White Rock Medical Center

All Charges

Charge

Type

Setting

Price

colchicine 0.6 mg Tab

Facility

$22.95

Service Code	HCPCS J3490
Hospital Charge Code	77483415
Hospital Revenue Code	250
Rate for Payer: Cash Price	$15.61

Colectomy, partial; with anastomosis

Facility

$64,200.00

Service Code	HCPCS 44140
Hospital Charge Code	991135
Hospital Revenue Code	360
Min. Negotiated Rate	$2,342.41
Max. Negotiated Rate	$46,224.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,778.00
Rate for Payer: BCBS of TX Blue Advantage	$2,342.41
Rate for Payer: BCBS of TX Blue Essentials	$2,805.28
Rate for Payer: BCBS of TX PPO	$3,534.65
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cigna Medicaid	$46,224.00
Rate for Payer: Molina CHIP/Medicaid	$46,224.00
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
Rate for Payer: Parkland Medicaid	$46,224.00
Rate for Payer: Scott and White EPO/PPO	$32,100.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,224.00
Rate for Payer: Superior Health Plan EPO	$8,731.20

Colectomy, partial; with anastomosis

Facility

$64,200.00

Service Code	HCPCS 44140
Hospital Charge Code	991135
Hospital Revenue Code	360
Rate for Payer: Cash Price	$43,656.00

Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure)

Facility

$64,200.00

Service Code	HCPCS 44143
Hospital Charge Code	991014
Hospital Revenue Code	360
Rate for Payer: Cash Price	$43,656.00

Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure)

Facility

$64,200.00

Service Code	HCPCS 44143
Hospital Charge Code	991014
Hospital Revenue Code	360
Min. Negotiated Rate	$2,905.15
Max. Negotiated Rate	$46,224.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,778.00
Rate for Payer: BCBS of TX Blue Advantage	$2,905.15
Rate for Payer: BCBS of TX Blue Essentials	$3,479.22
Rate for Payer: BCBS of TX PPO	$4,383.82
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cigna Medicaid	$46,224.00
Rate for Payer: Molina CHIP/Medicaid	$46,224.00
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
Rate for Payer: Parkland Medicaid	$46,224.00
Rate for Payer: Scott and White EPO/PPO	$32,100.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,224.00
Rate for Payer: Superior Health Plan EPO	$8,731.20

COLLAR CERV -- DHF

Facility

$126.33

Hospital Charge Code	81141707
Hospital Revenue Code	270
Rate for Payer: Cash Price	$85.90

COLLAR CERV -- DHF

Facility

$126.33

Hospital Charge Code	81141707
Hospital Revenue Code	270
Min. Negotiated Rate	$11.37
Max. Negotiated Rate	$90.96
Rate for Payer: Amerigroup CHIP/Medicaid	$11.37
Rate for Payer: BCBS of TX Blue Advantage	$37.90
Rate for Payer: BCBS of TX Blue Essentials	$45.48
Rate for Payer: BCBS of TX PPO	$50.53
Rate for Payer: Cash Price	$85.90
Rate for Payer: Cigna Medicaid	$90.96
Rate for Payer: Molina CHIP/Medicaid	$90.96
Rate for Payer: Multiplan Auto	$82.11
Rate for Payer: Multiplan Commercial	$82.11
Rate for Payer: Multiplan Workers Comp	$82.11
Rate for Payer: Parkland Medicaid	$90.96
Rate for Payer: Scott and White EPO/PPO	$63.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.96
Rate for Payer: Superior Health Plan EPO	$17.18

