White Rock Medical Center

All Charges

Charge

Type

Setting

Price

X-ray shoulder left 2 view

Facility

$624.00

Service Code	HCPCS 73030 LT
Hospital Charge Code	994189
Hospital Revenue Code	320
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$449.28
Rate for Payer: Amerigroup CHIP/Medicaid	$35.09
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	$424.32
Rate for Payer: Cash Price	$424.32
Rate for Payer: Cash Price	$424.32
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$449.28
Rate for Payer: Molina CHIP/Medicaid	$449.28
Rate for Payer: Multiplan Auto	$405.60
Rate for Payer: Multiplan Commercial	$405.60
Rate for Payer: Multiplan Workers Comp	$405.60
Rate for Payer: Parkland Medicaid	$449.28
Rate for Payer: Scott and White EPO/PPO	$312.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$449.28
Rate for Payer: Superior Health Plan EPO	$84.86

X-ray shoulder left 2 view

Facility

$624.00

Service Code	HCPCS 73030 LT
Hospital Charge Code	994189
Hospital Revenue Code	320
Rate for Payer: Cash Price	$424.32

X-ray shoulder right 2 view

Facility

$624.00

Service Code	HCPCS 73030 RT
Hospital Charge Code	994188
Hospital Revenue Code	320
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$449.28
Rate for Payer: Amerigroup CHIP/Medicaid	$35.09
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	$424.32
Rate for Payer: Cash Price	$424.32
Rate for Payer: Cash Price	$424.32
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$449.28
Rate for Payer: Molina CHIP/Medicaid	$449.28
Rate for Payer: Multiplan Auto	$405.60
Rate for Payer: Multiplan Commercial	$405.60
Rate for Payer: Multiplan Workers Comp	$405.60
Rate for Payer: Parkland Medicaid	$449.28
Rate for Payer: Scott and White EPO/PPO	$312.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$449.28
Rate for Payer: Superior Health Plan EPO	$84.86

X-ray shoulder right 2 view

Facility

$624.00

Service Code	HCPCS 73030 RT
Hospital Charge Code	994188
Hospital Revenue Code	320
Rate for Payer: Cash Price	$424.32

X-ray spine cervical one view

Facility

$364.00

Service Code	HCPCS 72020
Hospital Charge Code	994192
Hospital Revenue Code	320
Min. Negotiated Rate	$24.39
Max. Negotiated Rate	$262.08
Rate for Payer: Amerigroup CHIP/Medicaid	$24.39
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	$247.52
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$262.08
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	$262.08
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$236.60
Rate for Payer: Multiplan Commercial	$236.60
Rate for Payer: Multiplan Workers Comp	$236.60
Rate for Payer: Parkland Medicaid	$262.08
Rate for Payer: Scott and White EPO/PPO	$131.13
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.08
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

X-ray spine cervical one view

Facility

$364.00

Service Code	HCPCS 72020
Hospital Charge Code	994192
Hospital Revenue Code	320
Rate for Payer: Cash Price	$247.52

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	$157.53
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

X-ray spine thoracic cross table

Facility

$364.00

Service Code	HCPCS 72020
Hospital Charge Code	994193
Hospital Revenue Code	320
Rate for Payer: Cash Price	$247.52

X-ray spine thoracic cross table

Facility

$364.00

Service Code	HCPCS 72020
Hospital Charge Code	994193
Hospital Revenue Code	320
Min. Negotiated Rate	$24.39
Max. Negotiated Rate	$262.08
Rate for Payer: Amerigroup CHIP/Medicaid	$24.39
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	$247.52
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$262.08
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	$262.08
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$236.60
Rate for Payer: Multiplan Commercial	$236.60
Rate for Payer: Multiplan Workers Comp	$236.60
Rate for Payer: Parkland Medicaid	$262.08
Rate for Payer: Scott and White EPO/PPO	$131.13
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.08
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

X-ray Spine Thoracolumbar Junction

Facility

$364.00

Service Code	HCPCS 72020
Hospital Charge Code	994194
Hospital Revenue Code	320
Rate for Payer: Cash Price	$247.52

X-ray Spine Thoracolumbar Junction

Facility

$364.00

Service Code	HCPCS 72020
Hospital Charge Code	994194
Hospital Revenue Code	320
Min. Negotiated Rate	$24.39
Max. Negotiated Rate	$262.08
Rate for Payer: Amerigroup CHIP/Medicaid	$24.39
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	$247.52
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$262.08
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	$262.08
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$236.60
Rate for Payer: Multiplan Commercial	$236.60
Rate for Payer: Multiplan Workers Comp	$236.60
Rate for Payer: Parkland Medicaid	$262.08
Rate for Payer: Scott and White EPO/PPO	$131.13
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.08
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

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	$157.53
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

X-ray wrist left 1 view

Facility

$465.00

Service Code	HCPCS 73100 LT:52
Hospital Charge Code	994199
Hospital Revenue Code	320
Rate for Payer: Cash Price	$316.20

X-ray wrist left 1 view

Facility

$465.00

Service Code	HCPCS 73100 LT:52
Hospital Charge Code	994199
Hospital Revenue Code	320
Min. Negotiated Rate	$34.09
Max. Negotiated Rate	$334.80
Rate for Payer: Amerigroup CHIP/Medicaid	$34.09
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	$316.20
Rate for Payer: Cash Price	$316.20
Rate for Payer: Cash Price	$316.20
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$334.80
Rate for Payer: Molina CHIP/Medicaid	$334.80
Rate for Payer: Multiplan Auto	$302.25
Rate for Payer: Multiplan Commercial	$302.25
Rate for Payer: Multiplan Workers Comp	$302.25
Rate for Payer: Parkland Medicaid	$334.80
Rate for Payer: Scott and White EPO/PPO	$232.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$334.80
Rate for Payer: Superior Health Plan EPO	$63.24

X-ray wrist right 2 view

Facility

$465.00

Service Code	HCPCS 73100 RT:52
Hospital Charge Code	994200
Hospital Revenue Code	320
Rate for Payer: Cash Price	$316.20

X-ray wrist right 2 view

Facility

$465.00

Service Code	HCPCS 73100 RT:52
Hospital Charge Code	994200
Hospital Revenue Code	320
Min. Negotiated Rate	$34.09
Max. Negotiated Rate	$334.80
Rate for Payer: Amerigroup CHIP/Medicaid	$34.09
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	$316.20
Rate for Payer: Cash Price	$316.20
Rate for Payer: Cash Price	$316.20
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$334.80
Rate for Payer: Molina CHIP/Medicaid	$334.80
Rate for Payer: Multiplan Auto	$302.25
Rate for Payer: Multiplan Commercial	$302.25
Rate for Payer: Multiplan Workers Comp	$302.25
Rate for Payer: Parkland Medicaid	$334.80
Rate for Payer: Scott and White EPO/PPO	$232.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$334.80
Rate for Payer: Superior Health Plan EPO	$63.24

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	$264.30
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
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	$264.30
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 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 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	$157.53
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 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 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

Know your out-of-pocket cost for care.

All Charges