.32

Occult Blood Stool

Facility

$152.00

Service Code	CPT 82270
Hospital Charge Code	1604073
Hospital Revenue Code	301
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$98.80
Rate for Payer: Aetna Commercial	$4.60
Rate for Payer: Aetna Medicare	$6.57
Rate for Payer: Amerigroup CHIP/Medicaid	$1.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.38
Rate for Payer: Amerigroup Medicare	$4.38
Rate for Payer: BCBS of TX Blue Advantage	$7.23
Rate for Payer: BCBS of TX Blue Essentials	$8.67
Rate for Payer: BCBS of TX Medicare	$4.38
Rate for Payer: BCBS of TX PPO	$9.68
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cigna Medicaid	$4.38
Rate for Payer: Cigna Medicare	$4.38
Rate for Payer: Employer Direct Commercial	$4.38
Rate for Payer: Humana Medicare/TRICARE	$4.38
Rate for Payer: Molina CHIP/Medicaid	$4.38
Rate for Payer: Molina Dual Medicare/Medicaid	$4.38
Rate for Payer: Molina Medicare	$4.38
Rate for Payer: Multiplan Auto	$98.80
Rate for Payer: Multiplan Commercial	$98.80
Rate for Payer: Multiplan Workers Comp	$98.80
Rate for Payer: Parkland Medicaid	$4.38
Rate for Payer: Scott and White EPO/PPO	$5.48
Rate for Payer: Scott and White Medicare	$4.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.38
Rate for Payer: Superior Health Plan EPO	$4.38
Rate for Payer: Superior Health Plan Medicare	$4.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.38
Rate for Payer: Universal American Medicare	$4.38
Rate for Payer: Wellcare Medicare	$4.38
Rate for Payer: Wellmed Medicare	$4.38

Occult Blood Stool

Facility

$152.00

Service Code	CPT 82270
Hospital Charge Code	1604073
Hospital Revenue Code	301
Rate for Payer: Cash Price	$133.76

.Occult Blood Stool (POCT)

Facility

$152.00

Service Code	CPT 82270
Hospital Charge Code	4102270
Hospital Revenue Code	301
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$98.80
Rate for Payer: Aetna Commercial	$4.60
Rate for Payer: Aetna Medicare	$6.57
Rate for Payer: Amerigroup CHIP/Medicaid	$1.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.38
Rate for Payer: Amerigroup Medicare	$4.38
Rate for Payer: BCBS of TX Blue Advantage	$7.23
Rate for Payer: BCBS of TX Blue Essentials	$8.67
Rate for Payer: BCBS of TX Medicare	$4.38
Rate for Payer: BCBS of TX PPO	$9.68
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cigna Medicaid	$4.38
Rate for Payer: Cigna Medicare	$4.38
Rate for Payer: Employer Direct Commercial	$4.38
Rate for Payer: Humana Medicare/TRICARE	$4.38
Rate for Payer: Molina CHIP/Medicaid	$4.38
Rate for Payer: Molina Dual Medicare/Medicaid	$4.38
Rate for Payer: Molina Medicare	$4.38
Rate for Payer: Multiplan Auto	$98.80
Rate for Payer: Multiplan Commercial	$98.80
Rate for Payer: Multiplan Workers Comp	$98.80
Rate for Payer: Parkland Medicaid	$4.38
Rate for Payer: Scott and White EPO/PPO	$5.48
Rate for Payer: Scott and White Medicare	$4.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.38
Rate for Payer: Superior Health Plan EPO	$4.38
Rate for Payer: Superior Health Plan Medicare	$4.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.38
Rate for Payer: Universal American Medicare	$4.38
Rate for Payer: Wellcare Medicare	$4.38
Rate for Payer: Wellmed Medicare	$4.38

.Occult Blood Stool (POCT)

Facility

$152.00

Service Code	CPT 82270
Hospital Charge Code	4102270
Hospital Revenue Code	301
Rate for Payer: Cash Price	$133.76

octreotide 500 mcg/mL Inj Soln 1 mL

Facility

$203.00

Service Code	HCPCS J2354
Hospital Charge Code	77732066
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$131.95
Rate for Payer: Amerigroup CHIP/Medicaid	$18.27
Rate for Payer: BCBS of TX Blue Advantage	$0.90
Rate for Payer: BCBS of TX Blue Essentials	$1.08
Rate for Payer: BCBS of TX PPO	$1.20
Rate for Payer: Cash Price	$138.04
Rate for Payer: Cash Price	$138.04
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: Scott and White EPO/PPO	$101.50
Rate for Payer: Superior Health Plan EPO	$27.61

octreotide 500 mcg/mL Inj Soln 1 mL

Facility

$203.00

Service Code	HCPCS J2354
Hospital Charge Code	77732066
Hospital Revenue Code	636
Min. Negotiated Rate	$50.75
Max. Negotiated Rate	$101.50
Rate for Payer: Cash Price	$138.04
Rate for Payer: Cigna Commercial	$50.75
Rate for Payer: Scott and White EPO/PPO	$101.50

Know your out-of-pocket cost for care.

All Charges