White Rock Medical Center

All Charges

Charge

Type

Setting

Price

88300 AP Bill Surgical Pathology Level I Complexity

Facility

$221.00

Service Code	CPT 88300
Hospital Charge Code	1801901
Hospital Revenue Code	312
Rate for Payer: Cash Price	$194.48

88300 AP Bill Surgical Pathology Level I Complexity

Facility

$221.00

Service Code	CPT 88300
Hospital Charge Code	1801901
Hospital Revenue Code	312
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$143.65
Rate for Payer: Aetna Commercial	$11.76
Rate for Payer: Aetna Medicare	$40.84
Rate for Payer: Amerigroup CHIP/Medicaid	$6.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.23
Rate for Payer: Amerigroup Medicare	$27.23
Rate for Payer: BCBS of TX Blue Advantage	$37.93
Rate for Payer: BCBS of TX Blue Essentials	$45.52
Rate for Payer: BCBS of TX Medicare	$27.23
Rate for Payer: BCBS of TX PPO	$50.81
Rate for Payer: Cash Price	$194.48
Rate for Payer: Cash Price	$194.48
Rate for Payer: Cash Price	$194.48
Rate for Payer: Cigna Commercial	$61.69
Rate for Payer: Cigna Medicare	$27.23
Rate for Payer: Employer Direct Commercial	$27.23
Rate for Payer: Humana Medicare/TRICARE	$27.23
Rate for Payer: Molina Dual Medicare/Medicaid	$27.23
Rate for Payer: Molina Medicare	$27.23
Rate for Payer: Multiplan Auto	$143.65
Rate for Payer: Multiplan Commercial	$143.65
Rate for Payer: Multiplan Workers Comp	$143.65
Rate for Payer: Scott and White EPO/PPO	$0.49
Rate for Payer: Scott and White Medicare	$27.23
Rate for Payer: Superior Health Plan EPO	$27.23
Rate for Payer: Superior Health Plan Medicare	$27.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.23
Rate for Payer: Universal American Medicare	$27.23
Rate for Payer: Wellcare Medicare	$27.23
Rate for Payer: Wellmed Medicare	$27.23

88302 AP Bill Surgical Pathology Level II Complexity

Facility

$231.00

Service Code	CPT 88302
Hospital Charge Code	1801919
Hospital Revenue Code	312
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$150.15
Rate for Payer: Aetna Commercial	$27.04
Rate for Payer: Aetna Medicare	$40.84
Rate for Payer: Amerigroup CHIP/Medicaid	$12.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.23
Rate for Payer: Amerigroup Medicare	$27.23
Rate for Payer: BCBS of TX Blue Advantage	$37.93
Rate for Payer: BCBS of TX Blue Essentials	$45.52
Rate for Payer: BCBS of TX Medicare	$27.23
Rate for Payer: BCBS of TX PPO	$50.81
Rate for Payer: Cash Price	$203.28
Rate for Payer: Cash Price	$203.28
Rate for Payer: Cash Price	$203.28
Rate for Payer: Cigna Commercial	$61.69
Rate for Payer: Cigna Medicare	$27.23
Rate for Payer: Employer Direct Commercial	$27.23
Rate for Payer: Humana Medicare/TRICARE	$27.23
Rate for Payer: Molina Dual Medicare/Medicaid	$27.23
Rate for Payer: Molina Medicare	$27.23
Rate for Payer: Multiplan Auto	$150.15
Rate for Payer: Multiplan Commercial	$150.15
Rate for Payer: Multiplan Workers Comp	$150.15
Rate for Payer: Scott and White EPO/PPO	$0.49
Rate for Payer: Scott and White Medicare	$27.23
Rate for Payer: Superior Health Plan EPO	$27.23
Rate for Payer: Superior Health Plan Medicare	$27.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.23
Rate for Payer: Universal American Medicare	$27.23
Rate for Payer: Wellcare Medicare	$27.23
Rate for Payer: Wellmed Medicare	$27.23

88302 AP Bill Surgical Pathology Level II Complexity

Facility

$231.00

Service Code	CPT 88302
Hospital Charge Code	1801919
Hospital Revenue Code	312
Rate for Payer: Cash Price	$203.28

