White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ENTRY REAMER

Facility

$681.00

Hospital Charge Code	145216
Hospital Revenue Code	272
Min. Negotiated Rate	$61.29
Max. Negotiated Rate	$442.65
Rate for Payer: Aetna Commercial	$374.55
Rate for Payer: Amerigroup CHIP/Medicaid	$61.29
Rate for Payer: BCBS of TX Blue Advantage	$204.30
Rate for Payer: BCBS of TX Blue Essentials	$245.16
Rate for Payer: BCBS of TX PPO	$272.40
Rate for Payer: Cash Price	$599.28
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Scott and White EPO/PPO	$340.50
Rate for Payer: Superior Health Plan EPO	$92.62

Eosinophil Respiratory

Facility

$102.00

Service Code	CPT 89190
Hospital Charge Code	1600402
Hospital Revenue Code	300
Rate for Payer: Cash Price	$89.76

Eosinophil Respiratory

Facility

$102.00

Service Code	CPT 89190
Hospital Charge Code	1600402
Hospital Revenue Code	300
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$66.30
Rate for Payer: Aetna Commercial	$6.07
Rate for Payer: Aetna Medicare	$8.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.79
Rate for Payer: Amerigroup Medicare	$5.79
Rate for Payer: BCBS of TX Blue Advantage	$9.55
Rate for Payer: BCBS of TX Blue Essentials	$11.46
Rate for Payer: BCBS of TX Medicare	$5.79
Rate for Payer: BCBS of TX PPO	$12.80
Rate for Payer: Cash Price	$89.76
Rate for Payer: Cash Price	$89.76
Rate for Payer: Cigna Medicaid	$5.79
Rate for Payer: Cigna Medicare	$5.79
Rate for Payer: Employer Direct Commercial	$5.79
Rate for Payer: Humana Medicare/TRICARE	$5.79
Rate for Payer: Molina CHIP/Medicaid	$5.79
Rate for Payer: Molina Dual Medicare/Medicaid	$5.79
Rate for Payer: Molina Medicare	$5.79
Rate for Payer: Multiplan Auto	$66.30
Rate for Payer: Multiplan Commercial	$66.30
Rate for Payer: Multiplan Workers Comp	$66.30
Rate for Payer: Parkland Medicaid	$5.79
Rate for Payer: Scott and White EPO/PPO	$7.24
Rate for Payer: Scott and White Medicare	$5.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.79
Rate for Payer: Superior Health Plan EPO	$5.79
Rate for Payer: Superior Health Plan Medicare	$5.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.79
Rate for Payer: Universal American Medicare	$5.79
Rate for Payer: Wellcare Medicare	$5.79
Rate for Payer: Wellmed Medicare	$5.79

Eosinophil Urine

Facility

$138.00

Service Code	CPT 87205
Hospital Charge Code	4108705
Hospital Revenue Code	306
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$89.70
Rate for Payer: Aetna Commercial	$4.48
Rate for Payer: Aetna Medicare	$6.40
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.27
Rate for Payer: Amerigroup Medicare	$4.27
Rate for Payer: BCBS of TX Blue Advantage	$7.05
Rate for Payer: BCBS of TX Blue Essentials	$8.45
Rate for Payer: BCBS of TX Medicare	$4.27
Rate for Payer: BCBS of TX PPO	$9.44
Rate for Payer: Cash Price	$121.44
Rate for Payer: Cash Price	$121.44
Rate for Payer: Cigna Medicaid	$4.27
Rate for Payer: Cigna Medicare	$4.27
Rate for Payer: Employer Direct Commercial	$4.27
Rate for Payer: Humana Medicare/TRICARE	$4.27
Rate for Payer: Molina CHIP/Medicaid	$4.27
Rate for Payer: Molina Dual Medicare/Medicaid	$4.27
Rate for Payer: Molina Medicare	$4.27
Rate for Payer: Multiplan Auto	$89.70
Rate for Payer: Multiplan Commercial	$89.70
Rate for Payer: Multiplan Workers Comp	$89.70
Rate for Payer: Parkland Medicaid	$4.27
Rate for Payer: Scott and White EPO/PPO	$5.34
Rate for Payer: Scott and White Medicare	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.27
Rate for Payer: Superior Health Plan EPO	$4.27
Rate for Payer: Superior Health Plan Medicare	$4.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.27
Rate for Payer: Universal American Medicare	$4.27
Rate for Payer: Wellcare Medicare	$4.27
Rate for Payer: Wellmed Medicare	$4.27

