White Rock Medical Center

All Charges

Charge

Type

Setting

Price

US Breast Cyst Aspiration Right

Facility

$647.00

Service Code	HCPCS 19000
Hospital Charge Code	3520058
Hospital Revenue Code	361
Min. Negotiated Rate	$59.25
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$59.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
Rate for Payer: BCBS of TX Blue Advantage	$130.18
Rate for Payer: BCBS of TX Blue Essentials	$155.90
Rate for Payer: BCBS of TX Medicare	$711.36
Rate for Payer: BCBS of TX PPO	$196.43
Rate for Payer: Cash Price	$439.96
Rate for Payer: Cash Price	$439.96
Rate for Payer: Cash Price	$439.96
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$465.84
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	$465.84
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	$465.84
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	$465.84
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 Device Plcmnt w/US Guide Left

Facility

$1,500.00

Service Code	HCPCS 19285
Hospital Charge Code	3530041
Hospital Revenue Code	402
Rate for Payer: Cash Price	$1,020.00

US Breast Device Plcmnt w/US Guide Left

Facility

$1,500.00

Service Code	HCPCS 19285
Hospital Charge Code	3530041
Hospital Revenue Code	402
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,537.23
Rate for Payer: Amerigroup CHIP/Medicaid	$135.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
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	$711.36
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$1,080.00
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	$1,080.00
Rate for Payer: Molina Dual Medicare/Medicaid	$711.36
Rate for Payer: Molina Medicare	$711.36
Rate for Payer: Multiplan Auto	$975.00
Rate for Payer: Multiplan Commercial	$975.00
Rate for Payer: Multiplan Workers Comp	$975.00
Rate for Payer: Parkland Medicaid	$1,080.00
Rate for Payer: Scott and White EPO/PPO	$101.17
Rate for Payer: Scott and White Medicare	$711.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,080.00
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 Device Plcmnt w/US Guide Right

Facility

$1,500.00

Service Code	HCPCS 19285
Hospital Charge Code	3530039
Hospital Revenue Code	402
Rate for Payer: Cash Price	$1,020.00

US Breast Device Plcmnt w/US Guide Right

Facility

$1,500.00

Service Code	HCPCS 19285
Hospital Charge Code	3530039
Hospital Revenue Code	402
Min. Negotiated Rate	$101.17
Max. Negotiated Rate	$1,537.23
Rate for Payer: Amerigroup CHIP/Medicaid	$135.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
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	$711.36
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$1,080.00
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	$1,080.00
Rate for Payer: Molina Dual Medicare/Medicaid	$711.36
Rate for Payer: Molina Medicare	$711.36
Rate for Payer: Multiplan Auto	$975.00
Rate for Payer: Multiplan Commercial	$975.00
Rate for Payer: Multiplan Workers Comp	$975.00
Rate for Payer: Parkland Medicaid	$1,080.00
Rate for Payer: Scott and White EPO/PPO	$101.17
Rate for Payer: Scott and White Medicare	$711.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,080.00
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 Limited Left

Facility

$519.00

Service Code	HCPCS 76642 LT
Hospital Charge Code	3530063
Hospital Revenue Code	402
Min. Negotiated Rate	$70.58
Max. Negotiated Rate	$373.68
Rate for Payer: Amerigroup CHIP/Medicaid	$85.20
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	$352.92
Rate for Payer: Cash Price	$352.92
Rate for Payer: Cash Price	$352.92
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$373.68
Rate for Payer: Molina CHIP/Medicaid	$373.68
Rate for Payer: Multiplan Auto	$337.35
Rate for Payer: Multiplan Commercial	$337.35
Rate for Payer: Multiplan Workers Comp	$337.35
Rate for Payer: Parkland Medicaid	$373.68
Rate for Payer: Scott and White EPO/PPO	$259.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$373.68
Rate for Payer: Superior Health Plan EPO	$70.58

US Breast Limited Left

Facility

$519.00

Service Code	HCPCS 76642 LT
Hospital Charge Code	3530063
Hospital Revenue Code	402
Rate for Payer: Cash Price	$352.92

US Breast Limited Right

Facility

$519.00

Service Code	HCPCS 76642 RT
Hospital Charge Code	3530062
Hospital Revenue Code	402
Min. Negotiated Rate	$70.58
Max. Negotiated Rate	$373.68
Rate for Payer: Amerigroup CHIP/Medicaid	$85.20
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	$352.92
Rate for Payer: Cash Price	$352.92
Rate for Payer: Cash Price	$352.92
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$373.68
Rate for Payer: Molina CHIP/Medicaid	$373.68
Rate for Payer: Multiplan Auto	$337.35
Rate for Payer: Multiplan Commercial	$337.35
Rate for Payer: Multiplan Workers Comp	$337.35
Rate for Payer: Parkland Medicaid	$373.68
Rate for Payer: Scott and White EPO/PPO	$259.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$373.68
Rate for Payer: Superior Health Plan EPO	$70.58

