White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Sacroiliac Joints 3+ Views BCE

Facility

$241.00

Service Code	CPT 72202 FY
Hospital Charge Code	3100534
Hospital Revenue Code	320
Rate for Payer: Cash Price	$212.08

XR Sacrum/Coccyx 2+ Views

Facility

$344.00

Service Code	CPT 72220 FY
Hospital Charge Code	3100542
Hospital Revenue Code	320
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$223.60
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	$302.72
Rate for Payer: Cash Price	$302.72
Rate for Payer: Cash Price	$302.72
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	$223.60
Rate for Payer: Multiplan Commercial	$223.60
Rate for Payer: Multiplan Workers Comp	$223.60
Rate for Payer: Parkland Medicaid	$32.75
Rate for Payer: Scott and White EPO/PPO	$172.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.75
Rate for Payer: Superior Health Plan EPO	$46.78

XR Sacrum/Coccyx 2+ Views BCE

Facility

$344.00

Service Code	CPT 72220 FY
Hospital Charge Code	3100542
Hospital Revenue Code	320
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$223.60
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	$302.72
Rate for Payer: Cash Price	$302.72
Rate for Payer: Cash Price	$302.72
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	$223.60
Rate for Payer: Multiplan Commercial	$223.60
Rate for Payer: Multiplan Workers Comp	$223.60
Rate for Payer: Parkland Medicaid	$32.75
Rate for Payer: Scott and White EPO/PPO	$172.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.75
Rate for Payer: Superior Health Plan EPO	$46.78

XR Sacrum/Coccyx 2+ Views BCE

Facility

$344.00

Service Code	CPT 72220 FY
Hospital Charge Code	3100542
Hospital Revenue Code	320
Rate for Payer: Cash Price	$302.72

XR Scapula Left

Facility

$382.00

Service Code	CPT 73010 LT,FY
Hospital Charge Code	3100575
Hospital Revenue Code	320
Min. Negotiated Rate	$17.15
Max. Negotiated Rate	$248.30
Rate for Payer: Aetna Commercial	$17.15
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$23.73
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	$336.16
Rate for Payer: Cash Price	$336.16
Rate for Payer: Cash Price	$336.16
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$23.73
Rate for Payer: Molina CHIP/Medicaid	$23.73
Rate for Payer: Multiplan Auto	$248.30
Rate for Payer: Multiplan Commercial	$248.30
Rate for Payer: Multiplan Workers Comp	$248.30
Rate for Payer: Parkland Medicaid	$23.73
Rate for Payer: Scott and White EPO/PPO	$191.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.73
Rate for Payer: Superior Health Plan EPO	$51.95

XR Scapula Left BCE

Facility

$382.00

Service Code	CPT 73010 LT,FY
Hospital Charge Code	3100575
Hospital Revenue Code	320
Min. Negotiated Rate	$17.15
Max. Negotiated Rate	$248.30
Rate for Payer: Aetna Commercial	$17.15
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$23.73
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	$336.16
Rate for Payer: Cash Price	$336.16
Rate for Payer: Cash Price	$336.16
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$23.73
Rate for Payer: Molina CHIP/Medicaid	$23.73
Rate for Payer: Multiplan Auto	$248.30
Rate for Payer: Multiplan Commercial	$248.30
Rate for Payer: Multiplan Workers Comp	$248.30
Rate for Payer: Parkland Medicaid	$23.73
Rate for Payer: Scott and White EPO/PPO	$191.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.73
Rate for Payer: Superior Health Plan EPO	$51.95

XR Scapula Left BCE

Facility

$382.00

Service Code	CPT 73010 LT,FY
Hospital Charge Code	3100575
Hospital Revenue Code	320
Rate for Payer: Cash Price	$336.16

