White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Chest 2 Views w/ Apical Lordotic BCE

Facility

$718.00

Service Code	CPT 71047 FY
Hospital Charge Code	3181552
Hospital Revenue Code	320
Min. Negotiated Rate	$33.72
Max. Negotiated Rate	$466.70
Rate for Payer: Aetna Commercial	$33.72
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$42.44
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$42.44
Rate for Payer: Molina CHIP/Medicaid	$42.44
Rate for Payer: Multiplan Auto	$466.70
Rate for Payer: Multiplan Commercial	$466.70
Rate for Payer: Multiplan Workers Comp	$466.70
Rate for Payer: Parkland Medicaid	$42.44
Rate for Payer: Scott and White EPO/PPO	$359.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.44
Rate for Payer: Superior Health Plan EPO	$97.65

XR Chest 2 Views w/ Obliques

Facility

$767.00

Service Code	CPT 71048 FY
Hospital Charge Code	3181554
Hospital Revenue Code	320
Min. Negotiated Rate	$36.03
Max. Negotiated Rate	$498.55
Rate for Payer: Aetna Commercial	$36.03
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$46.45
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	$674.96
Rate for Payer: Cash Price	$674.96
Rate for Payer: Cash Price	$674.96
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$46.45
Rate for Payer: Molina CHIP/Medicaid	$46.45
Rate for Payer: Multiplan Auto	$498.55
Rate for Payer: Multiplan Commercial	$498.55
Rate for Payer: Multiplan Workers Comp	$498.55
Rate for Payer: Parkland Medicaid	$46.45
Rate for Payer: Scott and White EPO/PPO	$383.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.45
Rate for Payer: Superior Health Plan EPO	$104.31

XR Chest 3 Views

Facility

$718.00

Service Code	CPT 71047 FY
Hospital Charge Code	4901047
Hospital Revenue Code	324
Rate for Payer: Cash Price	$631.84

XR Chest 3 Views

Facility

$718.00

Service Code	CPT 71047 FY
Hospital Charge Code	4901047
Hospital Revenue Code	324
Min. Negotiated Rate	$33.72
Max. Negotiated Rate	$466.70
Rate for Payer: Aetna Commercial	$33.72
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$42.44
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$42.44
Rate for Payer: Molina CHIP/Medicaid	$42.44
Rate for Payer: Multiplan Auto	$466.70
Rate for Payer: Multiplan Commercial	$466.70
Rate for Payer: Multiplan Workers Comp	$466.70
Rate for Payer: Parkland Medicaid	$42.44
Rate for Payer: Scott and White EPO/PPO	$359.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.44
Rate for Payer: Superior Health Plan EPO	$97.65

XR Chest 4+ Views

Facility

$767.00

Service Code	CPT 71048 FY
Hospital Charge Code	3181554
Hospital Revenue Code	320
Min. Negotiated Rate	$36.03
Max. Negotiated Rate	$498.55
Rate for Payer: Aetna Commercial	$36.03
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$46.45
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	$674.96
Rate for Payer: Cash Price	$674.96
Rate for Payer: Cash Price	$674.96
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$46.45
Rate for Payer: Molina CHIP/Medicaid	$46.45
Rate for Payer: Multiplan Auto	$498.55
Rate for Payer: Multiplan Commercial	$498.55
Rate for Payer: Multiplan Workers Comp	$498.55
Rate for Payer: Parkland Medicaid	$46.45
Rate for Payer: Scott and White EPO/PPO	$383.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.45
Rate for Payer: Superior Health Plan EPO	$104.31

XR Chest 4+ Views BCE

Facility

$767.00

Service Code	CPT 71048 FY
Hospital Charge Code	3181554
Hospital Revenue Code	320
Min. Negotiated Rate	$36.03
Max. Negotiated Rate	$498.55
Rate for Payer: Aetna Commercial	$36.03
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$46.45
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	$674.96
Rate for Payer: Cash Price	$674.96
Rate for Payer: Cash Price	$674.96
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$46.45
Rate for Payer: Molina CHIP/Medicaid	$46.45
Rate for Payer: Multiplan Auto	$498.55
Rate for Payer: Multiplan Commercial	$498.55
Rate for Payer: Multiplan Workers Comp	$498.55
Rate for Payer: Parkland Medicaid	$46.45
Rate for Payer: Scott and White EPO/PPO	$383.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.45
Rate for Payer: Superior Health Plan EPO	$104.31

