White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CT Limited Study/Follow Up Study

Facility

$1,113.00

Service Code	HCPCS 76380
Hospital Charge Code	5056505
Hospital Revenue Code	351
Rate for Payer: Cash Price	$756.84

CT Maxillofacial w/ Contrast

Facility

$4,080.00

Service Code	HCPCS 70487
Hospital Charge Code	3800232
Hospital Revenue Code	351
Min. Negotiated Rate	$156.38
Max. Negotiated Rate	$2,937.60
Rate for Payer: Amerigroup CHIP/Medicaid	$156.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$2,774.40
Rate for Payer: Cash Price	$2,774.40
Rate for Payer: Cash Price	$2,774.40
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$2,937.60
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$2,937.60
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$2,652.00
Rate for Payer: Multiplan Commercial	$2,652.00
Rate for Payer: Multiplan Workers Comp	$2,652.00
Rate for Payer: Parkland Medicaid	$2,937.60
Rate for Payer: Scott and White EPO/PPO	$2,040.00
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,937.60
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Maxillofacial w/ Contrast

Facility

$4,080.00

Service Code	HCPCS 70487
Hospital Charge Code	3800232
Hospital Revenue Code	351
Rate for Payer: Cash Price	$2,774.40

CT Maxillofacial w/o Contrast

Facility

$3,586.00

Service Code	HCPCS 70486
Hospital Charge Code	3800307
Hospital Revenue Code	351
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$2,581.92
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	$2,438.48
Rate for Payer: Cash Price	$2,438.48
Rate for Payer: Cash Price	$2,438.48
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$2,581.92
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	$2,581.92
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$2,330.90
Rate for Payer: Multiplan Commercial	$2,330.90
Rate for Payer: Multiplan Workers Comp	$2,330.90
Rate for Payer: Parkland Medicaid	$2,581.92
Rate for Payer: Scott and White EPO/PPO	$1,793.00
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,581.92
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

CT Maxillofacial w/o Contrast

Facility

$3,586.00

Service Code	HCPCS 70486
Hospital Charge Code	3800307
Hospital Revenue Code	351
Rate for Payer: Cash Price	$2,438.48

CT Neck Soft Tissue w/ Contrast

Facility

$7,076.00

Service Code	HCPCS 70491
Hospital Charge Code	3800224
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$5,094.72
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$4,811.68
Rate for Payer: Cash Price	$4,811.68
Rate for Payer: Cash Price	$4,811.68
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$5,094.72
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$5,094.72
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$4,599.40
Rate for Payer: Multiplan Commercial	$4,599.40
Rate for Payer: Multiplan Workers Comp	$4,599.40
Rate for Payer: Parkland Medicaid	$5,094.72
Rate for Payer: Scott and White EPO/PPO	$3,538.00
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,094.72
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Neck Soft Tissue w/ Contrast

Facility

$7,076.00

Service Code	HCPCS 70491
Hospital Charge Code	3800224
Hospital Revenue Code	351
Rate for Payer: Cash Price	$4,811.68

CT Neck Soft Tissue w/o Contrast

Facility

$5,958.00

Service Code	HCPCS 70490
Hospital Charge Code	3800075
Hospital Revenue Code	351
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$4,289.76
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	$4,051.44
Rate for Payer: Cash Price	$4,051.44
Rate for Payer: Cash Price	$4,051.44
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$4,289.76
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	$4,289.76
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$3,872.70
Rate for Payer: Multiplan Commercial	$3,872.70
Rate for Payer: Multiplan Workers Comp	$3,872.70
Rate for Payer: Parkland Medicaid	$4,289.76
Rate for Payer: Scott and White EPO/PPO	$2,979.00
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,289.76
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

CT Neck Soft Tissue w/o Contrast

Facility

$5,958.00

Service Code	HCPCS 70490
Hospital Charge Code	3800075
Hospital Revenue Code	351
Rate for Payer: Cash Price	$4,051.44

CT Neck Soft Tissue w/ + w/o Contrast

Facility

$8,364.00

Service Code	HCPCS 70492
Hospital Charge Code	3800158
Hospital Revenue Code	351
Rate for Payer: Cash Price	$5,687.52

CT Neck Soft Tissue w/ + w/o Contrast

Facility

$8,364.00

Service Code	HCPCS 70492
Hospital Charge Code	3800158
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$6,022.08
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$5,687.52
Rate for Payer: Cash Price	$5,687.52
Rate for Payer: Cash Price	$5,687.52
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$6,022.08
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$6,022.08
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$5,436.60
Rate for Payer: Multiplan Commercial	$5,436.60
Rate for Payer: Multiplan Workers Comp	$5,436.60
Rate for Payer: Parkland Medicaid	$6,022.08
Rate for Payer: Scott and White EPO/PPO	$4,182.00
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,022.08
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Orbits Sella w/ Contrast

Facility

$4,332.00

Service Code	HCPCS 70481
Hospital Charge Code	3890027
Hospital Revenue Code	351
Rate for Payer: Cash Price	$2,945.76

CT Orbits Sella w/ Contrast

Facility

$4,332.00

Service Code	HCPCS 70481
Hospital Charge Code	3890027
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,119.04
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$2,945.76
Rate for Payer: Cash Price	$2,945.76
Rate for Payer: Cash Price	$2,945.76
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,119.04
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$3,119.04
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$2,815.80
Rate for Payer: Multiplan Commercial	$2,815.80
Rate for Payer: Multiplan Workers Comp	$2,815.80
Rate for Payer: Parkland Medicaid	$3,119.04
Rate for Payer: Scott and White EPO/PPO	$2,166.00
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,119.04
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Orbits Sella w/o Contrast