XR Scapula Right

Facility

$382.00

Service Code	CPT 73010 RT,FY
Hospital Charge Code	3100583
Hospital Revenue Code	320
Min. Negotiated Rate	$17.15
Max. Negotiated Rate	$248.30
Rate for Payer: Aetna Commercial	$17.15
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$23.73
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	$336.16
Rate for Payer: Cash Price	$336.16
Rate for Payer: Cash Price	$336.16
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$23.73
Rate for Payer: Molina CHIP/Medicaid	$23.73
Rate for Payer: Multiplan Auto	$248.30
Rate for Payer: Multiplan Commercial	$248.30
Rate for Payer: Multiplan Workers Comp	$248.30
Rate for Payer: Parkland Medicaid	$23.73
Rate for Payer: Scott and White EPO/PPO	$191.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.73
Rate for Payer: Superior Health Plan EPO	$51.95

XR Scapula Right BCE

Facility

$382.00

Service Code	CPT 73010 RT,FY
Hospital Charge Code	3100583
Hospital Revenue Code	320
Rate for Payer: Cash Price	$336.16

XR Scapula Right BCE

Facility

$382.00

Service Code	CPT 73010 RT,FY
Hospital Charge Code	3100583
Hospital Revenue Code	320
Min. Negotiated Rate	$17.15
Max. Negotiated Rate	$248.30
Rate for Payer: Aetna Commercial	$17.15
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$23.73
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	$336.16
Rate for Payer: Cash Price	$336.16
Rate for Payer: Cash Price	$336.16
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$23.73
Rate for Payer: Molina CHIP/Medicaid	$23.73
Rate for Payer: Multiplan Auto	$248.30
Rate for Payer: Multiplan Commercial	$248.30
Rate for Payer: Multiplan Workers Comp	$248.30
Rate for Payer: Parkland Medicaid	$23.73
Rate for Payer: Scott and White EPO/PPO	$191.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.73
Rate for Payer: Superior Health Plan EPO	$51.95

XR Shoulder 1 View Left

Facility

$507.00

Service Code	CPT 73020 LT,FY
Hospital Charge Code	3101565
Hospital Revenue Code	320
Min. Negotiated Rate	$15.99
Max. Negotiated Rate	$329.55
Rate for Payer: Aetna Commercial	$15.99
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$21.71
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	$446.16
Rate for Payer: Cash Price	$446.16
Rate for Payer: Cash Price	$446.16
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$21.71
Rate for Payer: Molina CHIP/Medicaid	$21.71
Rate for Payer: Multiplan Auto	$329.55
Rate for Payer: Multiplan Commercial	$329.55
Rate for Payer: Multiplan Workers Comp	$329.55
Rate for Payer: Parkland Medicaid	$21.71
Rate for Payer: Scott and White EPO/PPO	$253.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.71
Rate for Payer: Superior Health Plan EPO	$68.95

XR Shoulder 1 View Left BCE

Facility

$507.00

Service Code	CPT 73020 LT,FY
Hospital Charge Code	3101565
Hospital Revenue Code	320
Min. Negotiated Rate	$15.99
Max. Negotiated Rate	$329.55
Rate for Payer: Aetna Commercial	$15.99
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$21.71
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	$446.16
Rate for Payer: Cash Price	$446.16
Rate for Payer: Cash Price	$446.16
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$21.71
Rate for Payer: Molina CHIP/Medicaid	$21.71
Rate for Payer: Multiplan Auto	$329.55
Rate for Payer: Multiplan Commercial	$329.55
Rate for Payer: Multiplan Workers Comp	$329.55
Rate for Payer: Parkland Medicaid	$21.71
Rate for Payer: Scott and White EPO/PPO	$253.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.71
Rate for Payer: Superior Health Plan EPO	$68.95

XR Shoulder 1 View Left BCE

Facility

$507.00

Service Code	CPT 73020 LT,FY
Hospital Charge Code	3101565
Hospital Revenue Code	320
Rate for Payer: Cash Price	$446.16

