White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Arthrogram Hip Left BCE

Facility

$558.00

Service Code	CPT 73525 LT,FY
Hospital Charge Code	3170063
Hospital Revenue Code	322
Rate for Payer: Cash Price	$491.04

XR Arthrogram Hip Right

Facility

$558.00

Service Code	CPT 73525 RT,FY
Hospital Charge Code	3170062
Hospital Revenue Code	322
Min. Negotiated Rate	$75.89
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$123.48
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$131.31
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$131.31
Rate for Payer: Molina CHIP/Medicaid	$131.31
Rate for Payer: Multiplan Auto	$362.70
Rate for Payer: Multiplan Commercial	$362.70
Rate for Payer: Multiplan Workers Comp	$362.70
Rate for Payer: Parkland Medicaid	$131.31
Rate for Payer: Scott and White EPO/PPO	$279.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.31
Rate for Payer: Superior Health Plan EPO	$75.89

XR Arthrogram Hip Right BCE

Facility

$558.00

Service Code	CPT 73525 RT,FY
Hospital Charge Code	3170062
Hospital Revenue Code	322
Rate for Payer: Cash Price	$491.04

XR Arthrogram Hip Right BCE

Facility

$558.00

Service Code	CPT 73525 RT,FY
Hospital Charge Code	3170062
Hospital Revenue Code	322
Min. Negotiated Rate	$75.89
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$123.48
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$131.31
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cash Price	$491.04
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$131.31
Rate for Payer: Molina CHIP/Medicaid	$131.31
Rate for Payer: Multiplan Auto	$362.70
Rate for Payer: Multiplan Commercial	$362.70
Rate for Payer: Multiplan Workers Comp	$362.70
Rate for Payer: Parkland Medicaid	$131.31
Rate for Payer: Scott and White EPO/PPO	$279.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.31
Rate for Payer: Superior Health Plan EPO	$75.89

XR Arthrogram Knee Left

Facility

$908.00

Service Code	CPT 73580 LT,FY
Hospital Charge Code	3170066
Hospital Revenue Code	322
Min. Negotiated Rate	$123.49
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$139.67
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$128.31
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$128.31
Rate for Payer: Molina CHIP/Medicaid	$128.31
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$128.31
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$128.31
Rate for Payer: Superior Health Plan EPO	$123.49

XR Arthrogram Knee Left BCE

Facility

$908.00

Service Code	CPT 73580 LT,FY
Hospital Charge Code	3170066
Hospital Revenue Code	322
Rate for Payer: Cash Price	$799.04

XR Arthrogram Knee Left BCE

Facility

$908.00

Service Code	CPT 73580 LT,FY
Hospital Charge Code	3170066
Hospital Revenue Code	322
Min. Negotiated Rate	$123.49
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$139.67
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$128.31
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$128.31
Rate for Payer: Molina CHIP/Medicaid	$128.31
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$128.31
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$128.31
Rate for Payer: Superior Health Plan EPO	$123.49

XR Arthrogram Knee Right

Facility

$908.00

Service Code	CPT 73580 RT,FY
Hospital Charge Code	3170065
Hospital Revenue Code	322
Min. Negotiated Rate	$123.49
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$139.67
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$128.31
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$128.31
Rate for Payer: Molina CHIP/Medicaid	$128.31
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$128.31
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$128.31
Rate for Payer: Superior Health Plan EPO	$123.49

XR Arthrogram Knee Right BCE

Facility

$908.00

Service Code	CPT 73580 RT,FY
Hospital Charge Code	3170065
Hospital Revenue Code	322
Rate for Payer: Cash Price	$799.04

XR Arthrogram Knee Right BCE

Facility

$908.00

Service Code	CPT 73580 RT,FY
Hospital Charge Code	3170065
Hospital Revenue Code	322
Min. Negotiated Rate	$123.49
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$139.67
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$128.31
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cash Price	$799.04
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$128.31
Rate for Payer: Molina CHIP/Medicaid	$128.31
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$128.31
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$128.31
Rate for Payer: Superior Health Plan EPO	$123.49

