White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Hand 2 Views Right

Facility

$768.00

Service Code	HCPCS 73120 RT
Hospital Charge Code	3100757
Hospital Revenue Code	320
Rate for Payer: Cash Price	$522.24

XR Hand 2 Views Right

Facility

$768.00

Service Code	HCPCS 73120 RT
Hospital Charge Code	3100757
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 Complete 3+ Views Left

Facility

$813.00

Service Code	HCPCS 73130 LT
Hospital Charge Code	3160157
Hospital Revenue Code	320
Rate for Payer: Cash Price	$552.84

XR Hand Complete 3+ Views Left

Facility

$813.00

Service Code	HCPCS 73130 LT
Hospital Charge Code	3160157
Hospital Revenue Code	320
Min. Negotiated Rate	$37.43
Max. Negotiated Rate	$585.36
Rate for Payer: Amerigroup CHIP/Medicaid	$37.43
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	$552.84
Rate for Payer: Cash Price	$552.84
Rate for Payer: Cash Price	$552.84
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$585.36
Rate for Payer: Molina CHIP/Medicaid	$585.36
Rate for Payer: Multiplan Auto	$528.45
Rate for Payer: Multiplan Commercial	$528.45
Rate for Payer: Multiplan Workers Comp	$528.45
Rate for Payer: Parkland Medicaid	$585.36
Rate for Payer: Scott and White EPO/PPO	$406.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$585.36
Rate for Payer: Superior Health Plan EPO	$110.57

XR Hand Complete 3+ Views Right

Facility

$813.00

Service Code	HCPCS 73130 RT
Hospital Charge Code	3160140
Hospital Revenue Code	320
Min. Negotiated Rate	$37.43
Max. Negotiated Rate	$585.36
Rate for Payer: Amerigroup CHIP/Medicaid	$37.43
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	$552.84
Rate for Payer: Cash Price	$552.84
Rate for Payer: Cash Price	$552.84
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$585.36
Rate for Payer: Molina CHIP/Medicaid	$585.36
Rate for Payer: Multiplan Auto	$528.45
Rate for Payer: Multiplan Commercial	$528.45
Rate for Payer: Multiplan Workers Comp	$528.45
Rate for Payer: Parkland Medicaid	$585.36
Rate for Payer: Scott and White EPO/PPO	$406.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$585.36
Rate for Payer: Superior Health Plan EPO	$110.57

XR Hand Complete 3+ Views Right

Facility

$813.00

Service Code	HCPCS 73130 RT
Hospital Charge Code	3160140
Hospital Revenue Code	320
Rate for Payer: Cash Price	$552.84

XR Hip 1 View w/ AP Pelvis Left

Facility

$530.00

Service Code	HCPCS 73501 LT
Hospital Charge Code	3181204
Hospital Revenue Code	320
Min. Negotiated Rate	$33.08
Max. Negotiated Rate	$381.60
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	$360.40
Rate for Payer: Cash Price	$360.40
Rate for Payer: Cash Price	$360.40
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$381.60
Rate for Payer: Molina CHIP/Medicaid	$381.60
Rate for Payer: Multiplan Auto	$344.50
Rate for Payer: Multiplan Commercial	$344.50
Rate for Payer: Multiplan Workers Comp	$344.50
Rate for Payer: Parkland Medicaid	$381.60
Rate for Payer: Scott and White EPO/PPO	$265.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$381.60
Rate for Payer: Superior Health Plan EPO	$72.08

XR Hip 1 View w/ AP Pelvis Left

Facility

$530.00

Service Code	HCPCS 73501 LT
Hospital Charge Code	3181204
Hospital Revenue Code	320
Rate for Payer: Cash Price	$360.40

XR Hip 1 View w/ AP Pelvis Right

Facility

$530.00

Service Code	HCPCS 73501 RT
Hospital Charge Code	3181205
Hospital Revenue Code	320
Min. Negotiated Rate	$33.08
Max. Negotiated Rate	$381.60
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	$360.40
Rate for Payer: Cash Price	$360.40
Rate for Payer: Cash Price	$360.40
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$381.60
Rate for Payer: Molina CHIP/Medicaid	$381.60
Rate for Payer: Multiplan Auto	$344.50
Rate for Payer: Multiplan Commercial	$344.50
Rate for Payer: Multiplan Workers Comp	$344.50
Rate for Payer: Parkland Medicaid	$381.60
Rate for Payer: Scott and White EPO/PPO	$265.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$381.60
Rate for Payer: Superior Health Plan EPO	$72.08

