White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CT Humerus w/ + w/o Contrast Left

Facility

$3,348.00

Service Code	HCPCS 73202 LT
Hospital Charge Code	3800950
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,276.64

CT Humerus w/ + w/o Contrast Left

Facility

$3,348.00

Service Code	HCPCS 73202 LT
Hospital Charge Code	3800950
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$2,410.56
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	$2,276.64
Rate for Payer: Cash Price	$2,276.64
Rate for Payer: Cash Price	$2,276.64
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$2,410.56
Rate for Payer: Molina CHIP/Medicaid	$2,410.56
Rate for Payer: Multiplan Auto	$2,176.20
Rate for Payer: Multiplan Commercial	$2,176.20
Rate for Payer: Multiplan Workers Comp	$2,176.20
Rate for Payer: Parkland Medicaid	$2,410.56
Rate for Payer: Scott and White EPO/PPO	$1,674.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,410.56
Rate for Payer: Superior Health Plan EPO	$455.33

CT Humerus w/ + w/o Contrast Right

Facility

$3,348.00

Service Code	HCPCS 73202 RT
Hospital Charge Code	3801859
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,276.64

CT Humerus w/ + w/o Contrast Right

Facility

$3,348.00

Service Code	HCPCS 73202 RT
Hospital Charge Code	3801859
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$2,410.56
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	$2,276.64
Rate for Payer: Cash Price	$2,276.64
Rate for Payer: Cash Price	$2,276.64
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$2,410.56
Rate for Payer: Molina CHIP/Medicaid	$2,410.56
Rate for Payer: Multiplan Auto	$2,176.20
Rate for Payer: Multiplan Commercial	$2,176.20
Rate for Payer: Multiplan Workers Comp	$2,176.20
Rate for Payer: Parkland Medicaid	$2,410.56
Rate for Payer: Scott and White EPO/PPO	$1,674.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,410.56
Rate for Payer: Superior Health Plan EPO	$455.33

CT Incis/Drain Hema/Seroma/Fluid

Facility

$6,773.30

Service Code	HCPCS 10140
Hospital Charge Code	8912548
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,605.84

CT Incis/Drain Hema/Seroma/Fluid

Facility

$6,773.30

Service Code	HCPCS 10140
Hospital Charge Code	8912548
Hospital Revenue Code	361
Min. Negotiated Rate	$90.81
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$90.81
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	$183.82
Rate for Payer: BCBS of TX Blue Essentials	$220.14
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$277.38
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,876.78
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	$4,876.78
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	$4,876.78
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	$4,876.78
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 Joint/Bursa Major Arthr/Asp/Inj Right BCE

Facility

$1,676.00

Service Code	HCPCS 20610
Hospital Charge Code	3860001
Hospital Revenue Code	361
Min. Negotiated Rate	$27.96
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$27.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.35
Rate for Payer: Amerigroup Medicare	$308.35
Rate for Payer: BCBS of TX Blue Advantage	$51.84
Rate for Payer: BCBS of TX Blue Essentials	$62.08
Rate for Payer: BCBS of TX Medicare	$308.35
Rate for Payer: BCBS of TX PPO	$78.22
Rate for Payer: Cash Price	$1,139.68
Rate for Payer: Cash Price	$1,139.68
Rate for Payer: Cash Price	$1,139.68
Rate for Payer: Cigna Commercial	$651.79
Rate for Payer: Cigna Medicaid	$1,206.72
Rate for Payer: Cigna Medicare	$308.35
Rate for Payer: Employer Direct Commercial	$308.35
Rate for Payer: Humana Medicare/TRICARE	$308.35
Rate for Payer: Molina CHIP/Medicaid	$1,206.72
Rate for Payer: Molina Dual Medicare/Medicaid	$308.35
Rate for Payer: Molina Medicare	$308.35
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	$1,206.72
Rate for Payer: Scott and White EPO/PPO	$501.11
Rate for Payer: Scott and White Medicare	$308.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,206.72
Rate for Payer: Superior Health Plan EPO	$308.35
Rate for Payer: Superior Health Plan Medicare	$308.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.35
Rate for Payer: Universal American Medicare	$308.35
Rate for Payer: Wellcare Medicare	$308.35
Rate for Payer: Wellmed Medicare	$308.35

