White Rock Medical Center

All Charges

Charge

Type

Setting

Price

HL LIMB PR -- DHF

Facility

$225.38

Hospital Charge Code	81143257
Hospital Revenue Code	270
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$146.50
Rate for Payer: Aetna Commercial	$123.96
Rate for Payer: Amerigroup CHIP/Medicaid	$20.28
Rate for Payer: BCBS of TX Blue Advantage	$67.61
Rate for Payer: BCBS of TX Blue Essentials	$81.14
Rate for Payer: BCBS of TX PPO	$90.15
Rate for Payer: Cash Price	$198.33
Rate for Payer: Multiplan Auto	$146.50
Rate for Payer: Multiplan Commercial	$146.50
Rate for Payer: Multiplan Workers Comp	$146.50
Rate for Payer: Scott and White EPO/PPO	$112.69
Rate for Payer: Superior Health Plan EPO	$30.65

HL LIMB PR -- DHF

Facility

$225.38

Hospital Charge Code	81143257
Hospital Revenue Code	270
Rate for Payer: Cash Price	$198.33

HNDL DISP ALL -- DHF

Facility

$55.64

Hospital Charge Code	82136078
Hospital Revenue Code	270
Rate for Payer: Cash Price	$48.96

HNDL DISP ALL -- DHF

Facility

$55.64

Hospital Charge Code	82136078
Hospital Revenue Code	270
Min. Negotiated Rate	$5.01
Max. Negotiated Rate	$36.17
Rate for Payer: Aetna Commercial	$30.60
Rate for Payer: Amerigroup CHIP/Medicaid	$5.01
Rate for Payer: BCBS of TX Blue Advantage	$16.69
Rate for Payer: BCBS of TX Blue Essentials	$20.03
Rate for Payer: BCBS of TX PPO	$22.26
Rate for Payer: Cash Price	$48.96
Rate for Payer: Multiplan Auto	$36.17
Rate for Payer: Multiplan Commercial	$36.17
Rate for Payer: Multiplan Workers Comp	$36.17
Rate for Payer: Scott and White EPO/PPO	$27.82
Rate for Payer: Superior Health Plan EPO	$7.57

HNDPC ABLATION RF -- DHF

Facility

$4,880.50

Hospital Charge Code	80324114
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,294.84

HNDPC ABLATION RF -- DHF

Facility

$4,880.50

Hospital Charge Code	80324114
Hospital Revenue Code	272
Min. Negotiated Rate	$439.24
Max. Negotiated Rate	$3,172.32
Rate for Payer: Aetna Commercial	$2,684.28
Rate for Payer: Amerigroup CHIP/Medicaid	$439.24
Rate for Payer: BCBS of TX Blue Advantage	$1,464.15
Rate for Payer: BCBS of TX Blue Essentials	$1,756.98
Rate for Payer: BCBS of TX PPO	$1,952.20
Rate for Payer: Cash Price	$4,294.84
Rate for Payer: Multiplan Auto	$3,172.32
Rate for Payer: Multiplan Commercial	$3,172.32
Rate for Payer: Multiplan Workers Comp	$3,172.32
Rate for Payer: Scott and White EPO/PPO	$2,440.25
Rate for Payer: Superior Health Plan EPO	$663.75

HNDPC HYDRO SURG -- DHF

Facility

$235.85

Hospital Charge Code	81748295
Hospital Revenue Code	272
Rate for Payer: Cash Price	$207.55

HNDPC HYDRO SURG -- DHF

Facility

$235.85

Hospital Charge Code	81748295
Hospital Revenue Code	272
Min. Negotiated Rate	$21.23
Max. Negotiated Rate	$153.30
Rate for Payer: Aetna Commercial	$129.72
Rate for Payer: Amerigroup CHIP/Medicaid	$21.23
Rate for Payer: BCBS of TX Blue Advantage	$70.76
Rate for Payer: BCBS of TX Blue Essentials	$84.91
Rate for Payer: BCBS of TX PPO	$94.34
Rate for Payer: Cash Price	$207.55
Rate for Payer: Multiplan Auto	$153.30
Rate for Payer: Multiplan Commercial	$153.30
Rate for Payer: Multiplan Workers Comp	$153.30
Rate for Payer: Scott and White EPO/PPO	$117.92
Rate for Payer: Superior Health Plan EPO	$32.08

