White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Scapula Left

Facility

$382.00

Service Code	HCPCS 73010 LT
Hospital Charge Code	3100575
Hospital Revenue Code	320
Rate for Payer: Cash Price	$259.76

XR Scapula Left

Facility

$382.00

Service Code	HCPCS 73010 LT
Hospital Charge Code	3100575
Hospital Revenue Code	320
Min. Negotiated Rate	$24.06
Max. Negotiated Rate	$275.04
Rate for Payer: Amerigroup CHIP/Medicaid	$24.06
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	$259.76
Rate for Payer: Cash Price	$259.76
Rate for Payer: Cash Price	$259.76
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$275.04
Rate for Payer: Molina CHIP/Medicaid	$275.04
Rate for Payer: Multiplan Auto	$248.30
Rate for Payer: Multiplan Commercial	$248.30
Rate for Payer: Multiplan Workers Comp	$248.30
Rate for Payer: Parkland Medicaid	$275.04
Rate for Payer: Scott and White EPO/PPO	$191.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$275.04
Rate for Payer: Superior Health Plan EPO	$51.95

XR Scapula Right

Facility

$382.00

Service Code	HCPCS 73010 RT
Hospital Charge Code	3100583
Hospital Revenue Code	320
Min. Negotiated Rate	$24.06
Max. Negotiated Rate	$275.04
Rate for Payer: Amerigroup CHIP/Medicaid	$24.06
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	$259.76
Rate for Payer: Cash Price	$259.76
Rate for Payer: Cash Price	$259.76
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$275.04
Rate for Payer: Molina CHIP/Medicaid	$275.04
Rate for Payer: Multiplan Auto	$248.30
Rate for Payer: Multiplan Commercial	$248.30
Rate for Payer: Multiplan Workers Comp	$248.30
Rate for Payer: Parkland Medicaid	$275.04
Rate for Payer: Scott and White EPO/PPO	$191.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$275.04
Rate for Payer: Superior Health Plan EPO	$51.95

XR Scapula Right

Facility

$382.00

Service Code	HCPCS 73010 RT
Hospital Charge Code	3100583
Hospital Revenue Code	320
Rate for Payer: Cash Price	$259.76

XR Shoulder 1 View Left

Facility

$507.00

Service Code	HCPCS 73020 LT
Hospital Charge Code	3101565
Hospital Revenue Code	320
Rate for Payer: Cash Price	$344.76

XR Shoulder 1 View Left

Facility

$507.00

Service Code	HCPCS 73020 LT
Hospital Charge Code	3101565
Hospital Revenue Code	320
Min. Negotiated Rate	$21.71
Max. Negotiated Rate	$365.04
Rate for Payer: Amerigroup CHIP/Medicaid	$21.71
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	$344.76
Rate for Payer: Cash Price	$344.76
Rate for Payer: Cash Price	$344.76
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$365.04
Rate for Payer: Molina CHIP/Medicaid	$365.04
Rate for Payer: Multiplan Auto	$329.55
Rate for Payer: Multiplan Commercial	$329.55
Rate for Payer: Multiplan Workers Comp	$329.55
Rate for Payer: Parkland Medicaid	$365.04
Rate for Payer: Scott and White EPO/PPO	$253.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$365.04
Rate for Payer: Superior Health Plan EPO	$68.95

XR Shoulder 1 View Right

Facility

$507.00

Service Code	HCPCS 73020 RT
Hospital Charge Code	3101672
Hospital Revenue Code	320
Rate for Payer: Cash Price	$344.76

XR Shoulder 1 View Right

Facility

$507.00

Service Code	HCPCS 73020 RT
Hospital Charge Code	3101672
Hospital Revenue Code	320
Min. Negotiated Rate	$21.71
Max. Negotiated Rate	$365.04
Rate for Payer: Amerigroup CHIP/Medicaid	$21.71
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	$344.76
Rate for Payer: Cash Price	$344.76
Rate for Payer: Cash Price	$344.76
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$365.04
Rate for Payer: Molina CHIP/Medicaid	$365.04
Rate for Payer: Multiplan Auto	$329.55
Rate for Payer: Multiplan Commercial	$329.55
Rate for Payer: Multiplan Workers Comp	$329.55
Rate for Payer: Parkland Medicaid	$365.04
Rate for Payer: Scott and White EPO/PPO	$253.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$365.04
Rate for Payer: Superior Health Plan EPO	$68.95

