White Rock Medical Center

All Charges

Charge

Type

Setting

Price

702459

Facility

$728.92

Service Code	HCPCS C1769
Hospital Charge Code	994040
Hospital Revenue Code	272
Rate for Payer: Cash Price	$495.67

702459

Facility

$1,405.58

Service Code	HCPCS C1769
Hospital Charge Code	991172
Hospital Revenue Code	272
Min. Negotiated Rate	$126.50
Max. Negotiated Rate	$1,012.02
Rate for Payer: Amerigroup CHIP/Medicaid	$126.50
Rate for Payer: BCBS of TX Blue Advantage	$421.67
Rate for Payer: BCBS of TX Blue Essentials	$506.01
Rate for Payer: BCBS of TX PPO	$562.23
Rate for Payer: Cash Price	$955.79
Rate for Payer: Cigna Medicaid	$1,012.02
Rate for Payer: Molina CHIP/Medicaid	$1,012.02
Rate for Payer: Multiplan Auto	$913.63
Rate for Payer: Multiplan Commercial	$913.63
Rate for Payer: Multiplan Workers Comp	$913.63
Rate for Payer: Parkland Medicaid	$1,012.02
Rate for Payer: Scott and White EPO/PPO	$702.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,012.02
Rate for Payer: Superior Health Plan EPO	$191.16

702459

Facility

$1,405.58

Service Code	HCPCS C1769
Hospital Charge Code	991172
Hospital Revenue Code	272
Rate for Payer: Cash Price	$955.79

7030-6525

Facility

$284.35

Service Code	HCPCS C1713
Hospital Charge Code	993999
Hospital Revenue Code	278
Min. Negotiated Rate	$25.59
Max. Negotiated Rate	$204.73
Rate for Payer: Amerigroup CHIP/Medicaid	$25.59
Rate for Payer: BCBS of TX Blue Advantage	$85.31
Rate for Payer: BCBS of TX Blue Essentials	$102.37
Rate for Payer: BCBS of TX PPO	$113.74
Rate for Payer: Cash Price	$193.36
Rate for Payer: Cigna Medicaid	$204.73
Rate for Payer: Molina CHIP/Medicaid	$204.73
Rate for Payer: Multiplan Auto	$142.18
Rate for Payer: Multiplan Commercial	$142.18
Rate for Payer: Multiplan Workers Comp	$142.18
Rate for Payer: Parkland Medicaid	$204.73
Rate for Payer: Scott and White EPO/PPO	$142.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$204.73
Rate for Payer: Superior Health Plan EPO	$38.67

7030-6525

Facility

$284.35

Service Code	HCPCS C1713
Hospital Charge Code	993999
Hospital Revenue Code	278
Min. Negotiated Rate	$71.09
Max. Negotiated Rate	$142.18
Rate for Payer: Cash Price	$193.36
Rate for Payer: Cigna Commercial	$71.09
Rate for Payer: Multiplan Auto	$142.18
Rate for Payer: Multiplan Commercial	$142.18
Rate for Payer: Multiplan Workers Comp	$142.18
Rate for Payer: Scott and White EPO/PPO	$142.18

705235

Facility

$801.20

Service Code	HCPCS C1769
Hospital Charge Code	992005
Hospital Revenue Code	278
Min. Negotiated Rate	$200.30
Max. Negotiated Rate	$400.60
Rate for Payer: Cash Price	$544.82
Rate for Payer: Cigna Commercial	$200.30
Rate for Payer: Multiplan Auto	$400.60
Rate for Payer: Multiplan Commercial	$400.60
Rate for Payer: Multiplan Workers Comp	$400.60
Rate for Payer: Scott and White EPO/PPO	$400.60

