White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHED ID Drainage Eyelid BCE

Facility

$4,865.88

Service Code	HCPCS 67700
Hospital Charge Code	8914605
Hospital Revenue Code	450
Rate for Payer: Cash Price	$3,308.80

CHED ID Drainage Nose, Internal BCE

Facility

$1,990.00

Service Code	HCPCS 30000
Hospital Charge Code	8912622
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,353.20

CHED ID Drainage Nose, Internal BCE

Facility

$1,990.00

Service Code	HCPCS 30000
Hospital Charge Code	8912622
Hospital Revenue Code	450
Min. Negotiated Rate	$150.34
Max. Negotiated Rate	$1,432.80
Rate for Payer: Amerigroup CHIP/Medicaid	$179.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$237.93
Rate for Payer: Amerigroup Medicare	$237.93
Rate for Payer: BCBS of TX Blue Advantage	$171.83
Rate for Payer: BCBS of TX Blue Essentials	$205.78
Rate for Payer: BCBS of TX Medicare	$237.93
Rate for Payer: BCBS of TX PPO	$259.28
Rate for Payer: Cash Price	$1,353.20
Rate for Payer: Cash Price	$1,353.20
Rate for Payer: Cash Price	$1,353.20
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$1,432.80
Rate for Payer: Cigna Medicare	$237.93
Rate for Payer: Employer Direct Commercial	$237.93
Rate for Payer: Humana Medicare/TRICARE	$237.93
Rate for Payer: Molina CHIP/Medicaid	$1,432.80
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
Rate for Payer: Multiplan Auto	$1,293.50
Rate for Payer: Multiplan Commercial	$1,293.50
Rate for Payer: Multiplan Workers Comp	$1,293.50
Rate for Payer: Parkland Medicaid	$1,432.80
Rate for Payer: Scott and White EPO/PPO	$150.34
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,432.80
Rate for Payer: Superior Health Plan EPO	$237.93
Rate for Payer: Superior Health Plan Medicare	$237.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$237.93
Rate for Payer: Universal American Medicare	$237.93
Rate for Payer: Wellcare Medicare	$237.93
Rate for Payer: Wellmed Medicare	$237.93

CHED ID Drainage Roof of Mouth BCE

Facility

$837.55

Service Code	HCPCS 42000
Hospital Charge Code	8914606
Hospital Revenue Code	450
Min. Negotiated Rate	$75.38
Max. Negotiated Rate	$603.04
Rate for Payer: Amerigroup CHIP/Medicaid	$75.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$237.93
Rate for Payer: Amerigroup Medicare	$237.93
Rate for Payer: BCBS of TX Blue Advantage	$340.08
Rate for Payer: BCBS of TX Blue Essentials	$407.28
Rate for Payer: BCBS of TX Medicare	$237.93
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cash Price	$569.53
Rate for Payer: Cash Price	$569.53
Rate for Payer: Cash Price	$569.53
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$603.04
Rate for Payer: Cigna Medicare	$237.93
Rate for Payer: Employer Direct Commercial	$237.93
Rate for Payer: Humana Medicare/TRICARE	$237.93
Rate for Payer: Molina CHIP/Medicaid	$603.04
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
Rate for Payer: Multiplan Auto	$544.41
Rate for Payer: Multiplan Commercial	$544.41
Rate for Payer: Multiplan Workers Comp	$544.41
Rate for Payer: Parkland Medicaid	$603.04
Rate for Payer: Scott and White EPO/PPO	$135.62
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$603.04
Rate for Payer: Superior Health Plan EPO	$237.93
Rate for Payer: Superior Health Plan Medicare	$237.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$237.93
Rate for Payer: Universal American Medicare	$237.93
Rate for Payer: Wellcare Medicare	$237.93
Rate for Payer: Wellmed Medicare	$237.93

CHED ID Drainage Roof of Mouth BCE

Facility

$837.55

Service Code	HCPCS 42000
Hospital Charge Code	8914606
Hospital Revenue Code	450
Rate for Payer: Cash Price	$569.53