88304 AP Bill Surgical Pathology Level III Complexity

Facility

$374.00

Service Code	CPT 88304
Hospital Charge Code	1801935
Hospital Revenue Code	312
Rate for Payer: Cash Price	$329.12

88304 AP Bill Surgical Pathology Level III Complexity

Facility

$374.00

Service Code	CPT 88304
Hospital Charge Code	1801935
Hospital Revenue Code	312
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$243.10
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Aetna Medicare	$74.34
Rate for Payer: Amerigroup CHIP/Medicaid	$16.33
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$49.56
Rate for Payer: Amerigroup Medicare	$49.56
Rate for Payer: BCBS of TX Blue Advantage	$81.63
Rate for Payer: BCBS of TX Blue Essentials	$97.95
Rate for Payer: BCBS of TX Medicare	$49.56
Rate for Payer: BCBS of TX PPO	$109.33
Rate for Payer: Cash Price	$329.12
Rate for Payer: Cash Price	$329.12
Rate for Payer: Cash Price	$329.12
Rate for Payer: Cigna Commercial	$112.25
Rate for Payer: Cigna Medicare	$49.56
Rate for Payer: Employer Direct Commercial	$49.56
Rate for Payer: Humana Medicare/TRICARE	$49.56
Rate for Payer: Molina Dual Medicare/Medicaid	$49.56
Rate for Payer: Molina Medicare	$49.56
Rate for Payer: Multiplan Auto	$243.10
Rate for Payer: Multiplan Commercial	$243.10
Rate for Payer: Multiplan Workers Comp	$243.10
Rate for Payer: Scott and White EPO/PPO	$0.89
Rate for Payer: Scott and White Medicare	$49.56
Rate for Payer: Superior Health Plan EPO	$49.56
Rate for Payer: Superior Health Plan Medicare	$49.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$49.56
Rate for Payer: Universal American Medicare	$49.56
Rate for Payer: Wellcare Medicare	$49.56
Rate for Payer: Wellmed Medicare	$49.56

88305 AP Bill Surgical Pathology Level IV Complexity

Facility

$540.00

Service Code	CPT 88305
Hospital Charge Code	1801943
Hospital Revenue Code	312
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$351.00
Rate for Payer: Aetna Commercial	$37.10
Rate for Payer: Aetna Medicare	$74.34
Rate for Payer: Amerigroup CHIP/Medicaid	$27.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$49.56
Rate for Payer: Amerigroup Medicare	$49.56
Rate for Payer: BCBS of TX Blue Advantage	$81.63
Rate for Payer: BCBS of TX Blue Essentials	$97.95
Rate for Payer: BCBS of TX Medicare	$49.56
Rate for Payer: BCBS of TX PPO	$109.33
Rate for Payer: Cash Price	$475.20
Rate for Payer: Cash Price	$475.20
Rate for Payer: Cash Price	$475.20
Rate for Payer: Cigna Commercial	$112.25
Rate for Payer: Cigna Medicare	$49.56
Rate for Payer: Employer Direct Commercial	$49.56
Rate for Payer: Humana Medicare/TRICARE	$49.56
Rate for Payer: Molina Dual Medicare/Medicaid	$49.56
Rate for Payer: Molina Medicare	$49.56
Rate for Payer: Multiplan Auto	$351.00
Rate for Payer: Multiplan Commercial	$351.00
Rate for Payer: Multiplan Workers Comp	$351.00
Rate for Payer: Scott and White EPO/PPO	$0.89
Rate for Payer: Scott and White Medicare	$49.56
Rate for Payer: Superior Health Plan EPO	$49.56
Rate for Payer: Superior Health Plan Medicare	$49.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$49.56
Rate for Payer: Universal American Medicare	$49.56
Rate for Payer: Wellcare Medicare	$49.56
Rate for Payer: Wellmed Medicare	$49.56

88305 AP Bill Surgical Pathology Level IV Complexity

Facility

$540.00

Service Code	CPT 88305
Hospital Charge Code	1801943
Hospital Revenue Code	312
Rate for Payer: Cash Price	$475.20

88307 AP Bill Surgical Pathology Level V Complexity

Facility

$578.00

Service Code	CPT 88307
Hospital Charge Code	1801950
Hospital Revenue Code	312
Rate for Payer: Cash Price	$508.64

