White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BLADE, TONGUE, 6', STERILE

Facility

$0.18

Hospital Charge Code	993232
Hospital Revenue Code	270
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.13
Rate for Payer: Amerigroup CHIP/Medicaid	$0.02
Rate for Payer: BCBS of TX Blue Advantage	$0.05
Rate for Payer: BCBS of TX Blue Essentials	$0.06
Rate for Payer: BCBS of TX PPO	$0.07
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna Medicaid	$0.13
Rate for Payer: Molina CHIP/Medicaid	$0.13
Rate for Payer: Multiplan Auto	$0.12
Rate for Payer: Multiplan Commercial	$0.12
Rate for Payer: Multiplan Workers Comp	$0.12
Rate for Payer: Parkland Medicaid	$0.13
Rate for Payer: Scott and White EPO/PPO	$0.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.13
Rate for Payer: Superior Health Plan EPO	$0.02

BLADE, TONGUE, 6', STERILE

Facility

$0.18

Hospital Charge Code	993232
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.12

BLANKET WARMING FULL BODY

Facility

$104.05

Hospital Charge Code	8538531
Hospital Revenue Code	272
Min. Negotiated Rate	$9.36
Max. Negotiated Rate	$74.92
Rate for Payer: Amerigroup CHIP/Medicaid	$9.36
Rate for Payer: BCBS of TX Blue Advantage	$31.21
Rate for Payer: BCBS of TX Blue Essentials	$37.46
Rate for Payer: BCBS of TX PPO	$41.62
Rate for Payer: Cash Price	$70.75
Rate for Payer: Cigna Medicaid	$74.92
Rate for Payer: Molina CHIP/Medicaid	$74.92
Rate for Payer: Multiplan Auto	$67.63
Rate for Payer: Multiplan Commercial	$67.63
Rate for Payer: Multiplan Workers Comp	$67.63
Rate for Payer: Parkland Medicaid	$74.92
Rate for Payer: Scott and White EPO/PPO	$52.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.92
Rate for Payer: Superior Health Plan EPO	$14.15

BLANKET WARMING FULL BODY

Facility

$104.05

Hospital Charge Code	8538531
Hospital Revenue Code	272
Rate for Payer: Cash Price	$70.75

BLANKET WARMING HALF BODY

Facility

$23.24

Hospital Charge Code	8538532
Hospital Revenue Code	272
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$16.73
Rate for Payer: Amerigroup CHIP/Medicaid	$2.09
Rate for Payer: BCBS of TX Blue Advantage	$6.97
Rate for Payer: BCBS of TX Blue Essentials	$8.37
Rate for Payer: BCBS of TX PPO	$9.30
Rate for Payer: Cash Price	$15.80
Rate for Payer: Cigna Medicaid	$16.73
Rate for Payer: Molina CHIP/Medicaid	$16.73
Rate for Payer: Multiplan Auto	$15.11
Rate for Payer: Multiplan Commercial	$15.11
Rate for Payer: Multiplan Workers Comp	$15.11
Rate for Payer: Parkland Medicaid	$16.73
Rate for Payer: Scott and White EPO/PPO	$11.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.73
Rate for Payer: Superior Health Plan EPO	$3.16

BLANKET WARMING HALF BODY

Facility

$23.24

Hospital Charge Code	8538532
Hospital Revenue Code	272
Rate for Payer: Cash Price	$15.80

BLANKET, WARMING, LOWER BODY

Facility

$24.95

Hospital Charge Code	992901
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$17.96
Rate for Payer: Amerigroup CHIP/Medicaid	$2.25
Rate for Payer: BCBS of TX Blue Advantage	$7.49
Rate for Payer: BCBS of TX Blue Essentials	$8.98
Rate for Payer: BCBS of TX PPO	$9.98
Rate for Payer: Cash Price	$16.97
Rate for Payer: Cigna Medicaid	$17.96
Rate for Payer: Molina CHIP/Medicaid	$17.96
Rate for Payer: Multiplan Auto	$16.22
Rate for Payer: Multiplan Commercial	$16.22
Rate for Payer: Multiplan Workers Comp	$16.22
Rate for Payer: Parkland Medicaid	$17.96
Rate for Payer: Scott and White EPO/PPO	$12.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.96
Rate for Payer: Superior Health Plan EPO	$3.39

