White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CMV Quant DNA PCR (Plasma) SO

Facility

$355.00

Service Code	CPT 87497
Hospital Charge Code	1709518
Hospital Revenue Code	306
Rate for Payer: Cash Price	$312.40

CMV Quant DNA PCR (Plasma) SO

Facility

$355.00

Service Code	CPT 87497
Hospital Charge Code	1709518
Hospital Revenue Code	306
Min. Negotiated Rate	$16.71
Max. Negotiated Rate	$230.75
Rate for Payer: Aetna Commercial	$44.98
Rate for Payer: Aetna Medicare	$64.26
Rate for Payer: Amerigroup CHIP/Medicaid	$16.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.84
Rate for Payer: Amerigroup Medicare	$42.84
Rate for Payer: BCBS of TX Blue Advantage	$70.69
Rate for Payer: BCBS of TX Blue Essentials	$84.82
Rate for Payer: BCBS of TX Medicare	$42.84
Rate for Payer: BCBS of TX PPO	$94.68
Rate for Payer: Cash Price	$312.40
Rate for Payer: Cash Price	$312.40
Rate for Payer: Cigna Medicaid	$42.84
Rate for Payer: Cigna Medicare	$42.84
Rate for Payer: Employer Direct Commercial	$42.84
Rate for Payer: Humana Medicare/TRICARE	$42.84
Rate for Payer: Molina CHIP/Medicaid	$42.84
Rate for Payer: Molina Dual Medicare/Medicaid	$42.84
Rate for Payer: Molina Medicare	$42.84
Rate for Payer: Multiplan Auto	$230.75
Rate for Payer: Multiplan Commercial	$230.75
Rate for Payer: Multiplan Workers Comp	$230.75
Rate for Payer: Parkland Medicaid	$42.84
Rate for Payer: Scott and White EPO/PPO	$53.55
Rate for Payer: Scott and White Medicare	$42.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.84
Rate for Payer: Superior Health Plan EPO	$42.84
Rate for Payer: Superior Health Plan Medicare	$42.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.84
Rate for Payer: Universal American Medicare	$42.84
Rate for Payer: Wellcare Medicare	$42.84
Rate for Payer: Wellmed Medicare	$42.84

COAGULATION DISORDERS

Facility

$29,640.00

Service Code	MSDRG 813
Min. Negotiated Rate	$13,650.00
Max. Negotiated Rate	$29,640.00
Rate for Payer: Aetna Commercial	$17,550.00
Rate for Payer: Aetna Medicare	$20,980.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,987.03
Rate for Payer: Amerigroup Medicare	$13,987.03
Rate for Payer: BCBS of TX Blue Advantage	$16,551.56
Rate for Payer: BCBS of TX Blue Essentials	$16,629.07
Rate for Payer: BCBS of TX Medicare	$13,987.03
Rate for Payer: BCBS of TX PPO	$18,477.46
Rate for Payer: Cigna Commercial	$20,092.80
Rate for Payer: Cigna Medicare	$13,987.03
Rate for Payer: Employer Direct Commercial	$13,987.03
Rate for Payer: Humana Medicare/TRICARE	$13,987.03
Rate for Payer: Molina Dual Medicare/Medicaid	$13,987.03
Rate for Payer: Molina Medicare	$13,987.03
Rate for Payer: Multiplan Auto	$29,640.00
Rate for Payer: Multiplan Commercial	$29,640.00
Rate for Payer: Multiplan Workers Comp	$29,640.00
Rate for Payer: Scott and White EPO/PPO	$13,650.00
Rate for Payer: Scott and White Medicare	$13,987.03
Rate for Payer: Superior Health Plan EPO	$13,987.03
Rate for Payer: Superior Health Plan Medicare	$13,987.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,987.03
Rate for Payer: Universal American Medicare	$13,987.03
Rate for Payer: Wellcare Medicare	$13,987.03
Rate for Payer: Wellmed Medicare	$13,987.03

Cocaine Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640110
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$206.05
Rate for Payer: Aetna Commercial	$65.24
Rate for Payer: Aetna Medicare	$93.21
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$102.53
Rate for Payer: BCBS of TX Blue Essentials	$123.04
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$137.33
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cigna Medicaid	$62.14
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$62.14
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$62.14
Rate for Payer: Scott and White EPO/PPO	$77.68
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.14
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

Cocaine Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640110
Hospital Revenue Code	300
Rate for Payer: Cash Price	$278.96

