White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CUTTER, LINEAR ARTICULATING LONG FLEX 60MM 440MM -- DHF

Facility

$3,181.54

Hospital Charge Code	81945750
Hospital Revenue Code	272
Min. Negotiated Rate	$286.34
Max. Negotiated Rate	$2,068.00
Rate for Payer: Aetna Commercial	$1,749.85
Rate for Payer: Amerigroup CHIP/Medicaid	$286.34
Rate for Payer: BCBS of TX Blue Advantage	$954.46
Rate for Payer: BCBS of TX Blue Essentials	$1,145.35
Rate for Payer: BCBS of TX PPO	$1,272.62
Rate for Payer: Cash Price	$2,799.76
Rate for Payer: Multiplan Auto	$2,068.00
Rate for Payer: Multiplan Commercial	$2,068.00
Rate for Payer: Multiplan Workers Comp	$2,068.00
Rate for Payer: Scott and White EPO/PPO	$1,590.77
Rate for Payer: Superior Health Plan EPO	$432.69

CUTTER, LINEAR ARTICULATING LONG FLEX 60MM 440MM -- DHF

Facility

$3,181.54

Hospital Charge Code	81945750
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,799.76

CUTTER SUT/KNOT PUSHER -- DHF

Facility

$726.40

Hospital Charge Code	81739716
Hospital Revenue Code	272
Rate for Payer: Cash Price	$639.23

CUTTER SUT/KNOT PUSHER -- DHF

Facility

$726.40

Hospital Charge Code	81739716
Hospital Revenue Code	272
Min. Negotiated Rate	$65.38
Max. Negotiated Rate	$472.16
Rate for Payer: Aetna Commercial	$399.52
Rate for Payer: Amerigroup CHIP/Medicaid	$65.38
Rate for Payer: BCBS of TX Blue Advantage	$217.92
Rate for Payer: BCBS of TX Blue Essentials	$261.50
Rate for Payer: BCBS of TX PPO	$290.56
Rate for Payer: Cash Price	$639.23
Rate for Payer: Multiplan Auto	$472.16
Rate for Payer: Multiplan Commercial	$472.16
Rate for Payer: Multiplan Workers Comp	$472.16
Rate for Payer: Scott and White EPO/PPO	$363.20
Rate for Payer: Superior Health Plan EPO	$98.79

cyanocobalamin 1000 mcg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77487253
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

cyanocobalamin 1000 mcg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77487253
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

cyanocobalamin 1000 mcg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77487200
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

cyanocobalamin 1000 mcg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77487200
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

cyclobenzaprine 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77487885
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

cyclobenzaprine 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77487885
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

Cyclosporine, Blood SO

Facility

$359.00

Service Code	CPT 80158
Hospital Charge Code	1706928
Hospital Revenue Code	300
Min. Negotiated Rate	$7.04
Max. Negotiated Rate	$233.35
Rate for Payer: Aetna Commercial	$18.95
Rate for Payer: Aetna Medicare	$27.08
Rate for Payer: Amerigroup CHIP/Medicaid	$7.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.05
Rate for Payer: Amerigroup Medicare	$18.05
Rate for Payer: BCBS of TX Blue Advantage	$29.78
Rate for Payer: BCBS of TX Blue Essentials	$35.74
Rate for Payer: BCBS of TX Medicare	$18.05
Rate for Payer: BCBS of TX PPO	$39.89
Rate for Payer: Cash Price	$315.92
Rate for Payer: Cash Price	$315.92
Rate for Payer: Cigna Medicaid	$18.05
Rate for Payer: Cigna Medicare	$18.05
Rate for Payer: Employer Direct Commercial	$18.05
Rate for Payer: Humana Medicare/TRICARE	$18.05
Rate for Payer: Molina CHIP/Medicaid	$18.05
Rate for Payer: Molina Dual Medicare/Medicaid	$18.05
Rate for Payer: Molina Medicare	$18.05
Rate for Payer: Multiplan Auto	$233.35
Rate for Payer: Multiplan Commercial	$233.35
Rate for Payer: Multiplan Workers Comp	$233.35
Rate for Payer: Parkland Medicaid	$18.05
Rate for Payer: Scott and White EPO/PPO	$22.56
Rate for Payer: Scott and White Medicare	$18.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.05
Rate for Payer: Superior Health Plan EPO	$18.05
Rate for Payer: Superior Health Plan Medicare	$18.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.05
Rate for Payer: Universal American Medicare	$18.05
Rate for Payer: Wellcare Medicare	$18.05
Rate for Payer: Wellmed Medicare	$18.05