BLANKET, WARMING, LOWER BODY

Facility

$24.95

Hospital Charge Code	992901
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.97

BLANKET, WARMING MULTI POSITION UPPER BODY 24X78' -- DHF

Facility

$45.82

Hospital Charge Code	80334659
Hospital Revenue Code	270
Rate for Payer: Cash Price	$31.16

BLANKET, WARMING MULTI POSITION UPPER BODY 24X78' -- DHF

Facility

$45.82

Hospital Charge Code	80334659
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$32.99
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$31.16
Rate for Payer: Cigna Medicaid	$32.99
Rate for Payer: Molina CHIP/Medicaid	$32.99
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Parkland Medicaid	$32.99
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.99
Rate for Payer: Superior Health Plan EPO	$6.23

BLANKET, WARMING, UPPER BODY, MULTIPSTN

Facility

$27.39

Hospital Charge Code	992923
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.63

BLANKET, WARMING, UPPER BODY, MULTIPSTN

Facility

$27.39

Hospital Charge Code	992923
Hospital Revenue Code	270
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$19.72
Rate for Payer: Amerigroup CHIP/Medicaid	$2.47
Rate for Payer: BCBS of TX Blue Advantage	$8.22
Rate for Payer: BCBS of TX Blue Essentials	$9.86
Rate for Payer: BCBS of TX PPO	$10.96
Rate for Payer: Cash Price	$18.63
Rate for Payer: Cigna Medicaid	$19.72
Rate for Payer: Molina CHIP/Medicaid	$19.72
Rate for Payer: Multiplan Auto	$17.80
Rate for Payer: Multiplan Commercial	$17.80
Rate for Payer: Multiplan Workers Comp	$17.80
Rate for Payer: Parkland Medicaid	$19.72
Rate for Payer: Scott and White EPO/PPO	$13.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.72
Rate for Payer: Superior Health Plan EPO	$3.73

BLD ARTHRO -- DHF

Facility

$681.00

Hospital Charge Code	81713505
Hospital Revenue Code	272
Min. Negotiated Rate	$61.29
Max. Negotiated Rate	$490.32
Rate for Payer: Amerigroup CHIP/Medicaid	$61.29
Rate for Payer: BCBS of TX Blue Advantage	$204.30
Rate for Payer: BCBS of TX Blue Essentials	$245.16
Rate for Payer: BCBS of TX PPO	$272.40
Rate for Payer: Cash Price	$463.08
Rate for Payer: Cigna Medicaid	$490.32
Rate for Payer: Molina CHIP/Medicaid	$490.32
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Parkland Medicaid	$490.32
Rate for Payer: Scott and White EPO/PPO	$340.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$490.32
Rate for Payer: Superior Health Plan EPO	$92.62

BLD ARTHRO -- DHF

Facility

$681.00

Hospital Charge Code	81713505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$463.08

BLD BONE GRAFT -- DHF

Facility

$680.11

Hospital Charge Code	81722555
Hospital Revenue Code	272
Min. Negotiated Rate	$61.21
Max. Negotiated Rate	$489.68
Rate for Payer: Amerigroup CHIP/Medicaid	$61.21
Rate for Payer: BCBS of TX Blue Advantage	$204.03
Rate for Payer: BCBS of TX Blue Essentials	$244.84
Rate for Payer: BCBS of TX PPO	$272.04
Rate for Payer: Cash Price	$462.47
Rate for Payer: Cigna Medicaid	$489.68
Rate for Payer: Molina CHIP/Medicaid	$489.68
Rate for Payer: Multiplan Auto	$442.07
Rate for Payer: Multiplan Commercial	$442.07
Rate for Payer: Multiplan Workers Comp	$442.07
Rate for Payer: Parkland Medicaid	$489.68
Rate for Payer: Scott and White EPO/PPO	$340.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$489.68
Rate for Payer: Superior Health Plan EPO	$92.49

BLD BONE GRAFT -- DHF

Facility

$680.11

Hospital Charge Code	81722555
Hospital Revenue Code	272
Rate for Payer: Cash Price	$462.47

