White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ELCTRD LOOP -- DHF

Facility

$80.69

Hospital Charge Code	81823155
Hospital Revenue Code	270
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$52.45
Rate for Payer: Aetna Commercial	$44.38
Rate for Payer: Amerigroup CHIP/Medicaid	$7.26
Rate for Payer: BCBS of TX Blue Advantage	$24.21
Rate for Payer: BCBS of TX Blue Essentials	$29.05
Rate for Payer: BCBS of TX PPO	$32.28
Rate for Payer: Cash Price	$71.01
Rate for Payer: Multiplan Auto	$52.45
Rate for Payer: Multiplan Commercial	$52.45
Rate for Payer: Multiplan Workers Comp	$52.45
Rate for Payer: Scott and White EPO/PPO	$40.34
Rate for Payer: Superior Health Plan EPO	$10.97

ELCTRD MULTIFUNCTION -- DHF

Facility

$93.29

Hospital Charge Code	82030578
Hospital Revenue Code	271
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$60.64
Rate for Payer: Aetna Commercial	$51.31
Rate for Payer: Amerigroup CHIP/Medicaid	$8.40
Rate for Payer: BCBS of TX Blue Advantage	$27.99
Rate for Payer: BCBS of TX Blue Essentials	$33.58
Rate for Payer: BCBS of TX PPO	$37.32
Rate for Payer: Cash Price	$82.10
Rate for Payer: Multiplan Auto	$60.64
Rate for Payer: Multiplan Commercial	$60.64
Rate for Payer: Multiplan Workers Comp	$60.64
Rate for Payer: Scott and White EPO/PPO	$46.64
Rate for Payer: Superior Health Plan EPO	$12.69

ELCTRD MULTIFUNCTION -- DHF

Facility

$93.29

Hospital Charge Code	82030578
Hospital Revenue Code	271
Rate for Payer: Cash Price	$82.10

ELCTRD PACING -- DHF

Facility

$340.05

Hospital Charge Code	82030552
Hospital Revenue Code	271
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$221.03
Rate for Payer: Aetna Commercial	$187.03
Rate for Payer: Amerigroup CHIP/Medicaid	$30.60
Rate for Payer: BCBS of TX Blue Advantage	$102.02
Rate for Payer: BCBS of TX Blue Essentials	$122.42
Rate for Payer: BCBS of TX PPO	$136.02
Rate for Payer: Cash Price	$299.24
Rate for Payer: Multiplan Auto	$221.03
Rate for Payer: Multiplan Commercial	$221.03
Rate for Payer: Multiplan Workers Comp	$221.03
Rate for Payer: Scott and White EPO/PPO	$170.02
Rate for Payer: Superior Health Plan EPO	$46.25

ELCTRD PACING -- DHF

Facility

$340.05

Hospital Charge Code	82030552
Hospital Revenue Code	271
Rate for Payer: Cash Price	$299.24

ELECTRODE, ABLATION HIP SUCTION COOLPULSE 90 -- DHF

Facility

$908.00

Hospital Charge Code	80826449
Hospital Revenue Code	272
Rate for Payer: Cash Price	$799.04

ELECTRODE, ABLATION HIP SUCTION COOLPULSE 90 -- DHF

Facility

$908.00

Hospital Charge Code	80826449
Hospital Revenue Code	272
Min. Negotiated Rate	$81.72
Max. Negotiated Rate	$590.20
Rate for Payer: Aetna Commercial	$499.40
Rate for Payer: Amerigroup CHIP/Medicaid	$81.72
Rate for Payer: BCBS of TX Blue Advantage	$272.40
Rate for Payer: BCBS of TX Blue Essentials	$326.88
Rate for Payer: BCBS of TX PPO	$363.20
Rate for Payer: Cash Price	$799.04
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan EPO	$123.49

