White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Blood, occult, by peroxidase activity

Facility

$152.00

Service Code	HCPCS 82270
Hospital Charge Code	4102270
Hospital Revenue Code	301
Rate for Payer: Cash Price	$103.36

Blood, occult, by peroxidase activity

Facility

$152.00

Service Code	HCPCS 82270
Hospital Charge Code	4102270
Hospital Revenue Code	301
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$109.44
Rate for Payer: Amerigroup CHIP/Medicaid	$1.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.38
Rate for Payer: Amerigroup Medicare	$4.38
Rate for Payer: BCBS of TX Blue Advantage	$45.60
Rate for Payer: BCBS of TX Blue Essentials	$54.72
Rate for Payer: BCBS of TX Medicare	$4.38
Rate for Payer: BCBS of TX PPO	$60.80
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cigna Medicaid	$109.44
Rate for Payer: Cigna Medicare	$4.38
Rate for Payer: Employer Direct Commercial	$4.38
Rate for Payer: Humana Medicare/TRICARE	$4.38
Rate for Payer: Molina CHIP/Medicaid	$109.44
Rate for Payer: Molina Dual Medicare/Medicaid	$4.38
Rate for Payer: Molina Medicare	$4.38
Rate for Payer: Multiplan Auto	$98.80
Rate for Payer: Multiplan Commercial	$98.80
Rate for Payer: Multiplan Workers Comp	$98.80
Rate for Payer: Parkland Medicaid	$109.44
Rate for Payer: Scott and White EPO/PPO	$5.47
Rate for Payer: Scott and White Medicare	$4.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.44
Rate for Payer: Superior Health Plan EPO	$4.38
Rate for Payer: Superior Health Plan Medicare	$4.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.38
Rate for Payer: Universal American Medicare	$4.38
Rate for Payer: Wellcare Medicare	$4.38
Rate for Payer: Wellmed Medicare	$4.38

Blood Pressure Cuff Small 20 / Bx

Facility

$13.84

Hospital Charge Code	993947
Hospital Revenue Code	271
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$9.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1.25
Rate for Payer: BCBS of TX Blue Advantage	$4.15
Rate for Payer: BCBS of TX Blue Essentials	$4.98
Rate for Payer: BCBS of TX PPO	$5.54
Rate for Payer: Cash Price	$9.41
Rate for Payer: Cigna Medicaid	$9.96
Rate for Payer: Molina CHIP/Medicaid	$9.96
Rate for Payer: Multiplan Auto	$9.00
Rate for Payer: Multiplan Commercial	$9.00
Rate for Payer: Multiplan Workers Comp	$9.00
Rate for Payer: Parkland Medicaid	$9.96
Rate for Payer: Scott and White EPO/PPO	$6.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.96
Rate for Payer: Superior Health Plan EPO	$1.88

Blood Pressure Cuff Small 20 / Bx

Facility

$13.84

Hospital Charge Code	993947
Hospital Revenue Code	271
Rate for Payer: Cash Price	$9.41

Blood Urea Nitrogen

Facility

$164.00

Service Code	HCPCS 84520 QW
Hospital Charge Code	1602358
Hospital Revenue Code	301
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$118.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.95
Rate for Payer: Amerigroup Medicare	$3.95
Rate for Payer: BCBS of TX Blue Advantage	$49.20
Rate for Payer: BCBS of TX Blue Essentials	$59.04
Rate for Payer: BCBS of TX Medicare	$3.95
Rate for Payer: BCBS of TX PPO	$65.60
Rate for Payer: Cash Price	$111.52
Rate for Payer: Cash Price	$111.52
Rate for Payer: Cigna Medicaid	$118.08
Rate for Payer: Cigna Medicare	$3.95
Rate for Payer: Employer Direct Commercial	$3.95
Rate for Payer: Humana Medicare/TRICARE	$3.95
Rate for Payer: Molina CHIP/Medicaid	$118.08
Rate for Payer: Molina Dual Medicare/Medicaid	$3.95
Rate for Payer: Molina Medicare	$3.95
Rate for Payer: Multiplan Auto	$106.60
Rate for Payer: Multiplan Commercial	$106.60
Rate for Payer: Multiplan Workers Comp	$106.60
Rate for Payer: Parkland Medicaid	$118.08
Rate for Payer: Scott and White EPO/PPO	$4.94
Rate for Payer: Scott and White Medicare	$3.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.08
Rate for Payer: Superior Health Plan EPO	$3.95
Rate for Payer: Superior Health Plan Medicare	$3.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.95
Rate for Payer: Universal American Medicare	$3.95
Rate for Payer: Wellcare Medicare	$3.95
Rate for Payer: Wellmed Medicare	$3.95