Cyclosporine, Blood SO

Facility

$359.00

Service Code	CPT 80158
Hospital Charge Code	1706928
Hospital Revenue Code	300
Rate for Payer: Cash Price	$315.92

Cystic Fibrosis Profile SO

Facility

$157.00

Service Code	CPT 81220
Hospital Charge Code	1740969
Hospital Revenue Code	310
Rate for Payer: Cash Price	$138.16

Cystic Fibrosis Profile SO

Facility

$157.00

Service Code	CPT 81220
Hospital Charge Code	1740969
Hospital Revenue Code	310
Min. Negotiated Rate	$102.05
Max. Negotiated Rate	$1,230.09
Rate for Payer: Aetna Commercial	$584.43
Rate for Payer: Aetna Medicare	$834.90
Rate for Payer: Amerigroup CHIP/Medicaid	$217.07
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$556.60
Rate for Payer: Amerigroup Medicare	$556.60
Rate for Payer: BCBS of TX Blue Advantage	$918.39
Rate for Payer: BCBS of TX Blue Essentials	$1,102.07
Rate for Payer: BCBS of TX Medicare	$556.60
Rate for Payer: BCBS of TX PPO	$1,230.09
Rate for Payer: Cash Price	$138.16
Rate for Payer: Cash Price	$138.16
Rate for Payer: Cigna Medicaid	$556.60
Rate for Payer: Cigna Medicare	$556.60
Rate for Payer: Employer Direct Commercial	$556.60
Rate for Payer: Humana Medicare/TRICARE	$556.60
Rate for Payer: Molina CHIP/Medicaid	$556.60
Rate for Payer: Molina Dual Medicare/Medicaid	$556.60
Rate for Payer: Molina Medicare	$556.60
Rate for Payer: Multiplan Auto	$102.05
Rate for Payer: Multiplan Commercial	$102.05
Rate for Payer: Multiplan Workers Comp	$102.05
Rate for Payer: Parkland Medicaid	$556.60
Rate for Payer: Scott and White EPO/PPO	$695.75
Rate for Payer: Scott and White Medicare	$556.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$556.60
Rate for Payer: Superior Health Plan EPO	$556.60
Rate for Payer: Superior Health Plan Medicare	$556.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$556.60
Rate for Payer: Universal American Medicare	$556.60
Rate for Payer: Wellcare Medicare	$556.60
Rate for Payer: Wellmed Medicare	$556.60

Cytomegalovirus (CMV) Ab, IgG SO

Facility

$414.00

Service Code	CPT 86644
Hospital Charge Code	1702604
Hospital Revenue Code	302
Rate for Payer: Cash Price	$364.32

