White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Calcaneus Right

Facility

$307.00

Service Code	HCPCS 73650 RT
Hospital Charge Code	3101037
Hospital Revenue Code	320
Rate for Payer: Cash Price	$208.76

XR Cervical Or Pharynx Esophagus

Facility

$851.00

Service Code	HCPCS 74210
Hospital Charge Code	4904210
Hospital Revenue Code	320
Min. Negotiated Rate	$94.89
Max. Negotiated Rate	$612.72
Rate for Payer: Amerigroup CHIP/Medicaid	$94.89
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	$578.68
Rate for Payer: Cash Price	$578.68
Rate for Payer: Cash Price	$578.68
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$612.72
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	$612.72
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$553.15
Rate for Payer: Multiplan Commercial	$553.15
Rate for Payer: Multiplan Workers Comp	$553.15
Rate for Payer: Parkland Medicaid	$612.72
Rate for Payer: Scott and White EPO/PPO	$116.94
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$612.72
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 Cervical Or Pharynx Esophagus

Facility

$851.00

Service Code	HCPCS 74210
Hospital Charge Code	4904210
Hospital Revenue Code	320
Rate for Payer: Cash Price	$578.68

XR Change Cystostomy Tube

Facility

$2,426.00

Service Code	HCPCS 51705
Hospital Charge Code	8914598
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,649.68

XR Change Cystostomy Tube

Facility

$2,426.00

Service Code	HCPCS 51705
Hospital Charge Code	8914598
Hospital Revenue Code	360
Min. Negotiated Rate	$51.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$51.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$250.99
Rate for Payer: Amerigroup Medicare	$250.99
Rate for Payer: BCBS of TX Blue Advantage	$102.45
Rate for Payer: BCBS of TX Blue Essentials	$122.70
Rate for Payer: BCBS of TX Medicare	$250.99
Rate for Payer: BCBS of TX PPO	$154.60
Rate for Payer: Cash Price	$1,649.68
Rate for Payer: Cash Price	$1,649.68
Rate for Payer: Cash Price	$1,649.68
Rate for Payer: Cigna Commercial	$530.54
Rate for Payer: Cigna Medicaid	$1,746.72
Rate for Payer: Cigna Medicare	$250.99
Rate for Payer: Employer Direct Commercial	$250.99
Rate for Payer: Humana Medicare/TRICARE	$250.99
Rate for Payer: Molina CHIP/Medicaid	$1,746.72
Rate for Payer: Molina Dual Medicare/Medicaid	$250.99
Rate for Payer: Molina Medicare	$250.99
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	$1,746.72
Rate for Payer: Scott and White EPO/PPO	$418.16
Rate for Payer: Scott and White Medicare	$250.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,746.72
Rate for Payer: Superior Health Plan EPO	$250.99
Rate for Payer: Superior Health Plan Medicare	$250.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$250.99
Rate for Payer: Universal American Medicare	$250.99
Rate for Payer: Wellcare Medicare	$250.99
Rate for Payer: Wellmed Medicare	$250.99

XR Chest

Facility

$664.00

Service Code	HCPCS 71045
Hospital Charge Code	3181546
Hospital Revenue Code	320
Min. Negotiated Rate	$25.73
Max. Negotiated Rate	$478.08
Rate for Payer: Amerigroup CHIP/Medicaid	$25.73
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	$451.52
Rate for Payer: Cash Price	$451.52
Rate for Payer: Cash Price	$451.52
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$478.08
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	$478.08
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$431.60
Rate for Payer: Multiplan Commercial	$431.60
Rate for Payer: Multiplan Workers Comp	$431.60
Rate for Payer: Parkland Medicaid	$478.08
Rate for Payer: Scott and White EPO/PPO	$31.66
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$478.08
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 Chest

Facility

$664.00

Service Code	HCPCS 71045
Hospital Charge Code	3181546
Hospital Revenue Code	320
Rate for Payer: Cash Price	$451.52

