White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MG Breast Tissue Specimen Surgical Left BCE

Facility

$333.00

Service Code	CPT 76098 LT
Hospital Charge Code	3600111
Hospital Revenue Code	320
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$1,142.91
Rate for Payer: Aetna Commercial	$29.10
Rate for Payer: Aetna Medicare	$756.80
Rate for Payer: Amerigroup CHIP/Medicaid	$42.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$504.53
Rate for Payer: Amerigroup Medicare	$504.53
Rate for Payer: BCBS of TX Blue Advantage	$794.61
Rate for Payer: BCBS of TX Blue Essentials	$953.53
Rate for Payer: BCBS of TX Medicare	$504.53
Rate for Payer: BCBS of TX PPO	$1,064.29
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicaid	$12.03
Rate for Payer: Cigna Medicare	$504.53
Rate for Payer: Employer Direct Commercial	$504.53
Rate for Payer: Humana Medicare/TRICARE	$504.53
Rate for Payer: Molina CHIP/Medicaid	$12.03
Rate for Payer: Molina Dual Medicare/Medicaid	$504.53
Rate for Payer: Molina Medicare	$504.53
Rate for Payer: Multiplan Auto	$216.45
Rate for Payer: Multiplan Commercial	$216.45
Rate for Payer: Multiplan Workers Comp	$216.45
Rate for Payer: Parkland Medicaid	$12.03
Rate for Payer: Scott and White EPO/PPO	$9.02
Rate for Payer: Scott and White Medicare	$504.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.03
Rate for Payer: Superior Health Plan EPO	$504.53
Rate for Payer: Superior Health Plan Medicare	$504.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$504.53
Rate for Payer: Universal American Medicare	$504.53
Rate for Payer: Wellcare Medicare	$504.53
Rate for Payer: Wellmed Medicare	$504.53

MG Breast Tissue Specimen Surgical Right

Facility

$333.00

Service Code	CPT 76098 RT
Hospital Charge Code	3600111
Hospital Revenue Code	320
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$1,142.91
Rate for Payer: Aetna Commercial	$29.10
Rate for Payer: Aetna Medicare	$756.80
Rate for Payer: Amerigroup CHIP/Medicaid	$42.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$504.53
Rate for Payer: Amerigroup Medicare	$504.53
Rate for Payer: BCBS of TX Blue Advantage	$794.61
Rate for Payer: BCBS of TX Blue Essentials	$953.53
Rate for Payer: BCBS of TX Medicare	$504.53
Rate for Payer: BCBS of TX PPO	$1,064.29
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicaid	$12.03
Rate for Payer: Cigna Medicare	$504.53
Rate for Payer: Employer Direct Commercial	$504.53
Rate for Payer: Humana Medicare/TRICARE	$504.53
Rate for Payer: Molina CHIP/Medicaid	$12.03
Rate for Payer: Molina Dual Medicare/Medicaid	$504.53
Rate for Payer: Molina Medicare	$504.53
Rate for Payer: Multiplan Auto	$216.45
Rate for Payer: Multiplan Commercial	$216.45
Rate for Payer: Multiplan Workers Comp	$216.45
Rate for Payer: Parkland Medicaid	$12.03
Rate for Payer: Scott and White EPO/PPO	$9.02
Rate for Payer: Scott and White Medicare	$504.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.03
Rate for Payer: Superior Health Plan EPO	$504.53
Rate for Payer: Superior Health Plan Medicare	$504.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$504.53
Rate for Payer: Universal American Medicare	$504.53
Rate for Payer: Wellcare Medicare	$504.53
Rate for Payer: Wellmed Medicare	$504.53

MG Breast Tissue Specimen Surgical Right BCE

Facility

$333.00

Service Code	CPT 76098 RT
Hospital Charge Code	3600111
Hospital Revenue Code	320
Rate for Payer: Cash Price	$293.04

