White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CT Spine Cervical w/ Contrast

Facility

$6,442.00

Service Code	HCPCS 72126
Hospital Charge Code	3800273
Hospital Revenue Code	352
Min. Negotiated Rate	$173.41
Max. Negotiated Rate	$4,638.24
Rate for Payer: Amerigroup CHIP/Medicaid	$173.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX Medicare	$350.46
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$4,380.56
Rate for Payer: Cash Price	$4,380.56
Rate for Payer: Cash Price	$4,380.56
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$4,638.24
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	$4,638.24
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$4,187.30
Rate for Payer: Multiplan Commercial	$4,187.30
Rate for Payer: Multiplan Workers Comp	$4,187.30
Rate for Payer: Parkland Medicaid	$4,638.24
Rate for Payer: Scott and White EPO/PPO	$213.69
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,638.24
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 Spine Cervical w/ Contrast

Facility

$6,442.00

Service Code	HCPCS 72126
Hospital Charge Code	3800273
Hospital Revenue Code	352
Rate for Payer: Cash Price	$4,380.56

CT Spine Cervical w/o Contrast

Facility

$5,916.00

Service Code	HCPCS 72125
Hospital Charge Code	3800133
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$4,259.52
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	$4,022.88
Rate for Payer: Cash Price	$4,022.88
Rate for Payer: Cash Price	$4,022.88
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$4,259.52
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	$4,259.52
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$3,845.40
Rate for Payer: Multiplan Commercial	$3,845.40
Rate for Payer: Multiplan Workers Comp	$3,845.40
Rate for Payer: Parkland Medicaid	$4,259.52
Rate for Payer: Scott and White EPO/PPO	$164.71
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,259.52
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 Spine Cervical w/o Contrast

Facility

$5,916.00

Service Code	HCPCS 72125
Hospital Charge Code	3800133
Hospital Revenue Code	352
Rate for Payer: Cash Price	$4,022.88

CT Spine Lumbar w/ Contrast

Facility

$6,598.00

Service Code	HCPCS 72132
Hospital Charge Code	3800901
Hospital Revenue Code	352
Min. Negotiated Rate	$173.75
Max. Negotiated Rate	$4,750.56
Rate for Payer: Amerigroup CHIP/Medicaid	$173.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX Medicare	$350.46
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$4,486.64
Rate for Payer: Cash Price	$4,486.64
Rate for Payer: Cash Price	$4,486.64
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$4,750.56
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	$4,750.56
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$4,288.70
Rate for Payer: Multiplan Commercial	$4,288.70
Rate for Payer: Multiplan Workers Comp	$4,288.70
Rate for Payer: Parkland Medicaid	$4,750.56
Rate for Payer: Scott and White EPO/PPO	$214.10
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,750.56
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 Spine Lumbar w/ Contrast

Facility

$6,598.00

Service Code	HCPCS 72132
Hospital Charge Code	3800901
Hospital Revenue Code	352
Rate for Payer: Cash Price	$4,486.64

CT Spine Lumbar w/o Contrast

Facility

$5,120.00

Service Code	HCPCS 72131
Hospital Charge Code	3800893
Hospital Revenue Code	352
Rate for Payer: Cash Price	$3,481.60

CT Spine Lumbar w/o Contrast

Facility

$5,120.00

Service Code	HCPCS 72131
Hospital Charge Code	3800893
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$3,686.40
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	$3,481.60
Rate for Payer: Cash Price	$3,481.60
Rate for Payer: Cash Price	$3,481.60
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$3,686.40
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	$3,686.40
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$3,328.00
Rate for Payer: Multiplan Commercial	$3,328.00
Rate for Payer: Multiplan Workers Comp	$3,328.00
Rate for Payer: Parkland Medicaid	$3,686.40
Rate for Payer: Scott and White EPO/PPO	$163.47
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,686.40
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 Spine Lumbar w/ + w/o Contrast

Facility

$6,928.00

Service Code	HCPCS 72133
Hospital Charge Code	3800919
Hospital Revenue Code	352
Rate for Payer: Cash Price	$4,711.04

