White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate

Facility

$374.00

Service Code	HCPCS 87046
Hospital Charge Code	8220508
Hospital Revenue Code	301
Rate for Payer: Cash Price	$254.32

CULTURE CHOCOLATE AGAR PLATE 100/PK

Facility

$10.48

Hospital Charge Code	993651
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.13

CULTURE CHOCOLATE AGAR PLATE 100/PK

Facility

$10.48

Hospital Charge Code	993651
Hospital Revenue Code	270
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$7.55
Rate for Payer: Amerigroup CHIP/Medicaid	$0.94
Rate for Payer: BCBS of TX Blue Advantage	$3.14
Rate for Payer: BCBS of TX Blue Essentials	$3.77
Rate for Payer: BCBS of TX PPO	$4.19
Rate for Payer: Cash Price	$7.13
Rate for Payer: Cigna Medicaid	$7.55
Rate for Payer: Molina CHIP/Medicaid	$7.55
Rate for Payer: Multiplan Auto	$6.81
Rate for Payer: Multiplan Commercial	$6.81
Rate for Payer: Multiplan Workers Comp	$6.81
Rate for Payer: Parkland Medicaid	$7.55
Rate for Payer: Scott and White EPO/PPO	$5.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.55
Rate for Payer: Superior Health Plan EPO	$1.43

Culture Urine Colony BCE

Facility

$299.00

Service Code	HCPCS 87086
Hospital Charge Code	4107086
Hospital Revenue Code	306
Rate for Payer: Cash Price	$203.32

Culture Urine Colony BCE

Facility

$299.00

Service Code	HCPCS 87086
Hospital Charge Code	4107086
Hospital Revenue Code	306
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$215.28
Rate for Payer: Amerigroup CHIP/Medicaid	$3.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.07
Rate for Payer: Amerigroup Medicare	$8.07
Rate for Payer: BCBS of TX Blue Advantage	$89.70
Rate for Payer: BCBS of TX Blue Essentials	$107.64
Rate for Payer: BCBS of TX Medicare	$8.07
Rate for Payer: BCBS of TX PPO	$119.60
Rate for Payer: Cash Price	$203.32
Rate for Payer: Cash Price	$203.32
Rate for Payer: Cigna Medicaid	$215.28
Rate for Payer: Cigna Medicare	$8.07
Rate for Payer: Employer Direct Commercial	$8.07
Rate for Payer: Humana Medicare/TRICARE	$8.07
Rate for Payer: Molina CHIP/Medicaid	$215.28
Rate for Payer: Molina Dual Medicare/Medicaid	$8.07
Rate for Payer: Molina Medicare	$8.07
Rate for Payer: Multiplan Auto	$194.35
Rate for Payer: Multiplan Commercial	$194.35
Rate for Payer: Multiplan Workers Comp	$194.35
Rate for Payer: Parkland Medicaid	$215.28
Rate for Payer: Scott and White EPO/PPO	$10.09
Rate for Payer: Scott and White Medicare	$8.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$215.28
Rate for Payer: Superior Health Plan EPO	$8.07
Rate for Payer: Superior Health Plan Medicare	$8.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.07
Rate for Payer: Universal American Medicare	$8.07
Rate for Payer: Wellcare Medicare	$8.07
Rate for Payer: Wellmed Medicare	$8.07

CUP, ASSAY MINI HEMO CONS

Facility

$1,021.50

Hospital Charge Code	993974
Hospital Revenue Code	270
Min. Negotiated Rate	$91.94
Max. Negotiated Rate	$735.48
Rate for Payer: Amerigroup CHIP/Medicaid	$91.94
Rate for Payer: BCBS of TX Blue Advantage	$306.45
Rate for Payer: BCBS of TX Blue Essentials	$367.74
Rate for Payer: BCBS of TX PPO	$408.60
Rate for Payer: Cash Price	$694.62
Rate for Payer: Cigna Medicaid	$735.48
Rate for Payer: Molina CHIP/Medicaid	$735.48
Rate for Payer: Multiplan Auto	$663.98
Rate for Payer: Multiplan Commercial	$663.98
Rate for Payer: Multiplan Workers Comp	$663.98
Rate for Payer: Parkland Medicaid	$735.48
Rate for Payer: Scott and White EPO/PPO	$510.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$735.48
Rate for Payer: Superior Health Plan EPO	$138.92

CUP, ASSAY MINI HEMO CONS

Facility

$1,021.50

Hospital Charge Code	993974
Hospital Revenue Code	270
Rate for Payer: Cash Price	$694.62

CUP, FOAM, 12 OZ

Facility

$0.33

Hospital Charge Code	993966
Hospital Revenue Code	270
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.24
Rate for Payer: Amerigroup CHIP/Medicaid	$0.03
Rate for Payer: BCBS of TX Blue Advantage	$0.10
Rate for Payer: BCBS of TX Blue Essentials	$0.12
Rate for Payer: BCBS of TX PPO	$0.13
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna Medicaid	$0.24
Rate for Payer: Molina CHIP/Medicaid	$0.24
Rate for Payer: Multiplan Auto	$0.21
Rate for Payer: Multiplan Commercial	$0.21
Rate for Payer: Multiplan Workers Comp	$0.21
Rate for Payer: Parkland Medicaid	$0.24
Rate for Payer: Scott and White EPO/PPO	$0.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.24
Rate for Payer: Superior Health Plan EPO	$0.04