705235

Facility

$801.20

Service Code	HCPCS C1769
Hospital Charge Code	992005
Hospital Revenue Code	278
Min. Negotiated Rate	$72.11
Max. Negotiated Rate	$576.86
Rate for Payer: Amerigroup CHIP/Medicaid	$72.11
Rate for Payer: BCBS of TX Blue Advantage	$240.36
Rate for Payer: BCBS of TX Blue Essentials	$288.43
Rate for Payer: BCBS of TX PPO	$320.48
Rate for Payer: Cash Price	$544.82
Rate for Payer: Cigna Medicaid	$576.86
Rate for Payer: Molina CHIP/Medicaid	$576.86
Rate for Payer: Multiplan Auto	$400.60
Rate for Payer: Multiplan Commercial	$400.60
Rate for Payer: Multiplan Workers Comp	$400.60
Rate for Payer: Parkland Medicaid	$576.86
Rate for Payer: Scott and White EPO/PPO	$400.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$576.86
Rate for Payer: Superior Health Plan EPO	$108.96

707091202

Facility

$222.90

Service Code	HCPCS C1769
Hospital Charge Code	990960
Hospital Revenue Code	272
Rate for Payer: Cash Price	$151.57

707091202

Facility

$222.90

Service Code	HCPCS C1769
Hospital Charge Code	990960
Hospital Revenue Code	272
Min. Negotiated Rate	$20.06
Max. Negotiated Rate	$160.49
Rate for Payer: Amerigroup CHIP/Medicaid	$20.06
Rate for Payer: BCBS of TX Blue Advantage	$66.87
Rate for Payer: BCBS of TX Blue Essentials	$80.24
Rate for Payer: BCBS of TX PPO	$89.16
Rate for Payer: Cash Price	$151.57
Rate for Payer: Cigna Medicaid	$160.49
Rate for Payer: Molina CHIP/Medicaid	$160.49
Rate for Payer: Multiplan Auto	$144.88
Rate for Payer: Multiplan Commercial	$144.88
Rate for Payer: Multiplan Workers Comp	$144.88
Rate for Payer: Parkland Medicaid	$160.49
Rate for Payer: Scott and White EPO/PPO	$111.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$160.49
Rate for Payer: Superior Health Plan EPO	$30.31

707092502

Facility

$222.89

Service Code	HCPCS C1769
Hospital Charge Code	991056
Hospital Revenue Code	272
Min. Negotiated Rate	$20.06
Max. Negotiated Rate	$160.48
Rate for Payer: Amerigroup CHIP/Medicaid	$20.06
Rate for Payer: BCBS of TX Blue Advantage	$66.87
Rate for Payer: BCBS of TX Blue Essentials	$80.24
Rate for Payer: BCBS of TX PPO	$89.16
Rate for Payer: Cash Price	$151.57
Rate for Payer: Cigna Medicaid	$160.48
Rate for Payer: Molina CHIP/Medicaid	$160.48
Rate for Payer: Multiplan Auto	$144.88
Rate for Payer: Multiplan Commercial	$144.88
Rate for Payer: Multiplan Workers Comp	$144.88
Rate for Payer: Parkland Medicaid	$160.48
Rate for Payer: Scott and White EPO/PPO	$111.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$160.48
Rate for Payer: Superior Health Plan EPO	$30.31

707092502

Facility

$222.89

Service Code	HCPCS C1769
Hospital Charge Code	991056
Hospital Revenue Code	272
Rate for Payer: Cash Price	$151.57

71210002 71210003

Facility

$744.10

Service Code	HCPCS C1713
Hospital Charge Code	994082
Hospital Revenue Code	278
Min. Negotiated Rate	$66.97
Max. Negotiated Rate	$535.75
Rate for Payer: Amerigroup CHIP/Medicaid	$66.97
Rate for Payer: BCBS of TX Blue Advantage	$223.23
Rate for Payer: BCBS of TX Blue Essentials	$267.88
Rate for Payer: BCBS of TX PPO	$297.64
Rate for Payer: Cash Price	$505.99
Rate for Payer: Cigna Medicaid	$535.75
Rate for Payer: Molina CHIP/Medicaid	$535.75
Rate for Payer: Multiplan Auto	$372.05
Rate for Payer: Multiplan Commercial	$372.05
Rate for Payer: Multiplan Workers Comp	$372.05
Rate for Payer: Parkland Medicaid	$535.75
Rate for Payer: Scott and White EPO/PPO	$372.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$535.75
Rate for Payer: Superior Health Plan EPO	$101.20

