White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Arthrogram Hip Right

Facility

$558.00

Service Code	HCPCS 73525 RT
Hospital Charge Code	3170063
Hospital Revenue Code	322
Min. Negotiated Rate	$75.89
Max. Negotiated Rate	$843.89
Rate for Payer: Amerigroup CHIP/Medicaid	$129.31
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$379.44
Rate for Payer: Cash Price	$379.44
Rate for Payer: Cash Price	$379.44
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$401.76
Rate for Payer: Molina CHIP/Medicaid	$401.76
Rate for Payer: Multiplan Auto	$362.70
Rate for Payer: Multiplan Commercial	$362.70
Rate for Payer: Multiplan Workers Comp	$362.70
Rate for Payer: Parkland Medicaid	$401.76
Rate for Payer: Scott and White EPO/PPO	$279.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$401.76
Rate for Payer: Superior Health Plan EPO	$75.89

XR Arthrogram Hip Right

Facility

$558.00

Service Code	HCPCS 73525 RT
Hospital Charge Code	3170063
Hospital Revenue Code	322
Rate for Payer: Cash Price	$379.44

XR Arthrogram Knee Left

Facility

$908.00

Service Code	HCPCS 73580 LT
Hospital Charge Code	3170065
Hospital Revenue Code	322
Min. Negotiated Rate	$110.94
Max. Negotiated Rate	$843.89
Rate for Payer: Amerigroup CHIP/Medicaid	$110.94
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$653.76
Rate for Payer: Molina CHIP/Medicaid	$653.76
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$653.76
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$653.76
Rate for Payer: Superior Health Plan EPO	$123.49

XR Arthrogram Knee Left

Facility

$908.00

Service Code	HCPCS 73580 LT
Hospital Charge Code	3170065
Hospital Revenue Code	322
Rate for Payer: Cash Price	$617.44

XR Arthrogram Knee Right

Facility

$908.00

Service Code	HCPCS 73580 RT
Hospital Charge Code	3170066
Hospital Revenue Code	322
Rate for Payer: Cash Price	$617.44

XR Arthrogram Knee Right

Facility

$908.00

Service Code	HCPCS 73580 RT
Hospital Charge Code	3170066
Hospital Revenue Code	322
Min. Negotiated Rate	$110.94
Max. Negotiated Rate	$843.89
Rate for Payer: Amerigroup CHIP/Medicaid	$110.94
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$653.76
Rate for Payer: Molina CHIP/Medicaid	$653.76
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$653.76
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$653.76
Rate for Payer: Superior Health Plan EPO	$123.49

XR Arthrogram Shoulder Left

Facility

$681.00

Service Code	HCPCS 73040 LT
Hospital Charge Code	3101771
Hospital Revenue Code	320
Min. Negotiated Rate	$92.62
Max. Negotiated Rate	$843.89
Rate for Payer: Amerigroup CHIP/Medicaid	$131.99
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$463.08
Rate for Payer: Cash Price	$463.08
Rate for Payer: Cash Price	$463.08
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$490.32
Rate for Payer: Molina CHIP/Medicaid	$490.32
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Parkland Medicaid	$490.32
Rate for Payer: Scott and White EPO/PPO	$340.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$490.32
Rate for Payer: Superior Health Plan EPO	$92.62

XR Arthrogram Shoulder Left

Facility

$681.00

Service Code	HCPCS 73040 LT
Hospital Charge Code	3101771
Hospital Revenue Code	320
Rate for Payer: Cash Price	$463.08

XR Arthrogram Shoulder Right

Facility

$681.00

Service Code	HCPCS 73040 RT
Hospital Charge Code	3101763
Hospital Revenue Code	320
Min. Negotiated Rate	$92.62
Max. Negotiated Rate	$843.89
Rate for Payer: Amerigroup CHIP/Medicaid	$131.99
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$463.08
Rate for Payer: Cash Price	$463.08
Rate for Payer: Cash Price	$463.08
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$490.32
Rate for Payer: Molina CHIP/Medicaid	$490.32
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Parkland Medicaid	$490.32
Rate for Payer: Scott and White EPO/PPO	$340.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$490.32
Rate for Payer: Superior Health Plan EPO	$92.62