MG Breast Tissue Specimen Surgical Right BCE

Facility

$333.00

Service Code	CPT 76098 RT
Hospital Charge Code	3600111
Hospital Revenue Code	320
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$1,142.91
Rate for Payer: Aetna Commercial	$29.10
Rate for Payer: Aetna Medicare	$756.80
Rate for Payer: Amerigroup CHIP/Medicaid	$42.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$504.53
Rate for Payer: Amerigroup Medicare	$504.53
Rate for Payer: BCBS of TX Blue Advantage	$794.61
Rate for Payer: BCBS of TX Blue Essentials	$953.53
Rate for Payer: BCBS of TX Medicare	$504.53
Rate for Payer: BCBS of TX PPO	$1,064.29
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicaid	$12.03
Rate for Payer: Cigna Medicare	$504.53
Rate for Payer: Employer Direct Commercial	$504.53
Rate for Payer: Humana Medicare/TRICARE	$504.53
Rate for Payer: Molina CHIP/Medicaid	$12.03
Rate for Payer: Molina Dual Medicare/Medicaid	$504.53
Rate for Payer: Molina Medicare	$504.53
Rate for Payer: Multiplan Auto	$216.45
Rate for Payer: Multiplan Commercial	$216.45
Rate for Payer: Multiplan Workers Comp	$216.45
Rate for Payer: Parkland Medicaid	$12.03
Rate for Payer: Scott and White EPO/PPO	$9.02
Rate for Payer: Scott and White Medicare	$504.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.03
Rate for Payer: Superior Health Plan EPO	$504.53
Rate for Payer: Superior Health Plan Medicare	$504.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$504.53
Rate for Payer: Universal American Medicare	$504.53
Rate for Payer: Wellcare Medicare	$504.53
Rate for Payer: Wellmed Medicare	$504.53

MG Breast Tomo 3D Digital Diag Bilateral

Facility

$218.00

Service Code	CPT 77062
Hospital Charge Code	5017062
Hospital Revenue Code	401
Min. Negotiated Rate	$19.62
Max. Negotiated Rate	$207.87
Rate for Payer: Aetna Commercial	$128.48
Rate for Payer: Amerigroup CHIP/Medicaid	$19.62
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$191.84
Rate for Payer: Cash Price	$191.84
Rate for Payer: Multiplan Auto	$141.70
Rate for Payer: Multiplan Commercial	$141.70
Rate for Payer: Multiplan Workers Comp	$141.70
Rate for Payer: Scott and White EPO/PPO	$109.00
Rate for Payer: Superior Health Plan EPO	$29.65

MG Breast Tomo 3D Digital Diag Bilateral BCE

Facility

$218.00

Service Code	CPT 77062
Hospital Charge Code	5017062
Hospital Revenue Code	401
Min. Negotiated Rate	$19.62
Max. Negotiated Rate	$207.87
Rate for Payer: Aetna Commercial	$128.48
Rate for Payer: Amerigroup CHIP/Medicaid	$19.62
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$191.84
Rate for Payer: Cash Price	$191.84
Rate for Payer: Multiplan Auto	$141.70
Rate for Payer: Multiplan Commercial	$141.70
Rate for Payer: Multiplan Workers Comp	$141.70
Rate for Payer: Scott and White EPO/PPO	$109.00
Rate for Payer: Superior Health Plan EPO	$29.65

MG Breast Tomo 3D Digital Diag Bilateral BCE

Facility

$218.00

Service Code	CPT 77062
Hospital Charge Code	5017062
Hospital Revenue Code	401
Rate for Payer: Cash Price	$191.84

MG Breast Tomo 3D Digital Diag Left

Facility

$183.00

Service Code	CPT 77061 LT
Hospital Charge Code	5017061
Hospital Revenue Code	401
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$207.87
Rate for Payer: Aetna Commercial	$100.75
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$161.04
Rate for Payer: Cash Price	$161.04
Rate for Payer: Multiplan Auto	$118.95
Rate for Payer: Multiplan Commercial	$118.95
Rate for Payer: Multiplan Workers Comp	$118.95
Rate for Payer: Scott and White EPO/PPO	$91.50
Rate for Payer: Superior Health Plan EPO	$24.89

MG Breast Tomo 3D Digital Diag Left BCE

Facility

$183.00

Service Code	CPT 77061 LT
Hospital Charge Code	5017061
Hospital Revenue Code	401
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$207.87
Rate for Payer: Aetna Commercial	$100.75
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$161.04
Rate for Payer: Cash Price	$161.04
Rate for Payer: Multiplan Auto	$118.95
Rate for Payer: Multiplan Commercial	$118.95
Rate for Payer: Multiplan Workers Comp	$118.95
Rate for Payer: Scott and White EPO/PPO	$91.50
Rate for Payer: Superior Health Plan EPO	$24.89

MG Breast Tomo 3D Digital Diag Right

Facility

$183.00

Service Code	CPT 77061 RT
Hospital Charge Code	5017061
Hospital Revenue Code	401
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$207.87
Rate for Payer: Aetna Commercial	$100.75
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$161.04
Rate for Payer: Cash Price	$161.04
Rate for Payer: Multiplan Auto	$118.95
Rate for Payer: Multiplan Commercial	$118.95
Rate for Payer: Multiplan Workers Comp	$118.95
Rate for Payer: Scott and White EPO/PPO	$91.50
Rate for Payer: Superior Health Plan EPO	$24.89

