White Rock Medical Center

All Charges

Charge

Type

Setting

Price

80-0759

Facility

$1,355.20

Hospital Charge Code	994025
Hospital Revenue Code	272
Rate for Payer: Cash Price	$921.54

80-0760

Facility

$3,983.32

Hospital Charge Code	990425
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,708.66

80-0760

Facility

$3,983.32

Hospital Charge Code	990425
Hospital Revenue Code	272
Min. Negotiated Rate	$358.50
Max. Negotiated Rate	$2,867.99
Rate for Payer: Amerigroup CHIP/Medicaid	$358.50
Rate for Payer: BCBS of TX Blue Advantage	$1,195.00
Rate for Payer: BCBS of TX Blue Essentials	$1,434.00
Rate for Payer: BCBS of TX PPO	$1,593.33
Rate for Payer: Cash Price	$2,708.66
Rate for Payer: Cigna Medicaid	$2,867.99
Rate for Payer: Molina CHIP/Medicaid	$2,867.99
Rate for Payer: Multiplan Auto	$2,589.16
Rate for Payer: Multiplan Commercial	$2,589.16
Rate for Payer: Multiplan Workers Comp	$2,589.16
Rate for Payer: Parkland Medicaid	$2,867.99
Rate for Payer: Scott and White EPO/PPO	$1,991.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,867.99
Rate for Payer: Superior Health Plan EPO	$541.73

80184 - PHENOBARBITAL LEVEL, SO

Facility

$187.05

Service Code	HCPCS 80184
Hospital Charge Code	9038983
Hospital Revenue Code	301
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$134.68
Rate for Payer: Amerigroup CHIP/Medicaid	$5.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.30
Rate for Payer: Amerigroup Medicare	$15.30
Rate for Payer: BCBS of TX Blue Advantage	$56.12
Rate for Payer: BCBS of TX Blue Essentials	$67.34
Rate for Payer: BCBS of TX Medicare	$15.30
Rate for Payer: BCBS of TX PPO	$74.82
Rate for Payer: Cash Price	$127.19
Rate for Payer: Cash Price	$127.19
Rate for Payer: Cigna Medicaid	$134.68
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Employer Direct Commercial	$15.30
Rate for Payer: Humana Medicare/TRICARE	$15.30
Rate for Payer: Molina CHIP/Medicaid	$134.68
Rate for Payer: Molina Dual Medicare/Medicaid	$15.30
Rate for Payer: Molina Medicare	$15.30
Rate for Payer: Multiplan Auto	$121.58
Rate for Payer: Multiplan Commercial	$121.58
Rate for Payer: Multiplan Workers Comp	$121.58
Rate for Payer: Parkland Medicaid	$134.68
Rate for Payer: Scott and White EPO/PPO	$19.12
Rate for Payer: Scott and White Medicare	$15.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.68
Rate for Payer: Superior Health Plan EPO	$15.30
Rate for Payer: Superior Health Plan Medicare	$15.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.30
Rate for Payer: Universal American Medicare	$15.30
Rate for Payer: Wellcare Medicare	$15.30
Rate for Payer: Wellmed Medicare	$15.30

80184 - PHENOBARBITAL LEVEL, SO

Facility

$187.05

Service Code	HCPCS 80184
Hospital Charge Code	9038983
Hospital Revenue Code	301
Rate for Payer: Cash Price	$127.19

