White Rock Medical Center

All Charges

Charge

Type

Setting

Price

COR THROMBLYS-INTRA COR

Facility

$4,107.00

Service Code	CPT 92975
Hospital Charge Code	4612975
Hospital Revenue Code	481
Rate for Payer: Cash Price	$3,614.16

Cortisol

Facility

$296.00

Service Code	CPT 82533
Hospital Charge Code	1601749
Hospital Revenue Code	301
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$192.40
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: Aetna Medicare	$24.45
Rate for Payer: Amerigroup CHIP/Medicaid	$6.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.30
Rate for Payer: Amerigroup Medicare	$16.30
Rate for Payer: BCBS of TX Blue Advantage	$26.90
Rate for Payer: BCBS of TX Blue Essentials	$32.27
Rate for Payer: BCBS of TX Medicare	$16.30
Rate for Payer: BCBS of TX PPO	$36.02
Rate for Payer: Cash Price	$260.48
Rate for Payer: Cash Price	$260.48
Rate for Payer: Cigna Medicaid	$16.30
Rate for Payer: Cigna Medicare	$16.30
Rate for Payer: Employer Direct Commercial	$16.30
Rate for Payer: Humana Medicare/TRICARE	$16.30
Rate for Payer: Molina CHIP/Medicaid	$16.30
Rate for Payer: Molina Dual Medicare/Medicaid	$16.30
Rate for Payer: Molina Medicare	$16.30
Rate for Payer: Multiplan Auto	$192.40
Rate for Payer: Multiplan Commercial	$192.40
Rate for Payer: Multiplan Workers Comp	$192.40
Rate for Payer: Parkland Medicaid	$16.30
Rate for Payer: Scott and White EPO/PPO	$20.38
Rate for Payer: Scott and White Medicare	$16.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.30
Rate for Payer: Superior Health Plan EPO	$16.30
Rate for Payer: Superior Health Plan Medicare	$16.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.30
Rate for Payer: Universal American Medicare	$16.30
Rate for Payer: Wellcare Medicare	$16.30
Rate for Payer: Wellmed Medicare	$16.30

Cortisol 30 Minutes

Facility

$296.00

Service Code	CPT 82533
Hospital Charge Code	1601749
Hospital Revenue Code	301
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$192.40
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: Aetna Medicare	$24.45
Rate for Payer: Amerigroup CHIP/Medicaid	$6.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.30
Rate for Payer: Amerigroup Medicare	$16.30
Rate for Payer: BCBS of TX Blue Advantage	$26.90
Rate for Payer: BCBS of TX Blue Essentials	$32.27
Rate for Payer: BCBS of TX Medicare	$16.30
Rate for Payer: BCBS of TX PPO	$36.02
Rate for Payer: Cash Price	$260.48
Rate for Payer: Cash Price	$260.48
Rate for Payer: Cigna Medicaid	$16.30
Rate for Payer: Cigna Medicare	$16.30
Rate for Payer: Employer Direct Commercial	$16.30
Rate for Payer: Humana Medicare/TRICARE	$16.30
Rate for Payer: Molina CHIP/Medicaid	$16.30
Rate for Payer: Molina Dual Medicare/Medicaid	$16.30
Rate for Payer: Molina Medicare	$16.30
Rate for Payer: Multiplan Auto	$192.40
Rate for Payer: Multiplan Commercial	$192.40
Rate for Payer: Multiplan Workers Comp	$192.40
Rate for Payer: Parkland Medicaid	$16.30
Rate for Payer: Scott and White EPO/PPO	$20.38
Rate for Payer: Scott and White Medicare	$16.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.30
Rate for Payer: Superior Health Plan EPO	$16.30
Rate for Payer: Superior Health Plan Medicare	$16.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.30
Rate for Payer: Universal American Medicare	$16.30
Rate for Payer: Wellcare Medicare	$16.30
Rate for Payer: Wellmed Medicare	$16.30

