White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Elbow 2 Views Right

Facility

$594.00

Service Code	HCPCS 73070 RT
Hospital Charge Code	3100658
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

XR Elbow 2 Views Right

Facility

$594.00

Service Code	HCPCS 73070 RT
Hospital Charge Code	3100658
Hospital Revenue Code	320
Rate for Payer: Cash Price	$403.92

XR Elbow Complete 3+ Views Left

Facility

$664.00

Service Code	HCPCS 73080 LT
Hospital Charge Code	3100674
Hospital Revenue Code	320
Rate for Payer: Cash Price	$451.52

XR Elbow Complete 3+ Views Left

Facility

$664.00

Service Code	HCPCS 73080 LT
Hospital Charge Code	3100674
Hospital Revenue Code	320
Min. Negotiated Rate	$33.08
Max. Negotiated Rate	$478.08
Rate for Payer: Amerigroup CHIP/Medicaid	$33.08
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	$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: Molina CHIP/Medicaid	$478.08
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	$332.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$478.08
Rate for Payer: Superior Health Plan EPO	$90.30

XR Elbow Complete 3+ Views Right

Facility

$664.00

Service Code	HCPCS 73080 RT
Hospital Charge Code	3100682
Hospital Revenue Code	320
Rate for Payer: Cash Price	$451.52

XR Elbow Complete 3+ Views Right

Facility

$664.00

Service Code	HCPCS 73080 RT
Hospital Charge Code	3100682
Hospital Revenue Code	320
Min. Negotiated Rate	$33.08
Max. Negotiated Rate	$478.08
Rate for Payer: Amerigroup CHIP/Medicaid	$33.08
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	$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: Molina CHIP/Medicaid	$478.08
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	$332.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$478.08
Rate for Payer: Superior Health Plan EPO	$90.30

XR ERCP Biliary and Pancreatic Duct

Facility

$2,508.00

Service Code	HCPCS 74330
Hospital Charge Code	2161004
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,705.44

XR ERCP Biliary and Pancreatic Duct

Facility

$2,508.00

Service Code	HCPCS 74330
Hospital Charge Code	2161004
Hospital Revenue Code	320
Min. Negotiated Rate	$76.71
Max. Negotiated Rate	$1,805.76
Rate for Payer: Amerigroup CHIP/Medicaid	$225.72
Rate for Payer: BCBS of TX Blue Advantage	$76.71
Rate for Payer: BCBS of TX Blue Essentials	$92.05
Rate for Payer: BCBS of TX PPO	$102.74
Rate for Payer: Cash Price	$1,705.44
Rate for Payer: Cash Price	$1,705.44
Rate for Payer: Cigna Medicaid	$1,805.76
Rate for Payer: Molina CHIP/Medicaid	$1,805.76
Rate for Payer: Multiplan Auto	$1,630.20
Rate for Payer: Multiplan Commercial	$1,630.20
Rate for Payer: Multiplan Workers Comp	$1,630.20
Rate for Payer: Parkland Medicaid	$1,805.76
Rate for Payer: Scott and White EPO/PPO	$1,254.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,805.76
Rate for Payer: Superior Health Plan EPO	$341.09

XR Esophagus

Facility

$631.00

Service Code	HCPCS 74220
Hospital Charge Code	3101094
Hospital Revenue Code	320
Rate for Payer: Cash Price	$429.08

XR Esophagus

Facility

$631.00

Service Code	HCPCS 74220
Hospital Charge Code	3101094
Hospital Revenue Code	320
Min. Negotiated Rate	$97.56
Max. Negotiated Rate	$454.32
Rate for Payer: Amerigroup CHIP/Medicaid	$97.56
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	$429.08
Rate for Payer: Cash Price	$429.08
Rate for Payer: Cash Price	$429.08
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$454.32
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	$454.32
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$410.15
Rate for Payer: Multiplan Commercial	$410.15
Rate for Payer: Multiplan Workers Comp	$410.15
Rate for Payer: Parkland Medicaid	$454.32
Rate for Payer: Scott and White EPO/PPO	$120.24
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$454.32
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 Facial Bones < 3 Views

Facility

$315.00

Service Code	HCPCS 70140
Hospital Charge Code	3160397
Hospital Revenue Code	320
Min. Negotiated Rate	$32.08
Max. Negotiated Rate	$226.80
Rate for Payer: Amerigroup CHIP/Medicaid	$32.08
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	$214.20
Rate for Payer: Cash Price	$214.20
Rate for Payer: Cash Price	$214.20
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$226.80
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	$226.80
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$204.75
Rate for Payer: Multiplan Commercial	$204.75
Rate for Payer: Multiplan Workers Comp	$204.75
Rate for Payer: Parkland Medicaid	$226.80
Rate for Payer: Scott and White EPO/PPO	$39.49
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$226.80
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 Facial Bones < 3 Views

Facility

$315.00

Service Code	HCPCS 70140
Hospital Charge Code	3160397
Hospital Revenue Code	320
Rate for Payer: Cash Price	$214.20

XR Facial Bones 3+ Views

Facility

$381.00

Service Code	HCPCS 70150
Hospital Charge Code	3100146
Hospital Revenue Code	320
Rate for Payer: Cash Price	$259.08