88307 AP Bill Surgical Pathology Level V Complexity

Facility

$578.00

Service Code	CPT 88307
Hospital Charge Code	1801950
Hospital Revenue Code	312
Min. Negotiated Rate	$5.88
Max. Negotiated Rate	$744.67
Rate for Payer: Aetna Commercial	$223.74
Rate for Payer: Aetna Medicare	$493.10
Rate for Payer: Amerigroup CHIP/Medicaid	$109.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$328.73
Rate for Payer: Amerigroup Medicare	$328.73
Rate for Payer: BCBS of TX Blue Advantage	$467.63
Rate for Payer: BCBS of TX Blue Essentials	$561.15
Rate for Payer: BCBS of TX Medicare	$328.73
Rate for Payer: BCBS of TX PPO	$626.34
Rate for Payer: Cash Price	$508.64
Rate for Payer: Cash Price	$508.64
Rate for Payer: Cash Price	$508.64
Rate for Payer: Cigna Commercial	$744.67
Rate for Payer: Cigna Medicare	$328.73
Rate for Payer: Employer Direct Commercial	$328.73
Rate for Payer: Humana Medicare/TRICARE	$328.73
Rate for Payer: Molina Dual Medicare/Medicaid	$328.73
Rate for Payer: Molina Medicare	$328.73
Rate for Payer: Multiplan Auto	$375.70
Rate for Payer: Multiplan Commercial	$375.70
Rate for Payer: Multiplan Workers Comp	$375.70
Rate for Payer: Scott and White EPO/PPO	$5.88
Rate for Payer: Scott and White Medicare	$328.73
Rate for Payer: Superior Health Plan EPO	$328.73
Rate for Payer: Superior Health Plan Medicare	$328.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$328.73
Rate for Payer: Universal American Medicare	$328.73
Rate for Payer: Wellcare Medicare	$328.73
Rate for Payer: Wellmed Medicare	$328.73

88309 AP Bill Surgical Pathology Level VI Complexity

Facility

$925.00

Service Code	CPT 88309
Hospital Charge Code	1802016
Hospital Revenue Code	312
Min. Negotiated Rate	$14.06
Max. Negotiated Rate	$1,781.44
Rate for Payer: Aetna Commercial	$319.18
Rate for Payer: Aetna Medicare	$1,179.60
Rate for Payer: Amerigroup CHIP/Medicaid	$166.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$786.40
Rate for Payer: Amerigroup Medicare	$786.40
Rate for Payer: BCBS of TX Blue Advantage	$1,036.53
Rate for Payer: BCBS of TX Blue Essentials	$1,243.84
Rate for Payer: BCBS of TX Medicare	$786.40
Rate for Payer: BCBS of TX PPO	$1,388.32
Rate for Payer: Cash Price	$814.00
Rate for Payer: Cash Price	$814.00
Rate for Payer: Cash Price	$814.00
Rate for Payer: Cigna Commercial	$1,781.44
Rate for Payer: Cigna Medicare	$786.40
Rate for Payer: Employer Direct Commercial	$786.40
Rate for Payer: Humana Medicare/TRICARE	$786.40
Rate for Payer: Molina Dual Medicare/Medicaid	$786.40
Rate for Payer: Molina Medicare	$786.40
Rate for Payer: Multiplan Auto	$601.25
Rate for Payer: Multiplan Commercial	$601.25
Rate for Payer: Multiplan Workers Comp	$601.25
Rate for Payer: Scott and White EPO/PPO	$14.06
Rate for Payer: Scott and White Medicare	$786.40
Rate for Payer: Superior Health Plan EPO	$786.40
Rate for Payer: Superior Health Plan Medicare	$786.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$786.40
Rate for Payer: Universal American Medicare	$786.40
Rate for Payer: Wellcare Medicare	$786.40
Rate for Payer: Wellmed Medicare	$786.40

88309 AP Bill Surgical Pathology Level VI Complexity

Facility

$925.00

Service Code	CPT 88309
Hospital Charge Code	1802016
Hospital Revenue Code	312
Rate for Payer: Cash Price	$814.00

