White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED ID Body Site -> Scrotal Space

Facility

$7,660.00

Service Code	HCPCS 54700
Hospital Charge Code	5202542
Hospital Revenue Code	450
Min. Negotiated Rate	$689.40
Max. Negotiated Rate	$5,515.20
Rate for Payer: Amerigroup CHIP/Medicaid	$689.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Amerigroup Medicare	$2,099.91
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 Medicare	$2,099.91
Rate for Payer: BCBS of TX PPO	$4,464.31
Rate for Payer: Cash Price	$5,208.80
Rate for Payer: Cash Price	$5,208.80
Rate for Payer: Cash Price	$5,208.80
Rate for Payer: Cigna Commercial	$4,438.84
Rate for Payer: Cigna Medicaid	$5,515.20
Rate for Payer: Cigna Medicare	$2,099.91
Rate for Payer: Employer Direct Commercial	$2,099.91
Rate for Payer: Humana Medicare/TRICARE	$2,099.91
Rate for Payer: Molina CHIP/Medicaid	$5,515.20
Rate for Payer: Molina Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Molina Medicare	$2,099.91
Rate for Payer: Multiplan Auto	$4,979.00
Rate for Payer: Multiplan Commercial	$4,979.00
Rate for Payer: Multiplan Workers Comp	$4,979.00
Rate for Payer: Parkland Medicaid	$5,515.20
Rate for Payer: Scott and White EPO/PPO	$3,830.00
Rate for Payer: Scott and White Medicare	$2,099.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,515.20
Rate for Payer: Superior Health Plan EPO	$2,099.91
Rate for Payer: Superior Health Plan Medicare	$2,099.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Universal American Medicare	$2,099.91
Rate for Payer: Wellcare Medicare	$2,099.91
Rate for Payer: Wellmed Medicare	$2,099.91

ED ID Body Site -> Vestibule of Mouth, Simple

Facility

$1,175.00

Service Code	HCPCS 40800
Hospital Charge Code	8914604
Hospital Revenue Code	450
Min. Negotiated Rate	$105.75
Max. Negotiated Rate	$1,503.68
Rate for Payer: Amerigroup CHIP/Medicaid	$105.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
Rate for Payer: BCBS of TX Blue Advantage	$277.84
Rate for Payer: BCBS of TX Blue Essentials	$332.74
Rate for Payer: BCBS of TX Medicare	$711.36
Rate for Payer: BCBS of TX PPO	$419.25
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	$763.75
Rate for Payer: Multiplan Commercial	$763.75
Rate for Payer: Multiplan Workers Comp	$763.75
Rate for Payer: Parkland Medicaid	$846.00
Rate for Payer: Scott and White EPO/PPO	$587.50
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

ED ID Body Site -> Vestibule of Mouth, Simple

Facility

$1,175.00

Service Code	HCPCS 40800
Hospital Charge Code	8914604
Hospital Revenue Code	450
Rate for Payer: Cash Price	$799.00

ED ID Body Site -> Vulva/Perineum

Facility

$1,052.00

Service Code	HCPCS 56405
Hospital Charge Code	8682618
Hospital Revenue Code	450
Min. Negotiated Rate	$94.68
Max. Negotiated Rate	$757.44
Rate for Payer: Amerigroup CHIP/Medicaid	$94.68
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	$715.36
Rate for Payer: Cash Price	$715.36
Rate for Payer: Cash Price	$715.36
Rate for Payer: Cigna Commercial	$647.08
Rate for Payer: Cigna Medicaid	$757.44
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	$757.44
Rate for Payer: Molina Dual Medicare/Medicaid	$306.12
Rate for Payer: Molina Medicare	$306.12
Rate for Payer: Multiplan Auto	$683.80
Rate for Payer: Multiplan Commercial	$683.80
Rate for Payer: Multiplan Workers Comp	$683.80
Rate for Payer: Parkland Medicaid	$757.44
Rate for Payer: Scott and White EPO/PPO	$526.00
Rate for Payer: Scott and White Medicare	$306.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$757.44
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

