White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Gastrin, Serum SO

Facility

$167.00

Service Code	CPT 82941
Hospital Charge Code	1701374
Hospital Revenue Code	301
Rate for Payer: Cash Price	$146.96

Gastrocnemius recession (eg, Strayer procedure)

Facility

$10,000.00

Service Code	CPT 27687
Hospital Charge Code	36027687
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

GASTROINTESTINAL HEMORRHAGE WITH CC

Facility

$14,812.88

Service Code	MSDRG 378
Min. Negotiated Rate	$8,479.60
Max. Negotiated Rate	$14,812.88
Rate for Payer: Aetna Commercial	$11,067.75
Rate for Payer: Aetna Medicare	$14,812.88
Rate for Payer: BCBS of TX Blue Advantage	$8,479.60
Rate for Payer: BCBS of TX Blue Essentials	$10,218.91
Rate for Payer: BCBS of TX PPO	$11,354.78
Rate for Payer: Cigna Commercial	$12,671.34

GASTROINTESTINAL HEMORRHAGE WITH MCC

Facility

$23,445.72

Service Code	MSDRG 377
Min. Negotiated Rate	$15,247.80
Max. Negotiated Rate	$23,445.72
Rate for Payer: Aetna Commercial	$20,140.88
Rate for Payer: Aetna Medicare	$23,445.72
Rate for Payer: BCBS of TX Blue Advantage	$15,247.80
Rate for Payer: BCBS of TX Blue Essentials	$18,458.63
Rate for Payer: BCBS of TX PPO	$20,510.38
Rate for Payer: Cigna Commercial	$23,059.06

GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC

Facility

$11,060.00

Service Code	MSDRG 379
Min. Negotiated Rate	$5,647.62
Max. Negotiated Rate	$11,060.00
Rate for Payer: Aetna Commercial	$7,123.50
Rate for Payer: Aetna Medicare	$11,060.00
Rate for Payer: BCBS of TX Blue Advantage	$5,647.62
Rate for Payer: BCBS of TX Blue Essentials	$6,740.37
Rate for Payer: BCBS of TX PPO	$7,489.59
Rate for Payer: Cigna Commercial	$8,155.62

GASTROINTESTINAL OBSTRUCTION WITH CC

Facility

$12,806.90

Service Code	MSDRG 389
Min. Negotiated Rate	$7,383.10
Max. Negotiated Rate	$12,806.90
Rate for Payer: Aetna Commercial	$8,959.50
Rate for Payer: Aetna Medicare	$12,806.90
Rate for Payer: BCBS of TX Blue Advantage	$7,383.10
Rate for Payer: BCBS of TX Blue Essentials	$8,700.98
Rate for Payer: BCBS of TX PPO	$9,668.13
Rate for Payer: Cigna Commercial	$10,257.63

GASTROINTESTINAL OBSTRUCTION WITH MCC

Facility

$19,840.58

Service Code	MSDRG 388
Min. Negotiated Rate	$13,309.36
Max. Negotiated Rate	$19,840.58
Rate for Payer: Aetna Commercial	$16,351.88
Rate for Payer: Aetna Medicare	$19,840.58
Rate for Payer: BCBS of TX Blue Advantage	$13,309.36
Rate for Payer: BCBS of TX Blue Essentials	$15,795.29
Rate for Payer: BCBS of TX PPO	$17,551.01
Rate for Payer: Cigna Commercial	$18,721.08

GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC

Facility

$10,265.75

Service Code	MSDRG 390
Min. Negotiated Rate	$5,172.04
Max. Negotiated Rate	$10,265.75
Rate for Payer: Aetna Commercial	$6,288.75
Rate for Payer: Aetna Medicare	$10,265.75
Rate for Payer: BCBS of TX Blue Advantage	$5,172.04
Rate for Payer: BCBS of TX Blue Essentials	$6,098.53
Rate for Payer: BCBS of TX PPO	$6,776.41
Rate for Payer: Cigna Commercial	$7,199.92

Gastrojejunostomy

Facility

$10,000.00

Service Code	CPT 43820
Hospital Charge Code	36043820
Hospital Revenue Code	360
Min. Negotiated Rate	$1,638.28
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,017.00
Rate for Payer: BCBS of TX Blue Advantage	$2,345.41
Rate for Payer: BCBS of TX Blue Essentials	$2,808.88
Rate for Payer: BCBS of TX PPO	$3,539.19
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	$1,638.28

