White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHWR US BREAST BX/LOC/SPECIMEN EA ADD BCE

Facility

$1,974.00

Service Code	CPT 19084
Hospital Charge Code	5069184
Hospital Revenue Code	361
Min. Negotiated Rate	$60.14
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,085.70
Rate for Payer: Amerigroup CHIP/Medicaid	$177.66
Rate for Payer: Cash Price	$1,737.12
Rate for Payer: Cash Price	$1,737.12
Rate for Payer: Cash Price	$1,737.12
Rate for Payer: Cigna Medicaid	$60.14
Rate for Payer: Molina CHIP/Medicaid	$60.14
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	$60.14
Rate for Payer: Scott and White EPO/PPO	$987.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60.14
Rate for Payer: Superior Health Plan EPO	$268.46

CHWR US BREAST LOC DEVICE ADD LESION

Facility

$995.00

Service Code	CPT 19286
Hospital Charge Code	5069286
Hospital Revenue Code	361
Min. Negotiated Rate	$33.41
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$547.25
Rate for Payer: Amerigroup CHIP/Medicaid	$89.55
Rate for Payer: Cash Price	$875.60
Rate for Payer: Cash Price	$875.60
Rate for Payer: Cash Price	$875.60
Rate for Payer: Cigna Medicaid	$33.41
Rate for Payer: Molina CHIP/Medicaid	$33.41
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	$33.41
Rate for Payer: Scott and White EPO/PPO	$497.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.41
Rate for Payer: Superior Health Plan EPO	$135.32

CHWR US BREAST LOC DEVICE ADD LESION BCE

Facility

$995.00

Service Code	CPT 19286
Hospital Charge Code	5069286
Hospital Revenue Code	361
Rate for Payer: Cash Price	$875.60

CHWR US BREAST LOC DEVICE ADD LESION BCE

Facility

$995.00

Service Code	CPT 19286
Hospital Charge Code	5069286
Hospital Revenue Code	361
Min. Negotiated Rate	$33.41
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$547.25
Rate for Payer: Amerigroup CHIP/Medicaid	$89.55
Rate for Payer: Cash Price	$875.60
Rate for Payer: Cash Price	$875.60
Rate for Payer: Cash Price	$875.60
Rate for Payer: Cigna Medicaid	$33.41
Rate for Payer: Molina CHIP/Medicaid	$33.41
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	$33.41
Rate for Payer: Scott and White EPO/PPO	$497.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.41
Rate for Payer: Superior Health Plan EPO	$135.32

CHWR US GUIDE NEEDLE PLACEMENT

Facility

$1,596.00

Service Code	CPT 76942
Hospital Charge Code	5066960
Hospital Revenue Code	402
Min. Negotiated Rate	$31.41
Max. Negotiated Rate	$1,037.40
Rate for Payer: Aetna Commercial	$31.41
Rate for Payer: Amerigroup CHIP/Medicaid	$143.64
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	$1,404.48
Rate for Payer: Cash Price	$1,404.48
Rate for Payer: Multiplan Auto	$1,037.40
Rate for Payer: Multiplan Commercial	$1,037.40
Rate for Payer: Multiplan Workers Comp	$1,037.40
Rate for Payer: Scott and White EPO/PPO	$798.00
Rate for Payer: Superior Health Plan EPO	$217.06

CHWR US GUIDE NEEDLE PLACEMENT BCE

Facility

$1,596.00

Service Code	CPT 76942
Hospital Charge Code	5066960
Hospital Revenue Code	402
Min. Negotiated Rate	$31.41
Max. Negotiated Rate	$1,037.40
Rate for Payer: Aetna Commercial	$31.41
Rate for Payer: Amerigroup CHIP/Medicaid	$143.64
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	$1,404.48
Rate for Payer: Cash Price	$1,404.48
Rate for Payer: Multiplan Auto	$1,037.40
Rate for Payer: Multiplan Commercial	$1,037.40
Rate for Payer: Multiplan Workers Comp	$1,037.40
Rate for Payer: Scott and White EPO/PPO	$798.00
Rate for Payer: Superior Health Plan EPO	$217.06

CHWR US GUIDE NEEDLE PLACEMENT BCE

Facility

$1,596.00

Service Code	CPT 76942
Hospital Charge Code	5066960
Hospital Revenue Code	402
Rate for Payer: Cash Price	$1,404.48

