White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BUSHING

Facility

$730.94

Hospital Charge Code	993166
Hospital Revenue Code	272
Rate for Payer: Cash Price	$497.04

BUSHING

Facility

$730.94

Hospital Charge Code	993166
Hospital Revenue Code	272
Min. Negotiated Rate	$65.78
Max. Negotiated Rate	$526.28
Rate for Payer: Amerigroup CHIP/Medicaid	$65.78
Rate for Payer: BCBS of TX Blue Advantage	$219.28
Rate for Payer: BCBS of TX Blue Essentials	$263.14
Rate for Payer: BCBS of TX PPO	$292.38
Rate for Payer: Cash Price	$497.04
Rate for Payer: Cigna Medicaid	$526.28
Rate for Payer: Molina CHIP/Medicaid	$526.28
Rate for Payer: Multiplan Auto	$475.11
Rate for Payer: Multiplan Commercial	$475.11
Rate for Payer: Multiplan Workers Comp	$475.11
Rate for Payer: Parkland Medicaid	$526.28
Rate for Payer: Scott and White EPO/PPO	$365.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$526.28
Rate for Payer: Superior Health Plan EPO	$99.41

busPIRone 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77428639
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

busPIRone 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77428639
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

busPIRone 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77428802
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

busPIRone 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77428802
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

BUTTON ACL SECURE- LOOP 15MM

Facility

$1,325.30

Service Code	HCPCS C1713
Hospital Charge Code	992354
Hospital Revenue Code	278
Min. Negotiated Rate	$119.28
Max. Negotiated Rate	$954.22
Rate for Payer: Amerigroup CHIP/Medicaid	$119.28
Rate for Payer: BCBS of TX Blue Advantage	$397.59
Rate for Payer: BCBS of TX Blue Essentials	$477.11
Rate for Payer: BCBS of TX PPO	$530.12
Rate for Payer: Cash Price	$901.20
Rate for Payer: Cigna Medicaid	$954.22
Rate for Payer: Molina CHIP/Medicaid	$954.22
Rate for Payer: Multiplan Auto	$662.65
Rate for Payer: Multiplan Commercial	$662.65
Rate for Payer: Multiplan Workers Comp	$662.65
Rate for Payer: Parkland Medicaid	$954.22
Rate for Payer: Scott and White EPO/PPO	$662.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$954.22
Rate for Payer: Superior Health Plan EPO	$180.24

BUTTON ACL SECURE- LOOP 15MM

Facility

$1,325.30

Service Code	HCPCS C1713
Hospital Charge Code	992354
Hospital Revenue Code	278
Min. Negotiated Rate	$331.32
Max. Negotiated Rate	$662.65
Rate for Payer: Cash Price	$901.20
Rate for Payer: Cigna Commercial	$331.32
Rate for Payer: Multiplan Auto	$662.65
Rate for Payer: Multiplan Commercial	$662.65
Rate for Payer: Multiplan Workers Comp	$662.65
Rate for Payer: Scott and White EPO/PPO	$662.65

BUTTON FEM LOOP ADJ

Facility

$1,629.86

Service Code	HCPCS C1713
Hospital Charge Code	992650
Hospital Revenue Code	278
Min. Negotiated Rate	$407.46
Max. Negotiated Rate	$814.93
Rate for Payer: Cash Price	$1,108.30
Rate for Payer: Cigna Commercial	$407.46
Rate for Payer: Multiplan Auto	$814.93
Rate for Payer: Multiplan Commercial	$814.93
Rate for Payer: Multiplan Workers Comp	$814.93
Rate for Payer: Scott and White EPO/PPO	$814.93

BUTTON FEM LOOP ADJ

Facility

$1,629.86

Service Code	HCPCS C1713
Hospital Charge Code	992650
Hospital Revenue Code	278
Min. Negotiated Rate	$146.69
Max. Negotiated Rate	$1,173.50
Rate for Payer: Amerigroup CHIP/Medicaid	$146.69
Rate for Payer: BCBS of TX Blue Advantage	$488.96
Rate for Payer: BCBS of TX Blue Essentials	$586.75
Rate for Payer: BCBS of TX PPO	$651.94
Rate for Payer: Cash Price	$1,108.30
Rate for Payer: Cigna Medicaid	$1,173.50
Rate for Payer: Molina CHIP/Medicaid	$1,173.50
Rate for Payer: Multiplan Auto	$814.93
Rate for Payer: Multiplan Commercial	$814.93
Rate for Payer: Multiplan Workers Comp	$814.93
Rate for Payer: Parkland Medicaid	$1,173.50
Rate for Payer: Scott and White EPO/PPO	$814.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,173.50
Rate for Payer: Superior Health Plan EPO	$221.66

