White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$463.08

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 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
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

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 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

XRAY spine; thoracic, 3 views

Facility

$845.00

Service Code	HCPCS 72072
Hospital Charge Code	991136
Hospital Revenue Code	320
Rate for Payer: Cash Price	$574.60

XRAY spine; thoracic, 3 views

Facility

$845.00

Service Code	HCPCS 72072
Hospital Charge Code	991136
Hospital Revenue Code	320
Min. Negotiated Rate	$39.76
Max. Negotiated Rate	$608.40
Rate for Payer: Amerigroup CHIP/Medicaid	$39.76
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	$574.60
Rate for Payer: Cash Price	$574.60
Rate for Payer: Cash Price	$574.60
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$608.40
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	$608.40
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$549.25
Rate for Payer: Multiplan Commercial	$549.25
Rate for Payer: Multiplan Workers Comp	$549.25
Rate for Payer: Parkland Medicaid	$608.40
Rate for Payer: Scott and White EPO/PPO	$48.98
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$608.40
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

XRAY thoracic, minimum of 4 views

Facility

$419.00

Service Code	HCPCS 72074
Hospital Charge Code	990939
Hospital Revenue Code	320
Min. Negotiated Rate	$44.78
Max. Negotiated Rate	$301.68
Rate for Payer: Amerigroup CHIP/Medicaid	$44.78
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	$284.92
Rate for Payer: Cash Price	$284.92
Rate for Payer: Cash Price	$284.92
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$301.68
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	$301.68
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$272.35
Rate for Payer: Multiplan Commercial	$272.35
Rate for Payer: Multiplan Workers Comp	$272.35
Rate for Payer: Parkland Medicaid	$301.68
Rate for Payer: Scott and White EPO/PPO	$55.16
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$301.68
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

XRAY thoracic, minimum of 4 views

Facility

$419.00

Service Code	HCPCS 72074
Hospital Charge Code	990939
Hospital Revenue Code	320
Rate for Payer: Cash Price	$284.92

XR Barium Enema Complete

Facility

$779.00

Service Code	HCPCS 74270
Hospital Charge Code	3101144
Hospital Revenue Code	320
Min. Negotiated Rate	$153.70
Max. Negotiated Rate	$560.88
Rate for Payer: Amerigroup CHIP/Medicaid	$153.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
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 Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$529.72
Rate for Payer: Cash Price	$529.72
Rate for Payer: Cash Price	$529.72
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$560.88
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$560.88
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$506.35
Rate for Payer: Multiplan Commercial	$506.35
Rate for Payer: Multiplan Workers Comp	$506.35
Rate for Payer: Parkland Medicaid	$560.88
Rate for Payer: Scott and White EPO/PPO	$189.45
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$560.88
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

XR Barium Enema Complete

Facility

$779.00

Service Code	HCPCS 74270
Hospital Charge Code	3101144
Hospital Revenue Code	320
Rate for Payer: Cash Price	$529.72

XR Barium Enema w/ Air Complete

Facility

$892.00

Service Code	HCPCS 74280
Hospital Charge Code	3101151
Hospital Revenue Code	320
Rate for Payer: Cash Price	$606.56

XR Barium Enema w/ Air Complete

Facility

$892.00

Service Code	HCPCS 74280
Hospital Charge Code	3101151
Hospital Revenue Code	320
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$642.24
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
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 Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$402.71
Rate for Payer: Cash Price	$606.56
Rate for Payer: Cash Price	$606.56
Rate for Payer: Cash Price	$606.56
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$642.24
Rate for Payer: Cigna Medicare	$176.20
Rate for Payer: Employer Direct Commercial	$176.20
Rate for Payer: Humana Medicare/TRICARE	$176.20
Rate for Payer: Molina CHIP/Medicaid	$642.24
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
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	$642.24
Rate for Payer: Scott and White EPO/PPO	$271.35
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$642.24
Rate for Payer: Superior Health Plan EPO	$176.20
Rate for Payer: Superior Health Plan Medicare	$176.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$176.20
Rate for Payer: Universal American Medicare	$176.20
Rate for Payer: Wellcare Medicare	$176.20
Rate for Payer: Wellmed Medicare	$176.20

XR Bone Age Studies

Facility

$604.00

Service Code	HCPCS 77072
Hospital Charge Code	3170082
Hospital Revenue Code	320
Rate for Payer: Cash Price	$410.72

XR Bone Age Studies

Facility

$604.00

Service Code	HCPCS 77072
Hospital Charge Code	3170082
Hospital Revenue Code	320
Min. Negotiated Rate	$26.06
Max. Negotiated Rate	$434.88
Rate for Payer: Amerigroup CHIP/Medicaid	$26.06
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	$410.72
Rate for Payer: Cash Price	$410.72
Rate for Payer: Cash Price	$410.72
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$434.88
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	$434.88
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$392.60
Rate for Payer: Multiplan Commercial	$392.60
Rate for Payer: Multiplan Workers Comp	$392.60
Rate for Payer: Parkland Medicaid	$434.88
Rate for Payer: Scott and White EPO/PPO	$32.08
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$434.88
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 Calcaneus Left

Facility

$307.00

Service Code	HCPCS 73650 LT
Hospital Charge Code	3101045
Hospital Revenue Code	320
Rate for Payer: Cash Price	$208.76

XR Calcaneus Left

Facility

$307.00

Service Code	HCPCS 73650 LT
Hospital Charge Code	3101045
Hospital Revenue Code	320
Min. Negotiated Rate	$28.74
Max. Negotiated Rate	$221.04
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	$208.76
Rate for Payer: Cash Price	$208.76
Rate for Payer: Cash Price	$208.76
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$221.04
Rate for Payer: Molina CHIP/Medicaid	$221.04
Rate for Payer: Multiplan Auto	$199.55
Rate for Payer: Multiplan Commercial	$199.55
Rate for Payer: Multiplan Workers Comp	$199.55
Rate for Payer: Parkland Medicaid	$221.04
Rate for Payer: Scott and White EPO/PPO	$153.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$221.04
Rate for Payer: Superior Health Plan EPO	$41.75

XR Calcaneus Right

Facility

$307.00

Service Code	HCPCS 73650 RT
Hospital Charge Code	3101037
Hospital Revenue Code	320
Min. Negotiated Rate	$28.74
Max. Negotiated Rate	$221.04
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	$208.76
Rate for Payer: Cash Price	$208.76
Rate for Payer: Cash Price	$208.76
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$221.04
Rate for Payer: Molina CHIP/Medicaid	$221.04
Rate for Payer: Multiplan Auto	$199.55
Rate for Payer: Multiplan Commercial	$199.55
Rate for Payer: Multiplan Workers Comp	$199.55
Rate for Payer: Parkland Medicaid	$221.04
Rate for Payer: Scott and White EPO/PPO	$153.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$221.04
Rate for Payer: Superior Health Plan EPO	$41.75

Know your out-of-pocket cost for care.

All Charges