COLLAR CERV FM -- DHF

Facility

$32.08

Hospital Charge Code	81141806
Hospital Revenue Code	270
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$23.10
Rate for Payer: Amerigroup CHIP/Medicaid	$2.89
Rate for Payer: BCBS of TX Blue Advantage	$9.62
Rate for Payer: BCBS of TX Blue Essentials	$11.55
Rate for Payer: BCBS of TX PPO	$12.83
Rate for Payer: Cash Price	$21.81
Rate for Payer: Cigna Medicaid	$23.10
Rate for Payer: Molina CHIP/Medicaid	$23.10
Rate for Payer: Multiplan Auto	$20.85
Rate for Payer: Multiplan Commercial	$20.85
Rate for Payer: Multiplan Workers Comp	$20.85
Rate for Payer: Parkland Medicaid	$23.10
Rate for Payer: Scott and White EPO/PPO	$16.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.10
Rate for Payer: Superior Health Plan EPO	$4.36

COLLAR CERV FM -- DHF

Facility

$32.08

Hospital Charge Code	81141806
Hospital Revenue Code	270
Rate for Payer: Cash Price	$21.81

COLLAR, CERVICAL, PATRIOT, ADULT, 11-23

Facility

$26.51

Hospital Charge Code	993910
Hospital Revenue Code	274
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$19.09
Rate for Payer: Amerigroup CHIP/Medicaid	$2.39
Rate for Payer: BCBS of TX Blue Advantage	$7.95
Rate for Payer: BCBS of TX Blue Essentials	$9.54
Rate for Payer: BCBS of TX PPO	$10.60
Rate for Payer: Cash Price	$18.03
Rate for Payer: Cigna Medicaid	$19.09
Rate for Payer: Molina CHIP/Medicaid	$19.09
Rate for Payer: Multiplan Auto	$13.26
Rate for Payer: Multiplan Commercial	$13.26
Rate for Payer: Multiplan Workers Comp	$13.26
Rate for Payer: Parkland Medicaid	$19.09
Rate for Payer: Scott and White EPO/PPO	$13.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.09
Rate for Payer: Superior Health Plan EPO	$3.61

COLLAR, CERVICAL, PATRIOT, ADULT, 11-23

Facility

$26.51

Hospital Charge Code	993910
Hospital Revenue Code	274
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$13.26
Rate for Payer: Cash Price	$18.03
Rate for Payer: Cigna Commercial	$6.63
Rate for Payer: Multiplan Auto	$13.26
Rate for Payer: Multiplan Commercial	$13.26
Rate for Payer: Multiplan Workers Comp	$13.26
Rate for Payer: Scott and White EPO/PPO	$13.26

COLLAR PHIL -- DHF

Facility

$284.49

Hospital Charge Code	81142002
Hospital Revenue Code	270
Rate for Payer: Cash Price	$193.45

COLLAR PHIL -- DHF

Facility

$284.49

Hospital Charge Code	81142002
Hospital Revenue Code	270
Min. Negotiated Rate	$25.60
Max. Negotiated Rate	$204.83
Rate for Payer: Amerigroup CHIP/Medicaid	$25.60
Rate for Payer: BCBS of TX Blue Advantage	$85.35
Rate for Payer: BCBS of TX Blue Essentials	$102.42
Rate for Payer: BCBS of TX PPO	$113.80
Rate for Payer: Cash Price	$193.45
Rate for Payer: Cigna Medicaid	$204.83
Rate for Payer: Molina CHIP/Medicaid	$204.83
Rate for Payer: Multiplan Auto	$184.92
Rate for Payer: Multiplan Commercial	$184.92
Rate for Payer: Multiplan Workers Comp	$184.92
Rate for Payer: Parkland Medicaid	$204.83
Rate for Payer: Scott and White EPO/PPO	$142.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$204.83
Rate for Payer: Superior Health Plan EPO	$38.69

