White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Forearm 2 Views Right BCE

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

XR Forearm 2 Views Right BCE

Facility

$535.00

Service Code	CPT 73090 RT,FY
Hospital Charge Code	3100708
Hospital Revenue Code	320
Rate for Payer: Cash Price	$470.80

XR Foreign Body Localization Child 1 Vw

Facility

$401.00

Service Code	CPT 76010 FY
Hospital Charge Code	4904030
Hospital Revenue Code	320
Min. Negotiated Rate	$24.10
Max. Negotiated Rate	$260.65
Rate for Payer: Aetna Commercial	$24.10
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$80.90
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	$352.88
Rate for Payer: Cash Price	$352.88
Rate for Payer: Cash Price	$352.88
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$80.90
Rate for Payer: Molina CHIP/Medicaid	$80.90
Rate for Payer: Multiplan Auto	$260.65
Rate for Payer: Multiplan Commercial	$260.65
Rate for Payer: Multiplan Workers Comp	$260.65
Rate for Payer: Parkland Medicaid	$80.90
Rate for Payer: Scott and White EPO/PPO	$200.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$80.90
Rate for Payer: Superior Health Plan EPO	$54.54

XR Foreign Body Localization Child 1 Vw BCE

Facility

$401.00

Service Code	CPT 76010 FY
Hospital Charge Code	4904030
Hospital Revenue Code	320
Rate for Payer: Cash Price	$352.88

XR Foreign Body Localization Child 1 Vw BCE

Facility

$401.00

Service Code	CPT 76010 FY
Hospital Charge Code	4904030
Hospital Revenue Code	320
Min. Negotiated Rate	$24.10
Max. Negotiated Rate	$260.65
Rate for Payer: Aetna Commercial	$24.10
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$80.90
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	$352.88
Rate for Payer: Cash Price	$352.88
Rate for Payer: Cash Price	$352.88
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$80.90
Rate for Payer: Molina CHIP/Medicaid	$80.90
Rate for Payer: Multiplan Auto	$260.65
Rate for Payer: Multiplan Commercial	$260.65
Rate for Payer: Multiplan Workers Comp	$260.65
Rate for Payer: Parkland Medicaid	$80.90
Rate for Payer: Scott and White EPO/PPO	$200.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$80.90
Rate for Payer: Superior Health Plan EPO	$54.54

XR G Tube Placement Percutaneous

Facility

$5,522.00

Service Code	CPT 49440 FY
Hospital Charge Code	4619440
Hospital Revenue Code	361
Min. Negotiated Rate	$564.97
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,610.33
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cash Price	$4,859.36
Rate for Payer: Cash Price	$4,859.36
Rate for Payer: Cash Price	$4,859.36
Rate for Payer: Cigna Commercial	$3,942.10
Rate for Payer: Cigna Medicaid	$564.97
Rate for Payer: Molina CHIP/Medicaid	$564.97
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	$564.97
Rate for Payer: Scott and White EPO/PPO	$2,761.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.97
Rate for Payer: Superior Health Plan EPO	$750.99

XR G Tube Placement Percutaneous BCE

Facility

$5,522.00

Service Code	CPT 49440 FY
Hospital Charge Code	4619440
Hospital Revenue Code	361
Min. Negotiated Rate	$564.97
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,610.33
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cash Price	$4,859.36
Rate for Payer: Cash Price	$4,859.36
Rate for Payer: Cash Price	$4,859.36
Rate for Payer: Cigna Commercial	$3,942.10
Rate for Payer: Cigna Medicaid	$564.97
Rate for Payer: Molina CHIP/Medicaid	$564.97
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	$564.97
Rate for Payer: Scott and White EPO/PPO	$2,761.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.97
Rate for Payer: Superior Health Plan EPO	$750.99

XR G Tube Placement Percutaneous BCE

Facility

$5,522.00

Service Code	CPT 49440 FY
Hospital Charge Code	4619440
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,859.36

XR Hand 2 Views Left

Facility

$768.00

Service Code	CPT 73120 LT,FY
Hospital Charge Code	3100757
Hospital Revenue Code	320
Min. Negotiated Rate	$26.41
Max. Negotiated Rate	$499.20
Rate for Payer: Aetna Commercial	$26.41
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$31.41
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	$675.84
Rate for Payer: Cash Price	$675.84
Rate for Payer: Cash Price	$675.84
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$31.41
Rate for Payer: Molina CHIP/Medicaid	$31.41
Rate for Payer: Multiplan Auto	$499.20
Rate for Payer: Multiplan Commercial	$499.20
Rate for Payer: Multiplan Workers Comp	$499.20
Rate for Payer: Parkland Medicaid	$31.41
Rate for Payer: Scott and White EPO/PPO	$384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.41
Rate for Payer: Superior Health Plan EPO	$104.45

