White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHWR VACCUTAINER BCE

Facility

$29.00

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

CHWR WATER SEAL CHEST TUBE KIT

Facility

$134.96

Hospital Charge Code	8032060
Hospital Revenue Code	270
Min. Negotiated Rate	$12.15
Max. Negotiated Rate	$87.72
Rate for Payer: Aetna Commercial	$74.23
Rate for Payer: Amerigroup CHIP/Medicaid	$12.15
Rate for Payer: BCBS of TX Blue Advantage	$40.49
Rate for Payer: BCBS of TX Blue Essentials	$48.59
Rate for Payer: BCBS of TX PPO	$53.98
Rate for Payer: Cash Price	$118.76
Rate for Payer: Multiplan Auto	$87.72
Rate for Payer: Multiplan Commercial	$87.72
Rate for Payer: Multiplan Workers Comp	$87.72
Rate for Payer: Scott and White EPO/PPO	$67.48
Rate for Payer: Superior Health Plan EPO	$18.35

CHWR WATER SEAL CHEST TUBE KIT BCE

Facility

$134.96

Hospital Charge Code	8032060
Hospital Revenue Code	270
Min. Negotiated Rate	$12.15
Max. Negotiated Rate	$87.72
Rate for Payer: Aetna Commercial	$74.23
Rate for Payer: Amerigroup CHIP/Medicaid	$12.15
Rate for Payer: BCBS of TX Blue Advantage	$40.49
Rate for Payer: BCBS of TX Blue Essentials	$48.59
Rate for Payer: BCBS of TX PPO	$53.98
Rate for Payer: Cash Price	$118.76
Rate for Payer: Multiplan Auto	$87.72
Rate for Payer: Multiplan Commercial	$87.72
Rate for Payer: Multiplan Workers Comp	$87.72
Rate for Payer: Scott and White EPO/PPO	$67.48
Rate for Payer: Superior Health Plan EPO	$18.35

CHWR WATER SEAL CHEST TUBE KIT BCE

Facility

$134.96

Hospital Charge Code	8032060
Hospital Revenue Code	270
Rate for Payer: Cash Price	$118.76

CHWR WIRE GUIDE AMPLATZ SUPER 75 CM

Facility

$161.55

Service Code	HCPCS C1769
Hospital Charge Code	8073060
Hospital Revenue Code	272
Min. Negotiated Rate	$14.54
Max. Negotiated Rate	$105.01
Rate for Payer: Aetna Commercial	$88.85
Rate for Payer: Amerigroup CHIP/Medicaid	$14.54
Rate for Payer: BCBS of TX Blue Advantage	$48.46
Rate for Payer: BCBS of TX Blue Essentials	$58.16
Rate for Payer: BCBS of TX PPO	$64.62
Rate for Payer: Cash Price	$142.16
Rate for Payer: Multiplan Auto	$105.01
Rate for Payer: Multiplan Commercial	$105.01
Rate for Payer: Multiplan Workers Comp	$105.01
Rate for Payer: Scott and White EPO/PPO	$80.78
Rate for Payer: Superior Health Plan EPO	$21.97

CHWR WIRE GUIDE AMPLATZ SUPER 75 CM BCE

Facility

$161.55

Service Code	HCPCS C1769
Hospital Charge Code	8073060
Hospital Revenue Code	272
Min. Negotiated Rate	$14.54
Max. Negotiated Rate	$105.01
Rate for Payer: Aetna Commercial	$88.85
Rate for Payer: Amerigroup CHIP/Medicaid	$14.54
Rate for Payer: BCBS of TX Blue Advantage	$48.46
Rate for Payer: BCBS of TX Blue Essentials	$58.16
Rate for Payer: BCBS of TX PPO	$64.62
Rate for Payer: Cash Price	$142.16
Rate for Payer: Multiplan Auto	$105.01
Rate for Payer: Multiplan Commercial	$105.01
Rate for Payer: Multiplan Workers Comp	$105.01
Rate for Payer: Scott and White EPO/PPO	$80.78
Rate for Payer: Superior Health Plan EPO	$21.97

CHWR WIRE GUIDE AMPLATZ SUPER 75 CM BCE

Facility

$161.55

Service Code	HCPCS C1769
Hospital Charge Code	8073060
Hospital Revenue Code	272
Rate for Payer: Cash Price	$142.16