Bypass graft, with other than vein; axillary-femoral-femoral

Facility

$46,200.00

Service Code	HCPCS 35654
Hospital Charge Code	991146
Hospital Revenue Code	481
Min. Negotiated Rate	$2,387.55
Max. Negotiated Rate	$33,264.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4,158.00
Rate for Payer: BCBS of TX Blue Advantage	$2,387.55
Rate for Payer: BCBS of TX Blue Essentials	$2,859.34
Rate for Payer: BCBS of TX PPO	$3,602.77
Rate for Payer: Cash Price	$31,416.00
Rate for Payer: Cash Price	$31,416.00
Rate for Payer: Cigna Medicaid	$33,264.00
Rate for Payer: Molina CHIP/Medicaid	$33,264.00
Rate for Payer: Multiplan Auto	$30,030.00
Rate for Payer: Multiplan Commercial	$30,030.00
Rate for Payer: Multiplan Workers Comp	$30,030.00
Rate for Payer: Parkland Medicaid	$33,264.00
Rate for Payer: Scott and White EPO/PPO	$23,100.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,264.00
Rate for Payer: Superior Health Plan EPO	$6,283.20

Bypass graft, with other than vein; axillary-femoral-femoral

Facility

$46,200.00

Service Code	HCPCS 35654
Hospital Charge Code	991146
Hospital Revenue Code	481
Rate for Payer: Cash Price	$31,416.00

Bypass graft, with other than vein; femoral-popliteal

Facility

$64,200.00

Service Code	HCPCS 35656
Hospital Charge Code	991138
Hospital Revenue Code	480
Min. Negotiated Rate	$1,886.21
Max. Negotiated Rate	$46,224.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,778.00
Rate for Payer: BCBS of TX Blue Advantage	$1,886.21
Rate for Payer: BCBS of TX Blue Essentials	$2,258.94
Rate for Payer: BCBS of TX PPO	$2,846.26
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cigna Medicaid	$46,224.00
Rate for Payer: Molina CHIP/Medicaid	$46,224.00
Rate for Payer: Multiplan Auto	$41,730.00
Rate for Payer: Multiplan Commercial	$41,730.00
Rate for Payer: Multiplan Workers Comp	$41,730.00
Rate for Payer: Parkland Medicaid	$46,224.00
Rate for Payer: Scott and White EPO/PPO	$32,100.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,224.00
Rate for Payer: Superior Health Plan EPO	$8,731.20

Bypass graft, with other than vein; femoral-popliteal

Facility

$64,200.00

Service Code	HCPCS 35656
Hospital Charge Code	991138
Hospital Revenue Code	480
Rate for Payer: Cash Price	$43,656.00

Bypass graft, with vein; femoral-anterior tibial, posterior tibial, peroneal artery or other distal vessels

Facility

$46,200.00

Service Code	HCPCS 35566
Hospital Charge Code	991016
Hospital Revenue Code	360
Min. Negotiated Rate	$2,910.56
Max. Negotiated Rate	$33,264.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4,158.00
Rate for Payer: BCBS of TX Blue Advantage	$2,910.56
Rate for Payer: BCBS of TX Blue Essentials	$3,485.70
Rate for Payer: BCBS of TX PPO	$4,391.98
Rate for Payer: Cash Price	$31,416.00
Rate for Payer: Cash Price	$31,416.00
Rate for Payer: Cash Price	$31,416.00
Rate for Payer: Cigna Medicaid	$33,264.00
Rate for Payer: Molina CHIP/Medicaid	$33,264.00
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	$33,264.00
Rate for Payer: Scott and White EPO/PPO	$23,100.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,264.00
Rate for Payer: Superior Health Plan EPO	$6,283.20

Bypass graft, with vein; femoral-anterior tibial, posterior tibial, peroneal artery or other distal vessels

Facility

$46,200.00

Service Code	HCPCS 35566
Hospital Charge Code	991016
Hospital Revenue Code	360
Rate for Payer: Cash Price	$31,416.00

