White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHWR MA BREAST BX/LOC/SPECIMEN EA ADD

Facility

$1,913.00

Service Code	HCPCS 19082
Hospital Charge Code	5019182
Hospital Revenue Code	361
Min. Negotiated Rate	$172.17
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$172.17
Rate for Payer: BCBS of TX Blue Advantage	$573.90
Rate for Payer: BCBS of TX Blue Essentials	$688.68
Rate for Payer: BCBS of TX PPO	$765.20
Rate for Payer: Cash Price	$1,300.84
Rate for Payer: Cash Price	$1,300.84
Rate for Payer: Cigna Medicaid	$1,377.36
Rate for Payer: Molina CHIP/Medicaid	$1,377.36
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	$1,377.36
Rate for Payer: Scott and White EPO/PPO	$956.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,377.36
Rate for Payer: Superior Health Plan EPO	$260.17

CHWR MA BREAST BX/LOC/SPECIMEN EA ADD

Facility

$1,913.00

Service Code	HCPCS 19082
Hospital Charge Code	5019182
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,300.84

CHWR MA BRST LOC DEVICE ADD LES STEREO

Facility

$601.00

Service Code	HCPCS 19284
Hospital Charge Code	5019284
Hospital Revenue Code	361
Min. Negotiated Rate	$54.09
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$54.09
Rate for Payer: BCBS of TX Blue Advantage	$180.30
Rate for Payer: BCBS of TX Blue Essentials	$216.36
Rate for Payer: BCBS of TX PPO	$240.40
Rate for Payer: Cash Price	$408.68
Rate for Payer: Cash Price	$408.68
Rate for Payer: Cigna Medicaid	$432.72
Rate for Payer: Molina CHIP/Medicaid	$432.72
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	$432.72
Rate for Payer: Scott and White EPO/PPO	$300.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$432.72
Rate for Payer: Superior Health Plan EPO	$81.74

CHWR MA BRST LOC DEVICE ADD LES STEREO

Facility

$601.00

Service Code	HCPCS 19284
Hospital Charge Code	5019284
Hospital Revenue Code	361
Rate for Payer: Cash Price	$408.68

CHWR MANDRIL WIRE

Facility

$225.38

Hospital Charge Code	8073075
Hospital Revenue Code	272
Rate for Payer: Cash Price	$153.26

CHWR MANDRIL WIRE

Facility

$225.38

Hospital Charge Code	8073075
Hospital Revenue Code	272
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$162.27
Rate for Payer: Amerigroup CHIP/Medicaid	$20.28
Rate for Payer: BCBS of TX Blue Advantage	$67.61
Rate for Payer: BCBS of TX Blue Essentials	$81.14
Rate for Payer: BCBS of TX PPO	$90.15
Rate for Payer: Cash Price	$153.26
Rate for Payer: Cigna Medicaid	$162.27
Rate for Payer: Molina CHIP/Medicaid	$162.27
Rate for Payer: Multiplan Auto	$146.50
Rate for Payer: Multiplan Commercial	$146.50
Rate for Payer: Multiplan Workers Comp	$146.50
Rate for Payer: Parkland Medicaid	$162.27
Rate for Payer: Scott and White EPO/PPO	$112.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$162.27
Rate for Payer: Superior Health Plan EPO	$30.65

CHWR MA PERC DEVICE BREAST 1ST

Facility

$593.00

Service Code	HCPCS 19282
Hospital Charge Code	5019282
Hospital Revenue Code	361
Min. Negotiated Rate	$53.37
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$53.37
Rate for Payer: BCBS of TX Blue Advantage	$177.90
Rate for Payer: BCBS of TX Blue Essentials	$213.48
Rate for Payer: BCBS of TX PPO	$237.20
Rate for Payer: Cash Price	$403.24
Rate for Payer: Cash Price	$403.24
Rate for Payer: Cigna Medicaid	$426.96
Rate for Payer: Molina CHIP/Medicaid	$426.96
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	$426.96
Rate for Payer: Scott and White EPO/PPO	$296.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$426.96
Rate for Payer: Superior Health Plan EPO	$80.65

CHWR MA PERC DEVICE BREAST 1ST

Facility

$593.00

Service Code	HCPCS 19282
Hospital Charge Code	5019282
Hospital Revenue Code	361
Rate for Payer: Cash Price	$403.24