Blood Urea Nitrogen

Facility

$164.00

Service Code	HCPCS 84520 QW
Hospital Charge Code	1602358
Hospital Revenue Code	301
Rate for Payer: Cash Price	$111.52

BLT HL -- DHF

Facility

$211.71

Hospital Charge Code	81140105
Hospital Revenue Code	271
Rate for Payer: Cash Price	$143.96

BLT HL -- DHF

Facility

$211.71

Hospital Charge Code	81140105
Hospital Revenue Code	271
Min. Negotiated Rate	$19.05
Max. Negotiated Rate	$152.43
Rate for Payer: Amerigroup CHIP/Medicaid	$19.05
Rate for Payer: BCBS of TX Blue Advantage	$63.51
Rate for Payer: BCBS of TX Blue Essentials	$76.22
Rate for Payer: BCBS of TX PPO	$84.68
Rate for Payer: Cash Price	$143.96
Rate for Payer: Cigna Medicaid	$152.43
Rate for Payer: Molina CHIP/Medicaid	$152.43
Rate for Payer: Multiplan Auto	$137.61
Rate for Payer: Multiplan Commercial	$137.61
Rate for Payer: Multiplan Workers Comp	$137.61
Rate for Payer: Parkland Medicaid	$152.43
Rate for Payer: Scott and White EPO/PPO	$105.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$152.43
Rate for Payer: Superior Health Plan EPO	$28.79

BLT LG -- DHF

Facility

$507.22

Hospital Charge Code	80313430
Hospital Revenue Code	270
Rate for Payer: Cash Price	$344.91

BLT LG -- DHF

Facility

$507.22

Hospital Charge Code	80313430
Hospital Revenue Code	270
Min. Negotiated Rate	$45.65
Max. Negotiated Rate	$365.20
Rate for Payer: Amerigroup CHIP/Medicaid	$45.65
Rate for Payer: BCBS of TX Blue Advantage	$152.17
Rate for Payer: BCBS of TX Blue Essentials	$182.60
Rate for Payer: BCBS of TX PPO	$202.89
Rate for Payer: Cash Price	$344.91
Rate for Payer: Cigna Medicaid	$365.20
Rate for Payer: Molina CHIP/Medicaid	$365.20
Rate for Payer: Multiplan Auto	$329.69
Rate for Payer: Multiplan Commercial	$329.69
Rate for Payer: Multiplan Workers Comp	$329.69
Rate for Payer: Parkland Medicaid	$365.20
Rate for Payer: Scott and White EPO/PPO	$253.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$365.20
Rate for Payer: Superior Health Plan EPO	$68.98

BLT SAFETY -- DHF

Facility

$18.02

Hospital Charge Code	80313554
Hospital Revenue Code	270
Rate for Payer: Cash Price	$12.25