80299 QUANT OF DRUG NOT ELSEWHRE SPEC

Facility

$245.00

Service Code	HCPCS 80299
Hospital Charge Code	1707082
Hospital Revenue Code	300
Min. Negotiated Rate	$7.27
Max. Negotiated Rate	$176.40
Rate for Payer: Amerigroup CHIP/Medicaid	$7.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.64
Rate for Payer: Amerigroup Medicare	$18.64
Rate for Payer: BCBS of TX Blue Advantage	$73.50
Rate for Payer: BCBS of TX Blue Essentials	$88.20
Rate for Payer: BCBS of TX Medicare	$18.64
Rate for Payer: BCBS of TX PPO	$98.00
Rate for Payer: Cash Price	$166.60
Rate for Payer: Cash Price	$166.60
Rate for Payer: Cigna Medicaid	$176.40
Rate for Payer: Cigna Medicare	$18.64
Rate for Payer: Employer Direct Commercial	$18.64
Rate for Payer: Humana Medicare/TRICARE	$18.64
Rate for Payer: Molina CHIP/Medicaid	$176.40
Rate for Payer: Molina Dual Medicare/Medicaid	$18.64
Rate for Payer: Molina Medicare	$18.64
Rate for Payer: Multiplan Auto	$159.25
Rate for Payer: Multiplan Commercial	$159.25
Rate for Payer: Multiplan Workers Comp	$159.25
Rate for Payer: Parkland Medicaid	$176.40
Rate for Payer: Scott and White EPO/PPO	$23.30
Rate for Payer: Scott and White Medicare	$18.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$176.40
Rate for Payer: Superior Health Plan EPO	$18.64
Rate for Payer: Superior Health Plan Medicare	$18.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.64
Rate for Payer: Universal American Medicare	$18.64
Rate for Payer: Wellcare Medicare	$18.64
Rate for Payer: Wellmed Medicare	$18.64

80299 QUANT OF DRUG NOT ELSEWHRE SPEC

Facility

$245.00

Service Code	HCPCS 80299
Hospital Charge Code	1707082
Hospital Revenue Code	300
Rate for Payer: Cash Price	$166.60

80356 HEROIN METABOLITE

Facility

$143.50

Service Code	HCPCS 80356
Hospital Charge Code	1700033
Hospital Revenue Code	300
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$103.32
Rate for Payer: Amerigroup CHIP/Medicaid	$6.20
Rate for Payer: BCBS of TX Blue Advantage	$43.05
Rate for Payer: BCBS of TX Blue Essentials	$51.66
Rate for Payer: BCBS of TX PPO	$57.40
Rate for Payer: Cash Price	$97.58
Rate for Payer: Cash Price	$97.58
Rate for Payer: Cigna Medicaid	$103.32
Rate for Payer: Molina CHIP/Medicaid	$103.32
Rate for Payer: Multiplan Auto	$93.28
Rate for Payer: Multiplan Commercial	$93.28
Rate for Payer: Multiplan Workers Comp	$93.28
Rate for Payer: Parkland Medicaid	$103.32
Rate for Payer: Scott and White EPO/PPO	$71.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$103.32
Rate for Payer: Superior Health Plan EPO	$19.52

80356 HEROIN METABOLITE

Facility

$143.50

Service Code	HCPCS 80356
Hospital Charge Code	1700033
Hospital Revenue Code	300
Rate for Payer: Cash Price	$97.58

80361 ASSAY OPIATE DRUGS & METABOLITES EA

Facility

$145.00

Service Code	HCPCS 80361
Hospital Charge Code	1743022
Hospital Revenue Code	301
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$104.40
Rate for Payer: Amerigroup CHIP/Medicaid	$6.63
Rate for Payer: BCBS of TX Blue Advantage	$43.50
Rate for Payer: BCBS of TX Blue Essentials	$52.20
Rate for Payer: BCBS of TX PPO	$58.00
Rate for Payer: Cash Price	$98.60
Rate for Payer: Cash Price	$98.60
Rate for Payer: Cigna Medicaid	$104.40
Rate for Payer: Molina CHIP/Medicaid	$104.40
Rate for Payer: Multiplan Auto	$94.25
Rate for Payer: Multiplan Commercial	$94.25
Rate for Payer: Multiplan Workers Comp	$94.25
Rate for Payer: Parkland Medicaid	$104.40
Rate for Payer: Scott and White EPO/PPO	$72.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$104.40
Rate for Payer: Superior Health Plan EPO	$19.72

80361 ASSAY OPIATE DRUGS & METABOLITES EA

Facility

$145.00

Service Code	HCPCS 80361
Hospital Charge Code	1743022
Hospital Revenue Code	301
Rate for Payer: Cash Price	$98.60

8.0mm x 40mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992562
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

8.0mm x 40mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992562
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

81210 AP Bill Send Out BRAF mutation

Facility

$475.00

Service Code	HCPCS 81210
Hospital Charge Code	1740960
Hospital Revenue Code	310
Rate for Payer: Cash Price	$323.00