Cortisol 60 Minutes

Facility

$296.00

Service Code	CPT 82533
Hospital Charge Code	1601749
Hospital Revenue Code	301
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$192.40
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: Aetna Medicare	$24.45
Rate for Payer: Amerigroup CHIP/Medicaid	$6.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.30
Rate for Payer: Amerigroup Medicare	$16.30
Rate for Payer: BCBS of TX Blue Advantage	$26.90
Rate for Payer: BCBS of TX Blue Essentials	$32.27
Rate for Payer: BCBS of TX Medicare	$16.30
Rate for Payer: BCBS of TX PPO	$36.02
Rate for Payer: Cash Price	$260.48
Rate for Payer: Cash Price	$260.48
Rate for Payer: Cigna Medicaid	$16.30
Rate for Payer: Cigna Medicare	$16.30
Rate for Payer: Employer Direct Commercial	$16.30
Rate for Payer: Humana Medicare/TRICARE	$16.30
Rate for Payer: Molina CHIP/Medicaid	$16.30
Rate for Payer: Molina Dual Medicare/Medicaid	$16.30
Rate for Payer: Molina Medicare	$16.30
Rate for Payer: Multiplan Auto	$192.40
Rate for Payer: Multiplan Commercial	$192.40
Rate for Payer: Multiplan Workers Comp	$192.40
Rate for Payer: Parkland Medicaid	$16.30
Rate for Payer: Scott and White EPO/PPO	$20.38
Rate for Payer: Scott and White Medicare	$16.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.30
Rate for Payer: Superior Health Plan EPO	$16.30
Rate for Payer: Superior Health Plan Medicare	$16.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.30
Rate for Payer: Universal American Medicare	$16.30
Rate for Payer: Wellcare Medicare	$16.30
Rate for Payer: Wellmed Medicare	$16.30

Cortisol Baseline Level

Facility

$296.00

Service Code	CPT 82533
Hospital Charge Code	1601749
Hospital Revenue Code	301
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$192.40
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: Aetna Medicare	$24.45
Rate for Payer: Amerigroup CHIP/Medicaid	$6.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.30
Rate for Payer: Amerigroup Medicare	$16.30
Rate for Payer: BCBS of TX Blue Advantage	$26.90
Rate for Payer: BCBS of TX Blue Essentials	$32.27
Rate for Payer: BCBS of TX Medicare	$16.30
Rate for Payer: BCBS of TX PPO	$36.02
Rate for Payer: Cash Price	$260.48
Rate for Payer: Cash Price	$260.48
Rate for Payer: Cigna Medicaid	$16.30
Rate for Payer: Cigna Medicare	$16.30
Rate for Payer: Employer Direct Commercial	$16.30
Rate for Payer: Humana Medicare/TRICARE	$16.30
Rate for Payer: Molina CHIP/Medicaid	$16.30
Rate for Payer: Molina Dual Medicare/Medicaid	$16.30
Rate for Payer: Molina Medicare	$16.30
Rate for Payer: Multiplan Auto	$192.40
Rate for Payer: Multiplan Commercial	$192.40
Rate for Payer: Multiplan Workers Comp	$192.40
Rate for Payer: Parkland Medicaid	$16.30
Rate for Payer: Scott and White EPO/PPO	$20.38
Rate for Payer: Scott and White Medicare	$16.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.30
Rate for Payer: Superior Health Plan EPO	$16.30
Rate for Payer: Superior Health Plan Medicare	$16.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.30
Rate for Payer: Universal American Medicare	$16.30
Rate for Payer: Wellcare Medicare	$16.30
Rate for Payer: Wellmed Medicare	$16.30

Cortisol Baseline Level

Facility

$296.00

Service Code	CPT 82533
Hospital Charge Code	1601749
Hospital Revenue Code	301
Rate for Payer: Cash Price	$260.48

Cortisol, Urinary Free SO

Facility

$69.00

Service Code	CPT 82530
Hospital Charge Code	1740083
Hospital Revenue Code	301
Rate for Payer: Cash Price	$60.72