CHED ID Drainage Scrotal Wall BCE

Facility

$2,714.00

Service Code	HCPCS 55100
Hospital Charge Code	8912623
Hospital Revenue Code	450
Min. Negotiated Rate	$207.45
Max. Negotiated Rate	$3,507.10
Rate for Payer: Amerigroup CHIP/Medicaid	$244.26
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	$1,764.10
Rate for Payer: Multiplan Commercial	$1,764.10
Rate for Payer: Multiplan Workers Comp	$1,764.10
Rate for Payer: Parkland Medicaid	$1,954.08
Rate for Payer: Scott and White EPO/PPO	$207.45
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

CHED ID Drainage Scrotal Wall BCE

Facility

$2,714.00

Service Code	HCPCS 55100
Hospital Charge Code	8912623
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,845.52

CHED I & D OF VULVA/PERINEUM ABSCESS BCE

Facility

$1,364.25

Service Code	HCPCS 56405
Hospital Charge Code	8914599
Hospital Revenue Code	450
Rate for Payer: Cash Price	$927.69

CHED I & D OF VULVA/PERINEUM ABSCESS BCE

Facility

$1,364.25

Service Code	HCPCS 56405
Hospital Charge Code	8914599
Hospital Revenue Code	450
Min. Negotiated Rate	$116.92
Max. Negotiated Rate	$982.26
Rate for Payer: Amerigroup CHIP/Medicaid	$122.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$306.12
Rate for Payer: Amerigroup Medicare	$306.12
Rate for Payer: BCBS of TX Blue Advantage	$116.92
Rate for Payer: BCBS of TX Blue Essentials	$140.02
Rate for Payer: BCBS of TX Medicare	$306.12
Rate for Payer: BCBS of TX PPO	$176.43
Rate for Payer: Cash Price	$927.69
Rate for Payer: Cash Price	$927.69
Rate for Payer: Cash Price	$927.69
Rate for Payer: Cigna Commercial	$647.08
Rate for Payer: Cigna Medicaid	$982.26
Rate for Payer: Cigna Medicare	$306.12
Rate for Payer: Employer Direct Commercial	$306.12
Rate for Payer: Humana Medicare/TRICARE	$306.12
Rate for Payer: Molina CHIP/Medicaid	$982.26
Rate for Payer: Molina Dual Medicare/Medicaid	$306.12
Rate for Payer: Molina Medicare	$306.12
Rate for Payer: Multiplan Auto	$886.76
Rate for Payer: Multiplan Commercial	$886.76
Rate for Payer: Multiplan Workers Comp	$886.76
Rate for Payer: Parkland Medicaid	$982.26
Rate for Payer: Scott and White EPO/PPO	$157.60
Rate for Payer: Scott and White Medicare	$306.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$982.26
Rate for Payer: Superior Health Plan EPO	$306.12
Rate for Payer: Superior Health Plan Medicare	$306.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$306.12
Rate for Payer: Universal American Medicare	$306.12
Rate for Payer: Wellcare Medicare	$306.12
Rate for Payer: Wellmed Medicare	$306.12

CHED INCISION THROMBOSED HEMORRHOID EXTERNAL BCE

Facility

$818.00

Service Code	HCPCS 46083
Hospital Charge Code	8912624
Hospital Revenue Code	450
Rate for Payer: Cash Price	$556.24