HOLDER, ARTHROSCOPIC KNEE FOAM 3 X 11 X 10 1/2 -- DHF

Facility

$98.26

Hospital Charge Code	80383250
Hospital Revenue Code	272
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$63.87
Rate for Payer: Aetna Commercial	$54.04
Rate for Payer: Amerigroup CHIP/Medicaid	$8.84
Rate for Payer: BCBS of TX Blue Advantage	$29.48
Rate for Payer: BCBS of TX Blue Essentials	$35.37
Rate for Payer: BCBS of TX PPO	$39.30
Rate for Payer: Cash Price	$86.47
Rate for Payer: Multiplan Auto	$63.87
Rate for Payer: Multiplan Commercial	$63.87
Rate for Payer: Multiplan Workers Comp	$63.87
Rate for Payer: Scott and White EPO/PPO	$49.13
Rate for Payer: Superior Health Plan EPO	$13.36

HOLDER, LEG OPERATIVE UNCOVERED POLYETHYLN 3X11X7'''' -- DHF

Facility

$98.26

Hospital Charge Code	80383250
Hospital Revenue Code	272
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$63.87
Rate for Payer: Aetna Commercial	$54.04
Rate for Payer: Amerigroup CHIP/Medicaid	$8.84
Rate for Payer: BCBS of TX Blue Advantage	$29.48
Rate for Payer: BCBS of TX Blue Essentials	$35.37
Rate for Payer: BCBS of TX PPO	$39.30
Rate for Payer: Cash Price	$86.47
Rate for Payer: Multiplan Auto	$63.87
Rate for Payer: Multiplan Commercial	$63.87
Rate for Payer: Multiplan Workers Comp	$63.87
Rate for Payer: Scott and White EPO/PPO	$49.13
Rate for Payer: Superior Health Plan EPO	$13.36

HOLDER, LEG OPERATIVE UNCOVERED POLYETHYLN 3X11X7'''' -- DHF

Facility

$98.26

Hospital Charge Code	80383250
Hospital Revenue Code	272
Rate for Payer: Cash Price	$86.47

Holter scanning analysis w/ report 12-48 hrs 93226

Facility

$1,031.00

Service Code	CPT 93226
Hospital Charge Code	2800863
Hospital Revenue Code	731
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$670.15
Rate for Payer: Aetna Commercial	$64.37
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$92.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$189.71
Rate for Payer: BCBS of TX Blue Essentials	$226.78
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$252.95
Rate for Payer: Cash Price	$907.28
Rate for Payer: Cash Price	$907.28
Rate for Payer: Cash Price	$907.28
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
Rate for Payer: Multiplan Auto	$670.15
Rate for Payer: Multiplan Commercial	$670.15
Rate for Payer: Multiplan Workers Comp	$670.15
Rate for Payer: Scott and White EPO/PPO	$1.00
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

Holter scanning analysis w/ report 12-48 hrs 93226 BCE

Facility

$1,031.00

Service Code	CPT 93226
Hospital Charge Code	2800863
Hospital Revenue Code	731
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$670.15
Rate for Payer: Aetna Commercial	$64.37
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$92.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$189.71
Rate for Payer: BCBS of TX Blue Essentials	$226.78
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$252.95
Rate for Payer: Cash Price	$907.28
Rate for Payer: Cash Price	$907.28
Rate for Payer: Cash Price	$907.28
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
Rate for Payer: Multiplan Auto	$670.15
Rate for Payer: Multiplan Commercial	$670.15
Rate for Payer: Multiplan Workers Comp	$670.15
Rate for Payer: Scott and White EPO/PPO	$1.00
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

Holter scanning analysis w/ report 12-48 hrs 93226 BCE

Facility

$1,031.00

Service Code	CPT 93226
Hospital Charge Code	2800863
Hospital Revenue Code	731
Rate for Payer: Cash Price	$907.28