BLT SAFETY -- DHF

Facility

$18.02

Hospital Charge Code	80313554
Hospital Revenue Code	270
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$12.97
Rate for Payer: Amerigroup CHIP/Medicaid	$1.62
Rate for Payer: BCBS of TX Blue Advantage	$5.41
Rate for Payer: BCBS of TX Blue Essentials	$6.49
Rate for Payer: BCBS of TX PPO	$7.21
Rate for Payer: Cash Price	$12.25
Rate for Payer: Cigna Medicaid	$12.97
Rate for Payer: Molina CHIP/Medicaid	$12.97
Rate for Payer: Multiplan Auto	$11.71
Rate for Payer: Multiplan Commercial	$11.71
Rate for Payer: Multiplan Workers Comp	$11.71
Rate for Payer: Parkland Medicaid	$12.97
Rate for Payer: Scott and White EPO/PPO	$9.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.97
Rate for Payer: Superior Health Plan EPO	$2.45

BLUE LEAD PERC KIT

Facility

$2,270.00

Service Code	HCPCS C1822
Hospital Charge Code	993883
Hospital Revenue Code	278
Min. Negotiated Rate	$204.30
Max. Negotiated Rate	$1,634.40
Rate for Payer: Amerigroup CHIP/Medicaid	$204.30
Rate for Payer: BCBS of TX Blue Advantage	$681.00
Rate for Payer: BCBS of TX Blue Essentials	$817.20
Rate for Payer: BCBS of TX PPO	$908.00
Rate for Payer: Cash Price	$1,543.60
Rate for Payer: Cigna Medicaid	$1,634.40
Rate for Payer: Molina CHIP/Medicaid	$1,634.40
Rate for Payer: Multiplan Auto	$1,135.00
Rate for Payer: Multiplan Commercial	$1,135.00
Rate for Payer: Multiplan Workers Comp	$1,135.00
Rate for Payer: Parkland Medicaid	$1,634.40
Rate for Payer: Scott and White EPO/PPO	$1,135.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,634.40
Rate for Payer: Superior Health Plan EPO	$308.72

BLUE LEAD PERC KIT

Facility

$2,270.00

Service Code	HCPCS C1822
Hospital Charge Code	993883
Hospital Revenue Code	278
Min. Negotiated Rate	$567.50
Max. Negotiated Rate	$1,135.00
Rate for Payer: Cash Price	$1,543.60
Rate for Payer: Cigna Commercial	$567.50
Rate for Payer: Multiplan Auto	$1,135.00
Rate for Payer: Multiplan Commercial	$1,135.00
Rate for Payer: Multiplan Workers Comp	$1,135.00
Rate for Payer: Scott and White EPO/PPO	$1,135.00

BLUE LEAD PERC KIT

Facility

$2,270.00

Service Code	HCPCS C1822
Hospital Charge Code	993882
Hospital Revenue Code	278
Min. Negotiated Rate	$567.50
Max. Negotiated Rate	$1,135.00
Rate for Payer: Cash Price	$1,543.60
Rate for Payer: Cigna Commercial	$567.50
Rate for Payer: Multiplan Auto	$1,135.00
Rate for Payer: Multiplan Commercial	$1,135.00
Rate for Payer: Multiplan Workers Comp	$1,135.00
Rate for Payer: Scott and White EPO/PPO	$1,135.00

BLUE LEAD PERC KIT

Facility

$2,270.00

Service Code	HCPCS C1822
Hospital Charge Code	993882
Hospital Revenue Code	278
Min. Negotiated Rate	$204.30
Max. Negotiated Rate	$1,634.40
Rate for Payer: Amerigroup CHIP/Medicaid	$204.30
Rate for Payer: BCBS of TX Blue Advantage	$681.00
Rate for Payer: BCBS of TX Blue Essentials	$817.20
Rate for Payer: BCBS of TX PPO	$908.00
Rate for Payer: Cash Price	$1,543.60
Rate for Payer: Cigna Medicaid	$1,634.40
Rate for Payer: Molina CHIP/Medicaid	$1,634.40
Rate for Payer: Multiplan Auto	$1,135.00
Rate for Payer: Multiplan Commercial	$1,135.00
Rate for Payer: Multiplan Workers Comp	$1,135.00
Rate for Payer: Parkland Medicaid	$1,634.40
Rate for Payer: Scott and White EPO/PPO	$1,135.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,634.40
Rate for Payer: Superior Health Plan EPO	$308.72

