White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Correction of inverted nipples

Facility

$19,555.95

Service Code	HCPCS 19355
Hospital Charge Code	9900162
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,298.05

Correction of inverted nipples

Facility

$10,000.00

Service Code	CPT 19355
Hospital Charge Code	36019355
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Amerigroup Medicare	$3,933.28
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,933.28
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cigna Commercial	$8,314.23
Rate for Payer: Cigna Medicare	$3,933.28
Rate for Payer: Employer Direct Commercial	$3,933.28
Rate for Payer: Humana Medicare/TRICARE	$3,933.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Molina Medicare	$3,933.28
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	$6,449.12
Rate for Payer: Scott and White Medicare	$3,933.28
Rate for Payer: Superior Health Plan EPO	$3,933.28
Rate for Payer: Superior Health Plan Medicare	$3,933.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Universal American Medicare	$3,933.28
Rate for Payer: Wellcare Medicare	$3,933.28
Rate for Payer: Wellmed Medicare	$3,933.28

Correction of inverted nipples

Facility

$19,555.95

Service Code	HCPCS 19355
Hospital Charge Code	9900162
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$14,080.28
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Amerigroup Medicare	$3,933.28
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,933.28
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cash Price	$13,298.05
Rate for Payer: Cash Price	$13,298.05
Rate for Payer: Cash Price	$13,298.05
Rate for Payer: Cigna Commercial	$8,314.23
Rate for Payer: Cigna Medicaid	$14,080.28
Rate for Payer: Cigna Medicare	$3,933.28
Rate for Payer: Employer Direct Commercial	$3,933.28
Rate for Payer: Humana Medicare/TRICARE	$3,933.28
Rate for Payer: Molina CHIP/Medicaid	$14,080.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Molina Medicare	$3,933.28
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: Parkland Medicaid	$14,080.28
Rate for Payer: Scott and White EPO/PPO	$6,449.12
Rate for Payer: Scott and White Medicare	$3,933.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,080.28
Rate for Payer: Superior Health Plan EPO	$3,933.28
Rate for Payer: Superior Health Plan Medicare	$3,933.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Universal American Medicare	$3,933.28
Rate for Payer: Wellcare Medicare	$3,933.28
Rate for Payer: Wellmed Medicare	$3,933.28

COR THROMBLYS-INTRA COR

Facility

$4,107.00

Service Code	HCPCS 92975
Hospital Charge Code	4612975
Hospital Revenue Code	481
Min. Negotiated Rate	$369.63
Max. Negotiated Rate	$2,957.04
Rate for Payer: Amerigroup CHIP/Medicaid	$369.63
Rate for Payer: BCBS of TX Blue Advantage	$660.84
Rate for Payer: BCBS of TX Blue Essentials	$791.42
Rate for Payer: BCBS of TX PPO	$997.19
Rate for Payer: Cash Price	$2,792.76
Rate for Payer: Cash Price	$2,792.76
Rate for Payer: Cigna Medicaid	$2,957.04
Rate for Payer: Molina CHIP/Medicaid	$2,957.04
Rate for Payer: Multiplan Auto	$2,669.55
Rate for Payer: Multiplan Commercial	$2,669.55
Rate for Payer: Multiplan Workers Comp	$2,669.55
Rate for Payer: Parkland Medicaid	$2,957.04
Rate for Payer: Scott and White EPO/PPO	$445.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,957.04
Rate for Payer: Superior Health Plan EPO	$558.55

COR THROMBLYS-INTRA COR

Facility

$4,107.00

Service Code	HCPCS 92975
Hospital Charge Code	4612975
Hospital Revenue Code	481
Rate for Payer: Cash Price	$2,792.76

Cortisol Baseline Level

Facility

$296.00

Service Code	HCPCS 82533
Hospital Charge Code	1601749
Hospital Revenue Code	301
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$213.12
Rate for Payer: Amerigroup CHIP/Medicaid	$6.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.30
Rate for Payer: Amerigroup Medicare	$16.30
Rate for Payer: BCBS of TX Blue Advantage	$88.80
Rate for Payer: BCBS of TX Blue Essentials	$106.56
Rate for Payer: BCBS of TX Medicare	$16.30
Rate for Payer: BCBS of TX PPO	$118.40
Rate for Payer: Cash Price	$201.28
Rate for Payer: Cash Price	$201.28
Rate for Payer: Cigna Medicaid	$213.12
Rate for Payer: Cigna Medicare	$16.30
Rate for Payer: Employer Direct Commercial	$16.30
Rate for Payer: Humana Medicare/TRICARE	$16.30
Rate for Payer: Molina CHIP/Medicaid	$213.12
Rate for Payer: Molina Dual Medicare/Medicaid	$16.30
Rate for Payer: Molina Medicare	$16.30
Rate for Payer: Multiplan Auto	$192.40
Rate for Payer: Multiplan Commercial	$192.40
Rate for Payer: Multiplan Workers Comp	$192.40
Rate for Payer: Parkland Medicaid	$213.12
Rate for Payer: Scott and White EPO/PPO	$20.38
Rate for Payer: Scott and White Medicare	$16.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$213.12
Rate for Payer: Superior Health Plan EPO	$16.30
Rate for Payer: Superior Health Plan Medicare	$16.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.30
Rate for Payer: Universal American Medicare	$16.30
Rate for Payer: Wellcare Medicare	$16.30
Rate for Payer: Wellmed Medicare	$16.30

