White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CT Angio Abdomen

Facility

$6,558.00

Service Code	HCPCS 74175
Hospital Charge Code	3890209
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$4,721.76
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$4,459.44
Rate for Payer: Cash Price	$4,459.44
Rate for Payer: Cash Price	$4,459.44
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$4,721.76
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$4,721.76
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$4,262.70
Rate for Payer: Multiplan Commercial	$4,262.70
Rate for Payer: Multiplan Workers Comp	$4,262.70
Rate for Payer: Parkland Medicaid	$4,721.76
Rate for Payer: Scott and White EPO/PPO	$387.45
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,721.76
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Angio Abdomen and Pelvis

Facility

$12,903.00

Service Code	HCPCS 74174
Hospital Charge Code	3890220
Hospital Revenue Code	352
Rate for Payer: Cash Price	$8,774.04

CT Angio Abdomen and Pelvis

Facility

$12,903.00

Service Code	HCPCS 74174
Hospital Charge Code	3890220
Hospital Revenue Code	352
Min. Negotiated Rate	$350.46
Max. Negotiated Rate	$9,290.16
Rate for Payer: Amerigroup CHIP/Medicaid	$366.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
Rate for Payer: BCBS of TX Blue Advantage	$479.29
Rate for Payer: BCBS of TX Blue Essentials	$575.15
Rate for Payer: BCBS of TX Medicare	$350.46
Rate for Payer: BCBS of TX PPO	$641.96
Rate for Payer: Cash Price	$8,774.04
Rate for Payer: Cash Price	$8,774.04
Rate for Payer: Cash Price	$8,774.04
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$9,290.16
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$9,290.16
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$8,386.95
Rate for Payer: Multiplan Commercial	$8,386.95
Rate for Payer: Multiplan Workers Comp	$8,386.95
Rate for Payer: Parkland Medicaid	$9,290.16
Rate for Payer: Scott and White EPO/PPO	$482.16
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,290.16
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

CT Angio Abdomen Aorta + Iliofemoral

Facility

$5,448.00

Service Code	HCPCS 75635
Hospital Charge Code	3850088
Hospital Revenue Code	350
Rate for Payer: Cash Price	$3,704.64

CT Angio Abdomen Aorta + Iliofemoral

Facility

$5,448.00

Service Code	HCPCS 75635
Hospital Charge Code	3850088
Hospital Revenue Code	350
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,922.56
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,704.64
Rate for Payer: Cash Price	$3,704.64
Rate for Payer: Cash Price	$3,704.64
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,922.56
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$3,922.56
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$3,541.20
Rate for Payer: Multiplan Commercial	$3,541.20
Rate for Payer: Multiplan Workers Comp	$3,541.20
Rate for Payer: Parkland Medicaid	$3,922.56
Rate for Payer: Scott and White EPO/PPO	$520.41
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,922.56
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Angio Aorta Recon for Surgical Plan

Facility

$855.00

Hospital Charge Code	5050288
Hospital Revenue Code	350
Rate for Payer: Cash Price	$581.40

CT Angio Aorta Recon for Surgical Plan

Facility

$855.00

Hospital Charge Code	5050288
Hospital Revenue Code	350
Min. Negotiated Rate	$76.95
Max. Negotiated Rate	$615.60
Rate for Payer: Amerigroup CHIP/Medicaid	$76.95
Rate for Payer: BCBS of TX Blue Advantage	$256.50
Rate for Payer: BCBS of TX Blue Essentials	$307.80
Rate for Payer: BCBS of TX PPO	$342.00
Rate for Payer: Cash Price	$581.40
Rate for Payer: Cigna Medicaid	$615.60
Rate for Payer: Molina CHIP/Medicaid	$615.60
Rate for Payer: Multiplan Auto	$555.75
Rate for Payer: Multiplan Commercial	$555.75
Rate for Payer: Multiplan Workers Comp	$555.75
Rate for Payer: Parkland Medicaid	$615.60
Rate for Payer: Scott and White EPO/PPO	$427.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$615.60
Rate for Payer: Superior Health Plan EPO	$116.28

CT Angio Brain/Head

Facility

$6,952.00

Service Code	HCPCS 70496
Hospital Charge Code	3890167
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$5,005.44
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$4,727.36
Rate for Payer: Cash Price	$4,727.36
Rate for Payer: Cash Price	$4,727.36
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$5,005.44
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$5,005.44
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$4,518.80
Rate for Payer: Multiplan Commercial	$4,518.80
Rate for Payer: Multiplan Workers Comp	$4,518.80
Rate for Payer: Parkland Medicaid	$5,005.44
Rate for Payer: Scott and White EPO/PPO	$349.57
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,005.44
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Angio Brain/Head