CHED INCISION THROMBOSED HEMORRHOID EXTERNAL BCE

Facility

$818.00

Service Code	HCPCS 46083
Hospital Charge Code	8912624
Hospital Revenue Code	450
Min. Negotiated Rate	$73.62
Max. Negotiated Rate	$588.96
Rate for Payer: Amerigroup CHIP/Medicaid	$73.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$250.99
Rate for Payer: Amerigroup Medicare	$250.99
Rate for Payer: BCBS of TX Blue Advantage	$198.21
Rate for Payer: BCBS of TX Blue Essentials	$237.38
Rate for Payer: BCBS of TX Medicare	$250.99
Rate for Payer: BCBS of TX PPO	$299.10
Rate for Payer: Cash Price	$556.24
Rate for Payer: Cash Price	$556.24
Rate for Payer: Cash Price	$556.24
Rate for Payer: Cigna Commercial	$530.54
Rate for Payer: Cigna Medicaid	$588.96
Rate for Payer: Cigna Medicare	$250.99
Rate for Payer: Employer Direct Commercial	$250.99
Rate for Payer: Humana Medicare/TRICARE	$250.99
Rate for Payer: Molina CHIP/Medicaid	$588.96
Rate for Payer: Molina Dual Medicare/Medicaid	$250.99
Rate for Payer: Molina Medicare	$250.99
Rate for Payer: Multiplan Auto	$531.70
Rate for Payer: Multiplan Commercial	$531.70
Rate for Payer: Multiplan Workers Comp	$531.70
Rate for Payer: Parkland Medicaid	$588.96
Rate for Payer: Scott and White EPO/PPO	$136.05
Rate for Payer: Scott and White Medicare	$250.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$588.96
Rate for Payer: Superior Health Plan EPO	$250.99
Rate for Payer: Superior Health Plan Medicare	$250.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$250.99
Rate for Payer: Universal American Medicare	$250.99
Rate for Payer: Wellcare Medicare	$250.99
Rate for Payer: Wellmed Medicare	$250.99

CHED Initial Admin Charge 90471 BCE

Facility

$124.00

Service Code	HCPCS 90471
Hospital Charge Code	8912627
Hospital Revenue Code	771
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$152.89
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$37.20
Rate for Payer: BCBS of TX Blue Essentials	$44.64
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$49.60
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$89.28
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$89.28
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Parkland Medicaid	$89.28
Rate for Payer: Scott and White EPO/PPO	$25.52
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.28
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

CHED Initial Admin Charge 90471 BCE

Facility

$124.00

Service Code	HCPCS 90471
Hospital Charge Code	8912627
Hospital Revenue Code	771
Rate for Payer: Cash Price	$84.32

CHED Injections/Nerve Block Blood patch BCE

Facility

$1,339.00

Service Code	HCPCS 62273
Hospital Charge Code	8912628
Hospital Revenue Code	450
Min. Negotiated Rate	$120.51
Max. Negotiated Rate	$1,575.13
Rate for Payer: Amerigroup CHIP/Medicaid	$120.51
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$910.52
Rate for Payer: Cash Price	$910.52
Rate for Payer: Cash Price	$910.52
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$964.08
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$964.08
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
Rate for Payer: Multiplan Auto	$870.35
Rate for Payer: Multiplan Commercial	$870.35
Rate for Payer: Multiplan Workers Comp	$870.35
Rate for Payer: Parkland Medicaid	$964.08
Rate for Payer: Scott and White EPO/PPO	$138.09
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$964.08
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

CHED Injections/Nerve Block Blood patch BCE

Facility

$1,339.00

Service Code	HCPCS 62273
Hospital Charge Code	8912628
Hospital Revenue Code	450
Rate for Payer: Cash Price	$910.52

CHED Injections/Nerve Block Injcetion corpora cavernosa BCE

Facility

$799.00

Service Code	HCPCS 54235
Hospital Charge Code	8910627
Hospital Revenue Code	450
Rate for Payer: Cash Price	$543.32

