White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHWR LUMBAR PUNCTURE TRAY BCE

Facility

$47.23

Hospital Charge Code	8083805
Hospital Revenue Code	272
Rate for Payer: Cash Price	$41.56

CHWR LUMBAR PUNCTURE TRAY BCE

Facility

$47.23

Hospital Charge Code	8083805
Hospital Revenue Code	272
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$30.70
Rate for Payer: Aetna Commercial	$25.98
Rate for Payer: Amerigroup CHIP/Medicaid	$4.25
Rate for Payer: BCBS of TX Blue Advantage	$14.17
Rate for Payer: BCBS of TX Blue Essentials	$17.00
Rate for Payer: BCBS of TX PPO	$18.89
Rate for Payer: Cash Price	$41.56
Rate for Payer: Multiplan Auto	$30.70
Rate for Payer: Multiplan Commercial	$30.70
Rate for Payer: Multiplan Workers Comp	$30.70
Rate for Payer: Scott and White EPO/PPO	$23.62
Rate for Payer: Superior Health Plan EPO	$6.42

CHWR MA BREAST BX/LOC/SPECIMEN EA ADD

Facility

$1,913.00

Service Code	CPT 19082
Hospital Charge Code	5019182
Hospital Revenue Code	361
Min. Negotiated Rate	$64.69
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,052.15
Rate for Payer: Amerigroup CHIP/Medicaid	$172.17
Rate for Payer: Cash Price	$1,683.44
Rate for Payer: Cash Price	$1,683.44
Rate for Payer: Cash Price	$1,683.44
Rate for Payer: Cigna Medicaid	$64.69
Rate for Payer: Molina CHIP/Medicaid	$64.69
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	$64.69
Rate for Payer: Scott and White EPO/PPO	$956.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$64.69
Rate for Payer: Superior Health Plan EPO	$260.17

CHWR MA BREAST BX/LOC/SPECIMEN EA ADD BCE

Facility

$1,913.00

Service Code	CPT 19082
Hospital Charge Code	5019182
Hospital Revenue Code	361
Min. Negotiated Rate	$64.69
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,052.15
Rate for Payer: Amerigroup CHIP/Medicaid	$172.17
Rate for Payer: Cash Price	$1,683.44
Rate for Payer: Cash Price	$1,683.44
Rate for Payer: Cash Price	$1,683.44
Rate for Payer: Cigna Medicaid	$64.69
Rate for Payer: Molina CHIP/Medicaid	$64.69
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	$64.69
Rate for Payer: Scott and White EPO/PPO	$956.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$64.69
Rate for Payer: Superior Health Plan EPO	$260.17

CHWR MA BREAST BX/LOC/SPECIMEN EA ADD BCE

Facility

$1,913.00

Service Code	CPT 19082
Hospital Charge Code	5019182
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,683.44

CHWR MA BRST LOC DEVICE ADD LES STEREO

Facility

$601.00

Service Code	CPT 19284
Hospital Charge Code	5019284
Hospital Revenue Code	361
Min. Negotiated Rate	$39.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$330.55
Rate for Payer: Amerigroup CHIP/Medicaid	$54.09
Rate for Payer: Cash Price	$528.88
Rate for Payer: Cash Price	$528.88
Rate for Payer: Cash Price	$528.88
Rate for Payer: Cigna Medicaid	$39.29
Rate for Payer: Molina CHIP/Medicaid	$39.29
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	$39.29
Rate for Payer: Scott and White EPO/PPO	$300.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.29
Rate for Payer: Superior Health Plan EPO	$81.74

CHWR MA BRST LOC DEVICE ADD LES STEREO BCE

Facility

$601.00

Service Code	CPT 19284
Hospital Charge Code	5019284
Hospital Revenue Code	361
Min. Negotiated Rate	$39.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$330.55
Rate for Payer: Amerigroup CHIP/Medicaid	$54.09
Rate for Payer: Cash Price	$528.88
Rate for Payer: Cash Price	$528.88
Rate for Payer: Cash Price	$528.88
Rate for Payer: Cigna Medicaid	$39.29
Rate for Payer: Molina CHIP/Medicaid	$39.29
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	$39.29
Rate for Payer: Scott and White EPO/PPO	$300.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.29
Rate for Payer: Superior Health Plan EPO	$81.74