COLLECTION: 24 Hour Urine

Facility

$56.00

Service Code	HCPCS 81050
Hospital Charge Code	1704618
Hospital Revenue Code	307
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$40.32
Rate for Payer: Amerigroup CHIP/Medicaid	$1.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.64
Rate for Payer: Amerigroup Medicare	$3.64
Rate for Payer: BCBS of TX Blue Advantage	$16.80
Rate for Payer: BCBS of TX Blue Essentials	$20.16
Rate for Payer: BCBS of TX Medicare	$3.64
Rate for Payer: BCBS of TX PPO	$22.40
Rate for Payer: Cash Price	$38.08
Rate for Payer: Cash Price	$38.08
Rate for Payer: Cigna Medicaid	$40.32
Rate for Payer: Cigna Medicare	$3.64
Rate for Payer: Employer Direct Commercial	$3.64
Rate for Payer: Humana Medicare/TRICARE	$3.64
Rate for Payer: Molina CHIP/Medicaid	$40.32
Rate for Payer: Molina Dual Medicare/Medicaid	$3.64
Rate for Payer: Molina Medicare	$3.64
Rate for Payer: Multiplan Auto	$36.40
Rate for Payer: Multiplan Commercial	$36.40
Rate for Payer: Multiplan Workers Comp	$36.40
Rate for Payer: Parkland Medicaid	$40.32
Rate for Payer: Scott and White EPO/PPO	$4.55
Rate for Payer: Scott and White Medicare	$3.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.32
Rate for Payer: Superior Health Plan EPO	$3.64
Rate for Payer: Superior Health Plan Medicare	$3.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.64
Rate for Payer: Universal American Medicare	$3.64
Rate for Payer: Wellcare Medicare	$3.64
Rate for Payer: Wellmed Medicare	$3.64

COLLECTION: 24 Hour Urine

Facility

$56.00

Service Code	HCPCS 81050
Hospital Charge Code	1704618
Hospital Revenue Code	307
Rate for Payer: Cash Price	$38.08

COLLECTION: Capillary

Facility

$41.00

Service Code	HCPCS 36416
Hospital Charge Code	300673
Hospital Revenue Code	761
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$50.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.69
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$27.88
Rate for Payer: Cash Price	$27.88
Rate for Payer: Cigna Medicaid	$29.52
Rate for Payer: Molina CHIP/Medicaid	$29.52
Rate for Payer: Multiplan Auto	$26.65
Rate for Payer: Multiplan Commercial	$26.65
Rate for Payer: Multiplan Workers Comp	$26.65
Rate for Payer: Parkland Medicaid	$29.52
Rate for Payer: Scott and White EPO/PPO	$20.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.52
Rate for Payer: Superior Health Plan EPO	$5.58

COLLECTION: Capillary

Facility

$41.00

Service Code	HCPCS 36416
Hospital Charge Code	300673
Hospital Revenue Code	761
Rate for Payer: Cash Price	$27.88

COLLECTION: Venous Draw

Facility

$47.00

Service Code	HCPCS 36415
Hospital Charge Code	1605526
Hospital Revenue Code	300
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$33.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.34
Rate for Payer: Amerigroup Medicare	$9.34
Rate for Payer: BCBS of TX Blue Advantage	$14.10
Rate for Payer: BCBS of TX Blue Essentials	$16.92
Rate for Payer: BCBS of TX Medicare	$9.34
Rate for Payer: BCBS of TX PPO	$18.80
Rate for Payer: Cash Price	$31.96
Rate for Payer: Cash Price	$31.96
Rate for Payer: Cigna Medicaid	$33.84
Rate for Payer: Cigna Medicare	$9.34
Rate for Payer: Employer Direct Commercial	$9.34
Rate for Payer: Humana Medicare/TRICARE	$9.34
Rate for Payer: Molina CHIP/Medicaid	$33.84
Rate for Payer: Molina Dual Medicare/Medicaid	$9.34
Rate for Payer: Molina Medicare	$9.34
Rate for Payer: Multiplan Auto	$30.55
Rate for Payer: Multiplan Commercial	$30.55
Rate for Payer: Multiplan Workers Comp	$30.55
Rate for Payer: Parkland Medicaid	$33.84
Rate for Payer: Scott and White EPO/PPO	$11.04
Rate for Payer: Scott and White Medicare	$9.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.84
Rate for Payer: Superior Health Plan EPO	$9.34
Rate for Payer: Superior Health Plan Medicare	$9.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.34
Rate for Payer: Universal American Medicare	$9.34
Rate for Payer: Wellcare Medicare	$9.34
Rate for Payer: Wellmed Medicare	$9.34