ED ID Body Site -> Vulva/Perineum

Facility

$1,052.00

Service Code	HCPCS 56405
Hospital Charge Code	8682618
Hospital Revenue Code	450
Rate for Payer: Cash Price	$715.36

ED ID Drainage -> Eyelid

Facility

$4,866.00

Service Code	HCPCS 67700
Hospital Charge Code	5202546
Hospital Revenue Code	450
Rate for Payer: Cash Price	$3,308.88

ED ID Drainage -> Eyelid

Facility

$4,866.00

Service Code	HCPCS 67700
Hospital Charge Code	5202546
Hospital Revenue Code	450
Min. Negotiated Rate	$228.26
Max. Negotiated Rate	$3,503.52
Rate for Payer: Amerigroup CHIP/Medicaid	$437.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$318.85
Rate for Payer: Amerigroup Medicare	$318.85
Rate for Payer: BCBS of TX Blue Advantage	$228.26
Rate for Payer: BCBS of TX Blue Essentials	$273.36
Rate for Payer: BCBS of TX Medicare	$318.85
Rate for Payer: BCBS of TX PPO	$344.43
Rate for Payer: Cash Price	$3,308.88
Rate for Payer: Cash Price	$3,308.88
Rate for Payer: Cash Price	$3,308.88
Rate for Payer: Cigna Commercial	$673.99
Rate for Payer: Cigna Medicaid	$3,503.52
Rate for Payer: Cigna Medicare	$318.85
Rate for Payer: Employer Direct Commercial	$318.85
Rate for Payer: Humana Medicare/TRICARE	$318.85
Rate for Payer: Molina CHIP/Medicaid	$3,503.52
Rate for Payer: Molina Dual Medicare/Medicaid	$318.85
Rate for Payer: Molina Medicare	$318.85
Rate for Payer: Multiplan Auto	$3,162.90
Rate for Payer: Multiplan Commercial	$3,162.90
Rate for Payer: Multiplan Workers Comp	$3,162.90
Rate for Payer: Parkland Medicaid	$3,503.52
Rate for Payer: Scott and White EPO/PPO	$2,433.00
Rate for Payer: Scott and White Medicare	$318.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,503.52
Rate for Payer: Superior Health Plan EPO	$318.85
Rate for Payer: Superior Health Plan Medicare	$318.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$318.85
Rate for Payer: Universal American Medicare	$318.85
Rate for Payer: Wellcare Medicare	$318.85
Rate for Payer: Wellmed Medicare	$318.85

ED ID Drainage -> Nose, Internal

Facility

$1,990.00

Service Code	HCPCS 30000
Hospital Charge Code	5202543
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,353.20

ED ID Drainage -> Nose, Internal

Facility

$1,990.00

Service Code	HCPCS 30000
Hospital Charge Code	5202543
Hospital Revenue Code	450
Min. Negotiated Rate	$171.83
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	$995.00
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

ED ID Drainage -> Roof of Mouth

Facility

$838.00

Service Code	HCPCS 42000
Hospital Charge Code	5202544
Hospital Revenue Code	450
Rate for Payer: Cash Price	$569.84

ED ID Drainage -> Roof of Mouth

Facility

$838.00

Service Code	HCPCS 42000
Hospital Charge Code	5202544
Hospital Revenue Code	450
Min. Negotiated Rate	$75.42
Max. Negotiated Rate	$603.36
Rate for Payer: Amerigroup CHIP/Medicaid	$75.42
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	$569.84
Rate for Payer: Cash Price	$569.84
Rate for Payer: Cash Price	$569.84
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$603.36
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	$603.36
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
Rate for Payer: Multiplan Auto	$544.70
Rate for Payer: Multiplan Commercial	$544.70
Rate for Payer: Multiplan Workers Comp	$544.70
Rate for Payer: Parkland Medicaid	$603.36
Rate for Payer: Scott and White EPO/PPO	$419.00
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$603.36
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

