White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Filleted finger or toe flap, including preparation of recipient site

Facility

$10,000.00

Service Code	CPT 14350
Hospital Charge Code	36014350
Hospital Revenue Code	360
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: 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

filter capnoline

Facility

$118.40

Hospital Charge Code	132277
Hospital Revenue Code	270
Rate for Payer: Cash Price	$104.19

filter capnoline

Facility

$118.40

Hospital Charge Code	132277
Hospital Revenue Code	270
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$76.96
Rate for Payer: Aetna Commercial	$65.12
Rate for Payer: Amerigroup CHIP/Medicaid	$10.66
Rate for Payer: BCBS of TX Blue Advantage	$35.52
Rate for Payer: BCBS of TX Blue Essentials	$42.62
Rate for Payer: BCBS of TX PPO	$47.36
Rate for Payer: Cash Price	$104.19
Rate for Payer: Multiplan Auto	$76.96
Rate for Payer: Multiplan Commercial	$76.96
Rate for Payer: Multiplan Workers Comp	$76.96
Rate for Payer: Scott and White EPO/PPO	$59.20
Rate for Payer: Superior Health Plan EPO	$16.10

FILTER IVC CELECT 65CM G34309

Facility

$7,710.84

Service Code	HCPCS C1880
Hospital Charge Code	109361
Hospital Revenue Code	278
Min. Negotiated Rate	$693.98
Max. Negotiated Rate	$3,855.42
Rate for Payer: Aetna Commercial	$2,313.25
Rate for Payer: Amerigroup CHIP/Medicaid	$693.98
Rate for Payer: BCBS of TX Blue Advantage	$2,313.25
Rate for Payer: BCBS of TX Blue Essentials	$2,775.90
Rate for Payer: BCBS of TX PPO	$3,084.34
Rate for Payer: Cash Price	$6,785.54
Rate for Payer: Multiplan Auto	$3,855.42
Rate for Payer: Multiplan Commercial	$3,855.42
Rate for Payer: Multiplan Workers Comp	$3,855.42
Rate for Payer: Scott and White EPO/PPO	$3,855.42
Rate for Payer: Superior Health Plan EPO	$1,048.67

FILTER IVC CELECT 65CM G34309

Facility

$7,710.84

Service Code	HCPCS C1880
Hospital Charge Code	109361
Hospital Revenue Code	278
Min. Negotiated Rate	$1,927.71
Max. Negotiated Rate	$3,855.42
Rate for Payer: Aetna Commercial	$2,313.25
Rate for Payer: Cash Price	$6,785.54
Rate for Payer: Cigna Commercial	$1,927.71
Rate for Payer: Multiplan Auto	$3,855.42
Rate for Payer: Multiplan Commercial	$3,855.42
Rate for Payer: Multiplan Workers Comp	$3,855.42
Rate for Payer: Scott and White EPO/PPO	$3,855.42

FILTER, SMOKE EVACUATION PLUME 4.0 -- DHF

Facility

$93.77

Hospital Charge Code	81746679
Hospital Revenue Code	270
Rate for Payer: Cash Price	$82.52

FILTER, SMOKE EVACUATION PLUME 4.0 -- DHF

Facility

$93.77

Hospital Charge Code	81746679
Hospital Revenue Code	270
Min. Negotiated Rate	$8.44
Max. Negotiated Rate	$60.95
Rate for Payer: Aetna Commercial	$51.57
Rate for Payer: Amerigroup CHIP/Medicaid	$8.44
Rate for Payer: BCBS of TX Blue Advantage	$28.13
Rate for Payer: BCBS of TX Blue Essentials	$33.76
Rate for Payer: BCBS of TX PPO	$37.51
Rate for Payer: Cash Price	$82.52
Rate for Payer: Multiplan Auto	$60.95
Rate for Payer: Multiplan Commercial	$60.95
Rate for Payer: Multiplan Workers Comp	$60.95
Rate for Payer: Scott and White EPO/PPO	$46.88
Rate for Payer: Superior Health Plan EPO	$12.75

FILTER TPN IV -- DHF

Facility

$65.75

Hospital Charge Code	54202601
Hospital Revenue Code	270
Rate for Payer: Cash Price	$57.86

FILTER TPN IV -- DHF

Facility

$65.75

Hospital Charge Code	54202601
Hospital Revenue Code	270
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$42.74
Rate for Payer: Aetna Commercial	$36.16
Rate for Payer: Amerigroup CHIP/Medicaid	$5.92
Rate for Payer: BCBS of TX Blue Advantage	$19.72
Rate for Payer: BCBS of TX Blue Essentials	$23.67
Rate for Payer: BCBS of TX PPO	$26.30
Rate for Payer: Cash Price	$57.86
Rate for Payer: Multiplan Auto	$42.74
Rate for Payer: Multiplan Commercial	$42.74
Rate for Payer: Multiplan Workers Comp	$42.74
Rate for Payer: Scott and White EPO/PPO	$32.88
Rate for Payer: Superior Health Plan EPO	$8.94

finasteride 5 mg tablet

Facility

$8.00

Service Code	HCPCS S0138
Hospital Charge Code	77572100
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

finasteride 5 mg tablet

Facility

$8.00

Service Code	HCPCS S0138
Hospital Charge Code	77572100
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

