White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or

Facility

$10,000.00

Service Code	CPT 93971
Hospital Charge Code	36093971
Hospital Revenue Code	360
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$200.03
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$100.55
Rate for Payer: Amerigroup Medicare	$100.55
Rate for Payer: BCBS of TX Blue Advantage	$174.33
Rate for Payer: BCBS of TX Blue Essentials	$208.40
Rate for Payer: BCBS of TX Medicare	$100.55
Rate for Payer: BCBS of TX PPO	$232.44
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$106.88
Rate for Payer: Cigna Medicare	$100.55
Rate for Payer: Employer Direct Commercial	$100.55
Rate for Payer: Humana Medicare/TRICARE	$100.55
Rate for Payer: Molina CHIP/Medicaid	$106.88
Rate for Payer: Molina Dual Medicare/Medicaid	$100.55
Rate for Payer: Molina Medicare	$100.55
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	$106.88
Rate for Payer: Scott and White EPO/PPO	$1.80
Rate for Payer: Scott and White Medicare	$100.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$106.88
Rate for Payer: Superior Health Plan EPO	$100.55
Rate for Payer: Superior Health Plan Medicare	$100.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$100.55
Rate for Payer: Universal American Medicare	$100.55
Rate for Payer: Wellcare Medicare	$100.55
Rate for Payer: Wellmed Medicare	$100.55

DURAGEN GRAFT PATCH

Facility

$2,549.09

Service Code	HCPCS Q4100
Hospital Charge Code	8436483
Hospital Revenue Code	278
Min. Negotiated Rate	$229.42
Max. Negotiated Rate	$1,274.54
Rate for Payer: Aetna Commercial	$764.73
Rate for Payer: Amerigroup CHIP/Medicaid	$229.42
Rate for Payer: BCBS of TX Blue Advantage	$764.73
Rate for Payer: BCBS of TX Blue Essentials	$917.67
Rate for Payer: BCBS of TX PPO	$1,019.64
Rate for Payer: Cash Price	$2,243.20
Rate for Payer: Multiplan Auto	$1,274.54
Rate for Payer: Multiplan Commercial	$1,274.54
Rate for Payer: Multiplan Workers Comp	$1,274.54
Rate for Payer: Scott and White EPO/PPO	$1,274.54
Rate for Payer: Superior Health Plan EPO	$346.68

DURAGEN GRAFT PATCH

Facility

$2,549.09

Service Code	HCPCS Q4100
Hospital Charge Code	8436483
Hospital Revenue Code	278
Min. Negotiated Rate	$637.27
Max. Negotiated Rate	$1,274.54
Rate for Payer: Aetna Commercial	$764.73
Rate for Payer: Cash Price	$2,243.20
Rate for Payer: Cigna Commercial	$637.27
Rate for Payer: Multiplan Auto	$1,274.54
Rate for Payer: Multiplan Commercial	$1,274.54
Rate for Payer: Multiplan Workers Comp	$1,274.54
Rate for Payer: Scott and White EPO/PPO	$1,274.54

DVCE ASPIRATING -- DHF

Facility

$216.11

Hospital Charge Code	80321151
Hospital Revenue Code	270
Rate for Payer: Cash Price	$190.18

DVCE ASPIRATING -- DHF

Facility

$216.11

Hospital Charge Code	80321151
Hospital Revenue Code	270
Min. Negotiated Rate	$19.45
Max. Negotiated Rate	$140.47
Rate for Payer: Aetna Commercial	$118.86
Rate for Payer: Amerigroup CHIP/Medicaid	$19.45
Rate for Payer: BCBS of TX Blue Advantage	$64.83
Rate for Payer: BCBS of TX Blue Essentials	$77.80
Rate for Payer: BCBS of TX PPO	$86.44
Rate for Payer: Cash Price	$190.18
Rate for Payer: Multiplan Auto	$140.47
Rate for Payer: Multiplan Commercial	$140.47
Rate for Payer: Multiplan Workers Comp	$140.47
Rate for Payer: Scott and White EPO/PPO	$108.06
Rate for Payer: Superior Health Plan EPO	$29.39

DVCE CIRC AS -- DHF

Facility

$110.27

Hospital Charge Code	81741001
Hospital Revenue Code	270
Rate for Payer: Cash Price	$97.04

DVCE CIRC AS -- DHF

Facility

$110.27

Hospital Charge Code	81741001
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$71.68
Rate for Payer: Aetna Commercial	$60.65
Rate for Payer: Amerigroup CHIP/Medicaid	$9.92
Rate for Payer: BCBS of TX Blue Advantage	$33.08
Rate for Payer: BCBS of TX Blue Essentials	$39.70
Rate for Payer: BCBS of TX PPO	$44.11
Rate for Payer: Cash Price	$97.04
Rate for Payer: Multiplan Auto	$71.68
Rate for Payer: Multiplan Commercial	$71.68
Rate for Payer: Multiplan Workers Comp	$71.68
Rate for Payer: Scott and White EPO/PPO	$55.14
Rate for Payer: Superior Health Plan EPO	$15.00