CHWR MA BRST LOC DEVICE ADD LES STEREO BCE

Facility

$601.00

Service Code	CPT 19284
Hospital Charge Code	5019284
Hospital Revenue Code	361
Rate for Payer: Cash Price	$528.88

CHWR MA DIGITAL BREAST TOMO BILATERL

Facility

$218.00

Service Code	CPT 77062
Hospital Charge Code	5017062
Hospital Revenue Code	401
Min. Negotiated Rate	$19.62
Max. Negotiated Rate	$207.87
Rate for Payer: Aetna Commercial	$128.48
Rate for Payer: Amerigroup CHIP/Medicaid	$19.62
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$191.84
Rate for Payer: Cash Price	$191.84
Rate for Payer: Multiplan Auto	$141.70
Rate for Payer: Multiplan Commercial	$141.70
Rate for Payer: Multiplan Workers Comp	$141.70
Rate for Payer: Scott and White EPO/PPO	$109.00
Rate for Payer: Superior Health Plan EPO	$29.65

CHWR MA DIGITAL BREAST TOMO LT

Facility

$183.00

Service Code	CPT 77061
Hospital Charge Code	5017061
Hospital Revenue Code	401
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$207.87
Rate for Payer: Aetna Commercial	$100.75
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$161.04
Rate for Payer: Cash Price	$161.04
Rate for Payer: Multiplan Auto	$118.95
Rate for Payer: Multiplan Commercial	$118.95
Rate for Payer: Multiplan Workers Comp	$118.95
Rate for Payer: Scott and White EPO/PPO	$91.50
Rate for Payer: Superior Health Plan EPO	$24.89

CHWR MA DIGITAL BREAST TOMO RT

Facility

$183.00

Service Code	CPT 77061
Hospital Charge Code	5017061
Hospital Revenue Code	401
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$207.87
Rate for Payer: Aetna Commercial	$100.75
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$161.04
Rate for Payer: Cash Price	$161.04
Rate for Payer: Multiplan Auto	$118.95
Rate for Payer: Multiplan Commercial	$118.95
Rate for Payer: Multiplan Workers Comp	$118.95
Rate for Payer: Scott and White EPO/PPO	$91.50
Rate for Payer: Superior Health Plan EPO	$24.89

CHWR MANDRIL WIRE

Facility

$225.38

Service Code	HCPCS C1769
Hospital Charge Code	8073075
Hospital Revenue Code	272
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$146.50
Rate for Payer: Aetna Commercial	$123.96
Rate for Payer: Amerigroup CHIP/Medicaid	$20.28
Rate for Payer: BCBS of TX Blue Advantage	$67.61
Rate for Payer: BCBS of TX Blue Essentials	$81.14
Rate for Payer: BCBS of TX PPO	$90.15
Rate for Payer: Cash Price	$198.33
Rate for Payer: Multiplan Auto	$146.50
Rate for Payer: Multiplan Commercial	$146.50
Rate for Payer: Multiplan Workers Comp	$146.50
Rate for Payer: Scott and White EPO/PPO	$112.69
Rate for Payer: Superior Health Plan EPO	$30.65

CHWR MANDRIL WIRE BCE

Facility

$225.38

Service Code	HCPCS C1769
Hospital Charge Code	8073075
Hospital Revenue Code	272
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$146.50
Rate for Payer: Aetna Commercial	$123.96
Rate for Payer: Amerigroup CHIP/Medicaid	$20.28
Rate for Payer: BCBS of TX Blue Advantage	$67.61
Rate for Payer: BCBS of TX Blue Essentials	$81.14
Rate for Payer: BCBS of TX PPO	$90.15
Rate for Payer: Cash Price	$198.33
Rate for Payer: Multiplan Auto	$146.50
Rate for Payer: Multiplan Commercial	$146.50
Rate for Payer: Multiplan Workers Comp	$146.50
Rate for Payer: Scott and White EPO/PPO	$112.69
Rate for Payer: Superior Health Plan EPO	$30.65