XR Arthrogram Shoulder Right

Facility

$681.00

Service Code	HCPCS 73040 RT
Hospital Charge Code	3101763
Hospital Revenue Code	320
Rate for Payer: Cash Price	$463.08

XR Arthrogram Wrist Left

Facility

$896.00

Service Code	HCPCS 73115 LT
Hospital Charge Code	3170060
Hospital Revenue Code	322
Rate for Payer: Cash Price	$609.28

XR Arthrogram Wrist Left

Facility

$896.00

Service Code	HCPCS 73115 LT
Hospital Charge Code	3170060
Hospital Revenue Code	322
Min. Negotiated Rate	$121.86
Max. Negotiated Rate	$843.89
Rate for Payer: Amerigroup CHIP/Medicaid	$135.33
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$609.28
Rate for Payer: Cash Price	$609.28
Rate for Payer: Cash Price	$609.28
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$645.12
Rate for Payer: Molina CHIP/Medicaid	$645.12
Rate for Payer: Multiplan Auto	$582.40
Rate for Payer: Multiplan Commercial	$582.40
Rate for Payer: Multiplan Workers Comp	$582.40
Rate for Payer: Parkland Medicaid	$645.12
Rate for Payer: Scott and White EPO/PPO	$448.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$645.12
Rate for Payer: Superior Health Plan EPO	$121.86

XR Arthrogram Wrist RIGHT

Facility

$896.00

Service Code	HCPCS 73115 RT
Hospital Charge Code	3170061
Hospital Revenue Code	322
Rate for Payer: Cash Price	$609.28

XR Arthrogram Wrist RIGHT

Facility

$896.00

Service Code	HCPCS 73115 RT
Hospital Charge Code	3170061
Hospital Revenue Code	322
Min. Negotiated Rate	$121.86
Max. Negotiated Rate	$843.89
Rate for Payer: Amerigroup CHIP/Medicaid	$135.33
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$609.28
Rate for Payer: Cash Price	$609.28
Rate for Payer: Cash Price	$609.28
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$645.12
Rate for Payer: Molina CHIP/Medicaid	$645.12
Rate for Payer: Multiplan Auto	$582.40
Rate for Payer: Multiplan Commercial	$582.40
Rate for Payer: Multiplan Workers Comp	$582.40
Rate for Payer: Parkland Medicaid	$645.12
Rate for Payer: Scott and White EPO/PPO	$448.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$645.12
Rate for Payer: Superior Health Plan EPO	$121.86

X-Ray Detectable Sterile Lap Sponge,18' x 18'.5/Tray

Facility

$7.56

Hospital Charge Code	992834
Hospital Revenue Code	272
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$5.44
Rate for Payer: Amerigroup CHIP/Medicaid	$0.68
Rate for Payer: BCBS of TX Blue Advantage	$2.27
Rate for Payer: BCBS of TX Blue Essentials	$2.72
Rate for Payer: BCBS of TX PPO	$3.02
Rate for Payer: Cash Price	$5.14
Rate for Payer: Cigna Medicaid	$5.44
Rate for Payer: Molina CHIP/Medicaid	$5.44
Rate for Payer: Multiplan Auto	$4.91
Rate for Payer: Multiplan Commercial	$4.91
Rate for Payer: Multiplan Workers Comp	$4.91
Rate for Payer: Parkland Medicaid	$5.44
Rate for Payer: Scott and White EPO/PPO	$3.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.44
Rate for Payer: Superior Health Plan EPO	$1.03

X-Ray Detectable Sterile Lap Sponge,18' x 18'.5/Tray

Facility

$7.56

Hospital Charge Code	992834
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.14

