White Rock Medical Center

All Charges

Charge

Type

Setting

Price

COVER TIP HOT SHR MNPLR CRV SCSR

Facility

$953.40

Hospital Charge Code	992732
Hospital Revenue Code	270
Rate for Payer: Cash Price	$648.31

COVER ULTSND

Facility

$69.51

Hospital Charge Code	105436
Hospital Revenue Code	270
Rate for Payer: Cash Price	$47.27

COVER ULTSND

Facility

$69.51

Hospital Charge Code	105436
Hospital Revenue Code	270
Min. Negotiated Rate	$6.26
Max. Negotiated Rate	$50.05
Rate for Payer: Amerigroup CHIP/Medicaid	$6.26
Rate for Payer: BCBS of TX Blue Advantage	$20.85
Rate for Payer: BCBS of TX Blue Essentials	$25.02
Rate for Payer: BCBS of TX PPO	$27.80
Rate for Payer: Cash Price	$47.27
Rate for Payer: Cigna Medicaid	$50.05
Rate for Payer: Molina CHIP/Medicaid	$50.05
Rate for Payer: Multiplan Auto	$45.18
Rate for Payer: Multiplan Commercial	$45.18
Rate for Payer: Multiplan Workers Comp	$45.18
Rate for Payer: Parkland Medicaid	$50.05
Rate for Payer: Scott and White EPO/PPO	$34.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50.05
Rate for Payer: Superior Health Plan EPO	$9.45

COVID-19 NAA, Saliva SO

Facility

$256.55

Service Code	HCPCS 87635
Hospital Charge Code	8768554
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$184.72
Rate for Payer: Amerigroup CHIP/Medicaid	$51.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$51.31
Rate for Payer: Amerigroup Medicare	$51.31
Rate for Payer: BCBS of TX Blue Advantage	$76.97
Rate for Payer: BCBS of TX Blue Essentials	$92.36
Rate for Payer: BCBS of TX Medicare	$51.31
Rate for Payer: BCBS of TX PPO	$102.62
Rate for Payer: Cash Price	$174.45
Rate for Payer: Cash Price	$174.45
Rate for Payer: Cigna Medicaid	$184.72
Rate for Payer: Cigna Medicare	$51.31
Rate for Payer: Employer Direct Commercial	$51.31
Rate for Payer: Humana Medicare/TRICARE	$51.31
Rate for Payer: Molina CHIP/Medicaid	$184.72
Rate for Payer: Molina Dual Medicare/Medicaid	$51.31
Rate for Payer: Molina Medicare	$51.31
Rate for Payer: Multiplan Auto	$166.76
Rate for Payer: Multiplan Commercial	$166.76
Rate for Payer: Multiplan Workers Comp	$166.76
Rate for Payer: Parkland Medicaid	$184.72
Rate for Payer: Scott and White EPO/PPO	$64.14
Rate for Payer: Scott and White Medicare	$51.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$184.72
Rate for Payer: Superior Health Plan EPO	$51.31
Rate for Payer: Superior Health Plan Medicare	$51.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$51.31
Rate for Payer: Universal American Medicare	$51.31
Rate for Payer: Wellcare Medicare	$51.31
Rate for Payer: Wellmed Medicare	$51.31

COVID-19 NAA, Saliva SO

Facility

$256.55

Service Code	HCPCS 87635
Hospital Charge Code	8768554
Hospital Revenue Code	306
Rate for Payer: Cash Price	$174.45

COVIDIEN EEA ORVIL TRANSORAL CIRCULAR STAPLER ANVIL ADVANCING PROXIMAL, 21MM XL

Facility

$633.33

Hospital Charge Code	993639
Hospital Revenue Code	272
Rate for Payer: Cash Price	$430.66

COVIDIEN EEA ORVIL TRANSORAL CIRCULAR STAPLER ANVIL ADVANCING PROXIMAL, 21MM XL

Facility

$633.33

Hospital Charge Code	993639
Hospital Revenue Code	272
Min. Negotiated Rate	$57.00
Max. Negotiated Rate	$456.00
Rate for Payer: Amerigroup CHIP/Medicaid	$57.00
Rate for Payer: BCBS of TX Blue Advantage	$190.00
Rate for Payer: BCBS of TX Blue Essentials	$228.00
Rate for Payer: BCBS of TX PPO	$253.33
Rate for Payer: Cash Price	$430.66
Rate for Payer: Cigna Medicaid	$456.00
Rate for Payer: Molina CHIP/Medicaid	$456.00
Rate for Payer: Multiplan Auto	$411.66
Rate for Payer: Multiplan Commercial	$411.66
Rate for Payer: Multiplan Workers Comp	$411.66
Rate for Payer: Parkland Medicaid	$456.00
Rate for Payer: Scott and White EPO/PPO	$316.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$456.00
Rate for Payer: Superior Health Plan EPO	$86.13