Home Sleep Test Type 3 Unattended G0399

Facility

$819.00

Service Code	HCPCS G0399
Hospital Charge Code	6910399
Hospital Revenue Code	920
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$532.35
Rate for Payer: Aetna Commercial	$127.71
Rate for Payer: Aetna Medicare	$214.29
Rate for Payer: Amerigroup CHIP/Medicaid	$73.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$142.86
Rate for Payer: Amerigroup Medicare	$142.86
Rate for Payer: BCBS of TX Blue Advantage	$228.28
Rate for Payer: BCBS of TX Blue Essentials	$273.93
Rate for Payer: BCBS of TX Medicare	$142.86
Rate for Payer: BCBS of TX PPO	$305.75
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cigna Commercial	$323.61
Rate for Payer: Cigna Medicare	$142.86
Rate for Payer: Employer Direct Commercial	$142.86
Rate for Payer: Humana Medicare/TRICARE	$142.86
Rate for Payer: Molina Dual Medicare/Medicaid	$142.86
Rate for Payer: Molina Medicare	$142.86
Rate for Payer: Multiplan Auto	$532.35
Rate for Payer: Multiplan Commercial	$532.35
Rate for Payer: Multiplan Workers Comp	$532.35
Rate for Payer: Scott and White EPO/PPO	$2.55
Rate for Payer: Scott and White Medicare	$142.86
Rate for Payer: Superior Health Plan EPO	$142.86
Rate for Payer: Superior Health Plan Medicare	$142.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$142.86
Rate for Payer: Universal American Medicare	$142.86
Rate for Payer: Wellcare Medicare	$142.86
Rate for Payer: Wellmed Medicare	$142.86

Home Sleep Test Type 3 Unattended G0399

Facility

$819.00

Service Code	HCPCS G0399 52
Hospital Charge Code	6910399
Hospital Revenue Code	920
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$532.35
Rate for Payer: Aetna Commercial	$127.71
Rate for Payer: Aetna Medicare	$214.29
Rate for Payer: Amerigroup CHIP/Medicaid	$73.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$142.86
Rate for Payer: Amerigroup Medicare	$142.86
Rate for Payer: BCBS of TX Blue Advantage	$228.28
Rate for Payer: BCBS of TX Blue Essentials	$273.93
Rate for Payer: BCBS of TX Medicare	$142.86
Rate for Payer: BCBS of TX PPO	$305.75
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cigna Commercial	$323.61
Rate for Payer: Cigna Medicare	$142.86
Rate for Payer: Employer Direct Commercial	$142.86
Rate for Payer: Humana Medicare/TRICARE	$142.86
Rate for Payer: Molina Dual Medicare/Medicaid	$142.86
Rate for Payer: Molina Medicare	$142.86
Rate for Payer: Multiplan Auto	$532.35
Rate for Payer: Multiplan Commercial	$532.35
Rate for Payer: Multiplan Workers Comp	$532.35
Rate for Payer: Scott and White EPO/PPO	$2.55
Rate for Payer: Scott and White Medicare	$142.86
Rate for Payer: Superior Health Plan EPO	$142.86
Rate for Payer: Superior Health Plan Medicare	$142.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$142.86
Rate for Payer: Universal American Medicare	$142.86
Rate for Payer: Wellcare Medicare	$142.86
Rate for Payer: Wellmed Medicare	$142.86

Home Sleep Test Type 3 Unattended G0399 BCE

Facility

$819.00

Service Code	HCPCS G0399
Hospital Charge Code	6910399
Hospital Revenue Code	920
Rate for Payer: Cash Price	$720.72

Home Sleep Test Type 3 Unattended G0399 BCE

Facility

$819.00

Service Code	HCPCS G0399
Hospital Charge Code	6910399
Hospital Revenue Code	920
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$532.35
Rate for Payer: Aetna Commercial	$127.71
Rate for Payer: Aetna Medicare	$214.29
Rate for Payer: Amerigroup CHIP/Medicaid	$73.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$142.86
Rate for Payer: Amerigroup Medicare	$142.86
Rate for Payer: BCBS of TX Blue Advantage	$228.28
Rate for Payer: BCBS of TX Blue Essentials	$273.93
Rate for Payer: BCBS of TX Medicare	$142.86
Rate for Payer: BCBS of TX PPO	$305.75
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cigna Commercial	$323.61
Rate for Payer: Cigna Medicare	$142.86
Rate for Payer: Employer Direct Commercial	$142.86
Rate for Payer: Humana Medicare/TRICARE	$142.86
Rate for Payer: Molina Dual Medicare/Medicaid	$142.86
Rate for Payer: Molina Medicare	$142.86
Rate for Payer: Multiplan Auto	$532.35
Rate for Payer: Multiplan Commercial	$532.35
Rate for Payer: Multiplan Workers Comp	$532.35
Rate for Payer: Scott and White EPO/PPO	$2.55
Rate for Payer: Scott and White Medicare	$142.86
Rate for Payer: Superior Health Plan EPO	$142.86
Rate for Payer: Superior Health Plan Medicare	$142.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$142.86
Rate for Payer: Universal American Medicare	$142.86
Rate for Payer: Wellcare Medicare	$142.86
Rate for Payer: Wellmed Medicare	$142.86

