White Rock Medical Center

All Charges

Charge

Type

Setting

Price

US OB Growth or Anatomy f/u w/ BPP

Facility

$761.00

Service Code	HCPCS 76816
Hospital Charge Code	9331021
Hospital Revenue Code	402
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$547.92
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	$517.48
Rate for Payer: Cash Price	$517.48
Rate for Payer: Cash Price	$517.48
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$547.92
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	$547.92
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$494.65
Rate for Payer: Multiplan Commercial	$494.65
Rate for Payer: Multiplan Workers Comp	$494.65
Rate for Payer: Parkland Medicaid	$547.92
Rate for Payer: Scott and White EPO/PPO	$136.00
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$547.92
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 OB Growth or Anatomy f/u w/ BPP

Facility

$761.00

Service Code	HCPCS 76816
Hospital Charge Code	9331021
Hospital Revenue Code	402
Rate for Payer: Cash Price	$517.48

US OB Level II

Facility

$1,380.00

Service Code	HCPCS 76811
Hospital Charge Code	5066811
Hospital Revenue Code	402
Rate for Payer: Cash Price	$938.40

US OB Level II

Facility

$1,380.00

Service Code	HCPCS 76811
Hospital Charge Code	5066811
Hospital Revenue Code	402
Min. Negotiated Rate	$139.74
Max. Negotiated Rate	$993.60
Rate for Payer: Amerigroup CHIP/Medicaid	$177.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$139.74
Rate for Payer: BCBS of TX Blue Essentials	$167.69
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$187.16
Rate for Payer: Cash Price	$938.40
Rate for Payer: Cash Price	$938.40
Rate for Payer: Cash Price	$938.40
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$993.60
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	$993.60
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$897.00
Rate for Payer: Multiplan Commercial	$897.00
Rate for Payer: Multiplan Workers Comp	$897.00
Rate for Payer: Parkland Medicaid	$993.60
Rate for Payer: Scott and White EPO/PPO	$219.21
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$993.60
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 OB Limited

Facility

$596.00

Service Code	HCPCS 76815
Hospital Charge Code	3500196
Hospital Revenue Code	402
Rate for Payer: Cash Price	$405.28

US OB Limited

Facility

$596.00

Service Code	HCPCS 76815
Hospital Charge Code	3500196
Hospital Revenue Code	402
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$429.12
Rate for Payer: Amerigroup CHIP/Medicaid	$81.20
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	$405.28
Rate for Payer: Cash Price	$405.28
Rate for Payer: Cash Price	$405.28
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$429.12
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	$429.12
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$387.40
Rate for Payer: Multiplan Commercial	$387.40
Rate for Payer: Multiplan Workers Comp	$387.40
Rate for Payer: Parkland Medicaid	$429.12
Rate for Payer: Scott and White EPO/PPO	$100.05
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$429.12
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 OB Transvaginal

Facility

$303.00

Service Code	HCPCS 76817
Hospital Charge Code	3511169
Hospital Revenue Code	402
Min. Negotiated Rate	$92.89
Max. Negotiated Rate	$247.70
Rate for Payer: Amerigroup CHIP/Medicaid	$92.89
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	$206.04
Rate for Payer: Cash Price	$206.04
Rate for Payer: Cash Price	$206.04
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$218.16
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	$218.16
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$196.95
Rate for Payer: Multiplan Commercial	$196.95
Rate for Payer: Multiplan Workers Comp	$196.95
Rate for Payer: Parkland Medicaid	$218.16
Rate for Payer: Scott and White EPO/PPO	$114.49
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$218.16
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 OB Transvaginal

Facility

$303.00

Service Code	HCPCS 76817
Hospital Charge Code	3511169
Hospital Revenue Code	402
Rate for Payer: Cash Price	$206.04

US Paracentesis

Facility

$1,947.00

Service Code	HCPCS 49083
Hospital Charge Code	3520068
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,323.96