Coccidioides CF Antibody SO

Facility

$72.00

Service Code	CPT 86635
Hospital Charge Code	1704022
Hospital Revenue Code	302
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna Commercial	$12.04
Rate for Payer: Aetna Medicare	$17.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.47
Rate for Payer: Amerigroup Medicare	$11.47
Rate for Payer: BCBS of TX Blue Advantage	$18.93
Rate for Payer: BCBS of TX Blue Essentials	$22.71
Rate for Payer: BCBS of TX Medicare	$11.47
Rate for Payer: BCBS of TX PPO	$25.35
Rate for Payer: Cash Price	$63.36
Rate for Payer: Cash Price	$63.36
Rate for Payer: Cigna Medicaid	$11.47
Rate for Payer: Cigna Medicare	$11.47
Rate for Payer: Employer Direct Commercial	$11.47
Rate for Payer: Humana Medicare/TRICARE	$11.47
Rate for Payer: Molina CHIP/Medicaid	$11.47
Rate for Payer: Molina Dual Medicare/Medicaid	$11.47
Rate for Payer: Molina Medicare	$11.47
Rate for Payer: Multiplan Auto	$46.80
Rate for Payer: Multiplan Commercial	$46.80
Rate for Payer: Multiplan Workers Comp	$46.80
Rate for Payer: Parkland Medicaid	$11.47
Rate for Payer: Scott and White EPO/PPO	$14.34
Rate for Payer: Scott and White Medicare	$11.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.47
Rate for Payer: Superior Health Plan EPO	$11.47
Rate for Payer: Superior Health Plan Medicare	$11.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.47
Rate for Payer: Universal American Medicare	$11.47
Rate for Payer: Wellcare Medicare	$11.47
Rate for Payer: Wellmed Medicare	$11.47

Coccidioides CF Antibody SO

Facility

$72.00

Service Code	CPT 86635
Hospital Charge Code	1704022
Hospital Revenue Code	302
Rate for Payer: Cash Price	$63.36

codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 5 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77482140
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 5 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77482140
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

COIL EMBL DETACH

Facility

$1,733.55

Service Code	HCPCS L8699
Hospital Charge Code	8470497
Hospital Revenue Code	278
Min. Negotiated Rate	$433.39
Max. Negotiated Rate	$866.78
Rate for Payer: Aetna Commercial	$520.06
Rate for Payer: Cash Price	$1,525.52
Rate for Payer: Cigna Commercial	$433.39
Rate for Payer: Multiplan Auto	$866.78
Rate for Payer: Multiplan Commercial	$866.78
Rate for Payer: Multiplan Workers Comp	$866.78
Rate for Payer: Scott and White EPO/PPO	$866.78

COIL EMBL DETACH

Facility

$1,733.55

Service Code	HCPCS L8699
Hospital Charge Code	8470497
Hospital Revenue Code	278
Min. Negotiated Rate	$156.02
Max. Negotiated Rate	$866.78
Rate for Payer: Aetna Commercial	$520.06
Rate for Payer: Amerigroup CHIP/Medicaid	$156.02
Rate for Payer: BCBS of TX Blue Advantage	$520.06
Rate for Payer: BCBS of TX Blue Essentials	$624.08
Rate for Payer: BCBS of TX PPO	$693.42
Rate for Payer: Cash Price	$1,525.52
Rate for Payer: Multiplan Auto	$866.78
Rate for Payer: Multiplan Commercial	$866.78
Rate for Payer: Multiplan Workers Comp	$866.78
Rate for Payer: Scott and White EPO/PPO	$866.78
Rate for Payer: Superior Health Plan EPO	$235.76

COIL EMBOLIC DETACH -- DHF

Facility

$397.29

Hospital Charge Code	80603004
Hospital Revenue Code	278
Min. Negotiated Rate	$35.76
Max. Negotiated Rate	$198.64
Rate for Payer: Aetna Commercial	$119.19
Rate for Payer: Amerigroup CHIP/Medicaid	$35.76
Rate for Payer: BCBS of TX Blue Advantage	$119.19
Rate for Payer: BCBS of TX Blue Essentials	$143.02
Rate for Payer: BCBS of TX PPO	$158.92
Rate for Payer: Cash Price	$349.62
Rate for Payer: Multiplan Auto	$198.64
Rate for Payer: Multiplan Commercial	$198.64
Rate for Payer: Multiplan Workers Comp	$198.64
Rate for Payer: Scott and White EPO/PPO	$198.64
Rate for Payer: Superior Health Plan EPO	$54.03