88311 AP Bill Decalcification

Facility

$309.00

Service Code	CPT 88311
Hospital Charge Code	1801927
Hospital Revenue Code	312
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$200.85
Rate for Payer: Aetna Commercial	$9.15
Rate for Payer: Amerigroup CHIP/Medicaid	$8.58
Rate for Payer: BCBS of TX Blue Advantage	$14.87
Rate for Payer: BCBS of TX Blue Essentials	$17.84
Rate for Payer: BCBS of TX PPO	$19.91
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cash Price	$271.92
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Scott and White EPO/PPO	$154.50
Rate for Payer: Superior Health Plan EPO	$42.02

88311 AP Bill Decalcification

Facility

$309.00

Service Code	CPT 88311
Hospital Charge Code	1801927
Hospital Revenue Code	312
Rate for Payer: Cash Price	$271.92

88312 AP Bill Special Stains Group I

Facility

$371.00

Service Code	CPT 88312
Hospital Charge Code	1801711
Hospital Revenue Code	312
Rate for Payer: Cash Price	$326.48

88312 AP Bill Special Stains Group I

Facility

$371.00

Service Code	CPT 88312
Hospital Charge Code	1801711
Hospital Revenue Code	312
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$241.15
Rate for Payer: Aetna Commercial	$94.88
Rate for Payer: Aetna Medicare	$74.34
Rate for Payer: Amerigroup CHIP/Medicaid	$41.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$49.56
Rate for Payer: Amerigroup Medicare	$49.56
Rate for Payer: BCBS of TX Blue Advantage	$81.63
Rate for Payer: BCBS of TX Blue Essentials	$97.95
Rate for Payer: BCBS of TX Medicare	$49.56
Rate for Payer: BCBS of TX PPO	$109.33
Rate for Payer: Cash Price	$326.48
Rate for Payer: Cash Price	$326.48
Rate for Payer: Cash Price	$326.48
Rate for Payer: Cigna Commercial	$112.25
Rate for Payer: Cigna Medicare	$49.56
Rate for Payer: Employer Direct Commercial	$49.56
Rate for Payer: Humana Medicare/TRICARE	$49.56
Rate for Payer: Molina Dual Medicare/Medicaid	$49.56
Rate for Payer: Molina Medicare	$49.56
Rate for Payer: Multiplan Auto	$241.15
Rate for Payer: Multiplan Commercial	$241.15
Rate for Payer: Multiplan Workers Comp	$241.15
Rate for Payer: Scott and White EPO/PPO	$0.89
Rate for Payer: Scott and White Medicare	$49.56
Rate for Payer: Superior Health Plan EPO	$49.56
Rate for Payer: Superior Health Plan Medicare	$49.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$49.56
Rate for Payer: Universal American Medicare	$49.56
Rate for Payer: Wellcare Medicare	$49.56
Rate for Payer: Wellmed Medicare	$49.56

88313 AP Bill Special Stains Group II

Facility

$255.00

Service Code	CPT 88313
Hospital Charge Code	1801638
Hospital Revenue Code	312
Rate for Payer: Cash Price	$224.40

88313 AP Bill Special Stains Group II

Facility

$255.00

Service Code	CPT 88313
Hospital Charge Code	1801638
Hospital Revenue Code	312
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$165.75
Rate for Payer: Aetna Commercial	$75.51
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$30.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$55.16
Rate for Payer: BCBS of TX Blue Essentials	$66.19
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$73.88
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
Rate for Payer: Multiplan Auto	$165.75
Rate for Payer: Multiplan Commercial	$165.75
Rate for Payer: Multiplan Workers Comp	$165.75
Rate for Payer: Scott and White EPO/PPO	$1.00
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

88329 AP Bill Surgical Intraoperative Consult

Facility

$141.00

Service Code	CPT 88329
Hospital Charge Code	1800416
Hospital Revenue Code	312
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$126.71
Rate for Payer: Aetna Commercial	$37.62
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$14.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$55.16
Rate for Payer: BCBS of TX Blue Essentials	$66.19
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$73.88
Rate for Payer: Cash Price	$124.08
Rate for Payer: Cash Price	$124.08
Rate for Payer: Cash Price	$124.08
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
Rate for Payer: Multiplan Auto	$91.65
Rate for Payer: Multiplan Commercial	$91.65
Rate for Payer: Multiplan Workers Comp	$91.65
Rate for Payer: Scott and White EPO/PPO	$1.00
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