CHWR MANDRIL WIRE BCE

Facility

$225.38

Service Code	HCPCS C1769
Hospital Charge Code	8073075
Hospital Revenue Code	272
Rate for Payer: Cash Price	$198.33

CHWR MA PERC DEVICE BREAST 1ST

Facility

$593.00

Service Code	CPT 19282
Hospital Charge Code	5019282
Hospital Revenue Code	361
Min. Negotiated Rate	$38.76
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$326.15
Rate for Payer: Amerigroup CHIP/Medicaid	$53.37
Rate for Payer: Cash Price	$521.84
Rate for Payer: Cash Price	$521.84
Rate for Payer: Cash Price	$521.84
Rate for Payer: Cigna Medicaid	$38.76
Rate for Payer: Molina CHIP/Medicaid	$38.76
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	$38.76
Rate for Payer: Scott and White EPO/PPO	$296.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.76
Rate for Payer: Superior Health Plan EPO	$80.65

CHWR MA PERC DEVICE BREAST 1ST BCE

Facility

$593.00

Service Code	CPT 19282
Hospital Charge Code	5019282
Hospital Revenue Code	361
Min. Negotiated Rate	$38.76
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$326.15
Rate for Payer: Amerigroup CHIP/Medicaid	$53.37
Rate for Payer: Cash Price	$521.84
Rate for Payer: Cash Price	$521.84
Rate for Payer: Cash Price	$521.84
Rate for Payer: Cigna Medicaid	$38.76
Rate for Payer: Molina CHIP/Medicaid	$38.76
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	$38.76
Rate for Payer: Scott and White EPO/PPO	$296.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.76
Rate for Payer: Superior Health Plan EPO	$80.65

CHWR MA PERC DEVICE BREAST 1ST BCE

Facility

$593.00

Service Code	CPT 19282
Hospital Charge Code	5019282
Hospital Revenue Code	361
Rate for Payer: Cash Price	$521.84

CHWR MA SCREENING DIGITAL BRST TOMO BIL

Facility

$66.00

Service Code	CPT 77063
Hospital Charge Code	5017063
Hospital Revenue Code	403
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$55.76
Rate for Payer: Aetna Commercial	$26.97
Rate for Payer: Amerigroup CHIP/Medicaid	$52.79
Rate for Payer: BCBS of TX Blue Advantage	$41.63
Rate for Payer: BCBS of TX Blue Essentials	$49.96
Rate for Payer: BCBS of TX PPO	$55.76
Rate for Payer: Cash Price	$58.08
Rate for Payer: Cash Price	$58.08
Rate for Payer: Cigna Medicaid	$52.79
Rate for Payer: Molina CHIP/Medicaid	$52.79
Rate for Payer: Multiplan Auto	$42.90
Rate for Payer: Multiplan Commercial	$42.90
Rate for Payer: Multiplan Workers Comp	$42.90
Rate for Payer: Parkland Medicaid	$52.79
Rate for Payer: Scott and White EPO/PPO	$33.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.79
Rate for Payer: Superior Health Plan EPO	$8.98

CHWR MICRO MARK

Facility

$568.50

Service Code	HCPCS A4648
Hospital Charge Code	8240206
Hospital Revenue Code	278
Min. Negotiated Rate	$51.16
Max. Negotiated Rate	$284.25
Rate for Payer: Aetna Commercial	$170.55
Rate for Payer: Amerigroup CHIP/Medicaid	$51.16
Rate for Payer: BCBS of TX Blue Advantage	$170.55
Rate for Payer: BCBS of TX Blue Essentials	$204.66
Rate for Payer: BCBS of TX PPO	$227.40
Rate for Payer: Cash Price	$500.28
Rate for Payer: Multiplan Auto	$284.25
Rate for Payer: Multiplan Commercial	$284.25
Rate for Payer: Multiplan Workers Comp	$284.25
Rate for Payer: Scott and White EPO/PPO	$284.25
Rate for Payer: Superior Health Plan EPO	$77.32

