White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Carpectomy; all bones of proximal row

Facility

$10,000.00

Service Code	CPT 25215
Hospital Charge Code	36025215
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	$5,476.44
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

Carpectomy; all bones of proximal row

Facility

$12,960.00

Service Code	HCPCS 25215
Hospital Charge Code	9900278
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: Cash Price	$8,812.80
Rate for Payer: Cash Price	$8,812.80
Rate for Payer: Cash Price	$8,812.80
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$9,331.20
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	$9,331.20
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	$9,331.20
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,331.20
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

Carpectomy; all bones of proximal row

Facility

$12,960.00

Service Code	HCPCS 25215
Hospital Charge Code	9900278
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,812.80

Car Seat Challenge Duration Ea Addl 30 Min BCE

Facility

$50.00

Service Code	HCPCS 94781
Hospital Charge Code	10132
Hospital Revenue Code	920
Rate for Payer: Cash Price	$34.00

Car Seat Challenge Duration Ea Addl 30 Min BCE

Facility

$50.00

Service Code	HCPCS 94781
Hospital Charge Code	10132
Hospital Revenue Code	920
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$36.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: BCBS of TX Blue Advantage	$15.00
Rate for Payer: BCBS of TX Blue Essentials	$18.00
Rate for Payer: BCBS of TX PPO	$20.00
Rate for Payer: Cash Price	$34.00
Rate for Payer: Cash Price	$34.00
Rate for Payer: Cigna Medicaid	$36.00
Rate for Payer: Molina CHIP/Medicaid	$36.00
Rate for Payer: Multiplan Auto	$32.50
Rate for Payer: Multiplan Commercial	$32.50
Rate for Payer: Multiplan Workers Comp	$32.50
Rate for Payer: Parkland Medicaid	$36.00
Rate for Payer: Scott and White EPO/PPO	$9.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.00
Rate for Payer: Superior Health Plan EPO	$6.80

Car Seat Challenge Duration First 60 Min BCE

Facility

$68.00

Service Code	HCPCS 94780
Hospital Charge Code	10124
Hospital Revenue Code	920
Rate for Payer: Cash Price	$46.24

Car Seat Challenge Duration First 60 Min BCE

Facility

$68.00

Service Code	HCPCS 94780
Hospital Charge Code	10124
Hospital Revenue Code	920
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$79.31
Rate for Payer: Amerigroup CHIP/Medicaid	$6.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37.52
Rate for Payer: Amerigroup Medicare	$37.52
Rate for Payer: BCBS of TX Blue Advantage	$20.40
Rate for Payer: BCBS of TX Blue Essentials	$24.48
Rate for Payer: BCBS of TX Medicare	$37.52
Rate for Payer: BCBS of TX PPO	$27.20
Rate for Payer: Cash Price	$46.24
Rate for Payer: Cash Price	$46.24
Rate for Payer: Cash Price	$46.24
Rate for Payer: Cigna Commercial	$79.31
Rate for Payer: Cigna Medicaid	$48.96
Rate for Payer: Cigna Medicare	$37.52
Rate for Payer: Employer Direct Commercial	$37.52
Rate for Payer: Humana Medicare/TRICARE	$37.52
Rate for Payer: Molina CHIP/Medicaid	$48.96
Rate for Payer: Molina Dual Medicare/Medicaid	$37.52
Rate for Payer: Molina Medicare	$37.52
Rate for Payer: Multiplan Auto	$44.20
Rate for Payer: Multiplan Commercial	$44.20
Rate for Payer: Multiplan Workers Comp	$44.20
Rate for Payer: Parkland Medicaid	$48.96
Rate for Payer: Scott and White EPO/PPO	$28.36
Rate for Payer: Scott and White Medicare	$37.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48.96
Rate for Payer: Superior Health Plan EPO	$37.52
Rate for Payer: Superior Health Plan Medicare	$37.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$37.52
Rate for Payer: Universal American Medicare	$37.52
Rate for Payer: Wellcare Medicare	$37.52
Rate for Payer: Wellmed Medicare	$37.52