ED ID Drainage -> Scrotal Wall

Facility

$2,714.00

Service Code	HCPCS 55100
Hospital Charge Code	5202545
Hospital Revenue Code	450
Min. Negotiated Rate	$244.26
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	$1,357.00
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

ED ID Drainage -> Scrotal Wall

Facility

$2,714.00

Service Code	HCPCS 55100
Hospital Charge Code	5202545
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,845.52

ED I & D OF VULVA/PERINEUM ABSCESS BCE

Facility

$1,052.00

Service Code	HCPCS 56405
Hospital Charge Code	8414459
Hospital Revenue Code	450
Min. Negotiated Rate	$94.68
Max. Negotiated Rate	$757.44
Rate for Payer: Amerigroup CHIP/Medicaid	$94.68
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	$715.36
Rate for Payer: Cash Price	$715.36
Rate for Payer: Cash Price	$715.36
Rate for Payer: Cigna Commercial	$647.08
Rate for Payer: Cigna Medicaid	$757.44
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	$757.44
Rate for Payer: Molina Dual Medicare/Medicaid	$306.12
Rate for Payer: Molina Medicare	$306.12
Rate for Payer: Multiplan Auto	$683.80
Rate for Payer: Multiplan Commercial	$683.80
Rate for Payer: Multiplan Workers Comp	$683.80
Rate for Payer: Parkland Medicaid	$757.44
Rate for Payer: Scott and White EPO/PPO	$526.00
Rate for Payer: Scott and White Medicare	$306.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$757.44
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

ED I & D OF VULVA/PERINEUM ABSCESS BCE

Facility

$1,052.00

Service Code	HCPCS 56405
Hospital Charge Code	8414459
Hospital Revenue Code	450
Rate for Payer: Cash Price	$715.36

ED INCISION THROMBOSED HEMORRHOID EXTERNAL BCE

Facility

$818.00

Service Code	HCPCS 46083
Hospital Charge Code	8712540
Hospital Revenue Code	450
Rate for Payer: Cash Price	$556.24

ED INCISION THROMBOSED HEMORRHOID EXTERNAL BCE

Facility

$818.00

Service Code	HCPCS 46083
Hospital Charge Code	8712540
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	$409.00
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

ED Injections/Nerve Block -> Blood patch

Facility

$1,339.00

Service Code	HCPCS 62273
Hospital Charge Code	610025
Hospital Revenue Code	450
Rate for Payer: Cash Price	$910.52

ED Injections/Nerve Block -> Blood patch

Facility

$1,339.00

Service Code	HCPCS 62273
Hospital Charge Code	610025
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	$669.50
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

ED Injections/Nerve Block -> Injection corpora cavernosa

Facility

$799.00

Service Code	HCPCS 54235
Hospital Charge Code	5202547
Hospital Revenue Code	450
Rate for Payer: Cash Price	$543.32

ED Injections/Nerve Block -> Injection corpora cavernosa

Facility

$799.00

Service Code	HCPCS 54235
Hospital Charge Code	5202547
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	$399.50
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

ED Injections/Nerve Block -> Injection trigger point

Facility

$744.00

Service Code	HCPCS 20552
Hospital Charge Code	6100192
Hospital Revenue Code	450
Min. Negotiated Rate	$50.63
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	$372.00
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

ED Injections/Nerve Block -> Injection trigger point

Facility

$744.00

Service Code	HCPCS 20552
Hospital Charge Code	6100192
Hospital Revenue Code	450
Rate for Payer: Cash Price	$505.92

ED Injections/Nerve Block -> Lumbar puncture - Diagnostic

Facility

$1,261.00

Service Code	HCPCS 62270
Hospital Charge Code	315358
Hospital Revenue Code	450
Min. Negotiated Rate	$113.49
Max. Negotiated Rate	$1,575.13
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	$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	$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	$630.50
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

ED Injections/Nerve Block -> Lumbar puncture - Diagnostic

Facility

$1,261.00

Service Code	HCPCS 62270
Hospital Charge Code	315358
Hospital Revenue Code	450
Rate for Payer: Cash Price	$857.48

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