White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Fluoro Guidance Needle Placement

Facility

$559.00

Service Code	CPT 77002 FY
Hospital Charge Code	3120011
Hospital Revenue Code	320
Min. Negotiated Rate	$50.31
Max. Negotiated Rate	$363.35
Rate for Payer: Aetna Commercial	$103.44
Rate for Payer: Amerigroup CHIP/Medicaid	$50.31
Rate for Payer: BCBS of TX Blue Advantage	$123.09
Rate for Payer: BCBS of TX Blue Essentials	$147.71
Rate for Payer: BCBS of TX PPO	$164.87
Rate for Payer: Cash Price	$491.92
Rate for Payer: Cash Price	$491.92
Rate for Payer: Multiplan Auto	$363.35
Rate for Payer: Multiplan Commercial	$363.35
Rate for Payer: Multiplan Workers Comp	$363.35
Rate for Payer: Scott and White EPO/PPO	$279.50
Rate for Payer: Superior Health Plan EPO	$76.02

XR Fluoro Guidance Needle Placement BCE

Facility

$559.00

Service Code	CPT 77002 FY
Hospital Charge Code	3120011
Hospital Revenue Code	320
Rate for Payer: Cash Price	$491.92

XR Fluoro Guidance Needle Placement BCE

Facility

$559.00

Service Code	CPT 77002 FY
Hospital Charge Code	3120011
Hospital Revenue Code	320
Min. Negotiated Rate	$50.31
Max. Negotiated Rate	$363.35
Rate for Payer: Aetna Commercial	$103.44
Rate for Payer: Amerigroup CHIP/Medicaid	$50.31
Rate for Payer: BCBS of TX Blue Advantage	$123.09
Rate for Payer: BCBS of TX Blue Essentials	$147.71
Rate for Payer: BCBS of TX PPO	$164.87
Rate for Payer: Cash Price	$491.92
Rate for Payer: Cash Price	$491.92
Rate for Payer: Multiplan Auto	$363.35
Rate for Payer: Multiplan Commercial	$363.35
Rate for Payer: Multiplan Workers Comp	$363.35
Rate for Payer: Scott and White EPO/PPO	$279.50
Rate for Payer: Superior Health Plan EPO	$76.02

XR Fluoroscopy Eval Diaphragm Sniff Test

Facility

$480.00

Service Code	CPT 76000 FY
Hospital Charge Code	3101276
Hospital Revenue Code	320
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$507.64
Rate for Payer: Aetna Commercial	$31.80
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$52.92
Rate for Payer: BCBS of TX Blue Essentials	$63.50
Rate for Payer: BCBS of TX PPO	$70.87
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$43.44
Rate for Payer: Molina CHIP/Medicaid	$43.44
Rate for Payer: Multiplan Auto	$312.00
Rate for Payer: Multiplan Commercial	$312.00
Rate for Payer: Multiplan Workers Comp	$312.00
Rate for Payer: Parkland Medicaid	$43.44
Rate for Payer: Scott and White EPO/PPO	$240.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.44
Rate for Payer: Superior Health Plan EPO	$65.28

XR Fluoroscopy Guide Vein Device

Facility

$619.00

Service Code	CPT 77001 FY
Hospital Charge Code	3120003
Hospital Revenue Code	320
Min. Negotiated Rate	$55.71
Max. Negotiated Rate	$402.35
Rate for Payer: Aetna Commercial	$97.67
Rate for Payer: Amerigroup CHIP/Medicaid	$55.71
Rate for Payer: BCBS of TX Blue Advantage	$120.12
Rate for Payer: BCBS of TX Blue Essentials	$144.14
Rate for Payer: BCBS of TX PPO	$160.89
Rate for Payer: Cash Price	$544.72
Rate for Payer: Cash Price	$544.72
Rate for Payer: Multiplan Auto	$402.35
Rate for Payer: Multiplan Commercial	$402.35
Rate for Payer: Multiplan Workers Comp	$402.35
Rate for Payer: Scott and White EPO/PPO	$309.50
Rate for Payer: Superior Health Plan EPO	$84.18

XR Fluoroscopy Guide Vein Device BCE

Facility

$619.00

Service Code	CPT 77001 FY
Hospital Charge Code	3120003
Hospital Revenue Code	320
Min. Negotiated Rate	$55.71
Max. Negotiated Rate	$402.35
Rate for Payer: Aetna Commercial	$97.67
Rate for Payer: Amerigroup CHIP/Medicaid	$55.71
Rate for Payer: BCBS of TX Blue Advantage	$120.12
Rate for Payer: BCBS of TX Blue Essentials	$144.14
Rate for Payer: BCBS of TX PPO	$160.89
Rate for Payer: Cash Price	$544.72
Rate for Payer: Cash Price	$544.72
Rate for Payer: Multiplan Auto	$402.35
Rate for Payer: Multiplan Commercial	$402.35
Rate for Payer: Multiplan Workers Comp	$402.35
Rate for Payer: Scott and White EPO/PPO	$309.50
Rate for Payer: Superior Health Plan EPO	$84.18

