White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Clozapine (Clozaril), Serum SO

Facility

$155.00

Service Code	HCPCS 80159
Hospital Charge Code	1740988
Hospital Revenue Code	301
Min. Negotiated Rate	$7.86
Max. Negotiated Rate	$111.60
Rate for Payer: Amerigroup CHIP/Medicaid	$7.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.15
Rate for Payer: Amerigroup Medicare	$20.15
Rate for Payer: BCBS of TX Blue Advantage	$46.50
Rate for Payer: BCBS of TX Blue Essentials	$55.80
Rate for Payer: BCBS of TX Medicare	$20.15
Rate for Payer: BCBS of TX PPO	$62.00
Rate for Payer: Cash Price	$105.40
Rate for Payer: Cash Price	$105.40
Rate for Payer: Cigna Medicaid	$111.60
Rate for Payer: Cigna Medicare	$20.15
Rate for Payer: Employer Direct Commercial	$20.15
Rate for Payer: Humana Medicare/TRICARE	$20.15
Rate for Payer: Molina CHIP/Medicaid	$111.60
Rate for Payer: Molina Dual Medicare/Medicaid	$20.15
Rate for Payer: Molina Medicare	$20.15
Rate for Payer: Multiplan Auto	$100.75
Rate for Payer: Multiplan Commercial	$100.75
Rate for Payer: Multiplan Workers Comp	$100.75
Rate for Payer: Parkland Medicaid	$111.60
Rate for Payer: Scott and White EPO/PPO	$25.19
Rate for Payer: Scott and White Medicare	$20.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.60
Rate for Payer: Superior Health Plan EPO	$20.15
Rate for Payer: Superior Health Plan Medicare	$20.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.15
Rate for Payer: Universal American Medicare	$20.15
Rate for Payer: Wellcare Medicare	$20.15
Rate for Payer: Wellmed Medicare	$20.15

Clozapine (Clozaril), Serum SO

Facility

$155.00

Service Code	HCPCS 80159
Hospital Charge Code	1740988
Hospital Revenue Code	301
Rate for Payer: Cash Price	$105.40

Cluster-hole

Facility

$6,810.00

Service Code	HCPCS C1776
Hospital Charge Code	993670
Hospital Revenue Code	278
Min. Negotiated Rate	$612.90
Max. Negotiated Rate	$4,903.20
Rate for Payer: Amerigroup CHIP/Medicaid	$612.90
Rate for Payer: BCBS of TX Blue Advantage	$2,043.00
Rate for Payer: BCBS of TX Blue Essentials	$2,451.60
Rate for Payer: BCBS of TX PPO	$2,724.00
Rate for Payer: Cash Price	$4,630.80
Rate for Payer: Cigna Medicaid	$4,903.20
Rate for Payer: Molina CHIP/Medicaid	$4,903.20
Rate for Payer: Multiplan Auto	$3,405.00
Rate for Payer: Multiplan Commercial	$3,405.00
Rate for Payer: Multiplan Workers Comp	$3,405.00
Rate for Payer: Parkland Medicaid	$4,903.20
Rate for Payer: Scott and White EPO/PPO	$3,405.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,903.20
Rate for Payer: Superior Health Plan EPO	$926.16

Cluster-hole

Facility

$6,810.00

Service Code	HCPCS C1776
Hospital Charge Code	993670
Hospital Revenue Code	278
Min. Negotiated Rate	$1,702.50
Max. Negotiated Rate	$3,405.00
Rate for Payer: Cash Price	$4,630.80
Rate for Payer: Cigna Commercial	$1,702.50
Rate for Payer: Multiplan Auto	$3,405.00
Rate for Payer: Multiplan Commercial	$3,405.00
Rate for Payer: Multiplan Workers Comp	$3,405.00
Rate for Payer: Scott and White EPO/PPO	$3,405.00

CMPLX CHRON CARE ADDL 30 MIN Units

Facility

$129.00

Service Code	HCPCS 99489
Hospital Charge Code	6019902
Hospital Revenue Code	510
Rate for Payer: Cash Price	$87.72

CMPLX CHRON CARE ADDL 30 MIN Units

Facility

$129.00

Service Code	HCPCS 99489
Hospital Charge Code	6019902
Hospital Revenue Code	510
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$92.88
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$38.70
Rate for Payer: BCBS of TX Blue Essentials	$46.44
Rate for Payer: BCBS of TX PPO	$51.60
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cigna Medicaid	$92.88
Rate for Payer: Molina CHIP/Medicaid	$92.88
Rate for Payer: Multiplan Auto	$83.85
Rate for Payer: Multiplan Commercial	$83.85
Rate for Payer: Multiplan Workers Comp	$83.85
Rate for Payer: Parkland Medicaid	$92.88
Rate for Payer: Scott and White EPO/PPO	$61.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.88

