White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WC Hyperbaric O2 Full Body Chmbr/30Min BCE

Facility

$582.00

Service Code	HCPCS G0277
Hospital Charge Code	7150920
Hospital Revenue Code	413
Rate for Payer: Cash Price	$512.16

WC Hyperbaric O2 Full Body Chmbr/30Min BCE

Facility

$582.00

Service Code	HCPCS G0277
Hospital Charge Code	7150920
Hospital Revenue Code	413
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$378.30
Rate for Payer: Aetna Commercial	$320.10
Rate for Payer: Aetna Medicare	$190.35
Rate for Payer: Amerigroup CHIP/Medicaid	$52.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$126.90
Rate for Payer: Amerigroup Medicare	$126.90
Rate for Payer: BCBS of TX Blue Advantage	$200.20
Rate for Payer: BCBS of TX Blue Essentials	$239.32
Rate for Payer: BCBS of TX Medicare	$126.90
Rate for Payer: BCBS of TX PPO	$266.94
Rate for Payer: Cash Price	$512.16
Rate for Payer: Cash Price	$512.16
Rate for Payer: Cash Price	$512.16
Rate for Payer: Cigna Commercial	$287.47
Rate for Payer: Cigna Medicare	$126.90
Rate for Payer: Employer Direct Commercial	$126.90
Rate for Payer: Humana Medicare/TRICARE	$126.90
Rate for Payer: Molina Dual Medicare/Medicaid	$126.90
Rate for Payer: Molina Medicare	$126.90
Rate for Payer: Multiplan Auto	$378.30
Rate for Payer: Multiplan Commercial	$378.30
Rate for Payer: Multiplan Workers Comp	$378.30
Rate for Payer: Scott and White EPO/PPO	$2.27
Rate for Payer: Scott and White Medicare	$126.90
Rate for Payer: Superior Health Plan EPO	$126.90
Rate for Payer: Superior Health Plan Medicare	$126.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$126.90
Rate for Payer: Universal American Medicare	$126.90
Rate for Payer: Wellcare Medicare	$126.90
Rate for Payer: Wellmed Medicare	$126.90

WC I&D Abscess, Comp Or Mult BCE

Facility

$1,574.00

Service Code	CPT 10061
Hospital Charge Code	7150097
Hospital Revenue Code	761
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$1,023.10
Rate for Payer: Aetna Commercial	$865.70
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$141.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$192.87
Rate for Payer: BCBS of TX Blue Essentials	$230.98
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$291.03
Rate for Payer: Cash Price	$1,385.12
Rate for Payer: Cash Price	$1,385.12
Rate for Payer: Cash Price	$1,385.12
Rate for Payer: Cigna Commercial	$826.08
Rate for Payer: Cigna Medicaid	$98.28
Rate for Payer: Cigna Medicare	$364.67
Rate for Payer: Employer Direct Commercial	$364.67
Rate for Payer: Humana Medicare/TRICARE	$364.67
Rate for Payer: Molina CHIP/Medicaid	$98.28
Rate for Payer: Molina Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$1,023.10
Rate for Payer: Multiplan Commercial	$1,023.10
Rate for Payer: Multiplan Workers Comp	$1,023.10
Rate for Payer: Parkland Medicaid	$98.28
Rate for Payer: Scott and White EPO/PPO	$6.52
Rate for Payer: Scott and White Medicare	$364.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.28
Rate for Payer: Superior Health Plan EPO	$364.67
Rate for Payer: Superior Health Plan Medicare	$364.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.67
Rate for Payer: Universal American Medicare	$364.67
Rate for Payer: Wellcare Medicare	$364.67
Rate for Payer: Wellmed Medicare	$364.67

WC I&D Abscess, Comp Or Mult BCE

Facility

$1,574.00

Service Code	CPT 10061
Hospital Charge Code	7150097
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,385.12

WC I&D Abscess, Simple BCE

Facility

$821.00

Service Code	CPT 10060
Hospital Charge Code	7150089
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$533.65
Rate for Payer: Aetna Commercial	$451.55
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$73.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$125.97
Rate for Payer: BCBS of TX Blue Essentials	$150.86
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$190.08
Rate for Payer: Cash Price	$722.48
Rate for Payer: Cash Price	$722.48
Rate for Payer: Cash Price	$722.48
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$65.06
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina CHIP/Medicaid	$65.06
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$533.65
Rate for Payer: Multiplan Commercial	$533.65
Rate for Payer: Multiplan Workers Comp	$533.65
Rate for Payer: Parkland Medicaid	$65.06
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.06
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

WC I&D Abscess, Simple BCE

Facility

$821.00

Service Code	CPT 10060
Hospital Charge Code	7150089
Hospital Revenue Code	761
Rate for Payer: Cash Price	$722.48