XR Hip 1 View w/ AP Pelvis Right

Facility

$530.00

Service Code	HCPCS 73501 RT
Hospital Charge Code	3181205
Hospital Revenue Code	320
Rate for Payer: Cash Price	$360.40

XR Hip 2-3 Views w/AP Pelvis Left

Facility

$618.00

Service Code	HCPCS 73502 LT
Hospital Charge Code	3181206
Hospital Revenue Code	320
Rate for Payer: Cash Price	$420.24

XR Hip 2-3 Views w/AP Pelvis Left

Facility

$618.00

Service Code	HCPCS 73502 LT
Hospital Charge Code	3181206
Hospital Revenue Code	320
Min. Negotiated Rate	$47.78
Max. Negotiated Rate	$444.96
Rate for Payer: Amerigroup CHIP/Medicaid	$47.78
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	$420.24
Rate for Payer: Cash Price	$420.24
Rate for Payer: Cash Price	$420.24
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$444.96
Rate for Payer: Molina CHIP/Medicaid	$444.96
Rate for Payer: Multiplan Auto	$401.70
Rate for Payer: Multiplan Commercial	$401.70
Rate for Payer: Multiplan Workers Comp	$401.70
Rate for Payer: Parkland Medicaid	$444.96
Rate for Payer: Scott and White EPO/PPO	$309.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$444.96
Rate for Payer: Superior Health Plan EPO	$84.05

XR Hip 2-3 Views w/AP Pelvis Right

Facility

$618.00

Service Code	HCPCS 73502 RT
Hospital Charge Code	3181207
Hospital Revenue Code	320
Rate for Payer: Cash Price	$420.24

XR Hip 2-3 Views w/AP Pelvis Right

Facility

$618.00

Service Code	HCPCS 73502 RT
Hospital Charge Code	3181207
Hospital Revenue Code	320
Min. Negotiated Rate	$47.78
Max. Negotiated Rate	$444.96
Rate for Payer: Amerigroup CHIP/Medicaid	$47.78
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	$420.24
Rate for Payer: Cash Price	$420.24
Rate for Payer: Cash Price	$420.24
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$444.96
Rate for Payer: Molina CHIP/Medicaid	$444.96
Rate for Payer: Multiplan Auto	$401.70
Rate for Payer: Multiplan Commercial	$401.70
Rate for Payer: Multiplan Workers Comp	$401.70
Rate for Payer: Parkland Medicaid	$444.96
Rate for Payer: Scott and White EPO/PPO	$309.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$444.96
Rate for Payer: Superior Health Plan EPO	$84.05

XR Hips 2 Views w/AP Pelvis Bilat

Facility

$742.00

Service Code	HCPCS 73521
Hospital Charge Code	3181210
Hospital Revenue Code	320
Rate for Payer: Cash Price	$504.56

XR Hips 2 Views w/AP Pelvis Bilat

Facility

$742.00

Service Code	HCPCS 73521
Hospital Charge Code	3181210
Hospital Revenue Code	320
Min. Negotiated Rate	$41.44
Max. Negotiated Rate	$534.24
Rate for Payer: Amerigroup CHIP/Medicaid	$41.44
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	$504.56
Rate for Payer: Cash Price	$504.56
Rate for Payer: Cash Price	$504.56
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$534.24
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	$534.24
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$482.30
Rate for Payer: Multiplan Commercial	$482.30
Rate for Payer: Multiplan Workers Comp	$482.30
Rate for Payer: Parkland Medicaid	$534.24
Rate for Payer: Scott and White EPO/PPO	$51.04
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$534.24
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 Hips 3-4 Views w/AP Pelvis Bilat

Facility

$794.00

Service Code	HCPCS 73522
Hospital Charge Code	3181211
Hospital Revenue Code	320
Rate for Payer: Cash Price	$539.92

XR Hips 3-4 Views w/AP Pelvis Bilat

Facility

$794.00

Service Code	HCPCS 73522
Hospital Charge Code	3181211
Hospital Revenue Code	320
Min. Negotiated Rate	$54.13
Max. Negotiated Rate	$571.68
Rate for Payer: Amerigroup CHIP/Medicaid	$54.13
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	$539.92
Rate for Payer: Cash Price	$539.92
Rate for Payer: Cash Price	$539.92
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$571.68
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	$571.68
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$516.10
Rate for Payer: Multiplan Commercial	$516.10
Rate for Payer: Multiplan Workers Comp	$516.10
Rate for Payer: Parkland Medicaid	$571.68
Rate for Payer: Scott and White EPO/PPO	$66.71
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$571.68
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