US Breast Limited Right

Facility

$519.00

Service Code	HCPCS 76642 RT
Hospital Charge Code	3530062
Hospital Revenue Code	402
Rate for Payer: Cash Price	$352.92

US Carotid Duplex Bilateral

Facility

$3,317.00

Service Code	HCPCS 93880
Hospital Charge Code	3500139
Hospital Revenue Code	921
Rate for Payer: Cash Price	$2,255.56

US Carotid Duplex Bilateral

Facility

$3,317.00

Service Code	HCPCS 93880
Hospital Charge Code	3500139
Hospital Revenue Code	921
Min. Negotiated Rate	$234.54
Max. Negotiated Rate	$2,388.24
Rate for Payer: Amerigroup CHIP/Medicaid	$298.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$995.10
Rate for Payer: BCBS of TX Blue Essentials	$1,194.12
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$1,326.80
Rate for Payer: Cash Price	$2,255.56
Rate for Payer: Cash Price	$2,255.56
Rate for Payer: Cash Price	$2,255.56
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,388.24
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	$2,388.24
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$2,156.05
Rate for Payer: Multiplan Commercial	$2,156.05
Rate for Payer: Multiplan Workers Comp	$2,156.05
Rate for Payer: Parkland Medicaid	$2,388.24
Rate for Payer: Scott and White EPO/PPO	$234.54
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,388.24
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

US Carotid Duplex unilateral or limited study

Facility

$1,338.00

Service Code	HCPCS 93882
Hospital Charge Code	5036540
Hospital Revenue Code	921
Rate for Payer: Cash Price	$909.84

US Carotid Duplex unilateral or limited study

Facility

$1,338.00

Service Code	HCPCS 93882
Hospital Charge Code	5036540
Hospital Revenue Code	921
Min. Negotiated Rate	$105.02
Max. Negotiated Rate	$963.36
Rate for Payer: Amerigroup CHIP/Medicaid	$120.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$401.40
Rate for Payer: BCBS of TX Blue Essentials	$481.68
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$535.20
Rate for Payer: Cash Price	$909.84
Rate for Payer: Cash Price	$909.84
Rate for Payer: Cash Price	$909.84
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$963.36
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	$963.36
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$869.70
Rate for Payer: Multiplan Commercial	$869.70
Rate for Payer: Multiplan Workers Comp	$869.70
Rate for Payer: Parkland Medicaid	$963.36
Rate for Payer: Scott and White EPO/PPO	$153.81
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$963.36
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

US Cbl Extns Disposable Surg

Facility

$120.49

Hospital Charge Code	993852
Hospital Revenue Code	272
Rate for Payer: Cash Price	$81.93

US Cbl Extns Disposable Surg

Facility

$120.49

Hospital Charge Code	993852
Hospital Revenue Code	272
Min. Negotiated Rate	$10.84
Max. Negotiated Rate	$86.75
Rate for Payer: Amerigroup CHIP/Medicaid	$10.84
Rate for Payer: BCBS of TX Blue Advantage	$36.15
Rate for Payer: BCBS of TX Blue Essentials	$43.38
Rate for Payer: BCBS of TX PPO	$48.20
Rate for Payer: Cash Price	$81.93
Rate for Payer: Cigna Medicaid	$86.75
Rate for Payer: Molina CHIP/Medicaid	$86.75
Rate for Payer: Multiplan Auto	$78.32
Rate for Payer: Multiplan Commercial	$78.32
Rate for Payer: Multiplan Workers Comp	$78.32
Rate for Payer: Parkland Medicaid	$86.75
Rate for Payer: Scott and White EPO/PPO	$60.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.75
Rate for Payer: Superior Health Plan EPO	$16.39

US Chest

Facility

$471.00

Service Code	HCPCS 76604
Hospital Charge Code	3500030
Hospital Revenue Code	402
Min. Negotiated Rate	$57.14
Max. Negotiated Rate	$339.12
Rate for Payer: Amerigroup CHIP/Medicaid	$57.14
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	$320.28
Rate for Payer: Cash Price	$320.28
Rate for Payer: Cash Price	$320.28
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$339.12
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	$339.12
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$306.15
Rate for Payer: Multiplan Commercial	$306.15
Rate for Payer: Multiplan Workers Comp	$306.15
Rate for Payer: Parkland Medicaid	$339.12
Rate for Payer: Scott and White EPO/PPO	$70.36
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$339.12
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

