White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Finger(2nd Digit) 2+ Views Right

Facility

$486.00

Service Code	HCPCS 73140 F6
Hospital Charge Code	3100773
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 Fluoro Guidance Needle Placement

Facility

$559.00

Service Code	HCPCS 77002
Hospital Charge Code	3120011
Hospital Revenue Code	320
Min. Negotiated Rate	$50.31
Max. Negotiated Rate	$402.48
Rate for Payer: Amerigroup CHIP/Medicaid	$50.31
Rate for Payer: BCBS of TX Blue Advantage	$123.09
Rate for Payer: BCBS of TX Blue Essentials	$147.71
Rate for Payer: BCBS of TX PPO	$164.87
Rate for Payer: Cash Price	$380.12
Rate for Payer: Cash Price	$380.12
Rate for Payer: Cigna Medicaid	$402.48
Rate for Payer: Molina CHIP/Medicaid	$402.48
Rate for Payer: Multiplan Auto	$363.35
Rate for Payer: Multiplan Commercial	$363.35
Rate for Payer: Multiplan Workers Comp	$363.35
Rate for Payer: Parkland Medicaid	$402.48
Rate for Payer: Scott and White EPO/PPO	$143.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$402.48
Rate for Payer: Superior Health Plan EPO	$76.02

XR Fluoro Guidance Needle Placement

Facility

$559.00

Service Code	HCPCS 77002
Hospital Charge Code	3120011
Hospital Revenue Code	320
Rate for Payer: Cash Price	$380.12

XR Fluoroscopy Eval Diaphragm Sniff Test

Facility

$480.00

Service Code	HCPCS 76000
Hospital Charge Code	3101276
Hospital Revenue Code	320
Rate for Payer: Cash Price	$326.40

XR Fluoroscopy Eval Diaphragm Sniff Test

Facility

$480.00

Service Code	HCPCS 76000
Hospital Charge Code	3101276
Hospital Revenue Code	320
Min. Negotiated Rate	$42.78
Max. Negotiated Rate	$506.65
Rate for Payer: Amerigroup CHIP/Medicaid	$42.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$52.92
Rate for Payer: BCBS of TX Blue Essentials	$63.50
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$70.87
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$345.60
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$345.60
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$312.00
Rate for Payer: Multiplan Commercial	$312.00
Rate for Payer: Multiplan Workers Comp	$312.00
Rate for Payer: Parkland Medicaid	$345.60
Rate for Payer: Scott and White EPO/PPO	$52.59
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$345.60
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

XR Fluoroscopy Guide Vein Device

Facility

$619.00

Service Code	HCPCS 77001
Hospital Charge Code	3120003
Hospital Revenue Code	320
Rate for Payer: Cash Price	$420.92

XR Fluoroscopy Guide Vein Device

Facility

$619.00

Service Code	HCPCS 77001
Hospital Charge Code	3120003
Hospital Revenue Code	320
Min. Negotiated Rate	$55.71
Max. Negotiated Rate	$445.68
Rate for Payer: Amerigroup CHIP/Medicaid	$55.71
Rate for Payer: BCBS of TX Blue Advantage	$120.12
Rate for Payer: BCBS of TX Blue Essentials	$144.14
Rate for Payer: BCBS of TX PPO	$160.89
Rate for Payer: Cash Price	$420.92
Rate for Payer: Cash Price	$420.92
Rate for Payer: Cigna Medicaid	$445.68
Rate for Payer: Molina CHIP/Medicaid	$445.68
Rate for Payer: Multiplan Auto	$402.35
Rate for Payer: Multiplan Commercial	$402.35
Rate for Payer: Multiplan Workers Comp	$402.35
Rate for Payer: Parkland Medicaid	$445.68
Rate for Payer: Scott and White EPO/PPO	$121.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$445.68
Rate for Payer: Superior Health Plan EPO	$84.18

XR Foot 2 Views Left

Facility

$537.00

Service Code	HCPCS 73620 LT
Hospital Charge Code	3100997
Hospital Revenue Code	320
Rate for Payer: Cash Price	$365.16

XR Foot 2 Views Left

Facility

$537.00

Service Code	HCPCS 73620 LT
Hospital Charge Code	3100997
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

XR Foot 2 Views Right

Facility

$537.00

Service Code	HCPCS 73620 RT
Hospital Charge Code	3101003
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

XR Foot 2 Views Right

Facility

$537.00

Service Code	HCPCS 73620 RT
Hospital Charge Code	3101003
Hospital Revenue Code	320
Rate for Payer: Cash Price	$365.16

XR Foot Complete 3+ Views Left

Facility

$608.00

Service Code	HCPCS 73630 LT
Hospital Charge Code	3101029
Hospital Revenue Code	320
Min. Negotiated Rate	$34.41
Max. Negotiated Rate	$437.76
Rate for Payer: Amerigroup CHIP/Medicaid	$34.41
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	$413.44
Rate for Payer: Cash Price	$413.44
Rate for Payer: Cash Price	$413.44
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$437.76
Rate for Payer: Molina CHIP/Medicaid	$437.76
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$437.76
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$437.76
Rate for Payer: Superior Health Plan EPO	$82.69