XR Shoulder 1 View Right

Facility

$507.00

Service Code	CPT 73020 RT,FY
Hospital Charge Code	3101672
Hospital Revenue Code	320
Min. Negotiated Rate	$15.99
Max. Negotiated Rate	$329.55
Rate for Payer: Aetna Commercial	$15.99
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$21.71
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	$446.16
Rate for Payer: Cash Price	$446.16
Rate for Payer: Cash Price	$446.16
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$21.71
Rate for Payer: Molina CHIP/Medicaid	$21.71
Rate for Payer: Multiplan Auto	$329.55
Rate for Payer: Multiplan Commercial	$329.55
Rate for Payer: Multiplan Workers Comp	$329.55
Rate for Payer: Parkland Medicaid	$21.71
Rate for Payer: Scott and White EPO/PPO	$253.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.71
Rate for Payer: Superior Health Plan EPO	$68.95

XR Shoulder 1 View Right BCE

Facility

$507.00

Service Code	CPT 73020 RT,FY
Hospital Charge Code	3101672
Hospital Revenue Code	320
Min. Negotiated Rate	$15.99
Max. Negotiated Rate	$329.55
Rate for Payer: Aetna Commercial	$15.99
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$21.71
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	$446.16
Rate for Payer: Cash Price	$446.16
Rate for Payer: Cash Price	$446.16
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$21.71
Rate for Payer: Molina CHIP/Medicaid	$21.71
Rate for Payer: Multiplan Auto	$329.55
Rate for Payer: Multiplan Commercial	$329.55
Rate for Payer: Multiplan Workers Comp	$329.55
Rate for Payer: Parkland Medicaid	$21.71
Rate for Payer: Scott and White EPO/PPO	$253.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.71
Rate for Payer: Superior Health Plan EPO	$68.95

XR Shoulder 1 View Right BCE

Facility

$507.00

Service Code	CPT 73020 RT,FY
Hospital Charge Code	3101672
Hospital Revenue Code	320
Rate for Payer: Cash Price	$446.16

XR Shoulder Complete 2+ Views Left

Facility

$624.00

Service Code	CPT 73030 LT,FY
Hospital Charge Code	3100591
Hospital Revenue Code	320
Min. Negotiated Rate	$29.10
Max. Negotiated Rate	$405.60
Rate for Payer: Aetna Commercial	$29.10
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$34.75
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	$549.12
Rate for Payer: Cash Price	$549.12
Rate for Payer: Cash Price	$549.12
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$34.75
Rate for Payer: Molina CHIP/Medicaid	$34.75
Rate for Payer: Multiplan Auto	$405.60
Rate for Payer: Multiplan Commercial	$405.60
Rate for Payer: Multiplan Workers Comp	$405.60
Rate for Payer: Parkland Medicaid	$34.75
Rate for Payer: Scott and White EPO/PPO	$312.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.75
Rate for Payer: Superior Health Plan EPO	$84.86

XR Shoulder Complete 2+ Views Left BCE

Facility

$624.00

Service Code	CPT 73030 LT,FY
Hospital Charge Code	3100591
Hospital Revenue Code	320
Min. Negotiated Rate	$29.10
Max. Negotiated Rate	$405.60
Rate for Payer: Aetna Commercial	$29.10
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$34.75
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	$549.12
Rate for Payer: Cash Price	$549.12
Rate for Payer: Cash Price	$549.12
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$34.75
Rate for Payer: Molina CHIP/Medicaid	$34.75
Rate for Payer: Multiplan Auto	$405.60
Rate for Payer: Multiplan Commercial	$405.60
Rate for Payer: Multiplan Workers Comp	$405.60
Rate for Payer: Parkland Medicaid	$34.75
Rate for Payer: Scott and White EPO/PPO	$312.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.75
Rate for Payer: Superior Health Plan EPO	$84.86

XR Shoulder Complete 2+ Views Left BCE

Facility

$624.00

Service Code	CPT 73030 LT,FY
Hospital Charge Code	3100591
Hospital Revenue Code	320
Rate for Payer: Cash Price	$549.12