ELECTRODE, BLADE EXTENDED 6.50'''' STERILE DISPOSABLE -- DHF

Facility

$27.56

Hospital Charge Code	81723272
Hospital Revenue Code	272
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$17.91
Rate for Payer: Aetna Commercial	$15.16
Rate for Payer: Amerigroup CHIP/Medicaid	$2.48
Rate for Payer: BCBS of TX Blue Advantage	$8.27
Rate for Payer: BCBS of TX Blue Essentials	$9.92
Rate for Payer: BCBS of TX PPO	$11.02
Rate for Payer: Cash Price	$24.25
Rate for Payer: Multiplan Auto	$17.91
Rate for Payer: Multiplan Commercial	$17.91
Rate for Payer: Multiplan Workers Comp	$17.91
Rate for Payer: Scott and White EPO/PPO	$13.78
Rate for Payer: Superior Health Plan EPO	$3.75

ELECTRODE, BLADE EXTENDED 6.50'''' STERILE DISPOSABLE -- DHF

Facility

$27.56

Hospital Charge Code	81723272
Hospital Revenue Code	272
Rate for Payer: Cash Price	$24.25

ELECTRODE, DISPERSIVE DUAL FOIL W/10' CABLE DISP -- DHF

Facility

$33.71

Hospital Charge Code	82121799
Hospital Revenue Code	270
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$21.91
Rate for Payer: Aetna Commercial	$18.54
Rate for Payer: Amerigroup CHIP/Medicaid	$3.03
Rate for Payer: BCBS of TX Blue Advantage	$10.11
Rate for Payer: BCBS of TX Blue Essentials	$12.14
Rate for Payer: BCBS of TX PPO	$13.48
Rate for Payer: Cash Price	$29.66
Rate for Payer: Multiplan Auto	$21.91
Rate for Payer: Multiplan Commercial	$21.91
Rate for Payer: Multiplan Workers Comp	$21.91
Rate for Payer: Scott and White EPO/PPO	$16.86
Rate for Payer: Superior Health Plan EPO	$4.58

ELECTRODE, DISPERSIVE DUAL FOIL W/10' CABLE DISP -- DHF

Facility

$33.71

Hospital Charge Code	82121799
Hospital Revenue Code	270
Rate for Payer: Cash Price	$29.66

ELECTRODE, FOAM 455 SERIES FLUID RESISTANT -- DHF

Facility

$68.92

Hospital Charge Code	82030255
Hospital Revenue Code	270
Rate for Payer: Cash Price	$60.65

ELECTRODE, FOAM 455 SERIES FLUID RESISTANT -- DHF

Facility

$68.92

Hospital Charge Code	82030255
Hospital Revenue Code	270
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$44.80
Rate for Payer: Aetna Commercial	$37.91
Rate for Payer: Amerigroup CHIP/Medicaid	$6.20
Rate for Payer: BCBS of TX Blue Advantage	$20.68
Rate for Payer: BCBS of TX Blue Essentials	$24.81
Rate for Payer: BCBS of TX PPO	$27.57
Rate for Payer: Cash Price	$60.65
Rate for Payer: Multiplan Auto	$44.80
Rate for Payer: Multiplan Commercial	$44.80
Rate for Payer: Multiplan Workers Comp	$44.80
Rate for Payer: Scott and White EPO/PPO	$34.46
Rate for Payer: Superior Health Plan EPO	$9.37

ELECTRODE, LAPARASCOPIC WIRE L HOOK 44CM -- DHF

Facility

$244.05

Hospital Charge Code	82121831
Hospital Revenue Code	271
Min. Negotiated Rate	$21.96
Max. Negotiated Rate	$158.63
Rate for Payer: Aetna Commercial	$134.23
Rate for Payer: Amerigroup CHIP/Medicaid	$21.96
Rate for Payer: BCBS of TX Blue Advantage	$73.22
Rate for Payer: BCBS of TX Blue Essentials	$87.86
Rate for Payer: BCBS of TX PPO	$97.62
Rate for Payer: Cash Price	$214.76
Rate for Payer: Multiplan Auto	$158.63
Rate for Payer: Multiplan Commercial	$158.63
Rate for Payer: Multiplan Workers Comp	$158.63
Rate for Payer: Scott and White EPO/PPO	$122.02
Rate for Payer: Superior Health Plan EPO	$33.19

ELECTRODE, LAPARASCOPIC WIRE L HOOK 44CM -- DHF

Facility

$244.05

Hospital Charge Code	82121831
Hospital Revenue Code	271
Rate for Payer: Cash Price	$214.76