81210 AP Bill Send Out BRAF mutation

Facility

$475.00

Service Code	HCPCS 81210
Hospital Charge Code	1740960
Hospital Revenue Code	310
Min. Negotiated Rate	$68.41
Max. Negotiated Rate	$342.00
Rate for Payer: Amerigroup CHIP/Medicaid	$68.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$175.40
Rate for Payer: Amerigroup Medicare	$175.40
Rate for Payer: BCBS of TX Blue Advantage	$142.50
Rate for Payer: BCBS of TX Blue Essentials	$171.00
Rate for Payer: BCBS of TX Medicare	$175.40
Rate for Payer: BCBS of TX PPO	$190.00
Rate for Payer: Cash Price	$323.00
Rate for Payer: Cash Price	$323.00
Rate for Payer: Cigna Medicaid	$342.00
Rate for Payer: Cigna Medicare	$175.40
Rate for Payer: Employer Direct Commercial	$175.40
Rate for Payer: Humana Medicare/TRICARE	$175.40
Rate for Payer: Molina CHIP/Medicaid	$342.00
Rate for Payer: Molina Dual Medicare/Medicaid	$175.40
Rate for Payer: Molina Medicare	$175.40
Rate for Payer: Multiplan Auto	$308.75
Rate for Payer: Multiplan Commercial	$308.75
Rate for Payer: Multiplan Workers Comp	$308.75
Rate for Payer: Parkland Medicaid	$342.00
Rate for Payer: Scott and White EPO/PPO	$219.25
Rate for Payer: Scott and White Medicare	$175.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$342.00
Rate for Payer: Superior Health Plan EPO	$175.40
Rate for Payer: Superior Health Plan Medicare	$175.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$175.40
Rate for Payer: Universal American Medicare	$175.40
Rate for Payer: Wellcare Medicare	$175.40
Rate for Payer: Wellmed Medicare	$175.40

81235 AP Bill Send Out EGFR

Facility

$820.00

Service Code	HCPCS 81235
Hospital Charge Code	1740963
Hospital Revenue Code	310
Min. Negotiated Rate	$126.59
Max. Negotiated Rate	$590.40
Rate for Payer: Amerigroup CHIP/Medicaid	$126.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$324.58
Rate for Payer: Amerigroup Medicare	$324.58
Rate for Payer: BCBS of TX Blue Advantage	$246.00
Rate for Payer: BCBS of TX Blue Essentials	$295.20
Rate for Payer: BCBS of TX Medicare	$324.58
Rate for Payer: BCBS of TX PPO	$328.00
Rate for Payer: Cash Price	$557.60
Rate for Payer: Cash Price	$557.60
Rate for Payer: Cigna Medicaid	$590.40
Rate for Payer: Cigna Medicare	$324.58
Rate for Payer: Employer Direct Commercial	$324.58
Rate for Payer: Humana Medicare/TRICARE	$324.58
Rate for Payer: Molina CHIP/Medicaid	$590.40
Rate for Payer: Molina Dual Medicare/Medicaid	$324.58
Rate for Payer: Molina Medicare	$324.58
Rate for Payer: Multiplan Auto	$533.00
Rate for Payer: Multiplan Commercial	$533.00
Rate for Payer: Multiplan Workers Comp	$533.00
Rate for Payer: Parkland Medicaid	$590.40
Rate for Payer: Scott and White EPO/PPO	$405.73
Rate for Payer: Scott and White Medicare	$324.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$590.40
Rate for Payer: Superior Health Plan EPO	$324.58
Rate for Payer: Superior Health Plan Medicare	$324.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$324.58
Rate for Payer: Universal American Medicare	$324.58
Rate for Payer: Wellcare Medicare	$324.58
Rate for Payer: Wellmed Medicare	$324.58

81235 AP Bill Send Out EGFR

Facility

$820.00

Service Code	HCPCS 81235
Hospital Charge Code	1740963
Hospital Revenue Code	310
Rate for Payer: Cash Price	$557.60

