White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ACTH, Plasma SO

Facility

$328.00

Service Code	CPT 82024
Hospital Charge Code	1700889
Hospital Revenue Code	301
Min. Negotiated Rate	$15.06
Max. Negotiated Rate	$213.20
Rate for Payer: Aetna Commercial	$40.55
Rate for Payer: Aetna Medicare	$57.93
Rate for Payer: Amerigroup CHIP/Medicaid	$15.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$38.62
Rate for Payer: Amerigroup Medicare	$38.62
Rate for Payer: BCBS of TX Blue Advantage	$63.72
Rate for Payer: BCBS of TX Blue Essentials	$76.47
Rate for Payer: BCBS of TX Medicare	$38.62
Rate for Payer: BCBS of TX PPO	$85.35
Rate for Payer: Cash Price	$288.64
Rate for Payer: Cash Price	$288.64
Rate for Payer: Cigna Medicaid	$38.62
Rate for Payer: Cigna Medicare	$38.62
Rate for Payer: Employer Direct Commercial	$38.62
Rate for Payer: Humana Medicare/TRICARE	$38.62
Rate for Payer: Molina CHIP/Medicaid	$38.62
Rate for Payer: Molina Dual Medicare/Medicaid	$38.62
Rate for Payer: Molina Medicare	$38.62
Rate for Payer: Multiplan Auto	$213.20
Rate for Payer: Multiplan Commercial	$213.20
Rate for Payer: Multiplan Workers Comp	$213.20
Rate for Payer: Parkland Medicaid	$38.62
Rate for Payer: Scott and White EPO/PPO	$48.27
Rate for Payer: Scott and White Medicare	$38.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.62
Rate for Payer: Superior Health Plan EPO	$38.62
Rate for Payer: Superior Health Plan Medicare	$38.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$38.62
Rate for Payer: Universal American Medicare	$38.62
Rate for Payer: Wellcare Medicare	$38.62
Rate for Payer: Wellmed Medicare	$38.62

ACTH, Plasma SO

Facility

$328.00

Service Code	CPT 82024
Hospital Charge Code	1700889
Hospital Revenue Code	301
Rate for Payer: Cash Price	$288.64

ACTINOMYCES ANTIBODY

Facility

$74.00

Service Code	CPT 86602
Hospital Charge Code	1740729
Hospital Revenue Code	302
Rate for Payer: Cash Price	$65.12

ACTINOMYCES ANTIBODY

Facility

$74.00

Service Code	CPT 86602
Hospital Charge Code	1740729
Hospital Revenue Code	302
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$48.10
Rate for Payer: Aetna Commercial	$10.69
Rate for Payer: Aetna Medicare	$15.27
Rate for Payer: Amerigroup CHIP/Medicaid	$3.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.18
Rate for Payer: Amerigroup Medicare	$10.18
Rate for Payer: BCBS of TX Blue Advantage	$16.80
Rate for Payer: BCBS of TX Blue Essentials	$20.16
Rate for Payer: BCBS of TX Medicare	$10.18
Rate for Payer: BCBS of TX PPO	$22.50
Rate for Payer: Cash Price	$65.12
Rate for Payer: Cash Price	$65.12
Rate for Payer: Cigna Medicaid	$10.18
Rate for Payer: Cigna Medicare	$10.18
Rate for Payer: Employer Direct Commercial	$10.18
Rate for Payer: Humana Medicare/TRICARE	$10.18
Rate for Payer: Molina CHIP/Medicaid	$10.18
Rate for Payer: Molina Dual Medicare/Medicaid	$10.18
Rate for Payer: Molina Medicare	$10.18
Rate for Payer: Multiplan Auto	$48.10
Rate for Payer: Multiplan Commercial	$48.10
Rate for Payer: Multiplan Workers Comp	$48.10
Rate for Payer: Parkland Medicaid	$10.18
Rate for Payer: Scott and White EPO/PPO	$12.72
Rate for Payer: Scott and White Medicare	$10.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.18
Rate for Payer: Superior Health Plan EPO	$10.18
Rate for Payer: Superior Health Plan Medicare	$10.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.18
Rate for Payer: Universal American Medicare	$10.18
Rate for Payer: Wellcare Medicare	$10.18
Rate for Payer: Wellmed Medicare	$10.18

