White Rock Medical Center

All Charges

Charge

Type

Setting

Price

X-ray finger left 4th digit

Facility

$486.00

Service Code	HCPCS 73140 F3
Hospital Charge Code	994212
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 5th digit

Facility

$486.00

Service Code	HCPCS 73140 F4
Hospital Charge Code	994213
Hospital Revenue Code	320
Rate for Payer: Cash Price	$330.48

X-ray finger left 5th digit

Facility

$486.00

Service Code	HCPCS 73140 F4
Hospital Charge Code	994213
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 right 1st digit

Facility

$486.00

Service Code	HCPCS 73140 F5
Hospital Charge Code	994206
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 right 1st digit

Facility

$486.00

Service Code	HCPCS 73140 F5
Hospital Charge Code	994206
Hospital Revenue Code	320
Rate for Payer: Cash Price	$330.48

X-ray finger right 2nd digit

Facility

$486.00

Service Code	HCPCS 73140 F6
Hospital Charge Code	994207
Hospital Revenue Code	999
Rate for Payer: Cash Price	$330.48

X-ray finger right 2nd digit

Facility

$486.00

Service Code	HCPCS 73140 F6
Hospital Charge Code	994207
Hospital Revenue Code	999
Min. Negotiated Rate	$43.74
Max. Negotiated Rate	$349.92
Rate for Payer: Amerigroup CHIP/Medicaid	$43.74
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 right 3rd digit

Facility

$486.00

Service Code	HCPCS 73140 F7
Hospital Charge Code	994208
Hospital Revenue Code	320
Rate for Payer: Cash Price	$330.48

X-ray finger right 3rd digit

Facility

$486.00

Service Code	HCPCS 73140 F7
Hospital Charge Code	994208
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 right 4th digit

Facility

$486.00

Service Code	HCPCS 73140 F8
Hospital Charge Code	994209
Hospital Revenue Code	320
Rate for Payer: Cash Price	$330.48

X-ray finger right 4th digit

Facility

$486.00

Service Code	HCPCS 73140 F8
Hospital Charge Code	994209
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 foot left 1 view

Facility

$537.00

Service Code	HCPCS 73620 LT:52
Hospital Charge Code	994203
Hospital Revenue Code	320
Min. Negotiated Rate	$28.74
Max. Negotiated Rate	$386.64
Rate for Payer: Amerigroup CHIP/Medicaid	$28.74
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

X-ray foot left 1 view

Facility

$537.00

Service Code	HCPCS 73620 LT:52
Hospital Charge Code	994203
Hospital Revenue Code	320
Rate for Payer: Cash Price	$365.16

X-ray foot right 1 view

Facility

$537.00

Service Code	HCPCS 73620 RT:52
Hospital Charge Code	994204
Hospital Revenue Code	320
Rate for Payer: Cash Price	$365.16

X-ray foot right 1 view

Facility

$537.00

Service Code	HCPCS 73620 RT:52
Hospital Charge Code	994204
Hospital Revenue Code	320
Min. Negotiated Rate	$28.74
Max. Negotiated Rate	$386.64
Rate for Payer: Amerigroup CHIP/Medicaid	$28.74
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

X-ray forearm left 1 view

Facility

$535.00

Service Code	HCPCS 73090 LT:52
Hospital Charge Code	994197
Hospital Revenue Code	320
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$385.20
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	$363.80
Rate for Payer: Cash Price	$363.80
Rate for Payer: Cash Price	$363.80
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$385.20
Rate for Payer: Molina CHIP/Medicaid	$385.20
Rate for Payer: Multiplan Auto	$347.75
Rate for Payer: Multiplan Commercial	$347.75
Rate for Payer: Multiplan Workers Comp	$347.75
Rate for Payer: Parkland Medicaid	$385.20
Rate for Payer: Scott and White EPO/PPO	$267.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$385.20
Rate for Payer: Superior Health Plan EPO	$72.76

X-ray forearm left 1 view

Facility

$535.00

Service Code	HCPCS 73090 LT:52
Hospital Charge Code	994197
Hospital Revenue Code	320
Rate for Payer: Cash Price	$363.80