CHWR US GUIDE PERC DRAIN ABSCESS W/CATH

Facility

$3,174.00

Service Code	CPT 75989
Hospital Charge Code	5067630
Hospital Revenue Code	320
Min. Negotiated Rate	$88.25
Max. Negotiated Rate	$2,063.10
Rate for Payer: Aetna Commercial	$88.25
Rate for Payer: Amerigroup CHIP/Medicaid	$285.66
Rate for Payer: BCBS of TX Blue Advantage	$105.25
Rate for Payer: BCBS of TX Blue Essentials	$126.30
Rate for Payer: BCBS of TX PPO	$140.98
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Multiplan Auto	$2,063.10
Rate for Payer: Multiplan Commercial	$2,063.10
Rate for Payer: Multiplan Workers Comp	$2,063.10
Rate for Payer: Scott and White EPO/PPO	$1,587.00
Rate for Payer: Superior Health Plan EPO	$431.66

CHWR US GUIDE PERC DRAIN ABSCESS W/CATH BCE

Facility

$3,174.00

Service Code	CPT 75989
Hospital Charge Code	5067630
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,793.12

CHWR US GUIDE PERC DRAIN ABSCESS W/CATH BCE

Facility

$3,174.00

Service Code	CPT 75989
Hospital Charge Code	5067630
Hospital Revenue Code	320
Min. Negotiated Rate	$88.25
Max. Negotiated Rate	$2,063.10
Rate for Payer: Aetna Commercial	$88.25
Rate for Payer: Amerigroup CHIP/Medicaid	$285.66
Rate for Payer: BCBS of TX Blue Advantage	$105.25
Rate for Payer: BCBS of TX Blue Essentials	$126.30
Rate for Payer: BCBS of TX PPO	$140.98
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Multiplan Auto	$2,063.10
Rate for Payer: Multiplan Commercial	$2,063.10
Rate for Payer: Multiplan Workers Comp	$2,063.10
Rate for Payer: Scott and White EPO/PPO	$1,587.00
Rate for Payer: Superior Health Plan EPO	$431.66

CHWR US OB COMP>14WK ADD GEST

Facility

$1,076.00

Service Code	CPT 76810
Hospital Charge Code	5066843
Hospital Revenue Code	402
Min. Negotiated Rate	$47.97
Max. Negotiated Rate	$699.40
Rate for Payer: Aetna Commercial	$47.97
Rate for Payer: Amerigroup CHIP/Medicaid	$88.55
Rate for Payer: BCBS of TX Blue Advantage	$71.36
Rate for Payer: BCBS of TX Blue Essentials	$85.64
Rate for Payer: BCBS of TX PPO	$95.58
Rate for Payer: Cash Price	$946.88
Rate for Payer: Cash Price	$946.88
Rate for Payer: Cigna Medicaid	$88.55
Rate for Payer: Molina CHIP/Medicaid	$88.55
Rate for Payer: Multiplan Auto	$699.40
Rate for Payer: Multiplan Commercial	$699.40
Rate for Payer: Multiplan Workers Comp	$699.40
Rate for Payer: Parkland Medicaid	$88.55
Rate for Payer: Scott and White EPO/PPO	$538.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$88.55
Rate for Payer: Superior Health Plan EPO	$146.34

CHWR US OB COMP>14WK ADD GEST BCE

Facility

$1,076.00

Service Code	CPT 76810
Hospital Charge Code	5066843
Hospital Revenue Code	402
Min. Negotiated Rate	$47.97
Max. Negotiated Rate	$699.40
Rate for Payer: Aetna Commercial	$47.97
Rate for Payer: Amerigroup CHIP/Medicaid	$88.55
Rate for Payer: BCBS of TX Blue Advantage	$71.36
Rate for Payer: BCBS of TX Blue Essentials	$85.64
Rate for Payer: BCBS of TX PPO	$95.58
Rate for Payer: Cash Price	$946.88
Rate for Payer: Cash Price	$946.88
Rate for Payer: Cigna Medicaid	$88.55
Rate for Payer: Molina CHIP/Medicaid	$88.55
Rate for Payer: Multiplan Auto	$699.40
Rate for Payer: Multiplan Commercial	$699.40
Rate for Payer: Multiplan Workers Comp	$699.40
Rate for Payer: Parkland Medicaid	$88.55
Rate for Payer: Scott and White EPO/PPO	$538.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$88.55
Rate for Payer: Superior Health Plan EPO	$146.34

CHWR US OB COMP>14WK ADD GEST BCE

Facility

$1,076.00

Service Code	CPT 76810
Hospital Charge Code	5066843
Hospital Revenue Code	402
Rate for Payer: Cash Price	$946.88

