White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHWR XR FL GUIDE BX/ASP/INJ BCE

Facility

$559.00

Service Code	CPT 77002
Hospital Charge Code	4906010
Hospital Revenue Code	320
Min. Negotiated Rate	$50.31
Max. Negotiated Rate	$363.35
Rate for Payer: Aetna Commercial	$103.44
Rate for Payer: Amerigroup CHIP/Medicaid	$50.31
Rate for Payer: BCBS of TX Blue Advantage	$123.09
Rate for Payer: BCBS of TX Blue Essentials	$147.71
Rate for Payer: BCBS of TX PPO	$164.87
Rate for Payer: Cash Price	$491.92
Rate for Payer: Cash Price	$491.92
Rate for Payer: Multiplan Auto	$363.35
Rate for Payer: Multiplan Commercial	$363.35
Rate for Payer: Multiplan Workers Comp	$363.35
Rate for Payer: Scott and White EPO/PPO	$279.50
Rate for Payer: Superior Health Plan EPO	$76.02

CHWR XR FL GUIDE GI TUBE

Facility

$638.00

Service Code	CPT 74340
Hospital Charge Code	4904340
Hospital Revenue Code	320
Min. Negotiated Rate	$45.79
Max. Negotiated Rate	$414.70
Rate for Payer: Aetna Commercial	$86.84
Rate for Payer: Amerigroup CHIP/Medicaid	$57.42
Rate for Payer: BCBS of TX Blue Advantage	$45.79
Rate for Payer: BCBS of TX Blue Essentials	$54.94
Rate for Payer: BCBS of TX PPO	$61.33
Rate for Payer: Cash Price	$561.44
Rate for Payer: Cash Price	$561.44
Rate for Payer: Multiplan Auto	$414.70
Rate for Payer: Multiplan Commercial	$414.70
Rate for Payer: Multiplan Workers Comp	$414.70
Rate for Payer: Scott and White EPO/PPO	$319.00
Rate for Payer: Superior Health Plan EPO	$86.77

CHWR XR FLUORO GUID FOR SPINAL INJECTION

Facility

$1,020.00

Service Code	CPT 77003
Hospital Charge Code	4906011
Hospital Revenue Code	320
Min. Negotiated Rate	$88.81
Max. Negotiated Rate	$663.00
Rate for Payer: Aetna Commercial	$88.81
Rate for Payer: Amerigroup CHIP/Medicaid	$91.80
Rate for Payer: BCBS of TX Blue Advantage	$113.57
Rate for Payer: BCBS of TX Blue Essentials	$136.28
Rate for Payer: BCBS of TX PPO	$152.11
Rate for Payer: Cash Price	$897.60
Rate for Payer: Cash Price	$897.60
Rate for Payer: Multiplan Auto	$663.00
Rate for Payer: Multiplan Commercial	$663.00
Rate for Payer: Multiplan Workers Comp	$663.00
Rate for Payer: Scott and White EPO/PPO	$510.00
Rate for Payer: Superior Health Plan EPO	$138.72

CHWR XR FLUORO GUID FOR SPINAL INJECTION BCE

Facility

$1,020.00

Service Code	CPT 77003
Hospital Charge Code	4906011
Hospital Revenue Code	320
Rate for Payer: Cash Price	$897.60

CHWR XR FLUORO GUID FOR SPINAL INJECTION BCE

Facility

$1,020.00

Service Code	CPT 77003
Hospital Charge Code	4906011
Hospital Revenue Code	320
Min. Negotiated Rate	$88.81
Max. Negotiated Rate	$663.00
Rate for Payer: Aetna Commercial	$88.81
Rate for Payer: Amerigroup CHIP/Medicaid	$91.80
Rate for Payer: BCBS of TX Blue Advantage	$113.57
Rate for Payer: BCBS of TX Blue Essentials	$136.28
Rate for Payer: BCBS of TX PPO	$152.11
Rate for Payer: Cash Price	$897.60
Rate for Payer: Cash Price	$897.60
Rate for Payer: Multiplan Auto	$663.00
Rate for Payer: Multiplan Commercial	$663.00
Rate for Payer: Multiplan Workers Comp	$663.00
Rate for Payer: Scott and White EPO/PPO	$510.00
Rate for Payer: Superior Health Plan EPO	$138.72