XR Arthrogram Shoulder Left

Facility

$681.00

Service Code	CPT 73040 LT,FY
Hospital Charge Code	3101771
Hospital Revenue Code	320
Min. Negotiated Rate	$92.62
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$122.33
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$132.31
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$132.31
Rate for Payer: Molina CHIP/Medicaid	$132.31
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Parkland Medicaid	$132.31
Rate for Payer: Scott and White EPO/PPO	$340.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.31
Rate for Payer: Superior Health Plan EPO	$92.62

XR Arthrogram Shoulder Left BCE

Facility

$681.00

Service Code	CPT 73040 LT,FY
Hospital Charge Code	3101771
Hospital Revenue Code	320
Rate for Payer: Cash Price	$599.28

XR Arthrogram Shoulder Left BCE

Facility

$681.00

Service Code	CPT 73040 LT,FY
Hospital Charge Code	3101771
Hospital Revenue Code	320
Min. Negotiated Rate	$92.62
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$122.33
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$132.31
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$132.31
Rate for Payer: Molina CHIP/Medicaid	$132.31
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Parkland Medicaid	$132.31
Rate for Payer: Scott and White EPO/PPO	$340.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.31
Rate for Payer: Superior Health Plan EPO	$92.62

XR Arthrogram Shoulder Right

Facility

$681.00

Service Code	CPT 73040 RT,FY
Hospital Charge Code	3101763
Hospital Revenue Code	320
Min. Negotiated Rate	$92.62
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$122.33
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$132.31
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$132.31
Rate for Payer: Molina CHIP/Medicaid	$132.31
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Parkland Medicaid	$132.31
Rate for Payer: Scott and White EPO/PPO	$340.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.31
Rate for Payer: Superior Health Plan EPO	$92.62

XR Arthrogram Shoulder Right BCE

Facility

$681.00

Service Code	CPT 73040 RT,FY
Hospital Charge Code	3101763
Hospital Revenue Code	320
Rate for Payer: Cash Price	$599.28

XR Arthrogram Shoulder Right BCE

Facility

$681.00

Service Code	CPT 73040 RT,FY
Hospital Charge Code	3101763
Hospital Revenue Code	320
Min. Negotiated Rate	$92.62
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$122.33
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$132.31
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cash Price	$599.28
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$132.31
Rate for Payer: Molina CHIP/Medicaid	$132.31
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Parkland Medicaid	$132.31
Rate for Payer: Scott and White EPO/PPO	$340.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.31
Rate for Payer: Superior Health Plan EPO	$92.62

XR Arthrogram Wrist Left

Facility

$896.00

Service Code	CPT 73115 LT,FY
Hospital Charge Code	3170061
Hospital Revenue Code	322
Min. Negotiated Rate	$121.86
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$127.72
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$136.33
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$136.33
Rate for Payer: Molina CHIP/Medicaid	$136.33
Rate for Payer: Multiplan Auto	$582.40
Rate for Payer: Multiplan Commercial	$582.40
Rate for Payer: Multiplan Workers Comp	$582.40
Rate for Payer: Parkland Medicaid	$136.33
Rate for Payer: Scott and White EPO/PPO	$448.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$136.33
Rate for Payer: Superior Health Plan EPO	$121.86

XR Arthrogram Wrist Left BCE

Facility

$896.00

Service Code	CPT 73115 LT,FY
Hospital Charge Code	3170061
Hospital Revenue Code	322
Rate for Payer: Cash Price	$788.48

XR Arthrogram Wrist Left BCE

Facility

$896.00

Service Code	CPT 73115 LT,FY
Hospital Charge Code	3170061
Hospital Revenue Code	322
Min. Negotiated Rate	$121.86
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$127.72
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$136.33
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$136.33
Rate for Payer: Molina CHIP/Medicaid	$136.33
Rate for Payer: Multiplan Auto	$582.40
Rate for Payer: Multiplan Commercial	$582.40
Rate for Payer: Multiplan Workers Comp	$582.40
Rate for Payer: Parkland Medicaid	$136.33
Rate for Payer: Scott and White EPO/PPO	$448.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$136.33
Rate for Payer: Superior Health Plan EPO	$121.86

