White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CT Spine Lumbar w/ + w/o Contrast

Facility

$6,928.00

Service Code	HCPCS 72133
Hospital Charge Code	3800919
Hospital Revenue Code	352
Rate for Payer: Cash Price	$4,711.04

CT Spine Thoracic w/ Contrast

Facility

$3,350.00

Service Code	HCPCS 72129
Hospital Charge Code	3800877
Hospital Revenue Code	352
Min. Negotiated Rate	$174.75
Max. Negotiated Rate	$2,412.00
Rate for Payer: Amerigroup CHIP/Medicaid	$174.75
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	$2,278.00
Rate for Payer: Cash Price	$2,278.00
Rate for Payer: Cash Price	$2,278.00
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$2,412.00
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	$2,412.00
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$2,177.50
Rate for Payer: Multiplan Commercial	$2,177.50
Rate for Payer: Multiplan Workers Comp	$2,177.50
Rate for Payer: Parkland Medicaid	$2,412.00
Rate for Payer: Scott and White EPO/PPO	$1,675.00
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,412.00
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

CT Spine Thoracic w/ Contrast

Facility

$3,350.00

Service Code	HCPCS 72129
Hospital Charge Code	3800877
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,278.00

CT Spine Thoracic w/o Contrast

Facility

$2,402.00

Service Code	HCPCS 72128
Hospital Charge Code	3800869
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$1,729.44
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	$1,633.36
Rate for Payer: Cash Price	$1,633.36
Rate for Payer: Cash Price	$1,633.36
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$1,729.44
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	$1,729.44
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$1,561.30
Rate for Payer: Multiplan Commercial	$1,561.30
Rate for Payer: Multiplan Workers Comp	$1,561.30
Rate for Payer: Parkland Medicaid	$1,729.44
Rate for Payer: Scott and White EPO/PPO	$1,201.00
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,729.44
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

CT Spine Thoracic w/o Contrast

Facility

$2,402.00

Service Code	HCPCS 72128
Hospital Charge Code	3800869
Hospital Revenue Code	352
Rate for Payer: Cash Price	$1,633.36

CT Thoracentesis w/ CT Guidance Right

Facility

$1,959.00

Service Code	HCPCS 32555
Hospital Charge Code	3800000
Hospital Revenue Code	361
Min. Negotiated Rate	$223.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$223.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$630.16
Rate for Payer: Amerigroup Medicare	$630.16
Rate for Payer: BCBS of TX Blue Advantage	$1,052.95
Rate for Payer: BCBS of TX Blue Essentials	$1,261.02
Rate for Payer: BCBS of TX Medicare	$630.16
Rate for Payer: BCBS of TX PPO	$1,588.89
Rate for Payer: Cash Price	$1,332.12
Rate for Payer: Cash Price	$1,332.12
Rate for Payer: Cash Price	$1,332.12
Rate for Payer: Cigna Commercial	$1,332.05
Rate for Payer: Cigna Medicaid	$1,410.48
Rate for Payer: Cigna Medicare	$630.16
Rate for Payer: Employer Direct Commercial	$630.16
Rate for Payer: Humana Medicare/TRICARE	$630.16
Rate for Payer: Molina CHIP/Medicaid	$1,410.48
Rate for Payer: Molina Dual Medicare/Medicaid	$630.16
Rate for Payer: Molina Medicare	$630.16
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: Parkland Medicaid	$1,410.48
Rate for Payer: Scott and White EPO/PPO	$1,165.80
Rate for Payer: Scott and White Medicare	$630.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,410.48
Rate for Payer: Superior Health Plan EPO	$630.16
Rate for Payer: Superior Health Plan Medicare	$630.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$630.16
Rate for Payer: Universal American Medicare	$630.16
Rate for Payer: Wellcare Medicare	$630.16
Rate for Payer: Wellmed Medicare	$630.16

CT Thoracentesis w/ CT Guidance Right

Facility

$1,959.00

Service Code	HCPCS 32555
Hospital Charge Code	3800000
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,332.12

CT Thoracic Spine with & w/out contrast

Facility

$712.08

Service Code	HCPCS 72130
Hospital Charge Code	994145
Hospital Revenue Code	352
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$512.70
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	$484.21
Rate for Payer: Cash Price	$484.21
Rate for Payer: Cash Price	$484.21
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$512.70
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	$512.70
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$462.85
Rate for Payer: Multiplan Commercial	$462.85
Rate for Payer: Multiplan Workers Comp	$462.85
Rate for Payer: Parkland Medicaid	$512.70
Rate for Payer: Scott and White EPO/PPO	$356.04
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$512.70
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