Finger, Simple

Facility

$533.00

Service Code	CPT 26010
Hospital Charge Code	8682617
Hospital Revenue Code	450
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$414.75
Rate for Payer: Aetna Commercial	$293.15
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$47.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$147.44
Rate for Payer: BCBS of TX Blue Essentials	$176.58
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$222.49
Rate for Payer: Cash Price	$469.04
Rate for Payer: Cash Price	$469.04
Rate for Payer: Cash Price	$469.04
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$74.34
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina CHIP/Medicaid	$74.34
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$346.45
Rate for Payer: Multiplan Commercial	$346.45
Rate for Payer: Multiplan Workers Comp	$346.45
Rate for Payer: Parkland Medicaid	$74.34
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.34
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

Finger, Simple

Facility

$533.00

Service Code	CPT 26010
Hospital Charge Code	8682617
Hospital Revenue Code	450
Rate for Payer: Cash Price	$469.04

First Dose Janssen 0031A

Facility

$60.00

Service Code	CPT 0031A
Hospital Charge Code	8686556
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan EPO	$8.16

First Dose Janssen 0031A

Facility

$60.00

Service Code	CPT 0031A
Hospital Charge Code	8686556
Hospital Revenue Code	771
Rate for Payer: Cash Price	$52.80

First Dose Moderna 0011A

Facility

$60.00

Service Code	CPT 0011A
Hospital Charge Code	8686557
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan EPO	$8.16

First Dose Moderna 0011A

Facility

$60.00

Service Code	CPT 0011A
Hospital Charge Code	8686557
Hospital Revenue Code	771
Rate for Payer: Cash Price	$52.80

First Dose Pfizer 0001A

Facility

$60.00

Service Code	CPT 0001A
Hospital Charge Code	1500010
Hospital Revenue Code	771
Rate for Payer: Cash Price	$52.80

First Dose Pfizer 0001A

Facility

$60.00

Service Code	CPT 0001A
Hospital Charge Code	1500010
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan EPO	$8.16

First Dose Pfizer Peds 0071A

Facility

$60.00

Service Code	CPT 0071A
Hospital Charge Code	8734594
Hospital Revenue Code	771
Rate for Payer: Cash Price	$52.80

First Dose Pfizer Peds 0071A

Facility

$60.00

Service Code	CPT 0071A
Hospital Charge Code	8734594
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan EPO	$8.16

FIX FLUTED PIN 3.2 X 150MM

Facility

$391.57

Service Code	HCPCS C1713
Hospital Charge Code	8702508
Hospital Revenue Code	278
Min. Negotiated Rate	$35.24
Max. Negotiated Rate	$195.78
Rate for Payer: Aetna Commercial	$117.47
Rate for Payer: Amerigroup CHIP/Medicaid	$35.24
Rate for Payer: BCBS of TX Blue Advantage	$117.47
Rate for Payer: BCBS of TX Blue Essentials	$140.97
Rate for Payer: BCBS of TX PPO	$156.63
Rate for Payer: Cash Price	$344.58
Rate for Payer: Multiplan Auto	$195.78
Rate for Payer: Multiplan Commercial	$195.78
Rate for Payer: Multiplan Workers Comp	$195.78
Rate for Payer: Scott and White EPO/PPO	$195.78
Rate for Payer: Superior Health Plan EPO	$53.25

FIX FLUTED PIN 3.2 X 150MM

Facility

$391.57

Service Code	HCPCS C1713
Hospital Charge Code	8702508
Hospital Revenue Code	278
Min. Negotiated Rate	$97.89
Max. Negotiated Rate	$195.78
Rate for Payer: Aetna Commercial	$117.47
Rate for Payer: Cash Price	$344.58
Rate for Payer: Cigna Commercial	$97.89
Rate for Payer: Multiplan Auto	$195.78
Rate for Payer: Multiplan Commercial	$195.78
Rate for Payer: Multiplan Workers Comp	$195.78
Rate for Payer: Scott and White EPO/PPO	$195.78

FIX FLUTE PIN 3.2X 80MM PK/2

Facility

$391.57

Service Code	HCPCS C1713
Hospital Charge Code	8702507
Hospital Revenue Code	278
Min. Negotiated Rate	$35.24
Max. Negotiated Rate	$195.78
Rate for Payer: Aetna Commercial	$117.47
Rate for Payer: Amerigroup CHIP/Medicaid	$35.24
Rate for Payer: BCBS of TX Blue Advantage	$117.47
Rate for Payer: BCBS of TX Blue Essentials	$140.97
Rate for Payer: BCBS of TX PPO	$156.63
Rate for Payer: Cash Price	$344.58
Rate for Payer: Multiplan Auto	$195.78
Rate for Payer: Multiplan Commercial	$195.78
Rate for Payer: Multiplan Workers Comp	$195.78
Rate for Payer: Scott and White EPO/PPO	$195.78
Rate for Payer: Superior Health Plan EPO	$53.25

FIX FLUTE PIN 3.2X 80MM PK/2

Facility

$391.57

Service Code	HCPCS C1713
Hospital Charge Code	8702507
Hospital Revenue Code	278
Min. Negotiated Rate	$97.89
Max. Negotiated Rate	$195.78
Rate for Payer: Aetna Commercial	$117.47
Rate for Payer: Cash Price	$344.58
Rate for Payer: Cigna Commercial	$97.89
Rate for Payer: Multiplan Auto	$195.78
Rate for Payer: Multiplan Commercial	$195.78
Rate for Payer: Multiplan Workers Comp	$195.78
Rate for Payer: Scott and White EPO/PPO	$195.78

Know your out-of-pocket cost for care.

All Charges