White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BB Bill Only Cold Agglutinin Titer

Facility

$68.00

Service Code	CPT 86157
Hospital Charge Code	2400513
Hospital Revenue Code	302
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$44.20
Rate for Payer: Aetna Commercial	$8.47
Rate for Payer: Aetna Medicare	$12.09
Rate for Payer: Amerigroup CHIP/Medicaid	$3.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.06
Rate for Payer: Amerigroup Medicare	$8.06
Rate for Payer: BCBS of TX Blue Advantage	$13.30
Rate for Payer: BCBS of TX Blue Essentials	$15.96
Rate for Payer: BCBS of TX Medicare	$8.06
Rate for Payer: BCBS of TX PPO	$17.81
Rate for Payer: Cash Price	$59.84
Rate for Payer: Cash Price	$59.84
Rate for Payer: Cigna Medicaid	$8.06
Rate for Payer: Cigna Medicare	$8.06
Rate for Payer: Employer Direct Commercial	$8.06
Rate for Payer: Humana Medicare/TRICARE	$8.06
Rate for Payer: Molina CHIP/Medicaid	$8.06
Rate for Payer: Molina Dual Medicare/Medicaid	$8.06
Rate for Payer: Molina Medicare	$8.06
Rate for Payer: Multiplan Auto	$44.20
Rate for Payer: Multiplan Commercial	$44.20
Rate for Payer: Multiplan Workers Comp	$44.20
Rate for Payer: Parkland Medicaid	$8.06
Rate for Payer: Scott and White EPO/PPO	$10.08
Rate for Payer: Scott and White Medicare	$8.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.06
Rate for Payer: Superior Health Plan EPO	$8.06
Rate for Payer: Superior Health Plan Medicare	$8.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.06
Rate for Payer: Universal American Medicare	$8.06
Rate for Payer: Wellcare Medicare	$8.06
Rate for Payer: Wellmed Medicare	$8.06

BCE Booster Dose Moderna 0064A

Facility

$40.00

Service Code	CPT 0064A
Hospital Charge Code	8812543
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$22.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$35.20
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan EPO	$5.44

BCE Booster Dose Moderna 0064A

Facility

$40.00

Service Code	CPT 0064A
Hospital Charge Code	8812543
Hospital Revenue Code	771
Rate for Payer: Cash Price	$35.20

BCE Booster Dose Pfizer 0004A

Facility

$60.00

Service Code	CPT 0004A
Hospital Charge Code	8752545
Hospital Revenue Code	771
Rate for Payer: Cash Price	$52.80

BCE Booster Dose Pfizer 0004A

Facility

$60.00

Service Code	CPT 0004A
Hospital Charge Code	8752545
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan EPO	$8.16

BCE Booster Dose Pfizer 004A

Facility

$40.00

Service Code	CPT 0004A
Hospital Charge Code	8810545
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$22.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$35.20
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan EPO	$5.44

BCE Booster Dose Pfizer 004A

Facility

$40.00

Service Code	CPT 0004A
Hospital Charge Code	8810545
Hospital Revenue Code	771
Rate for Payer: Cash Price	$35.20

BCE First Dose Moderna 0011A

Facility

$40.00

Service Code	CPT 0011A
Hospital Charge Code	8812544
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$22.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$35.20
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan EPO	$5.44

BCE First Dose Moderna 0011A

Facility

$40.00

Service Code	CPT 0011A
Hospital Charge Code	8812544
Hospital Revenue Code	771
Rate for Payer: Cash Price	$35.20

BCE First Dose Pfizer 0001A

Facility

$40.00

Service Code	CPT 0001A
Hospital Charge Code	8814541
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$22.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$35.20
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan EPO	$5.44

BCE First Dose Pfizer 0001A

Facility

$40.00

Service Code	CPT 0001A
Hospital Charge Code	8814541
Hospital Revenue Code	771
Rate for Payer: Cash Price	$35.20