Eosinophil Urine

Facility

$138.00

Service Code	CPT 87205
Hospital Charge Code	4108705
Hospital Revenue Code	306
Rate for Payer: Cash Price	$121.44

EP CARDIAC MAPPING

Facility

$5,323.00

Service Code	CPT 93609
Hospital Charge Code	4610600
Hospital Revenue Code	480
Min. Negotiated Rate	$479.07
Max. Negotiated Rate	$3,459.95
Rate for Payer: Aetna Commercial	$2,927.65
Rate for Payer: Amerigroup CHIP/Medicaid	$479.07
Rate for Payer: BCBS of TX Blue Advantage	$507.94
Rate for Payer: BCBS of TX Blue Essentials	$607.19
Rate for Payer: BCBS of TX PPO	$677.25
Rate for Payer: Cash Price	$4,684.24
Rate for Payer: Cash Price	$4,684.24
Rate for Payer: Multiplan Auto	$3,459.95
Rate for Payer: Multiplan Commercial	$3,459.95
Rate for Payer: Multiplan Workers Comp	$3,459.95
Rate for Payer: Scott and White EPO/PPO	$2,661.50
Rate for Payer: Superior Health Plan EPO	$723.93

EP CARDIAC MAPPING

Facility

$5,323.00

Service Code	CPT 93609
Hospital Charge Code	4610600
Hospital Revenue Code	480
Rate for Payer: Cash Price	$4,684.24

EP COMP STUDY W/INDUCTN

Facility

$10,248.00

Service Code	CPT 93620
Hospital Charge Code	4610620
Hospital Revenue Code	480
Min. Negotiated Rate	$122.15
Max. Negotiated Rate	$15,471.93
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$10,245.00
Rate for Payer: Amerigroup CHIP/Medicaid	$922.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,830.00
Rate for Payer: Amerigroup Medicare	$6,830.00
Rate for Payer: BCBS of TX Blue Advantage	$9,829.14
Rate for Payer: BCBS of TX Blue Essentials	$11,771.42
Rate for Payer: BCBS of TX Medicare	$6,830.00
Rate for Payer: BCBS of TX PPO	$14,831.99
Rate for Payer: Cash Price	$9,018.24
Rate for Payer: Cash Price	$9,018.24
Rate for Payer: Cash Price	$9,018.24
Rate for Payer: Cigna Commercial	$15,471.93
Rate for Payer: Cigna Medicare	$6,830.00
Rate for Payer: Employer Direct Commercial	$6,830.00
Rate for Payer: Humana Medicare/TRICARE	$6,830.00
Rate for Payer: Molina Dual Medicare/Medicaid	$6,830.00
Rate for Payer: Molina Medicare	$6,830.00
Rate for Payer: Multiplan Auto	$6,661.20
Rate for Payer: Multiplan Commercial	$6,661.20
Rate for Payer: Multiplan Workers Comp	$6,661.20
Rate for Payer: Scott and White EPO/PPO	$122.15
Rate for Payer: Scott and White Medicare	$6,830.00
Rate for Payer: Superior Health Plan EPO	$6,830.00
Rate for Payer: Superior Health Plan Medicare	$6,830.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,830.00
Rate for Payer: Universal American Medicare	$6,830.00
Rate for Payer: Wellcare Medicare	$6,830.00
Rate for Payer: Wellmed Medicare	$6,830.00

EP COMP STUDY W/INDUCTN

Facility

$10,248.00

Service Code	CPT 93620
Hospital Charge Code	4610620
Hospital Revenue Code	480
Rate for Payer: Cash Price	$9,018.24

