White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Capsulotomy, midtarsal (eg, Heyman type procedure)

Facility

$6,125.32

Service Code	HCPCS 28264
Hospital Charge Code	991012
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,165.22

Capsulotomy, midtarsal (eg, Heyman type procedure)

Facility

$6,125.32

Service Code	HCPCS 28264
Hospital Charge Code	991012
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cash Price	$4,165.22
Rate for Payer: Cash Price	$4,165.22
Rate for Payer: Cash Price	$4,165.22
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$4,410.23
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina CHIP/Medicaid	$4,410.23
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$4,410.23
Rate for Payer: Scott and White EPO/PPO	$2,988.34
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,410.23
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

Capsulotomy, posterior capsular release, knee

Facility

$14,352.00

Service Code	HCPCS 27435
Hospital Charge Code	9900408
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,759.36

Capsulotomy, posterior capsular release, knee

Facility

$10,000.00

Service Code	CPT 27435
Hospital Charge Code	36027435
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Capsulotomy, posterior capsular release, knee

Facility

$14,352.00

Service Code	HCPCS 27435
Hospital Charge Code	9900408
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,333.44
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$9,759.36
Rate for Payer: Cash Price	$9,759.36
Rate for Payer: Cash Price	$9,759.36
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$10,333.44
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$10,333.44
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$10,333.44
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,333.44
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

CAP SURG BLU TIE BCK

Facility

$0.75

Hospital Charge Code	993054
Hospital Revenue Code	270
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.54
Rate for Payer: Amerigroup CHIP/Medicaid	$0.07
Rate for Payer: BCBS of TX Blue Advantage	$0.23
Rate for Payer: BCBS of TX Blue Essentials	$0.27
Rate for Payer: BCBS of TX PPO	$0.30
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cigna Medicaid	$0.54
Rate for Payer: Molina CHIP/Medicaid	$0.54
Rate for Payer: Multiplan Auto	$0.49
Rate for Payer: Multiplan Commercial	$0.49
Rate for Payer: Multiplan Workers Comp	$0.49
Rate for Payer: Parkland Medicaid	$0.54
Rate for Payer: Scott and White EPO/PPO	$0.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.54
Rate for Payer: Superior Health Plan EPO	$0.10

CAP SURG BLU TIE BCK

Facility

$0.75

Hospital Charge Code	993054
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.51

CARAFE, INSULATED, CLR, GRAD, BLUE LID, 32 O

Facility

$8.83

Hospital Charge Code	993879
Hospital Revenue Code	271
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$6.36
Rate for Payer: Amerigroup CHIP/Medicaid	$0.79
Rate for Payer: BCBS of TX Blue Advantage	$2.65
Rate for Payer: BCBS of TX Blue Essentials	$3.18
Rate for Payer: BCBS of TX PPO	$3.53
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cigna Medicaid	$6.36
Rate for Payer: Molina CHIP/Medicaid	$6.36
Rate for Payer: Multiplan Auto	$5.74
Rate for Payer: Multiplan Commercial	$5.74
Rate for Payer: Multiplan Workers Comp	$5.74
Rate for Payer: Parkland Medicaid	$6.36
Rate for Payer: Scott and White EPO/PPO	$4.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.36
Rate for Payer: Superior Health Plan EPO	$1.20

CARAFE, INSULATED, CLR, GRAD, BLUE LID, 32 O

Facility

$8.83

Hospital Charge Code	993879
Hospital Revenue Code	271
Rate for Payer: Cash Price	$6.00

carBAMazepine 100 mg ER Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77441148
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

carBAMazepine 100 mg ER Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77441148
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

carBAMazepine 200 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77441466
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

carBAMazepine 200 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77441466
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

carBAMazepine 200 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77441521
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

carBAMazepine 200 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77441521
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Carbamazepine(Tegretol) SO

