White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Tilt Table

Facility

$1,399.00

Service Code	HCPCS 93660
Hospital Charge Code	2301141
Hospital Revenue Code	480
Rate for Payer: Cash Price	$951.32

XR TMJ Open and Closed Bilateral

Facility

$608.00

Service Code	HCPCS 70330
Hospital Charge Code	3100237
Hospital Revenue Code	320
Min. Negotiated Rate	$53.13
Max. Negotiated Rate	$437.76
Rate for Payer: Amerigroup CHIP/Medicaid	$53.13
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	$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: 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	$437.76
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
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	$65.46
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$437.76
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 TMJ Open and Closed Bilateral

Facility

$608.00

Service Code	HCPCS 70330
Hospital Charge Code	3100237
Hospital Revenue Code	320
Rate for Payer: Cash Price	$413.44

XR Toe(2nd Digit) 2+ Views Left

Facility

$506.00

Service Code	HCPCS 73660 T1
Hospital Charge Code	3101052
Hospital Revenue Code	320
Rate for Payer: Cash Price	$344.08

XR Toe(2nd Digit) 2+ Views Left

Facility

$506.00

Service Code	HCPCS 73660 T1
Hospital Charge Code	3101052
Hospital Revenue Code	320
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$364.32
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	$344.08
Rate for Payer: Cash Price	$344.08
Rate for Payer: Cash Price	$344.08
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$364.32
Rate for Payer: Molina CHIP/Medicaid	$364.32
Rate for Payer: Multiplan Auto	$328.90
Rate for Payer: Multiplan Commercial	$328.90
Rate for Payer: Multiplan Workers Comp	$328.90
Rate for Payer: Parkland Medicaid	$364.32
Rate for Payer: Scott and White EPO/PPO	$253.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$364.32
Rate for Payer: Superior Health Plan EPO	$68.82

XR Toe(2nd Digit) 2+ Views Right

Facility

$506.00

Service Code	HCPCS 73660 T6
Hospital Charge Code	3101060
Hospital Revenue Code	320
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$364.32
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	$344.08
Rate for Payer: Cash Price	$344.08
Rate for Payer: Cash Price	$344.08
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$364.32
Rate for Payer: Molina CHIP/Medicaid	$364.32
Rate for Payer: Multiplan Auto	$328.90
Rate for Payer: Multiplan Commercial	$328.90
Rate for Payer: Multiplan Workers Comp	$328.90
Rate for Payer: Parkland Medicaid	$364.32
Rate for Payer: Scott and White EPO/PPO	$253.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$364.32
Rate for Payer: Superior Health Plan EPO	$68.82

XR Toe(2nd Digit) 2+ Views Right

Facility

$506.00

Service Code	HCPCS 73660 T6
Hospital Charge Code	3101060
Hospital Revenue Code	320
Rate for Payer: Cash Price	$344.08

XR Tube Replace G or J w/ Fluoro w/ Cnt

Facility

$1,591.00

Service Code	HCPCS 49451
Hospital Charge Code	4909452
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,081.88

XR Tube Replace G or J w/ Fluoro w/ Cnt

Facility

$1,591.00

Service Code	HCPCS 49451
Hospital Charge Code	4909452
Hospital Revenue Code	361
Min. Negotiated Rate	$334.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$334.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$911.12
Rate for Payer: Amerigroup Medicare	$911.12
Rate for Payer: BCBS of TX Blue Advantage	$1,312.49
Rate for Payer: BCBS of TX Blue Essentials	$1,571.84
Rate for Payer: BCBS of TX Medicare	$911.12
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cash Price	$1,081.88
Rate for Payer: Cash Price	$1,081.88
Rate for Payer: Cash Price	$1,081.88
Rate for Payer: Cigna Commercial	$1,925.93
Rate for Payer: Cigna Medicaid	$1,145.52
Rate for Payer: Cigna Medicare	$911.12
Rate for Payer: Employer Direct Commercial	$911.12
Rate for Payer: Humana Medicare/TRICARE	$911.12
Rate for Payer: Molina CHIP/Medicaid	$1,145.52
Rate for Payer: Molina Dual Medicare/Medicaid	$911.12
Rate for Payer: Molina Medicare	$911.12
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	$1,145.52
Rate for Payer: Scott and White EPO/PPO	$1,533.69
Rate for Payer: Scott and White Medicare	$911.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,145.52
Rate for Payer: Superior Health Plan EPO	$911.12
Rate for Payer: Superior Health Plan Medicare	$911.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$911.12
Rate for Payer: Universal American Medicare	$911.12
Rate for Payer: Wellcare Medicare	$911.12
Rate for Payer: Wellmed Medicare	$911.12

