White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHWR US BREAST LOC DEVICE ADD LESION

Facility

$995.00

Service Code	HCPCS 19286
Hospital Charge Code	5069286
Hospital Revenue Code	361
Min. Negotiated Rate	$89.55
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$89.55
Rate for Payer: BCBS of TX Blue Advantage	$298.50
Rate for Payer: BCBS of TX Blue Essentials	$358.20
Rate for Payer: BCBS of TX PPO	$398.00
Rate for Payer: Cash Price	$676.60
Rate for Payer: Cash Price	$676.60
Rate for Payer: Cigna Medicaid	$716.40
Rate for Payer: Molina CHIP/Medicaid	$716.40
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	$716.40
Rate for Payer: Scott and White EPO/PPO	$497.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$716.40
Rate for Payer: Superior Health Plan EPO	$135.32

CHWR US BREAST LOC DEVICE ADD LESION

Facility

$995.00

Service Code	HCPCS 19286
Hospital Charge Code	5069286
Hospital Revenue Code	361
Rate for Payer: Cash Price	$676.60

CHWR US GUIDE NEEDLE PLACEMENT

Facility

$1,596.00

Service Code	HCPCS 76942
Hospital Charge Code	5066960
Hospital Revenue Code	402
Min. Negotiated Rate	$41.63
Max. Negotiated Rate	$1,149.12
Rate for Payer: Amerigroup CHIP/Medicaid	$143.64
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	$1,085.28
Rate for Payer: Cash Price	$1,085.28
Rate for Payer: Cigna Medicaid	$1,149.12
Rate for Payer: Molina CHIP/Medicaid	$1,149.12
Rate for Payer: Multiplan Auto	$1,037.40
Rate for Payer: Multiplan Commercial	$1,037.40
Rate for Payer: Multiplan Workers Comp	$1,037.40
Rate for Payer: Parkland Medicaid	$1,149.12
Rate for Payer: Scott and White EPO/PPO	$71.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.12
Rate for Payer: Superior Health Plan EPO	$217.06

CHWR US GUIDE NEEDLE PLACEMENT

Facility

$1,596.00

Service Code	HCPCS 76942
Hospital Charge Code	5066960
Hospital Revenue Code	402
Rate for Payer: Cash Price	$1,085.28

CHWR US GUIDE PERC DRAIN ABSCESS W/CATH

Facility

$3,174.00

Service Code	HCPCS 75989
Hospital Charge Code	5055990
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,158.32

CHWR US GUIDE PERC DRAIN ABSCESS W/CATH

Facility

$3,174.00

Service Code	HCPCS 75989
Hospital Charge Code	5055990
Hospital Revenue Code	320
Min. Negotiated Rate	$105.25
Max. Negotiated Rate	$2,285.28
Rate for Payer: Amerigroup CHIP/Medicaid	$285.66
Rate for Payer: BCBS of TX Blue Advantage	$105.25
Rate for Payer: BCBS of TX Blue Essentials	$126.30
Rate for Payer: BCBS of TX PPO	$140.98
Rate for Payer: Cash Price	$2,158.32
Rate for Payer: Cash Price	$2,158.32
Rate for Payer: Cigna Medicaid	$2,285.28
Rate for Payer: Molina CHIP/Medicaid	$2,285.28
Rate for Payer: Multiplan Auto	$2,063.10
Rate for Payer: Multiplan Commercial	$2,063.10
Rate for Payer: Multiplan Workers Comp	$2,063.10
Rate for Payer: Parkland Medicaid	$2,285.28
Rate for Payer: Scott and White EPO/PPO	$137.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,285.28
Rate for Payer: Superior Health Plan EPO	$431.66

CHWR US GUIDE PERC DRAIN ABSCESS W/CATH

Facility

$3,174.00

Service Code	HCPCS 75989
Hospital Charge Code	5067630
Hospital Revenue Code	320
Min. Negotiated Rate	$105.25
Max. Negotiated Rate	$2,285.28
Rate for Payer: Amerigroup CHIP/Medicaid	$285.66
Rate for Payer: BCBS of TX Blue Advantage	$105.25
Rate for Payer: BCBS of TX Blue Essentials	$126.30
Rate for Payer: BCBS of TX PPO	$140.98
Rate for Payer: Cash Price	$2,158.32
Rate for Payer: Cash Price	$2,158.32
Rate for Payer: Cigna Medicaid	$2,285.28
Rate for Payer: Molina CHIP/Medicaid	$2,285.28
Rate for Payer: Multiplan Auto	$2,063.10
Rate for Payer: Multiplan Commercial	$2,063.10
Rate for Payer: Multiplan Workers Comp	$2,063.10
Rate for Payer: Parkland Medicaid	$2,285.28
Rate for Payer: Scott and White EPO/PPO	$137.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,285.28
Rate for Payer: Superior Health Plan EPO	$431.66

CHWR US GUIDE PERC DRAIN ABSCESS W/CATH

Facility

$3,174.00

Service Code	HCPCS 75989
Hospital Charge Code	5067630
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,158.32

