White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR AC Joints Bilateral BCE

Facility

$701.00

Service Code	CPT 73050 FY
Hospital Charge Code	3100617
Hospital Revenue Code	320
Rate for Payer: Cash Price	$616.88

XR AC Joints Bilateral BCE

Facility

$701.00

Service Code	CPT 73050 FY
Hospital Charge Code	3100617
Hospital Revenue Code	320
Min. Negotiated Rate	$22.16
Max. Negotiated Rate	$455.65
Rate for Payer: Aetna Commercial	$22.16
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$28.74
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 PPO	$176.38
Rate for Payer: Cash Price	$616.88
Rate for Payer: Cash Price	$616.88
Rate for Payer: Cash Price	$616.88
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$28.74
Rate for Payer: Molina CHIP/Medicaid	$28.74
Rate for Payer: Multiplan Auto	$455.65
Rate for Payer: Multiplan Commercial	$455.65
Rate for Payer: Multiplan Workers Comp	$455.65
Rate for Payer: Parkland Medicaid	$28.74
Rate for Payer: Scott and White EPO/PPO	$350.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.74
Rate for Payer: Superior Health Plan EPO	$95.34

XR Angio Extremity in OR Left

Facility

$4,768.00

Service Code	CPT 75710 LT,FY
Hospital Charge Code	3160561
Hospital Revenue Code	320
Min. Negotiated Rate	$79.96
Max. Negotiated Rate	$6,603.56
Rate for Payer: Aetna Commercial	$79.96
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$150.36
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$150.36
Rate for Payer: Molina CHIP/Medicaid	$150.36
Rate for Payer: Multiplan Auto	$3,099.20
Rate for Payer: Multiplan Commercial	$3,099.20
Rate for Payer: Multiplan Workers Comp	$3,099.20
Rate for Payer: Parkland Medicaid	$150.36
Rate for Payer: Scott and White EPO/PPO	$2,384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.36
Rate for Payer: Superior Health Plan EPO	$648.45

XR Angio Extremity in OR Left BCE

Facility

$4,768.00

Service Code	CPT 75710 LT,FY
Hospital Charge Code	3160561
Hospital Revenue Code	320
Min. Negotiated Rate	$79.96
Max. Negotiated Rate	$6,603.56
Rate for Payer: Aetna Commercial	$79.96
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$150.36
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$150.36
Rate for Payer: Molina CHIP/Medicaid	$150.36
Rate for Payer: Multiplan Auto	$3,099.20
Rate for Payer: Multiplan Commercial	$3,099.20
Rate for Payer: Multiplan Workers Comp	$3,099.20
Rate for Payer: Parkland Medicaid	$150.36
Rate for Payer: Scott and White EPO/PPO	$2,384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.36
Rate for Payer: Superior Health Plan EPO	$648.45

XR Angio Extremity in OR Left BCE

Facility

$4,768.00

Service Code	CPT 75710 LT,FY
Hospital Charge Code	3160561
Hospital Revenue Code	320
Rate for Payer: Cash Price	$4,195.84

XR Angio Extremity in OR Right

Facility

$4,768.00

Service Code	CPT 75710 RT,FY
Hospital Charge Code	3160579
Hospital Revenue Code	320
Min. Negotiated Rate	$79.96
Max. Negotiated Rate	$6,603.56
Rate for Payer: Aetna Commercial	$79.96
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$150.36
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$150.36
Rate for Payer: Molina CHIP/Medicaid	$150.36
Rate for Payer: Multiplan Auto	$3,099.20
Rate for Payer: Multiplan Commercial	$3,099.20
Rate for Payer: Multiplan Workers Comp	$3,099.20
Rate for Payer: Parkland Medicaid	$150.36
Rate for Payer: Scott and White EPO/PPO	$2,384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.36
Rate for Payer: Superior Health Plan EPO	$648.45

XR Angio Extremity in OR Right BCE

Facility

$4,768.00

Service Code	CPT 75710 RT,FY
Hospital Charge Code	3160579
Hospital Revenue Code	320
Rate for Payer: Cash Price	$4,195.84

XR Angio Extremity in OR Right BCE

Facility

$4,768.00

Service Code	CPT 75710 RT,FY
Hospital Charge Code	3160579
Hospital Revenue Code	320
Min. Negotiated Rate	$79.96
Max. Negotiated Rate	$6,603.56
Rate for Payer: Aetna Commercial	$79.96
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$150.36
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$150.36
Rate for Payer: Molina CHIP/Medicaid	$150.36
Rate for Payer: Multiplan Auto	$3,099.20
Rate for Payer: Multiplan Commercial	$3,099.20
Rate for Payer: Multiplan Workers Comp	$3,099.20
Rate for Payer: Parkland Medicaid	$150.36
Rate for Payer: Scott and White EPO/PPO	$2,384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.36
Rate for Payer: Superior Health Plan EPO	$648.45