71210002 71210003

Facility

$744.10

Service Code	HCPCS C1713
Hospital Charge Code	994082
Hospital Revenue Code	278
Min. Negotiated Rate	$186.03
Max. Negotiated Rate	$372.05
Rate for Payer: Cash Price	$505.99
Rate for Payer: Cigna Commercial	$186.03
Rate for Payer: Multiplan Auto	$372.05
Rate for Payer: Multiplan Commercial	$372.05
Rate for Payer: Multiplan Workers Comp	$372.05
Rate for Payer: Scott and White EPO/PPO	$372.05

7122Q/58 DURATA TACHY MRI LEADS_UMRI_PR

Facility

$17,352.88

Hospital Charge Code	993858
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11,799.96

7122Q/58 DURATA TACHY MRI LEADS_UMRI_PR

Facility

$17,352.88

Hospital Charge Code	993858
Hospital Revenue Code	272
Min. Negotiated Rate	$1,561.76
Max. Negotiated Rate	$12,494.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,561.76
Rate for Payer: BCBS of TX Blue Advantage	$5,205.86
Rate for Payer: BCBS of TX Blue Essentials	$6,247.04
Rate for Payer: BCBS of TX PPO	$6,941.15
Rate for Payer: Cash Price	$11,799.96
Rate for Payer: Cigna Medicaid	$12,494.07
Rate for Payer: Molina CHIP/Medicaid	$12,494.07
Rate for Payer: Multiplan Auto	$11,279.37
Rate for Payer: Multiplan Commercial	$11,279.37
Rate for Payer: Multiplan Workers Comp	$11,279.37
Rate for Payer: Parkland Medicaid	$12,494.07
Rate for Payer: Scott and White EPO/PPO	$8,676.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,494.07
Rate for Payer: Superior Health Plan EPO	$2,359.99

71250 CT SCAN CHEST WITHOUT CONTRAST

Facility

$4,075.00

Service Code	HCPCS 71250
Hospital Charge Code	3800091
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$2,934.00
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	$2,771.00
Rate for Payer: Cash Price	$2,771.00
Rate for Payer: Cash Price	$2,771.00
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$2,934.00
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	$2,934.00
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$2,648.75
Rate for Payer: Multiplan Commercial	$2,648.75
Rate for Payer: Multiplan Workers Comp	$2,648.75
Rate for Payer: Parkland Medicaid	$2,934.00
Rate for Payer: Scott and White EPO/PPO	$2,037.50
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,934.00
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

71250 CT SCAN CHEST WITHOUT CONTRAST

Facility

$4,075.00

Service Code	HCPCS 71250
Hospital Charge Code	3800091
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,771.00

71270 CT SCAN CHEST WITH+WITHOUT CONTR

Facility

$6,165.00

Service Code	HCPCS 71270
Hospital Charge Code	3800174
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$4,438.80
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	$4,192.20
Rate for Payer: Cash Price	$4,192.20
Rate for Payer: Cash Price	$4,192.20
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$4,438.80
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	$4,438.80
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$4,007.25
Rate for Payer: Multiplan Commercial	$4,007.25
Rate for Payer: Multiplan Workers Comp	$4,007.25
Rate for Payer: Parkland Medicaid	$4,438.80
Rate for Payer: Scott and White EPO/PPO	$3,082.50
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,438.80
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

71270 CT SCAN CHEST WITH+WITHOUT CONTR

Facility

$6,165.00

Service Code	HCPCS 71270
Hospital Charge Code	3800174
Hospital Revenue Code	352
Rate for Payer: Cash Price	$4,192.20

71271685

Facility

$2,469.88

Service Code	HCPCS C1734
Hospital Charge Code	994084
Hospital Revenue Code	278
Min. Negotiated Rate	$617.47
Max. Negotiated Rate	$1,234.94
Rate for Payer: Cash Price	$1,679.52
Rate for Payer: Cigna Commercial	$617.47
Rate for Payer: Multiplan Auto	$1,234.94
Rate for Payer: Multiplan Commercial	$1,234.94
Rate for Payer: Multiplan Workers Comp	$1,234.94
Rate for Payer: Scott and White EPO/PPO	$1,234.94