Actin (Smooth Muscle) Antibody SO

Facility

$195.00

Service Code	CPT 86015
Hospital Charge Code	1706019
Hospital Revenue Code	301
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$126.75
Rate for Payer: Aetna Commercial	$12.11
Rate for Payer: Aetna Medicare	$18.07
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.05
Rate for Payer: Amerigroup Medicare	$12.05
Rate for Payer: BCBS of TX Blue Advantage	$19.02
Rate for Payer: BCBS of TX Blue Essentials	$22.83
Rate for Payer: BCBS of TX Medicare	$12.05
Rate for Payer: BCBS of TX PPO	$25.48
Rate for Payer: Cash Price	$171.60
Rate for Payer: Cash Price	$171.60
Rate for Payer: Cigna Medicaid	$12.05
Rate for Payer: Cigna Medicare	$12.05
Rate for Payer: Employer Direct Commercial	$12.05
Rate for Payer: Humana Medicare/TRICARE	$12.05
Rate for Payer: Molina CHIP/Medicaid	$12.05
Rate for Payer: Molina Dual Medicare/Medicaid	$12.05
Rate for Payer: Molina Medicare	$12.05
Rate for Payer: Multiplan Auto	$126.75
Rate for Payer: Multiplan Commercial	$126.75
Rate for Payer: Multiplan Workers Comp	$126.75
Rate for Payer: Parkland Medicaid	$12.05
Rate for Payer: Scott and White EPO/PPO	$15.06
Rate for Payer: Scott and White Medicare	$12.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.05
Rate for Payer: Superior Health Plan EPO	$12.05
Rate for Payer: Superior Health Plan Medicare	$12.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.05
Rate for Payer: Universal American Medicare	$12.05
Rate for Payer: Wellcare Medicare	$12.05
Rate for Payer: Wellmed Medicare	$12.05

Actin (Smooth Muscle) Antibody SO

Facility

$195.00

Service Code	CPT 86015
Hospital Charge Code	1706019
Hospital Revenue Code	301
Rate for Payer: Cash Price	$171.60

ACTISHIELD AMNIOTIC MEMBRANE 4X8CM

Facility

$474.94

Service Code	HCPCS C1765
Hospital Charge Code	145563
Hospital Revenue Code	278
Min. Negotiated Rate	$118.73
Max. Negotiated Rate	$237.47
Rate for Payer: Aetna Commercial	$142.48
Rate for Payer: Cash Price	$417.95
Rate for Payer: Cigna Commercial	$118.73
Rate for Payer: Multiplan Auto	$237.47
Rate for Payer: Multiplan Commercial	$237.47
Rate for Payer: Multiplan Workers Comp	$237.47
Rate for Payer: Scott and White EPO/PPO	$237.47

ACTISHIELD AMNIOTIC MEMBRANE 4X8CM

Facility

$474.94

Service Code	HCPCS C1765
Hospital Charge Code	145563
Hospital Revenue Code	278
Min. Negotiated Rate	$42.74
Max. Negotiated Rate	$237.47
Rate for Payer: Aetna Commercial	$142.48
Rate for Payer: Amerigroup CHIP/Medicaid	$42.74
Rate for Payer: Cash Price	$417.95
Rate for Payer: Multiplan Auto	$237.47
Rate for Payer: Multiplan Commercial	$237.47
Rate for Payer: Multiplan Workers Comp	$237.47
Rate for Payer: Scott and White EPO/PPO	$237.47
Rate for Payer: Superior Health Plan EPO	$64.59

.Activated Clotting Time (POCT)

Facility

$141.00

Service Code	CPT 85347
Hospital Charge Code	4105347
Hospital Revenue Code	305
Rate for Payer: Cash Price	$124.08

.Activated Clotting Time (POCT)

Facility

$141.00

Service Code	CPT 85347
Hospital Charge Code	4105347
Hospital Revenue Code	305
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$91.65
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: Aetna Medicare	$6.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.28
Rate for Payer: Amerigroup Medicare	$4.28
Rate for Payer: BCBS of TX Blue Advantage	$7.06
Rate for Payer: BCBS of TX Blue Essentials	$8.47
Rate for Payer: BCBS of TX Medicare	$4.28
Rate for Payer: BCBS of TX PPO	$9.46
Rate for Payer: Cash Price	$124.08
Rate for Payer: Cash Price	$124.08
Rate for Payer: Cigna Medicaid	$4.28
Rate for Payer: Cigna Medicare	$4.28
Rate for Payer: Employer Direct Commercial	$4.28
Rate for Payer: Humana Medicare/TRICARE	$4.28
Rate for Payer: Molina CHIP/Medicaid	$4.28
Rate for Payer: Molina Dual Medicare/Medicaid	$4.28
Rate for Payer: Molina Medicare	$4.28
Rate for Payer: Multiplan Auto	$91.65
Rate for Payer: Multiplan Commercial	$91.65
Rate for Payer: Multiplan Workers Comp	$91.65
Rate for Payer: Parkland Medicaid	$4.28
Rate for Payer: Scott and White EPO/PPO	$5.35
Rate for Payer: Scott and White Medicare	$4.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.28
Rate for Payer: Superior Health Plan EPO	$4.28
Rate for Payer: Superior Health Plan Medicare	$4.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.28
Rate for Payer: Universal American Medicare	$4.28
Rate for Payer: Wellcare Medicare	$4.28
Rate for Payer: Wellmed Medicare	$4.28

ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION

Facility

$14,500.31

Service Code	MSDRG 880
Min. Negotiated Rate	$6,367.44
Max. Negotiated Rate	$14,500.31
Rate for Payer: Aetna Commercial	$10,739.25
Rate for Payer: Aetna Medicare	$14,500.31
Rate for Payer: BCBS of TX Blue Advantage	$6,367.44
Rate for Payer: BCBS of TX Blue Essentials	$8,369.74
Rate for Payer: BCBS of TX PPO	$9,300.07
Rate for Payer: Cigna Commercial	$12,295.25

ACUTE AND SUBACUTE ENDOCARDITIS WITH CC

Facility

$20,099.58

Service Code	MSDRG 289
Min. Negotiated Rate	$13,349.78
Max. Negotiated Rate	$20,099.58
Rate for Payer: Aetna Commercial	$16,624.12
Rate for Payer: Aetna Medicare	$20,099.58
Rate for Payer: BCBS of TX Blue Advantage	$13,349.78
Rate for Payer: BCBS of TX Blue Essentials	$17,644.46
Rate for Payer: BCBS of TX PPO	$19,605.71
Rate for Payer: Cigna Commercial	$19,032.78

ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC

Facility

$33,397.84

Service Code	MSDRG 288
Min. Negotiated Rate	$23,884.78
Max. Negotiated Rate	$33,397.84
Rate for Payer: Aetna Commercial	$29,171.25
Rate for Payer: Aetna Medicare	$32,037.90
Rate for Payer: BCBS of TX Blue Advantage	$23,884.78
Rate for Payer: BCBS of TX Blue Essentials	$27,800.42
Rate for Payer: BCBS of TX PPO	$30,890.55
Rate for Payer: Cigna Commercial	$33,397.84

ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC

Facility

$15,897.18

Service Code	MSDRG 290
Min. Negotiated Rate	$10,436.64
Max. Negotiated Rate	$15,897.18
Rate for Payer: Aetna Commercial	$11,533.50
Rate for Payer: Aetna Medicare	$15,897.18
Rate for Payer: BCBS of TX Blue Advantage	$10,840.30
Rate for Payer: BCBS of TX Blue Essentials	$10,436.64
Rate for Payer: BCBS of TX PPO	$11,596.71
Rate for Payer: Cigna Commercial	$13,204.58

ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC

Facility

$28,793.24

Service Code	MSDRG 835
Min. Negotiated Rate	$19,364.62
Max. Negotiated Rate	$28,793.24
Rate for Payer: Aetna Commercial	$25,149.38
Rate for Payer: Aetna Medicare	$28,211.16
Rate for Payer: BCBS of TX Blue Advantage	$19,364.62
Rate for Payer: BCBS of TX Blue Essentials	$22,041.38
Rate for Payer: BCBS of TX PPO	$24,491.38
Rate for Payer: Cigna Commercial	$28,793.24

ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC

Facility

$72,115.12

Service Code	MSDRG 834
Min. Negotiated Rate	$48,431.76
Max. Negotiated Rate	$72,115.12
Rate for Payer: Aetna Commercial	$62,988.75
Rate for Payer: Aetna Medicare	$64,214.37
Rate for Payer: BCBS of TX Blue Advantage	$48,431.76
Rate for Payer: BCBS of TX Blue Essentials	$56,834.99
Rate for Payer: BCBS of TX PPO	$63,152.43
Rate for Payer: Cigna Commercial	$72,115.12

ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$19,395.26

Service Code	MSDRG 836
Min. Negotiated Rate	$10,402.56
Max. Negotiated Rate	$19,395.26
Rate for Payer: Aetna Commercial	$13,469.62
Rate for Payer: Aetna Medicare	$19,395.26
Rate for Payer: BCBS of TX Blue Advantage	$10,402.56
Rate for Payer: BCBS of TX Blue Essentials	$12,512.82
Rate for Payer: BCBS of TX PPO	$13,903.67
Rate for Payer: Cigna Commercial	$15,421.22