CT Spine Lumbar w/ + w/o Contrast

Facility

$6,928.00

Service Code	HCPCS 72133
Hospital Charge Code	3800919
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$4,988.16
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	$4,711.04
Rate for Payer: Cash Price	$4,711.04
Rate for Payer: Cash Price	$4,711.04
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$4,988.16
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	$4,988.16
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$4,503.20
Rate for Payer: Multiplan Commercial	$4,503.20
Rate for Payer: Multiplan Workers Comp	$4,503.20
Rate for Payer: Parkland Medicaid	$4,988.16
Rate for Payer: Scott and White EPO/PPO	$250.74
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,988.16
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 Spine Thoracic w/ Contrast

Facility

$3,350.00

Service Code	HCPCS 72129
Hospital Charge Code	3800877
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,278.00

CT Spine Thoracic w/ Contrast

Facility

$3,350.00

Service Code	HCPCS 72129
Hospital Charge Code	3800877
Hospital Revenue Code	352
Min. Negotiated Rate	$174.75
Max. Negotiated Rate	$2,412.00
Rate for Payer: Amerigroup CHIP/Medicaid	$174.75
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	$2,278.00
Rate for Payer: Cash Price	$2,278.00
Rate for Payer: Cash Price	$2,278.00
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$2,412.00
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	$2,412.00
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$2,177.50
Rate for Payer: Multiplan Commercial	$2,177.50
Rate for Payer: Multiplan Workers Comp	$2,177.50
Rate for Payer: Parkland Medicaid	$2,412.00
Rate for Payer: Scott and White EPO/PPO	$215.29
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,412.00
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 Spine Thoracic w/o Contrast

Facility

$2,402.00

Service Code	HCPCS 72128
Hospital Charge Code	3800869
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$1,729.44
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	$1,633.36
Rate for Payer: Cash Price	$1,633.36
Rate for Payer: Cash Price	$1,633.36
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$1,729.44
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	$1,729.44
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$1,561.30
Rate for Payer: Multiplan Commercial	$1,561.30
Rate for Payer: Multiplan Workers Comp	$1,561.30
Rate for Payer: Parkland Medicaid	$1,729.44
Rate for Payer: Scott and White EPO/PPO	$164.30
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,729.44
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 Spine Thoracic w/o Contrast

Facility

$2,402.00

Service Code	HCPCS 72128
Hospital Charge Code	3800869
Hospital Revenue Code	352
Rate for Payer: Cash Price	$1,633.36

CT Thoracentesis w/ CT Guidance Right

Facility

$1,959.00

Service Code	HCPCS 32555
Hospital Charge Code	3800000
Hospital Revenue Code	361
Min. Negotiated Rate	$223.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$223.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$630.16
Rate for Payer: Amerigroup Medicare	$630.16
Rate for Payer: BCBS of TX Blue Advantage	$1,052.95
Rate for Payer: BCBS of TX Blue Essentials	$1,261.02
Rate for Payer: BCBS of TX Medicare	$630.16
Rate for Payer: BCBS of TX PPO	$1,588.89
Rate for Payer: Cash Price	$1,332.12
Rate for Payer: Cash Price	$1,332.12
Rate for Payer: Cash Price	$1,332.12
Rate for Payer: Cigna Commercial	$1,332.05
Rate for Payer: Cigna Medicaid	$1,410.48
Rate for Payer: Cigna Medicare	$630.16
Rate for Payer: Employer Direct Commercial	$630.16
Rate for Payer: Humana Medicare/TRICARE	$630.16
Rate for Payer: Molina CHIP/Medicaid	$1,410.48
Rate for Payer: Molina Dual Medicare/Medicaid	$630.16
Rate for Payer: Molina Medicare	$630.16
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	$1,410.48
Rate for Payer: Scott and White EPO/PPO	$1,062.86
Rate for Payer: Scott and White Medicare	$630.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,410.48
Rate for Payer: Superior Health Plan EPO	$630.16
Rate for Payer: Superior Health Plan Medicare	$630.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$630.16
Rate for Payer: Universal American Medicare	$630.16
Rate for Payer: Wellcare Medicare	$630.16
Rate for Payer: Wellmed Medicare	$630.16