Epdrml Atgrft,Face/Nk/Hf

Facility

$5,070.00

Service Code	CPT 15115
Hospital Charge Code	7150914
Hospital Revenue Code	361
Min. Negotiated Rate	$36.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,501.68
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Amerigroup Medicare	$1,667.79
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$1,667.79
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$4,461.60
Rate for Payer: Cash Price	$4,461.60
Rate for Payer: Cigna Commercial	$3,778.02
Rate for Payer: Cigna Medicaid	$709.01
Rate for Payer: Cigna Medicare	$1,667.79
Rate for Payer: Employer Direct Commercial	$1,667.79
Rate for Payer: Humana Medicare/TRICARE	$1,667.79
Rate for Payer: Molina CHIP/Medicaid	$709.01
Rate for Payer: Molina Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Molina Medicare	$1,667.79
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	$709.01
Rate for Payer: Scott and White EPO/PPO	$36.79
Rate for Payer: Scott and White Medicare	$1,667.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$709.01
Rate for Payer: Superior Health Plan EPO	$1,667.79
Rate for Payer: Superior Health Plan Medicare	$1,667.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Universal American Medicare	$1,667.79
Rate for Payer: Wellcare Medicare	$1,667.79
Rate for Payer: Wellmed Medicare	$1,667.79

EP DRUG FOLLOW-UP STUDY

Facility

$7,552.00

Service Code	CPT 93624
Hospital Charge Code	4610630
Hospital Revenue Code	480
Min. Negotiated Rate	$122.15
Max. Negotiated Rate	$15,471.93
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$10,245.00
Rate for Payer: Amerigroup CHIP/Medicaid	$679.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,830.00
Rate for Payer: Amerigroup Medicare	$6,830.00
Rate for Payer: BCBS of TX Blue Advantage	$10,241.14
Rate for Payer: BCBS of TX Blue Essentials	$12,242.28
Rate for Payer: BCBS of TX Medicare	$6,830.00
Rate for Payer: BCBS of TX PPO	$13,654.85
Rate for Payer: Cash Price	$6,645.76
Rate for Payer: Cash Price	$6,645.76
Rate for Payer: Cash Price	$6,645.76
Rate for Payer: Cigna Commercial	$15,471.93
Rate for Payer: Cigna Medicare	$6,830.00
Rate for Payer: Employer Direct Commercial	$6,830.00
Rate for Payer: Humana Medicare/TRICARE	$6,830.00
Rate for Payer: Molina Dual Medicare/Medicaid	$6,830.00
Rate for Payer: Molina Medicare	$6,830.00
Rate for Payer: Multiplan Auto	$4,908.80
Rate for Payer: Multiplan Commercial	$4,908.80
Rate for Payer: Multiplan Workers Comp	$4,908.80
Rate for Payer: Scott and White EPO/PPO	$122.15
Rate for Payer: Scott and White Medicare	$6,830.00
Rate for Payer: Superior Health Plan EPO	$6,830.00
Rate for Payer: Superior Health Plan Medicare	$6,830.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,830.00
Rate for Payer: Universal American Medicare	$6,830.00
Rate for Payer: Wellcare Medicare	$6,830.00
Rate for Payer: Wellmed Medicare	$6,830.00

EP DRUG FOLLOW-UP STUDY

Facility

$7,552.00

Service Code	CPT 93624
Hospital Charge Code	4610630
Hospital Revenue Code	480
Rate for Payer: Cash Price	$6,645.76

EP EVAL AICD LEADS INIT

Facility

$1,882.00

Service Code	CPT 93640
Hospital Charge Code	4610640
Hospital Revenue Code	480
Rate for Payer: Cash Price	$1,656.16

EP EVAL AICD LEADS INIT

Facility

$1,882.00

Service Code	CPT 93640
Hospital Charge Code	4610640
Hospital Revenue Code	480
Min. Negotiated Rate	$169.38
Max. Negotiated Rate	$1,223.30
Rate for Payer: Aetna Commercial	$1,035.10
Rate for Payer: Amerigroup CHIP/Medicaid	$169.38
Rate for Payer: BCBS of TX Blue Advantage	$326.08
Rate for Payer: BCBS of TX Blue Essentials	$389.79
Rate for Payer: BCBS of TX PPO	$434.77
Rate for Payer: Cash Price	$1,656.16
Rate for Payer: Cash Price	$1,656.16
Rate for Payer: Multiplan Auto	$1,223.30
Rate for Payer: Multiplan Commercial	$1,223.30
Rate for Payer: Multiplan Workers Comp	$1,223.30
Rate for Payer: Scott and White EPO/PPO	$941.00
Rate for Payer: Superior Health Plan EPO	$255.95

ePHEDrine 50 mg/ml 1 ml vial

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78406597
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

ePHEDrine 50 mg/ml 1 ml vial

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78406597
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

