White Rock Medical Center

All Charges

Charge

Type

Setting

Price

58884010

Facility

$3,783.00

Service Code	HCPCS C1776
Hospital Charge Code	991022
Hospital Revenue Code	278
Min. Negotiated Rate	$340.47
Max. Negotiated Rate	$2,723.76
Rate for Payer: Amerigroup CHIP/Medicaid	$340.47
Rate for Payer: BCBS of TX Blue Advantage	$1,134.90
Rate for Payer: BCBS of TX Blue Essentials	$1,361.88
Rate for Payer: BCBS of TX PPO	$1,513.20
Rate for Payer: Cash Price	$2,572.44
Rate for Payer: Cigna Medicaid	$2,723.76
Rate for Payer: Molina CHIP/Medicaid	$2,723.76
Rate for Payer: Multiplan Auto	$1,891.50
Rate for Payer: Multiplan Commercial	$1,891.50
Rate for Payer: Multiplan Workers Comp	$1,891.50
Rate for Payer: Parkland Medicaid	$2,723.76
Rate for Payer: Scott and White EPO/PPO	$1,891.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,723.76
Rate for Payer: Superior Health Plan EPO	$514.49

58884010

Facility

$3,783.00

Service Code	HCPCS C1776
Hospital Charge Code	991022
Hospital Revenue Code	278
Min. Negotiated Rate	$945.75
Max. Negotiated Rate	$1,891.50
Rate for Payer: Cash Price	$2,572.44
Rate for Payer: Cigna Commercial	$945.75
Rate for Payer: Multiplan Auto	$1,891.50
Rate for Payer: Multiplan Commercial	$1,891.50
Rate for Payer: Multiplan Workers Comp	$1,891.50
Rate for Payer: Scott and White EPO/PPO	$1,891.50

5888402L

Facility

$13,000.00

Service Code	HCPCS C1713
Hospital Charge Code	991314
Hospital Revenue Code	278
Min. Negotiated Rate	$3,250.00
Max. Negotiated Rate	$6,500.00
Rate for Payer: Cash Price	$8,840.00
Rate for Payer: Cigna Commercial	$3,250.00
Rate for Payer: Multiplan Auto	$6,500.00
Rate for Payer: Multiplan Commercial	$6,500.00
Rate for Payer: Multiplan Workers Comp	$6,500.00
Rate for Payer: Scott and White EPO/PPO	$6,500.00

5888402L

Facility

$13,000.00

Service Code	HCPCS C1713
Hospital Charge Code	991314
Hospital Revenue Code	278
Min. Negotiated Rate	$1,170.00
Max. Negotiated Rate	$9,360.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,170.00
Rate for Payer: BCBS of TX Blue Advantage	$3,900.00
Rate for Payer: BCBS of TX Blue Essentials	$4,680.00
Rate for Payer: BCBS of TX PPO	$5,200.00
Rate for Payer: Cash Price	$8,840.00
Rate for Payer: Cigna Medicaid	$9,360.00
Rate for Payer: Molina CHIP/Medicaid	$9,360.00
Rate for Payer: Multiplan Auto	$6,500.00
Rate for Payer: Multiplan Commercial	$6,500.00
Rate for Payer: Multiplan Workers Comp	$6,500.00
Rate for Payer: Parkland Medicaid	$9,360.00
Rate for Payer: Scott and White EPO/PPO	$6,500.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,360.00
Rate for Payer: Superior Health Plan EPO	$1,768.00

5888403R

Facility

$13,277.00

Service Code	HCPCS C1776
Hospital Charge Code	990954
Hospital Revenue Code	278
Min. Negotiated Rate	$1,194.93
Max. Negotiated Rate	$9,559.44
Rate for Payer: Amerigroup CHIP/Medicaid	$1,194.93
Rate for Payer: BCBS of TX Blue Advantage	$3,983.10
Rate for Payer: BCBS of TX Blue Essentials	$4,779.72
Rate for Payer: BCBS of TX PPO	$5,310.80
Rate for Payer: Cash Price	$9,028.36
Rate for Payer: Cigna Medicaid	$9,559.44
Rate for Payer: Molina CHIP/Medicaid	$9,559.44
Rate for Payer: Multiplan Auto	$6,638.50
Rate for Payer: Multiplan Commercial	$6,638.50
Rate for Payer: Multiplan Workers Comp	$6,638.50
Rate for Payer: Parkland Medicaid	$9,559.44
Rate for Payer: Scott and White EPO/PPO	$6,638.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,559.44
Rate for Payer: Superior Health Plan EPO	$1,805.67