XR Facial Bones 3+ Views

Facility

$381.00

Service Code	HCPCS 70150
Hospital Charge Code	3100146
Hospital Revenue Code	320
Min. Negotiated Rate	$47.45
Max. Negotiated Rate	$274.32
Rate for Payer: Amerigroup CHIP/Medicaid	$47.45
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	$259.08
Rate for Payer: Cash Price	$259.08
Rate for Payer: Cash Price	$259.08
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$274.32
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	$274.32
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$247.65
Rate for Payer: Multiplan Commercial	$247.65
Rate for Payer: Multiplan Workers Comp	$247.65
Rate for Payer: Parkland Medicaid	$274.32
Rate for Payer: Scott and White EPO/PPO	$58.46
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$274.32
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 Femur 1 View Left

Facility

$329.00

Service Code	HCPCS 73551 LT
Hospital Charge Code	3181214
Hospital Revenue Code	320
Rate for Payer: Cash Price	$223.72

XR Femur 1 View Left

Facility

$329.00

Service Code	HCPCS 73551 LT
Hospital Charge Code	3181214
Hospital Revenue Code	320
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$236.88
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	$223.72
Rate for Payer: Cash Price	$223.72
Rate for Payer: Cash Price	$223.72
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$236.88
Rate for Payer: Molina CHIP/Medicaid	$236.88
Rate for Payer: Multiplan Auto	$213.85
Rate for Payer: Multiplan Commercial	$213.85
Rate for Payer: Multiplan Workers Comp	$213.85
Rate for Payer: Parkland Medicaid	$236.88
Rate for Payer: Scott and White EPO/PPO	$164.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$236.88
Rate for Payer: Superior Health Plan EPO	$44.74

XR Femur 1 View Right

Facility

$329.00

Service Code	HCPCS 73551 RT
Hospital Charge Code	3181213
Hospital Revenue Code	320
Rate for Payer: Cash Price	$223.72

XR Femur 1 View Right

Facility

$329.00

Service Code	HCPCS 73551 RT
Hospital Charge Code	3181213
Hospital Revenue Code	320
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$236.88
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	$223.72
Rate for Payer: Cash Price	$223.72
Rate for Payer: Cash Price	$223.72
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$236.88
Rate for Payer: Molina CHIP/Medicaid	$236.88
Rate for Payer: Multiplan Auto	$213.85
Rate for Payer: Multiplan Commercial	$213.85
Rate for Payer: Multiplan Workers Comp	$213.85
Rate for Payer: Parkland Medicaid	$236.88
Rate for Payer: Scott and White EPO/PPO	$164.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$236.88
Rate for Payer: Superior Health Plan EPO	$44.74

XR Femur 2 Views Left

Facility

$627.00

Service Code	HCPCS 73552 LT
Hospital Charge Code	3181216
Hospital Revenue Code	320
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$451.44
Rate for Payer: Amerigroup CHIP/Medicaid	$35.75
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	$426.36
Rate for Payer: Cash Price	$426.36
Rate for Payer: Cash Price	$426.36
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$451.44
Rate for Payer: Molina CHIP/Medicaid	$451.44
Rate for Payer: Multiplan Auto	$407.55
Rate for Payer: Multiplan Commercial	$407.55
Rate for Payer: Multiplan Workers Comp	$407.55
Rate for Payer: Parkland Medicaid	$451.44
Rate for Payer: Scott and White EPO/PPO	$313.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$451.44
Rate for Payer: Superior Health Plan EPO	$85.27

XR Femur 2 Views Left

Facility

$627.00

Service Code	HCPCS 73552 LT
Hospital Charge Code	3181216
Hospital Revenue Code	320
Rate for Payer: Cash Price	$426.36

XR Femur 2 Views Right

Facility

$627.00

Service Code	HCPCS 73552 RT
Hospital Charge Code	3181215
Hospital Revenue Code	320
Rate for Payer: Cash Price	$426.36

XR Femur 2 Views Right

Facility

$627.00

Service Code	HCPCS 73552 RT
Hospital Charge Code	3181215
Hospital Revenue Code	320
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$451.44
Rate for Payer: Amerigroup CHIP/Medicaid	$35.75
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	$426.36
Rate for Payer: Cash Price	$426.36
Rate for Payer: Cash Price	$426.36
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$451.44
Rate for Payer: Molina CHIP/Medicaid	$451.44
Rate for Payer: Multiplan Auto	$407.55
Rate for Payer: Multiplan Commercial	$407.55
Rate for Payer: Multiplan Workers Comp	$407.55
Rate for Payer: Parkland Medicaid	$451.44
Rate for Payer: Scott and White EPO/PPO	$313.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$451.44
Rate for Payer: Superior Health Plan EPO	$85.27

XR Finger(2nd Digit) 2+ Views Left

Facility

$486.00

Service Code	HCPCS 73140 LT
Hospital Charge Code	3100781
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

XR Finger(2nd Digit) 2+ Views Left

Facility

$486.00

Service Code	HCPCS 73140 LT
Hospital Charge Code	3100781
Hospital Revenue Code	320
Rate for Payer: Cash Price	$330.48

XR Finger(2nd Digit) 2+ Views Right

Facility

$486.00

Service Code	HCPCS 73140 F6
Hospital Charge Code	3100773
Hospital Revenue Code	320
Rate for Payer: Cash Price	$330.48

Know your out-of-pocket cost for care.

All Charges