White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Cancer Antigen (CA) 15-3 SO

Facility

$148.00

Service Code	HCPCS 86300
Hospital Charge Code	9048975
Hospital Revenue Code	302
Rate for Payer: Cash Price	$100.64

Cancer Antigen (CA) 15-3 SO

Facility

$148.00

Service Code	HCPCS 86300
Hospital Charge Code	9048975
Hospital Revenue Code	302
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$106.56
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	$44.40
Rate for Payer: BCBS of TX Blue Essentials	$53.28
Rate for Payer: BCBS of TX Medicare	$20.81
Rate for Payer: BCBS of TX PPO	$59.20
Rate for Payer: Cash Price	$100.64
Rate for Payer: Cash Price	$100.64
Rate for Payer: Cigna Medicaid	$106.56
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	$106.56
Rate for Payer: Molina Dual Medicare/Medicaid	$20.81
Rate for Payer: Molina Medicare	$20.81
Rate for Payer: Multiplan Auto	$96.20
Rate for Payer: Multiplan Commercial	$96.20
Rate for Payer: Multiplan Workers Comp	$96.20
Rate for Payer: Parkland Medicaid	$106.56
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	$106.56
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

CANISTER ASPIRATION ENGINE

Facility

$1,634.40

Hospital Charge Code	8568962
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,111.39

CANISTER ASPIRATION ENGINE

Facility

$1,634.40

Hospital Charge Code	8568962
Hospital Revenue Code	272
Min. Negotiated Rate	$147.10
Max. Negotiated Rate	$1,176.77
Rate for Payer: Amerigroup CHIP/Medicaid	$147.10
Rate for Payer: BCBS of TX Blue Advantage	$490.32
Rate for Payer: BCBS of TX Blue Essentials	$588.38
Rate for Payer: BCBS of TX PPO	$653.76
Rate for Payer: Cash Price	$1,111.39
Rate for Payer: Cigna Medicaid	$1,176.77
Rate for Payer: Molina CHIP/Medicaid	$1,176.77
Rate for Payer: Multiplan Auto	$1,062.36
Rate for Payer: Multiplan Commercial	$1,062.36
Rate for Payer: Multiplan Workers Comp	$1,062.36
Rate for Payer: Parkland Medicaid	$1,176.77
Rate for Payer: Scott and White EPO/PPO	$817.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,176.77
Rate for Payer: Superior Health Plan EPO	$222.28

CANISTER, RIGID, 2000CC

Facility

$24.85

Hospital Charge Code	992938
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.90

CANISTER, RIGID, 2000CC

Facility

$24.85

Hospital Charge Code	992938
Hospital Revenue Code	270
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$17.89
Rate for Payer: Amerigroup CHIP/Medicaid	$2.24
Rate for Payer: BCBS of TX Blue Advantage	$7.46
Rate for Payer: BCBS of TX Blue Essentials	$8.95
Rate for Payer: BCBS of TX PPO	$9.94
Rate for Payer: Cash Price	$16.90
Rate for Payer: Cigna Medicaid	$17.89
Rate for Payer: Molina CHIP/Medicaid	$17.89
Rate for Payer: Multiplan Auto	$16.15
Rate for Payer: Multiplan Commercial	$16.15
Rate for Payer: Multiplan Workers Comp	$16.15
Rate for Payer: Parkland Medicaid	$17.89
Rate for Payer: Scott and White EPO/PPO	$12.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.89
Rate for Payer: Superior Health Plan EPO	$3.38

CANISTER, SUCTION GUARDIAN LRG VOL COLLECTION 12L -- DHF

Facility

$170.09

Hospital Charge Code	80342900
Hospital Revenue Code	270
Rate for Payer: Cash Price	$115.66

CANISTER, SUCTION GUARDIAN LRG VOL COLLECTION 12L -- DHF

Facility

$170.09

Hospital Charge Code	80342900
Hospital Revenue Code	270
Min. Negotiated Rate	$15.31
Max. Negotiated Rate	$122.46
Rate for Payer: Amerigroup CHIP/Medicaid	$15.31
Rate for Payer: BCBS of TX Blue Advantage	$51.03
Rate for Payer: BCBS of TX Blue Essentials	$61.23
Rate for Payer: BCBS of TX PPO	$68.04
Rate for Payer: Cash Price	$115.66
Rate for Payer: Cigna Medicaid	$122.46
Rate for Payer: Molina CHIP/Medicaid	$122.46
Rate for Payer: Multiplan Auto	$110.56
Rate for Payer: Multiplan Commercial	$110.56
Rate for Payer: Multiplan Workers Comp	$110.56
Rate for Payer: Parkland Medicaid	$122.46
Rate for Payer: Scott and White EPO/PPO	$85.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$122.46
Rate for Payer: Superior Health Plan EPO	$23.13

