White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CT Brain/Head w/ Contrast

Facility

$6,082.00

Service Code	HCPCS 70460
Hospital Charge Code	3800018
Hospital Revenue Code	351
Rate for Payer: Cash Price	$4,135.76

CT Brain/Head w/ + w/o Contrast

Facility

$8,702.00

Service Code	HCPCS 70470
Hospital Charge Code	3800026
Hospital Revenue Code	351
Rate for Payer: Cash Price	$5,917.36

CT Brain/Head w/ + w/o Contrast

Facility

$8,702.00

Service Code	HCPCS 70470
Hospital Charge Code	3800026
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$6,265.44
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	$5,917.36
Rate for Payer: Cash Price	$5,917.36
Rate for Payer: Cash Price	$5,917.36
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$6,265.44
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	$6,265.44
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$5,656.30
Rate for Payer: Multiplan Commercial	$5,656.30
Rate for Payer: Multiplan Workers Comp	$5,656.30
Rate for Payer: Parkland Medicaid	$6,265.44
Rate for Payer: Scott and White EPO/PPO	$219.82
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,265.44
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 Brain Stroke Protocol w/o Contrast

Facility

$4,495.00

Service Code	HCPCS 70450
Hospital Charge Code	3800034
Hospital Revenue Code	351
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$3,236.40
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$3,056.60
Rate for Payer: Cash Price	$3,056.60
Rate for Payer: Cash Price	$3,056.60
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$3,236.40
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$3,236.40
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$2,921.75
Rate for Payer: Multiplan Commercial	$2,921.75
Rate for Payer: Multiplan Workers Comp	$2,921.75
Rate for Payer: Parkland Medicaid	$3,236.40
Rate for Payer: Scott and White EPO/PPO	$134.24
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,236.40
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

CT Brain Stroke Protocol w/o Contrast

Facility

$4,495.00

Service Code	HCPCS 70450
Hospital Charge Code	3800034
Hospital Revenue Code	351
Rate for Payer: Cash Price	$3,056.60

CT Catheter Exchange

Facility

$815.00

Service Code	HCPCS 75984
Hospital Charge Code	4615985
Hospital Revenue Code	320
Min. Negotiated Rate	$73.35
Max. Negotiated Rate	$586.80
Rate for Payer: Amerigroup CHIP/Medicaid	$73.35
Rate for Payer: BCBS of TX Blue Advantage	$112.98
Rate for Payer: BCBS of TX Blue Essentials	$135.57
Rate for Payer: BCBS of TX PPO	$151.32
Rate for Payer: Cash Price	$554.20
Rate for Payer: Cash Price	$554.20
Rate for Payer: Cigna Medicaid	$586.80
Rate for Payer: Molina CHIP/Medicaid	$586.80
Rate for Payer: Multiplan Auto	$529.75
Rate for Payer: Multiplan Commercial	$529.75
Rate for Payer: Multiplan Workers Comp	$529.75
Rate for Payer: Parkland Medicaid	$586.80
Rate for Payer: Scott and White EPO/PPO	$117.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$586.80
Rate for Payer: Superior Health Plan EPO	$110.84

CT Catheter Exchange

Facility

$815.00

Service Code	HCPCS 75984
Hospital Charge Code	4615985
Hospital Revenue Code	320
Rate for Payer: Cash Price	$554.20

CT Cervical spine with & W/out contrast

Facility

$712.08

Service Code	HCPCS 72127
Hospital Charge Code	994146
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$512.70
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	$484.21
Rate for Payer: Cash Price	$484.21
Rate for Payer: Cash Price	$484.21
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$512.70
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	$512.70
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$462.85
Rate for Payer: Multiplan Commercial	$462.85
Rate for Payer: Multiplan Workers Comp	$462.85
Rate for Payer: Parkland Medicaid	$512.70
Rate for Payer: Scott and White EPO/PPO	$250.32
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$512.70
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 Cervical spine with & W/out contrast

Facility

$712.08

Service Code	HCPCS 72127
Hospital Charge Code	994146
Hospital Revenue Code	352
Rate for Payer: Cash Price	$484.21

CT Drain Per/Retr Fld w/Cath Perc

Facility

$6,783.00

Service Code	HCPCS 49406
Hospital Charge Code	3890227
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$4,612.44
Rate for Payer: Cash Price	$4,612.44
Rate for Payer: Cash Price	$4,612.44
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,883.76
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$4,883.76
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$4,883.76
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,883.76
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

