White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Mastoids < 3 Views Bilateral

Facility

$478.00

Service Code	HCPCS 70120
Hospital Charge Code	4930120
Hospital Revenue Code	320
Rate for Payer: Cash Price	$325.04

XR Mastoids < 3 Views Bilateral

Facility

$478.00

Service Code	HCPCS 70120
Hospital Charge Code	4930120
Hospital Revenue Code	320
Min. Negotiated Rate	$38.43
Max. Negotiated Rate	$344.16
Rate for Payer: Amerigroup CHIP/Medicaid	$38.43
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	$325.04
Rate for Payer: Cash Price	$325.04
Rate for Payer: Cash Price	$325.04
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$344.16
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	$344.16
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$310.70
Rate for Payer: Multiplan Commercial	$310.70
Rate for Payer: Multiplan Workers Comp	$310.70
Rate for Payer: Parkland Medicaid	$344.16
Rate for Payer: Scott and White EPO/PPO	$47.33
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$344.16
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

XR Myelogram Cervical Spine

Facility

$2,267.00

Service Code	HCPCS 72240
Hospital Charge Code	3180008
Hospital Revenue Code	320
Min. Negotiated Rate	$112.26
Max. Negotiated Rate	$1,664.61
Rate for Payer: Amerigroup CHIP/Medicaid	$112.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$787.49
Rate for Payer: Amerigroup Medicare	$787.49
Rate for Payer: BCBS of TX Blue Advantage	$1,123.35
Rate for Payer: BCBS of TX Blue Essentials	$1,348.02
Rate for Payer: BCBS of TX Medicare	$787.49
Rate for Payer: BCBS of TX PPO	$1,504.61
Rate for Payer: Cash Price	$1,541.56
Rate for Payer: Cash Price	$1,541.56
Rate for Payer: Cash Price	$1,541.56
Rate for Payer: Cigna Commercial	$1,664.61
Rate for Payer: Cigna Medicaid	$1,632.24
Rate for Payer: Cigna Medicare	$787.49
Rate for Payer: Employer Direct Commercial	$787.49
Rate for Payer: Humana Medicare/TRICARE	$787.49
Rate for Payer: Molina CHIP/Medicaid	$1,632.24
Rate for Payer: Molina Dual Medicare/Medicaid	$787.49
Rate for Payer: Molina Medicare	$787.49
Rate for Payer: Multiplan Auto	$1,473.55
Rate for Payer: Multiplan Commercial	$1,473.55
Rate for Payer: Multiplan Workers Comp	$1,473.55
Rate for Payer: Parkland Medicaid	$1,632.24
Rate for Payer: Scott and White EPO/PPO	$138.26
Rate for Payer: Scott and White Medicare	$787.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,632.24
Rate for Payer: Superior Health Plan EPO	$787.49
Rate for Payer: Superior Health Plan Medicare	$787.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$787.49
Rate for Payer: Universal American Medicare	$787.49
Rate for Payer: Wellcare Medicare	$787.49
Rate for Payer: Wellmed Medicare	$787.49

XR Myelogram Cervical Spine

Facility

$2,267.00

Service Code	HCPCS 72240
Hospital Charge Code	3180008
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,541.56

XR Myelogram Cervical Spine W/Lumbar Inj

Facility

$2,568.00

Service Code	HCPCS 62302
Hospital Charge Code	3181100
Hospital Revenue Code	361
Min. Negotiated Rate	$231.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$231.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$787.49
Rate for Payer: Amerigroup Medicare	$787.49
Rate for Payer: BCBS of TX Blue Advantage	$1,136.97
Rate for Payer: BCBS of TX Blue Essentials	$1,361.64
Rate for Payer: BCBS of TX Medicare	$787.49
Rate for Payer: BCBS of TX PPO	$1,715.67
Rate for Payer: Cash Price	$1,746.24
Rate for Payer: Cash Price	$1,746.24
Rate for Payer: Cash Price	$1,746.24
Rate for Payer: Cigna Commercial	$1,664.61
Rate for Payer: Cigna Medicaid	$1,848.96
Rate for Payer: Cigna Medicare	$787.49
Rate for Payer: Employer Direct Commercial	$787.49
Rate for Payer: Humana Medicare/TRICARE	$787.49
Rate for Payer: Molina CHIP/Medicaid	$1,848.96
Rate for Payer: Molina Dual Medicare/Medicaid	$787.49
Rate for Payer: Molina Medicare	$787.49
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	$1,848.96
Rate for Payer: Scott and White EPO/PPO	$1,354.68
Rate for Payer: Scott and White Medicare	$787.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,848.96
Rate for Payer: Superior Health Plan EPO	$787.49
Rate for Payer: Superior Health Plan Medicare	$787.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$787.49
Rate for Payer: Universal American Medicare	$787.49
Rate for Payer: Wellcare Medicare	$787.49
Rate for Payer: Wellmed Medicare	$787.49

