White Rock Medical Center

All Charges

Charge

Type

Setting

Price

XR Voiding Urethrocystography

Facility

$686.00

Service Code	HCPCS 74455
Hospital Charge Code	3101250
Hospital Revenue Code	320
Rate for Payer: Cash Price	$466.48

XR Voiding Urethrocystography

Facility

$686.00

Service Code	HCPCS 74455
Hospital Charge Code	3101250
Hospital Revenue Code	320
Min. Negotiated Rate	$104.25
Max. Negotiated Rate	$515.02
Rate for Payer: Amerigroup CHIP/Medicaid	$104.25
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	$466.48
Rate for Payer: Cash Price	$466.48
Rate for Payer: Cash Price	$466.48
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$493.92
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	$493.92
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$445.90
Rate for Payer: Multiplan Commercial	$445.90
Rate for Payer: Multiplan Workers Comp	$445.90
Rate for Payer: Parkland Medicaid	$493.92
Rate for Payer: Scott and White EPO/PPO	$128.55
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$493.92
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 Wrist 2 Views Left

Facility

$465.00

Service Code	HCPCS 73100 LT
Hospital Charge Code	3100716
Hospital Revenue Code	320
Min. Negotiated Rate	$34.09
Max. Negotiated Rate	$334.80
Rate for Payer: Amerigroup CHIP/Medicaid	$34.09
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	$316.20
Rate for Payer: Cash Price	$316.20
Rate for Payer: Cash Price	$316.20
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$334.80
Rate for Payer: Molina CHIP/Medicaid	$334.80
Rate for Payer: Multiplan Auto	$302.25
Rate for Payer: Multiplan Commercial	$302.25
Rate for Payer: Multiplan Workers Comp	$302.25
Rate for Payer: Parkland Medicaid	$334.80
Rate for Payer: Scott and White EPO/PPO	$232.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$334.80
Rate for Payer: Superior Health Plan EPO	$63.24

XR Wrist 2 Views Left

Facility

$465.00

Service Code	HCPCS 73100 LT
Hospital Charge Code	3100716
Hospital Revenue Code	320
Rate for Payer: Cash Price	$316.20

XR Wrist 2 Views Right

Facility

$465.00

Service Code	HCPCS 73100 RT
Hospital Charge Code	3100724
Hospital Revenue Code	320
Rate for Payer: Cash Price	$316.20

XR Wrist 2 Views Right

Facility

$465.00

Service Code	HCPCS 73100 RT
Hospital Charge Code	3100724
Hospital Revenue Code	320
Min. Negotiated Rate	$34.09
Max. Negotiated Rate	$334.80
Rate for Payer: Amerigroup CHIP/Medicaid	$34.09
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	$316.20
Rate for Payer: Cash Price	$316.20
Rate for Payer: Cash Price	$316.20
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$334.80
Rate for Payer: Molina CHIP/Medicaid	$334.80
Rate for Payer: Multiplan Auto	$302.25
Rate for Payer: Multiplan Commercial	$302.25
Rate for Payer: Multiplan Workers Comp	$302.25
Rate for Payer: Parkland Medicaid	$334.80
Rate for Payer: Scott and White EPO/PPO	$232.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$334.80
Rate for Payer: Superior Health Plan EPO	$63.24

XR Wrist Complete 3+ Views Left

Facility

$535.00

Service Code	HCPCS 73110 LT
Hospital Charge Code	3100732
Hospital Revenue Code	320
Rate for Payer: Cash Price	$363.80

XR Wrist Complete 3+ Views Left

Facility

$535.00

Service Code	HCPCS 73110 LT
Hospital Charge Code	3100732
Hospital Revenue Code	320
Min. Negotiated Rate	$41.44
Max. Negotiated Rate	$385.20
Rate for Payer: Amerigroup CHIP/Medicaid	$41.44
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 Wrist Complete 3+ Views Right

Facility

$535.00

Service Code	HCPCS 73110 RT
Hospital Charge Code	3100740
Hospital Revenue Code	320
Min. Negotiated Rate	$41.44
Max. Negotiated Rate	$385.20
Rate for Payer: Amerigroup CHIP/Medicaid	$41.44
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 Wrist Complete 3+ Views Right

Facility

$535.00

Service Code	HCPCS 73110 RT
Hospital Charge Code	3100740
Hospital Revenue Code	320
Rate for Payer: Cash Price	$363.80