US Paracentesis

Facility

$1,947.00

Service Code	HCPCS 49083
Hospital Charge Code	3520068
Hospital Revenue Code	361
Min. Negotiated Rate	$334.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$334.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$911.12
Rate for Payer: Amerigroup Medicare	$911.12
Rate for Payer: BCBS of TX Blue Advantage	$1,312.49
Rate for Payer: BCBS of TX Blue Essentials	$1,571.84
Rate for Payer: BCBS of TX Medicare	$911.12
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cash Price	$1,323.96
Rate for Payer: Cash Price	$1,323.96
Rate for Payer: Cash Price	$1,323.96
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicaid	$1,401.84
Rate for Payer: Cigna Medicare	$911.12
Rate for Payer: Employer Direct Commercial	$911.12
Rate for Payer: Humana Medicare/TRICARE	$911.12
Rate for Payer: Molina CHIP/Medicaid	$1,401.84
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
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	$1,401.84
Rate for Payer: Scott and White EPO/PPO	$1,533.69
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,401.84
Rate for Payer: Superior Health Plan EPO	$911.12
Rate for Payer: Superior Health Plan Medicare	$911.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$911.12
Rate for Payer: Universal American Medicare	$911.12
Rate for Payer: Wellcare Medicare	$911.12
Rate for Payer: Wellmed Medicare	$911.12

US Pelvis Complete Non-OB

Facility

$1,483.00

Service Code	HCPCS 76856
Hospital Charge Code	3500089
Hospital Revenue Code	402
Rate for Payer: Cash Price	$1,008.44

US Pelvis Complete Non-OB

Facility

$1,483.00

Service Code	HCPCS 76856
Hospital Charge Code	3500089
Hospital Revenue Code	402
Min. Negotiated Rate	$96.28
Max. Negotiated Rate	$1,067.76
Rate for Payer: Amerigroup CHIP/Medicaid	$96.28
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	$1,008.44
Rate for Payer: Cash Price	$1,008.44
Rate for Payer: Cash Price	$1,008.44
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$1,067.76
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	$1,067.76
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$963.95
Rate for Payer: Multiplan Commercial	$963.95
Rate for Payer: Multiplan Workers Comp	$963.95
Rate for Payer: Parkland Medicaid	$1,067.76
Rate for Payer: Scott and White EPO/PPO	$130.15
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,067.76
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 Pelvis Limited Non-OB

Facility

$613.00

Service Code	HCPCS 76857
Hospital Charge Code	3500535
Hospital Revenue Code	402
Rate for Payer: Cash Price	$416.84

US Pelvis Limited Non-OB

Facility

$613.00

Service Code	HCPCS 76857
Hospital Charge Code	3500535
Hospital Revenue Code	402
Min. Negotiated Rate	$50.79
Max. Negotiated Rate	$441.36
Rate for Payer: Amerigroup CHIP/Medicaid	$50.79
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	$416.84
Rate for Payer: Cash Price	$416.84
Rate for Payer: Cash Price	$416.84
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$441.36
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	$441.36
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$398.45
Rate for Payer: Multiplan Commercial	$398.45
Rate for Payer: Multiplan Workers Comp	$398.45
Rate for Payer: Parkland Medicaid	$441.36
Rate for Payer: Scott and White EPO/PPO	$60.92
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$441.36
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 Pelvis Non-OB Limited TA

Facility

$613.00

Service Code	HCPCS 76857
Hospital Charge Code	9341008
Hospital Revenue Code	402
Rate for Payer: Cash Price	$416.84