81301 AP Bill Send Out Microsatellite Instability

Facility

$790.08

Service Code	HCPCS 81301
Hospital Charge Code	9050994
Hospital Revenue Code	310
Min. Negotiated Rate	$135.94
Max. Negotiated Rate	$568.86
Rate for Payer: Amerigroup CHIP/Medicaid	$135.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$348.56
Rate for Payer: Amerigroup Medicare	$348.56
Rate for Payer: BCBS of TX Blue Advantage	$237.02
Rate for Payer: BCBS of TX Blue Essentials	$284.43
Rate for Payer: BCBS of TX Medicare	$348.56
Rate for Payer: BCBS of TX PPO	$316.03
Rate for Payer: Cash Price	$537.25
Rate for Payer: Cash Price	$537.25
Rate for Payer: Cigna Medicaid	$568.86
Rate for Payer: Cigna Medicare	$348.56
Rate for Payer: Employer Direct Commercial	$348.56
Rate for Payer: Humana Medicare/TRICARE	$348.56
Rate for Payer: Molina CHIP/Medicaid	$568.86
Rate for Payer: Molina Dual Medicare/Medicaid	$348.56
Rate for Payer: Molina Medicare	$348.56
Rate for Payer: Multiplan Auto	$513.55
Rate for Payer: Multiplan Commercial	$513.55
Rate for Payer: Multiplan Workers Comp	$513.55
Rate for Payer: Parkland Medicaid	$568.86
Rate for Payer: Scott and White EPO/PPO	$435.70
Rate for Payer: Scott and White Medicare	$348.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$568.86
Rate for Payer: Superior Health Plan EPO	$348.56
Rate for Payer: Superior Health Plan Medicare	$348.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$348.56
Rate for Payer: Universal American Medicare	$348.56
Rate for Payer: Wellcare Medicare	$348.56
Rate for Payer: Wellmed Medicare	$348.56

81301 AP Bill Send Out Microsatellite Instability

Facility

$790.08

Service Code	HCPCS 81301
Hospital Charge Code	9050994
Hospital Revenue Code	310
Rate for Payer: Cash Price	$537.25

81445 AP Bill Send Out Lung NGS Panel

Facility

$2,392.50

Service Code	HCPCS 81445
Hospital Charge Code	9050992
Hospital Revenue Code	310
Rate for Payer: Cash Price	$1,626.90

81445 AP Bill Send Out Lung NGS Panel

Facility

$2,392.50

Service Code	HCPCS 81445
Hospital Charge Code	9050992
Hospital Revenue Code	310
Min. Negotiated Rate	$233.18
Max. Negotiated Rate	$1,722.60
Rate for Payer: Amerigroup CHIP/Medicaid	$233.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$597.91
Rate for Payer: Amerigroup Medicare	$597.91
Rate for Payer: BCBS of TX Blue Advantage	$717.75
Rate for Payer: BCBS of TX Blue Essentials	$861.30
Rate for Payer: BCBS of TX Medicare	$597.91
Rate for Payer: BCBS of TX PPO	$957.00
Rate for Payer: Cash Price	$1,626.90
Rate for Payer: Cash Price	$1,626.90
Rate for Payer: Cigna Medicaid	$1,722.60
Rate for Payer: Cigna Medicare	$597.91
Rate for Payer: Employer Direct Commercial	$597.91
Rate for Payer: Humana Medicare/TRICARE	$597.91
Rate for Payer: Molina CHIP/Medicaid	$1,722.60
Rate for Payer: Molina Dual Medicare/Medicaid	$597.91
Rate for Payer: Molina Medicare	$597.91
Rate for Payer: Multiplan Auto	$1,555.12
Rate for Payer: Multiplan Commercial	$1,555.12
Rate for Payer: Multiplan Workers Comp	$1,555.12
Rate for Payer: Parkland Medicaid	$1,722.60
Rate for Payer: Scott and White EPO/PPO	$747.39
Rate for Payer: Scott and White Medicare	$597.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,722.60
Rate for Payer: Superior Health Plan EPO	$597.91
Rate for Payer: Superior Health Plan Medicare	$597.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$597.91
Rate for Payer: Universal American Medicare	$597.91
Rate for Payer: Wellcare Medicare	$597.91
Rate for Payer: Wellmed Medicare	$597.91

