White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), ma

Facility

$10,000.00

Service Code	CPT 66982
Hospital Charge Code	36066982
Hospital Revenue Code	360
Min. Negotiated Rate	$849.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$849.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Amerigroup Medicare	$2,318.34
Rate for Payer: BCBS of TX Blue Advantage	$3,376.51
Rate for Payer: BCBS of TX Blue Essentials	$4,043.72
Rate for Payer: BCBS of TX Medicare	$2,318.34
Rate for Payer: BCBS of TX PPO	$5,095.09
Rate for Payer: Cigna Commercial	$4,900.56
Rate for Payer: Cigna Medicare	$2,318.34
Rate for Payer: Employer Direct Commercial	$2,318.34
Rate for Payer: Humana Medicare/TRICARE	$2,318.34
Rate for Payer: Molina Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Molina Medicare	$2,318.34
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: Scott and White EPO/PPO	$4,288.93
Rate for Payer: Scott and White Medicare	$2,318.34
Rate for Payer: Superior Health Plan EPO	$2,318.34
Rate for Payer: Superior Health Plan Medicare	$2,318.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Universal American Medicare	$2,318.34
Rate for Payer: Wellcare Medicare	$2,318.34
Rate for Payer: Wellmed Medicare	$2,318.34

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility

$81,048.86

Service Code	APR-DRG 0093
Min. Negotiated Rate	$76,415.71
Max. Negotiated Rate	$81,048.86
Rate for Payer: Amerigroup CHIP/Medicaid	$76,415.71
Rate for Payer: Cigna Medicaid	$76,415.71
Rate for Payer: Molina CHIP/Medicaid	$76,415.71
Rate for Payer: Parkland Medicaid	$76,415.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81,048.86

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility

$164,968.89

Service Code	APR-DRG 0094
Min. Negotiated Rate	$155,538.45
Max. Negotiated Rate	$164,968.89
Rate for Payer: Amerigroup CHIP/Medicaid	$155,538.45
Rate for Payer: Cigna Medicaid	$155,538.45
Rate for Payer: Molina CHIP/Medicaid	$155,538.45
Rate for Payer: Parkland Medicaid	$155,538.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$164,968.89

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility

$51,695.64

Service Code	APR-DRG 0091
Min. Negotiated Rate	$48,740.46
Max. Negotiated Rate	$51,695.64
Rate for Payer: Amerigroup CHIP/Medicaid	$48,740.46
Rate for Payer: Cigna Medicaid	$48,740.46
Rate for Payer: Molina CHIP/Medicaid	$48,740.46
Rate for Payer: Parkland Medicaid	$48,740.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51,695.64

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility

$53,305.48

Service Code	APR-DRG 0092
Min. Negotiated Rate	$50,258.27
Max. Negotiated Rate	$53,305.48
Rate for Payer: Amerigroup CHIP/Medicaid	$50,258.27
Rate for Payer: Cigna Medicaid	$50,258.27
Rate for Payer: Molina CHIP/Medicaid	$50,258.27
Rate for Payer: Parkland Medicaid	$50,258.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53,305.48

EXTRACRANIAL PROCEDURES W CC

Facility

$30,829.40

Service Code	MSDRG 038
Min. Negotiated Rate	$14,197.75
Max. Negotiated Rate	$30,829.40
Rate for Payer: BCBS of TX Blue Advantage	$14,376.62
Rate for Payer: BCBS of TX Blue Essentials	$17,250.27
Rate for Payer: BCBS of TX PPO	$19,167.71