XR Angiogram Internal Mammary

Facility

$2,911.00

Service Code	CPT 75756 FY
Hospital Charge Code	4615757
Hospital Revenue Code	323
Min. Negotiated Rate	$119.07
Max. Negotiated Rate	$6,603.56
Rate for Payer: Aetna Commercial	$119.07
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$161.73
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$2,561.68
Rate for Payer: Cash Price	$2,561.68
Rate for Payer: Cash Price	$2,561.68
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$161.73
Rate for Payer: Molina CHIP/Medicaid	$161.73
Rate for Payer: Multiplan Auto	$1,892.15
Rate for Payer: Multiplan Commercial	$1,892.15
Rate for Payer: Multiplan Workers Comp	$1,892.15
Rate for Payer: Parkland Medicaid	$161.73
Rate for Payer: Scott and White EPO/PPO	$1,455.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$161.73
Rate for Payer: Superior Health Plan EPO	$395.90

XR Angiogram Internal Mammary BCE

Facility

$2,911.00

Service Code	CPT 75756 FY
Hospital Charge Code	4615757
Hospital Revenue Code	323
Rate for Payer: Cash Price	$2,561.68

XR Angiogram Internal Mammary BCE

Facility

$2,911.00

Service Code	CPT 75756 FY
Hospital Charge Code	4615757
Hospital Revenue Code	323
Min. Negotiated Rate	$119.07
Max. Negotiated Rate	$6,603.56
Rate for Payer: Aetna Commercial	$119.07
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$161.73
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$2,561.68
Rate for Payer: Cash Price	$2,561.68
Rate for Payer: Cash Price	$2,561.68
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$161.73
Rate for Payer: Molina CHIP/Medicaid	$161.73
Rate for Payer: Multiplan Auto	$1,892.15
Rate for Payer: Multiplan Commercial	$1,892.15
Rate for Payer: Multiplan Workers Comp	$1,892.15
Rate for Payer: Parkland Medicaid	$161.73
Rate for Payer: Scott and White EPO/PPO	$1,455.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$161.73
Rate for Payer: Superior Health Plan EPO	$395.90

XR Ankle 2 Views Left

Facility

$537.00

Service Code	CPT 73600 LT,FY
Hospital Charge Code	3100955
Hospital Revenue Code	320
Min. Negotiated Rate	$27.95
Max. Negotiated Rate	$349.05
Rate for Payer: Aetna Commercial	$27.95
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
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 PPO	$176.38
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$32.75
Rate for Payer: Molina CHIP/Medicaid	$32.75
Rate for Payer: Multiplan Auto	$349.05
Rate for Payer: Multiplan Commercial	$349.05
Rate for Payer: Multiplan Workers Comp	$349.05
Rate for Payer: Parkland Medicaid	$32.75
Rate for Payer: Scott and White EPO/PPO	$268.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.75
Rate for Payer: Superior Health Plan EPO	$73.03

XR Ankle 2 Views Left BCE

Facility

$537.00

Service Code	CPT 73600 LT,FY
Hospital Charge Code	3100955
Hospital Revenue Code	320
Rate for Payer: Cash Price	$472.56

XR Ankle 2 Views Left BCE

Facility

$537.00

Service Code	CPT 73600 LT,FY
Hospital Charge Code	3100955
Hospital Revenue Code	320
Min. Negotiated Rate	$27.95
Max. Negotiated Rate	$349.05
Rate for Payer: Aetna Commercial	$27.95
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
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 PPO	$176.38
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$32.75
Rate for Payer: Molina CHIP/Medicaid	$32.75
Rate for Payer: Multiplan Auto	$349.05
Rate for Payer: Multiplan Commercial	$349.05
Rate for Payer: Multiplan Workers Comp	$349.05
Rate for Payer: Parkland Medicaid	$32.75
Rate for Payer: Scott and White EPO/PPO	$268.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.75
Rate for Payer: Superior Health Plan EPO	$73.03

XR Ankle 2 Views Right

Facility

$537.00

Service Code	CPT 73600 RT,FY
Hospital Charge Code	3100963
Hospital Revenue Code	320
Min. Negotiated Rate	$27.95
Max. Negotiated Rate	$349.05
Rate for Payer: Aetna Commercial	$27.95
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
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 PPO	$176.38
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$32.75
Rate for Payer: Molina CHIP/Medicaid	$32.75
Rate for Payer: Multiplan Auto	$349.05
Rate for Payer: Multiplan Commercial	$349.05
Rate for Payer: Multiplan Workers Comp	$349.05
Rate for Payer: Parkland Medicaid	$32.75
Rate for Payer: Scott and White EPO/PPO	$268.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.75
Rate for Payer: Superior Health Plan EPO	$73.03