XR Arthrogram Wrist Right

Facility

$896.00

Service Code	CPT 73115 RT,FY
Hospital Charge Code	3170060
Hospital Revenue Code	322
Min. Negotiated Rate	$121.86
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$127.72
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$136.33
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$136.33
Rate for Payer: Molina CHIP/Medicaid	$136.33
Rate for Payer: Multiplan Auto	$582.40
Rate for Payer: Multiplan Commercial	$582.40
Rate for Payer: Multiplan Workers Comp	$582.40
Rate for Payer: Parkland Medicaid	$136.33
Rate for Payer: Scott and White EPO/PPO	$448.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$136.33
Rate for Payer: Superior Health Plan EPO	$121.86

XR Arthrogram Wrist Right BCE

Facility

$896.00

Service Code	CPT 73115 RT,FY
Hospital Charge Code	3170060
Hospital Revenue Code	322
Min. Negotiated Rate	$121.86
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$127.72
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$136.33
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cash Price	$788.48
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$136.33
Rate for Payer: Molina CHIP/Medicaid	$136.33
Rate for Payer: Multiplan Auto	$582.40
Rate for Payer: Multiplan Commercial	$582.40
Rate for Payer: Multiplan Workers Comp	$582.40
Rate for Payer: Parkland Medicaid	$136.33
Rate for Payer: Scott and White EPO/PPO	$448.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$136.33
Rate for Payer: Superior Health Plan EPO	$121.86

XR Arthrogram Wrist Right BCE

Facility

$896.00

Service Code	CPT 73115 RT,FY
Hospital Charge Code	3170060
Hospital Revenue Code	322
Rate for Payer: Cash Price	$788.48

XR Barium Enema Complete

Facility

$779.00

Service Code	CPT 74270 FY
Hospital Charge Code	3101144
Hospital Revenue Code	320
Min. Negotiated Rate	$105.94
Max. Negotiated Rate	$506.35
Rate for Payer: Aetna Commercial	$125.79
Rate for Payer: Aetna Medicare	$252.04
Rate for Payer: Amerigroup CHIP/Medicaid	$156.04
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	$685.52
Rate for Payer: Cash Price	$685.52
Rate for Payer: Cash Price	$685.52
Rate for Payer: Cigna Commercial	$380.65
Rate for Payer: Cigna Medicaid	$156.04
Rate for Payer: Molina CHIP/Medicaid	$156.04
Rate for Payer: Multiplan Auto	$506.35
Rate for Payer: Multiplan Commercial	$506.35
Rate for Payer: Multiplan Workers Comp	$506.35
Rate for Payer: Parkland Medicaid	$156.04
Rate for Payer: Scott and White EPO/PPO	$389.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$156.04
Rate for Payer: Superior Health Plan EPO	$105.94

XR Barium Enema Complete BCE

Facility

$779.00

Service Code	CPT 74270 FY
Hospital Charge Code	3101144
Hospital Revenue Code	320
Rate for Payer: Cash Price	$685.52

XR Barium Enema Complete BCE

Facility

$779.00

Service Code	CPT 74270 FY
Hospital Charge Code	3101144
Hospital Revenue Code	320
Min. Negotiated Rate	$105.94
Max. Negotiated Rate	$506.35
Rate for Payer: Aetna Commercial	$125.79
Rate for Payer: Aetna Medicare	$252.04
Rate for Payer: Amerigroup CHIP/Medicaid	$156.04
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	$685.52
Rate for Payer: Cash Price	$685.52
Rate for Payer: Cash Price	$685.52
Rate for Payer: Cigna Commercial	$380.65
Rate for Payer: Cigna Medicaid	$156.04
Rate for Payer: Molina CHIP/Medicaid	$156.04
Rate for Payer: Multiplan Auto	$506.35
Rate for Payer: Multiplan Commercial	$506.35
Rate for Payer: Multiplan Workers Comp	$506.35
Rate for Payer: Parkland Medicaid	$156.04
Rate for Payer: Scott and White EPO/PPO	$389.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$156.04
Rate for Payer: Superior Health Plan EPO	$105.94

Know your out-of-pocket cost for care.

All Charges