White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHWR XR ARTHROGRAM INJECTION HIP RIGHT

Facility

$581.00

Service Code	HCPCS 27093
Hospital Charge Code	4907650
Hospital Revenue Code	361
Rate for Payer: Cash Price	$395.08

CHWR XR ARTHROGRAM INJECTION KNEE RIGHT

Facility

$718.00

Service Code	HCPCS 27369
Hospital Charge Code	4907670
Hospital Revenue Code	361
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$64.62
Rate for Payer: BCBS of TX Blue Advantage	$215.40
Rate for Payer: BCBS of TX Blue Essentials	$258.48
Rate for Payer: BCBS of TX PPO	$287.20
Rate for Payer: Cash Price	$488.24
Rate for Payer: Cash Price	$488.24
Rate for Payer: Cigna Medicaid	$516.96
Rate for Payer: Molina CHIP/Medicaid	$516.96
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: Parkland Medicaid	$516.96
Rate for Payer: Scott and White EPO/PPO	$359.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$516.96
Rate for Payer: Superior Health Plan EPO	$97.65

CHWR XR ARTHROGRAM INJECTION KNEE RIGHT

Facility

$718.00

Service Code	HCPCS 27369
Hospital Charge Code	4907670
Hospital Revenue Code	361
Rate for Payer: Cash Price	$488.24

CHWR XR ARTHROGRAM INJECTION SHOULDER RT

Facility

$555.00

Service Code	HCPCS 23350
Hospital Charge Code	4907700
Hospital Revenue Code	361
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$49.95
Rate for Payer: BCBS of TX Blue Advantage	$166.50
Rate for Payer: BCBS of TX Blue Essentials	$199.80
Rate for Payer: BCBS of TX PPO	$222.00
Rate for Payer: Cash Price	$377.40
Rate for Payer: Cash Price	$377.40
Rate for Payer: Cigna Medicaid	$399.60
Rate for Payer: Molina CHIP/Medicaid	$399.60
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	$399.60
Rate for Payer: Scott and White EPO/PPO	$277.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$399.60
Rate for Payer: Superior Health Plan EPO	$75.48

CHWR XR ARTHROGRAM INJECTION SHOULDER RT

Facility

$555.00

Service Code	HCPCS 23350
Hospital Charge Code	4907700
Hospital Revenue Code	361
Rate for Payer: Cash Price	$377.40

CHWR XR ARTHROGRAM INJECTION WRIST RIGHT

Facility

$430.00

Service Code	HCPCS 25246
Hospital Charge Code	4907745
Hospital Revenue Code	361
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$38.70
Rate for Payer: BCBS of TX Blue Advantage	$129.00
Rate for Payer: BCBS of TX Blue Essentials	$154.80
Rate for Payer: BCBS of TX PPO	$172.00
Rate for Payer: Cash Price	$292.40
Rate for Payer: Cash Price	$292.40
Rate for Payer: Cigna Medicaid	$309.60
Rate for Payer: Molina CHIP/Medicaid	$309.60
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	$309.60
Rate for Payer: Scott and White EPO/PPO	$215.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$309.60
Rate for Payer: Superior Health Plan EPO	$58.48

CHWR XR ARTHROGRAM INJECTION WRIST RIGHT

Facility

$430.00

Service Code	HCPCS 25246
Hospital Charge Code	4907745
Hospital Revenue Code	361
Rate for Payer: Cash Price	$292.40

CHWR XR FL GUIDE BX/ASP/INJ

Facility

$559.00

Service Code	HCPCS 77002
Hospital Charge Code	4906010
Hospital Revenue Code	320
Min. Negotiated Rate	$50.31
Max. Negotiated Rate	$402.48
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	$380.12
Rate for Payer: Cash Price	$380.12
Rate for Payer: Cigna Medicaid	$402.48
Rate for Payer: Molina CHIP/Medicaid	$402.48
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: Parkland Medicaid	$402.48
Rate for Payer: Scott and White EPO/PPO	$143.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$402.48
Rate for Payer: Superior Health Plan EPO	$76.02