Cytomegalovirus (CMV) Ab, IgG SO

Facility

$414.00

Service Code	CPT 86644
Hospital Charge Code	1702604
Hospital Revenue Code	302
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$269.10
Rate for Payer: Aetna Commercial	$15.10
Rate for Payer: Aetna Medicare	$21.58
Rate for Payer: Amerigroup CHIP/Medicaid	$5.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.39
Rate for Payer: Amerigroup Medicare	$14.39
Rate for Payer: BCBS of TX Blue Advantage	$23.74
Rate for Payer: BCBS of TX Blue Essentials	$28.49
Rate for Payer: BCBS of TX Medicare	$14.39
Rate for Payer: BCBS of TX PPO	$31.80
Rate for Payer: Cash Price	$364.32
Rate for Payer: Cash Price	$364.32
Rate for Payer: Cigna Medicaid	$14.39
Rate for Payer: Cigna Medicare	$14.39
Rate for Payer: Employer Direct Commercial	$14.39
Rate for Payer: Humana Medicare/TRICARE	$14.39
Rate for Payer: Molina CHIP/Medicaid	$14.39
Rate for Payer: Molina Dual Medicare/Medicaid	$14.39
Rate for Payer: Molina Medicare	$14.39
Rate for Payer: Multiplan Auto	$269.10
Rate for Payer: Multiplan Commercial	$269.10
Rate for Payer: Multiplan Workers Comp	$269.10
Rate for Payer: Parkland Medicaid	$14.39
Rate for Payer: Scott and White EPO/PPO	$17.99
Rate for Payer: Scott and White Medicare	$14.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.39
Rate for Payer: Superior Health Plan EPO	$14.39
Rate for Payer: Superior Health Plan Medicare	$14.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.39
Rate for Payer: Universal American Medicare	$14.39
Rate for Payer: Wellcare Medicare	$14.39
Rate for Payer: Wellmed Medicare	$14.39

Cytomegalovirus (CMV) Ab, IgM SO

Facility

$414.00

Service Code	CPT 86645
Hospital Charge Code	1702596
Hospital Revenue Code	302
Rate for Payer: Cash Price	$364.32

Cytomegalovirus (CMV) Ab, IgM SO

Facility

$414.00

Service Code	CPT 86645
Hospital Charge Code	1702596
Hospital Revenue Code	302
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$269.10
Rate for Payer: Aetna Commercial	$17.69
Rate for Payer: Aetna Medicare	$25.28
Rate for Payer: Amerigroup CHIP/Medicaid	$6.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.85
Rate for Payer: Amerigroup Medicare	$16.85
Rate for Payer: BCBS of TX Blue Advantage	$27.80
Rate for Payer: BCBS of TX Blue Essentials	$33.36
Rate for Payer: BCBS of TX Medicare	$16.85
Rate for Payer: BCBS of TX PPO	$37.24
Rate for Payer: Cash Price	$364.32
Rate for Payer: Cash Price	$364.32
Rate for Payer: Cigna Medicaid	$16.85
Rate for Payer: Cigna Medicare	$16.85
Rate for Payer: Employer Direct Commercial	$16.85
Rate for Payer: Humana Medicare/TRICARE	$16.85
Rate for Payer: Molina CHIP/Medicaid	$16.85
Rate for Payer: Molina Dual Medicare/Medicaid	$16.85
Rate for Payer: Molina Medicare	$16.85
Rate for Payer: Multiplan Auto	$269.10
Rate for Payer: Multiplan Commercial	$269.10
Rate for Payer: Multiplan Workers Comp	$269.10
Rate for Payer: Parkland Medicaid	$16.85
Rate for Payer: Scott and White EPO/PPO	$21.06
Rate for Payer: Scott and White Medicare	$16.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.85
Rate for Payer: Superior Health Plan EPO	$16.85
Rate for Payer: Superior Health Plan Medicare	$16.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.85
Rate for Payer: Universal American Medicare	$16.85
Rate for Payer: Wellcare Medicare	$16.85
Rate for Payer: Wellmed Medicare	$16.85