WC I&D Hematoma/Seroma BCE

Facility

$3,948.00

Service Code	CPT 10140
Hospital Charge Code	7150105
Hospital Revenue Code	761
Rate for Payer: Cash Price	$3,474.24

WC I&D Hematoma/Seroma BCE

Facility

$3,948.00

Service Code	CPT 10140
Hospital Charge Code	7150105
Hospital Revenue Code	761
Min. Negotiated Rate	$26.52
Max. Negotiated Rate	$3,358.84
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$355.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
Rate for Payer: BCBS of TX Blue Advantage	$183.82
Rate for Payer: BCBS of TX Blue Essentials	$220.14
Rate for Payer: BCBS of TX Medicare	$1,482.74
Rate for Payer: BCBS of TX PPO	$277.38
Rate for Payer: Cash Price	$3,474.24
Rate for Payer: Cash Price	$3,474.24
Rate for Payer: Cash Price	$3,474.24
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$90.81
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$90.81
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
Rate for Payer: Multiplan Auto	$2,566.20
Rate for Payer: Multiplan Commercial	$2,566.20
Rate for Payer: Multiplan Workers Comp	$2,566.20
Rate for Payer: Parkland Medicaid	$90.81
Rate for Payer: Scott and White EPO/PPO	$26.52
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.81
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

WC Incisional Bx Skin Sep/Addl BCE

Facility

$1,014.00

Service Code	CPT 11107
Hospital Charge Code	7150056
Hospital Revenue Code	761
Rate for Payer: Cash Price	$892.32

WC Incisional Bx Skin Sep/Addl BCE

Facility

$1,014.00

Service Code	CPT 11107
Hospital Charge Code	7150056
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$659.10
Rate for Payer: Aetna Commercial	$557.70
Rate for Payer: Amerigroup CHIP/Medicaid	$91.26
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 PPO	$50.00
Rate for Payer: Cash Price	$892.32
Rate for Payer: Cash Price	$892.32
Rate for Payer: Multiplan Auto	$659.10
Rate for Payer: Multiplan Commercial	$659.10
Rate for Payer: Multiplan Workers Comp	$659.10
Rate for Payer: Scott and White EPO/PPO	$507.00
Rate for Payer: Superior Health Plan EPO	$137.90

WC Incisional Bx Skin Sgl Les BCE

Facility

$1,538.00

Service Code	CPT 11106
Hospital Charge Code	7150052
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,353.44

WC Incisional Bx Skin Sgl Les BCE

Facility

$1,538.00

Service Code	CPT 11106
Hospital Charge Code	7150052
Hospital Revenue Code	761
Min. Negotiated Rate	$10.27
Max. Negotiated Rate	$1,400.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$861.57
Rate for Payer: Amerigroup CHIP/Medicaid	$138.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$574.38
Rate for Payer: Amerigroup Medicare	$574.38
Rate for Payer: BCBS of TX Blue Advantage	$194.07
Rate for Payer: BCBS of TX Blue Essentials	$232.42
Rate for Payer: BCBS of TX Medicare	$574.38
Rate for Payer: BCBS of TX PPO	$292.85
Rate for Payer: Cash Price	$1,353.44
Rate for Payer: Cash Price	$1,353.44
Rate for Payer: Cash Price	$1,353.44
Rate for Payer: Cigna Commercial	$1,301.14
Rate for Payer: Cigna Medicaid	$98.83
Rate for Payer: Cigna Medicare	$574.38
Rate for Payer: Employer Direct Commercial	$574.38
Rate for Payer: Humana Medicare/TRICARE	$574.38
Rate for Payer: Molina CHIP/Medicaid	$98.83
Rate for Payer: Molina Dual Medicare/Medicaid	$574.38
Rate for Payer: Molina Medicare	$574.38
Rate for Payer: Multiplan Auto	$999.70
Rate for Payer: Multiplan Commercial	$999.70
Rate for Payer: Multiplan Workers Comp	$999.70
Rate for Payer: Parkland Medicaid	$98.83
Rate for Payer: Scott and White EPO/PPO	$10.27
Rate for Payer: Scott and White Medicare	$574.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.83
Rate for Payer: Superior Health Plan EPO	$574.38
Rate for Payer: Superior Health Plan Medicare	$574.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$574.38
Rate for Payer: Universal American Medicare	$574.38
Rate for Payer: Wellcare Medicare	$574.38
Rate for Payer: Wellmed Medicare	$574.38