CMPLX CHRON CARE W/O PT VSIT Units

Facility

$376.00

Service Code	HCPCS 99487
Hospital Charge Code	6019901
Hospital Revenue Code	510
Rate for Payer: Cash Price	$255.68

CMPLX CHRON CARE W/O PT VSIT Units

Facility

$376.00

Service Code	HCPCS 99487
Hospital Charge Code	6019901
Hospital Revenue Code	510
Min. Negotiated Rate	$33.84
Max. Negotiated Rate	$376.90
Rate for Payer: Amerigroup CHIP/Medicaid	$33.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$178.30
Rate for Payer: Amerigroup Medicare	$178.30
Rate for Payer: BCBS of TX Blue Advantage	$112.80
Rate for Payer: BCBS of TX Blue Essentials	$135.36
Rate for Payer: BCBS of TX Medicare	$178.30
Rate for Payer: BCBS of TX PPO	$150.40
Rate for Payer: Cash Price	$255.68
Rate for Payer: Cash Price	$255.68
Rate for Payer: Cash Price	$255.68
Rate for Payer: Cigna Commercial	$376.90
Rate for Payer: Cigna Medicaid	$270.72
Rate for Payer: Cigna Medicare	$178.30
Rate for Payer: Employer Direct Commercial	$178.30
Rate for Payer: Humana Medicare/TRICARE	$178.30
Rate for Payer: Molina CHIP/Medicaid	$270.72
Rate for Payer: Molina Dual Medicare/Medicaid	$178.30
Rate for Payer: Molina Medicare	$178.30
Rate for Payer: Multiplan Auto	$244.40
Rate for Payer: Multiplan Commercial	$244.40
Rate for Payer: Multiplan Workers Comp	$244.40
Rate for Payer: Parkland Medicaid	$270.72
Rate for Payer: Scott and White EPO/PPO	$110.11
Rate for Payer: Scott and White Medicare	$178.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$270.72
Rate for Payer: Superior Health Plan EPO	$178.30
Rate for Payer: Superior Health Plan Medicare	$178.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$178.30
Rate for Payer: Universal American Medicare	$178.30
Rate for Payer: Wellcare Medicare	$178.30
Rate for Payer: Wellmed Medicare	$178.30

CMP ST/CMP GLN/VE

Facility

$50,269.15

Service Code	HCPCS C1734
Hospital Charge Code	993174
Hospital Revenue Code	278
Min. Negotiated Rate	$4,524.22
Max. Negotiated Rate	$36,193.79
Rate for Payer: Amerigroup CHIP/Medicaid	$4,524.22
Rate for Payer: BCBS of TX Blue Advantage	$15,080.75
Rate for Payer: BCBS of TX Blue Essentials	$18,096.89
Rate for Payer: BCBS of TX PPO	$20,107.66
Rate for Payer: Cash Price	$34,183.02
Rate for Payer: Cigna Medicaid	$36,193.79
Rate for Payer: Molina CHIP/Medicaid	$36,193.79
Rate for Payer: Multiplan Auto	$25,134.58
Rate for Payer: Multiplan Commercial	$25,134.58
Rate for Payer: Multiplan Workers Comp	$25,134.58
Rate for Payer: Parkland Medicaid	$36,193.79
Rate for Payer: Scott and White EPO/PPO	$25,134.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36,193.79
Rate for Payer: Superior Health Plan EPO	$6,836.60

CMP ST/CMP GLN/VE

Facility

$50,269.15

Service Code	HCPCS C1734
Hospital Charge Code	993174
Hospital Revenue Code	278
Min. Negotiated Rate	$12,567.29
Max. Negotiated Rate	$25,134.58
Rate for Payer: Cash Price	$34,183.02
Rate for Payer: Cigna Commercial	$12,567.29
Rate for Payer: Multiplan Auto	$25,134.58
Rate for Payer: Multiplan Commercial	$25,134.58
Rate for Payer: Multiplan Workers Comp	$25,134.58
Rate for Payer: Scott and White EPO/PPO	$25,134.58

CMV PCR SO

Facility

$303.00

Service Code	HCPCS 87496
Hospital Charge Code	1740034
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$218.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$90.90
Rate for Payer: BCBS of TX Blue Essentials	$109.08
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$121.20
Rate for Payer: Cash Price	$206.04
Rate for Payer: Cash Price	$206.04
Rate for Payer: Cigna Medicaid	$218.16
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$218.16
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
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	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$218.16
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

CMV PCR SO

Facility

$303.00

Service Code	HCPCS 87496
Hospital Charge Code	1740034
Hospital Revenue Code	306
Rate for Payer: Cash Price	$206.04