CT Thoracic Spine with & w/out contrast

Facility

$712.08

Service Code	HCPCS 72130
Hospital Charge Code	994145
Hospital Revenue Code	352
Rate for Payer: Cash Price	$484.21

CT thorax, low dose for lung cancer screening, without contrast materia

Facility

$425.36

Service Code	HCPCS 71271
Hospital Charge Code	994131
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$306.26
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	$170.66
Rate for Payer: BCBS of TX Blue Essentials	$204.79
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$228.58
Rate for Payer: Cash Price	$289.24
Rate for Payer: Cash Price	$289.24
Rate for Payer: Cash Price	$289.24
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$306.26
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	$306.26
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$276.48
Rate for Payer: Multiplan Commercial	$276.48
Rate for Payer: Multiplan Workers Comp	$276.48
Rate for Payer: Parkland Medicaid	$306.26
Rate for Payer: Scott and White EPO/PPO	$212.68
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$306.26
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

CT thorax, low dose for lung cancer screening, without contrast materia

Facility

$425.36

Service Code	HCPCS 71271
Hospital Charge Code	994131
Hospital Revenue Code	352
Rate for Payer: Cash Price	$289.24

CT Thorax w/ Contrast

Facility

$5,138.00

Service Code	HCPCS 71260
Hospital Charge Code	3800240
Hospital Revenue Code	352
Min. Negotiated Rate	$171.74
Max. Negotiated Rate	$3,699.36
Rate for Payer: Amerigroup CHIP/Medicaid	$171.74
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	$3,493.84
Rate for Payer: Cash Price	$3,493.84
Rate for Payer: Cash Price	$3,493.84
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$3,699.36
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	$3,699.36
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$3,339.70
Rate for Payer: Multiplan Commercial	$3,339.70
Rate for Payer: Multiplan Workers Comp	$3,339.70
Rate for Payer: Parkland Medicaid	$3,699.36
Rate for Payer: Scott and White EPO/PPO	$2,569.00
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,699.36
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

CT Thorax w/ Contrast

Facility

$5,138.00

Service Code	HCPCS 71260
Hospital Charge Code	3800240
Hospital Revenue Code	352
Rate for Payer: Cash Price	$3,493.84

CT Tibia Fibula w/ Contrast Left

Facility

$3,797.00

Service Code	HCPCS 73701 LT
Hospital Charge Code	3800968
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,581.96

CT Tibia Fibula w/ Contrast Left

Facility

$3,797.00

Service Code	HCPCS 73701 LT
Hospital Charge Code	3800968
Hospital Revenue Code	352
Min. Negotiated Rate	$171.41
Max. Negotiated Rate	$2,733.84
Rate for Payer: Amerigroup CHIP/Medicaid	$171.41
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 PPO	$402.71
Rate for Payer: Cash Price	$2,581.96
Rate for Payer: Cash Price	$2,581.96
Rate for Payer: Cash Price	$2,581.96
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$2,733.84
Rate for Payer: Molina CHIP/Medicaid	$2,733.84
Rate for Payer: Multiplan Auto	$2,468.05
Rate for Payer: Multiplan Commercial	$2,468.05
Rate for Payer: Multiplan Workers Comp	$2,468.05
Rate for Payer: Parkland Medicaid	$2,733.84
Rate for Payer: Scott and White EPO/PPO	$1,898.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,733.84
Rate for Payer: Superior Health Plan EPO	$516.39

CT Tibia Fibula w/ Contrast Right

Facility

$3,797.00

Service Code	HCPCS 73701 RT
Hospital Charge Code	3801875
Hospital Revenue Code	352
Min. Negotiated Rate	$171.41
Max. Negotiated Rate	$2,733.84
Rate for Payer: Amerigroup CHIP/Medicaid	$171.41
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 PPO	$402.71
Rate for Payer: Cash Price	$2,581.96
Rate for Payer: Cash Price	$2,581.96
Rate for Payer: Cash Price	$2,581.96
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$2,733.84
Rate for Payer: Molina CHIP/Medicaid	$2,733.84
Rate for Payer: Multiplan Auto	$2,468.05
Rate for Payer: Multiplan Commercial	$2,468.05
Rate for Payer: Multiplan Workers Comp	$2,468.05
Rate for Payer: Parkland Medicaid	$2,733.84
Rate for Payer: Scott and White EPO/PPO	$1,898.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,733.84
Rate for Payer: Superior Health Plan EPO	$516.39