XR Ankle 2 Views Right BCE

Facility

$537.00

Service Code	CPT 73600 RT,FY
Hospital Charge Code	3100963
Hospital Revenue Code	320
Min. Negotiated Rate	$27.95
Max. Negotiated Rate	$349.05
Rate for Payer: Aetna Commercial	$27.95
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
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 PPO	$176.38
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$32.75
Rate for Payer: Molina CHIP/Medicaid	$32.75
Rate for Payer: Multiplan Auto	$349.05
Rate for Payer: Multiplan Commercial	$349.05
Rate for Payer: Multiplan Workers Comp	$349.05
Rate for Payer: Parkland Medicaid	$32.75
Rate for Payer: Scott and White EPO/PPO	$268.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.75
Rate for Payer: Superior Health Plan EPO	$73.03

XR Ankle 2 Views Right BCE

Facility

$537.00

Service Code	CPT 73600 RT,FY
Hospital Charge Code	3100963
Hospital Revenue Code	320
Rate for Payer: Cash Price	$472.56

XR Ankle Complete 3+ Views Left

Facility

$608.00

Service Code	CPT 73610 LT,FY
Hospital Charge Code	3100971
Hospital Revenue Code	320
Min. Negotiated Rate	$32.57
Max. Negotiated Rate	$395.20
Rate for Payer: Aetna Commercial	$32.57
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$37.09
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 PPO	$176.38
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$37.09
Rate for Payer: Molina CHIP/Medicaid	$37.09
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$37.09
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.09
Rate for Payer: Superior Health Plan EPO	$82.69

XR Ankle Complete 3+ Views Left BCE

Facility

$608.00

Service Code	CPT 73610 LT,FY
Hospital Charge Code	3100971
Hospital Revenue Code	320
Min. Negotiated Rate	$32.57
Max. Negotiated Rate	$395.20
Rate for Payer: Aetna Commercial	$32.57
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$37.09
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 PPO	$176.38
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$37.09
Rate for Payer: Molina CHIP/Medicaid	$37.09
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$37.09
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.09
Rate for Payer: Superior Health Plan EPO	$82.69

XR Ankle Complete 3+ Views Left BCE

Facility

$608.00

Service Code	CPT 73610 LT,FY
Hospital Charge Code	3100971
Hospital Revenue Code	320
Rate for Payer: Cash Price	$535.04

XR Ankle Complete 3+ Views Right

Facility

$608.00

Service Code	CPT 73610 RT,FY
Hospital Charge Code	3100989
Hospital Revenue Code	320
Min. Negotiated Rate	$32.57
Max. Negotiated Rate	$395.20
Rate for Payer: Aetna Commercial	$32.57
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$37.09
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 PPO	$176.38
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$37.09
Rate for Payer: Molina CHIP/Medicaid	$37.09
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$37.09
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.09
Rate for Payer: Superior Health Plan EPO	$82.69

XR Ankle Complete 3+ Views Right BCE

Facility

$608.00

Service Code	CPT 73610 RT,FY
Hospital Charge Code	3100989
Hospital Revenue Code	320
Min. Negotiated Rate	$32.57
Max. Negotiated Rate	$395.20
Rate for Payer: Aetna Commercial	$32.57
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$37.09
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 PPO	$176.38
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$37.09
Rate for Payer: Molina CHIP/Medicaid	$37.09
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$37.09
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.09
Rate for Payer: Superior Health Plan EPO	$82.69

XR Ankle Complete 3+ Views Right BCE

Facility

$608.00

Service Code	CPT 73610 RT,FY
Hospital Charge Code	3100989
Hospital Revenue Code	320
Rate for Payer: Cash Price	$535.04

XR Arthrogram Hip Left

Facility

$558.00

Service Code	CPT 73525 LT,FY
Hospital Charge Code	3170063
Hospital Revenue Code	322
Min. Negotiated Rate	$75.89
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$123.48
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$131.31
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 PPO	$843.89
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$131.31
Rate for Payer: Molina CHIP/Medicaid	$131.31
Rate for Payer: Multiplan Auto	$362.70
Rate for Payer: Multiplan Commercial	$362.70
Rate for Payer: Multiplan Workers Comp	$362.70
Rate for Payer: Parkland Medicaid	$131.31
Rate for Payer: Scott and White EPO/PPO	$279.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.31
Rate for Payer: Superior Health Plan EPO	$75.89

XR Arthrogram Hip Left BCE

Facility

$558.00

Service Code	CPT 73525 LT,FY
Hospital Charge Code	3170063
Hospital Revenue Code	322
Min. Negotiated Rate	$75.89
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$123.48
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$131.31
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 PPO	$843.89
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$131.31
Rate for Payer: Molina CHIP/Medicaid	$131.31
Rate for Payer: Multiplan Auto	$362.70
Rate for Payer: Multiplan Commercial	$362.70
Rate for Payer: Multiplan Workers Comp	$362.70
Rate for Payer: Parkland Medicaid	$131.31
Rate for Payer: Scott and White EPO/PPO	$279.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.31
Rate for Payer: Superior Health Plan EPO	$75.89

Know your out-of-pocket cost for care.

All Charges