CHWR MA SCREENING DIGITAL BRST TOMO BIL

Facility

$66.00

Service Code	HCPCS 77063
Hospital Charge Code	5017063
Hospital Revenue Code	403
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$55.76
Rate for Payer: Amerigroup CHIP/Medicaid	$52.46
Rate for Payer: BCBS of TX Blue Advantage	$41.63
Rate for Payer: BCBS of TX Blue Essentials	$49.96
Rate for Payer: BCBS of TX PPO	$55.76
Rate for Payer: Cash Price	$44.88
Rate for Payer: Cash Price	$44.88
Rate for Payer: Cigna Medicaid	$47.52
Rate for Payer: Molina CHIP/Medicaid	$47.52
Rate for Payer: Multiplan Auto	$42.90
Rate for Payer: Multiplan Commercial	$42.90
Rate for Payer: Multiplan Workers Comp	$42.90
Rate for Payer: Parkland Medicaid	$47.52
Rate for Payer: Scott and White EPO/PPO	$33.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47.52
Rate for Payer: Superior Health Plan EPO	$8.98

CHWR MA SCREENING DIGITAL BRST TOMO BIL

Facility

$66.00

Service Code	HCPCS 77063
Hospital Charge Code	5017063
Hospital Revenue Code	403
Rate for Payer: Cash Price	$44.88

CHWR MYELOGRAM TRAY

Facility

$575.58

Hospital Charge Code	8083900
Hospital Revenue Code	272
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$414.42
Rate for Payer: Amerigroup CHIP/Medicaid	$51.80
Rate for Payer: BCBS of TX Blue Advantage	$172.67
Rate for Payer: BCBS of TX Blue Essentials	$207.21
Rate for Payer: BCBS of TX PPO	$230.23
Rate for Payer: Cash Price	$391.39
Rate for Payer: Cigna Medicaid	$414.42
Rate for Payer: Molina CHIP/Medicaid	$414.42
Rate for Payer: Multiplan Auto	$374.13
Rate for Payer: Multiplan Commercial	$374.13
Rate for Payer: Multiplan Workers Comp	$374.13
Rate for Payer: Parkland Medicaid	$414.42
Rate for Payer: Scott and White EPO/PPO	$287.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$414.42
Rate for Payer: Superior Health Plan EPO	$78.28

CHWR MYELOGRAM TRAY

Facility

$575.58

Hospital Charge Code	8083900
Hospital Revenue Code	272
Rate for Payer: Cash Price	$391.39

CHWR NEEDLE GUIDE 12G

Facility

$42.70

Hospital Charge Code	8073029
Hospital Revenue Code	272
Min. Negotiated Rate	$3.84
Max. Negotiated Rate	$30.74
Rate for Payer: Amerigroup CHIP/Medicaid	$3.84
Rate for Payer: BCBS of TX Blue Advantage	$12.81
Rate for Payer: BCBS of TX Blue Essentials	$15.37
Rate for Payer: BCBS of TX PPO	$17.08
Rate for Payer: Cash Price	$29.04
Rate for Payer: Cigna Medicaid	$30.74
Rate for Payer: Molina CHIP/Medicaid	$30.74
Rate for Payer: Multiplan Auto	$27.75
Rate for Payer: Multiplan Commercial	$27.75
Rate for Payer: Multiplan Workers Comp	$27.75
Rate for Payer: Parkland Medicaid	$30.74
Rate for Payer: Scott and White EPO/PPO	$21.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.74
Rate for Payer: Superior Health Plan EPO	$5.81

CHWR NEEDLE GUIDE 12G

Facility

$42.70

Hospital Charge Code	8073029
Hospital Revenue Code	272
Rate for Payer: Cash Price	$29.04

CHWR NM Tc-99m FILTER SULFUR COOLID

Facility

$133.60

Hospital Charge Code	5199242
Hospital Revenue Code	343
Rate for Payer: Cash Price	$90.85

CHWR NM Tc-99m FILTER SULFUR COOLID

Facility

$133.60

Hospital Charge Code	5199242
Hospital Revenue Code	343
Min. Negotiated Rate	$12.02
Max. Negotiated Rate	$96.19
Rate for Payer: Amerigroup CHIP/Medicaid	$12.02
Rate for Payer: BCBS of TX Blue Advantage	$40.08
Rate for Payer: BCBS of TX Blue Essentials	$48.10
Rate for Payer: BCBS of TX PPO	$53.44
Rate for Payer: Cash Price	$90.85
Rate for Payer: Cigna Medicaid	$96.19
Rate for Payer: Molina CHIP/Medicaid	$96.19
Rate for Payer: Multiplan Auto	$86.84
Rate for Payer: Multiplan Commercial	$86.84
Rate for Payer: Multiplan Workers Comp	$86.84
Rate for Payer: Parkland Medicaid	$96.19
Rate for Payer: Scott and White EPO/PPO	$66.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.19
Rate for Payer: Superior Health Plan EPO	$18.17

CHWR PNEUMOTHORAX TRAY

Facility

$903.51

Hospital Charge Code	8082755
Hospital Revenue Code	270
Rate for Payer: Cash Price	$614.39