Covid/Strep/Flu

Facility

$383.04

Service Code	HCPCS 87636
Hospital Charge Code	993992
Hospital Revenue Code	300
Rate for Payer: Cash Price	$260.47

Covid/Strep/Flu

Facility

$383.04

Service Code	HCPCS 87636
Hospital Charge Code	993992
Hospital Revenue Code	300
Min. Negotiated Rate	$114.91
Max. Negotiated Rate	$275.79
Rate for Payer: Amerigroup CHIP/Medicaid	$142.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$142.63
Rate for Payer: Amerigroup Medicare	$142.63
Rate for Payer: BCBS of TX Blue Advantage	$114.91
Rate for Payer: BCBS of TX Blue Essentials	$137.89
Rate for Payer: BCBS of TX Medicare	$142.63
Rate for Payer: BCBS of TX PPO	$153.22
Rate for Payer: Cash Price	$260.47
Rate for Payer: Cash Price	$260.47
Rate for Payer: Cigna Medicaid	$275.79
Rate for Payer: Cigna Medicare	$142.63
Rate for Payer: Employer Direct Commercial	$142.63
Rate for Payer: Humana Medicare/TRICARE	$142.63
Rate for Payer: Molina CHIP/Medicaid	$275.79
Rate for Payer: Molina Dual Medicare/Medicaid	$142.63
Rate for Payer: Molina Medicare	$142.63
Rate for Payer: Multiplan Auto	$248.98
Rate for Payer: Multiplan Commercial	$248.98
Rate for Payer: Multiplan Workers Comp	$248.98
Rate for Payer: Parkland Medicaid	$275.79
Rate for Payer: Scott and White EPO/PPO	$178.29
Rate for Payer: Scott and White Medicare	$142.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$275.79
Rate for Payer: Superior Health Plan EPO	$142.63
Rate for Payer: Superior Health Plan Medicare	$142.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$142.63
Rate for Payer: Universal American Medicare	$142.63
Rate for Payer: Wellcare Medicare	$142.63
Rate for Payer: Wellmed Medicare	$142.63

Covid/Strep/Flu /RSV

Facility

$383.04

Service Code	HCPCS 87637
Hospital Charge Code	993993
Hospital Revenue Code	300
Min. Negotiated Rate	$114.91
Max. Negotiated Rate	$275.79
Rate for Payer: Amerigroup CHIP/Medicaid	$142.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$142.63
Rate for Payer: Amerigroup Medicare	$142.63
Rate for Payer: BCBS of TX Blue Advantage	$114.91
Rate for Payer: BCBS of TX Blue Essentials	$137.89
Rate for Payer: BCBS of TX Medicare	$142.63
Rate for Payer: BCBS of TX PPO	$153.22
Rate for Payer: Cash Price	$260.47
Rate for Payer: Cash Price	$260.47
Rate for Payer: Cigna Medicaid	$275.79
Rate for Payer: Cigna Medicare	$142.63
Rate for Payer: Employer Direct Commercial	$142.63
Rate for Payer: Humana Medicare/TRICARE	$142.63
Rate for Payer: Molina CHIP/Medicaid	$275.79
Rate for Payer: Molina Dual Medicare/Medicaid	$142.63
Rate for Payer: Molina Medicare	$142.63
Rate for Payer: Multiplan Auto	$248.98
Rate for Payer: Multiplan Commercial	$248.98
Rate for Payer: Multiplan Workers Comp	$248.98
Rate for Payer: Parkland Medicaid	$275.79
Rate for Payer: Scott and White EPO/PPO	$178.29
Rate for Payer: Scott and White Medicare	$142.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$275.79
Rate for Payer: Superior Health Plan EPO	$142.63
Rate for Payer: Superior Health Plan Medicare	$142.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$142.63
Rate for Payer: Universal American Medicare	$142.63
Rate for Payer: Wellcare Medicare	$142.63
Rate for Payer: Wellmed Medicare	$142.63

Covid/Strep/Flu /RSV

Facility

$383.04

Service Code	HCPCS 87637
Hospital Charge Code	993993
Hospital Revenue Code	300
Rate for Payer: Cash Price	$260.47