CUP, FOAM, 12 OZ

Facility

$0.33

Hospital Charge Code	993966
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.22

CUP, FOAM, 8 OZ

Facility

$2.28

Hospital Charge Code	993222
Hospital Revenue Code	270
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$1.64
Rate for Payer: Amerigroup CHIP/Medicaid	$0.21
Rate for Payer: BCBS of TX Blue Advantage	$0.68
Rate for Payer: BCBS of TX Blue Essentials	$0.82
Rate for Payer: BCBS of TX PPO	$0.91
Rate for Payer: Cash Price	$1.55
Rate for Payer: Cigna Medicaid	$1.64
Rate for Payer: Molina CHIP/Medicaid	$1.64
Rate for Payer: Multiplan Auto	$1.48
Rate for Payer: Multiplan Commercial	$1.48
Rate for Payer: Multiplan Workers Comp	$1.48
Rate for Payer: Parkland Medicaid	$1.64
Rate for Payer: Scott and White EPO/PPO	$1.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.64
Rate for Payer: Superior Health Plan EPO	$0.31

CUP, FOAM, 8 OZ

Facility

$2.28

Hospital Charge Code	993222
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.55

CUP, MEDICINE, GRAD, PLASTIC, 1OZ

Facility

$0.03

Hospital Charge Code	992976
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.02

CUP, MEDICINE, GRAD, PLASTIC, 1OZ

Facility

$0.03

Hospital Charge Code	992976
Hospital Revenue Code	272
Max. Negotiated Rate	$0.02
Rate for Payer: Amerigroup CHIP/Medicaid	$0.00
Rate for Payer: BCBS of TX Blue Advantage	$0.01
Rate for Payer: BCBS of TX Blue Essentials	$0.01
Rate for Payer: BCBS of TX PPO	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna Medicaid	$0.02
Rate for Payer: Molina CHIP/Medicaid	$0.02
Rate for Payer: Multiplan Auto	$0.02
Rate for Payer: Multiplan Commercial	$0.02
Rate for Payer: Multiplan Workers Comp	$0.02
Rate for Payer: Parkland Medicaid	$0.02
Rate for Payer: Scott and White EPO/PPO	$0.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.02
Rate for Payer: Superior Health Plan EPO	$0.00

CUP STYROFOAM 12 OZ DISP

Facility

$0.86

Hospital Charge Code	993190
Hospital Revenue Code	270
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.62
Rate for Payer: Amerigroup CHIP/Medicaid	$0.08
Rate for Payer: BCBS of TX Blue Advantage	$0.26
Rate for Payer: BCBS of TX Blue Essentials	$0.31
Rate for Payer: BCBS of TX PPO	$0.34
Rate for Payer: Cash Price	$0.58
Rate for Payer: Cigna Medicaid	$0.62
Rate for Payer: Molina CHIP/Medicaid	$0.62
Rate for Payer: Multiplan Auto	$0.56
Rate for Payer: Multiplan Commercial	$0.56
Rate for Payer: Multiplan Workers Comp	$0.56
Rate for Payer: Parkland Medicaid	$0.62
Rate for Payer: Scott and White EPO/PPO	$0.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.62
Rate for Payer: Superior Health Plan EPO	$0.12

CUP STYROFOAM 12 OZ DISP

Facility

$0.86

Hospital Charge Code	993190
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.58

CURAD Xeroform gauze dressing sterile 1x8

Facility

$2.61

Hospital Charge Code	992945
Hospital Revenue Code	272
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$1.88
Rate for Payer: Amerigroup CHIP/Medicaid	$0.23
Rate for Payer: BCBS of TX Blue Advantage	$0.78
Rate for Payer: BCBS of TX Blue Essentials	$0.94
Rate for Payer: BCBS of TX PPO	$1.04
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cigna Medicaid	$1.88
Rate for Payer: Molina CHIP/Medicaid	$1.88
Rate for Payer: Multiplan Auto	$1.70
Rate for Payer: Multiplan Commercial	$1.70
Rate for Payer: Multiplan Workers Comp	$1.70
Rate for Payer: Parkland Medicaid	$1.88
Rate for Payer: Scott and White EPO/PPO	$1.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.88
Rate for Payer: Superior Health Plan EPO	$0.35