XR Tube Reposition Gastric

Facility

$2,417.00

Service Code	HCPCS 43761
Hospital Charge Code	2425638
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,643.56

XR Tube Reposition Gastric

Facility

$2,417.00

Service Code	HCPCS 43761
Hospital Charge Code	2425638
Hospital Revenue Code	361
Min. Negotiated Rate	$110.15
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$110.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$250.99
Rate for Payer: Amerigroup Medicare	$250.99
Rate for Payer: BCBS of TX Blue Advantage	$392.28
Rate for Payer: BCBS of TX Blue Essentials	$469.80
Rate for Payer: BCBS of TX Medicare	$250.99
Rate for Payer: BCBS of TX PPO	$591.95
Rate for Payer: Cash Price	$1,643.56
Rate for Payer: Cash Price	$1,643.56
Rate for Payer: Cash Price	$1,643.56
Rate for Payer: Cigna Commercial	$530.54
Rate for Payer: Cigna Medicaid	$1,740.24
Rate for Payer: Cigna Medicare	$250.99
Rate for Payer: Employer Direct Commercial	$250.99
Rate for Payer: Humana Medicare/TRICARE	$250.99
Rate for Payer: Molina CHIP/Medicaid	$1,740.24
Rate for Payer: Molina Dual Medicare/Medicaid	$250.99
Rate for Payer: Molina Medicare	$250.99
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	$1,740.24
Rate for Payer: Scott and White EPO/PPO	$418.16
Rate for Payer: Scott and White Medicare	$250.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,740.24
Rate for Payer: Superior Health Plan EPO	$250.99
Rate for Payer: Superior Health Plan Medicare	$250.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$250.99
Rate for Payer: Universal American Medicare	$250.99
Rate for Payer: Wellcare Medicare	$250.99
Rate for Payer: Wellmed Medicare	$250.99

XR UGI & Small Bowel w/ or w/o Air

Facility

$981.00

Service Code	HCPCS 74248
Hospital Charge Code	3100002
Hospital Revenue Code	320
Min. Negotiated Rate	$79.08
Max. Negotiated Rate	$706.32
Rate for Payer: Amerigroup CHIP/Medicaid	$82.53
Rate for Payer: BCBS of TX Blue Advantage	$79.08
Rate for Payer: BCBS of TX Blue Essentials	$94.90
Rate for Payer: BCBS of TX PPO	$105.93
Rate for Payer: Cash Price	$667.08
Rate for Payer: Cash Price	$667.08
Rate for Payer: Cigna Medicaid	$706.32
Rate for Payer: Molina CHIP/Medicaid	$706.32
Rate for Payer: Multiplan Auto	$637.65
Rate for Payer: Multiplan Commercial	$637.65
Rate for Payer: Multiplan Workers Comp	$637.65
Rate for Payer: Parkland Medicaid	$706.32
Rate for Payer: Scott and White EPO/PPO	$101.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$706.32
Rate for Payer: Superior Health Plan EPO	$133.42

XR UGI & Small Bowel w/ or w/o Air

Facility

$981.00

Service Code	HCPCS 74248
Hospital Charge Code	3100002
Hospital Revenue Code	320
Rate for Payer: Cash Price	$667.08

XR Upper Extremity Infant (0-1yr) Left

Facility

$553.00

Service Code	HCPCS 73092 LT
Hospital Charge Code	3101573
Hospital Revenue Code	320
Min. Negotiated Rate	$75.21
Max. Negotiated Rate	$398.16
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
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	$376.04
Rate for Payer: Cash Price	$376.04
Rate for Payer: Cash Price	$376.04
Rate for Payer: Cigna Commercial	$222.00
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 Upper Extremity Infant (0-1yr) Left

Facility

$553.00

Service Code	HCPCS 73092 LT
Hospital Charge Code	3101573
Hospital Revenue Code	320
Rate for Payer: Cash Price	$376.04

XR Upper Extremity Infant (0-1yr) Right

Facility

$553.00

Service Code	HCPCS 73092 RT
Hospital Charge Code	3101680
Hospital Revenue Code	320
Rate for Payer: Cash Price	$376.04

XR Upper Extremity Infant (0-1yr) Right

Facility

$553.00

Service Code	HCPCS 73092 RT
Hospital Charge Code	3101680
Hospital Revenue Code	320
Min. Negotiated Rate	$75.21
Max. Negotiated Rate	$398.16
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
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	$376.04
Rate for Payer: Cash Price	$376.04
Rate for Payer: Cash Price	$376.04
Rate for Payer: Cigna Commercial	$222.00
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 Upper GI w/ Air Contrast

