White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Injection Contrast for Tube Eval

Facility

$857.00

Service Code	HCPCS 49465
Hospital Charge Code	3181070
Hospital Revenue Code	320
Min. Negotiated Rate	$77.13
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	$359.54
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 IVP

Facility

$1,041.00

Service Code	HCPCS 74400
Hospital Charge Code	4904400
Hospital Revenue Code	320
Rate for Payer: Cash Price	$707.88

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	$264.30
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

XR Joint/Bursa Major Arthr/Asp/Inj Right

Facility

$1,676.00

Service Code	HCPCS 20610
Hospital Charge Code	3170080
Hospital Revenue Code	361
Min. Negotiated Rate	$27.96
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$27.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.35
Rate for Payer: Amerigroup Medicare	$308.35
Rate for Payer: BCBS of TX Blue Advantage	$51.84
Rate for Payer: BCBS of TX Blue Essentials	$62.08
Rate for Payer: BCBS of TX Medicare	$308.35
Rate for Payer: BCBS of TX PPO	$78.22
Rate for Payer: Cash Price	$1,139.68
Rate for Payer: Cash Price	$1,139.68
Rate for Payer: Cash Price	$1,139.68
Rate for Payer: Cigna Commercial	$651.79
Rate for Payer: Cigna Medicaid	$1,206.72
Rate for Payer: Cigna Medicare	$308.35
Rate for Payer: Employer Direct Commercial	$308.35
Rate for Payer: Humana Medicare/TRICARE	$308.35
Rate for Payer: Molina CHIP/Medicaid	$1,206.72
Rate for Payer: Molina Dual Medicare/Medicaid	$308.35
Rate for Payer: Molina Medicare	$308.35
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	$1,206.72
Rate for Payer: Scott and White EPO/PPO	$570.45
Rate for Payer: Scott and White Medicare	$308.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,206.72
Rate for Payer: Superior Health Plan EPO	$308.35
Rate for Payer: Superior Health Plan Medicare	$308.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.35
Rate for Payer: Universal American Medicare	$308.35
Rate for Payer: Wellcare Medicare	$308.35
Rate for Payer: Wellmed Medicare	$308.35

XR Joint/Bursa Major Arthr/Asp/Inj Right

Facility

$1,676.00

Service Code	HCPCS 20610
Hospital Charge Code	3170080
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,139.68

XR Joint/Bursa Small Arthr/Asp/Inj Right

Facility

$622.00

Service Code	HCPCS 20600
Hospital Charge Code	4900600
Hospital Revenue Code	361
Min. Negotiated Rate	$22.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$22.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.35
Rate for Payer: Amerigroup Medicare	$308.35
Rate for Payer: BCBS of TX Blue Advantage	$41.58
Rate for Payer: BCBS of TX Blue Essentials	$49.80
Rate for Payer: BCBS of TX Medicare	$308.35
Rate for Payer: BCBS of TX PPO	$62.75
Rate for Payer: Cash Price	$422.96
Rate for Payer: Cash Price	$422.96
Rate for Payer: Cash Price	$422.96
Rate for Payer: Cigna Commercial	$651.79
Rate for Payer: Cigna Medicaid	$447.84
Rate for Payer: Cigna Medicare	$308.35
Rate for Payer: Employer Direct Commercial	$308.35
Rate for Payer: Humana Medicare/TRICARE	$308.35
Rate for Payer: Molina CHIP/Medicaid	$447.84
Rate for Payer: Molina Dual Medicare/Medicaid	$308.35
Rate for Payer: Molina Medicare	$308.35
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	$447.84
Rate for Payer: Scott and White EPO/PPO	$570.45
Rate for Payer: Scott and White Medicare	$308.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$447.84
Rate for Payer: Superior Health Plan EPO	$308.35
Rate for Payer: Superior Health Plan Medicare	$308.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.35
Rate for Payer: Universal American Medicare	$308.35
Rate for Payer: Wellcare Medicare	$308.35
Rate for Payer: Wellmed Medicare	$308.35

XR Joint/Bursa Small Arthr/Asp/Inj Right

Facility

$622.00

Service Code	HCPCS 20600
Hospital Charge Code	4900600
Hospital Revenue Code	361
Rate for Payer: Cash Price	$422.96