Cortisol Baseline Level

Facility

$296.00

Service Code	HCPCS 82533
Hospital Charge Code	1601749
Hospital Revenue Code	301
Rate for Payer: Cash Price	$201.28

Cortisol, Urinary Free SO

Facility

$148.62

Service Code	HCPCS 82530
Hospital Charge Code	1740083
Hospital Revenue Code	301
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$107.01
Rate for Payer: Amerigroup CHIP/Medicaid	$6.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.71
Rate for Payer: Amerigroup Medicare	$16.71
Rate for Payer: BCBS of TX Blue Advantage	$44.59
Rate for Payer: BCBS of TX Blue Essentials	$53.50
Rate for Payer: BCBS of TX Medicare	$16.71
Rate for Payer: BCBS of TX PPO	$59.45
Rate for Payer: Cash Price	$101.06
Rate for Payer: Cash Price	$101.06
Rate for Payer: Cigna Medicaid	$107.01
Rate for Payer: Cigna Medicare	$16.71
Rate for Payer: Employer Direct Commercial	$16.71
Rate for Payer: Humana Medicare/TRICARE	$16.71
Rate for Payer: Molina CHIP/Medicaid	$107.01
Rate for Payer: Molina Dual Medicare/Medicaid	$16.71
Rate for Payer: Molina Medicare	$16.71
Rate for Payer: Multiplan Auto	$96.60
Rate for Payer: Multiplan Commercial	$96.60
Rate for Payer: Multiplan Workers Comp	$96.60
Rate for Payer: Parkland Medicaid	$107.01
Rate for Payer: Scott and White EPO/PPO	$20.89
Rate for Payer: Scott and White Medicare	$16.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$107.01
Rate for Payer: Superior Health Plan EPO	$16.71
Rate for Payer: Superior Health Plan Medicare	$16.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.71
Rate for Payer: Universal American Medicare	$16.71
Rate for Payer: Wellcare Medicare	$16.71
Rate for Payer: Wellmed Medicare	$16.71

Cortisol, Urinary Free SO

Facility

$148.62

Service Code	HCPCS 82530
Hospital Charge Code	1740083
Hospital Revenue Code	301
Rate for Payer: Cash Price	$101.06

COUNSELLING SMOKING CESSATN 3-10MIN

Facility

$53.00

Service Code	HCPCS 99406
Hospital Charge Code	6010375
Hospital Revenue Code	942
Rate for Payer: Cash Price	$36.04

COUNSELLING SMOKING CESSATN 3-10MIN

Facility

$53.00

Service Code	HCPCS 99406
Hospital Charge Code	6010375
Hospital Revenue Code	942
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$79.55
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37.64
Rate for Payer: Amerigroup Medicare	$37.64
Rate for Payer: BCBS of TX Blue Advantage	$15.90
Rate for Payer: BCBS of TX Blue Essentials	$19.08
Rate for Payer: BCBS of TX Medicare	$37.64
Rate for Payer: BCBS of TX PPO	$21.20
Rate for Payer: Cash Price	$36.04
Rate for Payer: Cash Price	$36.04
Rate for Payer: Cash Price	$36.04
Rate for Payer: Cigna Commercial	$79.55
Rate for Payer: Cigna Medicaid	$38.16
Rate for Payer: Cigna Medicare	$37.64
Rate for Payer: Employer Direct Commercial	$37.64
Rate for Payer: Humana Medicare/TRICARE	$37.64
Rate for Payer: Molina CHIP/Medicaid	$38.16
Rate for Payer: Molina Dual Medicare/Medicaid	$37.64
Rate for Payer: Molina Medicare	$37.64
Rate for Payer: Multiplan Auto	$34.45
Rate for Payer: Multiplan Commercial	$34.45
Rate for Payer: Multiplan Workers Comp	$34.45
Rate for Payer: Parkland Medicaid	$38.16
Rate for Payer: Scott and White EPO/PPO	$14.36
Rate for Payer: Scott and White Medicare	$37.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.16
Rate for Payer: Superior Health Plan EPO	$37.64
Rate for Payer: Superior Health Plan Medicare	$37.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$37.64
Rate for Payer: Universal American Medicare	$37.64
Rate for Payer: Wellcare Medicare	$37.64
Rate for Payer: Wellmed Medicare	$37.64

