White Rock Medical Center

All Charges

Charge

Type

Setting

Price

US Biopsy Liver

Facility

$3,191.00

Service Code	HCPCS 47000
Hospital Charge Code	3500782
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,169.88

US Biopsy Liver

Facility

$3,191.00

Service Code	HCPCS 47000
Hospital Charge Code	3500782
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
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	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$2,169.88
Rate for Payer: Cash Price	$2,169.88
Rate for Payer: Cash Price	$2,169.88
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$2,297.52
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	$2,297.52
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	$2,297.52
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	$2,297.52
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

US Biopsy Lymph Node

Facility

$2,714.00

Service Code	HCPCS 38505
Hospital Charge Code	3521017
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
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	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$1,954.08
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	$1,954.08
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	$1,954.08
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	$1,954.08
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

US Biopsy Lymph Node

Facility

$2,714.00

Service Code	HCPCS 38505
Hospital Charge Code	3521017
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,845.52

US Biopsy Muscle

Facility

$3,321.00

Service Code	HCPCS 20206
Hospital Charge Code	3802220
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,258.28

US Biopsy Muscle

Facility

$3,321.00

Service Code	HCPCS 20206
Hospital Charge Code	3802220
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
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	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$2,258.28
Rate for Payer: Cash Price	$2,258.28
Rate for Payer: Cash Price	$2,258.28
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$2,391.12
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	$2,391.12
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	$2,391.12
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	$2,391.12
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

US Biopsy Pancreas

Facility

$2,714.00

Service Code	HCPCS 48102
Hospital Charge Code	2117570
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,845.52

US Biopsy Pancreas

Facility

$2,714.00

Service Code	HCPCS 48102
Hospital Charge Code	2117570
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
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	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$1,954.08
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	$1,954.08
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	$1,954.08
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	$1,954.08
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

US Biopsy Prostate

Facility

$1,833.00

Service Code	HCPCS 55700
Hospital Charge Code	3500741
Hospital Revenue Code	361
Min. Negotiated Rate	$164.97
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$164.97
Rate for Payer: BCBS of TX Blue Advantage	$2,958.49
Rate for Payer: BCBS of TX Blue Essentials	$3,543.10
Rate for Payer: BCBS of TX PPO	$4,464.31
Rate for Payer: Cash Price	$1,246.44
Rate for Payer: Cash Price	$1,246.44
Rate for Payer: Cash Price	$1,246.44
Rate for Payer: Cigna Medicaid	$1,319.76
Rate for Payer: Molina CHIP/Medicaid	$1,319.76
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	$1,319.76
Rate for Payer: Scott and White EPO/PPO	$3,446.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,319.76
Rate for Payer: Superior Health Plan EPO	$249.29

US Biopsy Prostate

Facility

$1,833.00

Service Code	HCPCS 55700
Hospital Charge Code	3500741
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,246.44

US Biopsy Renal Right

Facility

$1,821.00

Service Code	HCPCS 50200
Hospital Charge Code	3520020
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,238.28

US Biopsy Renal Right

Facility

$1,821.00

Service Code	HCPCS 50200
Hospital Charge Code	3520020
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
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	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$1,238.28
Rate for Payer: Cash Price	$1,238.28
Rate for Payer: Cash Price	$1,238.28
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$1,311.12
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	$1,311.12
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	$1,311.12
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	$1,311.12
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

US Biopsy Soft Tissue Neck

Facility

$4,329.00

Service Code	HCPCS 21550
Hospital Charge Code	5037507
Hospital Revenue Code	360
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
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	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$2,943.72
Rate for Payer: Cash Price	$2,943.72
Rate for Payer: Cash Price	$2,943.72
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$3,116.88
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	$3,116.88
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	$3,116.88
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	$3,116.88
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

US Biopsy Soft Tissue Neck

Facility

$4,329.00

Service Code	HCPCS 21550
Hospital Charge Code	5037507
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,943.72

US Biopsy Thyroid Perc Core Needle

Facility

$1,175.00

Service Code	HCPCS 60100
Hospital Charge Code	2117729
Hospital Revenue Code	361
Rate for Payer: Cash Price	$799.00

