White Rock Medical Center

All Charges

Charge

Type

Setting

Price

US Echo Fetal CV

Facility

$1,124.00

Service Code	HCPCS 76825
Hospital Charge Code	5066870
Hospital Revenue Code	402
Min. Negotiated Rate	$262.29
Max. Negotiated Rate	$1,160.29
Rate for Payer: Amerigroup CHIP/Medicaid	$262.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$548.90
Rate for Payer: Amerigroup Medicare	$548.90
Rate for Payer: BCBS of TX Blue Advantage	$321.70
Rate for Payer: BCBS of TX Blue Essentials	$386.04
Rate for Payer: BCBS of TX Medicare	$548.90
Rate for Payer: BCBS of TX PPO	$430.88
Rate for Payer: Cash Price	$764.32
Rate for Payer: Cash Price	$764.32
Rate for Payer: Cash Price	$764.32
Rate for Payer: Cigna Commercial	$1,160.29
Rate for Payer: Cigna Medicaid	$809.28
Rate for Payer: Cigna Medicare	$548.90
Rate for Payer: Employer Direct Commercial	$548.90
Rate for Payer: Humana Medicare/TRICARE	$548.90
Rate for Payer: Molina CHIP/Medicaid	$809.28
Rate for Payer: Molina Dual Medicare/Medicaid	$548.90
Rate for Payer: Molina Medicare	$548.90
Rate for Payer: Multiplan Auto	$730.60
Rate for Payer: Multiplan Commercial	$730.60
Rate for Payer: Multiplan Workers Comp	$730.60
Rate for Payer: Parkland Medicaid	$809.28
Rate for Payer: Scott and White EPO/PPO	$323.45
Rate for Payer: Scott and White Medicare	$548.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$809.28
Rate for Payer: Superior Health Plan EPO	$548.90
Rate for Payer: Superior Health Plan Medicare	$548.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$548.90
Rate for Payer: Universal American Medicare	$548.90
Rate for Payer: Wellcare Medicare	$548.90
Rate for Payer: Wellmed Medicare	$548.90

US Echo Fetal CV

Facility

$1,124.00

Service Code	HCPCS 76825
Hospital Charge Code	5066870
Hospital Revenue Code	402
Rate for Payer: Cash Price	$764.32

US Extremity Joint Complete Left

Facility

$974.00

Service Code	HCPCS 76881 LT
Hospital Charge Code	3530082
Hospital Revenue Code	402
Rate for Payer: Cash Price	$662.32

US Extremity Joint Complete Left

Facility

$974.00

Service Code	HCPCS 76881 LT
Hospital Charge Code	3530082
Hospital Revenue Code	402
Min. Negotiated Rate	$95.73
Max. Negotiated Rate	$701.28
Rate for Payer: Amerigroup CHIP/Medicaid	$96.28
Rate for Payer: BCBS of TX Blue Advantage	$95.73
Rate for Payer: BCBS of TX Blue Essentials	$114.88
Rate for Payer: BCBS of TX PPO	$128.22
Rate for Payer: Cash Price	$662.32
Rate for Payer: Cash Price	$662.32
Rate for Payer: Cash Price	$662.32
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$701.28
Rate for Payer: Molina CHIP/Medicaid	$701.28
Rate for Payer: Multiplan Auto	$633.10
Rate for Payer: Multiplan Commercial	$633.10
Rate for Payer: Multiplan Workers Comp	$633.10
Rate for Payer: Parkland Medicaid	$701.28
Rate for Payer: Scott and White EPO/PPO	$487.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$701.28
Rate for Payer: Superior Health Plan EPO	$132.46

