White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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
Rate for Payer: Cash Price	$385.90

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 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 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 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

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

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

5mm x 8cm x 135cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992547
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

604650

Facility

$1,891.56

Service Code	HCPCS C1713
Hospital Charge Code	994042
Hospital Revenue Code	278
Min. Negotiated Rate	$472.89
Max. Negotiated Rate	$945.78
Rate for Payer: Cash Price	$1,286.26
Rate for Payer: Cigna Commercial	$472.89
Rate for Payer: Multiplan Auto	$945.78
Rate for Payer: Multiplan Commercial	$945.78
Rate for Payer: Multiplan Workers Comp	$945.78
Rate for Payer: Scott and White EPO/PPO	$945.78

604650

Facility

$1,891.56

Service Code	HCPCS C1713
Hospital Charge Code	994042
Hospital Revenue Code	278
Min. Negotiated Rate	$170.24
Max. Negotiated Rate	$1,361.92
Rate for Payer: Amerigroup CHIP/Medicaid	$170.24
Rate for Payer: BCBS of TX Blue Advantage	$567.47
Rate for Payer: BCBS of TX Blue Essentials	$680.96
Rate for Payer: BCBS of TX PPO	$756.62
Rate for Payer: Cash Price	$1,286.26
Rate for Payer: Cigna Medicaid	$1,361.92
Rate for Payer: Molina CHIP/Medicaid	$1,361.92
Rate for Payer: Multiplan Auto	$945.78
Rate for Payer: Multiplan Commercial	$945.78
Rate for Payer: Multiplan Workers Comp	$945.78
Rate for Payer: Parkland Medicaid	$1,361.92
Rate for Payer: Scott and White EPO/PPO	$945.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,361.92
Rate for Payer: Superior Health Plan EPO	$257.25

6.0mm x 70mm Screw, Headless, PT, Ti

Facility

$2,819.28

Service Code	HCPCS C1713
Hospital Charge Code	992186
Hospital Revenue Code	278
Min. Negotiated Rate	$253.74
Max. Negotiated Rate	$2,029.88
Rate for Payer: Amerigroup CHIP/Medicaid	$253.74
Rate for Payer: BCBS of TX Blue Advantage	$845.78
Rate for Payer: BCBS of TX Blue Essentials	$1,014.94
Rate for Payer: BCBS of TX PPO	$1,127.71
Rate for Payer: Cash Price	$1,917.11
Rate for Payer: Cigna Medicaid	$2,029.88
Rate for Payer: Molina CHIP/Medicaid	$2,029.88
Rate for Payer: Multiplan Auto	$1,409.64
Rate for Payer: Multiplan Commercial	$1,409.64
Rate for Payer: Multiplan Workers Comp	$1,409.64
Rate for Payer: Parkland Medicaid	$2,029.88
Rate for Payer: Scott and White EPO/PPO	$1,409.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,029.88
Rate for Payer: Superior Health Plan EPO	$383.42

6.0mm x 70mm Screw, Headless, PT, Ti

Facility

$2,819.28

Service Code	HCPCS C1713
Hospital Charge Code	992186
Hospital Revenue Code	278
Min. Negotiated Rate	$704.82
Max. Negotiated Rate	$1,409.64
Rate for Payer: Cash Price	$1,917.11
Rate for Payer: Cigna Commercial	$704.82
Rate for Payer: Multiplan Auto	$1,409.64
Rate for Payer: Multiplan Commercial	$1,409.64
Rate for Payer: Multiplan Workers Comp	$1,409.64
Rate for Payer: Scott and White EPO/PPO	$1,409.64

6191-1-001

Facility

$572.59

Service Code	HCPCS A4649
Hospital Charge Code	991110
Hospital Revenue Code	272
Rate for Payer: Cash Price	$389.36

6191-1-001

Facility

$572.59

Service Code	HCPCS A4649
Hospital Charge Code	991110
Hospital Revenue Code	272
Min. Negotiated Rate	$51.53
Max. Negotiated Rate	$412.26
Rate for Payer: Amerigroup CHIP/Medicaid	$51.53
Rate for Payer: BCBS of TX Blue Advantage	$171.78
Rate for Payer: BCBS of TX Blue Essentials	$206.13
Rate for Payer: BCBS of TX PPO	$229.04
Rate for Payer: Cash Price	$389.36
Rate for Payer: Cigna Medicaid	$412.26
Rate for Payer: Molina CHIP/Medicaid	$412.26
Rate for Payer: Multiplan Auto	$372.18
Rate for Payer: Multiplan Commercial	$372.18
Rate for Payer: Multiplan Workers Comp	$372.18
Rate for Payer: Parkland Medicaid	$412.26
Rate for Payer: Scott and White EPO/PPO	$286.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$412.26
Rate for Payer: Superior Health Plan EPO	$77.87