XR Shoulder Complete 2+ Views Right

Facility

$624.00

Service Code	CPT 73030 RT,FY
Hospital Charge Code	3100609
Hospital Revenue Code	320
Min. Negotiated Rate	$29.10
Max. Negotiated Rate	$405.60
Rate for Payer: Aetna Commercial	$29.10
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$34.75
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	$549.12
Rate for Payer: Cash Price	$549.12
Rate for Payer: Cash Price	$549.12
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$34.75
Rate for Payer: Molina CHIP/Medicaid	$34.75
Rate for Payer: Multiplan Auto	$405.60
Rate for Payer: Multiplan Commercial	$405.60
Rate for Payer: Multiplan Workers Comp	$405.60
Rate for Payer: Parkland Medicaid	$34.75
Rate for Payer: Scott and White EPO/PPO	$312.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.75
Rate for Payer: Superior Health Plan EPO	$84.86

XR Shoulder Complete 2+ Views Right BCE

Facility

$624.00

Service Code	CPT 73030 RT,FY
Hospital Charge Code	3100609
Hospital Revenue Code	320
Min. Negotiated Rate	$29.10
Max. Negotiated Rate	$405.60
Rate for Payer: Aetna Commercial	$29.10
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$34.75
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	$549.12
Rate for Payer: Cash Price	$549.12
Rate for Payer: Cash Price	$549.12
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$34.75
Rate for Payer: Molina CHIP/Medicaid	$34.75
Rate for Payer: Multiplan Auto	$405.60
Rate for Payer: Multiplan Commercial	$405.60
Rate for Payer: Multiplan Workers Comp	$405.60
Rate for Payer: Parkland Medicaid	$34.75
Rate for Payer: Scott and White EPO/PPO	$312.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.75
Rate for Payer: Superior Health Plan EPO	$84.86

XR Shoulder Complete 2+ Views Right BCE

Facility

$624.00

Service Code	CPT 73030 RT,FY
Hospital Charge Code	3100609
Hospital Revenue Code	320
Rate for Payer: Cash Price	$549.12

XR SI Joint Arthrogram w Guidance L

Facility

$2,500.00

Service Code	CPT 27096 LT,FY
Hospital Charge Code	6110530
Hospital Revenue Code	761
Min. Negotiated Rate	$143.24
Max. Negotiated Rate	$1,625.00
Rate for Payer: Aetna Commercial	$1,375.00
Rate for Payer: Amerigroup CHIP/Medicaid	$225.00
Rate for Payer: BCBS of TX Blue Advantage	$143.24
Rate for Payer: BCBS of TX Blue Essentials	$171.54
Rate for Payer: BCBS of TX PPO	$216.14
Rate for Payer: Cash Price	$2,200.00
Rate for Payer: Cash Price	$2,200.00
Rate for Payer: Multiplan Auto	$1,625.00
Rate for Payer: Multiplan Commercial	$1,625.00
Rate for Payer: Multiplan Workers Comp	$1,625.00
Rate for Payer: Scott and White EPO/PPO	$1,250.00
Rate for Payer: Superior Health Plan EPO	$340.00

XR SI Joint Arthrogram w Guidance L BCE

Facility

$2,500.00

Service Code	CPT 27096 LT,FY
Hospital Charge Code	6110530
Hospital Revenue Code	761
Min. Negotiated Rate	$143.24
Max. Negotiated Rate	$1,625.00
Rate for Payer: Aetna Commercial	$1,375.00
Rate for Payer: Amerigroup CHIP/Medicaid	$225.00
Rate for Payer: BCBS of TX Blue Advantage	$143.24
Rate for Payer: BCBS of TX Blue Essentials	$171.54
Rate for Payer: BCBS of TX PPO	$216.14
Rate for Payer: Cash Price	$2,200.00
Rate for Payer: Cash Price	$2,200.00
Rate for Payer: Multiplan Auto	$1,625.00
Rate for Payer: Multiplan Commercial	$1,625.00
Rate for Payer: Multiplan Workers Comp	$1,625.00
Rate for Payer: Scott and White EPO/PPO	$1,250.00
Rate for Payer: Superior Health Plan EPO	$340.00

XR SI Joint Arthrogram w Guidance L BCE

Facility

$2,500.00

Service Code	CPT 27096 LT,FY
Hospital Charge Code	6110530
Hospital Revenue Code	761
Rate for Payer: Cash Price	$2,200.00

Know your out-of-pocket cost for care.

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