CHWR US OB COMP W/DET ADD GEST

Facility

$631.00

Service Code	CPT 76812
Hospital Charge Code	5066812
Hospital Revenue Code	402
Min. Negotiated Rate	$85.82
Max. Negotiated Rate	$410.15
Rate for Payer: Aetna Commercial	$124.84
Rate for Payer: Amerigroup CHIP/Medicaid	$192.13
Rate for Payer: BCBS of TX Blue Advantage	$184.34
Rate for Payer: BCBS of TX Blue Essentials	$221.21
Rate for Payer: BCBS of TX PPO	$246.90
Rate for Payer: Cash Price	$555.28
Rate for Payer: Cash Price	$555.28
Rate for Payer: Cigna Medicaid	$192.13
Rate for Payer: Molina CHIP/Medicaid	$192.13
Rate for Payer: Multiplan Auto	$410.15
Rate for Payer: Multiplan Commercial	$410.15
Rate for Payer: Multiplan Workers Comp	$410.15
Rate for Payer: Parkland Medicaid	$192.13
Rate for Payer: Scott and White EPO/PPO	$315.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.13
Rate for Payer: Superior Health Plan EPO	$85.82

CHWR US OB COMP W/DET ADD GEST BCE

Facility

$631.00

Service Code	CPT 76812
Hospital Charge Code	5066812
Hospital Revenue Code	402
Rate for Payer: Cash Price	$555.28

CHWR US OB COMP W/DET ADD GEST BCE

Facility

$631.00

Service Code	CPT 76812
Hospital Charge Code	5066812
Hospital Revenue Code	402
Min. Negotiated Rate	$85.82
Max. Negotiated Rate	$410.15
Rate for Payer: Aetna Commercial	$124.84
Rate for Payer: Amerigroup CHIP/Medicaid	$192.13
Rate for Payer: BCBS of TX Blue Advantage	$184.34
Rate for Payer: BCBS of TX Blue Essentials	$221.21
Rate for Payer: BCBS of TX PPO	$246.90
Rate for Payer: Cash Price	$555.28
Rate for Payer: Cash Price	$555.28
Rate for Payer: Cigna Medicaid	$192.13
Rate for Payer: Molina CHIP/Medicaid	$192.13
Rate for Payer: Multiplan Auto	$410.15
Rate for Payer: Multiplan Commercial	$410.15
Rate for Payer: Multiplan Workers Comp	$410.15
Rate for Payer: Parkland Medicaid	$192.13
Rate for Payer: Scott and White EPO/PPO	$315.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.13
Rate for Payer: Superior Health Plan EPO	$85.82

CHWR U/S STERILE PROBE COVER

Facility

$34.05

Hospital Charge Code	8034188
Hospital Revenue Code	270
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$22.13
Rate for Payer: Aetna Commercial	$18.73
Rate for Payer: Amerigroup CHIP/Medicaid	$3.06
Rate for Payer: BCBS of TX Blue Advantage	$10.22
Rate for Payer: BCBS of TX Blue Essentials	$12.26
Rate for Payer: BCBS of TX PPO	$13.62
Rate for Payer: Cash Price	$29.96
Rate for Payer: Multiplan Auto	$22.13
Rate for Payer: Multiplan Commercial	$22.13
Rate for Payer: Multiplan Workers Comp	$22.13
Rate for Payer: Scott and White EPO/PPO	$17.02
Rate for Payer: Superior Health Plan EPO	$4.63

CHWR U/S STERILE PROBE COVER BCE

Facility

$34.05

Hospital Charge Code	8034188
Hospital Revenue Code	270
Rate for Payer: Cash Price	$29.96

CHWR U/S STERILE PROBE COVER BCE

Facility

$34.05

Hospital Charge Code	8034188
Hospital Revenue Code	270
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$22.13
Rate for Payer: Aetna Commercial	$18.73
Rate for Payer: Amerigroup CHIP/Medicaid	$3.06
Rate for Payer: BCBS of TX Blue Advantage	$10.22
Rate for Payer: BCBS of TX Blue Essentials	$12.26
Rate for Payer: BCBS of TX PPO	$13.62
Rate for Payer: Cash Price	$29.96
Rate for Payer: Multiplan Auto	$22.13
Rate for Payer: Multiplan Commercial	$22.13
Rate for Payer: Multiplan Workers Comp	$22.13
Rate for Payer: Scott and White EPO/PPO	$17.02
Rate for Payer: Superior Health Plan EPO	$4.63

CHWR US TRANSVAGINAL NON-OB

Facility

$978.00

Service Code	CPT 76830
Hospital Charge Code	5066830
Hospital Revenue Code	402
Rate for Payer: Cash Price	$860.64