CHWR US OB COMP>14WK ADD GEST

Facility

$1,076.00

Service Code	HCPCS 76810
Hospital Charge Code	5066843
Hospital Revenue Code	402
Min. Negotiated Rate	$71.36
Max. Negotiated Rate	$774.72
Rate for Payer: Amerigroup CHIP/Medicaid	$87.54
Rate for Payer: BCBS of TX Blue Advantage	$71.36
Rate for Payer: BCBS of TX Blue Essentials	$85.64
Rate for Payer: BCBS of TX PPO	$95.58
Rate for Payer: Cash Price	$731.68
Rate for Payer: Cash Price	$731.68
Rate for Payer: Cigna Medicaid	$774.72
Rate for Payer: Molina CHIP/Medicaid	$774.72
Rate for Payer: Multiplan Auto	$699.40
Rate for Payer: Multiplan Commercial	$699.40
Rate for Payer: Multiplan Workers Comp	$699.40
Rate for Payer: Parkland Medicaid	$774.72
Rate for Payer: Scott and White EPO/PPO	$107.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$774.72
Rate for Payer: Superior Health Plan EPO	$146.34

CHWR US OB COMP>14WK ADD GEST

Facility

$1,076.00

Service Code	HCPCS 76810
Hospital Charge Code	5066843
Hospital Revenue Code	402
Rate for Payer: Cash Price	$731.68

CHWR US OB COMP W/DET ADD GEST

Facility

$631.00

Service Code	HCPCS 76812
Hospital Charge Code	5066812
Hospital Revenue Code	402
Rate for Payer: Cash Price	$429.08

CHWR US OB COMP W/DET ADD GEST

Facility

$631.00

Service Code	HCPCS 76812
Hospital Charge Code	5066812
Hospital Revenue Code	402
Min. Negotiated Rate	$85.82
Max. Negotiated Rate	$454.32
Rate for Payer: Amerigroup CHIP/Medicaid	$192.13
Rate for Payer: BCBS of TX Blue Advantage	$184.34
Rate for Payer: BCBS of TX Blue Essentials	$221.21
Rate for Payer: BCBS of TX PPO	$246.90
Rate for Payer: Cash Price	$429.08
Rate for Payer: Cash Price	$429.08
Rate for Payer: Cigna Medicaid	$454.32
Rate for Payer: Molina CHIP/Medicaid	$454.32
Rate for Payer: Multiplan Auto	$410.15
Rate for Payer: Multiplan Commercial	$410.15
Rate for Payer: Multiplan Workers Comp	$410.15
Rate for Payer: Parkland Medicaid	$454.32
Rate for Payer: Scott and White EPO/PPO	$236.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$454.32
Rate for Payer: Superior Health Plan EPO	$85.82

CHWR U/S STERILE PROBE COVER

Facility

$34.05

Hospital Charge Code	8034188
Hospital Revenue Code	270
Rate for Payer: Cash Price	$23.15

CHWR U/S STERILE PROBE COVER

Facility

$34.05

Hospital Charge Code	8034188
Hospital Revenue Code	270
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$24.52
Rate for Payer: Amerigroup CHIP/Medicaid	$3.06
Rate for Payer: BCBS of TX Blue Advantage	$10.21
Rate for Payer: BCBS of TX Blue Essentials	$12.26
Rate for Payer: BCBS of TX PPO	$13.62
Rate for Payer: Cash Price	$23.15
Rate for Payer: Cigna Medicaid	$24.52
Rate for Payer: Molina CHIP/Medicaid	$24.52
Rate for Payer: Multiplan Auto	$22.13
Rate for Payer: Multiplan Commercial	$22.13
Rate for Payer: Multiplan Workers Comp	$22.13
Rate for Payer: Parkland Medicaid	$24.52
Rate for Payer: Scott and White EPO/PPO	$17.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.52
Rate for Payer: Superior Health Plan EPO	$4.63

CHWR US TRANSVAGINAL NON-OB

Facility

$978.00

Service Code	HCPCS 76830
Hospital Charge Code	5066830
Hospital Revenue Code	402
Rate for Payer: Cash Price	$665.04

CHWR US TRANSVAGINAL NON-OB

Facility

$978.00

Service Code	HCPCS 76830
Hospital Charge Code	5066830
Hospital Revenue Code	402
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$704.16
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$145.69
Rate for Payer: BCBS of TX Blue Essentials	$174.83
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$195.14
Rate for Payer: Cash Price	$665.04
Rate for Payer: Cash Price	$665.04
Rate for Payer: Cash Price	$665.04
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$704.16
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$704.16
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$635.70
Rate for Payer: Multiplan Commercial	$635.70
Rate for Payer: Multiplan Workers Comp	$635.70
Rate for Payer: Parkland Medicaid	$704.16
Rate for Payer: Scott and White EPO/PPO	$147.40
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$704.16
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