CARTDGE ORBT ARHRCM 125 MICRO 145CM

Facility

$10,215.00

Hospital Charge Code	8582476
Hospital Revenue Code	272
Min. Negotiated Rate	$919.35
Max. Negotiated Rate	$7,354.80
Rate for Payer: Amerigroup CHIP/Medicaid	$919.35
Rate for Payer: BCBS of TX Blue Advantage	$3,064.50
Rate for Payer: BCBS of TX Blue Essentials	$3,677.40
Rate for Payer: BCBS of TX PPO	$4,086.00
Rate for Payer: Cash Price	$6,946.20
Rate for Payer: Cigna Medicaid	$7,354.80
Rate for Payer: Molina CHIP/Medicaid	$7,354.80
Rate for Payer: Multiplan Auto	$6,639.75
Rate for Payer: Multiplan Commercial	$6,639.75
Rate for Payer: Multiplan Workers Comp	$6,639.75
Rate for Payer: Parkland Medicaid	$7,354.80
Rate for Payer: Scott and White EPO/PPO	$5,107.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,354.80
Rate for Payer: Superior Health Plan EPO	$1,389.24

CARTDGE ORBT ARHRCM 125 MICRO 145CM

Facility

$10,215.00

Hospital Charge Code	8582476
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6,946.20

CARTDGE ORBT ARHRCM 1.5 CLSS 145CM

Facility

$10,215.00

Hospital Charge Code	8582474
Hospital Revenue Code	272
Min. Negotiated Rate	$919.35
Max. Negotiated Rate	$7,354.80
Rate for Payer: Amerigroup CHIP/Medicaid	$919.35
Rate for Payer: BCBS of TX Blue Advantage	$3,064.50
Rate for Payer: BCBS of TX Blue Essentials	$3,677.40
Rate for Payer: BCBS of TX PPO	$4,086.00
Rate for Payer: Cash Price	$6,946.20
Rate for Payer: Cigna Medicaid	$7,354.80
Rate for Payer: Molina CHIP/Medicaid	$7,354.80
Rate for Payer: Multiplan Auto	$6,639.75
Rate for Payer: Multiplan Commercial	$6,639.75
Rate for Payer: Multiplan Workers Comp	$6,639.75
Rate for Payer: Parkland Medicaid	$7,354.80
Rate for Payer: Scott and White EPO/PPO	$5,107.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,354.80
Rate for Payer: Superior Health Plan EPO	$1,389.24

CARTDGE ORBT ARHRCM 1.5 CLSS 145CM

Facility

$10,215.00

Hospital Charge Code	8582474
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6,946.20

Carter Table Repair Kit

Facility

$662.84

Hospital Charge Code	992714
Hospital Revenue Code	270
Rate for Payer: Cash Price	$450.73

Carter Table Repair Kit

Facility

$662.84

Hospital Charge Code	992714
Hospital Revenue Code	270
Min. Negotiated Rate	$59.66
Max. Negotiated Rate	$477.24
Rate for Payer: Amerigroup CHIP/Medicaid	$59.66
Rate for Payer: BCBS of TX Blue Advantage	$198.85
Rate for Payer: BCBS of TX Blue Essentials	$238.62
Rate for Payer: BCBS of TX PPO	$265.14
Rate for Payer: Cash Price	$450.73
Rate for Payer: Cigna Medicaid	$477.24
Rate for Payer: Molina CHIP/Medicaid	$477.24
Rate for Payer: Multiplan Auto	$430.85
Rate for Payer: Multiplan Commercial	$430.85
Rate for Payer: Multiplan Workers Comp	$430.85
Rate for Payer: Parkland Medicaid	$477.24
Rate for Payer: Scott and White EPO/PPO	$331.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$477.24
Rate for Payer: Superior Health Plan EPO	$90.15