Homocyst(e)ine SO

Facility

$527.00

Service Code	CPT 83090
Hospital Charge Code	1603513
Hospital Revenue Code	301
Rate for Payer: Cash Price	$463.76

Homocyst(e)ine SO

Facility

$527.00

Service Code	CPT 83090
Hospital Charge Code	1603513
Hospital Revenue Code	301
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$342.55
Rate for Payer: Aetna Commercial	$18.81
Rate for Payer: Aetna Medicare	$26.88
Rate for Payer: Amerigroup CHIP/Medicaid	$6.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.92
Rate for Payer: Amerigroup Medicare	$17.92
Rate for Payer: BCBS of TX Blue Advantage	$29.57
Rate for Payer: BCBS of TX Blue Essentials	$35.48
Rate for Payer: BCBS of TX Medicare	$17.92
Rate for Payer: BCBS of TX PPO	$39.60
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cigna Medicaid	$17.92
Rate for Payer: Cigna Medicare	$17.92
Rate for Payer: Employer Direct Commercial	$17.92
Rate for Payer: Humana Medicare/TRICARE	$17.92
Rate for Payer: Molina CHIP/Medicaid	$17.92
Rate for Payer: Molina Dual Medicare/Medicaid	$17.92
Rate for Payer: Molina Medicare	$17.92
Rate for Payer: Multiplan Auto	$342.55
Rate for Payer: Multiplan Commercial	$342.55
Rate for Payer: Multiplan Workers Comp	$342.55
Rate for Payer: Parkland Medicaid	$17.92
Rate for Payer: Scott and White EPO/PPO	$22.40
Rate for Payer: Scott and White Medicare	$17.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.92
Rate for Payer: Superior Health Plan EPO	$17.92
Rate for Payer: Superior Health Plan Medicare	$17.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.92
Rate for Payer: Universal American Medicare	$17.92
Rate for Payer: Wellcare Medicare	$17.92
Rate for Payer: Wellmed Medicare	$17.92

HOOD SRG STRSHIELD PEEL AWAY

Facility

$115.22

Hospital Charge Code	8428496
Hospital Revenue Code	270
Rate for Payer: Cash Price	$101.39

HOOD SRG STRSHIELD PEEL AWAY

Facility

$115.22

Hospital Charge Code	8428496
Hospital Revenue Code	270
Min. Negotiated Rate	$10.37
Max. Negotiated Rate	$74.89
Rate for Payer: Aetna Commercial	$63.37
Rate for Payer: Amerigroup CHIP/Medicaid	$10.37
Rate for Payer: BCBS of TX Blue Advantage	$34.57
Rate for Payer: BCBS of TX Blue Essentials	$41.48
Rate for Payer: BCBS of TX PPO	$46.09
Rate for Payer: Cash Price	$101.39
Rate for Payer: Multiplan Auto	$74.89
Rate for Payer: Multiplan Commercial	$74.89
Rate for Payer: Multiplan Workers Comp	$74.89
Rate for Payer: Scott and White EPO/PPO	$57.61
Rate for Payer: Superior Health Plan EPO	$15.67

HOOK, LAPAROSCOPIC CODED L SURGICAL 33CM -- DHF

Facility

$154.62

Hospital Charge Code	81743056
Hospital Revenue Code	272
Min. Negotiated Rate	$13.92
Max. Negotiated Rate	$100.50
Rate for Payer: Aetna Commercial	$85.04
Rate for Payer: Amerigroup CHIP/Medicaid	$13.92
Rate for Payer: BCBS of TX Blue Advantage	$46.39
Rate for Payer: BCBS of TX Blue Essentials	$55.66
Rate for Payer: BCBS of TX PPO	$61.85
Rate for Payer: Cash Price	$136.07
Rate for Payer: Multiplan Auto	$100.50
Rate for Payer: Multiplan Commercial	$100.50
Rate for Payer: Multiplan Workers Comp	$100.50
Rate for Payer: Scott and White EPO/PPO	$77.31
Rate for Payer: Superior Health Plan EPO	$21.03

HOOK, LAPAROSCOPIC CODED L SURGICAL 33CM -- DHF

Facility

$154.62

Hospital Charge Code	81743056
Hospital Revenue Code	272
Rate for Payer: Cash Price	$136.07

hook passer cresent

Facility

$796.18

Hospital Charge Code	8646517
Hospital Revenue Code	272
Rate for Payer: Cash Price	$700.64

Know your out-of-pocket cost for care.

All Charges