88329 AP Bill Surgical Intraoperative Consult

Facility

$141.00

Service Code	CPT 88329
Hospital Charge Code	1800416
Hospital Revenue Code	312
Rate for Payer: Cash Price	$124.08

88331 AP Bill Frozen single specimen

Facility

$333.00

Service Code	CPT 88331
Hospital Charge Code	1800283
Hospital Revenue Code	312
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$353.86
Rate for Payer: Aetna Commercial	$44.56
Rate for Payer: Aetna Medicare	$234.32
Rate for Payer: Amerigroup CHIP/Medicaid	$39.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.21
Rate for Payer: Amerigroup Medicare	$156.21
Rate for Payer: BCBS of TX Blue Advantage	$236.78
Rate for Payer: BCBS of TX Blue Essentials	$284.13
Rate for Payer: BCBS of TX Medicare	$156.21
Rate for Payer: BCBS of TX PPO	$317.14
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cigna Commercial	$353.86
Rate for Payer: Cigna Medicare	$156.21
Rate for Payer: Employer Direct Commercial	$156.21
Rate for Payer: Humana Medicare/TRICARE	$156.21
Rate for Payer: Molina Dual Medicare/Medicaid	$156.21
Rate for Payer: Molina Medicare	$156.21
Rate for Payer: Multiplan Auto	$216.45
Rate for Payer: Multiplan Commercial	$216.45
Rate for Payer: Multiplan Workers Comp	$216.45
Rate for Payer: Scott and White EPO/PPO	$2.79
Rate for Payer: Scott and White Medicare	$156.21
Rate for Payer: Superior Health Plan EPO	$156.21
Rate for Payer: Superior Health Plan Medicare	$156.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.21
Rate for Payer: Universal American Medicare	$156.21
Rate for Payer: Wellcare Medicare	$156.21
Rate for Payer: Wellmed Medicare	$156.21

88331 AP Bill Frozen single specimen

Facility

$333.00

Service Code	CPT 88331
Hospital Charge Code	1800283
Hospital Revenue Code	312
Rate for Payer: Cash Price	$293.04

88332 AP Bill Frozen add'l block

Facility

$278.00

Service Code	CPT 88332
Hospital Charge Code	1800291
Hospital Revenue Code	312
Min. Negotiated Rate	$21.68
Max. Negotiated Rate	$180.70
Rate for Payer: Aetna Commercial	$26.30
Rate for Payer: Amerigroup CHIP/Medicaid	$21.68
Rate for Payer: BCBS of TX Blue Advantage	$36.27
Rate for Payer: BCBS of TX Blue Essentials	$43.52
Rate for Payer: BCBS of TX PPO	$48.58
Rate for Payer: Cash Price	$244.64
Rate for Payer: Cash Price	$244.64
Rate for Payer: Multiplan Auto	$180.70
Rate for Payer: Multiplan Commercial	$180.70
Rate for Payer: Multiplan Workers Comp	$180.70
Rate for Payer: Scott and White EPO/PPO	$139.00
Rate for Payer: Superior Health Plan EPO	$37.81

88332 AP Bill Frozen add'l block

Facility

$278.00

Service Code	CPT 88332
Hospital Charge Code	1800291
Hospital Revenue Code	312
Rate for Payer: Cash Price	$244.64

88334 AP Bill Immediate Smear Touch Prep Add'l

Facility

$165.00

Service Code	CPT 88334
Hospital Charge Code	1802628
Hospital Revenue Code	312
Min. Negotiated Rate	$20.88
Max. Negotiated Rate	$107.25
Rate for Payer: Aetna Commercial	$20.88
Rate for Payer: Amerigroup CHIP/Medicaid	$22.52
Rate for Payer: BCBS of TX Blue Advantage	$27.95
Rate for Payer: BCBS of TX Blue Essentials	$33.54
Rate for Payer: BCBS of TX PPO	$37.44
Rate for Payer: Cash Price	$145.20
Rate for Payer: Cash Price	$145.20
Rate for Payer: Multiplan Auto	$107.25
Rate for Payer: Multiplan Commercial	$107.25
Rate for Payer: Multiplan Workers Comp	$107.25
Rate for Payer: Scott and White EPO/PPO	$82.50
Rate for Payer: Superior Health Plan EPO	$22.44

Know your out-of-pocket cost for care.

All Charges