Electrolyte Panel

Facility

$272.00

Service Code	CPT 80051
Hospital Charge Code	1602804
Hospital Revenue Code	301
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna Commercial	$7.37
Rate for Payer: Aetna Medicare	$10.52
Rate for Payer: Amerigroup CHIP/Medicaid	$2.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.01
Rate for Payer: Amerigroup Medicare	$7.01
Rate for Payer: BCBS of TX Blue Advantage	$11.57
Rate for Payer: BCBS of TX Blue Essentials	$13.88
Rate for Payer: BCBS of TX Medicare	$7.01
Rate for Payer: BCBS of TX PPO	$15.49
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cigna Medicaid	$7.01
Rate for Payer: Cigna Medicare	$7.01
Rate for Payer: Employer Direct Commercial	$7.01
Rate for Payer: Humana Medicare/TRICARE	$7.01
Rate for Payer: Molina CHIP/Medicaid	$7.01
Rate for Payer: Molina Dual Medicare/Medicaid	$7.01
Rate for Payer: Molina Medicare	$7.01
Rate for Payer: Multiplan Auto	$176.80
Rate for Payer: Multiplan Commercial	$176.80
Rate for Payer: Multiplan Workers Comp	$176.80
Rate for Payer: Parkland Medicaid	$7.01
Rate for Payer: Scott and White EPO/PPO	$8.76
Rate for Payer: Scott and White Medicare	$7.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.01
Rate for Payer: Superior Health Plan EPO	$7.01
Rate for Payer: Superior Health Plan Medicare	$7.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.01
Rate for Payer: Universal American Medicare	$7.01
Rate for Payer: Wellcare Medicare	$7.01
Rate for Payer: Wellmed Medicare	$7.01

Electrolyte Panel

Facility

$272.00

Service Code	CPT 80051
Hospital Charge Code	1602804
Hospital Revenue Code	301
Rate for Payer: Cash Price	$239.36

Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s],

Facility

$10,000.00

Service Code	CPT 95972
Hospital Charge Code	36095972
Hospital Revenue Code	360
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$132.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$88.53
Rate for Payer: Amerigroup Medicare	$88.53
Rate for Payer: BCBS of TX Blue Advantage	$74.63
Rate for Payer: BCBS of TX Blue Essentials	$89.21
Rate for Payer: BCBS of TX Medicare	$88.53
Rate for Payer: BCBS of TX PPO	$99.50
Rate for Payer: Cigna Commercial	$200.54
Rate for Payer: Cigna Medicare	$88.53
Rate for Payer: Employer Direct Commercial	$88.53
Rate for Payer: Humana Medicare/TRICARE	$88.53
Rate for Payer: Molina Dual Medicare/Medicaid	$88.53
Rate for Payer: Molina Medicare	$88.53
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: Scott and White EPO/PPO	$1.58
Rate for Payer: Scott and White Medicare	$88.53
Rate for Payer: Superior Health Plan EPO	$88.53
Rate for Payer: Superior Health Plan Medicare	$88.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$88.53
Rate for Payer: Universal American Medicare	$88.53
Rate for Payer: Wellcare Medicare	$88.53
Rate for Payer: Wellmed Medicare	$88.53

Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (inclu

Facility

$10,000.00

Service Code	CPT 62370
Hospital Charge Code	36062370
Hospital Revenue Code	360
Min. Negotiated Rate	$6.03
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$409.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$273.17
Rate for Payer: Amerigroup Medicare	$273.17
Rate for Payer: BCBS of TX Blue Advantage	$110.89
Rate for Payer: BCBS of TX Blue Essentials	$132.80
Rate for Payer: BCBS of TX Medicare	$273.17
Rate for Payer: BCBS of TX PPO	$167.33
Rate for Payer: Cigna Commercial	$618.79
Rate for Payer: Cigna Medicare	$273.17
Rate for Payer: Employer Direct Commercial	$273.17
Rate for Payer: Humana Medicare/TRICARE	$273.17
Rate for Payer: Molina Dual Medicare/Medicaid	$273.17
Rate for Payer: Molina Medicare	$273.17
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: Scott and White EPO/PPO	$6.03
Rate for Payer: Scott and White Medicare	$273.17
Rate for Payer: Superior Health Plan EPO	$273.17
Rate for Payer: Superior Health Plan Medicare	$273.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$273.17
Rate for Payer: Universal American Medicare	$273.17
Rate for Payer: Wellcare Medicare	$273.17
Rate for Payer: Wellmed Medicare	$273.17