Cortisol, Urinary Free SO

Facility

$69.00

Service Code	CPT 82530
Hospital Charge Code	1740083
Hospital Revenue Code	301
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$44.85
Rate for Payer: Aetna Commercial	$17.55
Rate for Payer: Aetna Medicare	$25.06
Rate for Payer: Amerigroup CHIP/Medicaid	$6.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.71
Rate for Payer: Amerigroup Medicare	$16.71
Rate for Payer: BCBS of TX Blue Advantage	$27.57
Rate for Payer: BCBS of TX Blue Essentials	$33.09
Rate for Payer: BCBS of TX Medicare	$16.71
Rate for Payer: BCBS of TX PPO	$36.93
Rate for Payer: Cash Price	$60.72
Rate for Payer: Cash Price	$60.72
Rate for Payer: Cigna Medicaid	$16.71
Rate for Payer: Cigna Medicare	$16.71
Rate for Payer: Employer Direct Commercial	$16.71
Rate for Payer: Humana Medicare/TRICARE	$16.71
Rate for Payer: Molina CHIP/Medicaid	$16.71
Rate for Payer: Molina Dual Medicare/Medicaid	$16.71
Rate for Payer: Molina Medicare	$16.71
Rate for Payer: Multiplan Auto	$44.85
Rate for Payer: Multiplan Commercial	$44.85
Rate for Payer: Multiplan Workers Comp	$44.85
Rate for Payer: Parkland Medicaid	$16.71
Rate for Payer: Scott and White EPO/PPO	$20.89
Rate for Payer: Scott and White Medicare	$16.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.71
Rate for Payer: Superior Health Plan EPO	$16.71
Rate for Payer: Superior Health Plan Medicare	$16.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.71
Rate for Payer: Universal American Medicare	$16.71
Rate for Payer: Wellcare Medicare	$16.71
Rate for Payer: Wellmed Medicare	$16.71

Cotinine Qualitative

Facility

$74.00

Service Code	CPT 80323
Hospital Charge Code	7258388
Hospital Revenue Code	301
Rate for Payer: Cash Price	$65.12

Cotinine Qualitative

Facility

$74.00

Service Code	CPT 80323
Hospital Charge Code	7258388
Hospital Revenue Code	301
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$48.10
Rate for Payer: Aetna Commercial	$0.02
Rate for Payer: Amerigroup CHIP/Medicaid	$7.94
Rate for Payer: Cash Price	$65.12
Rate for Payer: Cash Price	$65.12
Rate for Payer: Cigna Medicaid	$20.35
Rate for Payer: Molina CHIP/Medicaid	$20.35
Rate for Payer: Multiplan Auto	$48.10
Rate for Payer: Multiplan Commercial	$48.10
Rate for Payer: Multiplan Workers Comp	$48.10
Rate for Payer: Parkland Medicaid	$20.35
Rate for Payer: Scott and White EPO/PPO	$37.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.35
Rate for Payer: Superior Health Plan EPO	$10.06

COUNSELLING SMOKING CESSATN 3-10MIN

Facility

$53.00

Service Code	CPT 99406
Hospital Charge Code	6010375
Hospital Revenue Code	942
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$59.45
Rate for Payer: Aetna Commercial	$29.15
Rate for Payer: Aetna Medicare	$39.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.24
Rate for Payer: Amerigroup Medicare	$26.24
Rate for Payer: BCBS of TX Blue Advantage	$21.94
Rate for Payer: BCBS of TX Blue Essentials	$26.23
Rate for Payer: BCBS of TX Medicare	$26.24
Rate for Payer: BCBS of TX PPO	$29.26
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cigna Commercial	$59.45
Rate for Payer: Cigna Medicaid	$10.29
Rate for Payer: Cigna Medicare	$26.24
Rate for Payer: Employer Direct Commercial	$26.24
Rate for Payer: Humana Medicare/TRICARE	$26.24
Rate for Payer: Molina CHIP/Medicaid	$10.29
Rate for Payer: Molina Dual Medicare/Medicaid	$26.24
Rate for Payer: Molina Medicare	$26.24
Rate for Payer: Multiplan Auto	$34.45
Rate for Payer: Multiplan Commercial	$34.45
Rate for Payer: Multiplan Workers Comp	$34.45
Rate for Payer: Parkland Medicaid	$10.29
Rate for Payer: Scott and White EPO/PPO	$0.47
Rate for Payer: Scott and White Medicare	$26.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.29
Rate for Payer: Superior Health Plan EPO	$26.24
Rate for Payer: Superior Health Plan Medicare	$26.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.24
Rate for Payer: Universal American Medicare	$26.24
Rate for Payer: Wellcare Medicare	$26.24
Rate for Payer: Wellmed Medicare	$26.24