DVC EMBLZTN MICROSPHERE -- DHF

Facility

$794.05

Hospital Charge Code	80321268
Hospital Revenue Code	272
Min. Negotiated Rate	$71.46
Max. Negotiated Rate	$516.13
Rate for Payer: Aetna Commercial	$436.73
Rate for Payer: Amerigroup CHIP/Medicaid	$71.46
Rate for Payer: BCBS of TX Blue Advantage	$238.22
Rate for Payer: BCBS of TX Blue Essentials	$285.86
Rate for Payer: BCBS of TX PPO	$317.62
Rate for Payer: Cash Price	$698.76
Rate for Payer: Multiplan Auto	$516.13
Rate for Payer: Multiplan Commercial	$516.13
Rate for Payer: Multiplan Workers Comp	$516.13
Rate for Payer: Scott and White EPO/PPO	$397.02
Rate for Payer: Superior Health Plan EPO	$107.99

DVC EMBLZTN MICROSPHERE -- DHF

Facility

$794.05

Hospital Charge Code	80321268
Hospital Revenue Code	272
Rate for Payer: Cash Price	$698.76

DVCE SIZING -- DHF

Facility

$285.37

Hospital Charge Code	80811086
Hospital Revenue Code	270
Rate for Payer: Cash Price	$251.13

DVCE SIZING -- DHF

Facility

$285.37

Hospital Charge Code	80811086
Hospital Revenue Code	270
Min. Negotiated Rate	$25.68
Max. Negotiated Rate	$185.49
Rate for Payer: Aetna Commercial	$156.95
Rate for Payer: Amerigroup CHIP/Medicaid	$25.68
Rate for Payer: BCBS of TX Blue Advantage	$85.61
Rate for Payer: BCBS of TX Blue Essentials	$102.73
Rate for Payer: BCBS of TX PPO	$114.15
Rate for Payer: Cash Price	$251.13
Rate for Payer: Multiplan Auto	$185.49
Rate for Payer: Multiplan Commercial	$185.49
Rate for Payer: Multiplan Workers Comp	$185.49
Rate for Payer: Scott and White EPO/PPO	$142.68
Rate for Payer: Superior Health Plan EPO	$38.81

DVCE TORQUE -- DHF

Facility

$71.50

Hospital Charge Code	80811102
Hospital Revenue Code	272
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$46.48
Rate for Payer: Aetna Commercial	$39.32
Rate for Payer: Amerigroup CHIP/Medicaid	$6.44
Rate for Payer: BCBS of TX Blue Advantage	$21.45
Rate for Payer: BCBS of TX Blue Essentials	$25.74
Rate for Payer: BCBS of TX PPO	$28.60
Rate for Payer: Cash Price	$62.92
Rate for Payer: Multiplan Auto	$46.48
Rate for Payer: Multiplan Commercial	$46.48
Rate for Payer: Multiplan Workers Comp	$46.48
Rate for Payer: Scott and White EPO/PPO	$35.75
Rate for Payer: Superior Health Plan EPO	$9.72

DVCE TORQUE -- DHF

Facility

$71.50

Hospital Charge Code	80811102
Hospital Revenue Code	272
Rate for Payer: Cash Price	$62.92

DVC INFLAT SINUS BLLN -- DHF

Facility

$338.45

Hospital Charge Code	81741118
Hospital Revenue Code	272
Rate for Payer: Cash Price	$297.84

DVC INFLAT SINUS BLLN -- DHF

Facility

$338.45

Hospital Charge Code	81741118
Hospital Revenue Code	272
Min. Negotiated Rate	$30.46
Max. Negotiated Rate	$219.99
Rate for Payer: Aetna Commercial	$186.15
Rate for Payer: Amerigroup CHIP/Medicaid	$30.46
Rate for Payer: BCBS of TX Blue Advantage	$101.54
Rate for Payer: BCBS of TX Blue Essentials	$121.84
Rate for Payer: BCBS of TX PPO	$135.38
Rate for Payer: Cash Price	$297.84
Rate for Payer: Multiplan Auto	$219.99
Rate for Payer: Multiplan Commercial	$219.99
Rate for Payer: Multiplan Workers Comp	$219.99
Rate for Payer: Scott and White EPO/PPO	$169.22
Rate for Payer: Superior Health Plan EPO	$46.03

DVC MONITR INTRAABD PRES -- DHF

Facility

$360.68

Hospital Charge Code	80412885
Hospital Revenue Code	272
Min. Negotiated Rate	$32.46
Max. Negotiated Rate	$234.44
Rate for Payer: Aetna Commercial	$198.37
Rate for Payer: Amerigroup CHIP/Medicaid	$32.46
Rate for Payer: BCBS of TX Blue Advantage	$108.20
Rate for Payer: BCBS of TX Blue Essentials	$129.84
Rate for Payer: BCBS of TX PPO	$144.27
Rate for Payer: Cash Price	$317.40
Rate for Payer: Multiplan Auto	$234.44
Rate for Payer: Multiplan Commercial	$234.44
Rate for Payer: Multiplan Workers Comp	$234.44
Rate for Payer: Scott and White EPO/PPO	$180.34
Rate for Payer: Superior Health Plan EPO	$49.05