XR Shoulder Complete 2+ Views Left

Facility

$624.00

Service Code	HCPCS 73030 LT
Hospital Charge Code	3100591
Hospital Revenue Code	320
Rate for Payer: Cash Price	$424.32

XR Shoulder Complete 2+ Views Left

Facility

$624.00

Service Code	HCPCS 73030 LT
Hospital Charge Code	3100591
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

XR Shoulder Complete 2+ Views Right

Facility

$624.00

Service Code	HCPCS 73030 RT
Hospital Charge Code	3100609
Hospital Revenue Code	320
Rate for Payer: Cash Price	$424.32

XR Shoulder Complete 2+ Views Right

Facility

$624.00

Service Code	HCPCS 73030 RT
Hospital Charge Code	3100609
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

XR SI Joint Inj Anes an/or Arth w Gde L

Facility

$2,500.00

Service Code	HCPCS 27096
Hospital Charge Code	6110530
Hospital Revenue Code	761
Min. Negotiated Rate	$101.30
Max. Negotiated Rate	$1,800.00
Rate for Payer: Amerigroup CHIP/Medicaid	$225.00
Rate for Payer: BCBS of TX Blue Advantage	$143.24
Rate for Payer: BCBS of TX Blue Essentials	$171.54
Rate for Payer: BCBS of TX PPO	$216.14
Rate for Payer: Cash Price	$1,700.00
Rate for Payer: Cash Price	$1,700.00
Rate for Payer: Cigna Medicaid	$1,800.00
Rate for Payer: Molina CHIP/Medicaid	$1,800.00
Rate for Payer: Multiplan Auto	$1,625.00
Rate for Payer: Multiplan Commercial	$1,625.00
Rate for Payer: Multiplan Workers Comp	$1,625.00
Rate for Payer: Parkland Medicaid	$1,800.00
Rate for Payer: Scott and White EPO/PPO	$101.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,800.00
Rate for Payer: Superior Health Plan EPO	$340.00

XR SI Joint Inj Anes an/or Arth w Gde L

Facility

$2,500.00

Service Code	HCPCS 27096
Hospital Charge Code	6110530
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,700.00

XR Sinuses Paranasal < 3 Views

Facility

$193.00

Service Code	HCPCS 70210
Hospital Charge Code	3101490
Hospital Revenue Code	320
Rate for Payer: Cash Price	$131.24

XR Sinuses Paranasal < 3 Views

Facility

$193.00

Service Code	HCPCS 70210
Hospital Charge Code	3101490
Hospital Revenue Code	320
Min. Negotiated Rate	$32.41
Max. Negotiated Rate	$184.79
Rate for Payer: Amerigroup CHIP/Medicaid	$32.41
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	$131.24
Rate for Payer: Cash Price	$131.24
Rate for Payer: Cash Price	$131.24
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$138.96
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	$138.96
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$125.45
Rate for Payer: Multiplan Commercial	$125.45
Rate for Payer: Multiplan Workers Comp	$125.45
Rate for Payer: Parkland Medicaid	$138.96
Rate for Payer: Scott and White EPO/PPO	$39.90
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$138.96
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 Sinuses Paranasal Complete

Facility

$433.00

Service Code	HCPCS 70220
Hospital Charge Code	3100187
Hospital Revenue Code	320
Min. Negotiated Rate	$37.76
Max. Negotiated Rate	$311.76
Rate for Payer: Amerigroup CHIP/Medicaid	$37.76
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	$294.44
Rate for Payer: Cash Price	$294.44
Rate for Payer: Cash Price	$294.44
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$311.76
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	$311.76
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$281.45
Rate for Payer: Multiplan Commercial	$281.45
Rate for Payer: Multiplan Workers Comp	$281.45
Rate for Payer: Parkland Medicaid	$311.76
Rate for Payer: Scott and White EPO/PPO	$46.50
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$311.76
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 Sinuses Paranasal Complete

Facility

$433.00

Service Code	HCPCS 70220
Hospital Charge Code	3100187
Hospital Revenue Code	320
Rate for Payer: Cash Price	$294.44