BLUE PERC LEAD KIT

Facility

$3,087.00

Service Code	HCPCS C1778
Hospital Charge Code	13522718
Hospital Revenue Code	278
Min. Negotiated Rate	$277.83
Max. Negotiated Rate	$2,222.64
Rate for Payer: Amerigroup CHIP/Medicaid	$277.83
Rate for Payer: BCBS of TX Blue Advantage	$926.10
Rate for Payer: BCBS of TX Blue Essentials	$1,111.32
Rate for Payer: BCBS of TX PPO	$1,234.80
Rate for Payer: Cash Price	$2,099.16
Rate for Payer: Cigna Medicaid	$2,222.64
Rate for Payer: Molina CHIP/Medicaid	$2,222.64
Rate for Payer: Multiplan Auto	$1,543.50
Rate for Payer: Multiplan Commercial	$1,543.50
Rate for Payer: Multiplan Workers Comp	$1,543.50
Rate for Payer: Parkland Medicaid	$2,222.64
Rate for Payer: Scott and White EPO/PPO	$1,543.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,222.64
Rate for Payer: Superior Health Plan EPO	$419.83

BLUE PERC LEAD KIT

Facility

$3,087.00

Service Code	HCPCS C1778
Hospital Charge Code	13522718
Hospital Revenue Code	278
Min. Negotiated Rate	$771.75
Max. Negotiated Rate	$1,543.50
Rate for Payer: Cash Price	$2,099.16
Rate for Payer: Cigna Commercial	$771.75
Rate for Payer: Multiplan Auto	$1,543.50
Rate for Payer: Multiplan Commercial	$1,543.50
Rate for Payer: Multiplan Workers Comp	$1,543.50
Rate for Payer: Scott and White EPO/PPO	$1,543.50

BMA Concentrate 60ml

Facility

$11,445.78

Service Code	HCPCS C9359
Hospital Charge Code	992116
Hospital Revenue Code	278
Min. Negotiated Rate	$2,861.45
Max. Negotiated Rate	$5,722.89
Rate for Payer: Cash Price	$7,783.13
Rate for Payer: Cigna Commercial	$2,861.45
Rate for Payer: Multiplan Auto	$5,722.89
Rate for Payer: Multiplan Commercial	$5,722.89
Rate for Payer: Multiplan Workers Comp	$5,722.89
Rate for Payer: Scott and White EPO/PPO	$5,722.89

BMA Concentrate 60ml

Facility

$11,445.78

Service Code	HCPCS C9359
Hospital Charge Code	992116
Hospital Revenue Code	278
Min. Negotiated Rate	$1,030.12
Max. Negotiated Rate	$8,240.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1,030.12
Rate for Payer: BCBS of TX Blue Advantage	$3,433.73
Rate for Payer: BCBS of TX Blue Essentials	$4,120.48
Rate for Payer: BCBS of TX PPO	$4,578.31
Rate for Payer: Cash Price	$7,783.13
Rate for Payer: Cigna Medicaid	$8,240.96
Rate for Payer: Molina CHIP/Medicaid	$8,240.96
Rate for Payer: Multiplan Auto	$5,722.89
Rate for Payer: Multiplan Commercial	$5,722.89
Rate for Payer: Multiplan Workers Comp	$5,722.89
Rate for Payer: Parkland Medicaid	$8,240.96
Rate for Payer: Scott and White EPO/PPO	$5,722.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,240.96
Rate for Payer: Superior Health Plan EPO	$1,556.63