C1 Esterase Inhibitor, Func SO

Facility

$201.00

Service Code	HCPCS 86161
Hospital Charge Code	1707041
Hospital Revenue Code	302
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$144.72
Rate for Payer: Amerigroup CHIP/Medicaid	$4.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.00
Rate for Payer: Amerigroup Medicare	$12.00
Rate for Payer: BCBS of TX Blue Advantage	$60.30
Rate for Payer: BCBS of TX Blue Essentials	$72.36
Rate for Payer: BCBS of TX Medicare	$12.00
Rate for Payer: BCBS of TX PPO	$80.40
Rate for Payer: Cash Price	$136.68
Rate for Payer: Cash Price	$136.68
Rate for Payer: Cigna Medicaid	$144.72
Rate for Payer: Cigna Medicare	$12.00
Rate for Payer: Employer Direct Commercial	$12.00
Rate for Payer: Humana Medicare/TRICARE	$12.00
Rate for Payer: Molina CHIP/Medicaid	$144.72
Rate for Payer: Molina Dual Medicare/Medicaid	$12.00
Rate for Payer: Molina Medicare	$12.00
Rate for Payer: Multiplan Auto	$130.65
Rate for Payer: Multiplan Commercial	$130.65
Rate for Payer: Multiplan Workers Comp	$130.65
Rate for Payer: Parkland Medicaid	$144.72
Rate for Payer: Scott and White EPO/PPO	$15.00
Rate for Payer: Scott and White Medicare	$12.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$144.72
Rate for Payer: Superior Health Plan EPO	$12.00
Rate for Payer: Superior Health Plan Medicare	$12.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.00
Rate for Payer: Universal American Medicare	$12.00
Rate for Payer: Wellcare Medicare	$12.00
Rate for Payer: Wellmed Medicare	$12.00

C1 Esterase Inhibitor, Func SO

Facility

$201.00

Service Code	HCPCS 86161
Hospital Charge Code	1707041
Hospital Revenue Code	302
Rate for Payer: Cash Price	$136.68

C1 Esterase Inhibitor, Serum SO

Facility

$336.00

Service Code	HCPCS 86160
Hospital Charge Code	1702562
Hospital Revenue Code	302
Rate for Payer: Cash Price	$228.48

C1 Esterase Inhibitor, Serum SO

Facility

$336.00

Service Code	HCPCS 86160
Hospital Charge Code	1702562
Hospital Revenue Code	302
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$241.92
Rate for Payer: Amerigroup CHIP/Medicaid	$4.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.00
Rate for Payer: Amerigroup Medicare	$12.00
Rate for Payer: BCBS of TX Blue Advantage	$100.80
Rate for Payer: BCBS of TX Blue Essentials	$120.96
Rate for Payer: BCBS of TX Medicare	$12.00
Rate for Payer: BCBS of TX PPO	$134.40
Rate for Payer: Cash Price	$228.48
Rate for Payer: Cash Price	$228.48
Rate for Payer: Cigna Medicaid	$241.92
Rate for Payer: Cigna Medicare	$12.00
Rate for Payer: Employer Direct Commercial	$12.00
Rate for Payer: Humana Medicare/TRICARE	$12.00
Rate for Payer: Molina CHIP/Medicaid	$241.92
Rate for Payer: Molina Dual Medicare/Medicaid	$12.00
Rate for Payer: Molina Medicare	$12.00
Rate for Payer: Multiplan Auto	$218.40
Rate for Payer: Multiplan Commercial	$218.40
Rate for Payer: Multiplan Workers Comp	$218.40
Rate for Payer: Parkland Medicaid	$241.92
Rate for Payer: Scott and White EPO/PPO	$15.00
Rate for Payer: Scott and White Medicare	$12.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$241.92
Rate for Payer: Superior Health Plan EPO	$12.00
Rate for Payer: Superior Health Plan Medicare	$12.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.00
Rate for Payer: Universal American Medicare	$12.00
Rate for Payer: Wellcare Medicare	$12.00
Rate for Payer: Wellmed Medicare	$12.00

C3 Cortical Cancellous MIS Pedicle Screw, 5.25 MIS, 7.5mm x 40mm

Facility

$5,722.89

Service Code	HCPCS C1713
Hospital Charge Code	992226
Hospital Revenue Code	278
Min. Negotiated Rate	$515.06
Max. Negotiated Rate	$4,120.48
Rate for Payer: Amerigroup CHIP/Medicaid	$515.06
Rate for Payer: BCBS of TX Blue Advantage	$1,716.87
Rate for Payer: BCBS of TX Blue Essentials	$2,060.24
Rate for Payer: BCBS of TX PPO	$2,289.16
Rate for Payer: Cash Price	$3,891.57
Rate for Payer: Cigna Medicaid	$4,120.48
Rate for Payer: Molina CHIP/Medicaid	$4,120.48
Rate for Payer: Multiplan Auto	$2,861.45
Rate for Payer: Multiplan Commercial	$2,861.45
Rate for Payer: Multiplan Workers Comp	$2,861.45
Rate for Payer: Parkland Medicaid	$4,120.48
Rate for Payer: Scott and White EPO/PPO	$2,861.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,120.48
Rate for Payer: Superior Health Plan EPO	$778.31