X-ray elbow left 1 view

Facility

$594.00

Service Code	HCPCS 73070 LT:52
Hospital Charge Code	994195
Hospital Revenue Code	320
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$427.68
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	$403.92
Rate for Payer: Cash Price	$403.92
Rate for Payer: Cash Price	$403.92
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$427.68
Rate for Payer: Molina CHIP/Medicaid	$427.68
Rate for Payer: Multiplan Auto	$386.10
Rate for Payer: Multiplan Commercial	$386.10
Rate for Payer: Multiplan Workers Comp	$386.10
Rate for Payer: Parkland Medicaid	$427.68
Rate for Payer: Scott and White EPO/PPO	$297.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$427.68
Rate for Payer: Superior Health Plan EPO	$80.78

X-ray elbow left 1 view

Facility

$594.00

Service Code	HCPCS 73070 LT:52
Hospital Charge Code	994195
Hospital Revenue Code	320
Rate for Payer: Cash Price	$403.92

X-ray elbow right 1 view

Facility

$594.00

Service Code	HCPCS 73070 RT:52
Hospital Charge Code	994196
Hospital Revenue Code	320
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$427.68
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	$403.92
Rate for Payer: Cash Price	$403.92
Rate for Payer: Cash Price	$403.92
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$427.68
Rate for Payer: Molina CHIP/Medicaid	$427.68
Rate for Payer: Multiplan Auto	$386.10
Rate for Payer: Multiplan Commercial	$386.10
Rate for Payer: Multiplan Workers Comp	$386.10
Rate for Payer: Parkland Medicaid	$427.68
Rate for Payer: Scott and White EPO/PPO	$297.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$427.68
Rate for Payer: Superior Health Plan EPO	$80.78

X-ray elbow right 1 view

Facility

$594.00

Service Code	HCPCS 73070 RT:52
Hospital Charge Code	994196
Hospital Revenue Code	320
Rate for Payer: Cash Price	$403.92

X-ray finger left 2nd digit

Facility

$486.00

Service Code	HCPCS 73140 F1
Hospital Charge Code	994210
Hospital Revenue Code	320
Rate for Payer: Cash Price	$330.48

X-ray finger left 2nd digit

Facility

$486.00

Service Code	HCPCS 73140 F1
Hospital Charge Code	994210
Hospital Revenue Code	320
Min. Negotiated Rate	$38.43
Max. Negotiated Rate	$349.92
Rate for Payer: Amerigroup CHIP/Medicaid	$38.43
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	$330.48
Rate for Payer: Cash Price	$330.48
Rate for Payer: Cash Price	$330.48
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$349.92
Rate for Payer: Molina CHIP/Medicaid	$349.92
Rate for Payer: Multiplan Auto	$315.90
Rate for Payer: Multiplan Commercial	$315.90
Rate for Payer: Multiplan Workers Comp	$315.90
Rate for Payer: Parkland Medicaid	$349.92
Rate for Payer: Scott and White EPO/PPO	$243.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$349.92
Rate for Payer: Superior Health Plan EPO	$66.10

X-ray finger left 3rd digit

Facility

$486.00

Service Code	HCPCS 73140 F2
Hospital Charge Code	994211
Hospital Revenue Code	320
Min. Negotiated Rate	$38.43
Max. Negotiated Rate	$349.92
Rate for Payer: Amerigroup CHIP/Medicaid	$38.43
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	$330.48
Rate for Payer: Cash Price	$330.48
Rate for Payer: Cash Price	$330.48
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$349.92
Rate for Payer: Molina CHIP/Medicaid	$349.92
Rate for Payer: Multiplan Auto	$315.90
Rate for Payer: Multiplan Commercial	$315.90
Rate for Payer: Multiplan Workers Comp	$315.90
Rate for Payer: Parkland Medicaid	$349.92
Rate for Payer: Scott and White EPO/PPO	$243.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$349.92
Rate for Payer: Superior Health Plan EPO	$66.10

X-ray finger left 3rd digit

Facility

$486.00

Service Code	HCPCS 73140 F2
Hospital Charge Code	994211
Hospital Revenue Code	320
Rate for Payer: Cash Price	$330.48

X-ray finger left 4th digit

Facility

$486.00

Service Code	HCPCS 73140 F3
Hospital Charge Code	994212
Hospital Revenue Code	320
Rate for Payer: Cash Price	$330.48

Know your out-of-pocket cost for care.

All Charges