CHWR XR FL GUIDE BX/ASP/INJ

Facility

$559.00

Service Code	HCPCS 77002
Hospital Charge Code	4906010
Hospital Revenue Code	320
Rate for Payer: Cash Price	$380.12

CHWR XR FL GUIDE GI TUBE

Facility

$638.00

Service Code	HCPCS 74340
Hospital Charge Code	4904340
Hospital Revenue Code	320
Rate for Payer: Cash Price	$433.84

CHWR XR FL GUIDE GI TUBE

Facility

$638.00

Service Code	HCPCS 74340
Hospital Charge Code	4904340
Hospital Revenue Code	320
Min. Negotiated Rate	$45.79
Max. Negotiated Rate	$459.36
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	$54.95
Rate for Payer: BCBS of TX PPO	$61.33
Rate for Payer: Cash Price	$433.84
Rate for Payer: Cash Price	$433.84
Rate for Payer: Cigna Medicaid	$459.36
Rate for Payer: Molina CHIP/Medicaid	$459.36
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: Parkland Medicaid	$459.36
Rate for Payer: Scott and White EPO/PPO	$319.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$459.36
Rate for Payer: Superior Health Plan EPO	$86.77

CHWR XR FLUORO GUID FOR SPINAL INJECTION

Facility

$1,020.00

Service Code	HCPCS 77003
Hospital Charge Code	4906011
Hospital Revenue Code	320
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$734.40
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	$693.60
Rate for Payer: Cash Price	$693.60
Rate for Payer: Cigna Medicaid	$734.40
Rate for Payer: Molina CHIP/Medicaid	$734.40
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: Parkland Medicaid	$734.40
Rate for Payer: Scott and White EPO/PPO	$130.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$734.40
Rate for Payer: Superior Health Plan EPO	$138.72

CHWR XR FLUORO GUID FOR SPINAL INJECTION

Facility

$1,020.00

Service Code	HCPCS 77003
Hospital Charge Code	4906011
Hospital Revenue Code	320
Rate for Payer: Cash Price	$693.60

CHWR XR GUIDE PERC DRAIN ABSCESS W/CATH

Facility

$3,174.00

Service Code	HCPCS 75989
Hospital Charge Code	4905990
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,158.32

CHWR XR GUIDE PERC DRAIN ABSCESS W/CATH

Facility

$3,174.00

Service Code	HCPCS 75989
Hospital Charge Code	4905990
Hospital Revenue Code	320
Min. Negotiated Rate	$105.25
Max. Negotiated Rate	$2,285.28
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	$2,158.32
Rate for Payer: Cash Price	$2,158.32
Rate for Payer: Cigna Medicaid	$2,285.28
Rate for Payer: Molina CHIP/Medicaid	$2,285.28
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: Parkland Medicaid	$2,285.28
Rate for Payer: Scott and White EPO/PPO	$137.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,285.28
Rate for Payer: Superior Health Plan EPO	$431.66

CHWR XR INJ BLADDER CYSTO

Facility

$442.00

Service Code	HCPCS 51600
Hospital Charge Code	4907615
Hospital Revenue Code	361
Rate for Payer: Cash Price	$300.56

CHWR XR INJ BLADDER CYSTO

Facility

$442.00

Service Code	HCPCS 51600
Hospital Charge Code	4907615
Hospital Revenue Code	361
Min. Negotiated Rate	$39.78
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$39.78
Rate for Payer: BCBS of TX Blue Advantage	$132.60
Rate for Payer: BCBS of TX Blue Essentials	$159.12
Rate for Payer: BCBS of TX PPO	$176.80
Rate for Payer: Cash Price	$300.56
Rate for Payer: Cash Price	$300.56
Rate for Payer: Cigna Medicaid	$318.24
Rate for Payer: Molina CHIP/Medicaid	$318.24
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	$318.24
Rate for Payer: Scott and White EPO/PPO	$221.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$318.24
Rate for Payer: Superior Health Plan EPO	$60.11