EXTRACRANIAL PROCEDURES WITH CC

Facility

$30,829.40

Service Code	MSDRG 038
Min. Negotiated Rate	$14,197.75
Max. Negotiated Rate	$30,829.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,652.15
Rate for Payer: Amerigroup Medicare	$16,652.15
Rate for Payer: BCBS of TX Medicare	$16,652.15
Rate for Payer: Cigna Commercial	$20,899.09
Rate for Payer: Cigna Medicare	$16,652.15
Rate for Payer: Employer Direct Commercial	$16,652.15
Rate for Payer: Humana Medicare/TRICARE	$16,652.15
Rate for Payer: Molina Dual Medicare/Medicaid	$16,652.15
Rate for Payer: Molina Medicare	$16,652.15
Rate for Payer: Multiplan Auto	$30,829.40
Rate for Payer: Multiplan Commercial	$30,829.40
Rate for Payer: Multiplan Workers Comp	$30,829.40
Rate for Payer: Scott and White EPO/PPO	$14,197.75
Rate for Payer: Scott and White Medicare	$16,652.15
Rate for Payer: Superior Health Plan EPO	$16,652.15
Rate for Payer: Superior Health Plan Medicare	$16,652.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,652.15
Rate for Payer: Universal American Medicare	$16,652.15
Rate for Payer: Wellcare Medicare	$16,652.15
Rate for Payer: Wellmed Medicare	$16,652.15

EXTRACRANIAL PROCEDURES WITH MCC

Facility

$62,549.90

Service Code	MSDRG 037
Min. Negotiated Rate	$27,604.28
Max. Negotiated Rate	$62,549.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,887.97
Rate for Payer: Amerigroup Medicare	$28,887.97
Rate for Payer: BCBS of TX Medicare	$28,887.97
Rate for Payer: Cigna Commercial	$42,402.25
Rate for Payer: Cigna Medicare	$28,887.97
Rate for Payer: Employer Direct Commercial	$28,887.97
Rate for Payer: Humana Medicare/TRICARE	$28,887.97
Rate for Payer: Molina Dual Medicare/Medicaid	$28,887.97
Rate for Payer: Molina Medicare	$28,887.97
Rate for Payer: Multiplan Auto	$62,549.90
Rate for Payer: Multiplan Commercial	$62,549.90
Rate for Payer: Multiplan Workers Comp	$62,549.90
Rate for Payer: Scott and White EPO/PPO	$28,805.88
Rate for Payer: Scott and White Medicare	$28,887.97
Rate for Payer: Superior Health Plan EPO	$28,887.97
Rate for Payer: Superior Health Plan Medicare	$28,887.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,887.97
Rate for Payer: Universal American Medicare	$28,887.97
Rate for Payer: Wellcare Medicare	$28,887.97
Rate for Payer: Wellmed Medicare	$28,887.97

EXTRACRANIAL PROCEDURES WITHOUT CC/MCC

Facility

$22,334.50

Service Code	MSDRG 039
Min. Negotiated Rate	$9,738.64
Max. Negotiated Rate	$22,334.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,375.34
Rate for Payer: Amerigroup Medicare	$13,375.34
Rate for Payer: BCBS of TX Medicare	$13,375.34
Rate for Payer: Cigna Commercial	$15,140.44
Rate for Payer: Cigna Medicare	$13,375.34
Rate for Payer: Employer Direct Commercial	$13,375.34
Rate for Payer: Humana Medicare/TRICARE	$13,375.34
Rate for Payer: Molina Dual Medicare/Medicaid	$13,375.34
Rate for Payer: Molina Medicare	$13,375.34
Rate for Payer: Multiplan Auto	$22,334.50
Rate for Payer: Multiplan Commercial	$22,334.50
Rate for Payer: Multiplan Workers Comp	$22,334.50
Rate for Payer: Scott and White EPO/PPO	$10,285.62
Rate for Payer: Scott and White Medicare	$13,375.34
Rate for Payer: Superior Health Plan EPO	$13,375.34
Rate for Payer: Superior Health Plan Medicare	$13,375.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,375.34
Rate for Payer: Universal American Medicare	$13,375.34
Rate for Payer: Wellcare Medicare	$13,375.34
Rate for Payer: Wellmed Medicare	$13,375.34