XR Myelogram Cervical Spine W/Lumbar Inj

Facility

$2,568.00

Service Code	HCPCS 62302
Hospital Charge Code	3181100
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,746.24

XR Myelogram Lumbar Spine W/Lumbar Inj

Facility

$2,520.00

Service Code	HCPCS 62304
Hospital Charge Code	3181102
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,713.60

XR Myelogram Lumbar Spine W/Lumbar Inj

Facility

$2,520.00

Service Code	HCPCS 62304
Hospital Charge Code	3181102
Hospital Revenue Code	361
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$226.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$787.49
Rate for Payer: Amerigroup Medicare	$787.49
Rate for Payer: BCBS of TX Blue Advantage	$1,136.97
Rate for Payer: BCBS of TX Blue Essentials	$1,361.64
Rate for Payer: BCBS of TX Medicare	$787.49
Rate for Payer: BCBS of TX PPO	$1,715.67
Rate for Payer: Cash Price	$1,713.60
Rate for Payer: Cash Price	$1,713.60
Rate for Payer: Cash Price	$1,713.60
Rate for Payer: Cigna Commercial	$1,664.61
Rate for Payer: Cigna Medicaid	$1,814.40
Rate for Payer: Cigna Medicare	$787.49
Rate for Payer: Employer Direct Commercial	$787.49
Rate for Payer: Humana Medicare/TRICARE	$787.49
Rate for Payer: Molina CHIP/Medicaid	$1,814.40
Rate for Payer: Molina Dual Medicare/Medicaid	$787.49
Rate for Payer: Molina Medicare	$787.49
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	$1,814.40
Rate for Payer: Scott and White EPO/PPO	$1,354.68
Rate for Payer: Scott and White Medicare	$787.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,814.40
Rate for Payer: Superior Health Plan EPO	$787.49
Rate for Payer: Superior Health Plan Medicare	$787.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$787.49
Rate for Payer: Universal American Medicare	$787.49
Rate for Payer: Wellcare Medicare	$787.49
Rate for Payer: Wellmed Medicare	$787.49

XR Myelogram Lumb/Cervical SP W/Lumb Inj

Facility

$3,159.00

Service Code	HCPCS 62305
Hospital Charge Code	9900745
Hospital Revenue Code	361
Min. Negotiated Rate	$284.31
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$284.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$787.49
Rate for Payer: Amerigroup Medicare	$787.49
Rate for Payer: BCBS of TX Blue Advantage	$1,136.97
Rate for Payer: BCBS of TX Blue Essentials	$1,361.64
Rate for Payer: BCBS of TX Medicare	$787.49
Rate for Payer: BCBS of TX PPO	$1,715.67
Rate for Payer: Cash Price	$2,148.12
Rate for Payer: Cash Price	$2,148.12
Rate for Payer: Cash Price	$2,148.12
Rate for Payer: Cigna Commercial	$1,664.61
Rate for Payer: Cigna Medicaid	$2,274.48
Rate for Payer: Cigna Medicare	$787.49
Rate for Payer: Employer Direct Commercial	$787.49
Rate for Payer: Humana Medicare/TRICARE	$787.49
Rate for Payer: Molina CHIP/Medicaid	$2,274.48
Rate for Payer: Molina Dual Medicare/Medicaid	$787.49
Rate for Payer: Molina Medicare	$787.49
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	$2,274.48
Rate for Payer: Scott and White EPO/PPO	$1,354.68
Rate for Payer: Scott and White Medicare	$787.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,274.48
Rate for Payer: Superior Health Plan EPO	$787.49
Rate for Payer: Superior Health Plan Medicare	$787.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$787.49
Rate for Payer: Universal American Medicare	$787.49
Rate for Payer: Wellcare Medicare	$787.49
Rate for Payer: Wellmed Medicare	$787.49