COUNSEL SMOKING CESSATN 3-10MIN WOUND

Facility

$53.00

Service Code	CPT 99406
Hospital Charge Code	7150781
Hospital Revenue Code	510
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$59.45
Rate for Payer: Aetna Commercial	$29.15
Rate for Payer: Aetna Medicare	$39.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.24
Rate for Payer: Amerigroup Medicare	$26.24
Rate for Payer: BCBS of TX Blue Advantage	$21.94
Rate for Payer: BCBS of TX Blue Essentials	$26.23
Rate for Payer: BCBS of TX Medicare	$26.24
Rate for Payer: BCBS of TX PPO	$29.26
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cigna Commercial	$59.45
Rate for Payer: Cigna Medicaid	$10.29
Rate for Payer: Cigna Medicare	$26.24
Rate for Payer: Employer Direct Commercial	$26.24
Rate for Payer: Humana Medicare/TRICARE	$26.24
Rate for Payer: Molina CHIP/Medicaid	$10.29
Rate for Payer: Molina Dual Medicare/Medicaid	$26.24
Rate for Payer: Molina Medicare	$26.24
Rate for Payer: Multiplan Auto	$34.45
Rate for Payer: Multiplan Commercial	$34.45
Rate for Payer: Multiplan Workers Comp	$34.45
Rate for Payer: Parkland Medicaid	$10.29
Rate for Payer: Scott and White EPO/PPO	$0.47
Rate for Payer: Scott and White Medicare	$26.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.29
Rate for Payer: Superior Health Plan EPO	$26.24
Rate for Payer: Superior Health Plan Medicare	$26.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.24
Rate for Payer: Universal American Medicare	$26.24
Rate for Payer: Wellcare Medicare	$26.24
Rate for Payer: Wellmed Medicare	$26.24

COUNTERSINK 3.0

Facility

$1,702.50

Hospital Charge Code	145139
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,498.20

COUNTERSINK 3.0

Facility

$1,702.50

Hospital Charge Code	145139
Hospital Revenue Code	272
Min. Negotiated Rate	$153.22
Max. Negotiated Rate	$1,106.62
Rate for Payer: Aetna Commercial	$936.38
Rate for Payer: Amerigroup CHIP/Medicaid	$153.22
Rate for Payer: BCBS of TX Blue Advantage	$510.75
Rate for Payer: BCBS of TX Blue Essentials	$612.90
Rate for Payer: BCBS of TX PPO	$681.00
Rate for Payer: Cash Price	$1,498.20
Rate for Payer: Multiplan Auto	$1,106.62
Rate for Payer: Multiplan Commercial	$1,106.62
Rate for Payer: Multiplan Workers Comp	$1,106.62
Rate for Payer: Scott and White EPO/PPO	$851.25
Rate for Payer: Superior Health Plan EPO	$231.54

COUNTERSINK DISP -- DHF

Facility

$1,325.25

Hospital Charge Code	81315541
Hospital Revenue Code	272
Min. Negotiated Rate	$119.27
Max. Negotiated Rate	$861.41
Rate for Payer: Aetna Commercial	$728.89
Rate for Payer: Amerigroup CHIP/Medicaid	$119.27
Rate for Payer: BCBS of TX Blue Advantage	$397.58
Rate for Payer: BCBS of TX Blue Essentials	$477.09
Rate for Payer: BCBS of TX PPO	$530.10
Rate for Payer: Cash Price	$1,166.22
Rate for Payer: Multiplan Auto	$861.41
Rate for Payer: Multiplan Commercial	$861.41
Rate for Payer: Multiplan Workers Comp	$861.41
Rate for Payer: Scott and White EPO/PPO	$662.62
Rate for Payer: Superior Health Plan EPO	$180.23

