White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord

Facility

$28,192.28

Service Code	HCPCS 63048
Hospital Charge Code	9900765
Hospital Revenue Code	360
Rate for Payer: Cash Price	$19,170.75

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord

Facility

$28,192.28

Service Code	HCPCS 63048
Hospital Charge Code	9900765
Hospital Revenue Code	360
Min. Negotiated Rate	$2,537.31
Max. Negotiated Rate	$20,298.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2,537.31
Rate for Payer: BCBS of TX Blue Advantage	$8,457.68
Rate for Payer: BCBS of TX Blue Essentials	$10,149.22
Rate for Payer: BCBS of TX PPO	$11,276.91
Rate for Payer: Cash Price	$19,170.75
Rate for Payer: Cash Price	$19,170.75
Rate for Payer: Cigna Medicaid	$20,298.44
Rate for Payer: Molina CHIP/Medicaid	$20,298.44
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	$20,298.44
Rate for Payer: Scott and White EPO/PPO	$14,096.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,298.44
Rate for Payer: Superior Health Plan EPO	$3,834.15

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar

Facility

$48,000.00

Service Code	HCPCS 63267
Hospital Charge Code	9900770
Hospital Revenue Code	360
Min. Negotiated Rate	$4,320.00
Max. Negotiated Rate	$34,560.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4,320.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$32,640.00
Rate for Payer: Cash Price	$32,640.00
Rate for Payer: Cash Price	$32,640.00
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$34,560.00
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$34,560.00
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$34,560.00
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34,560.00
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar

Facility

$15,408.22

Service Code	CPT 63267
Hospital Charge Code	36063267
Hospital Revenue Code	360
Min. Negotiated Rate	$7,289.28
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar

Facility

$48,000.00

Service Code	HCPCS 63267
Hospital Charge Code	9900770
Hospital Revenue Code	360
Rate for Payer: Cash Price	$32,640.00

Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

Facility

$61,439.34

Service Code	HCPCS 63655
Hospital Charge Code	9900772
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$48,584.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13,714.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,488.52
Rate for Payer: Amerigroup Medicare	$19,488.52
Rate for Payer: BCBS of TX Blue Advantage	$32,196.63
Rate for Payer: BCBS of TX Blue Essentials	$38,558.84
Rate for Payer: BCBS of TX Medicare	$19,488.52
Rate for Payer: BCBS of TX PPO	$48,584.14
Rate for Payer: Cash Price	$41,778.75
Rate for Payer: Cash Price	$41,778.75
Rate for Payer: Cash Price	$41,778.75
Rate for Payer: Cigna Commercial	$41,195.19
Rate for Payer: Cigna Medicaid	$44,236.32
Rate for Payer: Cigna Medicare	$19,488.52
Rate for Payer: Employer Direct Commercial	$19,488.52
Rate for Payer: Humana Medicare/TRICARE	$19,488.52
Rate for Payer: Molina CHIP/Medicaid	$44,236.32
Rate for Payer: Molina Dual Medicare/Medicaid	$19,488.52
Rate for Payer: Molina Medicare	$19,488.52
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	$44,236.32
Rate for Payer: Scott and White EPO/PPO	$37,011.49
Rate for Payer: Scott and White Medicare	$19,488.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44,236.32
Rate for Payer: Superior Health Plan EPO	$19,488.52
Rate for Payer: Superior Health Plan Medicare	$19,488.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,488.52
Rate for Payer: Universal American Medicare	$19,488.52
Rate for Payer: Wellcare Medicare	$19,488.52
Rate for Payer: Wellmed Medicare	$19,488.52

Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

Facility

$48,584.14

Service Code	CPT 63655
Hospital Charge Code	36063655
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$48,584.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13,714.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,488.52
Rate for Payer: Amerigroup Medicare	$19,488.52
Rate for Payer: BCBS of TX Blue Advantage	$32,196.63
Rate for Payer: BCBS of TX Blue Essentials	$38,558.84
Rate for Payer: BCBS of TX Medicare	$19,488.52
Rate for Payer: BCBS of TX PPO	$48,584.14
Rate for Payer: Cigna Commercial	$41,195.19
Rate for Payer: Cigna Medicare	$19,488.52
Rate for Payer: Employer Direct Commercial	$19,488.52
Rate for Payer: Humana Medicare/TRICARE	$19,488.52
Rate for Payer: Molina Dual Medicare/Medicaid	$19,488.52
Rate for Payer: Molina Medicare	$19,488.52
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	$37,011.49
Rate for Payer: Scott and White Medicare	$19,488.52
Rate for Payer: Superior Health Plan EPO	$19,488.52
Rate for Payer: Superior Health Plan Medicare	$19,488.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,488.52
Rate for Payer: Universal American Medicare	$19,488.52
Rate for Payer: Wellcare Medicare	$19,488.52
Rate for Payer: Wellmed Medicare	$19,488.52

Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

Facility

$61,439.34

Service Code	HCPCS 63655
Hospital Charge Code	9900772
Hospital Revenue Code	360
Rate for Payer: Cash Price	$41,778.75

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$39,687.78

Service Code	HCPCS 63035
Hospital Charge Code	9900762
Hospital Revenue Code	360
Rate for Payer: Cash Price	$26,987.69

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$15,408.22

Service Code	CPT 63042
Hospital Charge Code	36063042
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$15,408.22

Service Code	CPT 63020
Hospital Charge Code	36063020
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$39,687.78

Service Code	HCPCS 63020
Hospital Charge Code	9900760
Hospital Revenue Code	360
Rate for Payer: Cash Price	$26,987.69

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$31,324.75

Service Code	HCPCS 63030
Hospital Charge Code	9900761
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$22,553.82
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$21,300.83
Rate for Payer: Cash Price	$21,300.83
Rate for Payer: Cash Price	$21,300.83
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$22,553.82
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$22,553.82
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$22,553.82
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,553.82
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$15,408.22

Service Code	CPT 63030
Hospital Charge Code	36063030
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$39,687.78

Service Code	HCPCS 63042
Hospital Charge Code	9900763
Hospital Revenue Code	360
Rate for Payer: Cash Price	$26,987.69

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$10,000.00

Service Code	CPT 63035
Hospital Charge Code	36063035
Hospital Revenue Code	360
Min. Negotiated Rate	$281.89
Max. Negotiated Rate	$10,000.00
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	$281.89

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$31,324.75

Service Code	HCPCS 63030
Hospital Charge Code	9900761
Hospital Revenue Code	360
Rate for Payer: Cash Price	$21,300.83

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$39,687.78

Service Code	HCPCS 63035
Hospital Charge Code	9900762
Hospital Revenue Code	360
Min. Negotiated Rate	$3,571.90
Max. Negotiated Rate	$28,575.20
Rate for Payer: Amerigroup CHIP/Medicaid	$3,571.90
Rate for Payer: BCBS of TX Blue Advantage	$11,906.33
Rate for Payer: BCBS of TX Blue Essentials	$14,287.60
Rate for Payer: BCBS of TX PPO	$15,875.11
Rate for Payer: Cash Price	$26,987.69
Rate for Payer: Cash Price	$26,987.69
Rate for Payer: Cigna Medicaid	$28,575.20
Rate for Payer: Molina CHIP/Medicaid	$28,575.20
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	$28,575.20
Rate for Payer: Scott and White EPO/PPO	$19,843.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28,575.20
Rate for Payer: Superior Health Plan EPO	$5,397.54

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$39,687.78

Service Code	HCPCS 63042
Hospital Charge Code	9900763
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$28,575.20
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$26,987.69
Rate for Payer: Cash Price	$26,987.69
Rate for Payer: Cash Price	$26,987.69
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$28,575.20
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$28,575.20
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$28,575.20
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28,575.20
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, fo

Facility

$39,687.78

Service Code	HCPCS 63020
Hospital Charge Code	9900760
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$28,575.20
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$26,987.69
Rate for Payer: Cash Price	$26,987.69
Rate for Payer: Cash Price	$26,987.69
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$28,575.20
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$28,575.20
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$28,575.20
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28,575.20
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

lamoTRIgine 100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77653245
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

lamoTRIgine 100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77653245
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

lamoTRIgine 25 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77653708
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

lamoTRIgine 25 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77653708
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Lamotrigine (Lamictal), Serum SO

Facility

$161.00

Service Code	HCPCS 80175
Hospital Charge Code	1740990
Hospital Revenue Code	301
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$115.92
Rate for Payer: Amerigroup CHIP/Medicaid	$5.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.25
Rate for Payer: Amerigroup Medicare	$13.25
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	$13.25
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	$13.25
Rate for Payer: Employer Direct Commercial	$13.25
Rate for Payer: Humana Medicare/TRICARE	$13.25
Rate for Payer: Molina CHIP/Medicaid	$115.92
Rate for Payer: Molina Dual Medicare/Medicaid	$13.25
Rate for Payer: Molina Medicare	$13.25
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	$16.56
Rate for Payer: Scott and White Medicare	$13.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.92
Rate for Payer: Superior Health Plan EPO	$13.25
Rate for Payer: Superior Health Plan Medicare	$13.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.25
Rate for Payer: Universal American Medicare	$13.25
Rate for Payer: Wellcare Medicare	$13.25
Rate for Payer: Wellmed Medicare	$13.25

Know your out-of-pocket cost for care.

All Charges