COLLECTION: Venous Draw

Facility

$47.00

Service Code	HCPCS 36415
Hospital Charge Code	1605526
Hospital Revenue Code	300
Rate for Payer: Cash Price	$31.96

COLLECTOR WOUND DRAINAGE /9778-LARGE

Facility

$24.20

Hospital Charge Code	131582
Hospital Revenue Code	270
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$17.42
Rate for Payer: Amerigroup CHIP/Medicaid	$2.18
Rate for Payer: BCBS of TX Blue Advantage	$7.26
Rate for Payer: BCBS of TX Blue Essentials	$8.71
Rate for Payer: BCBS of TX PPO	$9.68
Rate for Payer: Cash Price	$16.46
Rate for Payer: Cigna Medicaid	$17.42
Rate for Payer: Molina CHIP/Medicaid	$17.42
Rate for Payer: Multiplan Auto	$15.73
Rate for Payer: Multiplan Commercial	$15.73
Rate for Payer: Multiplan Workers Comp	$15.73
Rate for Payer: Parkland Medicaid	$17.42
Rate for Payer: Scott and White EPO/PPO	$12.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.42
Rate for Payer: Superior Health Plan EPO	$3.29

COLLECTOR WOUND DRAINAGE /9778-LARGE

Facility

$24.20

Hospital Charge Code	131582
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.46

COLLECTOR WOUND DRAINAGE W/BARRIER CAP 3 3/4

Facility

$15.89

Hospital Charge Code	2510865
Hospital Revenue Code	272
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$11.44
Rate for Payer: Amerigroup CHIP/Medicaid	$1.43
Rate for Payer: BCBS of TX Blue Advantage	$4.77
Rate for Payer: BCBS of TX Blue Essentials	$5.72
Rate for Payer: BCBS of TX PPO	$6.36
Rate for Payer: Cash Price	$10.81
Rate for Payer: Cigna Medicaid	$11.44
Rate for Payer: Molina CHIP/Medicaid	$11.44
Rate for Payer: Multiplan Auto	$10.33
Rate for Payer: Multiplan Commercial	$10.33
Rate for Payer: Multiplan Workers Comp	$10.33
Rate for Payer: Parkland Medicaid	$11.44
Rate for Payer: Scott and White EPO/PPO	$7.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.44
Rate for Payer: Superior Health Plan EPO	$2.16

COLLECTOR WOUND DRAINAGE W/BARRIER CAP 3 3/4

Facility

$15.89

Hospital Charge Code	2510865
Hospital Revenue Code	272
Rate for Payer: Cash Price	$10.81

COLL FLEXISEAL FECAL -- DHF

Facility

$472.47

Hospital Charge Code	80317639
Hospital Revenue Code	270
Min. Negotiated Rate	$42.52
Max. Negotiated Rate	$340.18
Rate for Payer: Amerigroup CHIP/Medicaid	$42.52
Rate for Payer: BCBS of TX Blue Advantage	$141.74
Rate for Payer: BCBS of TX Blue Essentials	$170.09
Rate for Payer: BCBS of TX PPO	$188.99
Rate for Payer: Cash Price	$321.28
Rate for Payer: Cigna Medicaid	$340.18
Rate for Payer: Molina CHIP/Medicaid	$340.18
Rate for Payer: Multiplan Auto	$307.11
Rate for Payer: Multiplan Commercial	$307.11
Rate for Payer: Multiplan Workers Comp	$307.11
Rate for Payer: Parkland Medicaid	$340.18
Rate for Payer: Scott and White EPO/PPO	$236.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$340.18
Rate for Payer: Superior Health Plan EPO	$64.26

COLL FLEXISEAL FECAL -- DHF

Facility

$472.47

Hospital Charge Code	80317639
Hospital Revenue Code	270
Rate for Payer: Cash Price	$321.28

Know your out-of-pocket cost for care.

All Charges