XR Myelogram Lumb/Cervical SP W/Lumb Inj

Facility

$3,159.00

Service Code	HCPCS 62305
Hospital Charge Code	9900745
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,148.12

XR Myelogram Lumbosacral Spine

Facility

$2,214.00

Service Code	HCPCS 72265
Hospital Charge Code	3180010
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,505.52

XR Myelogram Lumbosacral Spine

Facility

$2,214.00

Service Code	HCPCS 72265
Hospital Charge Code	3180010
Hospital Revenue Code	320
Min. Negotiated Rate	$109.26
Max. Negotiated Rate	$1,664.61
Rate for Payer: Amerigroup CHIP/Medicaid	$109.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$787.49
Rate for Payer: Amerigroup Medicare	$787.49
Rate for Payer: BCBS of TX Blue Advantage	$1,123.35
Rate for Payer: BCBS of TX Blue Essentials	$1,348.02
Rate for Payer: BCBS of TX Medicare	$787.49
Rate for Payer: BCBS of TX PPO	$1,504.61
Rate for Payer: Cash Price	$1,505.52
Rate for Payer: Cash Price	$1,505.52
Rate for Payer: Cash Price	$1,505.52
Rate for Payer: Cigna Commercial	$1,664.61
Rate for Payer: Cigna Medicaid	$1,594.08
Rate for Payer: Cigna Medicare	$787.49
Rate for Payer: Employer Direct Commercial	$787.49
Rate for Payer: Humana Medicare/TRICARE	$787.49
Rate for Payer: Molina CHIP/Medicaid	$1,594.08
Rate for Payer: Molina Dual Medicare/Medicaid	$787.49
Rate for Payer: Molina Medicare	$787.49
Rate for Payer: Multiplan Auto	$1,439.10
Rate for Payer: Multiplan Commercial	$1,439.10
Rate for Payer: Multiplan Workers Comp	$1,439.10
Rate for Payer: Parkland Medicaid	$1,594.08
Rate for Payer: Scott and White EPO/PPO	$134.65
Rate for Payer: Scott and White Medicare	$787.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,594.08
Rate for Payer: Superior Health Plan EPO	$787.49
Rate for Payer: Superior Health Plan Medicare	$787.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$787.49
Rate for Payer: Universal American Medicare	$787.49
Rate for Payer: Wellcare Medicare	$787.49
Rate for Payer: Wellmed Medicare	$787.49

XR Myelogram Thoracic Spine

Facility

$2,309.00

Service Code	HCPCS 72255
Hospital Charge Code	2100220
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,570.12

XR Myelogram Thoracic Spine

Facility

$2,309.00

Service Code	HCPCS 72255
Hospital Charge Code	2100220
Hospital Revenue Code	320
Min. Negotiated Rate	$107.93
Max. Negotiated Rate	$1,664.61
Rate for Payer: Amerigroup CHIP/Medicaid	$107.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$787.49
Rate for Payer: Amerigroup Medicare	$787.49
Rate for Payer: BCBS of TX Blue Advantage	$1,123.35
Rate for Payer: BCBS of TX Blue Essentials	$1,348.02
Rate for Payer: BCBS of TX Medicare	$787.49
Rate for Payer: BCBS of TX PPO	$1,504.61
Rate for Payer: Cash Price	$1,570.12
Rate for Payer: Cash Price	$1,570.12
Rate for Payer: Cash Price	$1,570.12
Rate for Payer: Cigna Commercial	$1,664.61
Rate for Payer: Cigna Medicaid	$1,662.48
Rate for Payer: Cigna Medicare	$787.49
Rate for Payer: Employer Direct Commercial	$787.49
Rate for Payer: Humana Medicare/TRICARE	$787.49
Rate for Payer: Molina CHIP/Medicaid	$1,662.48
Rate for Payer: Molina Dual Medicare/Medicaid	$787.49
Rate for Payer: Molina Medicare	$787.49
Rate for Payer: Multiplan Auto	$1,500.85
Rate for Payer: Multiplan Commercial	$1,500.85
Rate for Payer: Multiplan Workers Comp	$1,500.85
Rate for Payer: Parkland Medicaid	$1,662.48
Rate for Payer: Scott and White EPO/PPO	$132.96
Rate for Payer: Scott and White Medicare	$787.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,662.48
Rate for Payer: Superior Health Plan EPO	$787.49
Rate for Payer: Superior Health Plan Medicare	$787.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$787.49
Rate for Payer: Universal American Medicare	$787.49
Rate for Payer: Wellcare Medicare	$787.49
Rate for Payer: Wellmed Medicare	$787.49

