White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TIP, SCISSOR LAPCLINCH - DISPOSABLE -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Min. Negotiated Rate	$53.79
Max. Negotiated Rate	$388.45
Rate for Payer: Aetna Commercial	$328.69
Rate for Payer: Amerigroup CHIP/Medicaid	$53.79
Rate for Payer: BCBS of TX Blue Advantage	$179.29
Rate for Payer: BCBS of TX Blue Essentials	$215.14
Rate for Payer: BCBS of TX PPO	$239.05
Rate for Payer: Cash Price	$525.91
Rate for Payer: Multiplan Auto	$388.45
Rate for Payer: Multiplan Commercial	$388.45
Rate for Payer: Multiplan Workers Comp	$388.45
Rate for Payer: Scott and White EPO/PPO	$298.81
Rate for Payer: Superior Health Plan EPO	$81.28

TIP, SCISSOR LAPCLINCH - DISPOSABLE -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Rate for Payer: Cash Price	$525.91

TIP, SUCTION YANKAUER SOFT TIP W/VENT NONSTRL DISP -- DHF

Facility

$41.57

Hospital Charge Code	81855553
Hospital Revenue Code	270
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$27.02
Rate for Payer: Aetna Commercial	$22.86
Rate for Payer: Amerigroup CHIP/Medicaid	$3.74
Rate for Payer: BCBS of TX Blue Advantage	$12.47
Rate for Payer: BCBS of TX Blue Essentials	$14.97
Rate for Payer: BCBS of TX PPO	$16.63
Rate for Payer: Cash Price	$36.58
Rate for Payer: Multiplan Auto	$27.02
Rate for Payer: Multiplan Commercial	$27.02
Rate for Payer: Multiplan Workers Comp	$27.02
Rate for Payer: Scott and White EPO/PPO	$20.79
Rate for Payer: Superior Health Plan EPO	$5.65

TIP, SUCTION YANKAUER SOFT TIP W/VENT NONSTRL DISP -- DHF

Facility

$41.57

Hospital Charge Code	81855553
Hospital Revenue Code	270
Rate for Payer: Cash Price	$36.58

TIP, UTERINE MANIPULATOR BLU 6.7MMX8CM STRL DISP--DHF

Facility

$249.31

Hospital Charge Code	81810152
Hospital Revenue Code	270
Min. Negotiated Rate	$22.44
Max. Negotiated Rate	$162.05
Rate for Payer: Aetna Commercial	$137.12
Rate for Payer: Amerigroup CHIP/Medicaid	$22.44
Rate for Payer: BCBS of TX Blue Advantage	$74.79
Rate for Payer: BCBS of TX Blue Essentials	$89.75
Rate for Payer: BCBS of TX PPO	$99.72
Rate for Payer: Cash Price	$219.39
Rate for Payer: Multiplan Auto	$162.05
Rate for Payer: Multiplan Commercial	$162.05
Rate for Payer: Multiplan Workers Comp	$162.05
Rate for Payer: Scott and White EPO/PPO	$124.66
Rate for Payer: Superior Health Plan EPO	$33.91

TIP, UTERINE MANIPULATOR GRN 6.7MMX10CM STRL DISP -- DHF

Facility

$249.31

Hospital Charge Code	81810152
Hospital Revenue Code	270
Min. Negotiated Rate	$22.44
Max. Negotiated Rate	$162.05
Rate for Payer: Aetna Commercial	$137.12
Rate for Payer: Amerigroup CHIP/Medicaid	$22.44
Rate for Payer: BCBS of TX Blue Advantage	$74.79
Rate for Payer: BCBS of TX Blue Essentials	$89.75
Rate for Payer: BCBS of TX PPO	$99.72
Rate for Payer: Cash Price	$219.39
Rate for Payer: Multiplan Auto	$162.05
Rate for Payer: Multiplan Commercial	$162.05
Rate for Payer: Multiplan Workers Comp	$162.05
Rate for Payer: Scott and White EPO/PPO	$124.66
Rate for Payer: Superior Health Plan EPO	$33.91