MG Breast Tomo 3D Digital Diag Right BCE

Facility

$183.00

Service Code	CPT 77061 RT
Hospital Charge Code	5017061
Hospital Revenue Code	401
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$207.87
Rate for Payer: Aetna Commercial	$100.75
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$161.04
Rate for Payer: Cash Price	$161.04
Rate for Payer: Multiplan Auto	$118.95
Rate for Payer: Multiplan Commercial	$118.95
Rate for Payer: Multiplan Workers Comp	$118.95
Rate for Payer: Scott and White EPO/PPO	$91.50
Rate for Payer: Superior Health Plan EPO	$24.89

MG Breast Tomo 3D Digital Diag Right BCE

Facility

$183.00

Service Code	CPT 77061 RT
Hospital Charge Code	5017061
Hospital Revenue Code	401
Rate for Payer: Cash Price	$161.04

MG Breast Tomo 3D Digital Screening

Facility

$66.00

Service Code	CPT 77063
Hospital Charge Code	5017063
Hospital Revenue Code	403
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$55.76
Rate for Payer: Aetna Commercial	$26.97
Rate for Payer: Amerigroup CHIP/Medicaid	$52.79
Rate for Payer: BCBS of TX Blue Advantage	$41.63
Rate for Payer: BCBS of TX Blue Essentials	$49.96
Rate for Payer: BCBS of TX PPO	$55.76
Rate for Payer: Cash Price	$58.08
Rate for Payer: Cash Price	$58.08
Rate for Payer: Cigna Medicaid	$52.79
Rate for Payer: Molina CHIP/Medicaid	$52.79
Rate for Payer: Multiplan Auto	$42.90
Rate for Payer: Multiplan Commercial	$42.90
Rate for Payer: Multiplan Workers Comp	$42.90
Rate for Payer: Parkland Medicaid	$52.79
Rate for Payer: Scott and White EPO/PPO	$33.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.79
Rate for Payer: Superior Health Plan EPO	$8.98

MG Breast Tomo 3D Digital Screening BCE

Facility

$66.00

Service Code	CPT 77063
Hospital Charge Code	5017063
Hospital Revenue Code	403
Rate for Payer: Cash Price	$58.08

MG Breast Tomo 3D Digital Screening BCE

Facility

$66.00

Service Code	CPT 77063
Hospital Charge Code	5017063
Hospital Revenue Code	403
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$55.76
Rate for Payer: Aetna Commercial	$26.97
Rate for Payer: Amerigroup CHIP/Medicaid	$52.79
Rate for Payer: BCBS of TX Blue Advantage	$41.63
Rate for Payer: BCBS of TX Blue Essentials	$49.96
Rate for Payer: BCBS of TX PPO	$55.76
Rate for Payer: Cash Price	$58.08
Rate for Payer: Cash Price	$58.08
Rate for Payer: Cigna Medicaid	$52.79
Rate for Payer: Molina CHIP/Medicaid	$52.79
Rate for Payer: Multiplan Auto	$42.90
Rate for Payer: Multiplan Commercial	$42.90
Rate for Payer: Multiplan Workers Comp	$42.90
Rate for Payer: Parkland Medicaid	$52.79
Rate for Payer: Scott and White EPO/PPO	$33.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.79
Rate for Payer: Superior Health Plan EPO	$8.98

MG Device Plcmnt w/ Mammo Guide Left

Facility

$1,175.00

Service Code	CPT 19281 LT
Hospital Charge Code	3641063
Hospital Revenue Code	320
Min. Negotiated Rate	$26.52
Max. Negotiated Rate	$3,358.84
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$105.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
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	$1,482.74
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$77.52
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$77.52
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
Rate for Payer: Multiplan Auto	$763.75
Rate for Payer: Multiplan Commercial	$763.75
Rate for Payer: Multiplan Workers Comp	$763.75
Rate for Payer: Parkland Medicaid	$77.52
Rate for Payer: Scott and White EPO/PPO	$26.52
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77.52
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

MG Device Plcmnt w/ Mammo Guide Left BCE

Facility

$1,175.00

Service Code	CPT 19281 LT
Hospital Charge Code	3641063
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,034.00

MG Device Plcmnt w/ Mammo Guide Left BCE

Facility

$1,175.00

Service Code	CPT 19281 LT
Hospital Charge Code	3641063
Hospital Revenue Code	320
Min. Negotiated Rate	$26.52
Max. Negotiated Rate	$3,358.84
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$105.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
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	$1,482.74
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$77.52
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$77.52
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
Rate for Payer: Multiplan Auto	$763.75
Rate for Payer: Multiplan Commercial	$763.75
Rate for Payer: Multiplan Workers Comp	$763.75
Rate for Payer: Parkland Medicaid	$77.52
Rate for Payer: Scott and White EPO/PPO	$26.52
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77.52
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