CHED Injections/Nerve Block Injcetion corpora cavernosa BCE

Facility

$799.00

Service Code	HCPCS 54235
Hospital Charge Code	8910627
Hospital Revenue Code	450
Min. Negotiated Rate	$71.91
Max. Negotiated Rate	$575.28
Rate for Payer: Amerigroup CHIP/Medicaid	$71.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$250.99
Rate for Payer: Amerigroup Medicare	$250.99
Rate for Payer: BCBS of TX Blue Advantage	$72.93
Rate for Payer: BCBS of TX Blue Essentials	$87.34
Rate for Payer: BCBS of TX Medicare	$250.99
Rate for Payer: BCBS of TX PPO	$110.05
Rate for Payer: Cash Price	$543.32
Rate for Payer: Cash Price	$543.32
Rate for Payer: Cash Price	$543.32
Rate for Payer: Cigna Commercial	$530.54
Rate for Payer: Cigna Medicaid	$575.28
Rate for Payer: Cigna Medicare	$250.99
Rate for Payer: Employer Direct Commercial	$250.99
Rate for Payer: Humana Medicare/TRICARE	$250.99
Rate for Payer: Molina CHIP/Medicaid	$575.28
Rate for Payer: Molina Dual Medicare/Medicaid	$250.99
Rate for Payer: Molina Medicare	$250.99
Rate for Payer: Multiplan Auto	$519.35
Rate for Payer: Multiplan Commercial	$519.35
Rate for Payer: Multiplan Workers Comp	$519.35
Rate for Payer: Parkland Medicaid	$575.28
Rate for Payer: Scott and White EPO/PPO	$90.49
Rate for Payer: Scott and White Medicare	$250.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$575.28
Rate for Payer: Superior Health Plan EPO	$250.99
Rate for Payer: Superior Health Plan Medicare	$250.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$250.99
Rate for Payer: Universal American Medicare	$250.99
Rate for Payer: Wellcare Medicare	$250.99
Rate for Payer: Wellmed Medicare	$250.99

CHED Injections/Nerve Block Injection trigger point BCE

Facility

$744.00

Service Code	HCPCS 20552
Hospital Charge Code	8912629
Hospital Revenue Code	450
Rate for Payer: Cash Price	$505.92

CHED Injections/Nerve Block Injection trigger point BCE

Facility

$744.00

Service Code	HCPCS 20552
Hospital Charge Code	8912629
Hospital Revenue Code	450
Min. Negotiated Rate	$45.02
Max. Negotiated Rate	$651.79
Rate for Payer: Amerigroup CHIP/Medicaid	$66.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.35
Rate for Payer: Amerigroup Medicare	$308.35
Rate for Payer: BCBS of TX Blue Advantage	$50.63
Rate for Payer: BCBS of TX Blue Essentials	$60.64
Rate for Payer: BCBS of TX Medicare	$308.35
Rate for Payer: BCBS of TX PPO	$76.41
Rate for Payer: Cash Price	$505.92
Rate for Payer: Cash Price	$505.92
Rate for Payer: Cash Price	$505.92
Rate for Payer: Cigna Commercial	$651.79
Rate for Payer: Cigna Medicaid	$535.68
Rate for Payer: Cigna Medicare	$308.35
Rate for Payer: Employer Direct Commercial	$308.35
Rate for Payer: Humana Medicare/TRICARE	$308.35
Rate for Payer: Molina CHIP/Medicaid	$535.68
Rate for Payer: Molina Dual Medicare/Medicaid	$308.35
Rate for Payer: Molina Medicare	$308.35
Rate for Payer: Multiplan Auto	$483.60
Rate for Payer: Multiplan Commercial	$483.60
Rate for Payer: Multiplan Workers Comp	$483.60
Rate for Payer: Parkland Medicaid	$535.68
Rate for Payer: Scott and White EPO/PPO	$45.02
Rate for Payer: Scott and White Medicare	$308.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$535.68
Rate for Payer: Superior Health Plan EPO	$308.35
Rate for Payer: Superior Health Plan Medicare	$308.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.35
Rate for Payer: Universal American Medicare	$308.35
Rate for Payer: Wellcare Medicare	$308.35
Rate for Payer: Wellmed Medicare	$308.35

CHED Injections/Nerve Block Nerve block, peripheral BCE

Facility

$1,261.00

Service Code	HCPCS 64450
Hospital Charge Code	8910628
Hospital Revenue Code	450
Min. Negotiated Rate	$51.16
Max. Negotiated Rate	$1,498.91
Rate for Payer: Amerigroup CHIP/Medicaid	$113.49
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$80.76
Rate for Payer: BCBS of TX Blue Essentials	$96.72
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$121.87
Rate for Payer: Cash Price	$857.48
Rate for Payer: Cash Price	$857.48
Rate for Payer: Cash Price	$857.48
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$907.92
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$907.92
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
Rate for Payer: Multiplan Auto	$819.65
Rate for Payer: Multiplan Commercial	$819.65
Rate for Payer: Multiplan Workers Comp	$819.65
Rate for Payer: Parkland Medicaid	$907.92
Rate for Payer: Scott and White EPO/PPO	$51.16
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$907.92
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