TIP, UTERINE MANIPULATOR WHT 6.7MMX6CM STRL DISP -- DHF

Facility

$249.31

Hospital Charge Code	81810152
Hospital Revenue Code	270
Min. Negotiated Rate	$22.44
Max. Negotiated Rate	$162.05
Rate for Payer: Aetna Commercial	$137.12
Rate for Payer: Amerigroup CHIP/Medicaid	$22.44
Rate for Payer: BCBS of TX Blue Advantage	$74.79
Rate for Payer: BCBS of TX Blue Essentials	$89.75
Rate for Payer: BCBS of TX PPO	$99.72
Rate for Payer: Cash Price	$219.39
Rate for Payer: Multiplan Auto	$162.05
Rate for Payer: Multiplan Commercial	$162.05
Rate for Payer: Multiplan Workers Comp	$162.05
Rate for Payer: Scott and White EPO/PPO	$124.66
Rate for Payer: Superior Health Plan EPO	$33.91

TIP, UTERINE MANIPULATOR WHT 6.7MMX6CM STRL DISP -- DHF

Facility

$249.31

Hospital Charge Code	81810152
Hospital Revenue Code	270
Rate for Payer: Cash Price	$219.39

Tissue Culture

Facility

$151.00

Service Code	CPT 87252
Hospital Charge Code	7009356
Hospital Revenue Code	306
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$98.15
Rate for Payer: Aetna Commercial	$27.37
Rate for Payer: Aetna Medicare	$39.10
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.07
Rate for Payer: Amerigroup Medicare	$26.07
Rate for Payer: BCBS of TX Blue Advantage	$43.02
Rate for Payer: BCBS of TX Blue Essentials	$51.62
Rate for Payer: BCBS of TX Medicare	$26.07
Rate for Payer: BCBS of TX PPO	$57.61
Rate for Payer: Cash Price	$132.88
Rate for Payer: Cash Price	$132.88
Rate for Payer: Cigna Medicaid	$26.07
Rate for Payer: Cigna Medicare	$26.07
Rate for Payer: Employer Direct Commercial	$26.07
Rate for Payer: Humana Medicare/TRICARE	$26.07
Rate for Payer: Molina CHIP/Medicaid	$26.07
Rate for Payer: Molina Dual Medicare/Medicaid	$26.07
Rate for Payer: Molina Medicare	$26.07
Rate for Payer: Multiplan Auto	$98.15
Rate for Payer: Multiplan Commercial	$98.15
Rate for Payer: Multiplan Workers Comp	$98.15
Rate for Payer: Parkland Medicaid	$26.07
Rate for Payer: Scott and White EPO/PPO	$32.59
Rate for Payer: Scott and White Medicare	$26.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.07
Rate for Payer: Superior Health Plan EPO	$26.07
Rate for Payer: Superior Health Plan Medicare	$26.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.07
Rate for Payer: Universal American Medicare	$26.07
Rate for Payer: Wellcare Medicare	$26.07
Rate for Payer: Wellmed Medicare	$26.07

Tissue Culture

Facility

$151.00

Service Code	CPT 87252
Hospital Charge Code	7009356
Hospital Revenue Code	306
Rate for Payer: Cash Price	$132.88

TISSUE EXPANDER IMPLANT

Facility

$12,469.87

Service Code	HCPCS L8600
Hospital Charge Code	8470488
Hospital Revenue Code	278
Min. Negotiated Rate	$1,122.29
Max. Negotiated Rate	$6,234.94
Rate for Payer: Aetna Commercial	$3,740.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1,122.29
Rate for Payer: BCBS of TX Blue Advantage	$3,740.96
Rate for Payer: BCBS of TX Blue Essentials	$4,489.15
Rate for Payer: BCBS of TX PPO	$4,987.95
Rate for Payer: Cash Price	$10,973.49
Rate for Payer: Multiplan Auto	$6,234.94
Rate for Payer: Multiplan Commercial	$6,234.94
Rate for Payer: Multiplan Workers Comp	$6,234.94
Rate for Payer: Scott and White EPO/PPO	$6,234.94
Rate for Payer: Superior Health Plan EPO	$1,695.90

TISSUE EXPANDER IMPLANT

Facility

$12,469.87

Service Code	HCPCS L8600
Hospital Charge Code	8470488
Hospital Revenue Code	278
Min. Negotiated Rate	$3,117.47
Max. Negotiated Rate	$6,234.94
Rate for Payer: Aetna Commercial	$3,740.96
Rate for Payer: Cash Price	$10,973.49
Rate for Payer: Cigna Commercial	$3,117.47
Rate for Payer: Multiplan Auto	$6,234.94
Rate for Payer: Multiplan Commercial	$6,234.94
Rate for Payer: Multiplan Workers Comp	$6,234.94
Rate for Payer: Scott and White EPO/PPO	$6,234.94