XR Chest 4+ Views BCE

Facility

$767.00

Service Code	CPT 71048 FY
Hospital Charge Code	3181554
Hospital Revenue Code	320
Rate for Payer: Cash Price	$674.96

XR Chest 4+ Views w/ Fluoroscopy

Facility

$767.00

Service Code	CPT 71048 FY
Hospital Charge Code	3181554
Hospital Revenue Code	320
Min. Negotiated Rate	$36.03
Max. Negotiated Rate	$498.55
Rate for Payer: Aetna Commercial	$36.03
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$46.45
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	$674.96
Rate for Payer: Cash Price	$674.96
Rate for Payer: Cash Price	$674.96
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$46.45
Rate for Payer: Molina CHIP/Medicaid	$46.45
Rate for Payer: Multiplan Auto	$498.55
Rate for Payer: Multiplan Commercial	$498.55
Rate for Payer: Multiplan Workers Comp	$498.55
Rate for Payer: Parkland Medicaid	$46.45
Rate for Payer: Scott and White EPO/PPO	$383.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.45
Rate for Payer: Superior Health Plan EPO	$104.31

XR Chest Abdomen Infant

Facility

$664.00

Service Code	CPT 71045 FY
Hospital Charge Code	3181546
Hospital Revenue Code	320
Rate for Payer: Cash Price	$584.32

XR Chest Abdomen Infant

Facility

$664.00

Service Code	CPT 71045 FY
Hospital Charge Code	3181546
Hospital Revenue Code	320
Min. Negotiated Rate	$19.46
Max. Negotiated Rate	$431.60
Rate for Payer: Aetna Commercial	$19.46
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$26.06
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$584.32
Rate for Payer: Cash Price	$584.32
Rate for Payer: Cash Price	$584.32
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$20.85
Rate for Payer: Molina CHIP/Medicaid	$20.85
Rate for Payer: Multiplan Auto	$431.60
Rate for Payer: Multiplan Commercial	$431.60
Rate for Payer: Multiplan Workers Comp	$431.60
Rate for Payer: Parkland Medicaid	$20.85
Rate for Payer: Scott and White EPO/PPO	$332.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.85
Rate for Payer: Superior Health Plan EPO	$90.30

XR Cholangiogram in OR

Facility

$1,622.00

Service Code	CPT 74300 FY
Hospital Charge Code	3101177
Hospital Revenue Code	320
Min. Negotiated Rate	$27.02
Max. Negotiated Rate	$1,054.30
Rate for Payer: Aetna Commercial	$27.02
Rate for Payer: Amerigroup CHIP/Medicaid	$145.98
Rate for Payer: BCBS of TX Blue Advantage	$30.92
Rate for Payer: BCBS of TX Blue Essentials	$37.11
Rate for Payer: BCBS of TX PPO	$41.42
Rate for Payer: Cash Price	$1,427.36
Rate for Payer: Cash Price	$1,427.36
Rate for Payer: Multiplan Auto	$1,054.30
Rate for Payer: Multiplan Commercial	$1,054.30
Rate for Payer: Multiplan Workers Comp	$1,054.30
Rate for Payer: Scott and White EPO/PPO	$811.00
Rate for Payer: Superior Health Plan EPO	$220.59

XR Cholangiogram in OR BCE

Facility

$1,622.00

Service Code	CPT 74300 FY
Hospital Charge Code	3101177
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,427.36