XR Sinus Tract SI

Facility

$702.00

Service Code	HCPCS 76080
Hospital Charge Code	2101855
Hospital Revenue Code	320
Rate for Payer: Cash Price	$477.36

XR Sinus Tract SI

Facility

$702.00

Service Code	HCPCS 76080
Hospital Charge Code	2101855
Hospital Revenue Code	320
Min. Negotiated Rate	$59.81
Max. Negotiated Rate	$1,160.29
Rate for Payer: Amerigroup CHIP/Medicaid	$59.81
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$548.90
Rate for Payer: Amerigroup Medicare	$548.90
Rate for Payer: BCBS of TX Blue Advantage	$794.61
Rate for Payer: BCBS of TX Blue Essentials	$953.53
Rate for Payer: BCBS of TX Medicare	$548.90
Rate for Payer: BCBS of TX PPO	$1,064.29
Rate for Payer: Cash Price	$477.36
Rate for Payer: Cash Price	$477.36
Rate for Payer: Cash Price	$477.36
Rate for Payer: Cigna Commercial	$1,160.29
Rate for Payer: Cigna Medicaid	$505.44
Rate for Payer: Cigna Medicare	$548.90
Rate for Payer: Employer Direct Commercial	$548.90
Rate for Payer: Humana Medicare/TRICARE	$548.90
Rate for Payer: Molina CHIP/Medicaid	$505.44
Rate for Payer: Molina Dual Medicare/Medicaid	$548.90
Rate for Payer: Molina Medicare	$548.90
Rate for Payer: Multiplan Auto	$456.30
Rate for Payer: Multiplan Commercial	$456.30
Rate for Payer: Multiplan Workers Comp	$456.30
Rate for Payer: Parkland Medicaid	$505.44
Rate for Payer: Scott and White EPO/PPO	$73.60
Rate for Payer: Scott and White Medicare	$548.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$505.44
Rate for Payer: Superior Health Plan EPO	$548.90
Rate for Payer: Superior Health Plan Medicare	$548.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$548.90
Rate for Payer: Universal American Medicare	$548.90
Rate for Payer: Wellcare Medicare	$548.90
Rate for Payer: Wellmed Medicare	$548.90

XR Skull < 4 Views

Facility

$443.00

Service Code	HCPCS 70250
Hospital Charge Code	3100203
Hospital Revenue Code	320
Rate for Payer: Cash Price	$301.24

XR Skull < 4 Views

Facility

$443.00

Service Code	HCPCS 70250
Hospital Charge Code	3100203
Hospital Revenue Code	320
Min. Negotiated Rate	$36.09
Max. Negotiated Rate	$318.96
Rate for Payer: Amerigroup CHIP/Medicaid	$36.09
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	$301.24
Rate for Payer: Cash Price	$301.24
Rate for Payer: Cash Price	$301.24
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$318.96
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	$318.96
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$287.95
Rate for Payer: Multiplan Commercial	$287.95
Rate for Payer: Multiplan Workers Comp	$287.95
Rate for Payer: Parkland Medicaid	$318.96
Rate for Payer: Scott and White EPO/PPO	$44.44
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$318.96
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 Skull Complete

Facility

$637.00

Service Code	HCPCS 70260
Hospital Charge Code	3100211
Hospital Revenue Code	320
Min. Negotiated Rate	$44.78
Max. Negotiated Rate	$458.64
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	$433.16
Rate for Payer: Cash Price	$433.16
Rate for Payer: Cash Price	$433.16
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$458.64
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	$458.64
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$414.05
Rate for Payer: Multiplan Commercial	$414.05
Rate for Payer: Multiplan Workers Comp	$414.05
Rate for Payer: Parkland Medicaid	$458.64
Rate for Payer: Scott and White EPO/PPO	$55.17
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$458.64
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 Skull Complete

Facility

$637.00

Service Code	HCPCS 70260
Hospital Charge Code	3100211
Hospital Revenue Code	320
Rate for Payer: Cash Price	$433.16

XR Small Bowel via Enteroclysis Tube

Facility

$892.00

Service Code	HCPCS 74251
Hospital Charge Code	4904251
Hospital Revenue Code	320
Rate for Payer: Cash Price	$606.56

Know your out-of-pocket cost for care.

All Charges