dall miles cable

Facility

$1,457.34

Hospital Charge Code	8666515
Hospital Revenue Code	272
Min. Negotiated Rate	$131.16
Max. Negotiated Rate	$947.27
Rate for Payer: Aetna Commercial	$801.54
Rate for Payer: Amerigroup CHIP/Medicaid	$131.16
Rate for Payer: BCBS of TX Blue Advantage	$437.20
Rate for Payer: BCBS of TX Blue Essentials	$524.64
Rate for Payer: BCBS of TX PPO	$582.94
Rate for Payer: Cash Price	$1,282.46
Rate for Payer: Multiplan Auto	$947.27
Rate for Payer: Multiplan Commercial	$947.27
Rate for Payer: Multiplan Workers Comp	$947.27
Rate for Payer: Scott and White EPO/PPO	$728.67
Rate for Payer: Superior Health Plan EPO	$198.20

dall miles cable

Facility

$1,457.34

Hospital Charge Code	8666515
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,282.46

DAPTOmycin 500 mg IV Inj

Facility

$128.17

Service Code	HCPCS J0878
Hospital Charge Code	77492294
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

DAPTOmycin 500 mg IV Inj

Facility

$128.17

Service Code	HCPCS J0878
Hospital Charge Code	77492294
Hospital Revenue Code	636
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.81
Rate for Payer: BCBS of TX Blue Essentials	$0.97
Rate for Payer: BCBS of TX PPO	$1.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

DAT C3

Facility

$142.00

Service Code	CPT 86880
Hospital Charge Code	2403103
Hospital Revenue Code	302
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$126.71
Rate for Payer: Aetna Commercial	$5.65
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$2.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$55.16
Rate for Payer: BCBS of TX Blue Essentials	$66.19
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$73.88
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicaid	$5.39
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina CHIP/Medicaid	$5.39
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Parkland Medicaid	$5.39
Rate for Payer: Scott and White EPO/PPO	$6.74
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.39
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

DAT IgG

Facility

$142.00

Service Code	CPT 86880
Hospital Charge Code	2403103
Hospital Revenue Code	302
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$126.71
Rate for Payer: Aetna Commercial	$5.65
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$2.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$55.16
Rate for Payer: BCBS of TX Blue Essentials	$66.19
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$73.88
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicaid	$5.39
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina CHIP/Medicaid	$5.39
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Parkland Medicaid	$5.39
Rate for Payer: Scott and White EPO/PPO	$6.74
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.39
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC

Facility

$35,765.60

Service Code	MSDRG 744
Min. Negotiated Rate	$14,376.62
Max. Negotiated Rate	$35,765.60
Rate for Payer: Aetna Commercial	$21,177.00
Rate for Payer: Aetna Medicare	$24,431.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,287.70
Rate for Payer: Amerigroup Medicare	$16,287.70
Rate for Payer: BCBS of TX Blue Advantage	$14,376.62
Rate for Payer: BCBS of TX Blue Essentials	$17,442.21
Rate for Payer: BCBS of TX Medicare	$16,287.70
Rate for Payer: BCBS of TX PPO	$19,380.98
Rate for Payer: Cigna Commercial	$24,245.31
Rate for Payer: Cigna Medicare	$16,287.70
Rate for Payer: Employer Direct Commercial	$16,287.70
Rate for Payer: Humana Medicare/TRICARE	$16,287.70
Rate for Payer: Molina Dual Medicare/Medicaid	$16,287.70
Rate for Payer: Molina Medicare	$16,287.70
Rate for Payer: Multiplan Auto	$35,765.60
Rate for Payer: Multiplan Commercial	$35,765.60
Rate for Payer: Multiplan Workers Comp	$35,765.60
Rate for Payer: Scott and White EPO/PPO	$16,471.00
Rate for Payer: Scott and White Medicare	$16,287.70
Rate for Payer: Superior Health Plan EPO	$16,287.70
Rate for Payer: Superior Health Plan Medicare	$16,287.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,287.70
Rate for Payer: Universal American Medicare	$16,287.70
Rate for Payer: Wellcare Medicare	$16,287.70
Rate for Payer: Wellmed Medicare	$16,287.70

Know your out-of-pocket cost for care.

All Charges