XR Chest 2 Views

Facility

$695.00

Service Code	HCPCS 71046
Hospital Charge Code	3181550
Hospital Revenue Code	320
Min. Negotiated Rate	$33.75
Max. Negotiated Rate	$500.40
Rate for Payer: Amerigroup CHIP/Medicaid	$33.75
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	$472.60
Rate for Payer: Cash Price	$472.60
Rate for Payer: Cash Price	$472.60
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$500.40
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	$500.40
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$451.75
Rate for Payer: Multiplan Commercial	$451.75
Rate for Payer: Multiplan Workers Comp	$451.75
Rate for Payer: Parkland Medicaid	$500.40
Rate for Payer: Scott and White EPO/PPO	$41.56
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$500.40
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 Chest 2 Views

Facility

$695.00

Service Code	HCPCS 71046
Hospital Charge Code	3181550
Hospital Revenue Code	320
Rate for Payer: Cash Price	$472.60

XR Chest 2 Views w/ Apical Lordotic

Facility

$718.00

Service Code	HCPCS 71047
Hospital Charge Code	3181552
Hospital Revenue Code	320
Min. Negotiated Rate	$42.44
Max. Negotiated Rate	$516.96
Rate for Payer: Amerigroup CHIP/Medicaid	$42.44
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	$488.24
Rate for Payer: Cash Price	$488.24
Rate for Payer: Cash Price	$488.24
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$516.96
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	$516.96
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$466.70
Rate for Payer: Multiplan Commercial	$466.70
Rate for Payer: Multiplan Workers Comp	$466.70
Rate for Payer: Parkland Medicaid	$516.96
Rate for Payer: Scott and White EPO/PPO	$52.29
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$516.96
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 Chest 2 Views w/ Apical Lordotic

Facility

$718.00

Service Code	HCPCS 71047
Hospital Charge Code	3181552
Hospital Revenue Code	320
Rate for Payer: Cash Price	$488.24

XR Chest 3 Views

Facility

$718.00

Service Code	HCPCS 71047
Hospital Charge Code	4901047
Hospital Revenue Code	324
Min. Negotiated Rate	$42.44
Max. Negotiated Rate	$516.96
Rate for Payer: Amerigroup CHIP/Medicaid	$42.44
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	$488.24
Rate for Payer: Cash Price	$488.24
Rate for Payer: Cash Price	$488.24
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$516.96
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	$516.96
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$466.70
Rate for Payer: Multiplan Commercial	$466.70
Rate for Payer: Multiplan Workers Comp	$466.70
Rate for Payer: Parkland Medicaid	$516.96
Rate for Payer: Scott and White EPO/PPO	$52.29
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$516.96
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 Chest 3 Views

Facility

$718.00

Service Code	HCPCS 71047
Hospital Charge Code	4901047
Hospital Revenue Code	324
Rate for Payer: Cash Price	$488.24

XR Chest 4+ Views w/ Fluoroscopy

Facility

$767.00

Service Code	HCPCS 71048
Hospital Charge Code	3181554
Hospital Revenue Code	320
Min. Negotiated Rate	$45.78
Max. Negotiated Rate	$552.24
Rate for Payer: Amerigroup CHIP/Medicaid	$45.78
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	$521.56
Rate for Payer: Cash Price	$521.56
Rate for Payer: Cash Price	$521.56
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$552.24
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	$552.24
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$498.55
Rate for Payer: Multiplan Commercial	$498.55
Rate for Payer: Multiplan Workers Comp	$498.55
Rate for Payer: Parkland Medicaid	$552.24
Rate for Payer: Scott and White EPO/PPO	$56.41
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$552.24
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 Chest 4+ Views w/ Fluoroscopy

Facility

$767.00

Service Code	HCPCS 71048
Hospital Charge Code	3181554
Hospital Revenue Code	320
Rate for Payer: Cash Price	$521.56