Coxsackie Virus Group B Ab SO

Facility

$125.00

Service Code	HCPCS 86658
Hospital Charge Code	1702323
Hospital Revenue Code	302
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$90.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.03
Rate for Payer: Amerigroup Medicare	$13.03
Rate for Payer: BCBS of TX Blue Advantage	$37.50
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX Medicare	$13.03
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cigna Medicaid	$90.00
Rate for Payer: Cigna Medicare	$13.03
Rate for Payer: Employer Direct Commercial	$13.03
Rate for Payer: Humana Medicare/TRICARE	$13.03
Rate for Payer: Molina CHIP/Medicaid	$90.00
Rate for Payer: Molina Dual Medicare/Medicaid	$13.03
Rate for Payer: Molina Medicare	$13.03
Rate for Payer: Multiplan Auto	$81.25
Rate for Payer: Multiplan Commercial	$81.25
Rate for Payer: Multiplan Workers Comp	$81.25
Rate for Payer: Parkland Medicaid	$90.00
Rate for Payer: Scott and White EPO/PPO	$16.29
Rate for Payer: Scott and White Medicare	$13.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.00
Rate for Payer: Superior Health Plan EPO	$13.03
Rate for Payer: Superior Health Plan Medicare	$13.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.03
Rate for Payer: Universal American Medicare	$13.03
Rate for Payer: Wellcare Medicare	$13.03
Rate for Payer: Wellmed Medicare	$13.03

Coxsackie Virus Group B Ab SO

Facility

$125.00

Service Code	HCPCS 86658
Hospital Charge Code	1702323
Hospital Revenue Code	302
Rate for Payer: Cash Price	$85.00

COYOTE 2.5MM X 100MM X 150CM OTW

Facility

$6,265.20

Service Code	HCPCS C1726
Hospital Charge Code	993681
Hospital Revenue Code	272
Min. Negotiated Rate	$563.87
Max. Negotiated Rate	$4,510.94
Rate for Payer: Amerigroup CHIP/Medicaid	$563.87
Rate for Payer: BCBS of TX Blue Advantage	$1,879.56
Rate for Payer: BCBS of TX Blue Essentials	$2,255.47
Rate for Payer: BCBS of TX PPO	$2,506.08
Rate for Payer: Cash Price	$4,260.34
Rate for Payer: Cigna Medicaid	$4,510.94
Rate for Payer: Molina CHIP/Medicaid	$4,510.94
Rate for Payer: Multiplan Auto	$4,072.38
Rate for Payer: Multiplan Commercial	$4,072.38
Rate for Payer: Multiplan Workers Comp	$4,072.38
Rate for Payer: Parkland Medicaid	$4,510.94
Rate for Payer: Scott and White EPO/PPO	$3,132.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,510.94
Rate for Payer: Superior Health Plan EPO	$852.07

COYOTE 2.5MM X 100MM X 150CM OTW

Facility

$6,265.20

Service Code	HCPCS C1726
Hospital Charge Code	993681
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,260.34

COYOTE 3.0MM X 100MM X 150CM OTW

Facility

$6,265.20

Service Code	HCPCS C1726
Hospital Charge Code	993682
Hospital Revenue Code	272
Min. Negotiated Rate	$563.87
Max. Negotiated Rate	$4,510.94
Rate for Payer: Amerigroup CHIP/Medicaid	$563.87
Rate for Payer: BCBS of TX Blue Advantage	$1,879.56
Rate for Payer: BCBS of TX Blue Essentials	$2,255.47
Rate for Payer: BCBS of TX PPO	$2,506.08
Rate for Payer: Cash Price	$4,260.34
Rate for Payer: Cigna Medicaid	$4,510.94
Rate for Payer: Molina CHIP/Medicaid	$4,510.94
Rate for Payer: Multiplan Auto	$4,072.38
Rate for Payer: Multiplan Commercial	$4,072.38
Rate for Payer: Multiplan Workers Comp	$4,072.38
Rate for Payer: Parkland Medicaid	$4,510.94
Rate for Payer: Scott and White EPO/PPO	$3,132.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,510.94
Rate for Payer: Superior Health Plan EPO	$852.07

COYOTE 3.0MM X 100MM X 150CM OTW

Facility

$6,265.20

Service Code	HCPCS C1726
Hospital Charge Code	993682
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,260.34

C-Peptide, Serum SO

Facility

$185.00

Service Code	HCPCS 84681
Hospital Charge Code	1702141
Hospital Revenue Code	301
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$133.20
Rate for Payer: Amerigroup CHIP/Medicaid	$8.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.81
Rate for Payer: Amerigroup Medicare	$20.81
Rate for Payer: BCBS of TX Blue Advantage	$55.50
Rate for Payer: BCBS of TX Blue Essentials	$66.60
Rate for Payer: BCBS of TX Medicare	$20.81
Rate for Payer: BCBS of TX PPO	$74.00
Rate for Payer: Cash Price	$125.80
Rate for Payer: Cash Price	$125.80
Rate for Payer: Cigna Medicaid	$133.20
Rate for Payer: Cigna Medicare	$20.81
Rate for Payer: Employer Direct Commercial	$20.81
Rate for Payer: Humana Medicare/TRICARE	$20.81
Rate for Payer: Molina CHIP/Medicaid	$133.20
Rate for Payer: Molina Dual Medicare/Medicaid	$20.81
Rate for Payer: Molina Medicare	$20.81
Rate for Payer: Multiplan Auto	$120.25
Rate for Payer: Multiplan Commercial	$120.25
Rate for Payer: Multiplan Workers Comp	$120.25
Rate for Payer: Parkland Medicaid	$133.20
Rate for Payer: Scott and White EPO/PPO	$26.01
Rate for Payer: Scott and White Medicare	$20.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.20
Rate for Payer: Superior Health Plan EPO	$20.81
Rate for Payer: Superior Health Plan Medicare	$20.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.81
Rate for Payer: Universal American Medicare	$20.81
Rate for Payer: Wellcare Medicare	$20.81
Rate for Payer: Wellmed Medicare	$20.81