EMBOSHIELD SYSTEM

Facility

$6,583.00

Hospital Charge Code	8450467
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,793.04

EMBOSHIELD SYSTEM

Facility

$6,583.00

Hospital Charge Code	8450467
Hospital Revenue Code	272
Min. Negotiated Rate	$592.47
Max. Negotiated Rate	$4,278.95
Rate for Payer: Aetna Commercial	$3,620.65
Rate for Payer: Amerigroup CHIP/Medicaid	$592.47
Rate for Payer: BCBS of TX Blue Advantage	$1,974.90
Rate for Payer: BCBS of TX Blue Essentials	$2,369.88
Rate for Payer: BCBS of TX PPO	$2,633.20
Rate for Payer: Cash Price	$5,793.04
Rate for Payer: Multiplan Auto	$4,278.95
Rate for Payer: Multiplan Commercial	$4,278.95
Rate for Payer: Multiplan Workers Comp	$4,278.95
Rate for Payer: Scott and White EPO/PPO	$3,291.50
Rate for Payer: Superior Health Plan EPO	$895.29

.ENA+DNA/DS+Sjogren's 016123 SO

Facility

$426.00

Service Code	CPT 86225
Hospital Charge Code	1605344
Hospital Revenue Code	302
Min. Negotiated Rate	$5.36
Max. Negotiated Rate	$276.90
Rate for Payer: Aetna Commercial	$14.42
Rate for Payer: Aetna Medicare	$20.61
Rate for Payer: Amerigroup CHIP/Medicaid	$5.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.74
Rate for Payer: Amerigroup Medicare	$13.74
Rate for Payer: BCBS of TX Blue Advantage	$22.67
Rate for Payer: BCBS of TX Blue Essentials	$27.21
Rate for Payer: BCBS of TX Medicare	$13.74
Rate for Payer: BCBS of TX PPO	$30.37
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cigna Medicaid	$13.74
Rate for Payer: Cigna Medicare	$13.74
Rate for Payer: Employer Direct Commercial	$13.74
Rate for Payer: Humana Medicare/TRICARE	$13.74
Rate for Payer: Molina CHIP/Medicaid	$13.74
Rate for Payer: Molina Dual Medicare/Medicaid	$13.74
Rate for Payer: Molina Medicare	$13.74
Rate for Payer: Multiplan Auto	$276.90
Rate for Payer: Multiplan Commercial	$276.90
Rate for Payer: Multiplan Workers Comp	$276.90
Rate for Payer: Parkland Medicaid	$13.74
Rate for Payer: Scott and White EPO/PPO	$17.18
Rate for Payer: Scott and White Medicare	$13.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.74
Rate for Payer: Superior Health Plan EPO	$13.74
Rate for Payer: Superior Health Plan Medicare	$13.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.74
Rate for Payer: Universal American Medicare	$13.74
Rate for Payer: Wellcare Medicare	$13.74
Rate for Payer: Wellmed Medicare	$13.74

enalaprilat 1.25 mg/mL IV Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77545617
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

enalaprilat 1.25 mg/mL IV Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77545617
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

END CAP T2 SUPER CONDYLAR NAIL

Facility

$1,205.30

Service Code	HCPCS C1713
Hospital Charge Code	140511
Hospital Revenue Code	278
Min. Negotiated Rate	$108.48
Max. Negotiated Rate	$602.65
Rate for Payer: Aetna Commercial	$361.59
Rate for Payer: Amerigroup CHIP/Medicaid	$108.48
Rate for Payer: BCBS of TX Blue Advantage	$361.59
Rate for Payer: BCBS of TX Blue Essentials	$433.91
Rate for Payer: BCBS of TX PPO	$482.12
Rate for Payer: Cash Price	$1,060.66
Rate for Payer: Multiplan Auto	$602.65
Rate for Payer: Multiplan Commercial	$602.65
Rate for Payer: Multiplan Workers Comp	$602.65
Rate for Payer: Scott and White EPO/PPO	$602.65
Rate for Payer: Superior Health Plan EPO	$163.92

Know your out-of-pocket cost for care.

All Charges