CMV Quant DNA PCR (Plasma) SO

Facility

$355.00

Service Code	HCPCS 87497
Hospital Charge Code	1709518
Hospital Revenue Code	306
Min. Negotiated Rate	$16.71
Max. Negotiated Rate	$255.60
Rate for Payer: Amerigroup CHIP/Medicaid	$16.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.84
Rate for Payer: Amerigroup Medicare	$42.84
Rate for Payer: BCBS of TX Blue Advantage	$106.50
Rate for Payer: BCBS of TX Blue Essentials	$127.80
Rate for Payer: BCBS of TX Medicare	$42.84
Rate for Payer: BCBS of TX PPO	$142.00
Rate for Payer: Cash Price	$241.40
Rate for Payer: Cash Price	$241.40
Rate for Payer: Cigna Medicaid	$255.60
Rate for Payer: Cigna Medicare	$42.84
Rate for Payer: Employer Direct Commercial	$42.84
Rate for Payer: Humana Medicare/TRICARE	$42.84
Rate for Payer: Molina CHIP/Medicaid	$255.60
Rate for Payer: Molina Dual Medicare/Medicaid	$42.84
Rate for Payer: Molina Medicare	$42.84
Rate for Payer: Multiplan Auto	$230.75
Rate for Payer: Multiplan Commercial	$230.75
Rate for Payer: Multiplan Workers Comp	$230.75
Rate for Payer: Parkland Medicaid	$255.60
Rate for Payer: Scott and White EPO/PPO	$53.55
Rate for Payer: Scott and White Medicare	$42.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$255.60
Rate for Payer: Superior Health Plan EPO	$42.84
Rate for Payer: Superior Health Plan Medicare	$42.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.84
Rate for Payer: Universal American Medicare	$42.84
Rate for Payer: Wellcare Medicare	$42.84
Rate for Payer: Wellmed Medicare	$42.84

CMV Quant DNA PCR (Plasma) SO

Facility

$355.00

Service Code	HCPCS 87497
Hospital Charge Code	1709518
Hospital Revenue Code	306
Rate for Payer: Cash Price	$241.40

CO2 CANNULA, SSOFT, ADLT, 7O2, 7CO2, MA

Facility

$10.52

Hospital Charge Code	993258
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.15

CO2 CANNULA, SSOFT, ADLT, 7O2, 7CO2, MA

Facility

$10.52

Hospital Charge Code	993258
Hospital Revenue Code	270
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$7.57
Rate for Payer: Amerigroup CHIP/Medicaid	$0.95
Rate for Payer: BCBS of TX Blue Advantage	$3.16
Rate for Payer: BCBS of TX Blue Essentials	$3.79
Rate for Payer: BCBS of TX PPO	$4.21
Rate for Payer: Cash Price	$7.15
Rate for Payer: Cigna Medicaid	$7.57
Rate for Payer: Molina CHIP/Medicaid	$7.57
Rate for Payer: Multiplan Auto	$6.84
Rate for Payer: Multiplan Commercial	$6.84
Rate for Payer: Multiplan Workers Comp	$6.84
Rate for Payer: Parkland Medicaid	$7.57
Rate for Payer: Scott and White EPO/PPO	$5.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.57
Rate for Payer: Superior Health Plan EPO	$1.43

CO2 DETECTOR COLORIMETRIC PEDIATRIC

Facility

$38.00

Hospital Charge Code	993092
Hospital Revenue Code	270
Rate for Payer: Cash Price	$25.84

CO2 DETECTOR COLORIMETRIC PEDIATRIC

Facility

$38.00

Hospital Charge Code	993092
Hospital Revenue Code	270
Min. Negotiated Rate	$3.42
Max. Negotiated Rate	$27.36
Rate for Payer: Amerigroup CHIP/Medicaid	$3.42
Rate for Payer: BCBS of TX Blue Advantage	$11.40
Rate for Payer: BCBS of TX Blue Essentials	$13.68
Rate for Payer: BCBS of TX PPO	$15.20
Rate for Payer: Cash Price	$25.84
Rate for Payer: Cigna Medicaid	$27.36
Rate for Payer: Molina CHIP/Medicaid	$27.36
Rate for Payer: Multiplan Auto	$24.70
Rate for Payer: Multiplan Commercial	$24.70
Rate for Payer: Multiplan Workers Comp	$24.70
Rate for Payer: Parkland Medicaid	$27.36
Rate for Payer: Scott and White EPO/PPO	$19.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.36
Rate for Payer: Superior Health Plan EPO	$5.17