TK QUICK LOAD WITH TITANIUM KNOT

Facility

$210.00

Hospital Charge Code	8452484
Hospital Revenue Code	272
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$136.50
Rate for Payer: Aetna Commercial	$115.50
Rate for Payer: Amerigroup CHIP/Medicaid	$18.90
Rate for Payer: BCBS of TX Blue Advantage	$63.00
Rate for Payer: BCBS of TX Blue Essentials	$75.60
Rate for Payer: BCBS of TX PPO	$84.00
Rate for Payer: Cash Price	$184.80
Rate for Payer: Multiplan Auto	$136.50
Rate for Payer: Multiplan Commercial	$136.50
Rate for Payer: Multiplan Workers Comp	$136.50
Rate for Payer: Scott and White EPO/PPO	$105.00
Rate for Payer: Superior Health Plan EPO	$28.56

TK QUICK LOAD WITH TITANIUM KNOT

Facility

$210.00

Hospital Charge Code	8452484
Hospital Revenue Code	272
Rate for Payer: Cash Price	$184.80

TK TI-KNOT DEVICE

Facility

$885.30

Hospital Charge Code	8452482
Hospital Revenue Code	272
Rate for Payer: Cash Price	$779.06

TK TI-KNOT DEVICE

Facility

$885.30

Hospital Charge Code	8452482
Hospital Revenue Code	272
Min. Negotiated Rate	$79.68
Max. Negotiated Rate	$575.45
Rate for Payer: Aetna Commercial	$486.92
Rate for Payer: Amerigroup CHIP/Medicaid	$79.68
Rate for Payer: BCBS of TX Blue Advantage	$265.59
Rate for Payer: BCBS of TX Blue Essentials	$318.71
Rate for Payer: BCBS of TX PPO	$354.12
Rate for Payer: Cash Price	$779.06
Rate for Payer: Multiplan Auto	$575.45
Rate for Payer: Multiplan Commercial	$575.45
Rate for Payer: Multiplan Workers Comp	$575.45
Rate for Payer: Scott and White EPO/PPO	$442.65
Rate for Payer: Superior Health Plan EPO	$120.40

T-Lymphocyte Helper/Suppressor SO

Facility

$764.00

Service Code	CPT 86360
Hospital Charge Code	1708981
Hospital Revenue Code	302
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$496.60
Rate for Payer: Aetna Commercial	$49.33
Rate for Payer: Aetna Medicare	$70.47
Rate for Payer: Amerigroup CHIP/Medicaid	$18.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$46.98
Rate for Payer: Amerigroup Medicare	$46.98
Rate for Payer: BCBS of TX Blue Advantage	$77.52
Rate for Payer: BCBS of TX Blue Essentials	$93.02
Rate for Payer: BCBS of TX Medicare	$46.98
Rate for Payer: BCBS of TX PPO	$103.83
Rate for Payer: Cash Price	$672.32
Rate for Payer: Cash Price	$672.32
Rate for Payer: Cigna Medicaid	$46.98
Rate for Payer: Cigna Medicare	$46.98
Rate for Payer: Employer Direct Commercial	$46.98
Rate for Payer: Humana Medicare/TRICARE	$46.98
Rate for Payer: Molina CHIP/Medicaid	$46.98
Rate for Payer: Molina Dual Medicare/Medicaid	$46.98
Rate for Payer: Molina Medicare	$46.98
Rate for Payer: Multiplan Auto	$496.60
Rate for Payer: Multiplan Commercial	$496.60
Rate for Payer: Multiplan Workers Comp	$496.60
Rate for Payer: Parkland Medicaid	$46.98
Rate for Payer: Scott and White EPO/PPO	$58.73
Rate for Payer: Scott and White Medicare	$46.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.98
Rate for Payer: Superior Health Plan EPO	$46.98
Rate for Payer: Superior Health Plan Medicare	$46.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$46.98
Rate for Payer: Universal American Medicare	$46.98
Rate for Payer: Wellcare Medicare	$46.98
Rate for Payer: Wellmed Medicare	$46.98

T-Lymphocyte Helper/Suppressor SO

Facility

$764.00

Service Code	CPT 86360
Hospital Charge Code	1708981
Hospital Revenue Code	302
Rate for Payer: Cash Price	$672.32