CT Tibia Fibula w/ Contrast Right

Facility

$3,797.00

Service Code	HCPCS 73701 RT
Hospital Charge Code	3801875
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,581.96

CT Tibia Fibula w/o Contrast Left

Facility

$3,266.00

Service Code	HCPCS 73700 LT
Hospital Charge Code	3800141
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,220.88

CT Tibia Fibula w/o Contrast Left

Facility

$3,266.00

Service Code	HCPCS 73700 LT
Hospital Charge Code	3800141
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$2,351.52
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
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 PPO	$247.70
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$2,351.52
Rate for Payer: Molina CHIP/Medicaid	$2,351.52
Rate for Payer: Multiplan Auto	$2,122.90
Rate for Payer: Multiplan Commercial	$2,122.90
Rate for Payer: Multiplan Workers Comp	$2,122.90
Rate for Payer: Parkland Medicaid	$2,351.52
Rate for Payer: Scott and White EPO/PPO	$1,633.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,351.52
Rate for Payer: Superior Health Plan EPO	$444.18

CT Tibia Fibula w/o Contrast Right

Facility

$3,266.00

Service Code	HCPCS 73700 RT
Hospital Charge Code	3801867
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$2,351.52
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
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 PPO	$247.70
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$2,351.52
Rate for Payer: Molina CHIP/Medicaid	$2,351.52
Rate for Payer: Multiplan Auto	$2,122.90
Rate for Payer: Multiplan Commercial	$2,122.90
Rate for Payer: Multiplan Workers Comp	$2,122.90
Rate for Payer: Parkland Medicaid	$2,351.52
Rate for Payer: Scott and White EPO/PPO	$1,633.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,351.52
Rate for Payer: Superior Health Plan EPO	$444.18

CT Tibia Fibula w/o Contrast Right

Facility

$3,266.00

Service Code	HCPCS 73700 RT
Hospital Charge Code	3801867
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,220.88

CUFF, BLD PRES.REG ADULT

Facility

$6.28

Hospital Charge Code	993041
Hospital Revenue Code	270
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$4.52
Rate for Payer: Amerigroup CHIP/Medicaid	$0.57
Rate for Payer: BCBS of TX Blue Advantage	$1.88
Rate for Payer: BCBS of TX Blue Essentials	$2.26
Rate for Payer: BCBS of TX PPO	$2.51
Rate for Payer: Cash Price	$4.27
Rate for Payer: Cigna Medicaid	$4.52
Rate for Payer: Molina CHIP/Medicaid	$4.52
Rate for Payer: Multiplan Auto	$4.08
Rate for Payer: Multiplan Commercial	$4.08
Rate for Payer: Multiplan Workers Comp	$4.08
Rate for Payer: Parkland Medicaid	$4.52
Rate for Payer: Scott and White EPO/PPO	$3.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.52
Rate for Payer: Superior Health Plan EPO	$0.85

CUFF, BLD PRES.REG ADULT

Facility

$6.28

Hospital Charge Code	993041
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.27

CUFF, BP, ADULT, 1 TB, HP, CS

Facility

$37.68

Hospital Charge Code	993085
Hospital Revenue Code	270
Rate for Payer: Cash Price	$25.62

CUFF, BP, ADULT, 1 TB, HP, CS

Facility

$37.68

Hospital Charge Code	993085
Hospital Revenue Code	270
Min. Negotiated Rate	$3.39
Max. Negotiated Rate	$27.13
Rate for Payer: Amerigroup CHIP/Medicaid	$3.39
Rate for Payer: BCBS of TX Blue Advantage	$11.30
Rate for Payer: BCBS of TX Blue Essentials	$13.56
Rate for Payer: BCBS of TX PPO	$15.07
Rate for Payer: Cash Price	$25.62
Rate for Payer: Cigna Medicaid	$27.13
Rate for Payer: Molina CHIP/Medicaid	$27.13
Rate for Payer: Multiplan Auto	$24.49
Rate for Payer: Multiplan Commercial	$24.49
Rate for Payer: Multiplan Workers Comp	$24.49
Rate for Payer: Parkland Medicaid	$27.13
Rate for Payer: Scott and White EPO/PPO	$18.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.13
Rate for Payer: Superior Health Plan EPO	$5.12

Know your out-of-pocket cost for care.

All Charges