COUNTERSINK DISP -- DHF

Facility

$1,325.25

Hospital Charge Code	81315541
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,166.22

COVER PAD BILICOCOON KANGAROO DISP

Facility

$55.02

Hospital Charge Code	144850
Hospital Revenue Code	272
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$35.76
Rate for Payer: Aetna Commercial	$30.26
Rate for Payer: Amerigroup CHIP/Medicaid	$4.95
Rate for Payer: BCBS of TX Blue Advantage	$16.51
Rate for Payer: BCBS of TX Blue Essentials	$19.81
Rate for Payer: BCBS of TX PPO	$22.01
Rate for Payer: Cash Price	$48.42
Rate for Payer: Multiplan Auto	$35.76
Rate for Payer: Multiplan Commercial	$35.76
Rate for Payer: Multiplan Workers Comp	$35.76
Rate for Payer: Scott and White EPO/PPO	$27.51
Rate for Payer: Superior Health Plan EPO	$7.48

COVER PAD BILICOCOON KANGAROO DISP

Facility

$55.02

Hospital Charge Code	144850
Hospital Revenue Code	272
Rate for Payer: Cash Price	$48.42

COVER ULTRASOUND 9001C0197

Facility

$69.51

Hospital Charge Code	105436
Hospital Revenue Code	270
Min. Negotiated Rate	$6.26
Max. Negotiated Rate	$45.18
Rate for Payer: Aetna Commercial	$38.23
Rate for Payer: Amerigroup CHIP/Medicaid	$6.26
Rate for Payer: BCBS of TX Blue Advantage	$20.85
Rate for Payer: BCBS of TX Blue Essentials	$25.02
Rate for Payer: BCBS of TX PPO	$27.80
Rate for Payer: Cash Price	$61.17
Rate for Payer: Multiplan Auto	$45.18
Rate for Payer: Multiplan Commercial	$45.18
Rate for Payer: Multiplan Workers Comp	$45.18
Rate for Payer: Scott and White EPO/PPO	$34.76
Rate for Payer: Superior Health Plan EPO	$9.45

COVER ULTRASOUND 9001C0197

Facility

$69.51

Hospital Charge Code	105436
Hospital Revenue Code	270
Rate for Payer: Cash Price	$61.17

COVER, WARMING BODY LOWER SINGLE USE 58'''' X 34'''' -- DHF

Facility

$45.82

Hospital Charge Code	80334659
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$40.32
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan EPO	$6.23

COVER, WARMING BODY UPPER DUAL PRT SGL USE 78''''X21'''' -- DHF

Facility

$45.82

Hospital Charge Code	80334659
Hospital Revenue Code	270
Rate for Payer: Cash Price	$40.32

COVER, WARMING BODY UPPER DUAL PRT SGL USE 78''''X21'''' -- DHF

Facility

$45.82

Hospital Charge Code	80334659
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$40.32
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan EPO	$6.23

COVID-19 NAA, Saliva SO

Facility

$256.55

Service Code	HCPCS U0003
Hospital Charge Code	8768554
Hospital Revenue Code	306
Min. Negotiated Rate	$34.89
Max. Negotiated Rate	$166.76
Rate for Payer: Aetna Commercial	$141.10
Rate for Payer: Amerigroup CHIP/Medicaid	$75.00
Rate for Payer: BCBS of TX Blue Advantage	$76.96
Rate for Payer: BCBS of TX Blue Essentials	$92.36
Rate for Payer: BCBS of TX PPO	$102.62
Rate for Payer: Cash Price	$225.76
Rate for Payer: Cash Price	$225.76
Rate for Payer: Multiplan Auto	$166.76
Rate for Payer: Multiplan Commercial	$166.76
Rate for Payer: Multiplan Workers Comp	$166.76
Rate for Payer: Scott and White EPO/PPO	$128.28
Rate for Payer: Superior Health Plan EPO	$34.89

COVID-19 NAA, Saliva SO

Facility

$256.55

Service Code	HCPCS U0003
Hospital Charge Code	8768554
Hospital Revenue Code	306
Rate for Payer: Cash Price	$225.76

Know your out-of-pocket cost for care.

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