XR Myelogram Thoracic Spine W/Lumbar Inj

Facility

$3,159.00

Service Code	HCPCS 62303
Hospital Charge Code	4902302
Hospital Revenue Code	361
Min. Negotiated Rate	$284.31
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$284.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$787.49
Rate for Payer: Amerigroup Medicare	$787.49
Rate for Payer: BCBS of TX Blue Advantage	$1,136.97
Rate for Payer: BCBS of TX Blue Essentials	$1,361.64
Rate for Payer: BCBS of TX Medicare	$787.49
Rate for Payer: BCBS of TX PPO	$1,715.67
Rate for Payer: Cash Price	$2,148.12
Rate for Payer: Cash Price	$2,148.12
Rate for Payer: Cash Price	$2,148.12
Rate for Payer: Cigna Commercial	$1,664.61
Rate for Payer: Cigna Medicaid	$2,274.48
Rate for Payer: Cigna Medicare	$787.49
Rate for Payer: Employer Direct Commercial	$787.49
Rate for Payer: Humana Medicare/TRICARE	$787.49
Rate for Payer: Molina CHIP/Medicaid	$2,274.48
Rate for Payer: Molina Dual Medicare/Medicaid	$787.49
Rate for Payer: Molina Medicare	$787.49
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	$2,274.48
Rate for Payer: Scott and White EPO/PPO	$1,354.68
Rate for Payer: Scott and White Medicare	$787.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,274.48
Rate for Payer: Superior Health Plan EPO	$787.49
Rate for Payer: Superior Health Plan Medicare	$787.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$787.49
Rate for Payer: Universal American Medicare	$787.49
Rate for Payer: Wellcare Medicare	$787.49
Rate for Payer: Wellmed Medicare	$787.49

XR Myelogram Thoracic Spine W/Lumbar Inj

Facility

$3,159.00

Service Code	HCPCS 62303
Hospital Charge Code	4902302
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,148.12

XR Myelography 2 or More Regions

Facility

$3,190.00

Service Code	HCPCS 72270
Hospital Charge Code	3180011
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,169.20

XR Myelography 2 or More Regions

Facility

$3,190.00

Service Code	HCPCS 72270
Hospital Charge Code	3180011
Hospital Revenue Code	320
Min. Negotiated Rate	$153.04
Max. Negotiated Rate	$2,296.80
Rate for Payer: Amerigroup CHIP/Medicaid	$153.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$787.49
Rate for Payer: Amerigroup Medicare	$787.49
Rate for Payer: BCBS of TX Blue Advantage	$1,123.35
Rate for Payer: BCBS of TX Blue Essentials	$1,348.02
Rate for Payer: BCBS of TX Medicare	$787.49
Rate for Payer: BCBS of TX PPO	$1,504.61
Rate for Payer: Cash Price	$2,169.20
Rate for Payer: Cash Price	$2,169.20
Rate for Payer: Cash Price	$2,169.20
Rate for Payer: Cigna Commercial	$1,664.61
Rate for Payer: Cigna Medicaid	$2,296.80
Rate for Payer: Cigna Medicare	$787.49
Rate for Payer: Employer Direct Commercial	$787.49
Rate for Payer: Humana Medicare/TRICARE	$787.49
Rate for Payer: Molina CHIP/Medicaid	$2,296.80
Rate for Payer: Molina Dual Medicare/Medicaid	$787.49
Rate for Payer: Molina Medicare	$787.49
Rate for Payer: Multiplan Auto	$2,073.50
Rate for Payer: Multiplan Commercial	$2,073.50
Rate for Payer: Multiplan Workers Comp	$2,073.50
Rate for Payer: Parkland Medicaid	$2,296.80
Rate for Payer: Scott and White EPO/PPO	$188.51
Rate for Payer: Scott and White Medicare	$787.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,296.80
Rate for Payer: Superior Health Plan EPO	$787.49
Rate for Payer: Superior Health Plan Medicare	$787.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$787.49
Rate for Payer: Universal American Medicare	$787.49
Rate for Payer: Wellcare Medicare	$787.49
Rate for Payer: Wellmed Medicare	$787.49