Facility

$118.11

Service Code	HCPCS 80156
Hospital Charge Code	1603034
Hospital Revenue Code	300
Min. Negotiated Rate	$5.68
Max. Negotiated Rate	$85.04
Rate for Payer: Amerigroup CHIP/Medicaid	$5.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.57
Rate for Payer: Amerigroup Medicare	$14.57
Rate for Payer: BCBS of TX Blue Advantage	$35.43
Rate for Payer: BCBS of TX Blue Essentials	$42.52
Rate for Payer: BCBS of TX Medicare	$14.57
Rate for Payer: BCBS of TX PPO	$47.24
Rate for Payer: Cash Price	$80.31
Rate for Payer: Cash Price	$80.31
Rate for Payer: Cigna Medicaid	$85.04
Rate for Payer: Cigna Medicare	$14.57
Rate for Payer: Employer Direct Commercial	$14.57
Rate for Payer: Humana Medicare/TRICARE	$14.57
Rate for Payer: Molina CHIP/Medicaid	$85.04
Rate for Payer: Molina Dual Medicare/Medicaid	$14.57
Rate for Payer: Molina Medicare	$14.57
Rate for Payer: Multiplan Auto	$76.77
Rate for Payer: Multiplan Commercial	$76.77
Rate for Payer: Multiplan Workers Comp	$76.77
Rate for Payer: Parkland Medicaid	$85.04
Rate for Payer: Scott and White EPO/PPO	$18.21
Rate for Payer: Scott and White Medicare	$14.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$85.04
Rate for Payer: Superior Health Plan EPO	$14.57
Rate for Payer: Superior Health Plan Medicare	$14.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.57
Rate for Payer: Universal American Medicare	$14.57
Rate for Payer: Wellcare Medicare	$14.57
Rate for Payer: Wellmed Medicare	$14.57

Carbamazepine(Tegretol) SO

Facility

$118.11

Service Code	HCPCS 80156
Hospital Charge Code	1603034
Hospital Revenue Code	300
Rate for Payer: Cash Price	$80.31

carbidopa-levodopa 10 mg-100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77442784
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

carbidopa-levodopa 10 mg-100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77442784
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

carbidopa-levodopa 25 mg-100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77442931
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

carbidopa-levodopa 25 mg-100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77442931
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

CARBIDOP-LEV-ENT 31.25-125-200MG TAB

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78364642
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

CARBIDOP-LEV-ENT 31.25-125-200MG TAB

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78364642
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

Carbon Dioxide Level

Facility

$87.00

Service Code	HCPCS 82374 QW
Hospital Charge Code	1601681
Hospital Revenue Code	301
Rate for Payer: Cash Price	$59.16

Carbon Dioxide Level

Facility

$87.00

Service Code	HCPCS 82374 QW
Hospital Charge Code	1601681
Hospital Revenue Code	301
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$62.64
Rate for Payer: Amerigroup CHIP/Medicaid	$1.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.88
Rate for Payer: Amerigroup Medicare	$4.88
Rate for Payer: BCBS of TX Blue Advantage	$26.10
Rate for Payer: BCBS of TX Blue Essentials	$31.32
Rate for Payer: BCBS of TX Medicare	$4.88
Rate for Payer: BCBS of TX PPO	$34.80
Rate for Payer: Cash Price	$59.16
Rate for Payer: Cash Price	$59.16
Rate for Payer: Cigna Medicaid	$62.64
Rate for Payer: Cigna Medicare	$4.88
Rate for Payer: Employer Direct Commercial	$4.88
Rate for Payer: Humana Medicare/TRICARE	$4.88
Rate for Payer: Molina CHIP/Medicaid	$62.64
Rate for Payer: Molina Dual Medicare/Medicaid	$4.88
Rate for Payer: Molina Medicare	$4.88
Rate for Payer: Multiplan Auto	$56.55
Rate for Payer: Multiplan Commercial	$56.55
Rate for Payer: Multiplan Workers Comp	$56.55
Rate for Payer: Parkland Medicaid	$62.64
Rate for Payer: Scott and White EPO/PPO	$6.10
Rate for Payer: Scott and White Medicare	$4.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.64
Rate for Payer: Superior Health Plan EPO	$4.88
Rate for Payer: Superior Health Plan Medicare	$4.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.88
Rate for Payer: Universal American Medicare	$4.88
Rate for Payer: Wellcare Medicare	$4.88
Rate for Payer: Wellmed Medicare	$4.88

Know your out-of-pocket cost for care.

All Charges