COUNSEL SMOKING CESSATN 3-10MIN WOUND

Facility

$53.00

Service Code	HCPCS 99406
Hospital Charge Code	7150781
Hospital Revenue Code	510
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$79.55
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37.64
Rate for Payer: Amerigroup Medicare	$37.64
Rate for Payer: BCBS of TX Blue Advantage	$15.90
Rate for Payer: BCBS of TX Blue Essentials	$19.08
Rate for Payer: BCBS of TX Medicare	$37.64
Rate for Payer: BCBS of TX PPO	$21.20
Rate for Payer: Cash Price	$36.04
Rate for Payer: Cash Price	$36.04
Rate for Payer: Cash Price	$36.04
Rate for Payer: Cigna Commercial	$79.55
Rate for Payer: Cigna Medicaid	$38.16
Rate for Payer: Cigna Medicare	$37.64
Rate for Payer: Employer Direct Commercial	$37.64
Rate for Payer: Humana Medicare/TRICARE	$37.64
Rate for Payer: Molina CHIP/Medicaid	$38.16
Rate for Payer: Molina Dual Medicare/Medicaid	$37.64
Rate for Payer: Molina Medicare	$37.64
Rate for Payer: Multiplan Auto	$34.45
Rate for Payer: Multiplan Commercial	$34.45
Rate for Payer: Multiplan Workers Comp	$34.45
Rate for Payer: Parkland Medicaid	$38.16
Rate for Payer: Scott and White EPO/PPO	$14.36
Rate for Payer: Scott and White Medicare	$37.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.16
Rate for Payer: Superior Health Plan EPO	$37.64
Rate for Payer: Superior Health Plan Medicare	$37.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$37.64
Rate for Payer: Universal American Medicare	$37.64
Rate for Payer: Wellcare Medicare	$37.64
Rate for Payer: Wellmed Medicare	$37.64

COUNSEL SMOKING CESSATN 3-10MIN WOUND

Facility

$53.00

Service Code	HCPCS 99406
Hospital Charge Code	7150781
Hospital Revenue Code	510
Rate for Payer: Cash Price	$36.04

COUNTERSINK 3.0

Facility

$1,702.50

Hospital Charge Code	145139
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,157.70

COUNTERSINK 3.0

Facility

$1,702.50

Hospital Charge Code	145139
Hospital Revenue Code	272
Min. Negotiated Rate	$153.22
Max. Negotiated Rate	$1,225.80
Rate for Payer: Amerigroup CHIP/Medicaid	$153.22
Rate for Payer: BCBS of TX Blue Advantage	$510.75
Rate for Payer: BCBS of TX Blue Essentials	$612.90
Rate for Payer: BCBS of TX PPO	$681.00
Rate for Payer: Cash Price	$1,157.70
Rate for Payer: Cigna Medicaid	$1,225.80
Rate for Payer: Molina CHIP/Medicaid	$1,225.80
Rate for Payer: Multiplan Auto	$1,106.62
Rate for Payer: Multiplan Commercial	$1,106.62
Rate for Payer: Multiplan Workers Comp	$1,106.62
Rate for Payer: Parkland Medicaid	$1,225.80
Rate for Payer: Scott and White EPO/PPO	$851.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,225.80
Rate for Payer: Superior Health Plan EPO	$231.54

COUNTERSINK 4.0 HEADED R3CON

Facility

$844.44

Hospital Charge Code	146424
Hospital Revenue Code	272
Min. Negotiated Rate	$76.00
Max. Negotiated Rate	$608.00
Rate for Payer: Amerigroup CHIP/Medicaid	$76.00
Rate for Payer: BCBS of TX Blue Advantage	$253.33
Rate for Payer: BCBS of TX Blue Essentials	$304.00
Rate for Payer: BCBS of TX PPO	$337.78
Rate for Payer: Cash Price	$574.22
Rate for Payer: Cigna Medicaid	$608.00
Rate for Payer: Molina CHIP/Medicaid	$608.00
Rate for Payer: Multiplan Auto	$548.89
Rate for Payer: Multiplan Commercial	$548.89
Rate for Payer: Multiplan Workers Comp	$548.89
Rate for Payer: Parkland Medicaid	$608.00
Rate for Payer: Scott and White EPO/PPO	$422.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$608.00
Rate for Payer: Superior Health Plan EPO	$114.84

COUNTERSINK 4.0 HEADED R3CON

Facility

$844.44

Hospital Charge Code	146424
Hospital Revenue Code	272
Rate for Payer: Cash Price	$574.22