XR Fluoroscopy Guide Vein Device BCE

Facility

$619.00

Service Code	CPT 77001 FY
Hospital Charge Code	3120003
Hospital Revenue Code	320
Rate for Payer: Cash Price	$544.72

XR Fluoroscopy in Imaging per Hour

Facility

$480.00

Service Code	CPT 76000 FY
Hospital Charge Code	3101276
Hospital Revenue Code	320
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$507.64
Rate for Payer: Aetna Commercial	$31.80
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$52.92
Rate for Payer: BCBS of TX Blue Essentials	$63.50
Rate for Payer: BCBS of TX PPO	$70.87
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$43.44
Rate for Payer: Molina CHIP/Medicaid	$43.44
Rate for Payer: Multiplan Auto	$312.00
Rate for Payer: Multiplan Commercial	$312.00
Rate for Payer: Multiplan Workers Comp	$312.00
Rate for Payer: Parkland Medicaid	$43.44
Rate for Payer: Scott and White EPO/PPO	$240.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.44
Rate for Payer: Superior Health Plan EPO	$65.28

XR Fluoroscopy in Imaging per Hour BCE

Facility

$480.00

Service Code	CPT 76000 FY
Hospital Charge Code	3101276
Hospital Revenue Code	320
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$507.64
Rate for Payer: Aetna Commercial	$31.80
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$52.92
Rate for Payer: BCBS of TX Blue Essentials	$63.50
Rate for Payer: BCBS of TX PPO	$70.87
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$43.44
Rate for Payer: Molina CHIP/Medicaid	$43.44
Rate for Payer: Multiplan Auto	$312.00
Rate for Payer: Multiplan Commercial	$312.00
Rate for Payer: Multiplan Workers Comp	$312.00
Rate for Payer: Parkland Medicaid	$43.44
Rate for Payer: Scott and White EPO/PPO	$240.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.44
Rate for Payer: Superior Health Plan EPO	$65.28

XR Foot 2 Views Left

Facility

$537.00

Service Code	CPT 73620 LT,FY
Hospital Charge Code	3100997
Hospital Revenue Code	320
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$349.05
Rate for Payer: Aetna Commercial	$23.71
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$28.40
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	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$28.40
Rate for Payer: Molina CHIP/Medicaid	$28.40
Rate for Payer: Multiplan Auto	$349.05
Rate for Payer: Multiplan Commercial	$349.05
Rate for Payer: Multiplan Workers Comp	$349.05
Rate for Payer: Parkland Medicaid	$28.40
Rate for Payer: Scott and White EPO/PPO	$268.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.40
Rate for Payer: Superior Health Plan EPO	$73.03

XR Foot 2 Views Left BCE

Facility

$537.00

Service Code	CPT 73620 LT,FY
Hospital Charge Code	3100997
Hospital Revenue Code	320
Rate for Payer: Cash Price	$472.56

XR Foot 2 Views Left BCE

Facility

$537.00

Service Code	CPT 73620 LT,FY
Hospital Charge Code	3100997
Hospital Revenue Code	320
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$349.05
Rate for Payer: Aetna Commercial	$23.71
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$28.40
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	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$28.40
Rate for Payer: Molina CHIP/Medicaid	$28.40
Rate for Payer: Multiplan Auto	$349.05
Rate for Payer: Multiplan Commercial	$349.05
Rate for Payer: Multiplan Workers Comp	$349.05
Rate for Payer: Parkland Medicaid	$28.40
Rate for Payer: Scott and White EPO/PPO	$268.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.40
Rate for Payer: Superior Health Plan EPO	$73.03

XR Foot 2 Views Right

Facility

$537.00

Service Code	CPT 73620 RT,FY
Hospital Charge Code	3101003
Hospital Revenue Code	320
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$349.05
Rate for Payer: Aetna Commercial	$23.71
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$28.40
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	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$28.40
Rate for Payer: Molina CHIP/Medicaid	$28.40
Rate for Payer: Multiplan Auto	$349.05
Rate for Payer: Multiplan Commercial	$349.05
Rate for Payer: Multiplan Workers Comp	$349.05
Rate for Payer: Parkland Medicaid	$28.40
Rate for Payer: Scott and White EPO/PPO	$268.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.40
Rate for Payer: Superior Health Plan EPO	$73.03

XR Foot 2 Views Right BCE

Facility

$537.00

Service Code	CPT 73620 RT,FY
Hospital Charge Code	3101003
Hospital Revenue Code	320
Rate for Payer: Cash Price	$472.56

XR Foot 2 Views Right BCE

Facility

$537.00

Service Code	CPT 73620 RT,FY
Hospital Charge Code	3101003
Hospital Revenue Code	320
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$349.05
Rate for Payer: Aetna Commercial	$23.71
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$28.40
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	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cash Price	$472.56
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$28.40
Rate for Payer: Molina CHIP/Medicaid	$28.40
Rate for Payer: Multiplan Auto	$349.05
Rate for Payer: Multiplan Commercial	$349.05
Rate for Payer: Multiplan Workers Comp	$349.05
Rate for Payer: Parkland Medicaid	$28.40
Rate for Payer: Scott and White EPO/PPO	$268.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.40
Rate for Payer: Superior Health Plan EPO	$73.03