WC LC Skin Sub App Face/Nck/HF ad 100sqcm BCE

Facility

$4,073.00

Service Code	HCPCS C5278
Hospital Charge Code	7150908
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$2,647.45
Rate for Payer: Aetna Commercial	$2,240.15
Rate for Payer: Amerigroup CHIP/Medicaid	$366.57
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 PPO	$50.00
Rate for Payer: Cash Price	$3,584.24
Rate for Payer: Cash Price	$3,584.24
Rate for Payer: Multiplan Auto	$2,647.45
Rate for Payer: Multiplan Commercial	$2,647.45
Rate for Payer: Multiplan Workers Comp	$2,647.45
Rate for Payer: Scott and White EPO/PPO	$2,036.50
Rate for Payer: Superior Health Plan EPO	$553.93

WC LC Skin Sub App Face/Nck/HF ad 100sqcm BCE

Facility

$4,073.00

Service Code	HCPCS C5278
Hospital Charge Code	7150908
Hospital Revenue Code	761
Rate for Payer: Cash Price	$3,584.24

WC LC Skin Sub App Face/Nck/HF ad 25 sqcm BCE

Facility

$1,267.00

Service Code	HCPCS C5276
Hospital Charge Code	7150906
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,114.96

WC LC Skin Sub App Face/Nck/HF ad 25 sqcm BCE

Facility

$1,267.00

Service Code	HCPCS C5276
Hospital Charge Code	7150906
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$823.55
Rate for Payer: Aetna Commercial	$696.85
Rate for Payer: Amerigroup CHIP/Medicaid	$114.03
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 PPO	$50.00
Rate for Payer: Cash Price	$1,114.96
Rate for Payer: Cash Price	$1,114.96
Rate for Payer: Multiplan Auto	$823.55
Rate for Payer: Multiplan Commercial	$823.55
Rate for Payer: Multiplan Workers Comp	$823.55
Rate for Payer: Scott and White EPO/PPO	$633.50
Rate for Payer: Superior Health Plan EPO	$172.31

WC LC Skin Sub App Face/Nck/HF to100sqcm BCE

Facility

$5,030.00

Service Code	HCPCS C5277
Hospital Charge Code	7150907
Hospital Revenue Code	761
Rate for Payer: Cash Price	$4,426.40

WC LC Skin Sub App Face/Nck/HF to100sqcm BCE

Facility

$5,030.00

Service Code	HCPCS C5277
Hospital Charge Code	7150907
Hospital Revenue Code	761
Min. Negotiated Rate	$10.27
Max. Negotiated Rate	$3,269.50
Rate for Payer: Aetna Commercial	$2,766.50
Rate for Payer: Aetna Medicare	$861.57
Rate for Payer: Amerigroup CHIP/Medicaid	$452.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$574.38
Rate for Payer: Amerigroup Medicare	$574.38
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$574.38
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$4,426.40
Rate for Payer: Cash Price	$4,426.40
Rate for Payer: Cash Price	$4,426.40
Rate for Payer: Cigna Commercial	$1,301.14
Rate for Payer: Cigna Medicare	$574.38
Rate for Payer: Employer Direct Commercial	$574.38
Rate for Payer: Humana Medicare/TRICARE	$574.38
Rate for Payer: Molina Dual Medicare/Medicaid	$574.38
Rate for Payer: Molina Medicare	$574.38
Rate for Payer: Multiplan Auto	$3,269.50
Rate for Payer: Multiplan Commercial	$3,269.50
Rate for Payer: Multiplan Workers Comp	$3,269.50
Rate for Payer: Scott and White EPO/PPO	$10.27
Rate for Payer: Scott and White Medicare	$574.38
Rate for Payer: Superior Health Plan EPO	$574.38
Rate for Payer: Superior Health Plan Medicare	$574.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$574.38
Rate for Payer: Universal American Medicare	$574.38
Rate for Payer: Wellcare Medicare	$574.38
Rate for Payer: Wellmed Medicare	$574.38

WC LC Skin Sub App Face/Nck/HF to 25 sqcm BCE

Facility

$2,804.00

Service Code	HCPCS C5275
Hospital Charge Code	7150905
Hospital Revenue Code	761
Min. Negotiated Rate	$10.27
Max. Negotiated Rate	$1,822.60
Rate for Payer: Aetna Commercial	$1,542.20
Rate for Payer: Aetna Medicare	$861.57
Rate for Payer: Amerigroup CHIP/Medicaid	$252.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$574.38
Rate for Payer: Amerigroup Medicare	$574.38
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$574.38
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,467.52
Rate for Payer: Cash Price	$2,467.52
Rate for Payer: Cash Price	$2,467.52
Rate for Payer: Cigna Commercial	$1,301.14
Rate for Payer: Cigna Medicare	$574.38
Rate for Payer: Employer Direct Commercial	$574.38
Rate for Payer: Humana Medicare/TRICARE	$574.38
Rate for Payer: Molina Dual Medicare/Medicaid	$574.38
Rate for Payer: Molina Medicare	$574.38
Rate for Payer: Multiplan Auto	$1,822.60
Rate for Payer: Multiplan Commercial	$1,822.60
Rate for Payer: Multiplan Workers Comp	$1,822.60
Rate for Payer: Scott and White EPO/PPO	$10.27
Rate for Payer: Scott and White Medicare	$574.38
Rate for Payer: Superior Health Plan EPO	$574.38
Rate for Payer: Superior Health Plan Medicare	$574.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$574.38
Rate for Payer: Universal American Medicare	$574.38
Rate for Payer: Wellcare Medicare	$574.38
Rate for Payer: Wellmed Medicare	$574.38