CHWR XR ARTHROGRAM INJECTION HIP LEFT

Facility

$581.00

Service Code	CPT 27093 LT,FY
Hospital Charge Code	4907650
Hospital Revenue Code	361
Min. Negotiated Rate	$52.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$319.55
Rate for Payer: Amerigroup CHIP/Medicaid	$52.29
Rate for Payer: Cash Price	$511.28
Rate for Payer: Cash Price	$511.28
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	$290.50
Rate for Payer: Superior Health Plan EPO	$79.02

CHWR XR ARTHROGRAM INJECTION HIP LEFT BCE

Facility

$581.00

Service Code	CPT 27093 LT,FY
Hospital Charge Code	4907650
Hospital Revenue Code	361
Min. Negotiated Rate	$52.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$319.55
Rate for Payer: Amerigroup CHIP/Medicaid	$52.29
Rate for Payer: Cash Price	$511.28
Rate for Payer: Cash Price	$511.28
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	$290.50
Rate for Payer: Superior Health Plan EPO	$79.02

CHWR XR ARTHROGRAM INJECTION HIP RIGHT

Facility

$581.00

Service Code	CPT 27093 RT,FY
Hospital Charge Code	4907650
Hospital Revenue Code	361
Min. Negotiated Rate	$52.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$319.55
Rate for Payer: Amerigroup CHIP/Medicaid	$52.29
Rate for Payer: Cash Price	$511.28
Rate for Payer: Cash Price	$511.28
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	$290.50
Rate for Payer: Superior Health Plan EPO	$79.02

CHWR XR ARTHROGRAM INJECTION HIP RIGHT BCE

Facility

$581.00

Service Code	CPT 27093 RT,FY
Hospital Charge Code	4907650
Hospital Revenue Code	361
Min. Negotiated Rate	$52.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$319.55
Rate for Payer: Amerigroup CHIP/Medicaid	$52.29
Rate for Payer: Cash Price	$511.28
Rate for Payer: Cash Price	$511.28
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	$290.50
Rate for Payer: Superior Health Plan EPO	$79.02

CHWR XR ARTHROGRAM INJECTION KNEE LEFT

Facility

$718.00

Service Code	CPT 27369 LT,FY
Hospital Charge Code	4907670
Hospital Revenue Code	361
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$394.90
Rate for Payer: Amerigroup CHIP/Medicaid	$64.62
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cash Price	$631.84
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	$359.00
Rate for Payer: Superior Health Plan EPO	$97.65

CHWR XR ARTHROGRAM INJECTION KNEE LEFT BCE

Facility

$718.00

Service Code	CPT 27369 LT,FY
Hospital Charge Code	4907670
Hospital Revenue Code	361
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$394.90
Rate for Payer: Amerigroup CHIP/Medicaid	$64.62
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cash Price	$631.84
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	$359.00
Rate for Payer: Superior Health Plan EPO	$97.65

CHWR XR ARTHROGRAM INJECTION KNEE RIGHT

Facility

$718.00

Service Code	CPT 27369 RT,FY
Hospital Charge Code	4907670
Hospital Revenue Code	361
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$394.90
Rate for Payer: Amerigroup CHIP/Medicaid	$64.62
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cash Price	$631.84
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	$359.00
Rate for Payer: Superior Health Plan EPO	$97.65

CHWR XR ARTHROGRAM INJECTION KNEE RIGHT BCE

Facility

$718.00

Service Code	CPT 27369 RT,FY
Hospital Charge Code	4907670
Hospital Revenue Code	361
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$394.90
Rate for Payer: Amerigroup CHIP/Medicaid	$64.62
Rate for Payer: Cash Price	$631.84
Rate for Payer: Cash Price	$631.84
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	$359.00
Rate for Payer: Superior Health Plan EPO	$97.65

CHWR XR ARTHROGRAM INJECTION SHOULDER LT

Facility

$555.00

Service Code	CPT 23350 LT,FY
Hospital Charge Code	4907700
Hospital Revenue Code	361
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$305.25
Rate for Payer: Amerigroup CHIP/Medicaid	$49.95
Rate for Payer: Cash Price	$488.40
Rate for Payer: Cash Price	$488.40
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	$277.50
Rate for Payer: Superior Health Plan EPO	$75.48