ACUTE MAJOR EYE INFECTIONS WITH CC/MCC

Facility

$17,996.25

Service Code	MSDRG 121
Min. Negotiated Rate	$9,093.64
Max. Negotiated Rate	$17,996.25
Rate for Payer: Aetna Commercial	$14,413.50
Rate for Payer: Aetna Medicare	$17,996.25
Rate for Payer: BCBS of TX Blue Advantage	$9,093.64
Rate for Payer: BCBS of TX Blue Essentials	$10,930.92
Rate for Payer: BCBS of TX PPO	$12,145.93
Rate for Payer: Cigna Commercial	$16,501.86

ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC

Facility

$12,251.37

Service Code	MSDRG 122
Min. Negotiated Rate	$5,542.70
Max. Negotiated Rate	$12,251.37
Rate for Payer: Aetna Commercial	$8,375.62
Rate for Payer: Aetna Medicare	$12,251.37
Rate for Payer: BCBS of TX Blue Advantage	$5,542.70
Rate for Payer: BCBS of TX Blue Essentials	$7,283.15
Rate for Payer: BCBS of TX PPO	$8,092.70
Rate for Payer: Cigna Commercial	$9,589.16

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC

Facility

$14,055.01

Service Code	MSDRG 281
Min. Negotiated Rate	$8,572.48
Max. Negotiated Rate	$14,055.01
Rate for Payer: Aetna Commercial	$10,271.25
Rate for Payer: Aetna Medicare	$14,055.01
Rate for Payer: BCBS of TX Blue Advantage	$8,572.48
Rate for Payer: BCBS of TX Blue Essentials	$10,108.49
Rate for Payer: BCBS of TX PPO	$11,232.09
Rate for Payer: Cigna Commercial	$11,759.44

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC

Facility

$21,264.19

Service Code	MSDRG 280
Min. Negotiated Rate	$14,403.28
Max. Negotiated Rate	$21,264.19
Rate for Payer: Aetna Commercial	$17,848.12
Rate for Payer: Aetna Medicare	$21,264.19
Rate for Payer: BCBS of TX Blue Advantage	$14,403.28
Rate for Payer: BCBS of TX Blue Essentials	$17,099.61
Rate for Payer: BCBS of TX PPO	$19,000.31
Rate for Payer: Cigna Commercial	$20,434.12

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

Facility

$11,968.77

Service Code	MSDRG 282
Min. Negotiated Rate	$6,418.18
Max. Negotiated Rate	$11,968.77
Rate for Payer: Aetna Commercial	$8,078.62
Rate for Payer: Aetna Medicare	$11,968.77
Rate for Payer: BCBS of TX Blue Advantage	$6,418.18
Rate for Payer: BCBS of TX Blue Essentials	$7,728.93
Rate for Payer: BCBS of TX PPO	$8,588.03
Rate for Payer: Cigna Commercial	$9,249.13

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

Facility

$12,200.00

Service Code	MSDRG 284
Min. Negotiated Rate	$6,487.84
Max. Negotiated Rate	$12,200.00
Rate for Payer: Aetna Commercial	$8,321.62
Rate for Payer: Aetna Medicare	$12,200.00
Rate for Payer: BCBS of TX Blue Advantage	$6,487.84
Rate for Payer: BCBS of TX Blue Essentials	$7,910.55
Rate for Payer: BCBS of TX PPO	$8,789.84
Rate for Payer: Cigna Commercial	$9,527.34

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC

Facility

$25,391.63

Service Code	MSDRG 283
Min. Negotiated Rate	$14,555.50
Max. Negotiated Rate	$25,391.63
Rate for Payer: Aetna Commercial	$22,178.25
Rate for Payer: Aetna Medicare	$25,384.20
Rate for Payer: BCBS of TX Blue Advantage	$14,555.50
Rate for Payer: BCBS of TX Blue Essentials	$18,622.70
Rate for Payer: BCBS of TX PPO	$20,692.69
Rate for Payer: Cigna Commercial	$25,391.63

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Facility

$9,513.25

Service Code	MSDRG 285
Min. Negotiated Rate	$4,463.40
Max. Negotiated Rate	$9,513.25
Rate for Payer: Aetna Commercial	$5,497.88
Rate for Payer: Aetna Medicare	$9,513.25
Rate for Payer: BCBS of TX Blue Advantage	$4,463.40
Rate for Payer: BCBS of TX Blue Essentials	$6,154.25
Rate for Payer: BCBS of TX PPO	$6,838.32
Rate for Payer: Cigna Commercial	$6,294.46

Know your out-of-pocket cost for care.

All Charges