EXTRACRANIAL PROCEDURES W MCC

Facility

$62,549.90

Service Code	MSDRG 037
Min. Negotiated Rate	$27,604.28
Max. Negotiated Rate	$62,549.90
Rate for Payer: BCBS of TX Blue Advantage	$27,604.28
Rate for Payer: BCBS of TX Blue Essentials	$33,121.93
Rate for Payer: BCBS of TX PPO	$36,803.57

EXTRACRANIAL PROCEDURES W/O CC/MCC

Facility

$22,334.50

Service Code	MSDRG 039
Min. Negotiated Rate	$9,738.64
Max. Negotiated Rate	$22,334.50
Rate for Payer: BCBS of TX Blue Advantage	$9,738.64
Rate for Payer: BCBS of TX Blue Essentials	$11,685.24
Rate for Payer: BCBS of TX PPO	$12,984.10

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$29,163.10

Service Code	MSDRG 115
Min. Negotiated Rate	$11,714.06
Max. Negotiated Rate	$29,163.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,009.40
Rate for Payer: Amerigroup Medicare	$16,009.40
Rate for Payer: BCBS of TX Blue Advantage	$11,714.06
Rate for Payer: BCBS of TX Blue Essentials	$14,055.51
Rate for Payer: BCBS of TX Medicare	$16,009.40
Rate for Payer: BCBS of TX PPO	$15,617.84
Rate for Payer: Cigna Commercial	$19,769.51
Rate for Payer: Cigna Medicare	$16,009.40
Rate for Payer: Employer Direct Commercial	$16,009.40
Rate for Payer: Humana Medicare/TRICARE	$16,009.40
Rate for Payer: Molina Dual Medicare/Medicaid	$16,009.40
Rate for Payer: Molina Medicare	$16,009.40
Rate for Payer: Multiplan Auto	$29,163.10
Rate for Payer: Multiplan Commercial	$29,163.10
Rate for Payer: Multiplan Workers Comp	$29,163.10
Rate for Payer: Scott and White EPO/PPO	$13,430.38
Rate for Payer: Scott and White Medicare	$16,009.40
Rate for Payer: Superior Health Plan EPO	$16,009.40
Rate for Payer: Superior Health Plan Medicare	$16,009.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,009.40
Rate for Payer: Universal American Medicare	$16,009.40
Rate for Payer: Wellcare Medicare	$16,009.40
Rate for Payer: Wellmed Medicare	$16,009.40

Extra short Entermediate plat

Facility

$9,048.19

Service Code	HCPCS C1734
Hospital Charge Code	992171
Hospital Revenue Code	278
Min. Negotiated Rate	$2,262.05
Max. Negotiated Rate	$4,524.10
Rate for Payer: Cash Price	$6,152.77
Rate for Payer: Cigna Commercial	$2,262.05
Rate for Payer: Multiplan Auto	$4,524.10
Rate for Payer: Multiplan Commercial	$4,524.10
Rate for Payer: Multiplan Workers Comp	$4,524.10
Rate for Payer: Scott and White EPO/PPO	$4,524.10

Extra short Entermediate plat

Facility

$9,048.19

Service Code	HCPCS C1734
Hospital Charge Code	992171
Hospital Revenue Code	278
Min. Negotiated Rate	$814.34
Max. Negotiated Rate	$6,514.70
Rate for Payer: Amerigroup CHIP/Medicaid	$814.34
Rate for Payer: BCBS of TX Blue Advantage	$2,714.46
Rate for Payer: BCBS of TX Blue Essentials	$3,257.35
Rate for Payer: BCBS of TX PPO	$3,619.28
Rate for Payer: Cash Price	$6,152.77
Rate for Payer: Cigna Medicaid	$6,514.70
Rate for Payer: Molina CHIP/Medicaid	$6,514.70
Rate for Payer: Multiplan Auto	$4,524.10
Rate for Payer: Multiplan Commercial	$4,524.10
Rate for Payer: Multiplan Workers Comp	$4,524.10
Rate for Payer: Parkland Medicaid	$6,514.70
Rate for Payer: Scott and White EPO/PPO	$4,524.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,514.70
Rate for Payer: Superior Health Plan EPO	$1,230.55