BCE OP Peritoneal Dialysis Treatment Complete

Facility

$2,495.91

Service Code	CPT 90945
Hospital Charge Code	8862568
Hospital Revenue Code	830
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$1,622.34
Rate for Payer: Aetna Commercial	$1,372.75
Rate for Payer: Aetna Medicare	$607.59
Rate for Payer: Amerigroup CHIP/Medicaid	$224.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$405.06
Rate for Payer: Amerigroup Medicare	$405.06
Rate for Payer: BCBS of TX Blue Advantage	$748.77
Rate for Payer: BCBS of TX Blue Essentials	$898.53
Rate for Payer: BCBS of TX Medicare	$405.06
Rate for Payer: BCBS of TX PPO	$998.36
Rate for Payer: Cash Price	$2,196.40
Rate for Payer: Cash Price	$2,196.40
Rate for Payer: Cash Price	$2,196.40
Rate for Payer: Cigna Commercial	$917.59
Rate for Payer: Cigna Medicare	$405.06
Rate for Payer: Employer Direct Commercial	$405.06
Rate for Payer: Humana Medicare/TRICARE	$405.06
Rate for Payer: Molina Dual Medicare/Medicaid	$405.06
Rate for Payer: Molina Medicare	$405.06
Rate for Payer: Multiplan Auto	$1,622.34
Rate for Payer: Multiplan Commercial	$1,622.34
Rate for Payer: Multiplan Workers Comp	$1,622.34
Rate for Payer: Scott and White EPO/PPO	$7.24
Rate for Payer: Scott and White Medicare	$405.06
Rate for Payer: Superior Health Plan EPO	$405.06
Rate for Payer: Superior Health Plan Medicare	$405.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$405.06
Rate for Payer: Universal American Medicare	$405.06
Rate for Payer: Wellcare Medicare	$405.06
Rate for Payer: Wellmed Medicare	$405.06

BCE OP Peritoneal Dialysis Treatment Complete

Facility

$2,495.91

Service Code	CPT 90945
Hospital Charge Code	8862568
Hospital Revenue Code	830
Rate for Payer: Cash Price	$2,196.40

BCE Third Dose Moderna 0013A

Facility

$40.00

Service Code	CPT 0013A
Hospital Charge Code	8812542
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$22.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$35.20
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan EPO	$5.44

BCE Third Dose Moderna 0013A

Facility

$40.00

Service Code	CPT 0013A
Hospital Charge Code	8812542
Hospital Revenue Code	771
Rate for Payer: Cash Price	$35.20

BD Bone Density DEXA App Skeleton

Facility

$274.00

Service Code	CPT 77081
Hospital Charge Code	3620143
Hospital Revenue Code	320
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$188.25
Rate for Payer: Aetna Commercial	$24.10
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$31.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$83.10
Rate for Payer: Amerigroup Medicare	$83.10
Rate for Payer: BCBS of TX Blue Advantage	$38.66
Rate for Payer: BCBS of TX Blue Essentials	$46.39
Rate for Payer: BCBS of TX Medicare	$83.10
Rate for Payer: BCBS of TX PPO	$51.78
Rate for Payer: Cash Price	$241.12
Rate for Payer: Cash Price	$241.12
Rate for Payer: Cash Price	$241.12
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$31.41
Rate for Payer: Cigna Medicare	$83.10
Rate for Payer: Employer Direct Commercial	$83.10
Rate for Payer: Humana Medicare/TRICARE	$83.10
Rate for Payer: Molina CHIP/Medicaid	$31.41
Rate for Payer: Molina Dual Medicare/Medicaid	$83.10
Rate for Payer: Molina Medicare	$83.10
Rate for Payer: Multiplan Auto	$178.10
Rate for Payer: Multiplan Commercial	$178.10
Rate for Payer: Multiplan Workers Comp	$178.10
Rate for Payer: Parkland Medicaid	$31.41
Rate for Payer: Scott and White EPO/PPO	$1.49
Rate for Payer: Scott and White Medicare	$83.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.41
Rate for Payer: Superior Health Plan EPO	$83.10
Rate for Payer: Superior Health Plan Medicare	$83.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$83.10
Rate for Payer: Universal American Medicare	$83.10
Rate for Payer: Wellcare Medicare	$83.10
Rate for Payer: Wellmed Medicare	$83.10

BD Bone Density DEXA App Skeleton BCE

Facility

$274.00

Service Code	CPT 77081
Hospital Charge Code	3620143
Hospital Revenue Code	320
Rate for Payer: Cash Price	$241.12

BD Bone Density DEXA App Skeleton BCE

Facility

$274.00

Service Code	CPT 77081
Hospital Charge Code	3620143
Hospital Revenue Code	320
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$188.25
Rate for Payer: Aetna Commercial	$24.10
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$31.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$83.10
Rate for Payer: Amerigroup Medicare	$83.10
Rate for Payer: BCBS of TX Blue Advantage	$38.66
Rate for Payer: BCBS of TX Blue Essentials	$46.39
Rate for Payer: BCBS of TX Medicare	$83.10
Rate for Payer: BCBS of TX PPO	$51.78
Rate for Payer: Cash Price	$241.12
Rate for Payer: Cash Price	$241.12
Rate for Payer: Cash Price	$241.12
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$31.41
Rate for Payer: Cigna Medicare	$83.10
Rate for Payer: Employer Direct Commercial	$83.10
Rate for Payer: Humana Medicare/TRICARE	$83.10
Rate for Payer: Molina CHIP/Medicaid	$31.41
Rate for Payer: Molina Dual Medicare/Medicaid	$83.10
Rate for Payer: Molina Medicare	$83.10
Rate for Payer: Multiplan Auto	$178.10
Rate for Payer: Multiplan Commercial	$178.10
Rate for Payer: Multiplan Workers Comp	$178.10
Rate for Payer: Parkland Medicaid	$31.41
Rate for Payer: Scott and White EPO/PPO	$1.49
Rate for Payer: Scott and White Medicare	$83.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.41
Rate for Payer: Superior Health Plan EPO	$83.10
Rate for Payer: Superior Health Plan Medicare	$83.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$83.10
Rate for Payer: Universal American Medicare	$83.10
Rate for Payer: Wellcare Medicare	$83.10
Rate for Payer: Wellmed Medicare	$83.10

