White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR SI Joint Arthrogram w Guidance R

Facility

$2,500.00

Service Code	CPT 27096 RT,FY
Hospital Charge Code	6100007
Hospital Revenue Code	320
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 R BCE

Facility

$2,500.00

Service Code	CPT 27096 RT,FY
Hospital Charge Code	6100007
Hospital Revenue Code	320
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 R BCE

Facility

$2,500.00

Service Code	CPT 27096 RT,FY
Hospital Charge Code	6100007
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,200.00

XR SI Joint Inj Anes an/or Arth w Gde 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 Inj Anes an/or Arth w Gde R

Facility

$2,500.00

Service Code	CPT 27096 RT,FY
Hospital Charge Code	6100007
Hospital Revenue Code	320
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 Sinuses Paranasal < 3 Views

Facility

$193.00

Service Code	CPT 70210 FY
Hospital Charge Code	3101490
Hospital Revenue Code	320
Min. Negotiated Rate	$26.25
Max. Negotiated Rate	$188.25
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	$169.84
Rate for Payer: Cash Price	$169.84
Rate for Payer: Cash Price	$169.84
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	$125.45
Rate for Payer: Multiplan Commercial	$125.45
Rate for Payer: Multiplan Workers Comp	$125.45
Rate for Payer: Parkland Medicaid	$32.41
Rate for Payer: Scott and White EPO/PPO	$96.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.41
Rate for Payer: Superior Health Plan EPO	$26.25

XR Sinuses Paranasal < 3 Views BCE

Facility

$193.00

Service Code	CPT 70210 FY
Hospital Charge Code	3101490
Hospital Revenue Code	320
Rate for Payer: Cash Price	$169.84

XR Sinuses Paranasal < 3 Views BCE

Facility

$193.00

Service Code	CPT 70210 FY
Hospital Charge Code	3101490
Hospital Revenue Code	320
Min. Negotiated Rate	$26.25
Max. Negotiated Rate	$188.25
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	$169.84
Rate for Payer: Cash Price	$169.84
Rate for Payer: Cash Price	$169.84
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	$125.45
Rate for Payer: Multiplan Commercial	$125.45
Rate for Payer: Multiplan Workers Comp	$125.45
Rate for Payer: Parkland Medicaid	$32.41
Rate for Payer: Scott and White EPO/PPO	$96.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.41
Rate for Payer: Superior Health Plan EPO	$26.25

XR Sinuses Paranasal Complete

Facility

$433.00

Service Code	CPT 70220 FY
Hospital Charge Code	3100187
Hospital Revenue Code	320
Min. Negotiated Rate	$31.41
Max. Negotiated Rate	$281.45
Rate for Payer: Aetna Commercial	$31.41
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$37.76
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	$381.04
Rate for Payer: Cash Price	$381.04
Rate for Payer: Cash Price	$381.04
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$37.76
Rate for Payer: Molina CHIP/Medicaid	$37.76
Rate for Payer: Multiplan Auto	$281.45
Rate for Payer: Multiplan Commercial	$281.45
Rate for Payer: Multiplan Workers Comp	$281.45
Rate for Payer: Parkland Medicaid	$37.76
Rate for Payer: Scott and White EPO/PPO	$216.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.76
Rate for Payer: Superior Health Plan EPO	$58.89

XR Sinuses Paranasal Complete BCE

Facility

$433.00

Service Code	CPT 70220 FY
Hospital Charge Code	3100187
Hospital Revenue Code	320
Rate for Payer: Cash Price	$381.04

XR Sinuses Paranasal Complete BCE

Facility

$433.00

Service Code	CPT 70220 FY
Hospital Charge Code	3100187
Hospital Revenue Code	320
Min. Negotiated Rate	$31.41
Max. Negotiated Rate	$281.45
Rate for Payer: Aetna Commercial	$31.41
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$37.76
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	$381.04
Rate for Payer: Cash Price	$381.04
Rate for Payer: Cash Price	$381.04
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$37.76
Rate for Payer: Molina CHIP/Medicaid	$37.76
Rate for Payer: Multiplan Auto	$281.45
Rate for Payer: Multiplan Commercial	$281.45
Rate for Payer: Multiplan Workers Comp	$281.45
Rate for Payer: Parkland Medicaid	$37.76
Rate for Payer: Scott and White EPO/PPO	$216.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.76
Rate for Payer: Superior Health Plan EPO	$58.89