COIL EMBOLIC DETACH -- DHF

Facility

$397.29

Hospital Charge Code	80603004
Hospital Revenue Code	278
Min. Negotiated Rate	$99.32
Max. Negotiated Rate	$198.64
Rate for Payer: Aetna Commercial	$119.19
Rate for Payer: Cash Price	$349.62
Rate for Payer: Cigna Commercial	$99.32
Rate for Payer: Multiplan Auto	$198.64
Rate for Payer: Multiplan Commercial	$198.64
Rate for Payer: Multiplan Workers Comp	$198.64
Rate for Payer: Scott and White EPO/PPO	$198.64

COLLAR CERV -- DHF

Facility

$126.33

Hospital Charge Code	81141707
Hospital Revenue Code	270
Min. Negotiated Rate	$11.37
Max. Negotiated Rate	$82.11
Rate for Payer: Aetna Commercial	$69.48
Rate for Payer: Amerigroup CHIP/Medicaid	$11.37
Rate for Payer: BCBS of TX Blue Advantage	$37.90
Rate for Payer: BCBS of TX Blue Essentials	$45.48
Rate for Payer: BCBS of TX PPO	$50.53
Rate for Payer: Cash Price	$111.17
Rate for Payer: Multiplan Auto	$82.11
Rate for Payer: Multiplan Commercial	$82.11
Rate for Payer: Multiplan Workers Comp	$82.11
Rate for Payer: Scott and White EPO/PPO	$63.16
Rate for Payer: Superior Health Plan EPO	$17.18

COLLAR CERV -- DHF

Facility

$126.33

Hospital Charge Code	81141707
Hospital Revenue Code	270
Rate for Payer: Cash Price	$111.17

COLLAR CERV FM -- DHF

Facility

$32.08

Hospital Charge Code	81141806
Hospital Revenue Code	270
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$20.85
Rate for Payer: Aetna Commercial	$17.64
Rate for Payer: Amerigroup CHIP/Medicaid	$2.89
Rate for Payer: BCBS of TX Blue Advantage	$9.62
Rate for Payer: BCBS of TX Blue Essentials	$11.55
Rate for Payer: BCBS of TX PPO	$12.83
Rate for Payer: Cash Price	$28.23
Rate for Payer: Multiplan Auto	$20.85
Rate for Payer: Multiplan Commercial	$20.85
Rate for Payer: Multiplan Workers Comp	$20.85
Rate for Payer: Scott and White EPO/PPO	$16.04
Rate for Payer: Superior Health Plan EPO	$4.36

COLLAR CERV FM -- DHF

Facility

$32.08

Hospital Charge Code	81141806
Hospital Revenue Code	270
Rate for Payer: Cash Price	$28.23

COLLAR PHIL -- DHF

Facility

$284.49

Hospital Charge Code	81142002
Hospital Revenue Code	270
Rate for Payer: Cash Price	$250.35

COLLAR PHIL -- DHF

Facility

$284.49

Hospital Charge Code	81142002
Hospital Revenue Code	270
Min. Negotiated Rate	$25.60
Max. Negotiated Rate	$184.92
Rate for Payer: Aetna Commercial	$156.47
Rate for Payer: Amerigroup CHIP/Medicaid	$25.60
Rate for Payer: BCBS of TX Blue Advantage	$85.35
Rate for Payer: BCBS of TX Blue Essentials	$102.42
Rate for Payer: BCBS of TX PPO	$113.80
Rate for Payer: Cash Price	$250.35
Rate for Payer: Multiplan Auto	$184.92
Rate for Payer: Multiplan Commercial	$184.92
Rate for Payer: Multiplan Workers Comp	$184.92
Rate for Payer: Scott and White EPO/PPO	$142.24
Rate for Payer: Superior Health Plan EPO	$38.69