C-Peptide, Serum SO

Facility

$185.00

Service Code	HCPCS 84681
Hospital Charge Code	1702141
Hospital Revenue Code	301
Rate for Payer: Cash Price	$125.80

CPM PAD

Facility

$87.89

Hospital Charge Code	8570490
Hospital Revenue Code	272
Min. Negotiated Rate	$7.91
Max. Negotiated Rate	$63.28
Rate for Payer: Amerigroup CHIP/Medicaid	$7.91
Rate for Payer: BCBS of TX Blue Advantage	$26.37
Rate for Payer: BCBS of TX Blue Essentials	$31.64
Rate for Payer: BCBS of TX PPO	$35.16
Rate for Payer: Cash Price	$59.77
Rate for Payer: Cigna Medicaid	$63.28
Rate for Payer: Molina CHIP/Medicaid	$63.28
Rate for Payer: Multiplan Auto	$57.13
Rate for Payer: Multiplan Commercial	$57.13
Rate for Payer: Multiplan Workers Comp	$57.13
Rate for Payer: Parkland Medicaid	$63.28
Rate for Payer: Scott and White EPO/PPO	$43.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.28
Rate for Payer: Superior Health Plan EPO	$11.95

CPM PAD

Facility

$87.89

Hospital Charge Code	8570490
Hospital Revenue Code	272
Rate for Payer: Cash Price	$59.77

CPR

Facility

$1,150.00

Service Code	HCPCS 92950
Hospital Charge Code	4619130
Hospital Revenue Code	410
Rate for Payer: Cash Price	$782.00

CPR

Facility

$1,150.00

Service Code	HCPCS 92950
Hospital Charge Code	4619130
Hospital Revenue Code	410
Min. Negotiated Rate	$103.50
Max. Negotiated Rate	$828.00
Rate for Payer: Amerigroup CHIP/Medicaid	$103.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$422.68
Rate for Payer: BCBS of TX Blue Essentials	$506.20
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$637.81
Rate for Payer: Cash Price	$782.00
Rate for Payer: Cash Price	$782.00
Rate for Payer: Cash Price	$782.00
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$828.00
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$828.00
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$747.50
Rate for Payer: Multiplan Commercial	$747.50
Rate for Payer: Multiplan Workers Comp	$747.50
Rate for Payer: Parkland Medicaid	$828.00
Rate for Payer: Scott and White EPO/PPO	$221.51
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$828.00
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

CPS BEARING PERSONA 20MM

Facility

$11,488.00

Service Code	HCPCS C1776
Hospital Charge Code	146671
Hospital Revenue Code	278
Min. Negotiated Rate	$1,033.92
Max. Negotiated Rate	$8,271.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,033.92
Rate for Payer: BCBS of TX Blue Advantage	$3,446.40
Rate for Payer: BCBS of TX Blue Essentials	$4,135.68
Rate for Payer: BCBS of TX PPO	$4,595.20
Rate for Payer: Cash Price	$7,811.84
Rate for Payer: Cigna Medicaid	$8,271.36
Rate for Payer: Molina CHIP/Medicaid	$8,271.36
Rate for Payer: Multiplan Auto	$5,744.00
Rate for Payer: Multiplan Commercial	$5,744.00
Rate for Payer: Multiplan Workers Comp	$5,744.00
Rate for Payer: Parkland Medicaid	$8,271.36
Rate for Payer: Scott and White EPO/PPO	$5,744.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,271.36
Rate for Payer: Superior Health Plan EPO	$1,562.37

CPS BEARING PERSONA 20MM

Facility

$11,488.00

Service Code	HCPCS C1776
Hospital Charge Code	146671
Hospital Revenue Code	278
Min. Negotiated Rate	$2,872.00
Max. Negotiated Rate	$5,744.00
Rate for Payer: Cash Price	$7,811.84
Rate for Payer: Cigna Commercial	$2,872.00
Rate for Payer: Multiplan Auto	$5,744.00
Rate for Payer: Multiplan Commercial	$5,744.00
Rate for Payer: Multiplan Workers Comp	$5,744.00
Rate for Payer: Scott and White EPO/PPO	$5,744.00

Know your out-of-pocket cost for care.

All Charges