US Extremity Joint Complete Right

Facility

$974.00

Service Code	HCPCS 76881 RT
Hospital Charge Code	3530081
Hospital Revenue Code	402
Min. Negotiated Rate	$95.73
Max. Negotiated Rate	$701.28
Rate for Payer: Amerigroup CHIP/Medicaid	$96.28
Rate for Payer: BCBS of TX Blue Advantage	$95.73
Rate for Payer: BCBS of TX Blue Essentials	$114.88
Rate for Payer: BCBS of TX PPO	$128.22
Rate for Payer: Cash Price	$662.32
Rate for Payer: Cash Price	$662.32
Rate for Payer: Cash Price	$662.32
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$701.28
Rate for Payer: Molina CHIP/Medicaid	$701.28
Rate for Payer: Multiplan Auto	$633.10
Rate for Payer: Multiplan Commercial	$633.10
Rate for Payer: Multiplan Workers Comp	$633.10
Rate for Payer: Parkland Medicaid	$701.28
Rate for Payer: Scott and White EPO/PPO	$487.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$701.28
Rate for Payer: Superior Health Plan EPO	$132.46

US Extremity Joint Complete Right

Facility

$974.00

Service Code	HCPCS 76881 RT
Hospital Charge Code	3530081
Hospital Revenue Code	402
Rate for Payer: Cash Price	$662.32

US Extremity Joint Limited Right

Facility

$844.00

Service Code	HCPCS 76882 RT
Hospital Charge Code	3530083
Hospital Revenue Code	402
Min. Negotiated Rate	$30.35
Max. Negotiated Rate	$607.68
Rate for Payer: Amerigroup CHIP/Medicaid	$30.35
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	$573.92
Rate for Payer: Cash Price	$573.92
Rate for Payer: Cash Price	$573.92
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$607.68
Rate for Payer: Molina CHIP/Medicaid	$607.68
Rate for Payer: Multiplan Auto	$548.60
Rate for Payer: Multiplan Commercial	$548.60
Rate for Payer: Multiplan Workers Comp	$548.60
Rate for Payer: Parkland Medicaid	$607.68
Rate for Payer: Scott and White EPO/PPO	$422.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$607.68
Rate for Payer: Superior Health Plan EPO	$114.78

US Extremity Joint Limited Right

Facility

$844.00

Service Code	HCPCS 76882 RT
Hospital Charge Code	3530083
Hospital Revenue Code	402
Rate for Payer: Cash Price	$573.92

US Extremity Soft Tissue Ltd LEFT

Facility

$844.00

Service Code	HCPCS 76882 LT
Hospital Charge Code	3530084
Hospital Revenue Code	402
Rate for Payer: Cash Price	$573.92

US Extremity Soft Tissue Ltd LEFT

Facility

$844.00

Service Code	HCPCS 76882 LT
Hospital Charge Code	3530084
Hospital Revenue Code	402
Min. Negotiated Rate	$30.35
Max. Negotiated Rate	$607.68
Rate for Payer: Amerigroup CHIP/Medicaid	$30.35
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	$573.92
Rate for Payer: Cash Price	$573.92
Rate for Payer: Cash Price	$573.92
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$607.68
Rate for Payer: Molina CHIP/Medicaid	$607.68
Rate for Payer: Multiplan Auto	$548.60
Rate for Payer: Multiplan Commercial	$548.60
Rate for Payer: Multiplan Workers Comp	$548.60
Rate for Payer: Parkland Medicaid	$607.68
Rate for Payer: Scott and White EPO/PPO	$422.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$607.68
Rate for Payer: Superior Health Plan EPO	$114.78

US Fetal Biophysical Profile w/ Non-Str

Facility

$1,012.00

Service Code	HCPCS 76818
Hospital Charge Code	5066818
Hospital Revenue Code	402
Rate for Payer: Cash Price	$688.16

US Fetal Biophysical Profile w/ Non-Str

Facility

$1,012.00

Service Code	HCPCS 76818
Hospital Charge Code	5066818
Hospital Revenue Code	402
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$728.64
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$112.98
Rate for Payer: BCBS of TX Blue Essentials	$135.57
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$151.32
Rate for Payer: Cash Price	$688.16
Rate for Payer: Cash Price	$688.16
Rate for Payer: Cash Price	$688.16
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$728.64
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$728.64
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$657.80
Rate for Payer: Multiplan Commercial	$657.80
Rate for Payer: Multiplan Workers Comp	$657.80
Rate for Payer: Parkland Medicaid	$728.64
Rate for Payer: Scott and White EPO/PPO	$146.64
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$728.64
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