TOBACCO COUNSEL >10MIN SYMTOMATIC

Facility

$97.00

Service Code	CPT 99407
Hospital Charge Code	6010376
Hospital Revenue Code	942
Min. Negotiated Rate	$8.73
Max. Negotiated Rate	$63.05
Rate for Payer: Aetna Commercial	$53.35
Rate for Payer: Aetna Medicare	$39.36
Rate for Payer: Amerigroup CHIP/Medicaid	$8.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.24
Rate for Payer: Amerigroup Medicare	$26.24
Rate for Payer: BCBS of TX Blue Advantage	$45.78
Rate for Payer: BCBS of TX Blue Essentials	$54.72
Rate for Payer: BCBS of TX Medicare	$26.24
Rate for Payer: BCBS of TX PPO	$61.04
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cigna Commercial	$59.45
Rate for Payer: Cigna Medicaid	$20.07
Rate for Payer: Cigna Medicare	$26.24
Rate for Payer: Employer Direct Commercial	$26.24
Rate for Payer: Humana Medicare/TRICARE	$26.24
Rate for Payer: Molina CHIP/Medicaid	$20.07
Rate for Payer: Molina Dual Medicare/Medicaid	$26.24
Rate for Payer: Molina Medicare	$26.24
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$20.07
Rate for Payer: Scott and White EPO/PPO	$30.38
Rate for Payer: Scott and White Medicare	$26.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.07
Rate for Payer: Superior Health Plan EPO	$26.24
Rate for Payer: Superior Health Plan Medicare	$26.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.24
Rate for Payer: Universal American Medicare	$26.24
Rate for Payer: Wellcare Medicare	$26.24
Rate for Payer: Wellmed Medicare	$26.24

TOBACCO COUNSEL >10MIN SYMTOMATIC

Facility

$97.00

Service Code	CPT 99407
Hospital Charge Code	6010376
Hospital Revenue Code	942
Rate for Payer: Cash Price	$85.36

TOBACCO COUNSEL >10MIN SYMTOMATIC WOUND

Facility

$97.00

Service Code	CPT 99407
Hospital Charge Code	7150782
Hospital Revenue Code	761
Min. Negotiated Rate	$8.73
Max. Negotiated Rate	$63.05
Rate for Payer: Aetna Commercial	$53.35
Rate for Payer: Aetna Medicare	$39.36
Rate for Payer: Amerigroup CHIP/Medicaid	$8.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.24
Rate for Payer: Amerigroup Medicare	$26.24
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX Medicare	$26.24
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cigna Commercial	$59.45
Rate for Payer: Cigna Medicaid	$20.07
Rate for Payer: Cigna Medicare	$26.24
Rate for Payer: Employer Direct Commercial	$26.24
Rate for Payer: Humana Medicare/TRICARE	$26.24
Rate for Payer: Molina CHIP/Medicaid	$20.07
Rate for Payer: Molina Dual Medicare/Medicaid	$26.24
Rate for Payer: Molina Medicare	$26.24
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$20.07
Rate for Payer: Scott and White EPO/PPO	$30.38
Rate for Payer: Scott and White Medicare	$26.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.07
Rate for Payer: Superior Health Plan EPO	$26.24
Rate for Payer: Superior Health Plan Medicare	$26.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.24
Rate for Payer: Universal American Medicare	$26.24
Rate for Payer: Wellcare Medicare	$26.24
Rate for Payer: Wellmed Medicare	$26.24

Tobramycin Level

Facility

$396.00

Service Code	CPT 80200
Hospital Charge Code	1601475
Hospital Revenue Code	300
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$257.40
Rate for Payer: Aetna Commercial	$16.94
Rate for Payer: Aetna Medicare	$24.20
Rate for Payer: Amerigroup CHIP/Medicaid	$6.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.13
Rate for Payer: Amerigroup Medicare	$16.13
Rate for Payer: BCBS of TX Blue Advantage	$26.61
Rate for Payer: BCBS of TX Blue Essentials	$31.94
Rate for Payer: BCBS of TX Medicare	$16.13
Rate for Payer: BCBS of TX PPO	$35.65
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cigna Medicaid	$16.13
Rate for Payer: Cigna Medicare	$16.13
Rate for Payer: Employer Direct Commercial	$16.13
Rate for Payer: Humana Medicare/TRICARE	$16.13
Rate for Payer: Molina CHIP/Medicaid	$16.13
Rate for Payer: Molina Dual Medicare/Medicaid	$16.13
Rate for Payer: Molina Medicare	$16.13
Rate for Payer: Multiplan Auto	$257.40
Rate for Payer: Multiplan Commercial	$257.40
Rate for Payer: Multiplan Workers Comp	$257.40
Rate for Payer: Parkland Medicaid	$16.13
Rate for Payer: Scott and White EPO/PPO	$20.16
Rate for Payer: Scott and White Medicare	$16.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.13
Rate for Payer: Superior Health Plan EPO	$16.13
Rate for Payer: Superior Health Plan Medicare	$16.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.13
Rate for Payer: Universal American Medicare	$16.13
Rate for Payer: Wellcare Medicare	$16.13
Rate for Payer: Wellmed Medicare	$16.13