Carter-Thomason CloseSure System, 1 Box of 5 Systems

Facility

$408.60

Hospital Charge Code	993973
Hospital Revenue Code	272
Min. Negotiated Rate	$36.77
Max. Negotiated Rate	$294.19
Rate for Payer: Amerigroup CHIP/Medicaid	$36.77
Rate for Payer: BCBS of TX Blue Advantage	$122.58
Rate for Payer: BCBS of TX Blue Essentials	$147.10
Rate for Payer: BCBS of TX PPO	$163.44
Rate for Payer: Cash Price	$277.85
Rate for Payer: Cigna Medicaid	$294.19
Rate for Payer: Molina CHIP/Medicaid	$294.19
Rate for Payer: Multiplan Auto	$265.59
Rate for Payer: Multiplan Commercial	$265.59
Rate for Payer: Multiplan Workers Comp	$265.59
Rate for Payer: Parkland Medicaid	$294.19
Rate for Payer: Scott and White EPO/PPO	$204.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$294.19
Rate for Payer: Superior Health Plan EPO	$55.57

Carter-Thomason CloseSure System, 1 Box of 5 Systems

Facility

$408.60

Hospital Charge Code	993973
Hospital Revenue Code	272
Rate for Payer: Cash Price	$277.85

CARTIMAX

Facility

$22,019.00

Service Code	HCPCS C1762
Hospital Charge Code	993871
Hospital Revenue Code	278
Min. Negotiated Rate	$5,504.75
Max. Negotiated Rate	$11,009.50
Rate for Payer: Cash Price	$14,972.92
Rate for Payer: Cigna Commercial	$5,504.75
Rate for Payer: Multiplan Auto	$11,009.50
Rate for Payer: Multiplan Commercial	$11,009.50
Rate for Payer: Multiplan Workers Comp	$11,009.50
Rate for Payer: Scott and White EPO/PPO	$11,009.50

CARTIMAX

Facility

$22,019.00

Service Code	HCPCS C1762
Hospital Charge Code	993871
Hospital Revenue Code	278
Min. Negotiated Rate	$1,981.71
Max. Negotiated Rate	$15,853.68
Rate for Payer: Amerigroup CHIP/Medicaid	$1,981.71
Rate for Payer: BCBS of TX Blue Advantage	$6,605.70
Rate for Payer: BCBS of TX Blue Essentials	$7,926.84
Rate for Payer: BCBS of TX PPO	$8,807.60
Rate for Payer: Cash Price	$14,972.92
Rate for Payer: Cigna Medicaid	$15,853.68
Rate for Payer: Molina CHIP/Medicaid	$15,853.68
Rate for Payer: Multiplan Auto	$11,009.50
Rate for Payer: Multiplan Commercial	$11,009.50
Rate for Payer: Multiplan Workers Comp	$11,009.50
Rate for Payer: Parkland Medicaid	$15,853.68
Rate for Payer: Scott and White EPO/PPO	$11,009.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,853.68
Rate for Payer: Superior Health Plan EPO	$2,994.58

CARTRIDGE COAG -- DHF

Facility

$602.48

Hospital Charge Code	81731556
Hospital Revenue Code	270
Min. Negotiated Rate	$54.22
Max. Negotiated Rate	$433.79
Rate for Payer: Amerigroup CHIP/Medicaid	$54.22
Rate for Payer: BCBS of TX Blue Advantage	$180.74
Rate for Payer: BCBS of TX Blue Essentials	$216.89
Rate for Payer: BCBS of TX PPO	$240.99
Rate for Payer: Cash Price	$409.69
Rate for Payer: Cigna Medicaid	$433.79
Rate for Payer: Molina CHIP/Medicaid	$433.79
Rate for Payer: Multiplan Auto	$391.61
Rate for Payer: Multiplan Commercial	$391.61
Rate for Payer: Multiplan Workers Comp	$391.61
Rate for Payer: Parkland Medicaid	$433.79
Rate for Payer: Scott and White EPO/PPO	$301.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.79
Rate for Payer: Superior Health Plan EPO	$81.94