CHWR XR ARTHROGRAM INJECTION SHOULDER LT BCE

Facility

$555.00

Service Code	CPT 23350 LT,FY
Hospital Charge Code	4907700
Hospital Revenue Code	361
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$305.25
Rate for Payer: Amerigroup CHIP/Medicaid	$49.95
Rate for Payer: Cash Price	$488.40
Rate for Payer: Cash Price	$488.40
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	$277.50
Rate for Payer: Superior Health Plan EPO	$75.48

CHWR XR ARTHROGRAM INJECTION SHOULDER RT

Facility

$555.00

Service Code	CPT 23350 RT,FY
Hospital Charge Code	4907700
Hospital Revenue Code	361
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$305.25
Rate for Payer: Amerigroup CHIP/Medicaid	$49.95
Rate for Payer: Cash Price	$488.40
Rate for Payer: Cash Price	$488.40
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	$277.50
Rate for Payer: Superior Health Plan EPO	$75.48

CHWR XR ARTHROGRAM INJECTION SHOULDER RT BCE

Facility

$555.00

Service Code	CPT 23350 RT,FY
Hospital Charge Code	4907700
Hospital Revenue Code	361
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$305.25
Rate for Payer: Amerigroup CHIP/Medicaid	$49.95
Rate for Payer: Cash Price	$488.40
Rate for Payer: Cash Price	$488.40
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	$277.50
Rate for Payer: Superior Health Plan EPO	$75.48

CHWR XR ARTHROGRAM INJECTION WRIST LEFT

Facility

$430.00

Service Code	CPT 25246 LT,FY
Hospital Charge Code	4907745
Hospital Revenue Code	361
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$236.50
Rate for Payer: Amerigroup CHIP/Medicaid	$38.70
Rate for Payer: Cash Price	$378.40
Rate for Payer: Cash Price	$378.40
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	$215.00
Rate for Payer: Superior Health Plan EPO	$58.48

CHWR XR ARTHROGRAM INJECTION WRIST LEFT BCE

Facility

$430.00

Service Code	CPT 25246 LT,FY
Hospital Charge Code	4907745
Hospital Revenue Code	361
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$236.50
Rate for Payer: Amerigroup CHIP/Medicaid	$38.70
Rate for Payer: Cash Price	$378.40
Rate for Payer: Cash Price	$378.40
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	$215.00
Rate for Payer: Superior Health Plan EPO	$58.48

CHWR XR ARTHROGRAM INJECTION WRIST RIGHT

Facility

$430.00

Service Code	CPT 25246 RT,FY
Hospital Charge Code	4907745
Hospital Revenue Code	361
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$236.50
Rate for Payer: Amerigroup CHIP/Medicaid	$38.70
Rate for Payer: Cash Price	$378.40
Rate for Payer: Cash Price	$378.40
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	$215.00
Rate for Payer: Superior Health Plan EPO	$58.48

CHWR XR ARTHROGRAM INJECTION WRIST RIGHT BCE

Facility

$430.00

Service Code	CPT 25246 RT,FY
Hospital Charge Code	4907745
Hospital Revenue Code	361
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$236.50
Rate for Payer: Amerigroup CHIP/Medicaid	$38.70
Rate for Payer: Cash Price	$378.40
Rate for Payer: Cash Price	$378.40
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	$215.00
Rate for Payer: Superior Health Plan EPO	$58.48

CHWR XR FL GUIDE BX/ASP/INJ

Facility

$559.00

Service Code	CPT 77002
Hospital Charge Code	4906010
Hospital Revenue Code	320
Min. Negotiated Rate	$50.31
Max. Negotiated Rate	$363.35
Rate for Payer: Aetna Commercial	$103.44
Rate for Payer: Amerigroup CHIP/Medicaid	$50.31
Rate for Payer: BCBS of TX Blue Advantage	$123.09
Rate for Payer: BCBS of TX Blue Essentials	$147.71
Rate for Payer: BCBS of TX PPO	$164.87
Rate for Payer: Cash Price	$491.92
Rate for Payer: Cash Price	$491.92
Rate for Payer: Multiplan Auto	$363.35
Rate for Payer: Multiplan Commercial	$363.35
Rate for Payer: Multiplan Workers Comp	$363.35
Rate for Payer: Scott and White EPO/PPO	$279.50
Rate for Payer: Superior Health Plan EPO	$76.02

CHWR XR FL GUIDE BX/ASP/INJ BCE

Facility

$559.00

Service Code	CPT 77002
Hospital Charge Code	4906010
Hospital Revenue Code	320
Rate for Payer: Cash Price	$491.92

Know your out-of-pocket cost for care.

All Charges