BD Bone Density DEXA Axial Skeleton

Facility

$510.00

Service Code	CPT 77080
Hospital Charge Code	3620135
Hospital Revenue Code	320
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$331.50
Rate for Payer: Aetna Commercial	$31.41
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$38.09
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$100.55
Rate for Payer: Amerigroup Medicare	$100.55
Rate for Payer: BCBS of TX Blue Advantage	$50.54
Rate for Payer: BCBS of TX Blue Essentials	$60.65
Rate for Payer: BCBS of TX Medicare	$100.55
Rate for Payer: BCBS of TX PPO	$67.69
Rate for Payer: Cash Price	$448.80
Rate for Payer: Cash Price	$448.80
Rate for Payer: Cash Price	$448.80
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$38.09
Rate for Payer: Cigna Medicare	$100.55
Rate for Payer: Employer Direct Commercial	$100.55
Rate for Payer: Humana Medicare/TRICARE	$100.55
Rate for Payer: Molina CHIP/Medicaid	$38.09
Rate for Payer: Molina Dual Medicare/Medicaid	$100.55
Rate for Payer: Molina Medicare	$100.55
Rate for Payer: Multiplan Auto	$331.50
Rate for Payer: Multiplan Commercial	$331.50
Rate for Payer: Multiplan Workers Comp	$331.50
Rate for Payer: Parkland Medicaid	$38.09
Rate for Payer: Scott and White EPO/PPO	$1.80
Rate for Payer: Scott and White Medicare	$100.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.09
Rate for Payer: Superior Health Plan EPO	$100.55
Rate for Payer: Superior Health Plan Medicare	$100.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$100.55
Rate for Payer: Universal American Medicare	$100.55
Rate for Payer: Wellcare Medicare	$100.55
Rate for Payer: Wellmed Medicare	$100.55

BD Bone Density DEXA Axial Skeleton BCE

Facility

$510.00

Service Code	CPT 77080
Hospital Charge Code	3620135
Hospital Revenue Code	320
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$331.50
Rate for Payer: Aetna Commercial	$31.41
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$38.09
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$100.55
Rate for Payer: Amerigroup Medicare	$100.55
Rate for Payer: BCBS of TX Blue Advantage	$50.54
Rate for Payer: BCBS of TX Blue Essentials	$60.65
Rate for Payer: BCBS of TX Medicare	$100.55
Rate for Payer: BCBS of TX PPO	$67.69
Rate for Payer: Cash Price	$448.80
Rate for Payer: Cash Price	$448.80
Rate for Payer: Cash Price	$448.80
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$38.09
Rate for Payer: Cigna Medicare	$100.55
Rate for Payer: Employer Direct Commercial	$100.55
Rate for Payer: Humana Medicare/TRICARE	$100.55
Rate for Payer: Molina CHIP/Medicaid	$38.09
Rate for Payer: Molina Dual Medicare/Medicaid	$100.55
Rate for Payer: Molina Medicare	$100.55
Rate for Payer: Multiplan Auto	$331.50
Rate for Payer: Multiplan Commercial	$331.50
Rate for Payer: Multiplan Workers Comp	$331.50
Rate for Payer: Parkland Medicaid	$38.09
Rate for Payer: Scott and White EPO/PPO	$1.80
Rate for Payer: Scott and White Medicare	$100.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.09
Rate for Payer: Superior Health Plan EPO	$100.55
Rate for Payer: Superior Health Plan Medicare	$100.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$100.55
Rate for Payer: Universal American Medicare	$100.55
Rate for Payer: Wellcare Medicare	$100.55
Rate for Payer: Wellmed Medicare	$100.55

BD Bone Density DEXA Axial Skeleton BCE

Facility

$510.00

Service Code	CPT 77080
Hospital Charge Code	3620135
Hospital Revenue Code	320
Rate for Payer: Cash Price	$448.80