5888403R

Facility

$13,277.00

Service Code	HCPCS C1776
Hospital Charge Code	990954
Hospital Revenue Code	278
Min. Negotiated Rate	$3,319.25
Max. Negotiated Rate	$6,638.50
Rate for Payer: Cash Price	$9,028.36
Rate for Payer: Cigna Commercial	$3,319.25
Rate for Payer: Multiplan Auto	$6,638.50
Rate for Payer: Multiplan Commercial	$6,638.50
Rate for Payer: Multiplan Workers Comp	$6,638.50
Rate for Payer: Scott and White EPO/PPO	$6,638.50

5888404R

Facility

$13,907.40

Service Code	HCPCS C1776
Hospital Charge Code	991234
Hospital Revenue Code	278
Min. Negotiated Rate	$1,251.67
Max. Negotiated Rate	$10,013.33
Rate for Payer: Amerigroup CHIP/Medicaid	$1,251.67
Rate for Payer: BCBS of TX Blue Advantage	$4,172.22
Rate for Payer: BCBS of TX Blue Essentials	$5,006.66
Rate for Payer: BCBS of TX PPO	$5,562.96
Rate for Payer: Cash Price	$9,457.03
Rate for Payer: Cigna Medicaid	$10,013.33
Rate for Payer: Molina CHIP/Medicaid	$10,013.33
Rate for Payer: Multiplan Auto	$6,953.70
Rate for Payer: Multiplan Commercial	$6,953.70
Rate for Payer: Multiplan Workers Comp	$6,953.70
Rate for Payer: Parkland Medicaid	$10,013.33
Rate for Payer: Scott and White EPO/PPO	$6,953.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,013.33
Rate for Payer: Superior Health Plan EPO	$1,891.41

5888404R

Facility

$13,907.40

Service Code	HCPCS C1776
Hospital Charge Code	991234
Hospital Revenue Code	278
Min. Negotiated Rate	$3,476.85
Max. Negotiated Rate	$6,953.70
Rate for Payer: Cash Price	$9,457.03
Rate for Payer: Cigna Commercial	$3,476.85
Rate for Payer: Multiplan Auto	$6,953.70
Rate for Payer: Multiplan Commercial	$6,953.70
Rate for Payer: Multiplan Workers Comp	$6,953.70
Rate for Payer: Scott and White EPO/PPO	$6,953.70

5% Dextrose Solution, 0.45%, 1000 mL, Bag

Facility

$12.62

Hospital Charge Code	992982
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.58

5% Dextrose Solution, 0.45%, 1000 mL, Bag

Facility

$12.62

Hospital Charge Code	992982
Hospital Revenue Code	270
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$9.09
Rate for Payer: Amerigroup CHIP/Medicaid	$1.14
Rate for Payer: BCBS of TX Blue Advantage	$3.79
Rate for Payer: BCBS of TX Blue Essentials	$4.54
Rate for Payer: BCBS of TX PPO	$5.05
Rate for Payer: Cash Price	$8.58
Rate for Payer: Cigna Medicaid	$9.09
Rate for Payer: Molina CHIP/Medicaid	$9.09
Rate for Payer: Multiplan Auto	$8.20
Rate for Payer: Multiplan Commercial	$8.20
Rate for Payer: Multiplan Workers Comp	$8.20
Rate for Payer: Parkland Medicaid	$9.09
Rate for Payer: Scott and White EPO/PPO	$6.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.09
Rate for Payer: Superior Health Plan EPO	$1.72

5F CELT Arterial Closure Device Individual Units

Facility

$1,135.00

Hospital Charge Code	993890
Hospital Revenue Code	279
Min. Negotiated Rate	$102.15
Max. Negotiated Rate	$817.20
Rate for Payer: Amerigroup CHIP/Medicaid	$102.15
Rate for Payer: BCBS of TX Blue Advantage	$340.50
Rate for Payer: BCBS of TX Blue Essentials	$408.60
Rate for Payer: BCBS of TX PPO	$454.00
Rate for Payer: Cash Price	$771.80
Rate for Payer: Cigna Medicaid	$817.20
Rate for Payer: Molina CHIP/Medicaid	$817.20
Rate for Payer: Multiplan Auto	$737.75
Rate for Payer: Multiplan Commercial	$737.75
Rate for Payer: Multiplan Workers Comp	$737.75
Rate for Payer: Parkland Medicaid	$817.20
Rate for Payer: Scott and White EPO/PPO	$567.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$817.20
Rate for Payer: Superior Health Plan EPO	$154.36

5F CELT Arterial Closure Device Individual Units

Facility

$1,135.00

Hospital Charge Code	993890
Hospital Revenue Code	279
Rate for Payer: Cash Price	$771.80