6197-9-001

Facility

$2,152.00

Service Code	HCPCS C1713
Hospital Charge Code	990973
Hospital Revenue Code	278
Min. Negotiated Rate	$538.00
Max. Negotiated Rate	$1,076.00
Rate for Payer: Cash Price	$1,463.36
Rate for Payer: Cigna Commercial	$538.00
Rate for Payer: Multiplan Auto	$1,076.00
Rate for Payer: Multiplan Commercial	$1,076.00
Rate for Payer: Multiplan Workers Comp	$1,076.00
Rate for Payer: Scott and White EPO/PPO	$1,076.00

6197-9-001

Facility

$2,152.00

Service Code	HCPCS C1713
Hospital Charge Code	990973
Hospital Revenue Code	278
Min. Negotiated Rate	$193.68
Max. Negotiated Rate	$1,549.44
Rate for Payer: Amerigroup CHIP/Medicaid	$193.68
Rate for Payer: BCBS of TX Blue Advantage	$645.60
Rate for Payer: BCBS of TX Blue Essentials	$774.72
Rate for Payer: BCBS of TX PPO	$860.80
Rate for Payer: Cash Price	$1,463.36
Rate for Payer: Cigna Medicaid	$1,549.44
Rate for Payer: Molina CHIP/Medicaid	$1,549.44
Rate for Payer: Multiplan Auto	$1,076.00
Rate for Payer: Multiplan Commercial	$1,076.00
Rate for Payer: Multiplan Workers Comp	$1,076.00
Rate for Payer: Parkland Medicaid	$1,549.44
Rate for Payer: Scott and White EPO/PPO	$1,076.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,549.44
Rate for Payer: Superior Health Plan EPO	$292.67

619905

Facility

$240.96

Hospital Charge Code	994043
Hospital Revenue Code	272
Rate for Payer: Cash Price	$163.85

619905

Facility

$240.96

Hospital Charge Code	994043
Hospital Revenue Code	272
Min. Negotiated Rate	$21.69
Max. Negotiated Rate	$173.49
Rate for Payer: Amerigroup CHIP/Medicaid	$21.69
Rate for Payer: BCBS of TX Blue Advantage	$72.29
Rate for Payer: BCBS of TX Blue Essentials	$86.75
Rate for Payer: BCBS of TX PPO	$96.38
Rate for Payer: Cash Price	$163.85
Rate for Payer: Cigna Medicaid	$173.49
Rate for Payer: Molina CHIP/Medicaid	$173.49
Rate for Payer: Multiplan Auto	$156.62
Rate for Payer: Multiplan Commercial	$156.62
Rate for Payer: Multiplan Workers Comp	$156.62
Rate for Payer: Parkland Medicaid	$173.49
Rate for Payer: Scott and White EPO/PPO	$120.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$173.49
Rate for Payer: Superior Health Plan EPO	$32.77

626-00-38D

Facility

$2,874.96

Service Code	HCPCS C1776
Hospital Charge Code	994000
Hospital Revenue Code	278
Min. Negotiated Rate	$258.75
Max. Negotiated Rate	$2,069.97
Rate for Payer: Amerigroup CHIP/Medicaid	$258.75
Rate for Payer: BCBS of TX Blue Advantage	$862.49
Rate for Payer: BCBS of TX Blue Essentials	$1,034.99
Rate for Payer: BCBS of TX PPO	$1,149.98
Rate for Payer: Cash Price	$1,954.97
Rate for Payer: Cigna Medicaid	$2,069.97
Rate for Payer: Molina CHIP/Medicaid	$2,069.97
Rate for Payer: Multiplan Auto	$1,437.48
Rate for Payer: Multiplan Commercial	$1,437.48
Rate for Payer: Multiplan Workers Comp	$1,437.48
Rate for Payer: Parkland Medicaid	$2,069.97
Rate for Payer: Scott and White EPO/PPO	$1,437.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,069.97
Rate for Payer: Superior Health Plan EPO	$390.99

626-00-38D

Facility

$2,874.96

Service Code	HCPCS C1776
Hospital Charge Code	994000
Hospital Revenue Code	278
Min. Negotiated Rate	$718.74
Max. Negotiated Rate	$1,437.48
Rate for Payer: Cash Price	$1,954.97
Rate for Payer: Cigna Commercial	$718.74
Rate for Payer: Multiplan Auto	$1,437.48
Rate for Payer: Multiplan Commercial	$1,437.48
Rate for Payer: Multiplan Workers Comp	$1,437.48
Rate for Payer: Scott and White EPO/PPO	$1,437.48

Know your out-of-pocket cost for care.

All Charges