Facility

$6,952.00

Service Code	HCPCS 70496
Hospital Charge Code	3890167
Hospital Revenue Code	351
Rate for Payer: Cash Price	$4,727.36

CT Angio Coronary Artery Str/Mph/Fnt Cnt BCE

Facility

$1,385.00

Service Code	HCPCS 75574
Hospital Charge Code	3800004
Hospital Revenue Code	350
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$997.20
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
Rate for Payer: BCBS of TX Blue Advantage	$333.00
Rate for Payer: BCBS of TX Blue Essentials	$399.60
Rate for Payer: BCBS of TX Medicare	$350.46
Rate for Payer: BCBS of TX PPO	$446.02
Rate for Payer: Cash Price	$941.80
Rate for Payer: Cash Price	$941.80
Rate for Payer: Cash Price	$941.80
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$997.20
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$997.20
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$900.25
Rate for Payer: Multiplan Commercial	$900.25
Rate for Payer: Multiplan Workers Comp	$900.25
Rate for Payer: Parkland Medicaid	$997.20
Rate for Payer: Scott and White EPO/PPO	$407.64
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$997.20
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

CT Angio Coronary Artery Str/Mph/Fnt Cnt BCE

Facility

$1,385.00

Service Code	HCPCS 75574
Hospital Charge Code	3800004
Hospital Revenue Code	350
Rate for Payer: Cash Price	$941.80

CT Angio Lower Extremity Right

Facility

$6,112.00

Service Code	HCPCS 73706 RT
Hospital Charge Code	3890134
Hospital Revenue Code	352
Rate for Payer: Cash Price	$4,156.16

CT Angio Lower Extremity Right

Facility

$6,112.00

Service Code	HCPCS 73706 RT
Hospital Charge Code	3890134
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$4,400.64
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$4,156.16
Rate for Payer: Cash Price	$4,156.16
Rate for Payer: Cash Price	$4,156.16
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$4,400.64
Rate for Payer: Molina CHIP/Medicaid	$4,400.64
Rate for Payer: Multiplan Auto	$3,972.80
Rate for Payer: Multiplan Commercial	$3,972.80
Rate for Payer: Multiplan Workers Comp	$3,972.80
Rate for Payer: Parkland Medicaid	$4,400.64
Rate for Payer: Scott and White EPO/PPO	$3,056.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,400.64
Rate for Payer: Superior Health Plan EPO	$831.23

CT Angio Neck

Facility

$8,782.00

Service Code	HCPCS 70498
Hospital Charge Code	3890175
Hospital Revenue Code	350
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$6,323.04
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$5,971.76
Rate for Payer: Cash Price	$5,971.76
Rate for Payer: Cash Price	$5,971.76
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$6,323.04
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$6,323.04
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$5,708.30
Rate for Payer: Multiplan Commercial	$5,708.30
Rate for Payer: Multiplan Workers Comp	$5,708.30
Rate for Payer: Parkland Medicaid	$6,323.04
Rate for Payer: Scott and White EPO/PPO	$349.16
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,323.04
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Angio Neck

Facility

$8,782.00

Service Code	HCPCS 70498
Hospital Charge Code	3890175
Hospital Revenue Code	350
Rate for Payer: Cash Price	$5,971.76

CT Angio Pelvis

Facility

$5,003.00

Service Code	HCPCS 72191
Hospital Charge Code	3890183
Hospital Revenue Code	352
Rate for Payer: Cash Price	$3,402.04

CT Angio Pelvis

Facility

$5,003.00

Service Code	HCPCS 72191
Hospital Charge Code	3890183
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,602.16
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,402.04
Rate for Payer: Cash Price	$3,402.04
Rate for Payer: Cash Price	$3,402.04
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,602.16
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$3,602.16
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$3,251.95
Rate for Payer: Multiplan Commercial	$3,251.95
Rate for Payer: Multiplan Workers Comp	$3,251.95
Rate for Payer: Parkland Medicaid	$3,602.16
Rate for Payer: Scott and White EPO/PPO	$385.80
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,602.16
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Angio Upper Extremity Left