XR Sinus Tract SI

Facility

$702.00

Service Code	CPT 76080 FY
Hospital Charge Code	2101855
Hospital Revenue Code	320
Min. Negotiated Rate	$41.04
Max. Negotiated Rate	$1,142.91
Rate for Payer: Aetna Commercial	$41.04
Rate for Payer: Aetna Medicare	$756.79
Rate for Payer: Amerigroup CHIP/Medicaid	$60.14
Rate for Payer: BCBS of TX Blue Advantage	$794.61
Rate for Payer: BCBS of TX Blue Essentials	$953.53
Rate for Payer: BCBS of TX PPO	$1,064.29
Rate for Payer: Cash Price	$617.76
Rate for Payer: Cash Price	$617.76
Rate for Payer: Cash Price	$617.76
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicaid	$60.14
Rate for Payer: Molina CHIP/Medicaid	$60.14
Rate for Payer: Multiplan Auto	$456.30
Rate for Payer: Multiplan Commercial	$456.30
Rate for Payer: Multiplan Workers Comp	$456.30
Rate for Payer: Parkland Medicaid	$60.14
Rate for Payer: Scott and White EPO/PPO	$351.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60.14
Rate for Payer: Superior Health Plan EPO	$95.47

XR Sinus Tract SI BCE

Facility

$702.00

Service Code	CPT 76080 FY
Hospital Charge Code	2101855
Hospital Revenue Code	320
Rate for Payer: Cash Price	$617.76

XR Sinus Tract SI BCE

Facility

$702.00

Service Code	CPT 76080 FY
Hospital Charge Code	2101855
Hospital Revenue Code	320
Min. Negotiated Rate	$41.04
Max. Negotiated Rate	$1,142.91
Rate for Payer: Aetna Commercial	$41.04
Rate for Payer: Aetna Medicare	$756.79
Rate for Payer: Amerigroup CHIP/Medicaid	$60.14
Rate for Payer: BCBS of TX Blue Advantage	$794.61
Rate for Payer: BCBS of TX Blue Essentials	$953.53
Rate for Payer: BCBS of TX PPO	$1,064.29
Rate for Payer: Cash Price	$617.76
Rate for Payer: Cash Price	$617.76
Rate for Payer: Cash Price	$617.76
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicaid	$60.14
Rate for Payer: Molina CHIP/Medicaid	$60.14
Rate for Payer: Multiplan Auto	$456.30
Rate for Payer: Multiplan Commercial	$456.30
Rate for Payer: Multiplan Workers Comp	$456.30
Rate for Payer: Parkland Medicaid	$60.14
Rate for Payer: Scott and White EPO/PPO	$351.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60.14
Rate for Payer: Superior Health Plan EPO	$95.47

XR Skull < 4 Views

Facility

$443.00

Service Code	CPT 70250 FY
Hospital Charge Code	3100203
Hospital Revenue Code	320
Min. Negotiated Rate	$31.03
Max. Negotiated Rate	$287.95
Rate for Payer: Aetna Commercial	$31.03
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$36.09
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	$389.84
Rate for Payer: Cash Price	$389.84
Rate for Payer: Cash Price	$389.84
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$36.09
Rate for Payer: Molina CHIP/Medicaid	$36.09
Rate for Payer: Multiplan Auto	$287.95
Rate for Payer: Multiplan Commercial	$287.95
Rate for Payer: Multiplan Workers Comp	$287.95
Rate for Payer: Parkland Medicaid	$36.09
Rate for Payer: Scott and White EPO/PPO	$221.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.09
Rate for Payer: Superior Health Plan EPO	$60.25

XR Skull < 4 Views BCE

Facility

$443.00

Service Code	CPT 70250 FY
Hospital Charge Code	3100203
Hospital Revenue Code	320
Rate for Payer: Cash Price	$389.84

XR Skull < 4 Views BCE

Facility

$443.00

Service Code	CPT 70250 FY
Hospital Charge Code	3100203
Hospital Revenue Code	320
Min. Negotiated Rate	$31.03
Max. Negotiated Rate	$287.95
Rate for Payer: Aetna Commercial	$31.03
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$36.09
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	$389.84
Rate for Payer: Cash Price	$389.84
Rate for Payer: Cash Price	$389.84
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$36.09
Rate for Payer: Molina CHIP/Medicaid	$36.09
Rate for Payer: Multiplan Auto	$287.95
Rate for Payer: Multiplan Commercial	$287.95
Rate for Payer: Multiplan Workers Comp	$287.95
Rate for Payer: Parkland Medicaid	$36.09
Rate for Payer: Scott and White EPO/PPO	$221.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.09
Rate for Payer: Superior Health Plan EPO	$60.25

XR Skull Complete

Facility

$637.00

Service Code	CPT 70260 FY
Hospital Charge Code	3100211
Hospital Revenue Code	320
Min. Negotiated Rate	$36.03
Max. Negotiated Rate	$414.05
Rate for Payer: Aetna Commercial	$36.03
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$44.78
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	$560.56
Rate for Payer: Cash Price	$560.56
Rate for Payer: Cash Price	$560.56
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$44.78
Rate for Payer: Molina CHIP/Medicaid	$44.78
Rate for Payer: Multiplan Auto	$414.05
Rate for Payer: Multiplan Commercial	$414.05
Rate for Payer: Multiplan Workers Comp	$414.05
Rate for Payer: Parkland Medicaid	$44.78
Rate for Payer: Scott and White EPO/PPO	$318.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.78
Rate for Payer: Superior Health Plan EPO	$86.63