Facility

$3,273.00

Service Code	HCPCS 70480
Hospital Charge Code	3800331
Hospital Revenue Code	351
Rate for Payer: Cash Price	$2,225.64

CT Orbits Sella w/o Contrast

Facility

$3,273.00

Service Code	HCPCS 70480
Hospital Charge Code	3800331
Hospital Revenue Code	351
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$2,356.56
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	$2,225.64
Rate for Payer: Cash Price	$2,225.64
Rate for Payer: Cash Price	$2,225.64
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$2,356.56
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	$2,356.56
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$2,127.45
Rate for Payer: Multiplan Commercial	$2,127.45
Rate for Payer: Multiplan Workers Comp	$2,127.45
Rate for Payer: Parkland Medicaid	$2,356.56
Rate for Payer: Scott and White EPO/PPO	$1,636.50
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,356.56
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

CT Orbits Sella w/ + w/o Contrast

Facility

$5,435.00

Service Code	HCPCS 70482
Hospital Charge Code	3800372
Hospital Revenue Code	351
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,913.20
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,695.80
Rate for Payer: Cash Price	$3,695.80
Rate for Payer: Cash Price	$3,695.80
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,913.20
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$3,913.20
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$3,532.75
Rate for Payer: Multiplan Commercial	$3,532.75
Rate for Payer: Multiplan Workers Comp	$3,532.75
Rate for Payer: Parkland Medicaid	$3,913.20
Rate for Payer: Scott and White EPO/PPO	$2,717.50
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,913.20
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Orbits Sella w/ + w/o Contrast

Facility

$5,435.00

Service Code	HCPCS 70482
Hospital Charge Code	3800372
Hospital Revenue Code	351
Rate for Payer: Cash Price	$3,695.80

CT Pelvis w/ Contrast

Facility

$4,538.00

Service Code	HCPCS 72193
Hospital Charge Code	3800265
Hospital Revenue Code	352
Rate for Payer: Cash Price	$3,085.84

CT Pelvis w/ Contrast

Facility

$4,538.00

Service Code	HCPCS 72193
Hospital Charge Code	3800265
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,267.36
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,085.84
Rate for Payer: Cash Price	$3,085.84
Rate for Payer: Cash Price	$3,085.84
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,267.36
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$3,267.36
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$2,949.70
Rate for Payer: Multiplan Commercial	$2,949.70
Rate for Payer: Multiplan Workers Comp	$2,949.70
Rate for Payer: Parkland Medicaid	$3,267.36
Rate for Payer: Scott and White EPO/PPO	$2,269.00
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,267.36
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Pelvis w/o Contrast

Facility

$3,778.00

Service Code	HCPCS 72192
Hospital Charge Code	5052192
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,569.04

CT Pelvis w/o Contrast

Facility

$3,778.00

Service Code	HCPCS 72192
Hospital Charge Code	5052192
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$2,720.16
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	$2,569.04
Rate for Payer: Cash Price	$2,569.04
Rate for Payer: Cash Price	$2,569.04
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$2,720.16
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	$2,720.16
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$2,455.70
Rate for Payer: Multiplan Commercial	$2,455.70
Rate for Payer: Multiplan Workers Comp	$2,455.70
Rate for Payer: Parkland Medicaid	$2,720.16
Rate for Payer: Scott and White EPO/PPO	$1,889.00
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,720.16
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

CT Pelvis w/ + w/o Contrast

Facility

$4,765.00

Service Code	HCPCS 72194
Hospital Charge Code	3800190
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$3,430.80
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$300.66
Rate for Payer: BCBS of TX Blue Essentials	$360.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$3,240.20
Rate for Payer: Cash Price	$3,240.20
Rate for Payer: Cash Price	$3,240.20
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,430.80
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$3,430.80
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$3,097.25
Rate for Payer: Multiplan Commercial	$3,097.25
Rate for Payer: Multiplan Workers Comp	$3,097.25
Rate for Payer: Parkland Medicaid	$3,430.80
Rate for Payer: Scott and White EPO/PPO	$2,382.50
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,430.80
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

CT Pelvis w/ + w/o Contrast

Facility

$4,765.00

Service Code	HCPCS 72194
Hospital Charge Code	3800190
Hospital Revenue Code	352
Rate for Payer: Cash Price	$3,240.20

CT Sacroplasty Bilat 2 or more needles

Facility

$21,024.00

Service Code	HCPCS 0201T
Hospital Charge Code	4612011
Hospital Revenue Code	360
Min. Negotiated Rate	$1,892.16
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,892.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$14,296.32
Rate for Payer: Cash Price	$14,296.32
Rate for Payer: Cash Price	$14,296.32
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$15,137.28
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$15,137.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$15,137.28
Rate for Payer: Scott and White EPO/PPO	$10,512.00
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,137.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

CT Sacroplasty Bilat 2 or more needles

Facility

$21,024.00

Service Code	HCPCS 0201T
Hospital Charge Code	5052898
Hospital Revenue Code	360
Rate for Payer: Cash Price	$14,296.32

Know your out-of-pocket cost for care.

All Charges