BMM0710

Facility

$6,759.00

Service Code	HCPCS Q4166
Hospital Charge Code	991004
Hospital Revenue Code	278
Min. Negotiated Rate	$1,689.75
Max. Negotiated Rate	$3,379.50
Rate for Payer: Cash Price	$4,596.12
Rate for Payer: Cigna Commercial	$1,689.75
Rate for Payer: Multiplan Auto	$3,379.50
Rate for Payer: Multiplan Commercial	$3,379.50
Rate for Payer: Multiplan Workers Comp	$3,379.50
Rate for Payer: Scott and White EPO/PPO	$3,379.50

BMM0710

Facility

$6,759.00

Service Code	HCPCS Q4166
Hospital Charge Code	991004
Hospital Revenue Code	278
Min. Negotiated Rate	$125.01
Max. Negotiated Rate	$4,866.48
Rate for Payer: Amerigroup CHIP/Medicaid	$608.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$2,027.70
Rate for Payer: BCBS of TX Blue Essentials	$2,433.24
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$2,703.60
Rate for Payer: Cash Price	$4,596.12
Rate for Payer: Cash Price	$4,596.12
Rate for Payer: Cash Price	$4,596.12
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$4,866.48
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$4,866.48
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$3,379.50
Rate for Payer: Multiplan Commercial	$3,379.50
Rate for Payer: Multiplan Workers Comp	$3,379.50
Rate for Payer: Parkland Medicaid	$4,866.48
Rate for Payer: Scott and White EPO/PPO	$3,379.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,866.48
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

BN CHIPS -- DHF

Facility

$731.00

Service Code	HCPCS C1734
Hospital Charge Code	81312753
Hospital Revenue Code	278
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$365.50
Rate for Payer: Cash Price	$497.08
Rate for Payer: Cigna Commercial	$182.75
Rate for Payer: Multiplan Auto	$365.50
Rate for Payer: Multiplan Commercial	$365.50
Rate for Payer: Multiplan Workers Comp	$365.50
Rate for Payer: Scott and White EPO/PPO	$365.50

BN CHIPS -- DHF

Facility

$731.00

Service Code	HCPCS C1734
Hospital Charge Code	81312753
Hospital Revenue Code	278
Min. Negotiated Rate	$65.79
Max. Negotiated Rate	$526.32
Rate for Payer: Amerigroup CHIP/Medicaid	$65.79
Rate for Payer: BCBS of TX Blue Advantage	$219.30
Rate for Payer: BCBS of TX Blue Essentials	$263.16
Rate for Payer: BCBS of TX PPO	$292.40
Rate for Payer: Cash Price	$497.08
Rate for Payer: Cigna Medicaid	$526.32
Rate for Payer: Molina CHIP/Medicaid	$526.32
Rate for Payer: Multiplan Auto	$365.50
Rate for Payer: Multiplan Commercial	$365.50
Rate for Payer: Multiplan Workers Comp	$365.50
Rate for Payer: Parkland Medicaid	$526.32
Rate for Payer: Scott and White EPO/PPO	$365.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$526.32
Rate for Payer: Superior Health Plan EPO	$99.42

BND COBAN 4/5 -- DHF

Facility

$92.25

Hospital Charge Code	80240328
Hospital Revenue Code	270
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$66.42
Rate for Payer: Amerigroup CHIP/Medicaid	$8.30
Rate for Payer: BCBS of TX Blue Advantage	$27.68
Rate for Payer: BCBS of TX Blue Essentials	$33.21
Rate for Payer: BCBS of TX PPO	$36.90
Rate for Payer: Cash Price	$62.73
Rate for Payer: Cigna Medicaid	$66.42
Rate for Payer: Molina CHIP/Medicaid	$66.42
Rate for Payer: Multiplan Auto	$59.96
Rate for Payer: Multiplan Commercial	$59.96
Rate for Payer: Multiplan Workers Comp	$59.96
Rate for Payer: Parkland Medicaid	$66.42
Rate for Payer: Scott and White EPO/PPO	$46.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$66.42
Rate for Payer: Superior Health Plan EPO	$12.55

Know your out-of-pocket cost for care.

All Charges