X-Stem Implant, Tall, Size 3, Long with Tidal

Facility

$45,180.72

Service Code	HCPCS C1776
Hospital Charge Code	993127
Hospital Revenue Code	278
Min. Negotiated Rate	$11,295.18
Max. Negotiated Rate	$22,590.36
Rate for Payer: Cash Price	$30,722.89
Rate for Payer: Cigna Commercial	$11,295.18
Rate for Payer: Multiplan Auto	$22,590.36
Rate for Payer: Multiplan Commercial	$22,590.36
Rate for Payer: Multiplan Workers Comp	$22,590.36
Rate for Payer: Scott and White EPO/PPO	$22,590.36

X-Stem Implant, Tall, Size 3, Long with Tidal

Facility

$45,180.72

Service Code	HCPCS C1776
Hospital Charge Code	993127
Hospital Revenue Code	278
Min. Negotiated Rate	$4,066.26
Max. Negotiated Rate	$32,530.12
Rate for Payer: Amerigroup CHIP/Medicaid	$4,066.26
Rate for Payer: BCBS of TX Blue Advantage	$13,554.22
Rate for Payer: BCBS of TX Blue Essentials	$16,265.06
Rate for Payer: BCBS of TX PPO	$18,072.29
Rate for Payer: Cash Price	$30,722.89
Rate for Payer: Cigna Medicaid	$32,530.12
Rate for Payer: Molina CHIP/Medicaid	$32,530.12
Rate for Payer: Multiplan Auto	$22,590.36
Rate for Payer: Multiplan Commercial	$22,590.36
Rate for Payer: Multiplan Workers Comp	$22,590.36
Rate for Payer: Parkland Medicaid	$32,530.12
Rate for Payer: Scott and White EPO/PPO	$22,590.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32,530.12
Rate for Payer: Superior Health Plan EPO	$6,144.58

XWIK-STIK CONTROL EA

Facility

$635.15

Hospital Charge Code	993645
Hospital Revenue Code	270
Rate for Payer: Cash Price	$431.90

XWIK-STIK CONTROL EA

Facility

$635.15

Hospital Charge Code	993645
Hospital Revenue Code	270
Min. Negotiated Rate	$57.16
Max. Negotiated Rate	$457.31
Rate for Payer: Amerigroup CHIP/Medicaid	$57.16
Rate for Payer: BCBS of TX Blue Advantage	$190.54
Rate for Payer: BCBS of TX Blue Essentials	$228.65
Rate for Payer: BCBS of TX PPO	$254.06
Rate for Payer: Cash Price	$431.90
Rate for Payer: Cigna Medicaid	$457.31
Rate for Payer: Molina CHIP/Medicaid	$457.31
Rate for Payer: Multiplan Auto	$412.85
Rate for Payer: Multiplan Commercial	$412.85
Rate for Payer: Multiplan Workers Comp	$412.85
Rate for Payer: Parkland Medicaid	$457.31
Rate for Payer: Scott and White EPO/PPO	$317.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$457.31
Rate for Payer: Superior Health Plan EPO	$86.38

Yankauer, 1-piece bulb tip

Facility

$2.49

Hospital Charge Code	992954
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.69

Yankauer, 1-piece bulb tip

Facility

$2.49

Hospital Charge Code	992954
Hospital Revenue Code	272
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$1.79
Rate for Payer: Amerigroup CHIP/Medicaid	$0.22
Rate for Payer: BCBS of TX Blue Advantage	$0.75
Rate for Payer: BCBS of TX Blue Essentials	$0.90
Rate for Payer: BCBS of TX PPO	$1.00
Rate for Payer: Cash Price	$1.69
Rate for Payer: Cigna Medicaid	$1.79
Rate for Payer: Molina CHIP/Medicaid	$1.79
Rate for Payer: Multiplan Auto	$1.62
Rate for Payer: Multiplan Commercial	$1.62
Rate for Payer: Multiplan Workers Comp	$1.62
Rate for Payer: Parkland Medicaid	$1.79
Rate for Payer: Scott and White EPO/PPO	$1.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.79
Rate for Payer: Superior Health Plan EPO	$0.34

YANKAUER, BULB TIP

Facility

$4.67

Hospital Charge Code	993009
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.18

YANKAUER, BULB TIP

Facility

$4.67

Hospital Charge Code	993009
Hospital Revenue Code	272
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$3.36
Rate for Payer: Amerigroup CHIP/Medicaid	$0.42
Rate for Payer: BCBS of TX Blue Advantage	$1.40
Rate for Payer: BCBS of TX Blue Essentials	$1.68
Rate for Payer: BCBS of TX PPO	$1.87
Rate for Payer: Cash Price	$3.18
Rate for Payer: Cigna Medicaid	$3.36
Rate for Payer: Molina CHIP/Medicaid	$3.36
Rate for Payer: Multiplan Auto	$3.04
Rate for Payer: Multiplan Commercial	$3.04
Rate for Payer: Multiplan Workers Comp	$3.04
Rate for Payer: Parkland Medicaid	$3.36
Rate for Payer: Scott and White EPO/PPO	$2.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.36
Rate for Payer: Superior Health Plan EPO	$0.64