XR Knee 1 or 2 Views Left

Facility

$712.00

Service Code	HCPCS 73560 LT
Hospital Charge Code	3100872
Hospital Revenue Code	320
Min. Negotiated Rate	$34.41
Max. Negotiated Rate	$512.64
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	$484.16
Rate for Payer: Cash Price	$484.16
Rate for Payer: Cash Price	$484.16
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$512.64
Rate for Payer: Molina CHIP/Medicaid	$512.64
Rate for Payer: Multiplan Auto	$462.80
Rate for Payer: Multiplan Commercial	$462.80
Rate for Payer: Multiplan Workers Comp	$462.80
Rate for Payer: Parkland Medicaid	$512.64
Rate for Payer: Scott and White EPO/PPO	$356.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$512.64
Rate for Payer: Superior Health Plan EPO	$96.83

XR Knee 1 or 2 Views Left

Facility

$712.00

Service Code	HCPCS 73560 LT
Hospital Charge Code	3100872
Hospital Revenue Code	320
Rate for Payer: Cash Price	$484.16

XR Knee 1 or 2 Views Right

Facility

$712.00

Service Code	HCPCS 73560 RT
Hospital Charge Code	3100880
Hospital Revenue Code	320
Min. Negotiated Rate	$34.41
Max. Negotiated Rate	$512.64
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	$484.16
Rate for Payer: Cash Price	$484.16
Rate for Payer: Cash Price	$484.16
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$512.64
Rate for Payer: Molina CHIP/Medicaid	$512.64
Rate for Payer: Multiplan Auto	$462.80
Rate for Payer: Multiplan Commercial	$462.80
Rate for Payer: Multiplan Workers Comp	$462.80
Rate for Payer: Parkland Medicaid	$512.64
Rate for Payer: Scott and White EPO/PPO	$356.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$512.64
Rate for Payer: Superior Health Plan EPO	$96.83

XR Knee 1 or 2 Views Right

Facility

$712.00

Service Code	HCPCS 73560 RT
Hospital Charge Code	3100880
Hospital Revenue Code	320
Rate for Payer: Cash Price	$484.16

XR Knee 3 Views Left

Facility

$732.00

Service Code	HCPCS 73562 LT
Hospital Charge Code	3100898
Hospital Revenue Code	320
Rate for Payer: Cash Price	$497.76

XR Knee 3 Views Left

Facility

$732.00

Service Code	HCPCS 73562 LT
Hospital Charge Code	3100898
Hospital Revenue Code	320
Min. Negotiated Rate	$41.10
Max. Negotiated Rate	$527.04
Rate for Payer: Amerigroup CHIP/Medicaid	$41.10
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	$497.76
Rate for Payer: Cash Price	$497.76
Rate for Payer: Cash Price	$497.76
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$527.04
Rate for Payer: Molina CHIP/Medicaid	$527.04
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	$366.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$527.04
Rate for Payer: Superior Health Plan EPO	$99.55

XR Knee 3 Views Right

Facility

$732.00

Service Code	HCPCS 73562 RT
Hospital Charge Code	3100906
Hospital Revenue Code	320
Rate for Payer: Cash Price	$497.76

XR Knee 3 Views Right

Facility

$732.00

Service Code	HCPCS 73562 RT
Hospital Charge Code	3100906
Hospital Revenue Code	320
Min. Negotiated Rate	$41.10
Max. Negotiated Rate	$527.04
Rate for Payer: Amerigroup CHIP/Medicaid	$41.10
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	$497.76
Rate for Payer: Cash Price	$497.76
Rate for Payer: Cash Price	$497.76
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$527.04
Rate for Payer: Molina CHIP/Medicaid	$527.04
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	$366.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$527.04
Rate for Payer: Superior Health Plan EPO	$99.55

XR Knee Complete 4+ Views Left

Facility

$817.00

Service Code	HCPCS 73564 LT
Hospital Charge Code	3100914
Hospital Revenue Code	320
Rate for Payer: Cash Price	$555.56

XR Knee Complete 4+ Views Left

Facility

$817.00

Service Code	HCPCS 73564 LT
Hospital Charge Code	3100914
Hospital Revenue Code	320
Min. Negotiated Rate	$47.45
Max. Negotiated Rate	$588.24
Rate for Payer: Amerigroup CHIP/Medicaid	$47.45
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	$555.56
Rate for Payer: Cash Price	$555.56
Rate for Payer: Cash Price	$555.56
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$588.24
Rate for Payer: Molina CHIP/Medicaid	$588.24
Rate for Payer: Multiplan Auto	$531.05
Rate for Payer: Multiplan Commercial	$531.05
Rate for Payer: Multiplan Workers Comp	$531.05
Rate for Payer: Parkland Medicaid	$588.24
Rate for Payer: Scott and White EPO/PPO	$408.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$588.24
Rate for Payer: Superior Health Plan EPO	$111.11