CHWR XR GUIDE PERC DRAIN ABSCESS W/CATH

Facility

$3,174.00

Service Code	CPT 75989
Hospital Charge Code	4905990
Hospital Revenue Code	320
Min. Negotiated Rate	$88.25
Max. Negotiated Rate	$2,063.10
Rate for Payer: Aetna Commercial	$88.25
Rate for Payer: Amerigroup CHIP/Medicaid	$285.66
Rate for Payer: BCBS of TX Blue Advantage	$105.25
Rate for Payer: BCBS of TX Blue Essentials	$126.30
Rate for Payer: BCBS of TX PPO	$140.98
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Multiplan Auto	$2,063.10
Rate for Payer: Multiplan Commercial	$2,063.10
Rate for Payer: Multiplan Workers Comp	$2,063.10
Rate for Payer: Scott and White EPO/PPO	$1,587.00
Rate for Payer: Superior Health Plan EPO	$431.66

CHWR XR GUIDE PERC DRAIN ABSCESS W/CATH BCE

Facility

$3,174.00

Service Code	CPT 75989
Hospital Charge Code	4905990
Hospital Revenue Code	320
Min. Negotiated Rate	$88.25
Max. Negotiated Rate	$2,063.10
Rate for Payer: Aetna Commercial	$88.25
Rate for Payer: Amerigroup CHIP/Medicaid	$285.66
Rate for Payer: BCBS of TX Blue Advantage	$105.25
Rate for Payer: BCBS of TX Blue Essentials	$126.30
Rate for Payer: BCBS of TX PPO	$140.98
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Multiplan Auto	$2,063.10
Rate for Payer: Multiplan Commercial	$2,063.10
Rate for Payer: Multiplan Workers Comp	$2,063.10
Rate for Payer: Scott and White EPO/PPO	$1,587.00
Rate for Payer: Superior Health Plan EPO	$431.66

CHWR XR GUIDE PERC DRAIN ABSCESS W/CATH BCE

Facility

$3,174.00

Service Code	CPT 75989
Hospital Charge Code	4905990
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,793.12

CHWR XR INJ BLADDER CYSTO

Facility

$442.00

Service Code	CPT 51600
Hospital Charge Code	4907615
Hospital Revenue Code	361
Min. Negotiated Rate	$39.78
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$243.10
Rate for Payer: Amerigroup CHIP/Medicaid	$39.78
Rate for Payer: Cash Price	$388.96
Rate for Payer: Cash Price	$388.96
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: Scott and White EPO/PPO	$221.00
Rate for Payer: Superior Health Plan EPO	$60.11

CHWR XR INJ BLADDER CYSTO BCE

Facility

$442.00

Service Code	CPT 51600
Hospital Charge Code	4907615
Hospital Revenue Code	361
Min. Negotiated Rate	$39.78
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$243.10
Rate for Payer: Amerigroup CHIP/Medicaid	$39.78
Rate for Payer: Cash Price	$388.96
Rate for Payer: Cash Price	$388.96
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: Scott and White EPO/PPO	$221.00
Rate for Payer: Superior Health Plan EPO	$60.11

CHWR XR INJ BLADDER CYSTO BCE

Facility

$442.00

Service Code	CPT 51600
Hospital Charge Code	4907615
Hospital Revenue Code	361
Rate for Payer: Cash Price	$388.96

CHWR XR INJ BLADDER RETRO

Facility

$582.00

Service Code	CPT 51610
Hospital Charge Code	4907620
Hospital Revenue Code	361
Min. Negotiated Rate	$52.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$320.10
Rate for Payer: Amerigroup CHIP/Medicaid	$52.38
Rate for Payer: Cash Price	$512.16
Rate for Payer: Cash Price	$512.16
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: Scott and White EPO/PPO	$291.00
Rate for Payer: Superior Health Plan EPO	$79.15

CHWR XR INJ BLADDER RETRO BCE

Facility

$582.00

Service Code	CPT 51610
Hospital Charge Code	4907620
Hospital Revenue Code	361
Min. Negotiated Rate	$52.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$320.10
Rate for Payer: Amerigroup CHIP/Medicaid	$52.38
Rate for Payer: Cash Price	$512.16
Rate for Payer: Cash Price	$512.16
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: Scott and White EPO/PPO	$291.00
Rate for Payer: Superior Health Plan EPO	$79.15

CHWR XR INJ BLADDER RETRO BCE

Facility

$582.00

Service Code	CPT 51610
Hospital Charge Code	4907620
Hospital Revenue Code	361
Rate for Payer: Cash Price	$512.16