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$112,926.50

Service Code	MSDRG 790
Min. Negotiated Rate	$47,182.18
Max. Negotiated Rate	$112,926.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$48,320.16
Rate for Payer: Amerigroup Medicare	$48,320.16
Rate for Payer: BCBS of TX Blue Advantage	$47,182.18
Rate for Payer: BCBS of TX Blue Essentials	$56,613.13
Rate for Payer: BCBS of TX Medicare	$48,320.16
Rate for Payer: BCBS of TX PPO	$62,905.92
Rate for Payer: Cigna Commercial	$76,552.28
Rate for Payer: Cigna Medicare	$48,320.16
Rate for Payer: Employer Direct Commercial	$48,320.16
Rate for Payer: Humana Medicare/TRICARE	$48,320.16
Rate for Payer: Molina Dual Medicare/Medicaid	$48,320.16
Rate for Payer: Molina Medicare	$48,320.16
Rate for Payer: Multiplan Auto	$112,926.50
Rate for Payer: Multiplan Commercial	$112,926.50
Rate for Payer: Multiplan Workers Comp	$112,926.50
Rate for Payer: Scott and White EPO/PPO	$52,005.62
Rate for Payer: Scott and White Medicare	$48,320.16
Rate for Payer: Superior Health Plan EPO	$48,320.16
Rate for Payer: Superior Health Plan Medicare	$48,320.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$48,320.16
Rate for Payer: Universal American Medicare	$48,320.16
Rate for Payer: Wellcare Medicare	$48,320.16
Rate for Payer: Wellmed Medicare	$48,320.16

Extremity T-Drape, Sterile

Facility

$38.20

Hospital Charge Code	992857
Hospital Revenue Code	272
Rate for Payer: Cash Price	$25.98

Extremity T-Drape, Sterile

Facility

$38.20

Hospital Charge Code	992857
Hospital Revenue Code	272
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$27.50
Rate for Payer: Amerigroup CHIP/Medicaid	$3.44
Rate for Payer: BCBS of TX Blue Advantage	$11.46
Rate for Payer: BCBS of TX Blue Essentials	$13.75
Rate for Payer: BCBS of TX PPO	$15.28
Rate for Payer: Cash Price	$25.98
Rate for Payer: Cigna Medicaid	$27.50
Rate for Payer: Molina CHIP/Medicaid	$27.50
Rate for Payer: Multiplan Auto	$24.83
Rate for Payer: Multiplan Commercial	$24.83
Rate for Payer: Multiplan Workers Comp	$24.83
Rate for Payer: Parkland Medicaid	$27.50
Rate for Payer: Scott and White EPO/PPO	$19.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.50
Rate for Payer: Superior Health Plan EPO	$5.20

EXTR RETRV BALLOON -- DHF

Facility

$809.66

Hospital Charge Code	80322191
Hospital Revenue Code	272
Min. Negotiated Rate	$72.87
Max. Negotiated Rate	$582.96
Rate for Payer: Amerigroup CHIP/Medicaid	$72.87
Rate for Payer: BCBS of TX Blue Advantage	$242.90
Rate for Payer: BCBS of TX Blue Essentials	$291.48
Rate for Payer: BCBS of TX PPO	$323.86
Rate for Payer: Cash Price	$550.57
Rate for Payer: Cigna Medicaid	$582.96
Rate for Payer: Molina CHIP/Medicaid	$582.96
Rate for Payer: Multiplan Auto	$526.28
Rate for Payer: Multiplan Commercial	$526.28
Rate for Payer: Multiplan Workers Comp	$526.28
Rate for Payer: Parkland Medicaid	$582.96
Rate for Payer: Scott and White EPO/PPO	$404.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$582.96
Rate for Payer: Superior Health Plan EPO	$110.11