US Biopsy Thyroid Perc Core Needle

Facility

$1,175.00

Service Code	HCPCS 60100
Hospital Charge Code	2117729
Hospital Revenue Code	361
Min. Negotiated Rate	$42.63
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$42.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
Rate for Payer: BCBS of TX Blue Advantage	$89.80
Rate for Payer: BCBS of TX Blue Essentials	$107.54
Rate for Payer: BCBS of TX Medicare	$711.36
Rate for Payer: BCBS of TX PPO	$135.50
Rate for Payer: Cash Price	$799.00
Rate for Payer: Cash Price	$799.00
Rate for Payer: Cash Price	$799.00
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$846.00
Rate for Payer: Cigna Medicare	$711.36
Rate for Payer: Employer Direct Commercial	$711.36
Rate for Payer: Humana Medicare/TRICARE	$711.36
Rate for Payer: Molina CHIP/Medicaid	$846.00
Rate for Payer: Molina Dual Medicare/Medicaid	$711.36
Rate for Payer: Molina Medicare	$711.36
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	$846.00
Rate for Payer: Scott and White EPO/PPO	$1,190.38
Rate for Payer: Scott and White Medicare	$711.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$846.00
Rate for Payer: Superior Health Plan EPO	$711.36
Rate for Payer: Superior Health Plan Medicare	$711.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$711.36
Rate for Payer: Universal American Medicare	$711.36
Rate for Payer: Wellcare Medicare	$711.36
Rate for Payer: Wellmed Medicare	$711.36

US Breast Biopsy w/ US Guide Left

Facility

$5,178.00

Service Code	HCPCS 19083
Hospital Charge Code	3530037
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,521.04

US Breast Biopsy w/ US Guide Left

Facility

$5,178.00

Service Code	HCPCS 19083
Hospital Charge Code	3530037
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
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	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$3,521.04
Rate for Payer: Cash Price	$3,521.04
Rate for Payer: Cash Price	$3,521.04
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$3,728.16
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	$3,728.16
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	$3,728.16
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	$3,728.16
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

US Breast Biopsy w/ US Guide Right

Facility

$5,178.00

Service Code	HCPCS 19083
Hospital Charge Code	3530035
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
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	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$3,521.04
Rate for Payer: Cash Price	$3,521.04
Rate for Payer: Cash Price	$3,521.04
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$3,728.16
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	$3,728.16
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	$3,728.16
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	$3,728.16
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

US Breast Biopsy w/ US Guide Right

Facility

$5,178.00

Service Code	HCPCS 19083
Hospital Charge Code	3530035
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,521.04

US Breast Complete Left

Facility

$589.00

Service Code	HCPCS 76641 LT
Hospital Charge Code	3530061
Hospital Revenue Code	402
Rate for Payer: Cash Price	$400.52

US Breast Complete Left

Facility

$589.00

Service Code	HCPCS 76641 LT
Hospital Charge Code	3530061
Hospital Revenue Code	402
Min. Negotiated Rate	$80.10
Max. Negotiated Rate	$424.08
Rate for Payer: Amerigroup CHIP/Medicaid	$102.91
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 PPO	$247.70
Rate for Payer: Cash Price	$400.52
Rate for Payer: Cash Price	$400.52
Rate for Payer: Cash Price	$400.52
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$424.08
Rate for Payer: Molina CHIP/Medicaid	$424.08
Rate for Payer: Multiplan Auto	$382.85
Rate for Payer: Multiplan Commercial	$382.85
Rate for Payer: Multiplan Workers Comp	$382.85
Rate for Payer: Parkland Medicaid	$424.08
Rate for Payer: Scott and White EPO/PPO	$294.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$424.08
Rate for Payer: Superior Health Plan EPO	$80.10

US Breast Complete Right

Facility

$589.00

Service Code	HCPCS 76641 RT
Hospital Charge Code	3530060
Hospital Revenue Code	402
Min. Negotiated Rate	$80.10
Max. Negotiated Rate	$424.08
Rate for Payer: Amerigroup CHIP/Medicaid	$102.91
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 PPO	$247.70
Rate for Payer: Cash Price	$400.52
Rate for Payer: Cash Price	$400.52
Rate for Payer: Cash Price	$400.52
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$424.08
Rate for Payer: Molina CHIP/Medicaid	$424.08
Rate for Payer: Multiplan Auto	$382.85
Rate for Payer: Multiplan Commercial	$382.85
Rate for Payer: Multiplan Workers Comp	$382.85
Rate for Payer: Parkland Medicaid	$424.08
Rate for Payer: Scott and White EPO/PPO	$294.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$424.08
Rate for Payer: Superior Health Plan EPO	$80.10

US Breast Complete Right

Facility

$589.00

Service Code	HCPCS 76641 RT
Hospital Charge Code	3530060
Hospital Revenue Code	402
Rate for Payer: Cash Price	$400.52

US Breast Cyst Aspiration Right

Facility

$647.00

Service Code	HCPCS 19000
Hospital Charge Code	3520058
Hospital Revenue Code	361
Rate for Payer: Cash Price	$439.96

Know your out-of-pocket cost for care.

All Charges