XR Knee Complete 4+ Views Right

Facility

$817.00

Service Code	HCPCS 73564 RT
Hospital Charge Code	3100922
Hospital Revenue Code	320
Min. Negotiated Rate	$47.45
Max. Negotiated Rate	$588.24
Rate for Payer: Amerigroup CHIP/Medicaid	$47.45
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	$555.56
Rate for Payer: Cash Price	$555.56
Rate for Payer: Cash Price	$555.56
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$588.24
Rate for Payer: Molina CHIP/Medicaid	$588.24
Rate for Payer: Multiplan Auto	$531.05
Rate for Payer: Multiplan Commercial	$531.05
Rate for Payer: Multiplan Workers Comp	$531.05
Rate for Payer: Parkland Medicaid	$588.24
Rate for Payer: Scott and White EPO/PPO	$408.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$588.24
Rate for Payer: Superior Health Plan EPO	$111.11

XR Knee Complete 4+ Views Right

Facility

$817.00

Service Code	HCPCS 73564 RT
Hospital Charge Code	3100922
Hospital Revenue Code	320
Rate for Payer: Cash Price	$555.56

XR Lower Extremity Infant (0-1yr) Left

Facility

$553.00

Service Code	HCPCS 73592 LT
Hospital Charge Code	3101615
Hospital Revenue Code	320
Min. Negotiated Rate	$75.21
Max. Negotiated Rate	$398.16
Rate for Payer: Amerigroup CHIP/Medicaid	$86.58
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	$376.04
Rate for Payer: Cash Price	$376.04
Rate for Payer: Cash Price	$376.04
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$398.16
Rate for Payer: Molina CHIP/Medicaid	$398.16
Rate for Payer: Multiplan Auto	$359.45
Rate for Payer: Multiplan Commercial	$359.45
Rate for Payer: Multiplan Workers Comp	$359.45
Rate for Payer: Parkland Medicaid	$398.16
Rate for Payer: Scott and White EPO/PPO	$276.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$398.16
Rate for Payer: Superior Health Plan EPO	$75.21

XR Lower Extremity Infant (0-1yr) Left

Facility

$553.00

Service Code	HCPCS 73592 LT
Hospital Charge Code	3101615
Hospital Revenue Code	320
Rate for Payer: Cash Price	$376.04

XR Lower Extremity Infant (0-1yr) Right

Facility

$553.00

Service Code	HCPCS 73592 RT
Hospital Charge Code	3101706
Hospital Revenue Code	320
Rate for Payer: Cash Price	$376.04

XR Lower Extremity Infant (0-1yr) Right

Facility

$553.00

Service Code	HCPCS 73592 RT
Hospital Charge Code	3101706
Hospital Revenue Code	320
Min. Negotiated Rate	$75.21
Max. Negotiated Rate	$398.16
Rate for Payer: Amerigroup CHIP/Medicaid	$86.58
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	$376.04
Rate for Payer: Cash Price	$376.04
Rate for Payer: Cash Price	$376.04
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$398.16
Rate for Payer: Molina CHIP/Medicaid	$398.16
Rate for Payer: Multiplan Auto	$359.45
Rate for Payer: Multiplan Commercial	$359.45
Rate for Payer: Multiplan Workers Comp	$359.45
Rate for Payer: Parkland Medicaid	$398.16
Rate for Payer: Scott and White EPO/PPO	$276.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$398.16
Rate for Payer: Superior Health Plan EPO	$75.21

XR Mandible Complete 4+ Views

Facility

$341.00

Service Code	HCPCS 70110
Hospital Charge Code	3100120
Hospital Revenue Code	320
Min. Negotiated Rate	$43.78
Max. Negotiated Rate	$247.70
Rate for Payer: Amerigroup CHIP/Medicaid	$43.78
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	$231.88
Rate for Payer: Cash Price	$231.88
Rate for Payer: Cash Price	$231.88
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$245.52
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	$245.52
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$221.65
Rate for Payer: Multiplan Commercial	$221.65
Rate for Payer: Multiplan Workers Comp	$221.65
Rate for Payer: Parkland Medicaid	$245.52
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	$245.52
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 Mandible Complete 4+ Views

Facility

$341.00

Service Code	HCPCS 70110
Hospital Charge Code	3100120
Hospital Revenue Code	320
Rate for Payer: Cash Price	$231.88

Know your out-of-pocket cost for care.

All Charges