XR Cholangiogram in OR BCE

Facility

$1,622.00

Service Code	CPT 74300 FY
Hospital Charge Code	3101177
Hospital Revenue Code	320
Min. Negotiated Rate	$27.02
Max. Negotiated Rate	$1,054.30
Rate for Payer: Aetna Commercial	$27.02
Rate for Payer: Amerigroup CHIP/Medicaid	$145.98
Rate for Payer: BCBS of TX Blue Advantage	$30.92
Rate for Payer: BCBS of TX Blue Essentials	$37.11
Rate for Payer: BCBS of TX PPO	$41.42
Rate for Payer: Cash Price	$1,427.36
Rate for Payer: Cash Price	$1,427.36
Rate for Payer: Multiplan Auto	$1,054.30
Rate for Payer: Multiplan Commercial	$1,054.30
Rate for Payer: Multiplan Workers Comp	$1,054.30
Rate for Payer: Scott and White EPO/PPO	$811.00
Rate for Payer: Superior Health Plan EPO	$220.59

XR Clavicle Left

Facility

$463.00

Service Code	CPT 73000 LT,FY
Hospital Charge Code	3100559
Hospital Revenue Code	320
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$300.95
Rate for Payer: Aetna Commercial	$27.56
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.41
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$32.41
Rate for Payer: Molina CHIP/Medicaid	$32.41
Rate for Payer: Multiplan Auto	$300.95
Rate for Payer: Multiplan Commercial	$300.95
Rate for Payer: Multiplan Workers Comp	$300.95
Rate for Payer: Parkland Medicaid	$32.41
Rate for Payer: Scott and White EPO/PPO	$231.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.41
Rate for Payer: Superior Health Plan EPO	$62.97

XR Clavicle Left BCE

Facility

$463.00

Service Code	CPT 73000 LT,FY
Hospital Charge Code	3100559
Hospital Revenue Code	320
Rate for Payer: Cash Price	$407.44

XR Clavicle Left BCE

Facility

$463.00

Service Code	CPT 73000 LT,FY
Hospital Charge Code	3100559
Hospital Revenue Code	320
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$300.95
Rate for Payer: Aetna Commercial	$27.56
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.41
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$32.41
Rate for Payer: Molina CHIP/Medicaid	$32.41
Rate for Payer: Multiplan Auto	$300.95
Rate for Payer: Multiplan Commercial	$300.95
Rate for Payer: Multiplan Workers Comp	$300.95
Rate for Payer: Parkland Medicaid	$32.41
Rate for Payer: Scott and White EPO/PPO	$231.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.41
Rate for Payer: Superior Health Plan EPO	$62.97

XR Clavicle Right

Facility

$463.00

Service Code	CPT 73000 RT,FY
Hospital Charge Code	3100567
Hospital Revenue Code	320
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$300.95
Rate for Payer: Aetna Commercial	$27.56
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.41
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$32.41
Rate for Payer: Molina CHIP/Medicaid	$32.41
Rate for Payer: Multiplan Auto	$300.95
Rate for Payer: Multiplan Commercial	$300.95
Rate for Payer: Multiplan Workers Comp	$300.95
Rate for Payer: Parkland Medicaid	$32.41
Rate for Payer: Scott and White EPO/PPO	$231.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.41
Rate for Payer: Superior Health Plan EPO	$62.97

XR Clavicle Right BCE

Facility

$463.00

Service Code	CPT 73000 RT,FY
Hospital Charge Code	3100567
Hospital Revenue Code	320
Rate for Payer: Cash Price	$407.44

XR Clavicle Right BCE

Facility

$463.00

Service Code	CPT 73000 RT,FY
Hospital Charge Code	3100567
Hospital Revenue Code	320
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$300.95
Rate for Payer: Aetna Commercial	$27.56
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.41
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cash Price	$407.44
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$32.41
Rate for Payer: Molina CHIP/Medicaid	$32.41
Rate for Payer: Multiplan Auto	$300.95
Rate for Payer: Multiplan Commercial	$300.95
Rate for Payer: Multiplan Workers Comp	$300.95
Rate for Payer: Parkland Medicaid	$32.41
Rate for Payer: Scott and White EPO/PPO	$231.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.41
Rate for Payer: Superior Health Plan EPO	$62.97