CT Joint/Bursa Major Arthr/Asp/Inj Right BCE

Facility

$1,676.00

Service Code	HCPCS 20610
Hospital Charge Code	3860001
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,139.68

CT Limited Study/Follow Up Study

Facility

$1,113.00

Service Code	HCPCS 76380
Hospital Charge Code	5056505
Hospital Revenue Code	351
Rate for Payer: Cash Price	$756.84

CT Limited Study/Follow Up Study

Facility

$1,113.00

Service Code	HCPCS 76380
Hospital Charge Code	5056505
Hospital Revenue Code	351
Min. Negotiated Rate	$86.58
Max. Negotiated Rate	$801.36
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	$756.84
Rate for Payer: Cash Price	$756.84
Rate for Payer: Cash Price	$756.84
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$801.36
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	$801.36
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$723.45
Rate for Payer: Multiplan Commercial	$723.45
Rate for Payer: Multiplan Workers Comp	$723.45
Rate for Payer: Parkland Medicaid	$801.36
Rate for Payer: Scott and White EPO/PPO	$165.47
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$801.36
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

CT Maxillofacial w/ Contrast

Facility

$4,080.00

Service Code	HCPCS 70487
Hospital Charge Code	3800232
Hospital Revenue Code	351
Min. Negotiated Rate	$156.38
Max. Negotiated Rate	$2,937.60
Rate for Payer: Amerigroup CHIP/Medicaid	$156.38
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	$2,774.40
Rate for Payer: Cash Price	$2,774.40
Rate for Payer: Cash Price	$2,774.40
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$2,937.60
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	$2,937.60
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$2,652.00
Rate for Payer: Multiplan Commercial	$2,652.00
Rate for Payer: Multiplan Workers Comp	$2,652.00
Rate for Payer: Parkland Medicaid	$2,937.60
Rate for Payer: Scott and White EPO/PPO	$192.65
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,937.60
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 Maxillofacial w/ Contrast

Facility

$4,080.00

Service Code	HCPCS 70487
Hospital Charge Code	3800232
Hospital Revenue Code	351
Rate for Payer: Cash Price	$2,774.40

CT Maxillofacial w/o Contrast

Facility

$3,586.00

Service Code	HCPCS 70486
Hospital Charge Code	3800307
Hospital Revenue Code	351
Rate for Payer: Cash Price	$2,438.48

CT Maxillofacial w/o Contrast

Facility

$3,586.00

Service Code	HCPCS 70486
Hospital Charge Code	3800307
Hospital Revenue Code	351
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$2,581.92
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	$2,438.48
Rate for Payer: Cash Price	$2,438.48
Rate for Payer: Cash Price	$2,438.48
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$2,581.92
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	$2,581.92
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$2,330.90
Rate for Payer: Multiplan Commercial	$2,330.90
Rate for Payer: Multiplan Workers Comp	$2,330.90
Rate for Payer: Parkland Medicaid	$2,581.92
Rate for Payer: Scott and White EPO/PPO	$162.26
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,581.92
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 Neck Soft Tissue w/ Contrast

Facility

$7,076.00

Service Code	HCPCS 70491
Hospital Charge Code	3800224
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$5,094.72
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	$4,811.68
Rate for Payer: Cash Price	$4,811.68
Rate for Payer: Cash Price	$4,811.68
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$5,094.72
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	$5,094.72
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$4,599.40
Rate for Payer: Multiplan Commercial	$4,599.40
Rate for Payer: Multiplan Workers Comp	$4,599.40
Rate for Payer: Parkland Medicaid	$5,094.72
Rate for Payer: Scott and White EPO/PPO	$233.45
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,094.72
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 Neck Soft Tissue w/ Contrast

Facility

$7,076.00

Service Code	HCPCS 70491
Hospital Charge Code	3800224
Hospital Revenue Code	351
Rate for Payer: Cash Price	$4,811.68