BD Bone Density Vertebral FX 1+ Sites

Facility

$538.00

Service Code	CPT 77085
Hospital Charge Code	5017085
Hospital Revenue Code	320
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$349.70
Rate for Payer: Aetna Commercial	$41.42
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$51.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$100.55
Rate for Payer: Amerigroup Medicare	$100.55
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$100.55
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$473.44
Rate for Payer: Cash Price	$473.44
Rate for Payer: Cash Price	$473.44
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$51.79
Rate for Payer: Cigna Medicare	$100.55
Rate for Payer: Employer Direct Commercial	$100.55
Rate for Payer: Humana Medicare/TRICARE	$100.55
Rate for Payer: Molina CHIP/Medicaid	$51.79
Rate for Payer: Molina Dual Medicare/Medicaid	$100.55
Rate for Payer: Molina Medicare	$100.55
Rate for Payer: Multiplan Auto	$349.70
Rate for Payer: Multiplan Commercial	$349.70
Rate for Payer: Multiplan Workers Comp	$349.70
Rate for Payer: Parkland Medicaid	$51.79
Rate for Payer: Scott and White EPO/PPO	$1.80
Rate for Payer: Scott and White Medicare	$100.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.79
Rate for Payer: Superior Health Plan EPO	$100.55
Rate for Payer: Superior Health Plan Medicare	$100.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$100.55
Rate for Payer: Universal American Medicare	$100.55
Rate for Payer: Wellcare Medicare	$100.55
Rate for Payer: Wellmed Medicare	$100.55

BD Bone Density Vertebral FX 1+ Sites BCE

Facility

$538.00

Service Code	CPT 77085
Hospital Charge Code	5017085
Hospital Revenue Code	320
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$349.70
Rate for Payer: Aetna Commercial	$41.42
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$51.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$100.55
Rate for Payer: Amerigroup Medicare	$100.55
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$100.55
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$473.44
Rate for Payer: Cash Price	$473.44
Rate for Payer: Cash Price	$473.44
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$51.79
Rate for Payer: Cigna Medicare	$100.55
Rate for Payer: Employer Direct Commercial	$100.55
Rate for Payer: Humana Medicare/TRICARE	$100.55
Rate for Payer: Molina CHIP/Medicaid	$51.79
Rate for Payer: Molina Dual Medicare/Medicaid	$100.55
Rate for Payer: Molina Medicare	$100.55
Rate for Payer: Multiplan Auto	$349.70
Rate for Payer: Multiplan Commercial	$349.70
Rate for Payer: Multiplan Workers Comp	$349.70
Rate for Payer: Parkland Medicaid	$51.79
Rate for Payer: Scott and White EPO/PPO	$1.80
Rate for Payer: Scott and White Medicare	$100.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.79
Rate for Payer: Superior Health Plan EPO	$100.55
Rate for Payer: Superior Health Plan Medicare	$100.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$100.55
Rate for Payer: Universal American Medicare	$100.55
Rate for Payer: Wellcare Medicare	$100.55
Rate for Payer: Wellmed Medicare	$100.55

BD Bone Density Vertebral FX 1+ Sites BCE

Facility

$538.00

Service Code	CPT 77085
Hospital Charge Code	5017085
Hospital Revenue Code	320
Rate for Payer: Cash Price	$473.44

BEHAVIORAL AND DEVELOPMENTAL DISORDERS

Facility

$31,952.30

Service Code	MSDRG 886
Min. Negotiated Rate	$7,171.54
Max. Negotiated Rate	$31,952.30
Rate for Payer: Aetna Commercial	$18,919.12
Rate for Payer: Aetna Medicare	$22,283.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,855.50
Rate for Payer: Amerigroup Medicare	$14,855.50
Rate for Payer: BCBS of TX Blue Advantage	$7,171.54
Rate for Payer: BCBS of TX Blue Essentials	$10,202.40
Rate for Payer: BCBS of TX Medicare	$14,855.50
Rate for Payer: BCBS of TX PPO	$11,336.43
Rate for Payer: Cigna Commercial	$21,660.30
Rate for Payer: Cigna Medicare	$14,855.50
Rate for Payer: Employer Direct Commercial	$14,855.50
Rate for Payer: Molina Dual Medicare/Medicaid	$14,855.50
Rate for Payer: Molina Medicare	$14,855.50
Rate for Payer: Multiplan Auto	$31,952.30
Rate for Payer: Multiplan Commercial	$31,952.30
Rate for Payer: Multiplan Workers Comp	$31,952.30
Rate for Payer: Scott and White EPO/PPO	$14,714.88
Rate for Payer: Scott and White Medicare	$14,855.50
Rate for Payer: Superior Health Plan EPO	$14,855.50
Rate for Payer: Superior Health Plan Medicare	$14,855.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,855.50
Rate for Payer: Universal American Medicare	$14,855.50
Rate for Payer: Wellcare Medicare	$14,855.50
Rate for Payer: Wellmed Medicare	$14,855.50

Know your out-of-pocket cost for care.

All Charges