XR Cystogram

Facility

$732.00

Service Code	CPT 74430 FY
Hospital Charge Code	3101243
Hospital Revenue Code	320
Min. Negotiated Rate	$29.49
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$29.49
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$41.44
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	$644.16
Rate for Payer: Cash Price	$644.16
Rate for Payer: Cash Price	$644.16
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$41.44
Rate for Payer: Molina CHIP/Medicaid	$41.44
Rate for Payer: Multiplan Auto	$475.80
Rate for Payer: Multiplan Commercial	$475.80
Rate for Payer: Multiplan Workers Comp	$475.80
Rate for Payer: Parkland Medicaid	$41.44
Rate for Payer: Scott and White EPO/PPO	$366.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41.44
Rate for Payer: Superior Health Plan EPO	$99.55

XR Cystogram BCE

Facility

$732.00

Service Code	CPT 74430 FY
Hospital Charge Code	3101243
Hospital Revenue Code	320
Min. Negotiated Rate	$29.49
Max. Negotiated Rate	$843.89
Rate for Payer: Aetna Commercial	$29.49
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$41.44
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	$644.16
Rate for Payer: Cash Price	$644.16
Rate for Payer: Cash Price	$644.16
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$41.44
Rate for Payer: Molina CHIP/Medicaid	$41.44
Rate for Payer: Multiplan Auto	$475.80
Rate for Payer: Multiplan Commercial	$475.80
Rate for Payer: Multiplan Workers Comp	$475.80
Rate for Payer: Parkland Medicaid	$41.44
Rate for Payer: Scott and White EPO/PPO	$366.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41.44
Rate for Payer: Superior Health Plan EPO	$99.55

XR Cystogram BCE

Facility

$732.00

Service Code	CPT 74430 FY
Hospital Charge Code	3101243
Hospital Revenue Code	320
Rate for Payer: Cash Price	$644.16

XR Elbow 2 Views Left

Facility

$594.00

Service Code	CPT 73070 LT,FY
Hospital Charge Code	3100658
Hospital Revenue Code	320
Min. Negotiated Rate	$24.10
Max. Negotiated Rate	$386.10
Rate for Payer: Aetna Commercial	$24.10
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$29.40
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$522.72
Rate for Payer: Cash Price	$522.72
Rate for Payer: Cash Price	$522.72
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$29.40
Rate for Payer: Molina CHIP/Medicaid	$29.40
Rate for Payer: Multiplan Auto	$386.10
Rate for Payer: Multiplan Commercial	$386.10
Rate for Payer: Multiplan Workers Comp	$386.10
Rate for Payer: Parkland Medicaid	$29.40
Rate for Payer: Scott and White EPO/PPO	$297.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.40
Rate for Payer: Superior Health Plan EPO	$80.78

XR Elbow 2 Views Left BCE

Facility

$594.00

Service Code	CPT 73070 LT,FY
Hospital Charge Code	3100658
Hospital Revenue Code	320
Min. Negotiated Rate	$24.10
Max. Negotiated Rate	$386.10
Rate for Payer: Aetna Commercial	$24.10
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$29.40
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$522.72
Rate for Payer: Cash Price	$522.72
Rate for Payer: Cash Price	$522.72
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$29.40
Rate for Payer: Molina CHIP/Medicaid	$29.40
Rate for Payer: Multiplan Auto	$386.10
Rate for Payer: Multiplan Commercial	$386.10
Rate for Payer: Multiplan Workers Comp	$386.10
Rate for Payer: Parkland Medicaid	$29.40
Rate for Payer: Scott and White EPO/PPO	$297.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.40
Rate for Payer: Superior Health Plan EPO	$80.78

XR Elbow 2 Views Left BCE

Facility

$594.00

Service Code	CPT 73070 LT,FY
Hospital Charge Code	3100658
Hospital Revenue Code	320
Rate for Payer: Cash Price	$522.72

Know your out-of-pocket cost for care.

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