CT Neck Soft Tissue w/o Contrast

Facility

$5,958.00

Service Code	HCPCS 70490
Hospital Charge Code	3800075
Hospital Revenue Code	351
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$4,289.76
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	$4,051.44
Rate for Payer: Cash Price	$4,051.44
Rate for Payer: Cash Price	$4,051.44
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$4,289.76
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	$4,289.76
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$3,872.70
Rate for Payer: Multiplan Commercial	$3,872.70
Rate for Payer: Multiplan Workers Comp	$3,872.70
Rate for Payer: Parkland Medicaid	$4,289.76
Rate for Payer: Scott and White EPO/PPO	$189.79
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,289.76
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 Neck Soft Tissue w/o Contrast

Facility

$5,958.00

Service Code	HCPCS 70490
Hospital Charge Code	3800075
Hospital Revenue Code	351
Rate for Payer: Cash Price	$4,051.44

CT Neck Soft Tissue w/ + w/o Contrast

Facility

$8,364.00

Service Code	HCPCS 70492
Hospital Charge Code	3800158
Hospital Revenue Code	351
Rate for Payer: Cash Price	$5,687.52

CT Neck Soft Tissue w/ + w/o Contrast

Facility

$8,364.00

Service Code	HCPCS 70492
Hospital Charge Code	3800158
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$6,022.08
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	$5,687.52
Rate for Payer: Cash Price	$5,687.52
Rate for Payer: Cash Price	$5,687.52
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$6,022.08
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	$6,022.08
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$5,436.60
Rate for Payer: Multiplan Commercial	$5,436.60
Rate for Payer: Multiplan Workers Comp	$5,436.60
Rate for Payer: Parkland Medicaid	$6,022.08
Rate for Payer: Scott and White EPO/PPO	$280.01
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,022.08
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 Orbits Sella w/ Contrast

Facility

$4,332.00

Service Code	HCPCS 70481
Hospital Charge Code	3890027
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,119.04
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	$2,945.76
Rate for Payer: Cash Price	$2,945.76
Rate for Payer: Cash Price	$2,945.76
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,119.04
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	$3,119.04
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$2,815.80
Rate for Payer: Multiplan Commercial	$2,815.80
Rate for Payer: Multiplan Workers Comp	$2,815.80
Rate for Payer: Parkland Medicaid	$3,119.04
Rate for Payer: Scott and White EPO/PPO	$228.93
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,119.04
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 Orbits Sella w/ Contrast

Facility

$4,332.00

Service Code	HCPCS 70481
Hospital Charge Code	3890027
Hospital Revenue Code	351
Rate for Payer: Cash Price	$2,945.76

CT Orbits Sella w/o Contrast

Facility

$3,273.00

Service Code	HCPCS 70480
Hospital Charge Code	3800331
Hospital Revenue Code	351
Rate for Payer: Cash Price	$2,225.64

CT Orbits Sella w/o Contrast

Facility

$3,273.00

Service Code	HCPCS 70480
Hospital Charge Code	3800331
Hospital Revenue Code	351
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$2,356.56
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	$2,225.64
Rate for Payer: Cash Price	$2,225.64
Rate for Payer: Cash Price	$2,225.64
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$2,356.56
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	$2,356.56
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$2,127.45
Rate for Payer: Multiplan Commercial	$2,127.45
Rate for Payer: Multiplan Workers Comp	$2,127.45
Rate for Payer: Parkland Medicaid	$2,356.56
Rate for Payer: Scott and White EPO/PPO	$201.28
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,356.56
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 Orbits Sella w/ + w/o Contrast

Facility

$5,435.00

Service Code	HCPCS 70482
Hospital Charge Code	3800372
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,913.20
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	$3,695.80
Rate for Payer: Cash Price	$3,695.80
Rate for Payer: Cash Price	$3,695.80
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,913.20
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	$3,913.20
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$3,532.75
Rate for Payer: Multiplan Commercial	$3,532.75
Rate for Payer: Multiplan Workers Comp	$3,532.75
Rate for Payer: Parkland Medicaid	$3,913.20
Rate for Payer: Scott and White EPO/PPO	$267.23
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,913.20
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

Know your out-of-pocket cost for care.

All Charges