US Fetal Biophysical Profile w/o N-Str

Facility

$543.00

Service Code	HCPCS 76819
Hospital Charge Code	3500857
Hospital Revenue Code	402
Rate for Payer: Cash Price	$369.24

US Fetal Biophysical Profile w/o N-Str

Facility

$543.00

Service Code	HCPCS 76819
Hospital Charge Code	3500857
Hospital Revenue Code	402
Min. Negotiated Rate	$83.24
Max. Negotiated Rate	$390.96
Rate for Payer: Amerigroup CHIP/Medicaid	$85.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$83.24
Rate for Payer: BCBS of TX Blue Essentials	$99.89
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$111.49
Rate for Payer: Cash Price	$369.24
Rate for Payer: Cash Price	$369.24
Rate for Payer: Cash Price	$369.24
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$390.96
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$390.96
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$352.95
Rate for Payer: Multiplan Commercial	$352.95
Rate for Payer: Multiplan Workers Comp	$352.95
Rate for Payer: Parkland Medicaid	$390.96
Rate for Payer: Scott and White EPO/PPO	$105.84
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$390.96
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

US FNA Guide Initial 1st Lesion

Facility

$2,595.00

Service Code	HCPCS 10005
Hospital Charge Code	3500200
Hospital Revenue Code	361
Min. Negotiated Rate	$125.37
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$257.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
Rate for Payer: BCBS of TX Blue Advantage	$125.37
Rate for Payer: BCBS of TX Blue Essentials	$150.14
Rate for Payer: BCBS of TX Medicare	$711.36
Rate for Payer: BCBS of TX PPO	$189.18
Rate for Payer: Cash Price	$1,764.60
Rate for Payer: Cash Price	$1,764.60
Rate for Payer: Cash Price	$1,764.60
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$1,868.40
Rate for Payer: Cigna Medicare	$711.36
Rate for Payer: Employer Direct Commercial	$711.36
Rate for Payer: Humana Medicare/TRICARE	$711.36
Rate for Payer: Molina CHIP/Medicaid	$1,868.40
Rate for Payer: Molina Dual Medicare/Medicaid	$711.36
Rate for Payer: Molina Medicare	$711.36
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	$1,868.40
Rate for Payer: Scott and White EPO/PPO	$1,190.38
Rate for Payer: Scott and White Medicare	$711.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,868.40
Rate for Payer: Superior Health Plan EPO	$711.36
Rate for Payer: Superior Health Plan Medicare	$711.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$711.36
Rate for Payer: Universal American Medicare	$711.36
Rate for Payer: Wellcare Medicare	$711.36
Rate for Payer: Wellmed Medicare	$711.36

US FNA Guide Initial 1st Lesion

Facility

$2,595.00

Service Code	HCPCS 10005
Hospital Charge Code	3500200
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,764.60

US Guidance For Biopsy Needle Placement

Facility

$1,596.00

Service Code	HCPCS 76942
Hospital Charge Code	3500071
Hospital Revenue Code	402
Min. Negotiated Rate	$41.63
Max. Negotiated Rate	$1,149.12
Rate for Payer: Amerigroup CHIP/Medicaid	$143.64
Rate for Payer: BCBS of TX Blue Advantage	$41.63
Rate for Payer: BCBS of TX Blue Essentials	$49.96
Rate for Payer: BCBS of TX PPO	$55.76
Rate for Payer: Cash Price	$1,085.28
Rate for Payer: Cash Price	$1,085.28
Rate for Payer: Cigna Medicaid	$1,149.12
Rate for Payer: Molina CHIP/Medicaid	$1,149.12
Rate for Payer: Multiplan Auto	$1,037.40
Rate for Payer: Multiplan Commercial	$1,037.40
Rate for Payer: Multiplan Workers Comp	$1,037.40
Rate for Payer: Parkland Medicaid	$1,149.12
Rate for Payer: Scott and White EPO/PPO	$71.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.12
Rate for Payer: Superior Health Plan EPO	$217.06