CT Drain Per/Retr Fld w/Cath Perc

Facility

$6,783.00

Service Code	HCPCS 49406
Hospital Charge Code	3890227
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,612.44

CT Drain Pleura w Cath Right

Facility

$2,334.00

Service Code	HCPCS 32557
Hospital Charge Code	3800001
Hospital Revenue Code	361
Min. Negotiated Rate	$446.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$446.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Amerigroup Medicare	$1,581.33
Rate for Payer: BCBS of TX Blue Advantage	$2,723.99
Rate for Payer: BCBS of TX Blue Essentials	$3,262.26
Rate for Payer: BCBS of TX Medicare	$1,581.33
Rate for Payer: BCBS of TX PPO	$4,110.45
Rate for Payer: Cash Price	$1,587.12
Rate for Payer: Cash Price	$1,587.12
Rate for Payer: Cash Price	$1,587.12
Rate for Payer: Cigna Commercial	$3,342.63
Rate for Payer: Cigna Medicaid	$1,680.48
Rate for Payer: Cigna Medicare	$1,581.33
Rate for Payer: Employer Direct Commercial	$1,581.33
Rate for Payer: Humana Medicare/TRICARE	$1,581.33
Rate for Payer: Molina CHIP/Medicaid	$1,680.48
Rate for Payer: Molina Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Molina Medicare	$1,581.33
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	$1,680.48
Rate for Payer: Scott and White EPO/PPO	$2,709.66
Rate for Payer: Scott and White Medicare	$1,581.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,680.48
Rate for Payer: Superior Health Plan EPO	$1,581.33
Rate for Payer: Superior Health Plan Medicare	$1,581.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Universal American Medicare	$1,581.33
Rate for Payer: Wellcare Medicare	$1,581.33
Rate for Payer: Wellmed Medicare	$1,581.33

CT Drain Pleura w Cath Right

Facility

$2,334.00

Service Code	HCPCS 32557
Hospital Charge Code	3800001
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,587.12

CT Drain Soft Tissue Fluid w/Cath Perc

Facility

$3,790.00

Service Code	HCPCS 10030
Hospital Charge Code	3890225
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,577.20

CT Drain Soft Tissue Fluid w/Cath Perc

Facility

$3,790.00

Service Code	HCPCS 10030
Hospital Charge Code	3890225
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	$2,577.20
Rate for Payer: Cash Price	$2,577.20
Rate for Payer: Cash Price	$2,577.20
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$2,728.80
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	$2,728.80
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	$2,728.80
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	$2,728.80
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 Drain Visceral Fluid w/Cath Perc

Facility

$6,667.00

Service Code	HCPCS 49405
Hospital Charge Code	3890226
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,533.56

CT Drain Visceral Fluid w/Cath Perc

Facility

$6,667.00

Service Code	HCPCS 49405
Hospital Charge Code	3890226
Hospital Revenue Code	361
Min. Negotiated Rate	$600.03
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$600.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$4,533.56
Rate for Payer: Cash Price	$4,533.56
Rate for Payer: Cash Price	$4,533.56
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,800.24
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$4,800.24
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$4,800.24
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,800.24
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

C-Telopeptide, Serum SO

Facility

$226.00

Service Code	HCPCS 82523
Hospital Charge Code	1709161
Hospital Revenue Code	301
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$162.72
Rate for Payer: Amerigroup CHIP/Medicaid	$7.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.68
Rate for Payer: Amerigroup Medicare	$18.68
Rate for Payer: BCBS of TX Blue Advantage	$67.80
Rate for Payer: BCBS of TX Blue Essentials	$81.36
Rate for Payer: BCBS of TX Medicare	$18.68
Rate for Payer: BCBS of TX PPO	$90.40
Rate for Payer: Cash Price	$153.68
Rate for Payer: Cash Price	$153.68
Rate for Payer: Cigna Medicaid	$162.72
Rate for Payer: Cigna Medicare	$18.68
Rate for Payer: Employer Direct Commercial	$18.68
Rate for Payer: Humana Medicare/TRICARE	$18.68
Rate for Payer: Molina CHIP/Medicaid	$162.72
Rate for Payer: Molina Dual Medicare/Medicaid	$18.68
Rate for Payer: Molina Medicare	$18.68
Rate for Payer: Multiplan Auto	$146.90
Rate for Payer: Multiplan Commercial	$146.90
Rate for Payer: Multiplan Workers Comp	$146.90
Rate for Payer: Parkland Medicaid	$162.72
Rate for Payer: Scott and White EPO/PPO	$23.35
Rate for Payer: Scott and White Medicare	$18.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$162.72
Rate for Payer: Superior Health Plan EPO	$18.68
Rate for Payer: Superior Health Plan Medicare	$18.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.68
Rate for Payer: Universal American Medicare	$18.68
Rate for Payer: Wellcare Medicare	$18.68
Rate for Payer: Wellmed Medicare	$18.68