COUNTERSINK 5.0MM CANNULATED DART-FIRE COMPRESSION SCREW

Facility

$1,168.67

Service Code	HCPCS C1713
Hospital Charge Code	992410
Hospital Revenue Code	278
Min. Negotiated Rate	$292.17
Max. Negotiated Rate	$584.34
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Commercial	$292.17
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Scott and White EPO/PPO	$584.34

COUNTERSINK 5.0MM CANNULATED DART-FIRE COMPRESSION SCREW

Facility

$1,168.67

Service Code	HCPCS C1713
Hospital Charge Code	992410
Hospital Revenue Code	278
Min. Negotiated Rate	$105.18
Max. Negotiated Rate	$841.44
Rate for Payer: Amerigroup CHIP/Medicaid	$105.18
Rate for Payer: BCBS of TX Blue Advantage	$350.60
Rate for Payer: BCBS of TX Blue Essentials	$420.72
Rate for Payer: BCBS of TX PPO	$467.47
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Medicaid	$841.44
Rate for Payer: Molina CHIP/Medicaid	$841.44
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Parkland Medicaid	$841.44
Rate for Payer: Scott and White EPO/PPO	$584.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$841.44
Rate for Payer: Superior Health Plan EPO	$158.94

COUNTERSINK DISP -- DHF

Facility

$1,325.25

Hospital Charge Code	81315541
Hospital Revenue Code	272
Min. Negotiated Rate	$119.27
Max. Negotiated Rate	$954.18
Rate for Payer: Amerigroup CHIP/Medicaid	$119.27
Rate for Payer: BCBS of TX Blue Advantage	$397.57
Rate for Payer: BCBS of TX Blue Essentials	$477.09
Rate for Payer: BCBS of TX PPO	$530.10
Rate for Payer: Cash Price	$901.17
Rate for Payer: Cigna Medicaid	$954.18
Rate for Payer: Molina CHIP/Medicaid	$954.18
Rate for Payer: Multiplan Auto	$861.41
Rate for Payer: Multiplan Commercial	$861.41
Rate for Payer: Multiplan Workers Comp	$861.41
Rate for Payer: Parkland Medicaid	$954.18
Rate for Payer: Scott and White EPO/PPO	$662.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$954.18
Rate for Payer: Superior Health Plan EPO	$180.23

COUNTERSINK DISP -- DHF

Facility

$1,325.25

Hospital Charge Code	81315541
Hospital Revenue Code	272
Rate for Payer: Cash Price	$901.17

COUPLER, AIR QUICK CONNECT DISS MALE FITTING

Facility

$167.98

Hospital Charge Code	993546
Hospital Revenue Code	270
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$120.95
Rate for Payer: Amerigroup CHIP/Medicaid	$15.12
Rate for Payer: BCBS of TX Blue Advantage	$50.39
Rate for Payer: BCBS of TX Blue Essentials	$60.47
Rate for Payer: BCBS of TX PPO	$67.19
Rate for Payer: Cash Price	$114.23
Rate for Payer: Cigna Medicaid	$120.95
Rate for Payer: Molina CHIP/Medicaid	$120.95
Rate for Payer: Multiplan Auto	$109.19
Rate for Payer: Multiplan Commercial	$109.19
Rate for Payer: Multiplan Workers Comp	$109.19
Rate for Payer: Parkland Medicaid	$120.95
Rate for Payer: Scott and White EPO/PPO	$83.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.95
Rate for Payer: Superior Health Plan EPO	$22.85

COUPLER, AIR QUICK CONNECT DISS MALE FITTING

Facility

$167.98

Hospital Charge Code	993546
Hospital Revenue Code	270
Rate for Payer: Cash Price	$114.23

COVERALL , OPEN CUFFS, ANKLE

Facility

$10.09

Hospital Charge Code	993726
Hospital Revenue Code	271
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$7.26
Rate for Payer: Amerigroup CHIP/Medicaid	$0.91
Rate for Payer: BCBS of TX Blue Advantage	$3.03
Rate for Payer: BCBS of TX Blue Essentials	$3.63
Rate for Payer: BCBS of TX PPO	$4.04
Rate for Payer: Cash Price	$6.86
Rate for Payer: Cigna Medicaid	$7.26
Rate for Payer: Molina CHIP/Medicaid	$7.26
Rate for Payer: Multiplan Auto	$6.56
Rate for Payer: Multiplan Commercial	$6.56
Rate for Payer: Multiplan Workers Comp	$6.56
Rate for Payer: Parkland Medicaid	$7.26
Rate for Payer: Scott and White EPO/PPO	$5.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.26
Rate for Payer: Superior Health Plan EPO	$1.37

COVERALL , OPEN CUFFS, ANKLE

Facility

$10.09

Hospital Charge Code	993726
Hospital Revenue Code	271
Rate for Payer: Cash Price	$6.86

Know your out-of-pocket cost for care.

All Charges