White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Abdomen KUB 1 View

Facility

$739.00

Service Code	HCPCS 74018
Hospital Charge Code	3181556
Hospital Revenue Code	320
Min. Negotiated Rate	$30.40
Max. Negotiated Rate	$532.08
Rate for Payer: Amerigroup CHIP/Medicaid	$30.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$87.42
Rate for Payer: Amerigroup Medicare	$87.42
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 Medicare	$87.42
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$502.52
Rate for Payer: Cash Price	$502.52
Rate for Payer: Cash Price	$502.52
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$532.08
Rate for Payer: Cigna Medicare	$87.42
Rate for Payer: Employer Direct Commercial	$87.42
Rate for Payer: Humana Medicare/TRICARE	$87.42
Rate for Payer: Molina CHIP/Medicaid	$532.08
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$480.35
Rate for Payer: Multiplan Commercial	$480.35
Rate for Payer: Multiplan Workers Comp	$480.35
Rate for Payer: Parkland Medicaid	$532.08
Rate for Payer: Scott and White EPO/PPO	$37.42
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$532.08
Rate for Payer: Superior Health Plan EPO	$87.42
Rate for Payer: Superior Health Plan Medicare	$87.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$87.42
Rate for Payer: Universal American Medicare	$87.42
Rate for Payer: Wellcare Medicare	$87.42
Rate for Payer: Wellmed Medicare	$87.42

XR Abdomen Series + Chest 1 View

Facility

$827.00

Service Code	HCPCS 74022
Hospital Charge Code	3160314
Hospital Revenue Code	320
Min. Negotiated Rate	$50.13
Max. Negotiated Rate	$595.44
Rate for Payer: Amerigroup CHIP/Medicaid	$50.13
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	$562.36
Rate for Payer: Cash Price	$562.36
Rate for Payer: Cash Price	$562.36
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$595.44
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	$595.44
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$537.55
Rate for Payer: Multiplan Commercial	$537.55
Rate for Payer: Multiplan Workers Comp	$537.55
Rate for Payer: Parkland Medicaid	$595.44
Rate for Payer: Scott and White EPO/PPO	$61.71
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$595.44
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

XR Abdomen Series + Chest 1 View

Facility

$827.00

Service Code	HCPCS 74022
Hospital Charge Code	3160314
Hospital Revenue Code	320
Rate for Payer: Cash Price	$562.36

XR AC Joints Bilateral

Facility

$701.00

Service Code	HCPCS 73050
Hospital Charge Code	3100617
Hospital Revenue Code	320
Rate for Payer: Cash Price	$476.68

XR AC Joints Bilateral

Facility

$701.00

Service Code	HCPCS 73050
Hospital Charge Code	3100617
Hospital Revenue Code	320
Min. Negotiated Rate	$29.08
Max. Negotiated Rate	$504.72
Rate for Payer: Amerigroup CHIP/Medicaid	$29.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$87.42
Rate for Payer: Amerigroup Medicare	$87.42
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 Medicare	$87.42
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$476.68
Rate for Payer: Cash Price	$476.68
Rate for Payer: Cash Price	$476.68
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$504.72
Rate for Payer: Cigna Medicare	$87.42
Rate for Payer: Employer Direct Commercial	$87.42
Rate for Payer: Humana Medicare/TRICARE	$87.42
Rate for Payer: Molina CHIP/Medicaid	$504.72
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$455.65
Rate for Payer: Multiplan Commercial	$455.65
Rate for Payer: Multiplan Workers Comp	$455.65
Rate for Payer: Parkland Medicaid	$504.72
Rate for Payer: Scott and White EPO/PPO	$35.79
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$504.72
Rate for Payer: Superior Health Plan EPO	$87.42
Rate for Payer: Superior Health Plan Medicare	$87.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$87.42
Rate for Payer: Universal American Medicare	$87.42
Rate for Payer: Wellcare Medicare	$87.42
Rate for Payer: Wellmed Medicare	$87.42

XR Angio Extremity in OR Left

Facility

$4,768.00

Service Code	HCPCS 75710 LT
Hospital Charge Code	3160561
Hospital Revenue Code	320
Rate for Payer: Cash Price	$3,242.24

XR Angio Extremity in OR Left

Facility

$4,768.00

Service Code	HCPCS 75710 LT
Hospital Charge Code	3160561
Hospital Revenue Code	320
Min. Negotiated Rate	$150.36
Max. Negotiated Rate	$6,704.76
Rate for Payer: Amerigroup CHIP/Medicaid	$150.36
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$3,432.96
Rate for Payer: Molina CHIP/Medicaid	$3,432.96
Rate for Payer: Multiplan Auto	$3,099.20
Rate for Payer: Multiplan Commercial	$3,099.20
Rate for Payer: Multiplan Workers Comp	$3,099.20
Rate for Payer: Parkland Medicaid	$3,432.96
Rate for Payer: Scott and White EPO/PPO	$2,384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,432.96
Rate for Payer: Superior Health Plan EPO	$648.45

XR Angio Extremity in OR Right

Facility

$4,768.00

Service Code	HCPCS 75710 RT
Hospital Charge Code	3160579
Hospital Revenue Code	320
Rate for Payer: Cash Price	$3,242.24

XR Angio Extremity in OR Right

Facility

$4,768.00

Service Code	HCPCS 75710 RT
Hospital Charge Code	3160579
Hospital Revenue Code	320
Min. Negotiated Rate	$150.36
Max. Negotiated Rate	$6,704.76
Rate for Payer: Amerigroup CHIP/Medicaid	$150.36
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$3,432.96
Rate for Payer: Molina CHIP/Medicaid	$3,432.96
Rate for Payer: Multiplan Auto	$3,099.20
Rate for Payer: Multiplan Commercial	$3,099.20
Rate for Payer: Multiplan Workers Comp	$3,099.20
Rate for Payer: Parkland Medicaid	$3,432.96
Rate for Payer: Scott and White EPO/PPO	$2,384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,432.96
Rate for Payer: Superior Health Plan EPO	$648.45

