White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Elbow 2 Views Right

Facility

$594.00

Service Code	CPT 73070 RT,FY
Hospital Charge Code	3100666
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 Right BCE

Facility

$594.00

Service Code	CPT 73070 RT,FY
Hospital Charge Code	3100666
Hospital Revenue Code	320
Rate for Payer: Cash Price	$522.72

XR Elbow 2 Views Right BCE

Facility

$594.00

Service Code	CPT 73070 RT,FY
Hospital Charge Code	3100666
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 Complete 3+ Views Left

Facility

$664.00

Service Code	CPT 73080 LT,FY
Hospital Charge Code	3100674
Hospital Revenue Code	320
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$431.60
Rate for Payer: Aetna Commercial	$27.56
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
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	$32.75
Rate for Payer: Molina CHIP/Medicaid	$32.75
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	$32.75
Rate for Payer: Scott and White EPO/PPO	$332.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.75
Rate for Payer: Superior Health Plan EPO	$90.30

XR Elbow Complete 3+ Views Left BCE

Facility

$664.00

Service Code	CPT 73080 LT,FY
Hospital Charge Code	3100674
Hospital Revenue Code	320
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$431.60
Rate for Payer: Aetna Commercial	$27.56
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
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	$32.75
Rate for Payer: Molina CHIP/Medicaid	$32.75
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	$32.75
Rate for Payer: Scott and White EPO/PPO	$332.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.75
Rate for Payer: Superior Health Plan EPO	$90.30

XR Elbow Complete 3+ Views Left BCE

Facility

$664.00

Service Code	CPT 73080 LT,FY
Hospital Charge Code	3100674
Hospital Revenue Code	320
Rate for Payer: Cash Price	$584.32

XR Elbow Complete 3+ Views Right

Facility

$664.00

Service Code	CPT 73080 RT,FY
Hospital Charge Code	3100682
Hospital Revenue Code	320
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$431.60
Rate for Payer: Aetna Commercial	$27.56
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
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	$32.75
Rate for Payer: Molina CHIP/Medicaid	$32.75
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	$32.75
Rate for Payer: Scott and White EPO/PPO	$332.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.75
Rate for Payer: Superior Health Plan EPO	$90.30

XR Elbow Complete 3+ Views Right BCE

Facility

$664.00

Service Code	CPT 73080 RT,FY
Hospital Charge Code	3100682
Hospital Revenue Code	320
Rate for Payer: Cash Price	$584.32

XR Elbow Complete 3+ Views Right BCE

Facility

$664.00

Service Code	CPT 73080 RT,FY
Hospital Charge Code	3100682
Hospital Revenue Code	320
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$431.60
Rate for Payer: Aetna Commercial	$27.56
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
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	$32.75
Rate for Payer: Molina CHIP/Medicaid	$32.75
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	$32.75
Rate for Payer: Scott and White EPO/PPO	$332.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.75
Rate for Payer: Superior Health Plan EPO	$90.30

XR ERCP Biliary and Pancreatic Duct

Facility

$2,508.00

Service Code	CPT 74330 FY
Hospital Charge Code	2161004
Hospital Revenue Code	320
Min. Negotiated Rate	$76.71
Max. Negotiated Rate	$1,630.20
Rate for Payer: Aetna Commercial	$86.83
Rate for Payer: Amerigroup CHIP/Medicaid	$225.72
Rate for Payer: BCBS of TX Blue Advantage	$76.71
Rate for Payer: BCBS of TX Blue Essentials	$92.05
Rate for Payer: BCBS of TX PPO	$102.74
Rate for Payer: Cash Price	$2,207.04
Rate for Payer: Cash Price	$2,207.04
Rate for Payer: Multiplan Auto	$1,630.20
Rate for Payer: Multiplan Commercial	$1,630.20
Rate for Payer: Multiplan Workers Comp	$1,630.20
Rate for Payer: Scott and White EPO/PPO	$1,254.00
Rate for Payer: Superior Health Plan EPO	$341.09

XR ERCP Biliary and Pancreatic Duct BCE

Facility

$2,508.00

Service Code	CPT 74330 FY
Hospital Charge Code	2161004
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,207.04