CHWR US TRANSVAGINAL NON-OB

Facility

$978.00

Service Code	CPT 76830
Hospital Charge Code	5066830
Hospital Revenue Code	402
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$635.70
Rate for Payer: Aetna Commercial	$101.13
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$106.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$100.55
Rate for Payer: Amerigroup Medicare	$100.55
Rate for Payer: BCBS of TX Blue Advantage	$145.70
Rate for Payer: BCBS of TX Blue Essentials	$174.83
Rate for Payer: BCBS of TX Medicare	$100.55
Rate for Payer: BCBS of TX PPO	$195.14
Rate for Payer: Cash Price	$860.64
Rate for Payer: Cash Price	$860.64
Rate for Payer: Cash Price	$860.64
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$106.88
Rate for Payer: Cigna Medicare	$100.55
Rate for Payer: Employer Direct Commercial	$100.55
Rate for Payer: Humana Medicare/TRICARE	$100.55
Rate for Payer: Molina CHIP/Medicaid	$106.88
Rate for Payer: Molina Dual Medicare/Medicaid	$100.55
Rate for Payer: Molina Medicare	$100.55
Rate for Payer: Multiplan Auto	$635.70
Rate for Payer: Multiplan Commercial	$635.70
Rate for Payer: Multiplan Workers Comp	$635.70
Rate for Payer: Parkland Medicaid	$106.88
Rate for Payer: Scott and White EPO/PPO	$1.80
Rate for Payer: Scott and White Medicare	$100.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$106.88
Rate for Payer: Superior Health Plan EPO	$100.55
Rate for Payer: Superior Health Plan Medicare	$100.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$100.55
Rate for Payer: Universal American Medicare	$100.55
Rate for Payer: Wellcare Medicare	$100.55
Rate for Payer: Wellmed Medicare	$100.55

CHWR US TRANSVAGINAL OB

Facility

$303.00

Service Code	CPT 76817
Hospital Charge Code	5066816
Hospital Revenue Code	402
Rate for Payer: Cash Price	$266.64

CHWR US TRANSVAGINAL OB

Facility

$303.00

Service Code	CPT 76817
Hospital Charge Code	5066816
Hospital Revenue Code	402
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$247.70
Rate for Payer: Aetna Commercial	$66.08
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$93.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$100.55
Rate for Payer: Amerigroup Medicare	$100.55
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$100.55
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$266.64
Rate for Payer: Cash Price	$266.64
Rate for Payer: Cash Price	$266.64
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$93.23
Rate for Payer: Cigna Medicare	$100.55
Rate for Payer: Employer Direct Commercial	$100.55
Rate for Payer: Humana Medicare/TRICARE	$100.55
Rate for Payer: Molina CHIP/Medicaid	$93.23
Rate for Payer: Molina Dual Medicare/Medicaid	$100.55
Rate for Payer: Molina Medicare	$100.55
Rate for Payer: Multiplan Auto	$196.95
Rate for Payer: Multiplan Commercial	$196.95
Rate for Payer: Multiplan Workers Comp	$196.95
Rate for Payer: Parkland Medicaid	$93.23
Rate for Payer: Scott and White EPO/PPO	$1.80
Rate for Payer: Scott and White Medicare	$100.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$93.23
Rate for Payer: Superior Health Plan EPO	$100.55
Rate for Payer: Superior Health Plan Medicare	$100.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$100.55
Rate for Payer: Universal American Medicare	$100.55
Rate for Payer: Wellcare Medicare	$100.55
Rate for Payer: Wellmed Medicare	$100.55

CHWR VACCUTAINER

Facility

$29.00

Hospital Charge Code	5420130
Hospital Revenue Code	272
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$18.85
Rate for Payer: Aetna Commercial	$15.95
Rate for Payer: Amerigroup CHIP/Medicaid	$2.61
Rate for Payer: BCBS of TX Blue Advantage	$8.70
Rate for Payer: BCBS of TX Blue Essentials	$10.44
Rate for Payer: BCBS of TX PPO	$11.60
Rate for Payer: Cash Price	$25.52
Rate for Payer: Multiplan Auto	$18.85
Rate for Payer: Multiplan Commercial	$18.85
Rate for Payer: Multiplan Workers Comp	$18.85
Rate for Payer: Scott and White EPO/PPO	$14.50
Rate for Payer: Superior Health Plan EPO	$3.94

CHWR VACCUTAINER BCE

Facility

$29.00

Hospital Charge Code	5420130
Hospital Revenue Code	272
Rate for Payer: Cash Price	$25.52

Know your out-of-pocket cost for care.

All Charges