5-HIAA,Quant.,24 Hr Urine SO

Facility

$80.00

Service Code	HCPCS 83497
Hospital Charge Code	1702067
Hospital Revenue Code	301
Min. Negotiated Rate	$5.03
Max. Negotiated Rate	$57.60
Rate for Payer: Amerigroup CHIP/Medicaid	$5.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.90
Rate for Payer: Amerigroup Medicare	$12.90
Rate for Payer: BCBS of TX Blue Advantage	$24.00
Rate for Payer: BCBS of TX Blue Essentials	$28.80
Rate for Payer: BCBS of TX Medicare	$12.90
Rate for Payer: BCBS of TX PPO	$32.00
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cigna Medicaid	$57.60
Rate for Payer: Cigna Medicare	$12.90
Rate for Payer: Employer Direct Commercial	$12.90
Rate for Payer: Humana Medicare/TRICARE	$12.90
Rate for Payer: Molina CHIP/Medicaid	$57.60
Rate for Payer: Molina Dual Medicare/Medicaid	$12.90
Rate for Payer: Molina Medicare	$12.90
Rate for Payer: Multiplan Auto	$52.00
Rate for Payer: Multiplan Commercial	$52.00
Rate for Payer: Multiplan Workers Comp	$52.00
Rate for Payer: Parkland Medicaid	$57.60
Rate for Payer: Scott and White EPO/PPO	$16.12
Rate for Payer: Scott and White Medicare	$12.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$57.60
Rate for Payer: Superior Health Plan EPO	$12.90
Rate for Payer: Superior Health Plan Medicare	$12.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.90
Rate for Payer: Universal American Medicare	$12.90
Rate for Payer: Wellcare Medicare	$12.90
Rate for Payer: Wellmed Medicare	$12.90

5-HIAA,Quant.,24 Hr Urine SO

Facility

$80.00

Service Code	HCPCS 83497
Hospital Charge Code	1702067
Hospital Revenue Code	301
Rate for Payer: Cash Price	$54.40

5K BG/COOK 75 TEST PAK 31D

Facility

$6,419.92

Hospital Charge Code	993566
Hospital Revenue Code	270
Min. Negotiated Rate	$577.79
Max. Negotiated Rate	$4,622.34
Rate for Payer: Amerigroup CHIP/Medicaid	$577.79
Rate for Payer: BCBS of TX Blue Advantage	$1,925.98
Rate for Payer: BCBS of TX Blue Essentials	$2,311.17
Rate for Payer: BCBS of TX PPO	$2,567.97
Rate for Payer: Cash Price	$4,365.55
Rate for Payer: Cigna Medicaid	$4,622.34
Rate for Payer: Molina CHIP/Medicaid	$4,622.34
Rate for Payer: Multiplan Auto	$4,172.95
Rate for Payer: Multiplan Commercial	$4,172.95
Rate for Payer: Multiplan Workers Comp	$4,172.95
Rate for Payer: Parkland Medicaid	$4,622.34
Rate for Payer: Scott and White EPO/PPO	$3,209.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,622.34
Rate for Payer: Superior Health Plan EPO	$873.11

5K BG/COOK 75 TEST PAK 31D

Facility

$6,419.92

Hospital Charge Code	993566
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4,365.55

5mm x 10cm x 135cm

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992548
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

5mm x 10cm x 135cm

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992548
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

5mm x 12cm x 135cm Saber Balloon

Facility

$612.90

Service Code	HCPCS C1726
Hospital Charge Code	992549
Hospital Revenue Code	272
Min. Negotiated Rate	$55.16
Max. Negotiated Rate	$441.29
Rate for Payer: Amerigroup CHIP/Medicaid	$55.16
Rate for Payer: BCBS of TX Blue Advantage	$183.87
Rate for Payer: BCBS of TX Blue Essentials	$220.64
Rate for Payer: BCBS of TX PPO	$245.16
Rate for Payer: Cash Price	$416.77
Rate for Payer: Cigna Medicaid	$441.29
Rate for Payer: Molina CHIP/Medicaid	$441.29
Rate for Payer: Multiplan Auto	$398.38
Rate for Payer: Multiplan Commercial	$398.38
Rate for Payer: Multiplan Workers Comp	$398.38
Rate for Payer: Parkland Medicaid	$441.29
Rate for Payer: Scott and White EPO/PPO	$306.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$441.29
Rate for Payer: Superior Health Plan EPO	$83.35

5mm x 12cm x 135cm Saber Balloon

Facility

$612.90

Service Code	HCPCS C1726
Hospital Charge Code	992549
Hospital Revenue Code	272
Rate for Payer: Cash Price	$416.77

5mm x 40mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992545
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

5mm x 40mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992545
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

5mmx60mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992546
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

5mmx60mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992546
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

5mm x 8cm x 135cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992547
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

Know your out-of-pocket cost for care.

All Charges