X-ray forearm right 1 view

Facility

$535.00

Service Code	HCPCS 73090 RT:52
Hospital Charge Code	994198
Hospital Revenue Code	320
Rate for Payer: Cash Price	$363.80

X-ray forearm right 1 view

Facility

$535.00

Service Code	HCPCS 73090 RT:52
Hospital Charge Code	994198
Hospital Revenue Code	320
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$385.20
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	$363.80
Rate for Payer: Cash Price	$363.80
Rate for Payer: Cash Price	$363.80
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$385.20
Rate for Payer: Molina CHIP/Medicaid	$385.20
Rate for Payer: Multiplan Auto	$347.75
Rate for Payer: Multiplan Commercial	$347.75
Rate for Payer: Multiplan Workers Comp	$347.75
Rate for Payer: Parkland Medicaid	$385.20
Rate for Payer: Scott and White EPO/PPO	$267.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$385.20
Rate for Payer: Superior Health Plan EPO	$72.76

X-ray hand bilateral 2 view

Facility

$1,536.00

Service Code	HCPCS 73120 50
Hospital Charge Code	994205
Hospital Revenue Code	320
Min. Negotiated Rate	$31.74
Max. Negotiated Rate	$1,105.92
Rate for Payer: Amerigroup CHIP/Medicaid	$31.74
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	$1,044.48
Rate for Payer: Cash Price	$1,044.48
Rate for Payer: Cash Price	$1,044.48
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$1,105.92
Rate for Payer: Molina CHIP/Medicaid	$1,105.92
Rate for Payer: Multiplan Auto	$998.40
Rate for Payer: Multiplan Commercial	$998.40
Rate for Payer: Multiplan Workers Comp	$998.40
Rate for Payer: Parkland Medicaid	$1,105.92
Rate for Payer: Scott and White EPO/PPO	$768.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,105.92
Rate for Payer: Superior Health Plan EPO	$208.90

X-ray hand bilateral 2 view

Facility

$1,536.00

Service Code	HCPCS 73120 50
Hospital Charge Code	994205
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,044.48

X-ray hand left 1 view

Facility

$768.00

Service Code	HCPCS 73120 LT:52
Hospital Charge Code	994201
Hospital Revenue Code	320
Min. Negotiated Rate	$31.74
Max. Negotiated Rate	$552.96
Rate for Payer: Amerigroup CHIP/Medicaid	$31.74
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	$522.24
Rate for Payer: Cash Price	$522.24
Rate for Payer: Cash Price	$522.24
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$552.96
Rate for Payer: Molina CHIP/Medicaid	$552.96
Rate for Payer: Multiplan Auto	$499.20
Rate for Payer: Multiplan Commercial	$499.20
Rate for Payer: Multiplan Workers Comp	$499.20
Rate for Payer: Parkland Medicaid	$552.96
Rate for Payer: Scott and White EPO/PPO	$384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$552.96
Rate for Payer: Superior Health Plan EPO	$104.45

X-ray hand left 1 view

Facility

$768.00

Service Code	HCPCS 73120 LT:52
Hospital Charge Code	994201
Hospital Revenue Code	320
Rate for Payer: Cash Price	$522.24

X-ray hand right 1 view

Facility

$768.00

Service Code	HCPCS 73120 RT:52
Hospital Charge Code	994202
Hospital Revenue Code	320
Min. Negotiated Rate	$31.74
Max. Negotiated Rate	$552.96
Rate for Payer: Amerigroup CHIP/Medicaid	$31.74
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	$522.24
Rate for Payer: Cash Price	$522.24
Rate for Payer: Cash Price	$522.24
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$552.96
Rate for Payer: Molina CHIP/Medicaid	$552.96
Rate for Payer: Multiplan Auto	$499.20
Rate for Payer: Multiplan Commercial	$499.20
Rate for Payer: Multiplan Workers Comp	$499.20
Rate for Payer: Parkland Medicaid	$552.96
Rate for Payer: Scott and White EPO/PPO	$384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$552.96
Rate for Payer: Superior Health Plan EPO	$104.45

X-ray hand right 1 view

Facility

$768.00

Service Code	HCPCS 73120 RT:52
Hospital Charge Code	994202
Hospital Revenue Code	320
Rate for Payer: Cash Price	$522.24

Know your out-of-pocket cost for care.

All Charges