Facility

$5,854.00

Service Code	HCPCS 73206 LT
Hospital Charge Code	629776
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$4,214.88
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,980.72
Rate for Payer: Cash Price	$3,980.72
Rate for Payer: Cash Price	$3,980.72
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$4,214.88
Rate for Payer: Molina CHIP/Medicaid	$4,214.88
Rate for Payer: Multiplan Auto	$3,805.10
Rate for Payer: Multiplan Commercial	$3,805.10
Rate for Payer: Multiplan Workers Comp	$3,805.10
Rate for Payer: Parkland Medicaid	$4,214.88
Rate for Payer: Scott and White EPO/PPO	$2,927.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,214.88
Rate for Payer: Superior Health Plan EPO	$796.14

CT Angio Upper Extremity Left

Facility

$5,854.00

Service Code	HCPCS 73206 LT
Hospital Charge Code	3890191
Hospital Revenue Code	352
Rate for Payer: Cash Price	$3,980.72

CT Angio Upper Extremity Left

Facility

$5,854.00

Service Code	HCPCS 73206 LT
Hospital Charge Code	3890191
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$4,214.88
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,980.72
Rate for Payer: Cash Price	$3,980.72
Rate for Payer: Cash Price	$3,980.72
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$4,214.88
Rate for Payer: Molina CHIP/Medicaid	$4,214.88
Rate for Payer: Multiplan Auto	$3,805.10
Rate for Payer: Multiplan Commercial	$3,805.10
Rate for Payer: Multiplan Workers Comp	$3,805.10
Rate for Payer: Parkland Medicaid	$4,214.88
Rate for Payer: Scott and White EPO/PPO	$2,927.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,214.88
Rate for Payer: Superior Health Plan EPO	$796.14

CT Angio Upper Extremity Left

Facility

$5,854.00

Service Code	HCPCS 73206 LT
Hospital Charge Code	629776
Hospital Revenue Code	352
Rate for Payer: Cash Price	$3,980.72

CT Angio Upper Extremity Right

Facility

$5,854.00

Service Code	HCPCS 73206 RT
Hospital Charge Code	3800007
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$4,214.88
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,980.72
Rate for Payer: Cash Price	$3,980.72
Rate for Payer: Cash Price	$3,980.72
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$4,214.88
Rate for Payer: Molina CHIP/Medicaid	$4,214.88
Rate for Payer: Multiplan Auto	$3,805.10
Rate for Payer: Multiplan Commercial	$3,805.10
Rate for Payer: Multiplan Workers Comp	$3,805.10
Rate for Payer: Parkland Medicaid	$4,214.88
Rate for Payer: Scott and White EPO/PPO	$2,927.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,214.88
Rate for Payer: Superior Health Plan EPO	$796.14

CT Angio Upper Extremity Right

Facility

$5,854.00

Service Code	HCPCS 73206 RT
Hospital Charge Code	3800007
Hospital Revenue Code	352
Rate for Payer: Cash Price	$3,980.72

CT Asp/Inject Renal Cyst/Pelvis Right

Facility

$2,001.00

Service Code	HCPCS 50390
Hospital Charge Code	5057585
Hospital Revenue Code	361
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$257.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
Rate for Payer: BCBS of TX Blue Advantage	$1,018.72
Rate for Payer: BCBS of TX Blue Essentials	$1,220.02
Rate for Payer: BCBS of TX Medicare	$711.36
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$1,360.68
Rate for Payer: Cash Price	$1,360.68
Rate for Payer: Cash Price	$1,360.68
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$1,440.72
Rate for Payer: Cigna Medicare	$711.36
Rate for Payer: Employer Direct Commercial	$711.36
Rate for Payer: Humana Medicare/TRICARE	$711.36
Rate for Payer: Molina CHIP/Medicaid	$1,440.72
Rate for Payer: Molina Dual Medicare/Medicaid	$711.36
Rate for Payer: Molina Medicare	$711.36
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	$1,440.72
Rate for Payer: Scott and White EPO/PPO	$1,190.38
Rate for Payer: Scott and White Medicare	$711.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,440.72
Rate for Payer: Superior Health Plan EPO	$711.36
Rate for Payer: Superior Health Plan Medicare	$711.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$711.36
Rate for Payer: Universal American Medicare	$711.36
Rate for Payer: Wellcare Medicare	$711.36
Rate for Payer: Wellmed Medicare	$711.36

CT Asp/Inject Renal Cyst/Pelvis Right

Facility

$2,001.00

Service Code	HCPCS 50390
Hospital Charge Code	5057585
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,360.68

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