82042 ALBUMIN URINE/OTHER SOURCE QUANT

Facility

$140.00

Service Code	HCPCS 82042
Hospital Charge Code	1600816
Hospital Revenue Code	301
Rate for Payer: Cash Price	$95.20

82042 ALBUMIN URINE/OTHER SOURCE QUANT

Facility

$140.00

Service Code	HCPCS 82042
Hospital Charge Code	1600816
Hospital Revenue Code	301
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$100.80
Rate for Payer: Amerigroup CHIP/Medicaid	$3.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.78
Rate for Payer: Amerigroup Medicare	$7.78
Rate for Payer: BCBS of TX Blue Advantage	$42.00
Rate for Payer: BCBS of TX Blue Essentials	$50.40
Rate for Payer: BCBS of TX Medicare	$7.78
Rate for Payer: BCBS of TX PPO	$56.00
Rate for Payer: Cash Price	$95.20
Rate for Payer: Cash Price	$95.20
Rate for Payer: Cigna Medicaid	$100.80
Rate for Payer: Cigna Medicare	$7.78
Rate for Payer: Employer Direct Commercial	$7.78
Rate for Payer: Humana Medicare/TRICARE	$7.78
Rate for Payer: Molina CHIP/Medicaid	$100.80
Rate for Payer: Molina Dual Medicare/Medicaid	$7.78
Rate for Payer: Molina Medicare	$7.78
Rate for Payer: Multiplan Auto	$91.00
Rate for Payer: Multiplan Commercial	$91.00
Rate for Payer: Multiplan Workers Comp	$91.00
Rate for Payer: Parkland Medicaid	$100.80
Rate for Payer: Scott and White EPO/PPO	$9.72
Rate for Payer: Scott and White Medicare	$7.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.80
Rate for Payer: Superior Health Plan EPO	$7.78
Rate for Payer: Superior Health Plan Medicare	$7.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.78
Rate for Payer: Universal American Medicare	$7.78
Rate for Payer: Wellcare Medicare	$7.78
Rate for Payer: Wellmed Medicare	$7.78

82105 ALPHA-FETOPROTEIN SERUM

Facility

$243.00

Service Code	HCPCS 82105
Hospital Charge Code	1603075
Hospital Revenue Code	301
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$174.96
Rate for Payer: Amerigroup CHIP/Medicaid	$6.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.77
Rate for Payer: Amerigroup Medicare	$16.77
Rate for Payer: BCBS of TX Blue Advantage	$72.90
Rate for Payer: BCBS of TX Blue Essentials	$87.48
Rate for Payer: BCBS of TX Medicare	$16.77
Rate for Payer: BCBS of TX PPO	$97.20
Rate for Payer: Cash Price	$165.24
Rate for Payer: Cash Price	$165.24
Rate for Payer: Cigna Medicaid	$174.96
Rate for Payer: Cigna Medicare	$16.77
Rate for Payer: Employer Direct Commercial	$16.77
Rate for Payer: Humana Medicare/TRICARE	$16.77
Rate for Payer: Molina CHIP/Medicaid	$174.96
Rate for Payer: Molina Dual Medicare/Medicaid	$16.77
Rate for Payer: Molina Medicare	$16.77
Rate for Payer: Multiplan Auto	$157.95
Rate for Payer: Multiplan Commercial	$157.95
Rate for Payer: Multiplan Workers Comp	$157.95
Rate for Payer: Parkland Medicaid	$174.96
Rate for Payer: Scott and White EPO/PPO	$20.96
Rate for Payer: Scott and White Medicare	$16.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$174.96
Rate for Payer: Superior Health Plan EPO	$16.77
Rate for Payer: Superior Health Plan Medicare	$16.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.77
Rate for Payer: Universal American Medicare	$16.77
Rate for Payer: Wellcare Medicare	$16.77
Rate for Payer: Wellmed Medicare	$16.77

82105 ALPHA-FETOPROTEIN SERUM

Facility

$243.00

Service Code	HCPCS 82105
Hospital Charge Code	1603075
Hospital Revenue Code	301
Rate for Payer: Cash Price	$165.24

Know your out-of-pocket cost for care.

All Charges