XR Hand 2 Views Left BCE

Facility

$768.00

Service Code	CPT 73120 LT,FY
Hospital Charge Code	3100757
Hospital Revenue Code	320
Min. Negotiated Rate	$26.41
Max. Negotiated Rate	$499.20
Rate for Payer: Aetna Commercial	$26.41
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$31.41
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	$675.84
Rate for Payer: Cash Price	$675.84
Rate for Payer: Cash Price	$675.84
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$31.41
Rate for Payer: Molina CHIP/Medicaid	$31.41
Rate for Payer: Multiplan Auto	$499.20
Rate for Payer: Multiplan Commercial	$499.20
Rate for Payer: Multiplan Workers Comp	$499.20
Rate for Payer: Parkland Medicaid	$31.41
Rate for Payer: Scott and White EPO/PPO	$384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.41
Rate for Payer: Superior Health Plan EPO	$104.45

XR Hand 2 Views Left BCE

Facility

$768.00

Service Code	CPT 73120 LT,FY
Hospital Charge Code	3100757
Hospital Revenue Code	320
Rate for Payer: Cash Price	$675.84

XR Hand 2 Views Right

Facility

$768.00

Service Code	CPT 73120 RT,FY
Hospital Charge Code	3100765
Hospital Revenue Code	320
Min. Negotiated Rate	$26.41
Max. Negotiated Rate	$499.20
Rate for Payer: Aetna Commercial	$26.41
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$31.41
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	$675.84
Rate for Payer: Cash Price	$675.84
Rate for Payer: Cash Price	$675.84
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$31.41
Rate for Payer: Molina CHIP/Medicaid	$31.41
Rate for Payer: Multiplan Auto	$499.20
Rate for Payer: Multiplan Commercial	$499.20
Rate for Payer: Multiplan Workers Comp	$499.20
Rate for Payer: Parkland Medicaid	$31.41
Rate for Payer: Scott and White EPO/PPO	$384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.41
Rate for Payer: Superior Health Plan EPO	$104.45

XR Hand 2 Views Right BCE

Facility

$768.00

Service Code	CPT 73120 RT,FY
Hospital Charge Code	3100765
Hospital Revenue Code	320
Min. Negotiated Rate	$26.41
Max. Negotiated Rate	$499.20
Rate for Payer: Aetna Commercial	$26.41
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$31.41
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	$675.84
Rate for Payer: Cash Price	$675.84
Rate for Payer: Cash Price	$675.84
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$31.41
Rate for Payer: Molina CHIP/Medicaid	$31.41
Rate for Payer: Multiplan Auto	$499.20
Rate for Payer: Multiplan Commercial	$499.20
Rate for Payer: Multiplan Workers Comp	$499.20
Rate for Payer: Parkland Medicaid	$31.41
Rate for Payer: Scott and White EPO/PPO	$384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.41
Rate for Payer: Superior Health Plan EPO	$104.45

XR Hand 2 Views Right BCE

Facility

$768.00

Service Code	CPT 73120 RT,FY
Hospital Charge Code	3100765
Hospital Revenue Code	320
Rate for Payer: Cash Price	$675.84

XR Hand Complete 3+ Views Left

Facility

$813.00

Service Code	CPT 73130 LT,FY
Hospital Charge Code	3160157
Hospital Revenue Code	320
Min. Negotiated Rate	$32.18
Max. Negotiated Rate	$528.45
Rate for Payer: Aetna Commercial	$32.18
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$37.09
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	$715.44
Rate for Payer: Cash Price	$715.44
Rate for Payer: Cash Price	$715.44
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$37.09
Rate for Payer: Molina CHIP/Medicaid	$37.09
Rate for Payer: Multiplan Auto	$528.45
Rate for Payer: Multiplan Commercial	$528.45
Rate for Payer: Multiplan Workers Comp	$528.45
Rate for Payer: Parkland Medicaid	$37.09
Rate for Payer: Scott and White EPO/PPO	$406.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.09
Rate for Payer: Superior Health Plan EPO	$110.57

XR Hand Complete 3+ Views Left BCE

Facility

$813.00

Service Code	CPT 73130 LT,FY
Hospital Charge Code	3160157
Hospital Revenue Code	320
Min. Negotiated Rate	$32.18
Max. Negotiated Rate	$528.45
Rate for Payer: Aetna Commercial	$32.18
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$37.09
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	$715.44
Rate for Payer: Cash Price	$715.44
Rate for Payer: Cash Price	$715.44
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$37.09
Rate for Payer: Molina CHIP/Medicaid	$37.09
Rate for Payer: Multiplan Auto	$528.45
Rate for Payer: Multiplan Commercial	$528.45
Rate for Payer: Multiplan Workers Comp	$528.45
Rate for Payer: Parkland Medicaid	$37.09
Rate for Payer: Scott and White EPO/PPO	$406.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.09
Rate for Payer: Superior Health Plan EPO	$110.57

XR Hand Complete 3+ Views Left BCE

Facility

$813.00

Service Code	CPT 73130 LT,FY
Hospital Charge Code	3160157
Hospital Revenue Code	320
Rate for Payer: Cash Price	$715.44