GAUZE, PACKING IODOFORM 1/2''''X 5YD STERILE -- DHF

Facility

$247.86

Hospital Charge Code	80247307
Hospital Revenue Code	270
Min. Negotiated Rate	$22.31
Max. Negotiated Rate	$161.11
Rate for Payer: Aetna Commercial	$136.32
Rate for Payer: Amerigroup CHIP/Medicaid	$22.31
Rate for Payer: BCBS of TX Blue Advantage	$74.36
Rate for Payer: BCBS of TX Blue Essentials	$89.23
Rate for Payer: BCBS of TX PPO	$99.14
Rate for Payer: Cash Price	$218.12
Rate for Payer: Multiplan Auto	$161.11
Rate for Payer: Multiplan Commercial	$161.11
Rate for Payer: Multiplan Workers Comp	$161.11
Rate for Payer: Scott and White EPO/PPO	$123.93
Rate for Payer: Superior Health Plan EPO	$33.71

GAUZE, PACKING IODOFORM 1/2''''X 5YD STERILE -- DHF

Facility

$247.86

Hospital Charge Code	80247307
Hospital Revenue Code	270
Rate for Payer: Cash Price	$218.12

GAUZE, PACKING IODOFORM 1/4'''' X 5 YD STERILE -- DHF

Facility

$234.19

Hospital Charge Code	80247356
Hospital Revenue Code	270
Rate for Payer: Cash Price	$206.09

GAUZE, PACKING IODOFORM 1/4'''' X 5 YD STERILE -- DHF

Facility

$234.19

Hospital Charge Code	80247356
Hospital Revenue Code	270
Min. Negotiated Rate	$21.08
Max. Negotiated Rate	$152.22
Rate for Payer: Aetna Commercial	$128.80
Rate for Payer: Amerigroup CHIP/Medicaid	$21.08
Rate for Payer: BCBS of TX Blue Advantage	$70.26
Rate for Payer: BCBS of TX Blue Essentials	$84.31
Rate for Payer: BCBS of TX PPO	$93.68
Rate for Payer: Cash Price	$206.09
Rate for Payer: Multiplan Auto	$152.22
Rate for Payer: Multiplan Commercial	$152.22
Rate for Payer: Multiplan Workers Comp	$152.22
Rate for Payer: Scott and White EPO/PPO	$117.09
Rate for Payer: Superior Health Plan EPO	$31.85

GCATH CRDS VISTABRT TP 7 -- DHF

Facility

$267.20

Service Code	HCPCS C1887
Hospital Charge Code	82410762
Hospital Revenue Code	278
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$133.60
Rate for Payer: Aetna Commercial	$80.16
Rate for Payer: Amerigroup CHIP/Medicaid	$24.05
Rate for Payer: BCBS of TX Blue Advantage	$80.16
Rate for Payer: BCBS of TX Blue Essentials	$96.19
Rate for Payer: BCBS of TX PPO	$106.88
Rate for Payer: Cash Price	$235.14
Rate for Payer: Multiplan Auto	$133.60
Rate for Payer: Multiplan Commercial	$133.60
Rate for Payer: Multiplan Workers Comp	$133.60
Rate for Payer: Scott and White EPO/PPO	$133.60
Rate for Payer: Superior Health Plan EPO	$36.34

GCATH CRDS VISTABRT TP 7 -- DHF

Facility

$267.20

Service Code	HCPCS C1887
Hospital Charge Code	82410762
Hospital Revenue Code	278
Min. Negotiated Rate	$66.80
Max. Negotiated Rate	$133.60
Rate for Payer: Aetna Commercial	$80.16
Rate for Payer: Cash Price	$235.14
Rate for Payer: Cigna Commercial	$66.80
Rate for Payer: Multiplan Auto	$133.60
Rate for Payer: Multiplan Commercial	$133.60
Rate for Payer: Multiplan Workers Comp	$133.60
Rate for Payer: Scott and White EPO/PPO	$133.60

GCATH MEDTRON AVE5F ZUMA -- DHF

Facility

$1,237.17

Service Code	HCPCS C1725
Hospital Charge Code	82401720
Hospital Revenue Code	278
Min. Negotiated Rate	$309.29
Max. Negotiated Rate	$618.59
Rate for Payer: Aetna Commercial	$371.15
Rate for Payer: Cash Price	$1,088.71
Rate for Payer: Cigna Commercial	$309.29
Rate for Payer: Multiplan Auto	$618.59
Rate for Payer: Multiplan Commercial	$618.59
Rate for Payer: Multiplan Workers Comp	$618.59
Rate for Payer: Scott and White EPO/PPO	$618.59