COLLECTION: 24 Hour Urine

Facility

$56.00

Service Code	CPT 81050
Hospital Charge Code	1704618
Hospital Revenue Code	307
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$36.40
Rate for Payer: Aetna Commercial	$3.82
Rate for Payer: Aetna Medicare	$5.46
Rate for Payer: Amerigroup CHIP/Medicaid	$1.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.64
Rate for Payer: Amerigroup Medicare	$3.64
Rate for Payer: BCBS of TX Blue Advantage	$6.01
Rate for Payer: BCBS of TX Blue Essentials	$7.21
Rate for Payer: BCBS of TX Medicare	$3.64
Rate for Payer: BCBS of TX PPO	$8.04
Rate for Payer: Cash Price	$49.28
Rate for Payer: Cash Price	$49.28
Rate for Payer: Cigna Medicaid	$3.64
Rate for Payer: Cigna Medicare	$3.64
Rate for Payer: Employer Direct Commercial	$3.64
Rate for Payer: Humana Medicare/TRICARE	$3.64
Rate for Payer: Molina CHIP/Medicaid	$3.64
Rate for Payer: Molina Dual Medicare/Medicaid	$3.64
Rate for Payer: Molina Medicare	$3.64
Rate for Payer: Multiplan Auto	$36.40
Rate for Payer: Multiplan Commercial	$36.40
Rate for Payer: Multiplan Workers Comp	$36.40
Rate for Payer: Parkland Medicaid	$3.64
Rate for Payer: Scott and White EPO/PPO	$4.55
Rate for Payer: Scott and White Medicare	$3.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.64
Rate for Payer: Superior Health Plan EPO	$3.64
Rate for Payer: Superior Health Plan Medicare	$3.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.64
Rate for Payer: Universal American Medicare	$3.64
Rate for Payer: Wellcare Medicare	$3.64
Rate for Payer: Wellmed Medicare	$3.64

COLLECTION: Capillary

Facility

$41.00

Service Code	CPT 36416
Hospital Charge Code	300673
Hospital Revenue Code	761
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$22.55
Rate for Payer: Amerigroup CHIP/Medicaid	$3.69
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$36.08
Rate for Payer: Cash Price	$36.08
Rate for Payer: Multiplan Auto	$26.65
Rate for Payer: Multiplan Commercial	$26.65
Rate for Payer: Multiplan Workers Comp	$26.65
Rate for Payer: Scott and White EPO/PPO	$20.50
Rate for Payer: Superior Health Plan EPO	$5.58

COLLECTION: Capillary

Facility

$41.00

Service Code	CPT 36416
Hospital Charge Code	300673
Hospital Revenue Code	761
Rate for Payer: Cash Price	$36.08

COLLECTION: Venous Draw

Facility

$47.00

Service Code	CPT 36415
Hospital Charge Code	1605526
Hospital Revenue Code	300
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$30.55
Rate for Payer: Aetna Commercial	$25.85
Rate for Payer: Aetna Medicare	$13.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.83
Rate for Payer: Amerigroup Medicare	$8.83
Rate for Payer: BCBS of TX Medicare	$8.83
Rate for Payer: Cash Price	$41.36
Rate for Payer: Cash Price	$41.36
Rate for Payer: Cigna Medicare	$8.83
Rate for Payer: Employer Direct Commercial	$8.83
Rate for Payer: Humana Medicare/TRICARE	$8.83
Rate for Payer: Molina Dual Medicare/Medicaid	$8.83
Rate for Payer: Molina Medicare	$8.83
Rate for Payer: Multiplan Auto	$30.55
Rate for Payer: Multiplan Commercial	$30.55
Rate for Payer: Multiplan Workers Comp	$30.55
Rate for Payer: Scott and White EPO/PPO	$11.04
Rate for Payer: Scott and White Medicare	$8.83
Rate for Payer: Superior Health Plan EPO	$8.83
Rate for Payer: Superior Health Plan Medicare	$8.83
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.83
Rate for Payer: Universal American Medicare	$8.83
Rate for Payer: Wellcare Medicare	$8.83
Rate for Payer: Wellmed Medicare	$8.83

COLLECTION: Venous Draw

Facility

$47.00

Service Code	CPT 36415
Hospital Charge Code	1605526
Hospital Revenue Code	300
Rate for Payer: Cash Price	$41.36

COLLECTOR WOUND DRAINAGE /9778-LARGE

Facility

$24.20

Hospital Charge Code	131582
Hospital Revenue Code	270
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$15.73
Rate for Payer: Aetna Commercial	$13.31
Rate for Payer: Amerigroup CHIP/Medicaid	$2.18
Rate for Payer: BCBS of TX Blue Advantage	$7.26
Rate for Payer: BCBS of TX Blue Essentials	$8.71
Rate for Payer: BCBS of TX PPO	$9.68
Rate for Payer: Cash Price	$21.30
Rate for Payer: Multiplan Auto	$15.73
Rate for Payer: Multiplan Commercial	$15.73
Rate for Payer: Multiplan Workers Comp	$15.73
Rate for Payer: Scott and White EPO/PPO	$12.10
Rate for Payer: Superior Health Plan EPO	$3.29

Know your out-of-pocket cost for care.

All Charges