XR Hysterosalpingography

Facility

$821.00

Service Code	HCPCS 74740
Hospital Charge Code	3101268
Hospital Revenue Code	320
Min. Negotiated Rate	$66.83
Max. Negotiated Rate	$591.12
Rate for Payer: Amerigroup CHIP/Medicaid	$66.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$384.52
Rate for Payer: BCBS of TX Blue Essentials	$461.42
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$515.02
Rate for Payer: Cash Price	$558.28
Rate for Payer: Cash Price	$558.28
Rate for Payer: Cash Price	$558.28
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$591.12
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	$591.12
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$533.65
Rate for Payer: Multiplan Commercial	$533.65
Rate for Payer: Multiplan Workers Comp	$533.65
Rate for Payer: Parkland Medicaid	$591.12
Rate for Payer: Scott and White EPO/PPO	$115.72
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$591.12
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 Hysterosalpingography

Facility

$821.00

Service Code	HCPCS 74740
Hospital Charge Code	3101268
Hospital Revenue Code	320
Rate for Payer: Cash Price	$558.28

XR Injection Air Contrast Prtnl Cavity BCE

Facility

$1,446.25

Service Code	HCPCS 49400
Hospital Charge Code	2103935
Hospital Revenue Code	360
Min. Negotiated Rate	$130.16
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$130.16
Rate for Payer: BCBS of TX Blue Advantage	$433.88
Rate for Payer: BCBS of TX Blue Essentials	$520.65
Rate for Payer: BCBS of TX PPO	$578.50
Rate for Payer: Cash Price	$983.45
Rate for Payer: Cash Price	$983.45
Rate for Payer: Cigna Medicaid	$1,041.30
Rate for Payer: Molina CHIP/Medicaid	$1,041.30
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	$1,041.30
Rate for Payer: Scott and White EPO/PPO	$723.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,041.30
Rate for Payer: Superior Health Plan EPO	$196.69

XR Injection Air Contrast Prtnl Cavity BCE

Facility

$1,446.25

Service Code	HCPCS 49400
Hospital Charge Code	2103935
Hospital Revenue Code	360
Rate for Payer: Cash Price	$983.45

XR Injection Contrast for Tube Eval

Facility

$857.00

Service Code	HCPCS 49465
Hospital Charge Code	3181070
Hospital Revenue Code	320
Min. Negotiated Rate	$36.46
Max. Negotiated Rate	$617.04
Rate for Payer: Amerigroup CHIP/Medicaid	$77.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$389.18
Rate for Payer: BCBS of TX Blue Essentials	$466.08
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$587.26
Rate for Payer: Cash Price	$582.76
Rate for Payer: Cash Price	$582.76
Rate for Payer: Cash Price	$582.76
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$617.04
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	$617.04
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$557.05
Rate for Payer: Multiplan Commercial	$557.05
Rate for Payer: Multiplan Workers Comp	$557.05
Rate for Payer: Parkland Medicaid	$617.04
Rate for Payer: Scott and White EPO/PPO	$36.46
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$617.04
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 Injection Contrast for Tube Eval

Facility

$857.00

Service Code	HCPCS 49465
Hospital Charge Code	3181070
Hospital Revenue Code	320
Rate for Payer: Cash Price	$582.76

XR IVP

Facility

$1,041.00

Service Code	HCPCS 74400
Hospital Charge Code	4904400
Hospital Revenue Code	320
Min. Negotiated Rate	$135.33
Max. Negotiated Rate	$749.52
Rate for Payer: Amerigroup CHIP/Medicaid	$135.33
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$176.20
Rate for Payer: Amerigroup Medicare	$176.20
Rate for Payer: BCBS of TX Blue Advantage	$158.17
Rate for Payer: BCBS of TX Blue Essentials	$189.80
Rate for Payer: BCBS of TX Medicare	$176.20
Rate for Payer: BCBS of TX PPO	$211.85
Rate for Payer: Cash Price	$707.88
Rate for Payer: Cash Price	$707.88
Rate for Payer: Cash Price	$707.88
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$749.52
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	$749.52
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$676.65
Rate for Payer: Multiplan Commercial	$676.65
Rate for Payer: Multiplan Workers Comp	$676.65
Rate for Payer: Parkland Medicaid	$749.52
Rate for Payer: Scott and White EPO/PPO	$166.74
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$749.52
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

Know your out-of-pocket cost for care.

All Charges