XR ERCP Biliary and Pancreatic Duct BCE

Facility

$2,508.00

Service Code	CPT 74330 FY
Hospital Charge Code	2161004
Hospital Revenue Code	320
Min. Negotiated Rate	$76.71
Max. Negotiated Rate	$1,630.20
Rate for Payer: Aetna Commercial	$86.83
Rate for Payer: Amerigroup CHIP/Medicaid	$225.72
Rate for Payer: BCBS of TX Blue Advantage	$76.71
Rate for Payer: BCBS of TX Blue Essentials	$92.05
Rate for Payer: BCBS of TX PPO	$102.74
Rate for Payer: Cash Price	$2,207.04
Rate for Payer: Cash Price	$2,207.04
Rate for Payer: Multiplan Auto	$1,630.20
Rate for Payer: Multiplan Commercial	$1,630.20
Rate for Payer: Multiplan Workers Comp	$1,630.20
Rate for Payer: Scott and White EPO/PPO	$1,254.00
Rate for Payer: Superior Health Plan EPO	$341.09

XR Esophagus

Facility

$631.00

Service Code	CPT 74220 FY
Hospital Charge Code	3101094
Hospital Revenue Code	320
Min. Negotiated Rate	$83.04
Max. Negotiated Rate	$410.15
Rate for Payer: Aetna Commercial	$83.04
Rate for Payer: Aetna Medicare	$252.04
Rate for Payer: Amerigroup CHIP/Medicaid	$99.90
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	$555.28
Rate for Payer: Cash Price	$555.28
Rate for Payer: Cash Price	$555.28
Rate for Payer: Cigna Commercial	$380.65
Rate for Payer: Cigna Medicaid	$99.90
Rate for Payer: Molina CHIP/Medicaid	$99.90
Rate for Payer: Multiplan Auto	$410.15
Rate for Payer: Multiplan Commercial	$410.15
Rate for Payer: Multiplan Workers Comp	$410.15
Rate for Payer: Parkland Medicaid	$99.90
Rate for Payer: Scott and White EPO/PPO	$315.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.90
Rate for Payer: Superior Health Plan EPO	$85.82

XR Esophagus BCE

Facility

$631.00

Service Code	CPT 74220 FY
Hospital Charge Code	3101094
Hospital Revenue Code	320
Rate for Payer: Cash Price	$555.28

XR Esophagus BCE

Facility

$631.00

Service Code	CPT 74220 FY
Hospital Charge Code	3101094
Hospital Revenue Code	320
Min. Negotiated Rate	$83.04
Max. Negotiated Rate	$410.15
Rate for Payer: Aetna Commercial	$83.04
Rate for Payer: Aetna Medicare	$252.04
Rate for Payer: Amerigroup CHIP/Medicaid	$99.90
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	$555.28
Rate for Payer: Cash Price	$555.28
Rate for Payer: Cash Price	$555.28
Rate for Payer: Cigna Commercial	$380.65
Rate for Payer: Cigna Medicaid	$99.90
Rate for Payer: Molina CHIP/Medicaid	$99.90
Rate for Payer: Multiplan Auto	$410.15
Rate for Payer: Multiplan Commercial	$410.15
Rate for Payer: Multiplan Workers Comp	$410.15
Rate for Payer: Parkland Medicaid	$99.90
Rate for Payer: Scott and White EPO/PPO	$315.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.90
Rate for Payer: Superior Health Plan EPO	$85.82

XR Facial Bones < 3 Views

Facility

$315.00

Service Code	CPT 70140 FY
Hospital Charge Code	3160397
Hospital Revenue Code	320
Min. Negotiated Rate	$25.64
Max. Negotiated Rate	$204.75
Rate for Payer: Aetna Commercial	$25.64
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	$277.20
Rate for Payer: Cash Price	$277.20
Rate for Payer: Cash Price	$277.20
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	$204.75
Rate for Payer: Multiplan Commercial	$204.75
Rate for Payer: Multiplan Workers Comp	$204.75
Rate for Payer: Parkland Medicaid	$32.41
Rate for Payer: Scott and White EPO/PPO	$157.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.41
Rate for Payer: Superior Health Plan EPO	$42.84

XR Facial Bones 3+ Views

Facility

$381.00

Service Code	CPT 70150 FY
Hospital Charge Code	3100146
Hospital Revenue Code	320
Min. Negotiated Rate	$40.27
Max. Negotiated Rate	$247.70
Rate for Payer: Aetna Commercial	$40.27
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$47.11
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	$335.28
Rate for Payer: Cash Price	$335.28
Rate for Payer: Cash Price	$335.28
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$47.11
Rate for Payer: Molina CHIP/Medicaid	$47.11
Rate for Payer: Multiplan Auto	$247.65
Rate for Payer: Multiplan Commercial	$247.65
Rate for Payer: Multiplan Workers Comp	$247.65
Rate for Payer: Parkland Medicaid	$47.11
Rate for Payer: Scott and White EPO/PPO	$190.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47.11
Rate for Payer: Superior Health Plan EPO	$51.82