XR Angiogram Internal Mammary

Facility

$2,911.00

Service Code	HCPCS 75756
Hospital Charge Code	4615757
Hospital Revenue Code	323
Min. Negotiated Rate	$165.40
Max. Negotiated Rate	$6,704.76
Rate for Payer: Amerigroup CHIP/Medicaid	$165.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$1,979.48
Rate for Payer: Cash Price	$1,979.48
Rate for Payer: Cash Price	$1,979.48
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$2,095.92
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$2,095.92
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
Rate for Payer: Multiplan Auto	$1,892.15
Rate for Payer: Multiplan Commercial	$1,892.15
Rate for Payer: Multiplan Workers Comp	$1,892.15
Rate for Payer: Parkland Medicaid	$2,095.92
Rate for Payer: Scott and White EPO/PPO	$203.46
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,095.92
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

XR Angiogram Internal Mammary

Facility

$2,911.00

Service Code	HCPCS 75756
Hospital Charge Code	4615757
Hospital Revenue Code	323
Rate for Payer: Cash Price	$1,979.48

XR Ankle 2 Views Left

Facility

$537.00

Service Code	HCPCS 73600 LT
Hospital Charge Code	3100955
Hospital Revenue Code	320
Min. Negotiated Rate	$32.41
Max. Negotiated Rate	$386.64
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	$365.16
Rate for Payer: Cash Price	$365.16
Rate for Payer: Cash Price	$365.16
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$386.64
Rate for Payer: Molina CHIP/Medicaid	$386.64
Rate for Payer: Multiplan Auto	$349.05
Rate for Payer: Multiplan Commercial	$349.05
Rate for Payer: Multiplan Workers Comp	$349.05
Rate for Payer: Parkland Medicaid	$386.64
Rate for Payer: Scott and White EPO/PPO	$268.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$386.64
Rate for Payer: Superior Health Plan EPO	$73.03

XR Ankle 2 Views Left

Facility

$537.00

Service Code	HCPCS 73600 LT
Hospital Charge Code	3100955
Hospital Revenue Code	320
Rate for Payer: Cash Price	$365.16

XR Ankle 2 Views Right

Facility

$537.00

Service Code	HCPCS 73600 RT
Hospital Charge Code	3100963
Hospital Revenue Code	320
Rate for Payer: Cash Price	$365.16

XR Ankle 2 Views Right

Facility

$537.00

Service Code	HCPCS 73600 RT
Hospital Charge Code	3100963
Hospital Revenue Code	320
Min. Negotiated Rate	$32.41
Max. Negotiated Rate	$386.64
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	$365.16
Rate for Payer: Cash Price	$365.16
Rate for Payer: Cash Price	$365.16
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$386.64
Rate for Payer: Molina CHIP/Medicaid	$386.64
Rate for Payer: Multiplan Auto	$349.05
Rate for Payer: Multiplan Commercial	$349.05
Rate for Payer: Multiplan Workers Comp	$349.05
Rate for Payer: Parkland Medicaid	$386.64
Rate for Payer: Scott and White EPO/PPO	$268.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$386.64
Rate for Payer: Superior Health Plan EPO	$73.03

XR Ankle Complete 3+ Views Left

Facility

$608.00

Service Code	HCPCS 73610 LT
Hospital Charge Code	3100971
Hospital Revenue Code	320
Min. Negotiated Rate	$36.75
Max. Negotiated Rate	$437.76
Rate for Payer: Amerigroup CHIP/Medicaid	$36.75
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	$413.44
Rate for Payer: Cash Price	$413.44
Rate for Payer: Cash Price	$413.44
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$437.76
Rate for Payer: Molina CHIP/Medicaid	$437.76
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$437.76
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$437.76
Rate for Payer: Superior Health Plan EPO	$82.69

XR Ankle Complete 3+ Views Left

Facility

$608.00

Service Code	HCPCS 73610 LT
Hospital Charge Code	3100971
Hospital Revenue Code	320
Rate for Payer: Cash Price	$413.44

XR Ankle Complete 3+ Views Right

Facility

$608.00

Service Code	HCPCS 73610 RT
Hospital Charge Code	3100989
Hospital Revenue Code	320
Min. Negotiated Rate	$36.75
Max. Negotiated Rate	$437.76
Rate for Payer: Amerigroup CHIP/Medicaid	$36.75
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	$413.44
Rate for Payer: Cash Price	$413.44
Rate for Payer: Cash Price	$413.44
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$437.76
Rate for Payer: Molina CHIP/Medicaid	$437.76
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$437.76
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$437.76
Rate for Payer: Superior Health Plan EPO	$82.69

XR Ankle Complete 3+ Views Right

Facility

$608.00

Service Code	HCPCS 73610 RT
Hospital Charge Code	3100989
Hospital Revenue Code	320
Rate for Payer: Cash Price	$413.44

XR Arthrogram Hip Left

Facility

$558.00

Service Code	HCPCS 73525 LT
Hospital Charge Code	3170062
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 Left

Facility

$558.00

Service Code	HCPCS 73525 LT
Hospital Charge Code	3170062
Hospital Revenue Code	322
Rate for Payer: Cash Price	$379.44

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 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 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 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

Know your out-of-pocket cost for care.

All Charges