YANKAUER, BULB TIP, W/O VENT, RIGID, STERILE

Facility

$3.55

Hospital Charge Code	993746
Hospital Revenue Code	272
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$2.56
Rate for Payer: Amerigroup CHIP/Medicaid	$0.32
Rate for Payer: BCBS of TX Blue Advantage	$1.06
Rate for Payer: BCBS of TX Blue Essentials	$1.28
Rate for Payer: BCBS of TX PPO	$1.42
Rate for Payer: Cash Price	$2.41
Rate for Payer: Cigna Medicaid	$2.56
Rate for Payer: Molina CHIP/Medicaid	$2.56
Rate for Payer: Multiplan Auto	$2.31
Rate for Payer: Multiplan Commercial	$2.31
Rate for Payer: Multiplan Workers Comp	$2.31
Rate for Payer: Parkland Medicaid	$2.56
Rate for Payer: Scott and White EPO/PPO	$1.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.56
Rate for Payer: Superior Health Plan EPO	$0.48

YANKAUER, BULB TIP, W/O VENT, RIGID, STERILE

Facility

$3.55

Hospital Charge Code	993746
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2.41

Yeast identification (Vitek)

Facility

$191.00

Service Code	HCPCS 87106
Hospital Charge Code	4107106
Hospital Revenue Code	306
Rate for Payer: Cash Price	$129.88

Yeast identification (Vitek)

Facility

$191.00

Service Code	HCPCS 87106
Hospital Charge Code	4107106
Hospital Revenue Code	306
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$137.52
Rate for Payer: Amerigroup CHIP/Medicaid	$4.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.32
Rate for Payer: Amerigroup Medicare	$10.32
Rate for Payer: BCBS of TX Blue Advantage	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX Medicare	$10.32
Rate for Payer: BCBS of TX PPO	$76.40
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cigna Medicaid	$137.52
Rate for Payer: Cigna Medicare	$10.32
Rate for Payer: Employer Direct Commercial	$10.32
Rate for Payer: Humana Medicare/TRICARE	$10.32
Rate for Payer: Molina CHIP/Medicaid	$137.52
Rate for Payer: Molina Dual Medicare/Medicaid	$10.32
Rate for Payer: Molina Medicare	$10.32
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Parkland Medicaid	$137.52
Rate for Payer: Scott and White EPO/PPO	$12.90
Rate for Payer: Scott and White Medicare	$10.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$10.32
Rate for Payer: Superior Health Plan Medicare	$10.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.32
Rate for Payer: Universal American Medicare	$10.32
Rate for Payer: Wellcare Medicare	$10.32
Rate for Payer: Wellmed Medicare	$10.32

Y-KNOT DISP BROACH PUNCH

Facility

$616.17

Hospital Charge Code	145132
Hospital Revenue Code	272
Rate for Payer: Cash Price	$419.00

Y-KNOT DISP BROACH PUNCH

Facility

$616.17

Hospital Charge Code	145132
Hospital Revenue Code	272
Min. Negotiated Rate	$55.46
Max. Negotiated Rate	$443.64
Rate for Payer: Amerigroup CHIP/Medicaid	$55.46
Rate for Payer: BCBS of TX Blue Advantage	$184.85
Rate for Payer: BCBS of TX Blue Essentials	$221.82
Rate for Payer: BCBS of TX PPO	$246.47
Rate for Payer: Cash Price	$419.00
Rate for Payer: Cigna Medicaid	$443.64
Rate for Payer: Molina CHIP/Medicaid	$443.64
Rate for Payer: Multiplan Auto	$400.51
Rate for Payer: Multiplan Commercial	$400.51
Rate for Payer: Multiplan Workers Comp	$400.51
Rate for Payer: Parkland Medicaid	$443.64
Rate for Payer: Scott and White EPO/PPO	$308.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$443.64
Rate for Payer: Superior Health Plan EPO	$83.80

Y-KNOT FLEX DISP. PERC PK

Facility

$545.89

Hospital Charge Code	146673
Hospital Revenue Code	272
Rate for Payer: Cash Price	$371.21

Know your out-of-pocket cost for care.

All Charges