Facility

$1,359.00

Service Code	HCPCS 74246
Hospital Charge Code	3101110
Hospital Revenue Code	320
Rate for Payer: Cash Price	$924.12

XR Upper GI w/ Air Contrast

Facility

$1,359.00

Service Code	HCPCS 74246
Hospital Charge Code	3101110
Hospital Revenue Code	320
Min. Negotiated Rate	$139.34
Max. Negotiated Rate	$978.48
Rate for Payer: Amerigroup CHIP/Medicaid	$139.34
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	$924.12
Rate for Payer: Cash Price	$924.12
Rate for Payer: Cash Price	$924.12
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$978.48
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	$978.48
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$883.35
Rate for Payer: Multiplan Commercial	$883.35
Rate for Payer: Multiplan Workers Comp	$883.35
Rate for Payer: Parkland Medicaid	$978.48
Rate for Payer: Scott and White EPO/PPO	$171.70
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$978.48
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 Upper GI w/ Small Bowel

Facility

$981.00

Service Code	HCPCS 74240
Hospital Charge Code	3160181
Hospital Revenue Code	320
Rate for Payer: Cash Price	$667.08

XR Upper GI w/ Small Bowel

Facility

$981.00

Service Code	HCPCS 74240
Hospital Charge Code	3160181
Hospital Revenue Code	320
Min. Negotiated Rate	$122.96
Max. Negotiated Rate	$706.32
Rate for Payer: Amerigroup CHIP/Medicaid	$122.96
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	$667.08
Rate for Payer: Cash Price	$667.08
Rate for Payer: Cash Price	$667.08
Rate for Payer: Cigna Commercial	$372.46
Rate for Payer: Cigna Medicaid	$706.32
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	$706.32
Rate for Payer: Molina Dual Medicare/Medicaid	$176.20
Rate for Payer: Molina Medicare	$176.20
Rate for Payer: Multiplan Auto	$637.65
Rate for Payer: Multiplan Commercial	$637.65
Rate for Payer: Multiplan Workers Comp	$637.65
Rate for Payer: Parkland Medicaid	$706.32
Rate for Payer: Scott and White EPO/PPO	$151.54
Rate for Payer: Scott and White Medicare	$176.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$706.32
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 Urethrocystography Retrograde

Facility

$1,057.00

Service Code	HCPCS 74450
Hospital Charge Code	3170070
Hospital Revenue Code	320
Rate for Payer: Cash Price	$718.76

XR Urethrocystography Retrograde

Facility

$1,057.00

Service Code	HCPCS 74450
Hospital Charge Code	3170070
Hospital Revenue Code	320
Min. Negotiated Rate	$81.38
Max. Negotiated Rate	$761.04
Rate for Payer: Amerigroup CHIP/Medicaid	$81.38
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	$718.76
Rate for Payer: Cash Price	$718.76
Rate for Payer: Cash Price	$718.76
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$761.04
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	$761.04
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$687.05
Rate for Payer: Multiplan Commercial	$687.05
Rate for Payer: Multiplan Workers Comp	$687.05
Rate for Payer: Parkland Medicaid	$761.04
Rate for Payer: Scott and White EPO/PPO	$528.50
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$761.04
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 Urography Retrograde Right

Facility

$814.00

Service Code	HCPCS 74420
Hospital Charge Code	3101235
Hospital Revenue Code	320
Rate for Payer: Cash Price	$553.52

XR Urography Retrograde Right

Facility

$814.00

Service Code	HCPCS 74420
Hospital Charge Code	3101235
Hospital Revenue Code	320
Min. Negotiated Rate	$76.71
Max. Negotiated Rate	$740.81
Rate for Payer: Amerigroup CHIP/Medicaid	$78.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
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 Medicare	$350.46
Rate for Payer: BCBS of TX PPO	$102.74
Rate for Payer: Cash Price	$553.52
Rate for Payer: Cash Price	$553.52
Rate for Payer: Cash Price	$553.52
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$586.08
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$586.08
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$529.10
Rate for Payer: Multiplan Commercial	$529.10
Rate for Payer: Multiplan Workers Comp	$529.10
Rate for Payer: Parkland Medicaid	$586.08
Rate for Payer: Scott and White EPO/PPO	$96.38
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$586.08
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

Know your out-of-pocket cost for care.

All Charges