CT Thoracentesis w/ CT Guidance Right

Facility

$1,959.00

Service Code	HCPCS 32555
Hospital Charge Code	3800000
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,332.12

CT Thoracic Spine with & w/out contrast

Facility

$712.08

Service Code	HCPCS 72130
Hospital Charge Code	994145
Hospital Revenue Code	352
Rate for Payer: Cash Price	$484.21

CT Thoracic Spine with & w/out contrast

Facility

$712.08

Service Code	HCPCS 72130
Hospital Charge Code	994145
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	$251.97
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 thorax, low dose for lung cancer screening, without contrast materia

Facility

$425.36

Service Code	HCPCS 71271
Hospital Charge Code	994131
Hospital Revenue Code	352
Rate for Payer: Cash Price	$289.24

CT thorax, low dose for lung cancer screening, without contrast materia

Facility

$425.36

Service Code	HCPCS 71271
Hospital Charge Code	994131
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$306.26
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	$170.66
Rate for Payer: BCBS of TX Blue Essentials	$204.79
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$228.58
Rate for Payer: Cash Price	$289.24
Rate for Payer: Cash Price	$289.24
Rate for Payer: Cash Price	$289.24
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$306.26
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	$306.26
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$276.48
Rate for Payer: Multiplan Commercial	$276.48
Rate for Payer: Multiplan Workers Comp	$276.48
Rate for Payer: Parkland Medicaid	$306.26
Rate for Payer: Scott and White EPO/PPO	$174.10
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$306.26
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 Thorax w/ Contrast

Facility

$5,138.00

Service Code	HCPCS 71260
Hospital Charge Code	3800240
Hospital Revenue Code	352
Min. Negotiated Rate	$171.74
Max. Negotiated Rate	$3,699.36
Rate for Payer: Amerigroup CHIP/Medicaid	$171.74
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	$3,493.84
Rate for Payer: Cash Price	$3,493.84
Rate for Payer: Cash Price	$3,493.84
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,699.36
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	$3,699.36
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$3,339.70
Rate for Payer: Multiplan Commercial	$3,339.70
Rate for Payer: Multiplan Workers Comp	$3,339.70
Rate for Payer: Parkland Medicaid	$3,699.36
Rate for Payer: Scott and White EPO/PPO	$211.61
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,699.36
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 Thorax w/ Contrast

Facility

$5,138.00

Service Code	HCPCS 71260
Hospital Charge Code	3800240
Hospital Revenue Code	352
Rate for Payer: Cash Price	$3,493.84

CT Tibia Fibula w/ Contrast Left

Facility

$3,797.00

Service Code	HCPCS 73701 LT
Hospital Charge Code	3800968
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,581.96

CT Tibia Fibula w/ Contrast Left

Facility

$3,797.00

Service Code	HCPCS 73701 LT
Hospital Charge Code	3800968
Hospital Revenue Code	352
Min. Negotiated Rate	$171.41
Max. Negotiated Rate	$2,733.84
Rate for Payer: Amerigroup CHIP/Medicaid	$171.41
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	$2,581.96
Rate for Payer: Cash Price	$2,581.96
Rate for Payer: Cash Price	$2,581.96
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$2,733.84
Rate for Payer: Molina CHIP/Medicaid	$2,733.84
Rate for Payer: Multiplan Auto	$2,468.05
Rate for Payer: Multiplan Commercial	$2,468.05
Rate for Payer: Multiplan Workers Comp	$2,468.05
Rate for Payer: Parkland Medicaid	$2,733.84
Rate for Payer: Scott and White EPO/PPO	$1,898.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,733.84
Rate for Payer: Superior Health Plan EPO	$516.39

CT Tibia Fibula w/ Contrast Right

Facility

$3,797.00

Service Code	HCPCS 73701 RT
Hospital Charge Code	3801875
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,581.96

Know your out-of-pocket cost for care.

All Charges