C-Telopeptide, Serum SO

Facility

$226.00

Service Code	HCPCS 82523
Hospital Charge Code	1709161
Hospital Revenue Code	301
Rate for Payer: Cash Price	$153.68

CT Guidance for Needle Placement

Facility

$4,508.00

Service Code	HCPCS 77012
Hospital Charge Code	3820024
Hospital Revenue Code	350
Min. Negotiated Rate	$129.03
Max. Negotiated Rate	$3,245.76
Rate for Payer: Amerigroup CHIP/Medicaid	$405.72
Rate for Payer: BCBS of TX Blue Advantage	$129.03
Rate for Payer: BCBS of TX Blue Essentials	$154.84
Rate for Payer: BCBS of TX PPO	$172.82
Rate for Payer: Cash Price	$3,065.44
Rate for Payer: Cash Price	$3,065.44
Rate for Payer: Cigna Medicaid	$3,245.76
Rate for Payer: Molina CHIP/Medicaid	$3,245.76
Rate for Payer: Multiplan Auto	$2,930.20
Rate for Payer: Multiplan Commercial	$2,930.20
Rate for Payer: Multiplan Workers Comp	$2,930.20
Rate for Payer: Parkland Medicaid	$3,245.76
Rate for Payer: Scott and White EPO/PPO	$171.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,245.76
Rate for Payer: Superior Health Plan EPO	$613.09

CT Guidance for Needle Placement

Facility

$4,508.00

Service Code	HCPCS 77012
Hospital Charge Code	3820024
Hospital Revenue Code	350
Rate for Payer: Cash Price	$3,065.44

CT Guided FNA Biopsy, First Lesion

Facility

$2,851.00

Service Code	HCPCS 10009
Hospital Charge Code	3800245
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	$514.74
Rate for Payer: BCBS of TX Blue Essentials	$616.46
Rate for Payer: BCBS of TX Medicare	$711.36
Rate for Payer: BCBS of TX PPO	$776.74
Rate for Payer: Cash Price	$1,938.68
Rate for Payer: Cash Price	$1,938.68
Rate for Payer: Cash Price	$1,938.68
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$2,052.72
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	$2,052.72
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	$2,052.72
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	$2,052.72
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 Guided FNA Biopsy, First Lesion

Facility

$2,851.00

Service Code	HCPCS 10009
Hospital Charge Code	3800245
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,938.68

CT Heart Calcium Scoring

Facility

$151.00

Service Code	HCPCS 75571
Hospital Charge Code	3860005
Hospital Revenue Code	350
Rate for Payer: Cash Price	$102.68

CT Heart Calcium Scoring

Facility

$151.00

Service Code	HCPCS 75571
Hospital Charge Code	3860005
Hospital Revenue Code	350
Min. Negotiated Rate	$86.58
Max. Negotiated Rate	$184.79
Rate for Payer: Amerigroup CHIP/Medicaid	$86.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$87.42
Rate for Payer: Amerigroup Medicare	$87.42
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX Medicare	$87.42
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$102.68
Rate for Payer: Cash Price	$102.68
Rate for Payer: Cash Price	$102.68
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$108.72
Rate for Payer: Cigna Medicare	$87.42
Rate for Payer: Employer Direct Commercial	$87.42
Rate for Payer: Humana Medicare/TRICARE	$87.42
Rate for Payer: Molina CHIP/Medicaid	$108.72
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
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	$108.72
Rate for Payer: Scott and White EPO/PPO	$126.36
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.72
Rate for Payer: Superior Health Plan EPO	$87.42
Rate for Payer: Superior Health Plan Medicare	$87.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$87.42
Rate for Payer: Universal American Medicare	$87.42
Rate for Payer: Wellcare Medicare	$87.42
Rate for Payer: Wellmed Medicare	$87.42

Know your out-of-pocket cost for care.

All Charges