CARTRIDGE COAG -- DHF

Facility

$602.48

Hospital Charge Code	81731556
Hospital Revenue Code	270
Rate for Payer: Cash Price	$409.69

CARTRIDGE KIT ZEBRA WRISTBAND, 175-Pack

Facility

$194.18

Hospital Charge Code	993187
Hospital Revenue Code	270
Rate for Payer: Cash Price	$132.04

CARTRIDGE KIT ZEBRA WRISTBAND, 175-Pack

Facility

$194.18

Hospital Charge Code	993187
Hospital Revenue Code	270
Min. Negotiated Rate	$17.48
Max. Negotiated Rate	$139.81
Rate for Payer: Amerigroup CHIP/Medicaid	$17.48
Rate for Payer: BCBS of TX Blue Advantage	$58.25
Rate for Payer: BCBS of TX Blue Essentials	$69.90
Rate for Payer: BCBS of TX PPO	$77.67
Rate for Payer: Cash Price	$132.04
Rate for Payer: Cigna Medicaid	$139.81
Rate for Payer: Molina CHIP/Medicaid	$139.81
Rate for Payer: Multiplan Auto	$126.22
Rate for Payer: Multiplan Commercial	$126.22
Rate for Payer: Multiplan Workers Comp	$126.22
Rate for Payer: Parkland Medicaid	$139.81
Rate for Payer: Scott and White EPO/PPO	$97.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$139.81
Rate for Payer: Superior Health Plan EPO	$26.41

CARTRIDGE, WHT RELOAD, F/ENDOCUTTER, ECHEL

Facility

$913.45

Hospital Charge Code	992334
Hospital Revenue Code	272
Min. Negotiated Rate	$82.21
Max. Negotiated Rate	$657.68
Rate for Payer: Amerigroup CHIP/Medicaid	$82.21
Rate for Payer: BCBS of TX Blue Advantage	$274.04
Rate for Payer: BCBS of TX Blue Essentials	$328.84
Rate for Payer: BCBS of TX PPO	$365.38
Rate for Payer: Cash Price	$621.15
Rate for Payer: Cigna Medicaid	$657.68
Rate for Payer: Molina CHIP/Medicaid	$657.68
Rate for Payer: Multiplan Auto	$593.74
Rate for Payer: Multiplan Commercial	$593.74
Rate for Payer: Multiplan Workers Comp	$593.74
Rate for Payer: Parkland Medicaid	$657.68
Rate for Payer: Scott and White EPO/PPO	$456.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$657.68
Rate for Payer: Superior Health Plan EPO	$124.23

CARTRIDGE, WHT RELOAD, F/ENDOCUTTER, ECHEL

Facility

$913.45

Hospital Charge Code	992334
Hospital Revenue Code	272
Rate for Payer: Cash Price	$621.15

carvedilol 25 mg Tab

Facility

$9.30

Service Code	HCPCS J3490
Hospital Charge Code	77444538
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.70
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.79
Rate for Payer: BCBS of TX Blue Essentials	$3.35
Rate for Payer: BCBS of TX PPO	$3.72
Rate for Payer: Cash Price	$6.32
Rate for Payer: Cigna Medicaid	$6.70
Rate for Payer: Molina CHIP/Medicaid	$6.70
Rate for Payer: Multiplan Auto	$6.04
Rate for Payer: Multiplan Commercial	$6.04
Rate for Payer: Multiplan Workers Comp	$6.04
Rate for Payer: Parkland Medicaid	$6.70
Rate for Payer: Scott and White EPO/PPO	$4.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.70
Rate for Payer: Superior Health Plan EPO	$1.26

carvedilol 25 mg Tab

Facility

$9.30

Service Code	HCPCS J3490
Hospital Charge Code	77444538
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.32

Know your out-of-pocket cost for care.

All Charges