Epi Auto Trnk/Arms/Legs ea/add 100 sqcm

Facility

$5,206.00

Service Code	CPT 15111
Hospital Charge Code	7150913
Hospital Revenue Code	361
Min. Negotiated Rate	$468.54
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,863.30
Rate for Payer: Amerigroup CHIP/Medicaid	$468.54
Rate for Payer: Cash Price	$4,581.28
Rate for Payer: Cash Price	$4,581.28
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	$2,603.00
Rate for Payer: Superior Health Plan EPO	$708.02

Epidermal Autograft,T/A/L

Facility

$5,206.00

Service Code	CPT 15110
Hospital Charge Code	7150912
Hospital Revenue Code	361
Min. Negotiated Rate	$36.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,501.68
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Amerigroup Medicare	$1,667.79
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$1,667.79
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$4,581.28
Rate for Payer: Cash Price	$4,581.28
Rate for Payer: Cigna Commercial	$3,778.02
Rate for Payer: Cigna Medicaid	$709.01
Rate for Payer: Cigna Medicare	$1,667.79
Rate for Payer: Employer Direct Commercial	$1,667.79
Rate for Payer: Humana Medicare/TRICARE	$1,667.79
Rate for Payer: Molina CHIP/Medicaid	$709.01
Rate for Payer: Molina Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Molina Medicare	$1,667.79
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	$709.01
Rate for Payer: Scott and White EPO/PPO	$36.79
Rate for Payer: Scott and White Medicare	$1,667.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$709.01
Rate for Payer: Superior Health Plan EPO	$1,667.79
Rate for Payer: Superior Health Plan Medicare	$1,667.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Universal American Medicare	$1,667.79
Rate for Payer: Wellcare Medicare	$1,667.79
Rate for Payer: Wellmed Medicare	$1,667.79

Epidural Ea Addl 15 Min BCE

Facility

$625.00

Hospital Charge Code	320020
Hospital Revenue Code	370
Rate for Payer: Cash Price	$550.00

Epidural Ea Addl 15 Min BCE

Facility

$625.00

Hospital Charge Code	320020
Hospital Revenue Code	370
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$406.25
Rate for Payer: Aetna Commercial	$343.75
Rate for Payer: Amerigroup CHIP/Medicaid	$56.25
Rate for Payer: BCBS of TX Blue Advantage	$187.50
Rate for Payer: BCBS of TX Blue Essentials	$225.00
Rate for Payer: BCBS of TX PPO	$250.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Multiplan Auto	$406.25
Rate for Payer: Multiplan Commercial	$406.25
Rate for Payer: Multiplan Workers Comp	$406.25
Rate for Payer: Scott and White EPO/PPO	$312.50
Rate for Payer: Superior Health Plan EPO	$85.00

Epidural First 60 Min BCE

Facility

$4,210.00

Hospital Charge Code	320019
Hospital Revenue Code	370
Rate for Payer: Cash Price	$3,704.80

Epidural First 60 Min BCE

Facility

$4,210.00

Hospital Charge Code	320019
Hospital Revenue Code	370
Min. Negotiated Rate	$378.90
Max. Negotiated Rate	$2,736.50
Rate for Payer: Aetna Commercial	$2,315.50
Rate for Payer: Amerigroup CHIP/Medicaid	$378.90
Rate for Payer: BCBS of TX Blue Advantage	$1,263.00
Rate for Payer: BCBS of TX Blue Essentials	$1,515.60
Rate for Payer: BCBS of TX PPO	$1,684.00
Rate for Payer: Cash Price	$3,704.80
Rate for Payer: Multiplan Auto	$2,736.50
Rate for Payer: Multiplan Commercial	$2,736.50
Rate for Payer: Multiplan Workers Comp	$2,736.50
Rate for Payer: Scott and White EPO/PPO	$2,105.00
Rate for Payer: Superior Health Plan EPO	$572.56

Epidurography, radiological supervision and interpretation

Facility

$10,000.00

Service Code	CPT 72275
Hospital Charge Code	36072275
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
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

EPINEPHrine 0.1 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0171
Hospital Charge Code	78435731
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

EPINEPHrine 0.1 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0171
Hospital Charge Code	78435731
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.13
Rate for Payer: BCBS of TX Blue Essentials	$0.16
Rate for Payer: BCBS of TX PPO	$0.17
Rate for Payer: Cash Price	$87.16
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

Know your out-of-pocket cost for care.

All Charges