BLD BONE LG HA -- DHF

Facility

$1,282.55

Hospital Charge Code	81722605
Hospital Revenue Code	272
Min. Negotiated Rate	$115.43
Max. Negotiated Rate	$923.44
Rate for Payer: Amerigroup CHIP/Medicaid	$115.43
Rate for Payer: BCBS of TX Blue Advantage	$384.76
Rate for Payer: BCBS of TX Blue Essentials	$461.72
Rate for Payer: BCBS of TX PPO	$513.02
Rate for Payer: Cash Price	$872.13
Rate for Payer: Cigna Medicaid	$923.44
Rate for Payer: Molina CHIP/Medicaid	$923.44
Rate for Payer: Multiplan Auto	$833.66
Rate for Payer: Multiplan Commercial	$833.66
Rate for Payer: Multiplan Workers Comp	$833.66
Rate for Payer: Parkland Medicaid	$923.44
Rate for Payer: Scott and White EPO/PPO	$641.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$923.44
Rate for Payer: Superior Health Plan EPO	$174.43

BLD BONE LG HA -- DHF

Facility

$1,282.55

Hospital Charge Code	81722605
Hospital Revenue Code	272
Rate for Payer: Cash Price	$872.13

BLD OTOLARYNGOLOY DISP -- DHF

Facility

$967.14

Hospital Charge Code	81723249
Hospital Revenue Code	272
Min. Negotiated Rate	$87.04
Max. Negotiated Rate	$696.34
Rate for Payer: Amerigroup CHIP/Medicaid	$87.04
Rate for Payer: BCBS of TX Blue Advantage	$290.14
Rate for Payer: BCBS of TX Blue Essentials	$348.17
Rate for Payer: BCBS of TX PPO	$386.86
Rate for Payer: Cash Price	$657.66
Rate for Payer: Cigna Medicaid	$696.34
Rate for Payer: Molina CHIP/Medicaid	$696.34
Rate for Payer: Multiplan Auto	$628.64
Rate for Payer: Multiplan Commercial	$628.64
Rate for Payer: Multiplan Workers Comp	$628.64
Rate for Payer: Parkland Medicaid	$696.34
Rate for Payer: Scott and White EPO/PPO	$483.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$696.34
Rate for Payer: Superior Health Plan EPO	$131.53

BLD OTOLARYNGOLOY DISP -- DHF

Facility

$967.14

Hospital Charge Code	81723249
Hospital Revenue Code	272
Rate for Payer: Cash Price	$657.66

BLD SINUS RADICAL DISP -- DHF

Facility

$790.48

Hospital Charge Code	81723660
Hospital Revenue Code	272
Min. Negotiated Rate	$71.14
Max. Negotiated Rate	$569.15
Rate for Payer: Amerigroup CHIP/Medicaid	$71.14
Rate for Payer: BCBS of TX Blue Advantage	$237.14
Rate for Payer: BCBS of TX Blue Essentials	$284.57
Rate for Payer: BCBS of TX PPO	$316.19
Rate for Payer: Cash Price	$537.53
Rate for Payer: Cigna Medicaid	$569.15
Rate for Payer: Molina CHIP/Medicaid	$569.15
Rate for Payer: Multiplan Auto	$513.81
Rate for Payer: Multiplan Commercial	$513.81
Rate for Payer: Multiplan Workers Comp	$513.81
Rate for Payer: Parkland Medicaid	$569.15
Rate for Payer: Scott and White EPO/PPO	$395.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$569.15
Rate for Payer: Superior Health Plan EPO	$107.51

BLD SINUS RADICAL DISP -- DHF

Facility

$790.48

Hospital Charge Code	81723660
Hospital Revenue Code	272
Rate for Payer: Cash Price	$537.53

Blepharoplasty, upper eyelid

Facility

$10,000.00

Service Code	CPT 15822
Hospital Charge Code	36015822
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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: Scott and White EPO/PPO	$3,834.46
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Blepharoplasty, upper eyelid

Facility

$7,719.12

Service Code	HCPCS 15822
Hospital Charge Code	9900139
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,249.00

Blepharoplasty, upper eyelid

Facility

$7,719.12

Service Code	HCPCS 15822
Hospital Charge Code	9900139
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$5,249.00
Rate for Payer: Cash Price	$5,249.00
Rate for Payer: Cash Price	$5,249.00
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$5,557.77
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$5,557.77
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$5,557.77
Rate for Payer: Scott and White EPO/PPO	$3,834.46
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,557.77
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Know your out-of-pocket cost for care.

All Charges