COAGULATION AND PLATELET DISORDERS

Facility

$4,556.82

Service Code	APR-DRG 6611
Min. Negotiated Rate	$4,296.33
Max. Negotiated Rate	$4,556.82
Rate for Payer: Amerigroup CHIP/Medicaid	$4,296.33
Rate for Payer: Cigna Medicaid	$4,296.33
Rate for Payer: Molina CHIP/Medicaid	$4,296.33
Rate for Payer: Parkland Medicaid	$4,296.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,556.82

COAGULATION AND PLATELET DISORDERS

Facility

$28,144.33

Service Code	APR-DRG 6614
Min. Negotiated Rate	$26,535.46
Max. Negotiated Rate	$28,144.33
Rate for Payer: Amerigroup CHIP/Medicaid	$26,535.46
Rate for Payer: Cigna Medicaid	$26,535.46
Rate for Payer: Molina CHIP/Medicaid	$26,535.46
Rate for Payer: Parkland Medicaid	$26,535.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28,144.33

COAGULATION AND PLATELET DISORDERS

Facility

$4,975.50

Service Code	APR-DRG 6612
Min. Negotiated Rate	$4,691.08
Max. Negotiated Rate	$4,975.50
Rate for Payer: Amerigroup CHIP/Medicaid	$4,691.08
Rate for Payer: Cigna Medicaid	$4,691.08
Rate for Payer: Molina CHIP/Medicaid	$4,691.08
Rate for Payer: Parkland Medicaid	$4,691.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,975.50

COAGULATION AND PLATELET DISORDERS

Facility

$23,075.29

Service Code	APR-DRG 6613
Min. Negotiated Rate	$21,756.19
Max. Negotiated Rate	$23,075.29
Rate for Payer: Amerigroup CHIP/Medicaid	$21,756.19
Rate for Payer: Cigna Medicaid	$21,756.19
Rate for Payer: Molina CHIP/Medicaid	$21,756.19
Rate for Payer: Parkland Medicaid	$21,756.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,075.29

COAGULATION DISORDERS

Facility

$29,736.90

Service Code	MSDRG 813
Min. Negotiated Rate	$13,694.62
Max. Negotiated Rate	$29,736.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,939.04
Rate for Payer: Amerigroup Medicare	$15,939.04
Rate for Payer: BCBS of TX Blue Advantage	$13,858.90
Rate for Payer: BCBS of TX Blue Essentials	$16,629.07
Rate for Payer: BCBS of TX Medicare	$15,939.04
Rate for Payer: BCBS of TX PPO	$18,477.46
Rate for Payer: Cigna Commercial	$19,645.86
Rate for Payer: Cigna Medicare	$15,939.04
Rate for Payer: Employer Direct Commercial	$15,939.04
Rate for Payer: Humana Medicare/TRICARE	$15,939.04
Rate for Payer: Molina Dual Medicare/Medicaid	$15,939.04
Rate for Payer: Molina Medicare	$15,939.04
Rate for Payer: Multiplan Auto	$29,736.90
Rate for Payer: Multiplan Commercial	$29,736.90
Rate for Payer: Multiplan Workers Comp	$29,736.90
Rate for Payer: Scott and White EPO/PPO	$13,694.62
Rate for Payer: Scott and White Medicare	$15,939.04
Rate for Payer: Superior Health Plan EPO	$15,939.04
Rate for Payer: Superior Health Plan Medicare	$15,939.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,939.04
Rate for Payer: Universal American Medicare	$15,939.04
Rate for Payer: Wellcare Medicare	$15,939.04
Rate for Payer: Wellmed Medicare	$15,939.04

COATED LAPAROSCOPIC WIRE L-HOOK 44CM

Facility

$101.42

Hospital Charge Code	993959
Hospital Revenue Code	279
Rate for Payer: Cash Price	$68.97

COATED LAPAROSCOPIC WIRE L-HOOK 44CM

Facility

$101.42

Hospital Charge Code	993959
Hospital Revenue Code	279
Min. Negotiated Rate	$9.13
Max. Negotiated Rate	$73.02
Rate for Payer: Amerigroup CHIP/Medicaid	$9.13
Rate for Payer: BCBS of TX Blue Advantage	$30.43
Rate for Payer: BCBS of TX Blue Essentials	$36.51
Rate for Payer: BCBS of TX PPO	$40.57
Rate for Payer: Cash Price	$68.97
Rate for Payer: Cigna Medicaid	$73.02
Rate for Payer: Molina CHIP/Medicaid	$73.02
Rate for Payer: Multiplan Auto	$65.92
Rate for Payer: Multiplan Commercial	$65.92
Rate for Payer: Multiplan Workers Comp	$65.92
Rate for Payer: Parkland Medicaid	$73.02
Rate for Payer: Scott and White EPO/PPO	$50.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$73.02
Rate for Payer: Superior Health Plan EPO	$13.79

Know your out-of-pocket cost for care.

All Charges