CHWR PNEUMOTHORAX TRAY

Facility

$903.51

Hospital Charge Code	8082755
Hospital Revenue Code	270
Min. Negotiated Rate	$81.32
Max. Negotiated Rate	$650.53
Rate for Payer: Amerigroup CHIP/Medicaid	$81.32
Rate for Payer: BCBS of TX Blue Advantage	$271.05
Rate for Payer: BCBS of TX Blue Essentials	$325.26
Rate for Payer: BCBS of TX PPO	$361.40
Rate for Payer: Cash Price	$614.39
Rate for Payer: Cigna Medicaid	$650.53
Rate for Payer: Molina CHIP/Medicaid	$650.53
Rate for Payer: Multiplan Auto	$587.28
Rate for Payer: Multiplan Commercial	$587.28
Rate for Payer: Multiplan Workers Comp	$587.28
Rate for Payer: Parkland Medicaid	$650.53
Rate for Payer: Scott and White EPO/PPO	$451.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$650.53
Rate for Payer: Superior Health Plan EPO	$122.88

CHWR PROTECTOR WIRE LOC NEEDLE

Facility

$54.74

Hospital Charge Code	8073177
Hospital Revenue Code	272
Rate for Payer: Cash Price	$37.22

CHWR PROTECTOR WIRE LOC NEEDLE

Facility

$54.74

Hospital Charge Code	8073177
Hospital Revenue Code	272
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$39.41
Rate for Payer: Amerigroup CHIP/Medicaid	$4.93
Rate for Payer: BCBS of TX Blue Advantage	$16.42
Rate for Payer: BCBS of TX Blue Essentials	$19.71
Rate for Payer: BCBS of TX PPO	$21.90
Rate for Payer: Cash Price	$37.22
Rate for Payer: Cigna Medicaid	$39.41
Rate for Payer: Molina CHIP/Medicaid	$39.41
Rate for Payer: Multiplan Auto	$35.58
Rate for Payer: Multiplan Commercial	$35.58
Rate for Payer: Multiplan Workers Comp	$35.58
Rate for Payer: Parkland Medicaid	$39.41
Rate for Payer: Scott and White EPO/PPO	$27.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.41
Rate for Payer: Superior Health Plan EPO	$7.44

CHWR SAFETY SOFT TISSUE BIOPSY TRAY

Facility

$123.54

Hospital Charge Code	8083040
Hospital Revenue Code	272
Rate for Payer: Cash Price	$84.01

CHWR SAFETY SOFT TISSUE BIOPSY TRAY

Facility

$123.54

Hospital Charge Code	8083040
Hospital Revenue Code	272
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$88.95
Rate for Payer: Amerigroup CHIP/Medicaid	$11.12
Rate for Payer: BCBS of TX Blue Advantage	$37.06
Rate for Payer: BCBS of TX Blue Essentials	$44.47
Rate for Payer: BCBS of TX PPO	$49.42
Rate for Payer: Cash Price	$84.01
Rate for Payer: Cigna Medicaid	$88.95
Rate for Payer: Molina CHIP/Medicaid	$88.95
Rate for Payer: Multiplan Auto	$80.30
Rate for Payer: Multiplan Commercial	$80.30
Rate for Payer: Multiplan Workers Comp	$80.30
Rate for Payer: Parkland Medicaid	$88.95
Rate for Payer: Scott and White EPO/PPO	$61.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$88.95
Rate for Payer: Superior Health Plan EPO	$16.80

CHWR SPINAL NEEDLE ANY SIZE

Facility

$78.04

Hospital Charge Code	8032875
Hospital Revenue Code	272
Rate for Payer: Cash Price	$53.07

CHWR SPINAL NEEDLE ANY SIZE

Facility

$78.04

Hospital Charge Code	8032875
Hospital Revenue Code	272
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$56.19
Rate for Payer: Amerigroup CHIP/Medicaid	$7.02
Rate for Payer: BCBS of TX Blue Advantage	$23.41
Rate for Payer: BCBS of TX Blue Essentials	$28.09
Rate for Payer: BCBS of TX PPO	$31.22
Rate for Payer: Cash Price	$53.07
Rate for Payer: Cigna Medicaid	$56.19
Rate for Payer: Molina CHIP/Medicaid	$56.19
Rate for Payer: Multiplan Auto	$50.73
Rate for Payer: Multiplan Commercial	$50.73
Rate for Payer: Multiplan Workers Comp	$50.73
Rate for Payer: Parkland Medicaid	$56.19
Rate for Payer: Scott and White EPO/PPO	$39.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56.19
Rate for Payer: Superior Health Plan EPO	$10.61

CHWR STERI STRIPS

Facility

$55.15

Hospital Charge Code	8185055
Hospital Revenue Code	272
Rate for Payer: Cash Price	$37.50

Know your out-of-pocket cost for care.

All Charges