XR Cholangiogram in OR

Facility

$1,622.00

Service Code	HCPCS 74300
Hospital Charge Code	3101177
Hospital Revenue Code	320
Min. Negotiated Rate	$30.92
Max. Negotiated Rate	$1,167.84
Rate for Payer: Amerigroup CHIP/Medicaid	$145.98
Rate for Payer: BCBS of TX Blue Advantage	$30.92
Rate for Payer: BCBS of TX Blue Essentials	$37.11
Rate for Payer: BCBS of TX PPO	$41.42
Rate for Payer: Cash Price	$1,102.96
Rate for Payer: Cash Price	$1,102.96
Rate for Payer: Cigna Medicaid	$1,167.84
Rate for Payer: Molina CHIP/Medicaid	$1,167.84
Rate for Payer: Multiplan Auto	$1,054.30
Rate for Payer: Multiplan Commercial	$1,054.30
Rate for Payer: Multiplan Workers Comp	$1,054.30
Rate for Payer: Parkland Medicaid	$1,167.84
Rate for Payer: Scott and White EPO/PPO	$811.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,167.84
Rate for Payer: Superior Health Plan EPO	$220.59

XR Cholangiogram in OR

Facility

$1,622.00

Service Code	HCPCS 74300
Hospital Charge Code	3101177
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,102.96

XR Clavicle Left

Facility

$463.00

Service Code	HCPCS 73000 LT
Hospital Charge Code	3100559
Hospital Revenue Code	320
Rate for Payer: Cash Price	$314.84

XR Clavicle Left

Facility

$463.00

Service Code	HCPCS 73000 LT
Hospital Charge Code	3100559
Hospital Revenue Code	320
Min. Negotiated Rate	$32.75
Max. Negotiated Rate	$333.36
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
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	$314.84
Rate for Payer: Cash Price	$314.84
Rate for Payer: Cash Price	$314.84
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$333.36
Rate for Payer: Molina CHIP/Medicaid	$333.36
Rate for Payer: Multiplan Auto	$300.95
Rate for Payer: Multiplan Commercial	$300.95
Rate for Payer: Multiplan Workers Comp	$300.95
Rate for Payer: Parkland Medicaid	$333.36
Rate for Payer: Scott and White EPO/PPO	$231.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$333.36
Rate for Payer: Superior Health Plan EPO	$62.97

XR Clavicle Right

Facility

$463.00

Service Code	HCPCS 73000 RT
Hospital Charge Code	3100567
Hospital Revenue Code	320
Min. Negotiated Rate	$32.75
Max. Negotiated Rate	$333.36
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
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	$314.84
Rate for Payer: Cash Price	$314.84
Rate for Payer: Cash Price	$314.84
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$333.36
Rate for Payer: Molina CHIP/Medicaid	$333.36
Rate for Payer: Multiplan Auto	$300.95
Rate for Payer: Multiplan Commercial	$300.95
Rate for Payer: Multiplan Workers Comp	$300.95
Rate for Payer: Parkland Medicaid	$333.36
Rate for Payer: Scott and White EPO/PPO	$231.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$333.36
Rate for Payer: Superior Health Plan EPO	$62.97

XR Clavicle Right

Facility

$463.00

Service Code	HCPCS 73000 RT
Hospital Charge Code	3100567
Hospital Revenue Code	320
Rate for Payer: Cash Price	$314.84

XR Cystogram

Facility

$732.00

Service Code	HCPCS 74430
Hospital Charge Code	3101243
Hospital Revenue Code	320
Min. Negotiated Rate	$41.44
Max. Negotiated Rate	$843.89
Rate for Payer: Amerigroup CHIP/Medicaid	$41.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
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 Medicare	$350.46
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$497.76
Rate for Payer: Cash Price	$497.76
Rate for Payer: Cash Price	$497.76
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$527.04
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$527.04
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$475.80
Rate for Payer: Multiplan Commercial	$475.80
Rate for Payer: Multiplan Workers Comp	$475.80
Rate for Payer: Parkland Medicaid	$527.04
Rate for Payer: Scott and White EPO/PPO	$51.00
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$527.04
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

XR Cystogram

Facility

$732.00

Service Code	HCPCS 74430
Hospital Charge Code	3101243
Hospital Revenue Code	320
Rate for Payer: Cash Price	$497.76

XR Elbow 2 Views Left

Facility

$594.00

Service Code	HCPCS 73070 LT
Hospital Charge Code	3100666
Hospital Revenue Code	320
Rate for Payer: Cash Price	$403.92

XR Elbow 2 Views Left

Facility

$594.00

Service Code	HCPCS 73070 LT
Hospital Charge Code	3100666
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

Know your out-of-pocket cost for care.

All Charges