US Pelvis Non-OB Limited TA

Facility

$613.00

Service Code	HCPCS 76857
Hospital Charge Code	9341008
Hospital Revenue Code	402
Min. Negotiated Rate	$50.79
Max. Negotiated Rate	$441.36
Rate for Payer: Amerigroup CHIP/Medicaid	$50.79
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	$416.84
Rate for Payer: Cash Price	$416.84
Rate for Payer: Cash Price	$416.84
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$441.36
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	$441.36
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$398.45
Rate for Payer: Multiplan Commercial	$398.45
Rate for Payer: Multiplan Workers Comp	$398.45
Rate for Payer: Parkland Medicaid	$441.36
Rate for Payer: Scott and White EPO/PPO	$60.92
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$441.36
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 Prostate Transrectal

Facility

$469.00

Service Code	HCPCS 76872
Hospital Charge Code	3500105
Hospital Revenue Code	402
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$337.68
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	$158.76
Rate for Payer: BCBS of TX Blue Essentials	$190.52
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$212.65
Rate for Payer: Cash Price	$318.92
Rate for Payer: Cash Price	$318.92
Rate for Payer: Cash Price	$318.92
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$337.68
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	$337.68
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$304.85
Rate for Payer: Multiplan Commercial	$304.85
Rate for Payer: Multiplan Workers Comp	$304.85
Rate for Payer: Parkland Medicaid	$337.68
Rate for Payer: Scott and White EPO/PPO	$248.85
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$337.68
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 Prostate Transrectal

Facility

$469.00

Service Code	HCPCS 76872
Hospital Charge Code	3500105
Hospital Revenue Code	402
Rate for Payer: Cash Price	$318.92

US Retroperitoneal Complete

Facility

$1,551.00

Service Code	HCPCS 76770
Hospital Charge Code	3501103
Hospital Revenue Code	402
Rate for Payer: Cash Price	$1,054.68

US Retroperitoneal Complete

Facility

$1,551.00

Service Code	HCPCS 76770
Hospital Charge Code	3501103
Hospital Revenue Code	402
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$1,116.72
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	$1,054.68
Rate for Payer: Cash Price	$1,054.68
Rate for Payer: Cash Price	$1,054.68
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$1,116.72
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	$1,116.72
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$1,008.15
Rate for Payer: Multiplan Commercial	$1,008.15
Rate for Payer: Multiplan Workers Comp	$1,008.15
Rate for Payer: Parkland Medicaid	$1,116.72
Rate for Payer: Scott and White EPO/PPO	$133.81
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,116.72
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 Scrotum (Contents) w/ Doppler if ind

Facility

$1,241.00

Service Code	HCPCS 76870
Hospital Charge Code	3500121
Hospital Revenue Code	402
Rate for Payer: Cash Price	$843.88

US Scrotum (Contents) w/ Doppler if ind

Facility

$1,241.00

Service Code	HCPCS 76870
Hospital Charge Code	3500121
Hospital Revenue Code	402
Min. Negotiated Rate	$100.24
Max. Negotiated Rate	$893.52
Rate for Payer: Amerigroup CHIP/Medicaid	$100.24
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	$843.88
Rate for Payer: Cash Price	$843.88
Rate for Payer: Cash Price	$843.88
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$893.52
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	$893.52
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$806.65
Rate for Payer: Multiplan Commercial	$806.65
Rate for Payer: Multiplan Workers Comp	$806.65
Rate for Payer: Parkland Medicaid	$893.52
Rate for Payer: Scott and White EPO/PPO	$123.54
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$893.52
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 Segmental Pressures LE 1-2 Lvls Bilat

Facility

$720.00

Service Code	HCPCS 93922
Hospital Charge Code	3501020
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	$101.58
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

US Segmental Pressures LE 1-2 Lvls Bilat

Facility

$720.00

Service Code	HCPCS 93922
Hospital Charge Code	3501020
Hospital Revenue Code	921
Rate for Payer: Cash Price	$489.60

US Segmental Pressures LE 3+ Lvls Bilat

Facility

$1,579.00

Service Code	HCPCS 93923
Hospital Charge Code	3501038
Hospital Revenue Code	921
Rate for Payer: Cash Price	$1,073.72

Know your out-of-pocket cost for care.

All Charges