XR Hand Complete 3+ Views Right

Facility

$813.00

Service Code	CPT 73130 RT,FY
Hospital Charge Code	3160140
Hospital Revenue Code	320
Min. Negotiated Rate	$32.18
Max. Negotiated Rate	$528.45
Rate for Payer: Aetna Commercial	$32.18
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$37.09
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	$715.44
Rate for Payer: Cash Price	$715.44
Rate for Payer: Cash Price	$715.44
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$37.09
Rate for Payer: Molina CHIP/Medicaid	$37.09
Rate for Payer: Multiplan Auto	$528.45
Rate for Payer: Multiplan Commercial	$528.45
Rate for Payer: Multiplan Workers Comp	$528.45
Rate for Payer: Parkland Medicaid	$37.09
Rate for Payer: Scott and White EPO/PPO	$406.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.09
Rate for Payer: Superior Health Plan EPO	$110.57

XR Hand Complete 3+ Views Right BCE

Facility

$813.00

Service Code	CPT 73130 RT,FY
Hospital Charge Code	3160140
Hospital Revenue Code	320
Min. Negotiated Rate	$32.18
Max. Negotiated Rate	$528.45
Rate for Payer: Aetna Commercial	$32.18
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$37.09
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	$715.44
Rate for Payer: Cash Price	$715.44
Rate for Payer: Cash Price	$715.44
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$37.09
Rate for Payer: Molina CHIP/Medicaid	$37.09
Rate for Payer: Multiplan Auto	$528.45
Rate for Payer: Multiplan Commercial	$528.45
Rate for Payer: Multiplan Workers Comp	$528.45
Rate for Payer: Parkland Medicaid	$37.09
Rate for Payer: Scott and White EPO/PPO	$406.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.09
Rate for Payer: Superior Health Plan EPO	$110.57

XR Hand Complete 3+ Views Right BCE

Facility

$813.00

Service Code	CPT 73130 RT,FY
Hospital Charge Code	3160140
Hospital Revenue Code	320
Rate for Payer: Cash Price	$715.44

XR Hip 1 View Left

Facility

$530.00

Service Code	CPT 73501 LT,FY
Hospital Charge Code	3181205
Hospital Revenue Code	320
Min. Negotiated Rate	$26.79
Max. Negotiated Rate	$344.50
Rate for Payer: Aetna Commercial	$26.79
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$33.08
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	$466.40
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$33.08
Rate for Payer: Molina CHIP/Medicaid	$33.08
Rate for Payer: Multiplan Auto	$344.50
Rate for Payer: Multiplan Commercial	$344.50
Rate for Payer: Multiplan Workers Comp	$344.50
Rate for Payer: Parkland Medicaid	$33.08
Rate for Payer: Scott and White EPO/PPO	$265.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.08
Rate for Payer: Superior Health Plan EPO	$72.08

XR Hip 1 View Left BCE

Facility

$530.00

Service Code	CPT 73501 LT,FY
Hospital Charge Code	3181205
Hospital Revenue Code	320
Min. Negotiated Rate	$26.79
Max. Negotiated Rate	$344.50
Rate for Payer: Aetna Commercial	$26.79
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$33.08
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	$466.40
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$33.08
Rate for Payer: Molina CHIP/Medicaid	$33.08
Rate for Payer: Multiplan Auto	$344.50
Rate for Payer: Multiplan Commercial	$344.50
Rate for Payer: Multiplan Workers Comp	$344.50
Rate for Payer: Parkland Medicaid	$33.08
Rate for Payer: Scott and White EPO/PPO	$265.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.08
Rate for Payer: Superior Health Plan EPO	$72.08

XR Hip 1 View Left BCE

Facility

$530.00

Service Code	CPT 73501 LT,FY
Hospital Charge Code	3181205
Hospital Revenue Code	320
Rate for Payer: Cash Price	$466.40

XR Hip 1 View Right

Facility

$530.00

Service Code	CPT 73501 RT,FY
Hospital Charge Code	3181204
Hospital Revenue Code	320
Min. Negotiated Rate	$26.79
Max. Negotiated Rate	$344.50
Rate for Payer: Aetna Commercial	$26.79
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$33.08
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	$466.40
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$33.08
Rate for Payer: Molina CHIP/Medicaid	$33.08
Rate for Payer: Multiplan Auto	$344.50
Rate for Payer: Multiplan Commercial	$344.50
Rate for Payer: Multiplan Workers Comp	$344.50
Rate for Payer: Parkland Medicaid	$33.08
Rate for Payer: Scott and White EPO/PPO	$265.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.08
Rate for Payer: Superior Health Plan EPO	$72.08

XR Hip 1 View Right BCE

Facility

$530.00

Service Code	CPT 73501 RT,FY
Hospital Charge Code	3181204
Hospital Revenue Code	320
Rate for Payer: Cash Price	$466.40

Know your out-of-pocket cost for care.

All Charges