WC LC Skin Sub App Face/Nck/HF to 25 sqcm BCE

Facility

$2,804.00

Service Code	HCPCS C5275
Hospital Charge Code	7150905
Hospital Revenue Code	761
Rate for Payer: Cash Price	$2,467.52

WC LC Skin Sub App Trnk/Arm/Leg ad 100sqcm BCE

Facility

$1,623.00

Service Code	HCPCS C5274
Hospital Charge Code	7150904
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,428.24

WC LC Skin Sub App Trnk/Arm/Leg ad 100sqcm BCE

Facility

$1,623.00

Service Code	HCPCS C5274
Hospital Charge Code	7150904
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$1,054.95
Rate for Payer: Aetna Commercial	$892.65
Rate for Payer: Amerigroup CHIP/Medicaid	$146.07
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 PPO	$50.00
Rate for Payer: Cash Price	$1,428.24
Rate for Payer: Cash Price	$1,428.24
Rate for Payer: Multiplan Auto	$1,054.95
Rate for Payer: Multiplan Commercial	$1,054.95
Rate for Payer: Multiplan Workers Comp	$1,054.95
Rate for Payer: Scott and White EPO/PPO	$811.50
Rate for Payer: Superior Health Plan EPO	$220.73

WC LC Skin Sub App Trnk/Arm/Leg ad 25 sqcm BCE

Facility

$1,037.00

Service Code	HCPCS C5272
Hospital Charge Code	7150902
Hospital Revenue Code	761
Rate for Payer: Cash Price	$912.56

WC LC Skin Sub App Trnk/Arm/Leg ad 25 sqcm BCE

Facility

$1,037.00

Service Code	HCPCS C5272
Hospital Charge Code	7150902
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$674.05
Rate for Payer: Aetna Commercial	$570.35
Rate for Payer: Amerigroup CHIP/Medicaid	$93.33
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 PPO	$50.00
Rate for Payer: Cash Price	$912.56
Rate for Payer: Cash Price	$912.56
Rate for Payer: Multiplan Auto	$674.05
Rate for Payer: Multiplan Commercial	$674.05
Rate for Payer: Multiplan Workers Comp	$674.05
Rate for Payer: Scott and White EPO/PPO	$518.50
Rate for Payer: Superior Health Plan EPO	$141.03

WC LC Skin Sub App Trnk/Arm/Leg to 25 sqcm BCE

Facility

$1,845.00

Service Code	HCPCS C5271
Hospital Charge Code	7150901
Hospital Revenue Code	761
Min. Negotiated Rate	$10.27
Max. Negotiated Rate	$1,301.14
Rate for Payer: Aetna Commercial	$1,014.75
Rate for Payer: Aetna Medicare	$861.57
Rate for Payer: Amerigroup CHIP/Medicaid	$166.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$574.38
Rate for Payer: Amerigroup Medicare	$574.38
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$574.38
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$1,623.60
Rate for Payer: Cash Price	$1,623.60
Rate for Payer: Cash Price	$1,623.60
Rate for Payer: Cigna Commercial	$1,301.14
Rate for Payer: Cigna Medicare	$574.38
Rate for Payer: Employer Direct Commercial	$574.38
Rate for Payer: Humana Medicare/TRICARE	$574.38
Rate for Payer: Molina Dual Medicare/Medicaid	$574.38
Rate for Payer: Molina Medicare	$574.38
Rate for Payer: Multiplan Auto	$1,199.25
Rate for Payer: Multiplan Commercial	$1,199.25
Rate for Payer: Multiplan Workers Comp	$1,199.25
Rate for Payer: Scott and White EPO/PPO	$10.27
Rate for Payer: Scott and White Medicare	$574.38
Rate for Payer: Superior Health Plan EPO	$574.38
Rate for Payer: Superior Health Plan Medicare	$574.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$574.38
Rate for Payer: Universal American Medicare	$574.38
Rate for Payer: Wellcare Medicare	$574.38
Rate for Payer: Wellmed Medicare	$574.38

Know your out-of-pocket cost for care.

All Charges