CHWR XR INJ HIP ARTHROGRAM

Facility

$581.00

Service Code	CPT 27093
Hospital Charge Code	4907650
Hospital Revenue Code	361
Min. Negotiated Rate	$52.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$319.55
Rate for Payer: Amerigroup CHIP/Medicaid	$52.29
Rate for Payer: Cash Price	$511.28
Rate for Payer: Cash Price	$511.28
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: Scott and White EPO/PPO	$290.50
Rate for Payer: Superior Health Plan EPO	$79.02

CHWR XR INJ HIP ARTHROGRAM BCE

Facility

$581.00

Service Code	CPT 27093
Hospital Charge Code	4907650
Hospital Revenue Code	361
Rate for Payer: Cash Price	$511.28

CHWR XR INJ HIP ARTHROGRAM BCE

Facility

$581.00

Service Code	CPT 27093
Hospital Charge Code	4907650
Hospital Revenue Code	361
Min. Negotiated Rate	$52.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$319.55
Rate for Payer: Amerigroup CHIP/Medicaid	$52.29
Rate for Payer: Cash Price	$511.28
Rate for Payer: Cash Price	$511.28
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: Scott and White EPO/PPO	$290.50
Rate for Payer: Superior Health Plan EPO	$79.02

CHWR XR INJ KNEE ARTHRO

Facility

$718.00

Service Code	CPT 27369
Hospital Charge Code	4907670
Hospital Revenue Code	361
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$394.90
Rate for Payer: Amerigroup CHIP/Medicaid	$64.62
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cash Price	$631.84
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: Scott and White EPO/PPO	$359.00
Rate for Payer: Superior Health Plan EPO	$97.65

CHWR XR INJ KNEE ARTHRO BCE

Facility

$718.00

Service Code	CPT 27369
Hospital Charge Code	4907670
Hospital Revenue Code	361
Rate for Payer: Cash Price	$631.84

CHWR XR INJ KNEE ARTHRO BCE

Facility

$718.00

Service Code	CPT 27369
Hospital Charge Code	4907670
Hospital Revenue Code	361
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$394.90
Rate for Payer: Amerigroup CHIP/Medicaid	$64.62
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cash Price	$631.84
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: Scott and White EPO/PPO	$359.00
Rate for Payer: Superior Health Plan EPO	$97.65

CHWR XR INJ SHOULDER ARTHRO

Facility

$555.00

Service Code	CPT 23350
Hospital Charge Code	4907700
Hospital Revenue Code	361
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$305.25
Rate for Payer: Amerigroup CHIP/Medicaid	$49.95
Rate for Payer: Cash Price	$488.40
Rate for Payer: Cash Price	$488.40
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: Scott and White EPO/PPO	$277.50
Rate for Payer: Superior Health Plan EPO	$75.48

CHWR XR INJ SHOULDER ARTHRO BCE

Facility

$555.00

Service Code	CPT 23350
Hospital Charge Code	4907700
Hospital Revenue Code	361
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$305.25
Rate for Payer: Amerigroup CHIP/Medicaid	$49.95
Rate for Payer: Cash Price	$488.40
Rate for Payer: Cash Price	$488.40
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: Scott and White EPO/PPO	$277.50
Rate for Payer: Superior Health Plan EPO	$75.48

CHWR XR INJ SHOULDER ARTHRO BCE

Facility

$555.00

Service Code	CPT 23350
Hospital Charge Code	4907700
Hospital Revenue Code	361
Rate for Payer: Cash Price	$488.40

CHWR XR INJ SI JT ARTHROGRAM

Facility

$2,500.00

Service Code	CPT 27096
Hospital Charge Code	4907096
Hospital Revenue Code	360
Min. Negotiated Rate	$143.24
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,375.00
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	$2,200.00
Rate for Payer: Cash Price	$2,200.00
Rate for Payer: Cash Price	$2,200.00
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: Scott and White EPO/PPO	$1,250.00
Rate for Payer: Superior Health Plan EPO	$340.00

CHWR XR INJ SI JT ARTHROGRAM BCE

Facility

$2,500.00

Service Code	CPT 27096
Hospital Charge Code	4907096
Hospital Revenue Code	360
Min. Negotiated Rate	$143.24
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,375.00
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	$2,200.00
Rate for Payer: Cash Price	$2,200.00
Rate for Payer: Cash Price	$2,200.00
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: Scott and White EPO/PPO	$1,250.00
Rate for Payer: Superior Health Plan EPO	$340.00

Know your out-of-pocket cost for care.

All Charges