XR Skull Complete BCE

Facility

$637.00

Service Code	CPT 70260 FY
Hospital Charge Code	3100211
Hospital Revenue Code	320
Rate for Payer: Cash Price	$560.56

XR Skull Complete BCE

Facility

$637.00

Service Code	CPT 70260 FY
Hospital Charge Code	3100211
Hospital Revenue Code	320
Min. Negotiated Rate	$36.03
Max. Negotiated Rate	$414.05
Rate for Payer: Aetna Commercial	$36.03
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$44.78
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	$560.56
Rate for Payer: Cash Price	$560.56
Rate for Payer: Cash Price	$560.56
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$44.78
Rate for Payer: Molina CHIP/Medicaid	$44.78
Rate for Payer: Multiplan Auto	$414.05
Rate for Payer: Multiplan Commercial	$414.05
Rate for Payer: Multiplan Workers Comp	$414.05
Rate for Payer: Parkland Medicaid	$44.78
Rate for Payer: Scott and White EPO/PPO	$318.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.78
Rate for Payer: Superior Health Plan EPO	$86.63

XR Small Bowel via Enteroclysis Tube

Facility

$892.00

Service Code	CPT 74251 FY
Hospital Charge Code	4904251
Hospital Revenue Code	320
Min. Negotiated Rate	$121.31
Max. Negotiated Rate	$579.80
Rate for Payer: Aetna Commercial	$203.23
Rate for Payer: Aetna Medicare	$252.04
Rate for Payer: Amerigroup CHIP/Medicaid	$180.34
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	$784.96
Rate for Payer: Cash Price	$784.96
Rate for Payer: Cash Price	$784.96
Rate for Payer: Cigna Commercial	$380.65
Rate for Payer: Cigna Medicaid	$180.34
Rate for Payer: Molina CHIP/Medicaid	$180.34
Rate for Payer: Multiplan Auto	$579.80
Rate for Payer: Multiplan Commercial	$579.80
Rate for Payer: Multiplan Workers Comp	$579.80
Rate for Payer: Parkland Medicaid	$180.34
Rate for Payer: Scott and White EPO/PPO	$446.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.34
Rate for Payer: Superior Health Plan EPO	$121.31

XR Small Bowel via Enteroclysis Tube BCE

Facility

$892.00

Service Code	CPT 74251 FY
Hospital Charge Code	4904251
Hospital Revenue Code	320
Min. Negotiated Rate	$121.31
Max. Negotiated Rate	$579.80
Rate for Payer: Aetna Commercial	$203.23
Rate for Payer: Aetna Medicare	$252.04
Rate for Payer: Amerigroup CHIP/Medicaid	$180.34
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	$784.96
Rate for Payer: Cash Price	$784.96
Rate for Payer: Cash Price	$784.96
Rate for Payer: Cigna Commercial	$380.65
Rate for Payer: Cigna Medicaid	$180.34
Rate for Payer: Molina CHIP/Medicaid	$180.34
Rate for Payer: Multiplan Auto	$579.80
Rate for Payer: Multiplan Commercial	$579.80
Rate for Payer: Multiplan Workers Comp	$579.80
Rate for Payer: Parkland Medicaid	$180.34
Rate for Payer: Scott and White EPO/PPO	$446.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.34
Rate for Payer: Superior Health Plan EPO	$121.31

XR Small Bowel via Enteroclysis Tube BCE

Facility

$892.00

Service Code	CPT 74251 FY
Hospital Charge Code	4904251
Hospital Revenue Code	320
Rate for Payer: Cash Price	$784.96

XR Small Bowel w/ Multiple Series

Facility

$685.00

Service Code	CPT 74250 FY
Hospital Charge Code	3101136
Hospital Revenue Code	320
Min. Negotiated Rate	$93.16
Max. Negotiated Rate	$445.25
Rate for Payer: Aetna Commercial	$100.75
Rate for Payer: Aetna Medicare	$252.04
Rate for Payer: Amerigroup CHIP/Medicaid	$124.30
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	$602.80
Rate for Payer: Cash Price	$602.80
Rate for Payer: Cash Price	$602.80
Rate for Payer: Cigna Commercial	$380.65
Rate for Payer: Cigna Medicaid	$124.30
Rate for Payer: Molina CHIP/Medicaid	$124.30
Rate for Payer: Multiplan Auto	$445.25
Rate for Payer: Multiplan Commercial	$445.25
Rate for Payer: Multiplan Workers Comp	$445.25
Rate for Payer: Parkland Medicaid	$124.30
Rate for Payer: Scott and White EPO/PPO	$342.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$124.30
Rate for Payer: Superior Health Plan EPO	$93.16

XR Small Bowel w/ Multiple Series BCE

Facility

$685.00

Service Code	CPT 74250 FY
Hospital Charge Code	3101136
Hospital Revenue Code	320
Rate for Payer: Cash Price	$602.80

Know your out-of-pocket cost for care.

All Charges