CANISTER, SUCTION W/O GEL

Facility

$127.61

Hospital Charge Code	993543
Hospital Revenue Code	270
Min. Negotiated Rate	$11.48
Max. Negotiated Rate	$91.88
Rate for Payer: Amerigroup CHIP/Medicaid	$11.48
Rate for Payer: BCBS of TX Blue Advantage	$38.28
Rate for Payer: BCBS of TX Blue Essentials	$45.94
Rate for Payer: BCBS of TX PPO	$51.04
Rate for Payer: Cash Price	$86.77
Rate for Payer: Cigna Medicaid	$91.88
Rate for Payer: Molina CHIP/Medicaid	$91.88
Rate for Payer: Multiplan Auto	$82.95
Rate for Payer: Multiplan Commercial	$82.95
Rate for Payer: Multiplan Workers Comp	$82.95
Rate for Payer: Parkland Medicaid	$91.88
Rate for Payer: Scott and White EPO/PPO	$63.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.88
Rate for Payer: Superior Health Plan EPO	$17.35

CANISTER, SUCTION W/O GEL

Facility

$127.61

Hospital Charge Code	993543
Hospital Revenue Code	270
Rate for Payer: Cash Price	$86.77

CANISTER, SUCTION W/O GEL 500ML -- DHF

Facility

$127.66

Hospital Charge Code	80315096
Hospital Revenue Code	272
Min. Negotiated Rate	$11.49
Max. Negotiated Rate	$91.92
Rate for Payer: Amerigroup CHIP/Medicaid	$11.49
Rate for Payer: BCBS of TX Blue Advantage	$38.30
Rate for Payer: BCBS of TX Blue Essentials	$45.96
Rate for Payer: BCBS of TX PPO	$51.06
Rate for Payer: Cash Price	$86.81
Rate for Payer: Cigna Medicaid	$91.92
Rate for Payer: Molina CHIP/Medicaid	$91.92
Rate for Payer: Multiplan Auto	$82.98
Rate for Payer: Multiplan Commercial	$82.98
Rate for Payer: Multiplan Workers Comp	$82.98
Rate for Payer: Parkland Medicaid	$91.92
Rate for Payer: Scott and White EPO/PPO	$63.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.92
Rate for Payer: Superior Health Plan EPO	$17.36

CANISTER, SUCTION W/O GEL 500ML -- DHF

Facility

$127.66

Hospital Charge Code	80315096
Hospital Revenue Code	272
Rate for Payer: Cash Price	$86.81

CANISTER WND VAC 1000ML -- DHF

Facility

$247.82

Hospital Charge Code	80315161
Hospital Revenue Code	272
Min. Negotiated Rate	$22.30
Max. Negotiated Rate	$178.43
Rate for Payer: Amerigroup CHIP/Medicaid	$22.30
Rate for Payer: BCBS of TX Blue Advantage	$74.35
Rate for Payer: BCBS of TX Blue Essentials	$89.22
Rate for Payer: BCBS of TX PPO	$99.13
Rate for Payer: Cash Price	$168.52
Rate for Payer: Cigna Medicaid	$178.43
Rate for Payer: Molina CHIP/Medicaid	$178.43
Rate for Payer: Multiplan Auto	$161.08
Rate for Payer: Multiplan Commercial	$161.08
Rate for Payer: Multiplan Workers Comp	$161.08
Rate for Payer: Parkland Medicaid	$178.43
Rate for Payer: Scott and White EPO/PPO	$123.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$178.43
Rate for Payer: Superior Health Plan EPO	$33.70

CANISTER WND VAC 1000ML -- DHF

Facility

$247.82

Hospital Charge Code	80315161
Hospital Revenue Code	272
Rate for Payer: Cash Price	$168.52

CANN DISP INER -- DHF

Facility

$224.92

Hospital Charge Code	82020215
Hospital Revenue Code	272
Min. Negotiated Rate	$20.24
Max. Negotiated Rate	$161.94
Rate for Payer: Amerigroup CHIP/Medicaid	$20.24
Rate for Payer: BCBS of TX Blue Advantage	$67.48
Rate for Payer: BCBS of TX Blue Essentials	$80.97
Rate for Payer: BCBS of TX PPO	$89.97
Rate for Payer: Cash Price	$152.95
Rate for Payer: Cigna Medicaid	$161.94
Rate for Payer: Molina CHIP/Medicaid	$161.94
Rate for Payer: Multiplan Auto	$146.20
Rate for Payer: Multiplan Commercial	$146.20
Rate for Payer: Multiplan Workers Comp	$146.20
Rate for Payer: Parkland Medicaid	$161.94
Rate for Payer: Scott and White EPO/PPO	$112.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$161.94
Rate for Payer: Superior Health Plan EPO	$30.59

CANN DISP INER -- DHF

Facility

$224.92

Hospital Charge Code	82020215
Hospital Revenue Code	272
Rate for Payer: Cash Price	$152.95

CANN ORTHO

Facility

$124.76

Hospital Charge Code	80315104
Hospital Revenue Code	270
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$89.83
Rate for Payer: Amerigroup CHIP/Medicaid	$11.23
Rate for Payer: BCBS of TX Blue Advantage	$37.43
Rate for Payer: BCBS of TX Blue Essentials	$44.91
Rate for Payer: BCBS of TX PPO	$49.90
Rate for Payer: Cash Price	$84.84
Rate for Payer: Cigna Medicaid	$89.83
Rate for Payer: Molina CHIP/Medicaid	$89.83
Rate for Payer: Multiplan Auto	$81.09
Rate for Payer: Multiplan Commercial	$81.09
Rate for Payer: Multiplan Workers Comp	$81.09
Rate for Payer: Parkland Medicaid	$89.83
Rate for Payer: Scott and White EPO/PPO	$62.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.83
Rate for Payer: Superior Health Plan EPO	$16.97