DVC MONITR INTRAABD PRES -- DHF

Facility

$360.68

Hospital Charge Code	80412885
Hospital Revenue Code	272
Rate for Payer: Cash Price	$317.40

DVC RADIAL COMPRESSION -- DHF

Facility

$177.06

Hospital Charge Code	80320096
Hospital Revenue Code	270
Rate for Payer: Cash Price	$155.81

DVC RADIAL COMPRESSION -- DHF

Facility

$177.06

Hospital Charge Code	80320096
Hospital Revenue Code	270
Min. Negotiated Rate	$15.94
Max. Negotiated Rate	$115.09
Rate for Payer: Aetna Commercial	$97.38
Rate for Payer: Amerigroup CHIP/Medicaid	$15.94
Rate for Payer: BCBS of TX Blue Advantage	$53.12
Rate for Payer: BCBS of TX Blue Essentials	$63.74
Rate for Payer: BCBS of TX PPO	$70.82
Rate for Payer: Cash Price	$155.81
Rate for Payer: Multiplan Auto	$115.09
Rate for Payer: Multiplan Commercial	$115.09
Rate for Payer: Multiplan Workers Comp	$115.09
Rate for Payer: Scott and White EPO/PPO	$88.53
Rate for Payer: Superior Health Plan EPO	$24.08

DVC STONE ANTIRETROPULSN -- DHF

Facility

$2,427.66

Hospital Charge Code	80412869
Hospital Revenue Code	272
Min. Negotiated Rate	$218.49
Max. Negotiated Rate	$1,577.98
Rate for Payer: Aetna Commercial	$1,335.21
Rate for Payer: Amerigroup CHIP/Medicaid	$218.49
Rate for Payer: BCBS of TX Blue Advantage	$728.30
Rate for Payer: BCBS of TX Blue Essentials	$873.96
Rate for Payer: BCBS of TX PPO	$971.06
Rate for Payer: Cash Price	$2,136.34
Rate for Payer: Multiplan Auto	$1,577.98
Rate for Payer: Multiplan Commercial	$1,577.98
Rate for Payer: Multiplan Workers Comp	$1,577.98
Rate for Payer: Scott and White EPO/PPO	$1,213.83
Rate for Payer: Superior Health Plan EPO	$330.16

DVC STONE ANTIRETROPULSN -- DHF

Facility

$2,427.66

Hospital Charge Code	80412869
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,136.34

DX BONE MARROW ASP/BX MULTI

Facility

$4,639.00

Service Code	CPT 38222
Hospital Charge Code	4613822
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,082.32

DX BONE MARROW ASP/BX MULTI

Facility

$4,639.00

Service Code	CPT 38222
Hospital Charge Code	4613822
Hospital Revenue Code	360
Min. Negotiated Rate	$57.32
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$3,898.02
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,598.68
Rate for Payer: Amerigroup Medicare	$2,598.68
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,598.68
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cash Price	$4,082.32
Rate for Payer: Cash Price	$4,082.32
Rate for Payer: Cigna Commercial	$5,886.75
Rate for Payer: Cigna Medicaid	$815.20
Rate for Payer: Cigna Medicare	$2,598.68
Rate for Payer: Employer Direct Commercial	$2,598.68
Rate for Payer: Humana Medicare/TRICARE	$2,598.68
Rate for Payer: Molina CHIP/Medicaid	$815.20
Rate for Payer: Molina Dual Medicare/Medicaid	$2,598.68
Rate for Payer: Molina Medicare	$2,598.68
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	$815.20
Rate for Payer: Scott and White EPO/PPO	$57.32
Rate for Payer: Scott and White Medicare	$2,598.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$815.20
Rate for Payer: Superior Health Plan EPO	$2,598.68
Rate for Payer: Superior Health Plan Medicare	$2,598.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,598.68
Rate for Payer: Universal American Medicare	$2,598.68
Rate for Payer: Wellcare Medicare	$2,598.68
Rate for Payer: Wellmed Medicare	$2,598.68

DYNACLIP FIXATION SYSTEM

Facility

$5,970.10

Hospital Charge Code	145502
Hospital Revenue Code	272
Min. Negotiated Rate	$537.31
Max. Negotiated Rate	$3,880.56
Rate for Payer: Aetna Commercial	$3,283.56
Rate for Payer: Amerigroup CHIP/Medicaid	$537.31
Rate for Payer: BCBS of TX Blue Advantage	$1,791.03
Rate for Payer: BCBS of TX Blue Essentials	$2,149.24
Rate for Payer: BCBS of TX PPO	$2,388.04
Rate for Payer: Cash Price	$5,253.69
Rate for Payer: Multiplan Auto	$3,880.56
Rate for Payer: Multiplan Commercial	$3,880.56
Rate for Payer: Multiplan Workers Comp	$3,880.56
Rate for Payer: Scott and White EPO/PPO	$2,985.05
Rate for Payer: Superior Health Plan EPO	$811.93

DYNACLIP FIXATION SYSTEM

Facility

$5,970.10

Hospital Charge Code	145502
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,253.69

Know your out-of-pocket cost for care.

All Charges