XR Nasal Bones 3+ Views

Facility

$387.00

Service Code	HCPCS 70160
Hospital Charge Code	3100153
Hospital Revenue Code	320
Rate for Payer: Cash Price	$263.16

XR Nasal Bones 3+ Views

Facility

$387.00

Service Code	HCPCS 70160
Hospital Charge Code	3100153
Hospital Revenue Code	320
Min. Negotiated Rate	$37.76
Max. Negotiated Rate	$278.64
Rate for Payer: Amerigroup CHIP/Medicaid	$37.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$87.42
Rate for Payer: Amerigroup Medicare	$87.42
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 Medicare	$87.42
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$263.16
Rate for Payer: Cash Price	$263.16
Rate for Payer: Cash Price	$263.16
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$278.64
Rate for Payer: Cigna Medicare	$87.42
Rate for Payer: Employer Direct Commercial	$87.42
Rate for Payer: Humana Medicare/TRICARE	$87.42
Rate for Payer: Molina CHIP/Medicaid	$278.64
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$251.55
Rate for Payer: Multiplan Commercial	$251.55
Rate for Payer: Multiplan Workers Comp	$251.55
Rate for Payer: Parkland Medicaid	$278.64
Rate for Payer: Scott and White EPO/PPO	$46.50
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$278.64
Rate for Payer: Superior Health Plan EPO	$87.42
Rate for Payer: Superior Health Plan Medicare	$87.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$87.42
Rate for Payer: Universal American Medicare	$87.42
Rate for Payer: Wellcare Medicare	$87.42
Rate for Payer: Wellmed Medicare	$87.42

XR Neck Soft Tissue

Facility

$667.00

Service Code	HCPCS 70360
Hospital Charge Code	3100245
Hospital Revenue Code	320
Min. Negotiated Rate	$31.41
Max. Negotiated Rate	$480.24
Rate for Payer: Amerigroup CHIP/Medicaid	$31.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$87.42
Rate for Payer: Amerigroup Medicare	$87.42
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 Medicare	$87.42
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$453.56
Rate for Payer: Cash Price	$453.56
Rate for Payer: Cash Price	$453.56
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$480.24
Rate for Payer: Cigna Medicare	$87.42
Rate for Payer: Employer Direct Commercial	$87.42
Rate for Payer: Humana Medicare/TRICARE	$87.42
Rate for Payer: Molina CHIP/Medicaid	$480.24
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$433.55
Rate for Payer: Multiplan Commercial	$433.55
Rate for Payer: Multiplan Workers Comp	$433.55
Rate for Payer: Parkland Medicaid	$480.24
Rate for Payer: Scott and White EPO/PPO	$38.66
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$480.24
Rate for Payer: Superior Health Plan EPO	$87.42
Rate for Payer: Superior Health Plan Medicare	$87.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$87.42
Rate for Payer: Universal American Medicare	$87.42
Rate for Payer: Wellcare Medicare	$87.42
Rate for Payer: Wellmed Medicare	$87.42

XR Neck Soft Tissue

Facility

$667.00

Service Code	HCPCS 70360
Hospital Charge Code	3100245
Hospital Revenue Code	320
Rate for Payer: Cash Price	$453.56

XR Orbits Complete

Facility

$349.00

Service Code	HCPCS 70200
Hospital Charge Code	3150067
Hospital Revenue Code	320
Rate for Payer: Cash Price	$237.32

XR Orbits Complete

Facility

$349.00

Service Code	HCPCS 70200
Hospital Charge Code	3150067
Hospital Revenue Code	320
Min. Negotiated Rate	$48.11
Max. Negotiated Rate	$251.28
Rate for Payer: Amerigroup CHIP/Medicaid	$48.11
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	$237.32
Rate for Payer: Cash Price	$237.32
Rate for Payer: Cash Price	$237.32
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$251.28
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	$251.28
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$226.85
Rate for Payer: Multiplan Commercial	$226.85
Rate for Payer: Multiplan Workers Comp	$226.85
Rate for Payer: Parkland Medicaid	$251.28
Rate for Payer: Scott and White EPO/PPO	$59.29
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$251.28
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

XR Osseous Survey Complete

Facility

$475.00

Service Code	HCPCS 77075
Hospital Charge Code	3120078
Hospital Revenue Code	320
Rate for Payer: Cash Price	$323.00

Know your out-of-pocket cost for care.

All Charges