CHWR US TRANSVAGINAL OB

Facility

$303.00

Service Code	HCPCS 76817
Hospital Charge Code	5066816
Hospital Revenue Code	402
Min. Negotiated Rate	$92.89
Max. Negotiated Rate	$247.70
Rate for Payer: Amerigroup CHIP/Medicaid	$92.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$206.04
Rate for Payer: Cash Price	$206.04
Rate for Payer: Cash Price	$206.04
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$218.16
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$218.16
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$196.95
Rate for Payer: Multiplan Commercial	$196.95
Rate for Payer: Multiplan Workers Comp	$196.95
Rate for Payer: Parkland Medicaid	$218.16
Rate for Payer: Scott and White EPO/PPO	$114.49
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$218.16
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

CHWR US TRANSVAGINAL OB

Facility

$303.00

Service Code	HCPCS 76817
Hospital Charge Code	5066816
Hospital Revenue Code	402
Rate for Payer: Cash Price	$206.04

CHWR VACCUTAINER

Facility

$29.00

Hospital Charge Code	5420130
Hospital Revenue Code	272
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$20.88
Rate for Payer: Amerigroup CHIP/Medicaid	$2.61
Rate for Payer: BCBS of TX Blue Advantage	$8.70
Rate for Payer: BCBS of TX Blue Essentials	$10.44
Rate for Payer: BCBS of TX PPO	$11.60
Rate for Payer: Cash Price	$19.72
Rate for Payer: Cigna Medicaid	$20.88
Rate for Payer: Molina CHIP/Medicaid	$20.88
Rate for Payer: Multiplan Auto	$18.85
Rate for Payer: Multiplan Commercial	$18.85
Rate for Payer: Multiplan Workers Comp	$18.85
Rate for Payer: Parkland Medicaid	$20.88
Rate for Payer: Scott and White EPO/PPO	$14.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.88
Rate for Payer: Superior Health Plan EPO	$3.94

CHWR VACCUTAINER

Facility

$29.00

Hospital Charge Code	5420130
Hospital Revenue Code	272
Rate for Payer: Cash Price	$19.72

CHWR WATER SEAL CHEST TUBE KIT

Facility

$134.96

Hospital Charge Code	8032060
Hospital Revenue Code	270
Rate for Payer: Cash Price	$91.77

CHWR WATER SEAL CHEST TUBE KIT

Facility

$134.96

Hospital Charge Code	8032060
Hospital Revenue Code	270
Min. Negotiated Rate	$12.15
Max. Negotiated Rate	$97.17
Rate for Payer: Amerigroup CHIP/Medicaid	$12.15
Rate for Payer: BCBS of TX Blue Advantage	$40.49
Rate for Payer: BCBS of TX Blue Essentials	$48.59
Rate for Payer: BCBS of TX PPO	$53.98
Rate for Payer: Cash Price	$91.77
Rate for Payer: Cigna Medicaid	$97.17
Rate for Payer: Molina CHIP/Medicaid	$97.17
Rate for Payer: Multiplan Auto	$87.72
Rate for Payer: Multiplan Commercial	$87.72
Rate for Payer: Multiplan Workers Comp	$87.72
Rate for Payer: Parkland Medicaid	$97.17
Rate for Payer: Scott and White EPO/PPO	$67.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.17
Rate for Payer: Superior Health Plan EPO	$18.35

CHWR WIRE GUIDE AMPLATZ SUPER 75 CM

Facility

$161.55

Hospital Charge Code	8073060
Hospital Revenue Code	272
Min. Negotiated Rate	$14.54
Max. Negotiated Rate	$116.32
Rate for Payer: Amerigroup CHIP/Medicaid	$14.54
Rate for Payer: BCBS of TX Blue Advantage	$48.47
Rate for Payer: BCBS of TX Blue Essentials	$58.16
Rate for Payer: BCBS of TX PPO	$64.62
Rate for Payer: Cash Price	$109.85
Rate for Payer: Cigna Medicaid	$116.32
Rate for Payer: Molina CHIP/Medicaid	$116.32
Rate for Payer: Multiplan Auto	$105.01
Rate for Payer: Multiplan Commercial	$105.01
Rate for Payer: Multiplan Workers Comp	$105.01
Rate for Payer: Parkland Medicaid	$116.32
Rate for Payer: Scott and White EPO/PPO	$80.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$116.32
Rate for Payer: Superior Health Plan EPO	$21.97

CHWR WIRE GUIDE AMPLATZ SUPER 75 CM

Facility

$161.55

Hospital Charge Code	8073060
Hospital Revenue Code	272
Rate for Payer: Cash Price	$109.85

CHWR XR ARTHROGRAM INJECTION HIP RIGHT

Facility

$581.00

Service Code	HCPCS 27093
Hospital Charge Code	4907650
Hospital Revenue Code	361
Min. Negotiated Rate	$52.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$52.29
Rate for Payer: BCBS of TX Blue Advantage	$174.30
Rate for Payer: BCBS of TX Blue Essentials	$209.16
Rate for Payer: BCBS of TX PPO	$232.40
Rate for Payer: Cash Price	$395.08
Rate for Payer: Cash Price	$395.08
Rate for Payer: Cigna Medicaid	$418.32
Rate for Payer: Molina CHIP/Medicaid	$418.32
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	$418.32
Rate for Payer: Scott and White EPO/PPO	$290.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$418.32
Rate for Payer: Superior Health Plan EPO	$79.02

Know your out-of-pocket cost for care.

All Charges