CHWR XR INJ BLADDER RETRO

Facility

$582.00

Service Code	HCPCS 51610
Hospital Charge Code	4907620
Hospital Revenue Code	361
Min. Negotiated Rate	$52.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$52.38
Rate for Payer: BCBS of TX Blue Advantage	$174.60
Rate for Payer: BCBS of TX Blue Essentials	$209.52
Rate for Payer: BCBS of TX PPO	$232.80
Rate for Payer: Cash Price	$395.76
Rate for Payer: Cash Price	$395.76
Rate for Payer: Cigna Medicaid	$419.04
Rate for Payer: Molina CHIP/Medicaid	$419.04
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	$419.04
Rate for Payer: Scott and White EPO/PPO	$291.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$419.04
Rate for Payer: Superior Health Plan EPO	$79.15

CHWR XR INJ BLADDER RETRO

Facility

$582.00

Service Code	HCPCS 51610
Hospital Charge Code	4907620
Hospital Revenue Code	361
Rate for Payer: Cash Price	$395.76

CHWR XR INJ SI JT ARTHROGRAM

Facility

$2,500.00

Service Code	HCPCS 27096
Hospital Charge Code	4907096
Hospital Revenue Code	360
Min. Negotiated Rate	$143.24
Max. Negotiated Rate	$10,000.00
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: 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	$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	$1,800.00
Rate for Payer: Scott and White EPO/PPO	$1,250.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,800.00
Rate for Payer: Superior Health Plan EPO	$340.00

CHWR XR INJ SI JT ARTHROGRAM

Facility

$2,500.00

Service Code	HCPCS 27096
Hospital Charge Code	4907096
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,700.00

CHWR XR INJ SINUS TRACT DX

Facility

$354.00

Service Code	HCPCS 20501
Hospital Charge Code	4907705
Hospital Revenue Code	361
Min. Negotiated Rate	$31.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$31.86
Rate for Payer: BCBS of TX Blue Advantage	$106.20
Rate for Payer: BCBS of TX Blue Essentials	$127.44
Rate for Payer: BCBS of TX PPO	$141.60
Rate for Payer: Cash Price	$240.72
Rate for Payer: Cash Price	$240.72
Rate for Payer: Cigna Medicaid	$254.88
Rate for Payer: Molina CHIP/Medicaid	$254.88
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	$254.88
Rate for Payer: Scott and White EPO/PPO	$177.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$254.88
Rate for Payer: Superior Health Plan EPO	$48.14

CHWR XR INJ SINUS TRACT DX

Facility

$354.00

Service Code	HCPCS 20501
Hospital Charge Code	4907705
Hospital Revenue Code	361
Rate for Payer: Cash Price	$240.72

CHWR YUEH NEEDLE

Facility

$134.49

Hospital Charge Code	8178171
Hospital Revenue Code	272
Rate for Payer: Cash Price	$91.45

CHWR YUEH NEEDLE

Facility

$134.49

Hospital Charge Code	8178171
Hospital Revenue Code	272
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$96.83
Rate for Payer: Amerigroup CHIP/Medicaid	$12.10
Rate for Payer: BCBS of TX Blue Advantage	$40.35
Rate for Payer: BCBS of TX Blue Essentials	$48.42
Rate for Payer: BCBS of TX PPO	$53.80
Rate for Payer: Cash Price	$91.45
Rate for Payer: Cigna Medicaid	$96.83
Rate for Payer: Molina CHIP/Medicaid	$96.83
Rate for Payer: Multiplan Auto	$87.42
Rate for Payer: Multiplan Commercial	$87.42
Rate for Payer: Multiplan Workers Comp	$87.42
Rate for Payer: Parkland Medicaid	$96.83
Rate for Payer: Scott and White EPO/PPO	$67.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.83
Rate for Payer: Superior Health Plan EPO	$18.29

Know your out-of-pocket cost for care.

All Charges