C3 Cortical Cancellous MIS Pedicle Screw, 5.25 MIS, 7.5mm x 40mm

Facility

$5,722.89

Service Code	HCPCS C1713
Hospital Charge Code	992226
Hospital Revenue Code	278
Min. Negotiated Rate	$1,430.72
Max. Negotiated Rate	$2,861.45
Rate for Payer: Cash Price	$3,891.57
Rate for Payer: Cigna Commercial	$1,430.72
Rate for Payer: Multiplan Auto	$2,861.45
Rate for Payer: Multiplan Commercial	$2,861.45
Rate for Payer: Multiplan Workers Comp	$2,861.45
Rate for Payer: Scott and White EPO/PPO	$2,861.45

C3 Cortical Cancellous MIS Pedicle Screw 6.5mm x 40mm

Facility

$5,722.89

Service Code	HCPCS C1713
Hospital Charge Code	992225
Hospital Revenue Code	278
Min. Negotiated Rate	$515.06
Max. Negotiated Rate	$4,120.48
Rate for Payer: Amerigroup CHIP/Medicaid	$515.06
Rate for Payer: BCBS of TX Blue Advantage	$1,716.87
Rate for Payer: BCBS of TX Blue Essentials	$2,060.24
Rate for Payer: BCBS of TX PPO	$2,289.16
Rate for Payer: Cash Price	$3,891.57
Rate for Payer: Cigna Medicaid	$4,120.48
Rate for Payer: Molina CHIP/Medicaid	$4,120.48
Rate for Payer: Multiplan Auto	$2,861.45
Rate for Payer: Multiplan Commercial	$2,861.45
Rate for Payer: Multiplan Workers Comp	$2,861.45
Rate for Payer: Parkland Medicaid	$4,120.48
Rate for Payer: Scott and White EPO/PPO	$2,861.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,120.48
Rate for Payer: Superior Health Plan EPO	$778.31

C3 Cortical Cancellous MIS Pedicle Screw 6.5mm x 40mm

Facility

$5,722.89

Service Code	HCPCS C1713
Hospital Charge Code	992225
Hospital Revenue Code	278
Min. Negotiated Rate	$1,430.72
Max. Negotiated Rate	$2,861.45
Rate for Payer: Cash Price	$3,891.57
Rate for Payer: Cigna Commercial	$1,430.72
Rate for Payer: Multiplan Auto	$2,861.45
Rate for Payer: Multiplan Commercial	$2,861.45
Rate for Payer: Multiplan Workers Comp	$2,861.45
Rate for Payer: Scott and White EPO/PPO	$2,861.45

CA 19-9 SO

Facility

$300.00

Service Code	HCPCS 86301
Hospital Charge Code	1706258
Hospital Revenue Code	302
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$216.00
Rate for Payer: Amerigroup CHIP/Medicaid	$8.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.81
Rate for Payer: Amerigroup Medicare	$20.81
Rate for Payer: BCBS of TX Blue Advantage	$90.00
Rate for Payer: BCBS of TX Blue Essentials	$108.00
Rate for Payer: BCBS of TX Medicare	$20.81
Rate for Payer: BCBS of TX PPO	$120.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cigna Medicaid	$216.00
Rate for Payer: Cigna Medicare	$20.81
Rate for Payer: Employer Direct Commercial	$20.81
Rate for Payer: Humana Medicare/TRICARE	$20.81
Rate for Payer: Molina CHIP/Medicaid	$216.00
Rate for Payer: Molina Dual Medicare/Medicaid	$20.81
Rate for Payer: Molina Medicare	$20.81
Rate for Payer: Multiplan Auto	$195.00
Rate for Payer: Multiplan Commercial	$195.00
Rate for Payer: Multiplan Workers Comp	$195.00
Rate for Payer: Parkland Medicaid	$216.00
Rate for Payer: Scott and White EPO/PPO	$26.01
Rate for Payer: Scott and White Medicare	$20.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.00
Rate for Payer: Superior Health Plan EPO	$20.81
Rate for Payer: Superior Health Plan Medicare	$20.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.81
Rate for Payer: Universal American Medicare	$20.81
Rate for Payer: Wellcare Medicare	$20.81
Rate for Payer: Wellmed Medicare	$20.81

Know your out-of-pocket cost for care.

All Charges