71271685

Facility

$2,469.88

Service Code	HCPCS C1734
Hospital Charge Code	994084
Hospital Revenue Code	278
Min. Negotiated Rate	$222.29
Max. Negotiated Rate	$1,778.31
Rate for Payer: Amerigroup CHIP/Medicaid	$222.29
Rate for Payer: BCBS of TX Blue Advantage	$740.96
Rate for Payer: BCBS of TX Blue Essentials	$889.16
Rate for Payer: BCBS of TX PPO	$987.95
Rate for Payer: Cash Price	$1,679.52
Rate for Payer: Cigna Medicaid	$1,778.31
Rate for Payer: Molina CHIP/Medicaid	$1,778.31
Rate for Payer: Multiplan Auto	$1,234.94
Rate for Payer: Multiplan Commercial	$1,234.94
Rate for Payer: Multiplan Workers Comp	$1,234.94
Rate for Payer: Parkland Medicaid	$1,778.31
Rate for Payer: Scott and White EPO/PPO	$1,234.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,778.31
Rate for Payer: Superior Health Plan EPO	$335.90

71275 CT ANGIOGRAPHY CHEST

Facility

$7,351.00

Service Code	HCPCS 71275
Hospital Charge Code	3801636
Hospital Revenue Code	350
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$5,292.72
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	$4,998.68
Rate for Payer: Cash Price	$4,998.68
Rate for Payer: Cash Price	$4,998.68
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$5,292.72
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	$5,292.72
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$4,778.15
Rate for Payer: Multiplan Commercial	$4,778.15
Rate for Payer: Multiplan Workers Comp	$4,778.15
Rate for Payer: Parkland Medicaid	$5,292.72
Rate for Payer: Scott and White EPO/PPO	$3,675.50
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,292.72
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

71275 CT ANGIOGRAPHY CHEST

Facility

$7,351.00

Service Code	HCPCS 71275
Hospital Charge Code	3801636
Hospital Revenue Code	350
Rate for Payer: Cash Price	$4,998.68

71302803

Facility

$12,183.73

Service Code	HCPCS C1776
Hospital Charge Code	994091
Hospital Revenue Code	278
Min. Negotiated Rate	$1,096.54
Max. Negotiated Rate	$8,772.29
Rate for Payer: Amerigroup CHIP/Medicaid	$1,096.54
Rate for Payer: BCBS of TX Blue Advantage	$3,655.12
Rate for Payer: BCBS of TX Blue Essentials	$4,386.14
Rate for Payer: BCBS of TX PPO	$4,873.49
Rate for Payer: Cash Price	$8,284.94
Rate for Payer: Cigna Medicaid	$8,772.29
Rate for Payer: Molina CHIP/Medicaid	$8,772.29
Rate for Payer: Multiplan Auto	$6,091.86
Rate for Payer: Multiplan Commercial	$6,091.86
Rate for Payer: Multiplan Workers Comp	$6,091.86
Rate for Payer: Parkland Medicaid	$8,772.29
Rate for Payer: Scott and White EPO/PPO	$6,091.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,772.29
Rate for Payer: Superior Health Plan EPO	$1,656.99

71302803

Facility

$6,810.00

Service Code	HCPCS C1776
Hospital Charge Code	992170
Hospital Revenue Code	278
Min. Negotiated Rate	$1,702.50
Max. Negotiated Rate	$3,405.00
Rate for Payer: Cash Price	$4,630.80
Rate for Payer: Cigna Commercial	$1,702.50
Rate for Payer: Multiplan Auto	$3,405.00
Rate for Payer: Multiplan Commercial	$3,405.00
Rate for Payer: Multiplan Workers Comp	$3,405.00
Rate for Payer: Scott and White EPO/PPO	$3,405.00

Know your out-of-pocket cost for care.

All Charges