EXTR RETRV BALLOON -- DHF

Facility

$809.66

Hospital Charge Code	80322191
Hospital Revenue Code	272
Rate for Payer: Cash Price	$550.57

*Ext Study Levels -> Duplex Scan Extremity Veins Complete Bilateral

Facility

$2,850.00

Service Code	HCPCS 93970
Hospital Charge Code	7100332
Hospital Revenue Code	921
Rate for Payer: Cash Price	$1,938.00

*Ext Study Levels -> Duplex Scan Extremity Veins Complete Bilateral

Facility

$2,850.00

Service Code	HCPCS 93970
Hospital Charge Code	7100332
Hospital Revenue Code	921
Min. Negotiated Rate	$239.69
Max. Negotiated Rate	$2,052.00
Rate for Payer: Amerigroup CHIP/Medicaid	$256.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$855.00
Rate for Payer: BCBS of TX Blue Essentials	$1,026.00
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$1,140.00
Rate for Payer: Cash Price	$1,938.00
Rate for Payer: Cash Price	$1,938.00
Rate for Payer: Cash Price	$1,938.00
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,052.00
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$2,052.00
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$1,852.50
Rate for Payer: Multiplan Commercial	$1,852.50
Rate for Payer: Multiplan Workers Comp	$1,852.50
Rate for Payer: Parkland Medicaid	$2,052.00
Rate for Payer: Scott and White EPO/PPO	$1,425.00
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,052.00
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

*Ext Study Levels -> Extremity Study Bilateral 1-2 Levels

Facility

$720.00

Service Code	HCPCS 93922
Hospital Charge Code	7150844
Hospital Revenue Code	921
Rate for Payer: Cash Price	$489.60

*Ext Study Levels -> Extremity Study Bilateral 1-2 Levels

Facility

$720.00

Service Code	HCPCS 93922
Hospital Charge Code	7150844
Hospital Revenue Code	921
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$518.40
Rate for Payer: Amerigroup CHIP/Medicaid	$64.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$216.00
Rate for Payer: BCBS of TX Blue Essentials	$259.20
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$288.00
Rate for Payer: Cash Price	$489.60
Rate for Payer: Cash Price	$489.60
Rate for Payer: Cash Price	$489.60
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$518.40
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$518.40
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$468.00
Rate for Payer: Multiplan Commercial	$468.00
Rate for Payer: Multiplan Workers Comp	$468.00
Rate for Payer: Parkland Medicaid	$518.40
Rate for Payer: Scott and White EPO/PPO	$360.00
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$518.40
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

*Ext Study Levels -> Extremity Study Bilateral 3+ Levels

Facility

$1,579.00

Service Code	HCPCS 93923
Hospital Charge Code	6620804
Hospital Revenue Code	921
Min. Negotiated Rate	$142.11
Max. Negotiated Rate	$1,136.88
Rate for Payer: Amerigroup CHIP/Medicaid	$142.11
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$473.70
Rate for Payer: BCBS of TX Blue Essentials	$568.44
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$631.60
Rate for Payer: Cash Price	$1,073.72
Rate for Payer: Cash Price	$1,073.72
Rate for Payer: Cash Price	$1,073.72
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$1,136.88
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$1,136.88
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$1,026.35
Rate for Payer: Multiplan Commercial	$1,026.35
Rate for Payer: Multiplan Workers Comp	$1,026.35
Rate for Payer: Parkland Medicaid	$1,136.88
Rate for Payer: Scott and White EPO/PPO	$789.50
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,136.88
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

*Ext Study Levels -> Extremity Study Bilateral 3+ Levels

Facility

$1,579.00

Service Code	HCPCS 93923
Hospital Charge Code	6620804
Hospital Revenue Code	921
Rate for Payer: Cash Price	$1,073.72

Know your out-of-pocket cost for care.

All Charges