XR Facial Bones < 3 Views BCE

Facility

$315.00

Service Code	CPT 70140 FY
Hospital Charge Code	3160397
Hospital Revenue Code	320
Min. Negotiated Rate	$25.64
Max. Negotiated Rate	$204.75
Rate for Payer: Aetna Commercial	$25.64
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	$277.20
Rate for Payer: Cash Price	$277.20
Rate for Payer: Cash Price	$277.20
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	$204.75
Rate for Payer: Multiplan Commercial	$204.75
Rate for Payer: Multiplan Workers Comp	$204.75
Rate for Payer: Parkland Medicaid	$32.41
Rate for Payer: Scott and White EPO/PPO	$157.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.41
Rate for Payer: Superior Health Plan EPO	$42.84

XR Facial Bones < 3 Views BCE

Facility

$315.00

Service Code	CPT 70140 FY
Hospital Charge Code	3160397
Hospital Revenue Code	320
Rate for Payer: Cash Price	$277.20

XR Facial Bones 3+ Views BCE

Facility

$381.00

Service Code	CPT 70150 FY
Hospital Charge Code	3100146
Hospital Revenue Code	320
Min. Negotiated Rate	$40.27
Max. Negotiated Rate	$247.70
Rate for Payer: Aetna Commercial	$40.27
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$47.11
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	$335.28
Rate for Payer: Cash Price	$335.28
Rate for Payer: Cash Price	$335.28
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$47.11
Rate for Payer: Molina CHIP/Medicaid	$47.11
Rate for Payer: Multiplan Auto	$247.65
Rate for Payer: Multiplan Commercial	$247.65
Rate for Payer: Multiplan Workers Comp	$247.65
Rate for Payer: Parkland Medicaid	$47.11
Rate for Payer: Scott and White EPO/PPO	$190.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47.11
Rate for Payer: Superior Health Plan EPO	$51.82

XR Facial Bones 3+ Views BCE

Facility

$381.00

Service Code	CPT 70150 FY
Hospital Charge Code	3100146
Hospital Revenue Code	320
Rate for Payer: Cash Price	$335.28

XR Femur 1 View Left

Facility

$329.00

Service Code	CPT 73551 LT,FY
Hospital Charge Code	3181214
Hospital Revenue Code	320
Min. Negotiated Rate	$24.10
Max. Negotiated Rate	$213.85
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	$289.52
Rate for Payer: Cash Price	$289.52
Rate for Payer: Cash Price	$289.52
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	$213.85
Rate for Payer: Multiplan Commercial	$213.85
Rate for Payer: Multiplan Workers Comp	$213.85
Rate for Payer: Parkland Medicaid	$29.40
Rate for Payer: Scott and White EPO/PPO	$164.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.40
Rate for Payer: Superior Health Plan EPO	$44.74

XR Femur 1 View Left BCE

Facility

$329.00

Service Code	CPT 73551 LT,FY
Hospital Charge Code	3181214
Hospital Revenue Code	320
Rate for Payer: Cash Price	$289.52

XR Femur 1 View Left BCE

Facility

$329.00

Service Code	CPT 73551 LT,FY
Hospital Charge Code	3181214
Hospital Revenue Code	320
Min. Negotiated Rate	$24.10
Max. Negotiated Rate	$213.85
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	$289.52
Rate for Payer: Cash Price	$289.52
Rate for Payer: Cash Price	$289.52
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	$213.85
Rate for Payer: Multiplan Commercial	$213.85
Rate for Payer: Multiplan Workers Comp	$213.85
Rate for Payer: Parkland Medicaid	$29.40
Rate for Payer: Scott and White EPO/PPO	$164.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.40
Rate for Payer: Superior Health Plan EPO	$44.74

XR Femur 1 View Right

Facility

$329.00

Service Code	CPT 73551 RT,FY
Hospital Charge Code	3181213
Hospital Revenue Code	320
Min. Negotiated Rate	$24.10
Max. Negotiated Rate	$213.85
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	$289.52
Rate for Payer: Cash Price	$289.52
Rate for Payer: Cash Price	$289.52
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	$213.85
Rate for Payer: Multiplan Commercial	$213.85
Rate for Payer: Multiplan Workers Comp	$213.85
Rate for Payer: Parkland Medicaid	$29.40
Rate for Payer: Scott and White EPO/PPO	$164.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.40
Rate for Payer: Superior Health Plan EPO	$44.74

Know your out-of-pocket cost for care.

All Charges