CHWR MICRO MARK

Facility

$568.50

Service Code	HCPCS A4648
Hospital Charge Code	8240206
Hospital Revenue Code	278
Min. Negotiated Rate	$142.12
Max. Negotiated Rate	$284.25
Rate for Payer: Aetna Commercial	$170.55
Rate for Payer: Cash Price	$500.28
Rate for Payer: Cigna Commercial	$142.12
Rate for Payer: Multiplan Auto	$284.25
Rate for Payer: Multiplan Commercial	$284.25
Rate for Payer: Multiplan Workers Comp	$284.25
Rate for Payer: Scott and White EPO/PPO	$284.25

CHWR MICRO MARK BCE

Facility

$568.50

Service Code	HCPCS A4648
Hospital Charge Code	8240206
Hospital Revenue Code	278
Min. Negotiated Rate	$142.12
Max. Negotiated Rate	$284.25
Rate for Payer: Aetna Commercial	$170.55
Rate for Payer: Cash Price	$500.28
Rate for Payer: Cigna Commercial	$142.12
Rate for Payer: Multiplan Auto	$284.25
Rate for Payer: Multiplan Commercial	$284.25
Rate for Payer: Multiplan Workers Comp	$284.25
Rate for Payer: Scott and White EPO/PPO	$284.25

CHWR MICRO MARK BCE

Facility

$568.50

Service Code	HCPCS A4648
Hospital Charge Code	8240206
Hospital Revenue Code	278
Min. Negotiated Rate	$51.16
Max. Negotiated Rate	$284.25
Rate for Payer: Aetna Commercial	$170.55
Rate for Payer: Amerigroup CHIP/Medicaid	$51.16
Rate for Payer: BCBS of TX Blue Advantage	$170.55
Rate for Payer: BCBS of TX Blue Essentials	$204.66
Rate for Payer: BCBS of TX PPO	$227.40
Rate for Payer: Cash Price	$500.28
Rate for Payer: Multiplan Auto	$284.25
Rate for Payer: Multiplan Commercial	$284.25
Rate for Payer: Multiplan Workers Comp	$284.25
Rate for Payer: Scott and White EPO/PPO	$284.25
Rate for Payer: Superior Health Plan EPO	$77.32

CHWR MYELOGRAM TRAY

Facility

$575.58

Hospital Charge Code	8083900
Hospital Revenue Code	272
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$374.13
Rate for Payer: Aetna Commercial	$316.57
Rate for Payer: Amerigroup CHIP/Medicaid	$51.80
Rate for Payer: BCBS of TX Blue Advantage	$172.67
Rate for Payer: BCBS of TX Blue Essentials	$207.21
Rate for Payer: BCBS of TX PPO	$230.23
Rate for Payer: Cash Price	$506.51
Rate for Payer: Multiplan Auto	$374.13
Rate for Payer: Multiplan Commercial	$374.13
Rate for Payer: Multiplan Workers Comp	$374.13
Rate for Payer: Scott and White EPO/PPO	$287.79
Rate for Payer: Superior Health Plan EPO	$78.28

CHWR MYELOGRAM TRAY BCE

Facility

$575.58

Hospital Charge Code	8083900
Hospital Revenue Code	272
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$374.13
Rate for Payer: Aetna Commercial	$316.57
Rate for Payer: Amerigroup CHIP/Medicaid	$51.80
Rate for Payer: BCBS of TX Blue Advantage	$172.67
Rate for Payer: BCBS of TX Blue Essentials	$207.21
Rate for Payer: BCBS of TX PPO	$230.23
Rate for Payer: Cash Price	$506.51
Rate for Payer: Multiplan Auto	$374.13
Rate for Payer: Multiplan Commercial	$374.13
Rate for Payer: Multiplan Workers Comp	$374.13
Rate for Payer: Scott and White EPO/PPO	$287.79
Rate for Payer: Superior Health Plan EPO	$78.28

CHWR MYELOGRAM TRAY BCE

Facility

$575.58

Hospital Charge Code	8083900
Hospital Revenue Code	272
Rate for Payer: Cash Price	$506.51

Know your out-of-pocket cost for care.

All Charges