XR Foot Complete 3+ Views Left

Facility

$608.00

Service Code	CPT 73630 LT,FY
Hospital Charge Code	3101011
Hospital Revenue Code	320
Min. Negotiated Rate	$30.26
Max. Negotiated Rate	$395.20
Rate for Payer: Aetna Commercial	$30.26
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$34.41
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	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$34.41
Rate for Payer: Molina CHIP/Medicaid	$34.41
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$34.41
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.41
Rate for Payer: Superior Health Plan EPO	$82.69

XR Foot Complete 3+ Views Left BCE

Facility

$608.00

Service Code	CPT 73630 LT,FY
Hospital Charge Code	3101011
Hospital Revenue Code	320
Min. Negotiated Rate	$30.26
Max. Negotiated Rate	$395.20
Rate for Payer: Aetna Commercial	$30.26
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$34.41
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	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$34.41
Rate for Payer: Molina CHIP/Medicaid	$34.41
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$34.41
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.41
Rate for Payer: Superior Health Plan EPO	$82.69

XR Foot Complete 3+ Views Left BCE

Facility

$608.00

Service Code	CPT 73630 LT,FY
Hospital Charge Code	3101011
Hospital Revenue Code	320
Rate for Payer: Cash Price	$535.04

XR Foot Complete 3+ Views Right

Facility

$608.00

Service Code	CPT 73630 RT,FY
Hospital Charge Code	3101029
Hospital Revenue Code	320
Min. Negotiated Rate	$30.26
Max. Negotiated Rate	$395.20
Rate for Payer: Aetna Commercial	$30.26
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$34.41
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	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$34.41
Rate for Payer: Molina CHIP/Medicaid	$34.41
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$34.41
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.41
Rate for Payer: Superior Health Plan EPO	$82.69

XR Foot Complete 3+ Views Right BCE

Facility

$608.00

Service Code	CPT 73630 RT,FY
Hospital Charge Code	3101029
Hospital Revenue Code	320
Rate for Payer: Cash Price	$535.04

XR Foot Complete 3+ Views Right BCE

Facility

$608.00

Service Code	CPT 73630 RT,FY
Hospital Charge Code	3101029
Hospital Revenue Code	320
Min. Negotiated Rate	$30.26
Max. Negotiated Rate	$395.20
Rate for Payer: Aetna Commercial	$30.26
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$34.41
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	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cash Price	$535.04
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$34.41
Rate for Payer: Molina CHIP/Medicaid	$34.41
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$34.41
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.41
Rate for Payer: Superior Health Plan EPO	$82.69

XR Forearm 2 Views Left

Facility

$535.00

Service Code	CPT 73090 LT,FY
Hospital Charge Code	3100690
Hospital Revenue Code	320
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$347.75
Rate for Payer: Aetna Commercial	$24.48
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	$470.80
Rate for Payer: Cash Price	$470.80
Rate for Payer: Cash Price	$470.80
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	$347.75
Rate for Payer: Multiplan Commercial	$347.75
Rate for Payer: Multiplan Workers Comp	$347.75
Rate for Payer: Parkland Medicaid	$29.40
Rate for Payer: Scott and White EPO/PPO	$267.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.40
Rate for Payer: Superior Health Plan EPO	$72.76

XR Forearm 2 Views Left BCE

Facility

$535.00

Service Code	CPT 73090 LT,FY
Hospital Charge Code	3100690
Hospital Revenue Code	320
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$347.75
Rate for Payer: Aetna Commercial	$24.48
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	$470.80
Rate for Payer: Cash Price	$470.80
Rate for Payer: Cash Price	$470.80
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	$347.75
Rate for Payer: Multiplan Commercial	$347.75
Rate for Payer: Multiplan Workers Comp	$347.75
Rate for Payer: Parkland Medicaid	$29.40
Rate for Payer: Scott and White EPO/PPO	$267.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.40
Rate for Payer: Superior Health Plan EPO	$72.76

XR Forearm 2 Views Left BCE

Facility

$535.00

Service Code	CPT 73090 LT,FY
Hospital Charge Code	3100690
Hospital Revenue Code	320
Rate for Payer: Cash Price	$470.80

XR Forearm 2 Views Right

Facility

$535.00

Service Code	CPT 73090 RT,FY
Hospital Charge Code	3100708
Hospital Revenue Code	320
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$347.75
Rate for Payer: Aetna Commercial	$24.48
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	$470.80
Rate for Payer: Cash Price	$470.80
Rate for Payer: Cash Price	$470.80
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	$347.75
Rate for Payer: Multiplan Commercial	$347.75
Rate for Payer: Multiplan Workers Comp	$347.75
Rate for Payer: Parkland Medicaid	$29.40
Rate for Payer: Scott and White EPO/PPO	$267.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.40
Rate for Payer: Superior Health Plan EPO	$72.76

Know your out-of-pocket cost for care.

All Charges