CANN ORTHO

Facility

$124.76

Hospital Charge Code	80315104
Hospital Revenue Code	270
Rate for Payer: Cash Price	$84.84

CANN STIMULAT ECHOGENIC -- DHF

Facility

$77.61

Hospital Charge Code	80315476
Hospital Revenue Code	272
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$55.88
Rate for Payer: Amerigroup CHIP/Medicaid	$6.98
Rate for Payer: BCBS of TX Blue Advantage	$23.28
Rate for Payer: BCBS of TX Blue Essentials	$27.94
Rate for Payer: BCBS of TX PPO	$31.04
Rate for Payer: Cash Price	$52.77
Rate for Payer: Cigna Medicaid	$55.88
Rate for Payer: Molina CHIP/Medicaid	$55.88
Rate for Payer: Multiplan Auto	$50.45
Rate for Payer: Multiplan Commercial	$50.45
Rate for Payer: Multiplan Workers Comp	$50.45
Rate for Payer: Parkland Medicaid	$55.88
Rate for Payer: Scott and White EPO/PPO	$38.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$55.88
Rate for Payer: Superior Health Plan EPO	$10.55

CANN STIMULAT ECHOGENIC -- DHF

Facility

$77.61

Hospital Charge Code	80315476
Hospital Revenue Code	272
Rate for Payer: Cash Price	$52.77

CANNULA 75X7MM DIST W OBT CLR

Facility

$187.05

Hospital Charge Code	992666
Hospital Revenue Code	272
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$134.68
Rate for Payer: Amerigroup CHIP/Medicaid	$16.83
Rate for Payer: BCBS of TX Blue Advantage	$56.12
Rate for Payer: BCBS of TX Blue Essentials	$67.34
Rate for Payer: BCBS of TX PPO	$74.82
Rate for Payer: Cash Price	$127.19
Rate for Payer: Cigna Medicaid	$134.68
Rate for Payer: Molina CHIP/Medicaid	$134.68
Rate for Payer: Multiplan Auto	$121.58
Rate for Payer: Multiplan Commercial	$121.58
Rate for Payer: Multiplan Workers Comp	$121.58
Rate for Payer: Parkland Medicaid	$134.68
Rate for Payer: Scott and White EPO/PPO	$93.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.68
Rate for Payer: Superior Health Plan EPO	$25.44

CANNULA 75X7MM DIST W OBT CLR

Facility

$187.05

Hospital Charge Code	992666
Hospital Revenue Code	272
Rate for Payer: Cash Price	$127.19

CANNULA 7MM

Facility

$187.05

Hospital Charge Code	992664
Hospital Revenue Code	272
Rate for Payer: Cash Price	$127.19

CANNULA 7MM

Facility

$187.05

Hospital Charge Code	992664
Hospital Revenue Code	272
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$134.68
Rate for Payer: Amerigroup CHIP/Medicaid	$16.83
Rate for Payer: BCBS of TX Blue Advantage	$56.12
Rate for Payer: BCBS of TX Blue Essentials	$67.34
Rate for Payer: BCBS of TX PPO	$74.82
Rate for Payer: Cash Price	$127.19
Rate for Payer: Cigna Medicaid	$134.68
Rate for Payer: Molina CHIP/Medicaid	$134.68
Rate for Payer: Multiplan Auto	$121.58
Rate for Payer: Multiplan Commercial	$121.58
Rate for Payer: Multiplan Workers Comp	$121.58
Rate for Payer: Parkland Medicaid	$134.68
Rate for Payer: Scott and White EPO/PPO	$93.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.68
Rate for Payer: Superior Health Plan EPO	$25.44

CANNULA ARTHROSCOPIC

Facility

$319.84

Hospital Charge Code	8414484
Hospital Revenue Code	272
Min. Negotiated Rate	$28.79
Max. Negotiated Rate	$230.28
Rate for Payer: Amerigroup CHIP/Medicaid	$28.79
Rate for Payer: BCBS of TX Blue Advantage	$95.95
Rate for Payer: BCBS of TX Blue Essentials	$115.14
Rate for Payer: BCBS of TX PPO	$127.94
Rate for Payer: Cash Price	$217.49
Rate for Payer: Cigna Medicaid	$230.28
Rate for Payer: Molina CHIP/Medicaid	$230.28
Rate for Payer: Multiplan Auto	$207.90
Rate for Payer: Multiplan Commercial	$207.90
Rate for Payer: Multiplan Workers Comp	$207.90
Rate for Payer: Parkland Medicaid	$230.28
Rate for Payer: Scott and White EPO/PPO	$159.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$230.28
Rate for Payer: Superior Health Plan EPO	$43.50

Know your out-of-pocket cost for care.

All Charges