CHED Injections/Nerve Block Nerve block, peripheral BCE

Facility

$1,261.00

Service Code	HCPCS 64450
Hospital Charge Code	8910628
Hospital Revenue Code	450
Rate for Payer: Cash Price	$857.48

CHED Injections/Nerve Block Nerve block, trigeminal BCE

Facility

$535.00

Service Code	HCPCS 64400
Hospital Charge Code	8910629
Hospital Revenue Code	450
Rate for Payer: Cash Price	$363.80

CHED Injections/Nerve Block Nerve block, trigeminal BCE

Facility

$535.00

Service Code	HCPCS 64400
Hospital Charge Code	8910629
Hospital Revenue Code	450
Min. Negotiated Rate	$48.15
Max. Negotiated Rate	$651.79
Rate for Payer: Amerigroup CHIP/Medicaid	$48.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.35
Rate for Payer: Amerigroup Medicare	$308.35
Rate for Payer: BCBS of TX Blue Advantage	$127.77
Rate for Payer: BCBS of TX Blue Essentials	$153.02
Rate for Payer: BCBS of TX Medicare	$308.35
Rate for Payer: BCBS of TX PPO	$192.81
Rate for Payer: Cash Price	$363.80
Rate for Payer: Cash Price	$363.80
Rate for Payer: Cash Price	$363.80
Rate for Payer: Cigna Commercial	$651.79
Rate for Payer: Cigna Medicaid	$385.20
Rate for Payer: Cigna Medicare	$308.35
Rate for Payer: Employer Direct Commercial	$308.35
Rate for Payer: Humana Medicare/TRICARE	$308.35
Rate for Payer: Molina CHIP/Medicaid	$385.20
Rate for Payer: Molina Dual Medicare/Medicaid	$308.35
Rate for Payer: Molina Medicare	$308.35
Rate for Payer: Multiplan Auto	$347.75
Rate for Payer: Multiplan Commercial	$347.75
Rate for Payer: Multiplan Workers Comp	$347.75
Rate for Payer: Parkland Medicaid	$385.20
Rate for Payer: Scott and White EPO/PPO	$62.89
Rate for Payer: Scott and White Medicare	$308.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$385.20
Rate for Payer: Superior Health Plan EPO	$308.35
Rate for Payer: Superior Health Plan Medicare	$308.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.35
Rate for Payer: Universal American Medicare	$308.35
Rate for Payer: Wellcare Medicare	$308.35
Rate for Payer: Wellmed Medicare	$308.35

CHED Injections/Nerve Block Sacroiliac Joint Arthrography BCE

Facility

$2,500.00

Service Code	HCPCS 27096
Hospital Charge Code	8914608
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,700.00

CHED Injections/Nerve Block Sacroiliac Joint Arthrography BCE

Facility

$2,500.00

Service Code	HCPCS 27096
Hospital Charge Code	8914608
Hospital Revenue Code	450
Min. Negotiated Rate	$101.30
Max. Negotiated Rate	$1,800.00
Rate for Payer: Amerigroup CHIP/Medicaid	$225.00
Rate for Payer: BCBS of TX Blue Advantage	$143.24
Rate for Payer: BCBS of TX Blue Essentials	$171.54
Rate for Payer: BCBS of TX PPO	$216.14
Rate for Payer: Cash Price	$1,700.00
Rate for Payer: Cash Price	$1,700.00
Rate for Payer: Cigna Medicaid	$1,800.00
Rate for Payer: Molina CHIP/Medicaid	$1,800.00
Rate for Payer: Multiplan Auto	$1,625.00
Rate for Payer: Multiplan Commercial	$1,625.00
Rate for Payer: Multiplan Workers Comp	$1,625.00
Rate for Payer: Parkland Medicaid	$1,800.00
Rate for Payer: Scott and White EPO/PPO	$101.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,800.00
Rate for Payer: Superior Health Plan EPO	$340.00

Know your out-of-pocket cost for care.

All Charges