US Chest

Facility

$471.00

Service Code	HCPCS 76604
Hospital Charge Code	3500030
Hospital Revenue Code	402
Rate for Payer: Cash Price	$320.28

US Cholecystostomy Percutaneous

Facility

$7,171.00

Service Code	HCPCS 47490
Hospital Charge Code	5067490
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,876.28

US Cholecystostomy Percutaneous

Facility

$7,171.00

Service Code	HCPCS 47490
Hospital Charge Code	5067490
Hospital Revenue Code	360
Min. Negotiated Rate	$645.39
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$645.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Amerigroup Medicare	$3,596.72
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX Medicare	$3,596.72
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cash Price	$4,876.28
Rate for Payer: Cash Price	$4,876.28
Rate for Payer: Cash Price	$4,876.28
Rate for Payer: Cigna Commercial	$7,602.81
Rate for Payer: Cigna Medicaid	$5,163.12
Rate for Payer: Cigna Medicare	$3,596.72
Rate for Payer: Employer Direct Commercial	$3,596.72
Rate for Payer: Humana Medicare/TRICARE	$3,596.72
Rate for Payer: Molina CHIP/Medicaid	$5,163.12
Rate for Payer: Molina Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Molina Medicare	$3,596.72
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	$5,163.12
Rate for Payer: Scott and White EPO/PPO	$5,853.44
Rate for Payer: Scott and White Medicare	$3,596.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,163.12
Rate for Payer: Superior Health Plan EPO	$3,596.72
Rate for Payer: Superior Health Plan Medicare	$3,596.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Universal American Medicare	$3,596.72
Rate for Payer: Wellcare Medicare	$3,596.72
Rate for Payer: Wellmed Medicare	$3,596.72

US Drain Soft Tissue Fluid w/Cath Perc

Facility

$3,790.00

Service Code	HCPCS 10030
Hospital Charge Code	3500005
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,577.20

US Drain Soft Tissue Fluid w/Cath Perc

Facility

$3,790.00

Service Code	HCPCS 10030
Hospital Charge Code	3500005
Hospital Revenue Code	361
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$257.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
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	$711.36
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$2,577.20
Rate for Payer: Cash Price	$2,577.20
Rate for Payer: Cash Price	$2,577.20
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$2,728.80
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	$2,728.80
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	$2,728.80
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	$2,728.80
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 Duplex Hemodialysis Access Flow

Facility

$793.00

Service Code	HCPCS 93990
Hospital Charge Code	3501061
Hospital Revenue Code	921
Rate for Payer: Cash Price	$539.24

US Duplex Hemodialysis Access Flow

Facility

$793.00

Service Code	HCPCS 93990
Hospital Charge Code	3501061
Hospital Revenue Code	921
Min. Negotiated Rate	$71.37
Max. Negotiated Rate	$570.96
Rate for Payer: Amerigroup CHIP/Medicaid	$71.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$237.90
Rate for Payer: BCBS of TX Blue Essentials	$285.48
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$317.20
Rate for Payer: Cash Price	$539.24
Rate for Payer: Cash Price	$539.24
Rate for Payer: Cash Price	$539.24
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$570.96
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	$570.96
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$515.45
Rate for Payer: Multiplan Commercial	$515.45
Rate for Payer: Multiplan Workers Comp	$515.45
Rate for Payer: Parkland Medicaid	$570.96
Rate for Payer: Scott and White EPO/PPO	$181.26
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$570.96
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

US ECHOENCEPHALOGRAPHY

Facility

$622.00

Service Code	HCPCS 76506
Hospital Charge Code	3500063
Hospital Revenue Code	402
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$447.84
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	$422.96
Rate for Payer: Cash Price	$422.96
Rate for Payer: Cash Price	$422.96
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$447.84
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	$447.84
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$404.30
Rate for Payer: Multiplan Commercial	$404.30
Rate for Payer: Multiplan Workers Comp	$404.30
Rate for Payer: Parkland Medicaid	$447.84
Rate for Payer: Scott and White EPO/PPO	$139.45
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$447.84
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

US ECHOENCEPHALOGRAPHY

Facility

$622.00

Service Code	HCPCS 76506
Hospital Charge Code	3500063
Hospital Revenue Code	402
Rate for Payer: Cash Price	$422.96

Know your out-of-pocket cost for care.

All Charges