XR Foot Complete 3+ Views Left

Facility

$608.00

Service Code	HCPCS 73630 LT
Hospital Charge Code	3101029
Hospital Revenue Code	320
Rate for Payer: Cash Price	$413.44

XR Foot Complete 3+ Views Right

Facility

$608.00

Service Code	HCPCS 73630 RT
Hospital Charge Code	3101011
Hospital Revenue Code	320
Rate for Payer: Cash Price	$413.44

XR Foot Complete 3+ Views Right

Facility

$608.00

Service Code	HCPCS 73630 RT
Hospital Charge Code	3101011
Hospital Revenue Code	320
Min. Negotiated Rate	$34.41
Max. Negotiated Rate	$437.76
Rate for Payer: Amerigroup CHIP/Medicaid	$34.41
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	$413.44
Rate for Payer: Cash Price	$413.44
Rate for Payer: Cash Price	$413.44
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$437.76
Rate for Payer: Molina CHIP/Medicaid	$437.76
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$437.76
Rate for Payer: Scott and White EPO/PPO	$304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$437.76
Rate for Payer: Superior Health Plan EPO	$82.69

XR Forearm 2 Views Left

Facility

$535.00

Service Code	HCPCS 73090 LT
Hospital Charge Code	3100690
Hospital Revenue Code	320
Rate for Payer: Cash Price	$363.80

XR Forearm 2 Views Left

Facility

$535.00

Service Code	HCPCS 73090 LT
Hospital Charge Code	3100690
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

XR Forearm 2 Views Right

Facility

$535.00

Service Code	HCPCS 73090 RT
Hospital Charge Code	3100708
Hospital Revenue Code	320
Rate for Payer: Cash Price	$363.80

XR Forearm 2 Views Right

Facility

$535.00

Service Code	HCPCS 73090 RT
Hospital Charge Code	3100708
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

XR Foreign Body Localization Child 1 Vw

Facility

$401.00

Service Code	HCPCS 76010
Hospital Charge Code	4904030
Hospital Revenue Code	320
Min. Negotiated Rate	$36.20
Max. Negotiated Rate	$288.72
Rate for Payer: Amerigroup CHIP/Medicaid	$86.58
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	$272.68
Rate for Payer: Cash Price	$272.68
Rate for Payer: Cash Price	$272.68
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$288.72
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	$288.72
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$260.65
Rate for Payer: Multiplan Commercial	$260.65
Rate for Payer: Multiplan Workers Comp	$260.65
Rate for Payer: Parkland Medicaid	$288.72
Rate for Payer: Scott and White EPO/PPO	$36.20
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$288.72
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 Foreign Body Localization Child 1 Vw

Facility

$401.00

Service Code	HCPCS 76010
Hospital Charge Code	4904030
Hospital Revenue Code	320
Rate for Payer: Cash Price	$272.68

XR G Tube Placement Percutaneous

Facility

$5,522.00

Service Code	HCPCS 49440
Hospital Charge Code	4619440
Hospital Revenue Code	361
Min. Negotiated Rate	$564.97
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Amerigroup Medicare	$1,927.65
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,927.65
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cash Price	$3,754.96
Rate for Payer: Cash Price	$3,754.96
Rate for Payer: Cash Price	$3,754.96
Rate for Payer: Cigna Commercial	$4,074.70
Rate for Payer: Cigna Medicaid	$3,975.84
Rate for Payer: Cigna Medicare	$1,927.65
Rate for Payer: Employer Direct Commercial	$1,927.65
Rate for Payer: Humana Medicare/TRICARE	$1,927.65
Rate for Payer: Molina CHIP/Medicaid	$3,975.84
Rate for Payer: Molina Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Molina Medicare	$1,927.65
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	$3,975.84
Rate for Payer: Scott and White EPO/PPO	$3,219.41
Rate for Payer: Scott and White Medicare	$1,927.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,975.84
Rate for Payer: Superior Health Plan EPO	$1,927.65
Rate for Payer: Superior Health Plan Medicare	$1,927.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Universal American Medicare	$1,927.65
Rate for Payer: Wellcare Medicare	$1,927.65
Rate for Payer: Wellmed Medicare	$1,927.65

XR G Tube Placement Percutaneous

Facility

$5,522.00

Service Code	HCPCS 49440
Hospital Charge Code	4619440
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,754.96

XR Hand 2 Views Left

Facility

$768.00

Service Code	HCPCS 73120 LT
Hospital Charge Code	3100765
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

XR Hand 2 Views Left

Facility

$768.00

Service Code	HCPCS 73120 LT
Hospital Charge Code	3100765
Hospital Revenue Code	320
Rate for Payer: Cash Price	$522.24

Know your out-of-pocket cost for care.

All Charges