Tobramycin Level Peak

Facility

$396.00

Service Code	CPT 80200
Hospital Charge Code	1601475
Hospital Revenue Code	300
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$257.40
Rate for Payer: Aetna Commercial	$16.94
Rate for Payer: Aetna Medicare	$24.20
Rate for Payer: Amerigroup CHIP/Medicaid	$6.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.13
Rate for Payer: Amerigroup Medicare	$16.13
Rate for Payer: BCBS of TX Blue Advantage	$26.61
Rate for Payer: BCBS of TX Blue Essentials	$31.94
Rate for Payer: BCBS of TX Medicare	$16.13
Rate for Payer: BCBS of TX PPO	$35.65
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cigna Medicaid	$16.13
Rate for Payer: Cigna Medicare	$16.13
Rate for Payer: Employer Direct Commercial	$16.13
Rate for Payer: Humana Medicare/TRICARE	$16.13
Rate for Payer: Molina CHIP/Medicaid	$16.13
Rate for Payer: Molina Dual Medicare/Medicaid	$16.13
Rate for Payer: Molina Medicare	$16.13
Rate for Payer: Multiplan Auto	$257.40
Rate for Payer: Multiplan Commercial	$257.40
Rate for Payer: Multiplan Workers Comp	$257.40
Rate for Payer: Parkland Medicaid	$16.13
Rate for Payer: Scott and White EPO/PPO	$20.16
Rate for Payer: Scott and White Medicare	$16.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.13
Rate for Payer: Superior Health Plan EPO	$16.13
Rate for Payer: Superior Health Plan Medicare	$16.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.13
Rate for Payer: Universal American Medicare	$16.13
Rate for Payer: Wellcare Medicare	$16.13
Rate for Payer: Wellmed Medicare	$16.13

Tobramycin Level Trough

Facility

$396.00

Service Code	CPT 80200
Hospital Charge Code	1601475
Hospital Revenue Code	300
Rate for Payer: Cash Price	$348.48

Tobramycin Level Trough

Facility

$396.00

Service Code	CPT 80200
Hospital Charge Code	1601475
Hospital Revenue Code	300
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$257.40
Rate for Payer: Aetna Commercial	$16.94
Rate for Payer: Aetna Medicare	$24.20
Rate for Payer: Amerigroup CHIP/Medicaid	$6.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.13
Rate for Payer: Amerigroup Medicare	$16.13
Rate for Payer: BCBS of TX Blue Advantage	$26.61
Rate for Payer: BCBS of TX Blue Essentials	$31.94
Rate for Payer: BCBS of TX Medicare	$16.13
Rate for Payer: BCBS of TX PPO	$35.65
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cigna Medicaid	$16.13
Rate for Payer: Cigna Medicare	$16.13
Rate for Payer: Employer Direct Commercial	$16.13
Rate for Payer: Humana Medicare/TRICARE	$16.13
Rate for Payer: Molina CHIP/Medicaid	$16.13
Rate for Payer: Molina Dual Medicare/Medicaid	$16.13
Rate for Payer: Molina Medicare	$16.13
Rate for Payer: Multiplan Auto	$257.40
Rate for Payer: Multiplan Commercial	$257.40
Rate for Payer: Multiplan Workers Comp	$257.40
Rate for Payer: Parkland Medicaid	$16.13
Rate for Payer: Scott and White EPO/PPO	$20.16
Rate for Payer: Scott and White Medicare	$16.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.13
Rate for Payer: Superior Health Plan EPO	$16.13
Rate for Payer: Superior Health Plan Medicare	$16.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.13
Rate for Payer: Universal American Medicare	$16.13
Rate for Payer: Wellcare Medicare	$16.13
Rate for Payer: Wellmed Medicare	$16.13

Know your out-of-pocket cost for care.

All Charges