US Guidance For Biopsy Needle Placement

Facility

$1,596.00

Service Code	HCPCS 76942
Hospital Charge Code	3500071
Hospital Revenue Code	402
Rate for Payer: Cash Price	$1,085.28

US Guide Compression PseudoAneurysm

Facility

$1,094.00

Service Code	HCPCS 76936
Hospital Charge Code	5066936
Hospital Revenue Code	402
Rate for Payer: Cash Price	$743.92

US Guide Compression PseudoAneurysm

Facility

$1,094.00

Service Code	HCPCS 76936
Hospital Charge Code	5066936
Hospital Revenue Code	402
Min. Negotiated Rate	$216.91
Max. Negotiated Rate	$787.68
Rate for Payer: Amerigroup CHIP/Medicaid	$260.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$287.22
Rate for Payer: BCBS of TX Blue Essentials	$344.66
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$384.69
Rate for Payer: Cash Price	$743.92
Rate for Payer: Cash Price	$743.92
Rate for Payer: Cash Price	$743.92
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$787.68
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$787.68
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$711.10
Rate for Payer: Multiplan Commercial	$711.10
Rate for Payer: Multiplan Workers Comp	$711.10
Rate for Payer: Parkland Medicaid	$787.68
Rate for Payer: Scott and White EPO/PPO	$320.95
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$787.68
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

US Head/Neck Soft Tissue

Facility

$1,130.00

Service Code	HCPCS 76536
Hospital Charge Code	3500113
Hospital Revenue Code	402
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$813.60
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
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 Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$768.40
Rate for Payer: Cash Price	$768.40
Rate for Payer: Cash Price	$768.40
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$813.60
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$813.60
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$734.50
Rate for Payer: Multiplan Commercial	$734.50
Rate for Payer: Multiplan Workers Comp	$734.50
Rate for Payer: Parkland Medicaid	$813.60
Rate for Payer: Scott and White EPO/PPO	$136.31
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$813.60
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

US Head/Neck Soft Tissue

Facility

$1,130.00

Service Code	HCPCS 76536
Hospital Charge Code	3500113
Hospital Revenue Code	402
Rate for Payer: Cash Price	$768.40

US Hysterosonogram

Facility

$1,711.00

Service Code	HCPCS 76831
Hospital Charge Code	5036831
Hospital Revenue Code	402
Rate for Payer: Cash Price	$1,163.48

US Hysterosonogram

Facility

$1,711.00

Service Code	HCPCS 76831
Hospital Charge Code	5036831
Hospital Revenue Code	402
Min. Negotiated Rate	$116.61
Max. Negotiated Rate	$1,231.92
Rate for Payer: Amerigroup CHIP/Medicaid	$116.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$384.52
Rate for Payer: BCBS of TX Blue Essentials	$461.42
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$515.02
Rate for Payer: Cash Price	$1,163.48
Rate for Payer: Cash Price	$1,163.48
Rate for Payer: Cash Price	$1,163.48
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$1,231.92
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$1,231.92
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$1,112.15
Rate for Payer: Multiplan Commercial	$1,112.15
Rate for Payer: Multiplan Workers Comp	$1,112.15
Rate for Payer: Parkland Medicaid	$1,231.92
Rate for Payer: Scott and White EPO/PPO	$143.80
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,231.92
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

US Intraoperative

Facility

$1,502.00

Service Code	HCPCS 76998
Hospital Charge Code	3520012
Hospital Revenue Code	402
Rate for Payer: Cash Price	$1,021.36

Know your out-of-pocket cost for care.

All Charges