GCATH MEDTRON AVE5F ZUMA -- DHF

Facility

$1,237.17

Service Code	HCPCS C1725
Hospital Charge Code	82401720
Hospital Revenue Code	278
Min. Negotiated Rate	$111.35
Max. Negotiated Rate	$618.59
Rate for Payer: Aetna Commercial	$371.15
Rate for Payer: Amerigroup CHIP/Medicaid	$111.35
Rate for Payer: BCBS of TX Blue Advantage	$371.15
Rate for Payer: BCBS of TX Blue Essentials	$445.38
Rate for Payer: BCBS of TX PPO	$494.87
Rate for Payer: Cash Price	$1,088.71
Rate for Payer: Multiplan Auto	$618.59
Rate for Payer: Multiplan Commercial	$618.59
Rate for Payer: Multiplan Workers Comp	$618.59
Rate for Payer: Scott and White EPO/PPO	$618.59
Rate for Payer: Superior Health Plan EPO	$168.26

GDE NDL BX COMP -- DHF

Facility

$42.70

Hospital Charge Code	80730294
Hospital Revenue Code	272
Rate for Payer: Cash Price	$37.58

GDE NDL BX COMP -- DHF

Facility

$42.70

Hospital Charge Code	80730294
Hospital Revenue Code	272
Min. Negotiated Rate	$3.84
Max. Negotiated Rate	$27.75
Rate for Payer: Aetna Commercial	$23.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.84
Rate for Payer: BCBS of TX Blue Advantage	$12.81
Rate for Payer: BCBS of TX Blue Essentials	$15.37
Rate for Payer: BCBS of TX PPO	$17.08
Rate for Payer: Cash Price	$37.58
Rate for Payer: Multiplan Auto	$27.75
Rate for Payer: Multiplan Commercial	$27.75
Rate for Payer: Multiplan Workers Comp	$27.75
Rate for Payer: Scott and White EPO/PPO	$21.35
Rate for Payer: Superior Health Plan EPO	$5.81

GDE PINS -- DHF

Facility

$522.19

Hospital Charge Code	81327009
Hospital Revenue Code	272
Rate for Payer: Cash Price	$459.53

GDE PINS -- DHF

Facility

$522.19

Hospital Charge Code	81327009
Hospital Revenue Code	272
Min. Negotiated Rate	$47.00
Max. Negotiated Rate	$339.42
Rate for Payer: Aetna Commercial	$287.20
Rate for Payer: Amerigroup CHIP/Medicaid	$47.00
Rate for Payer: BCBS of TX Blue Advantage	$156.66
Rate for Payer: BCBS of TX Blue Essentials	$187.99
Rate for Payer: BCBS of TX PPO	$208.88
Rate for Payer: Cash Price	$459.53
Rate for Payer: Multiplan Auto	$339.42
Rate for Payer: Multiplan Commercial	$339.42
Rate for Payer: Multiplan Workers Comp	$339.42
Rate for Payer: Scott and White EPO/PPO	$261.10
Rate for Payer: Superior Health Plan EPO	$71.02

gel adhesive tensive conductive

Facility

$13.17

Hospital Charge Code	144857
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.59

gel adhesive tensive conductive

Facility

$13.17

Hospital Charge Code	144857
Hospital Revenue Code	272
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$8.56
Rate for Payer: Aetna Commercial	$7.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1.19
Rate for Payer: BCBS of TX Blue Advantage	$3.95
Rate for Payer: BCBS of TX Blue Essentials	$4.74
Rate for Payer: BCBS of TX PPO	$5.27
Rate for Payer: Cash Price	$11.59
Rate for Payer: Multiplan Auto	$8.56
Rate for Payer: Multiplan Commercial	$8.56
Rate for Payer: Multiplan Workers Comp	$8.56
Rate for Payer: Scott and White EPO/PPO	$6.58
Rate for Payer: Superior Health Plan EPO	$1.79

GEL DRML WND 10 -- DHF

Facility

$331.23

Hospital Charge Code	80322860
Hospital Revenue Code	270
Min. Negotiated Rate	$29.81
Max. Negotiated Rate	$215.30
Rate for Payer: Aetna Commercial	$182.18
Rate for Payer: Amerigroup CHIP/Medicaid	$29.81
Rate for Payer: BCBS of TX Blue Advantage	$99.37
Rate for Payer: BCBS of TX Blue Essentials	$119.24
Rate for Payer: BCBS of TX PPO	$132.49
Rate for Payer: Cash Price	$291.48
Rate for Payer: Multiplan Auto	$215.30
Rate for Payer: Multiplan Commercial	$215.30
Rate for Payer: Multiplan Workers Comp	$215.30
Rate for Payer: Scott and White EPO/PPO	$165.62
Rate for Payer: Superior Health Plan EPO	$45.05

GEL DRML WND 10 -- DHF

Facility

$331.23

Hospital Charge Code	80322860
Hospital Revenue Code	270
Rate for Payer: Cash Price	$291.48

Know your out-of-pocket cost for care.

All Charges