MG Device Plcmnt w/ Mammo Guide Right

Facility

$1,175.00

Service Code	CPT 19281 RT
Hospital Charge Code	3641061
Hospital Revenue Code	320
Min. Negotiated Rate	$26.52
Max. Negotiated Rate	$3,358.84
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$105.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
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	$1,482.74
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$77.52
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$77.52
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
Rate for Payer: Multiplan Auto	$763.75
Rate for Payer: Multiplan Commercial	$763.75
Rate for Payer: Multiplan Workers Comp	$763.75
Rate for Payer: Parkland Medicaid	$77.52
Rate for Payer: Scott and White EPO/PPO	$26.52
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77.52
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

MG Device Plcmnt w/ Mammo Guide Right BCE

Facility

$1,175.00

Service Code	CPT 19281 RT
Hospital Charge Code	3641061
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,034.00

MG Device Plcmnt w/ Mammo Guide Right BCE

Facility

$1,175.00

Service Code	CPT 19281 RT
Hospital Charge Code	3641061
Hospital Revenue Code	320
Min. Negotiated Rate	$26.52
Max. Negotiated Rate	$3,358.84
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$105.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
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	$1,482.74
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cash Price	$1,034.00
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$77.52
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$77.52
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
Rate for Payer: Multiplan Auto	$763.75
Rate for Payer: Multiplan Commercial	$763.75
Rate for Payer: Multiplan Workers Comp	$763.75
Rate for Payer: Parkland Medicaid	$77.52
Rate for Payer: Scott and White EPO/PPO	$26.52
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77.52
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

MG Mammo Digital Diagnostic Bilat

Facility

$672.00

Service Code	CPT 77066
Hospital Charge Code	3641094
Hospital Revenue Code	401
Min. Negotiated Rate	$60.48
Max. Negotiated Rate	$436.80
Rate for Payer: Aetna Commercial	$128.48
Rate for Payer: Amerigroup CHIP/Medicaid	$60.48
Rate for Payer: BCBS of TX Blue Advantage	$198.61
Rate for Payer: BCBS of TX Blue Essentials	$238.33
Rate for Payer: BCBS of TX PPO	$266.02
Rate for Payer: Cash Price	$591.36
Rate for Payer: Cash Price	$591.36
Rate for Payer: Multiplan Auto	$436.80
Rate for Payer: Multiplan Commercial	$436.80
Rate for Payer: Multiplan Workers Comp	$436.80
Rate for Payer: Scott and White EPO/PPO	$336.00
Rate for Payer: Superior Health Plan EPO	$91.39

MG Mammo Digital Diagnostic Bilat BCE

Facility

$672.00

Service Code	CPT 77066
Hospital Charge Code	3641094
Hospital Revenue Code	401
Min. Negotiated Rate	$60.48
Max. Negotiated Rate	$436.80
Rate for Payer: Aetna Commercial	$128.48
Rate for Payer: Amerigroup CHIP/Medicaid	$60.48
Rate for Payer: BCBS of TX Blue Advantage	$198.61
Rate for Payer: BCBS of TX Blue Essentials	$238.33
Rate for Payer: BCBS of TX PPO	$266.02
Rate for Payer: Cash Price	$591.36
Rate for Payer: Cash Price	$591.36
Rate for Payer: Multiplan Auto	$436.80
Rate for Payer: Multiplan Commercial	$436.80
Rate for Payer: Multiplan Workers Comp	$436.80
Rate for Payer: Scott and White EPO/PPO	$336.00
Rate for Payer: Superior Health Plan EPO	$91.39

MG Mammo Digital Diagnostic Bilat BCE

Facility

$672.00

Service Code	CPT 77066
Hospital Charge Code	3641094
Hospital Revenue Code	401
Rate for Payer: Cash Price	$591.36

MG Mammo Digital Diagnostic Left

Facility

$483.00

Service Code	CPT 77065 LT
Hospital Charge Code	3641096
Hospital Revenue Code	401
Min. Negotiated Rate	$30.47
Max. Negotiated Rate	$313.95
Rate for Payer: Aetna Commercial	$100.75
Rate for Payer: Amerigroup CHIP/Medicaid	$43.47
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$425.04
Rate for Payer: Cash Price	$425.04
Rate for Payer: Cigna Medicaid	$30.47
Rate for Payer: Molina CHIP/Medicaid	$30.47
Rate for Payer: Multiplan Auto	$313.95
Rate for Payer: Multiplan Commercial	$313.95
Rate for Payer: Multiplan Workers Comp	$313.95
Rate for Payer: Parkland Medicaid	$30.47
Rate for Payer: Scott and White EPO/PPO	$241.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.47
Rate for Payer: Superior Health Plan EPO	$65.69

Know your out-of-pocket cost for care.

All Charges