CURAD Xeroform gauze dressing sterile 1x8

Facility

$2.61

Hospital Charge Code	992945
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.77

curved cutter stapler

Facility

$1,044.20

Hospital Charge Code	993971
Hospital Revenue Code	272
Min. Negotiated Rate	$93.98
Max. Negotiated Rate	$751.82
Rate for Payer: Amerigroup CHIP/Medicaid	$93.98
Rate for Payer: BCBS of TX Blue Advantage	$313.26
Rate for Payer: BCBS of TX Blue Essentials	$375.91
Rate for Payer: BCBS of TX PPO	$417.68
Rate for Payer: Cash Price	$710.06
Rate for Payer: Cigna Medicaid	$751.82
Rate for Payer: Molina CHIP/Medicaid	$751.82
Rate for Payer: Multiplan Auto	$678.73
Rate for Payer: Multiplan Commercial	$678.73
Rate for Payer: Multiplan Workers Comp	$678.73
Rate for Payer: Parkland Medicaid	$751.82
Rate for Payer: Scott and White EPO/PPO	$522.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$751.82
Rate for Payer: Superior Health Plan EPO	$142.01

curved cutter stapler

Facility

$1,044.20

Hospital Charge Code	993971
Hospital Revenue Code	272
Rate for Payer: Cash Price	$710.06

Custom PSI MTP Fusion Cage

Facility

$84,307.23

Service Code	HCPCS C1831
Hospital Charge Code	8504492
Hospital Revenue Code	278
Min. Negotiated Rate	$21,076.81
Max. Negotiated Rate	$42,153.61
Rate for Payer: Cash Price	$57,328.92
Rate for Payer: Cigna Commercial	$21,076.81
Rate for Payer: Multiplan Auto	$42,153.61
Rate for Payer: Multiplan Commercial	$42,153.61
Rate for Payer: Multiplan Workers Comp	$42,153.61
Rate for Payer: Scott and White EPO/PPO	$42,153.61

Custom PSI MTP Fusion Cage

Facility

$84,307.23

Service Code	HCPCS C1831
Hospital Charge Code	993129
Hospital Revenue Code	278
Min. Negotiated Rate	$7,587.65
Max. Negotiated Rate	$60,701.21
Rate for Payer: Amerigroup CHIP/Medicaid	$7,587.65
Rate for Payer: Cash Price	$57,328.92
Rate for Payer: Cigna Medicaid	$60,701.21
Rate for Payer: Molina CHIP/Medicaid	$60,701.21
Rate for Payer: Multiplan Auto	$42,153.61
Rate for Payer: Multiplan Commercial	$42,153.61
Rate for Payer: Multiplan Workers Comp	$42,153.61
Rate for Payer: Parkland Medicaid	$60,701.21
Rate for Payer: Scott and White EPO/PPO	$42,153.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60,701.21
Rate for Payer: Superior Health Plan EPO	$11,465.78

Custom PSI MTP Fusion Cage

Facility

$84,307.23

Service Code	HCPCS C1831
Hospital Charge Code	8504492
Hospital Revenue Code	278
Min. Negotiated Rate	$7,587.65
Max. Negotiated Rate	$60,701.21
Rate for Payer: Amerigroup CHIP/Medicaid	$7,587.65
Rate for Payer: Cash Price	$57,328.92
Rate for Payer: Cigna Medicaid	$60,701.21
Rate for Payer: Molina CHIP/Medicaid	$60,701.21
Rate for Payer: Multiplan Auto	$42,153.61
Rate for Payer: Multiplan Commercial	$42,153.61
Rate for Payer: Multiplan Workers Comp	$42,153.61
Rate for Payer: Parkland Medicaid	$60,701.21
Rate for Payer: Scott and White EPO/PPO	$42,153.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60,701.21
Rate for Payer: Superior Health Plan EPO	$11,465.78

Custom PSI MTP Fusion Cage

Facility

$84,307.23

Service Code	HCPCS C1831
Hospital Charge Code	993129
Hospital Revenue Code	278
Min. Negotiated Rate	$21,076.81
Max. Negotiated Rate	$42,153.61
Rate for Payer: Cash Price	$57,328.92
Rate for Payer: Cigna Commercial	$21,076.81
Rate for Payer: Multiplan Auto	$42,153.61
Rate for Payer: Multiplan Commercial	$42,153.61
Rate for Payer: Multiplan Workers Comp	$42,153.61
Rate for Payer: Scott and White EPO/PPO	$42,153.61

CUTTER/CRUSHER, PILL, BLUE

Facility

$34.62

Hospital Charge Code	993220
Hospital Revenue Code	270
Rate for Payer: Cash Price	$23.54

CUTTER/CRUSHER, PILL, BLUE

Facility

$34.62

Hospital Charge Code	993220
Hospital Revenue Code	270
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$24.93
Rate for Payer: Amerigroup CHIP/Medicaid	$3.12
Rate for Payer: BCBS of TX Blue Advantage	$10.39
Rate for Payer: BCBS of TX Blue Essentials	$12.46
Rate for Payer: BCBS of TX PPO	$13.85
Rate for Payer: Cash Price	$23.54
Rate for Payer: Cigna Medicaid	$24.93
Rate for Payer: Molina CHIP/Medicaid	$24.93
Rate for Payer: Multiplan Auto	$22.50
Rate for Payer: Multiplan Commercial	$22.50
Rate for Payer: Multiplan Workers Comp	$22.50
Rate for Payer: Parkland Medicaid	$24.93
Rate for Payer: Scott and White EPO/PPO	$17.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.93
Rate for Payer: Superior Health Plan EPO	$4.71

Know your out-of-pocket cost for care.

All Charges