White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Drainage of finger abscess simple

Facility

$10,000.00

Service Code	CPT 26010
Hospital Charge Code	36026010
Hospital Revenue Code	360
Min. Negotiated Rate	$74.34
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$74.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$147.44
Rate for Payer: BCBS of TX Blue Essentials	$176.58
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$222.49
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
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	$372.87
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

Drainage of finger abscess simple

Facility

$1,077.30

Service Code	HCPCS 26010
Hospital Charge Code	8682617
Hospital Revenue Code	360
Min. Negotiated Rate	$74.34
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$74.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$147.44
Rate for Payer: BCBS of TX Blue Essentials	$176.58
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$222.49
Rate for Payer: Cash Price	$732.56
Rate for Payer: Cash Price	$732.56
Rate for Payer: Cash Price	$732.56
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$775.66
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$775.66
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
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	$775.66
Rate for Payer: Scott and White EPO/PPO	$372.87
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$775.66
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

Drainage of palmar bursa; single, bursa

Facility

$10,000.00

Service Code	CPT 26025
Hospital Charge Code	36026025
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Drainage of palmar bursa; single, bursa

Facility

$11,283.29

Service Code	HCPCS 26025
Hospital Charge Code	9900312
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$7,672.64
Rate for Payer: Cash Price	$7,672.64
Rate for Payer: Cash Price	$7,672.64
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,123.97
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$8,123.97
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$8,123.97
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,123.97
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Drainage of palmar bursa; single, bursa

Facility

$11,283.29

Service Code	HCPCS 26025
Hospital Charge Code	9900312
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,672.64

Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open

Facility

$64,200.00

Service Code	HCPCS 49020
Hospital Charge Code	991072
Hospital Revenue Code	360
Min. Negotiated Rate	$2,776.34
Max. Negotiated Rate	$46,224.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,778.00
Rate for Payer: BCBS of TX Blue Advantage	$2,776.34
Rate for Payer: BCBS of TX Blue Essentials	$3,324.96
Rate for Payer: BCBS of TX PPO	$4,189.45
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cigna Medicaid	$46,224.00
Rate for Payer: Molina CHIP/Medicaid	$46,224.00
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	$46,224.00
Rate for Payer: Scott and White EPO/PPO	$32,100.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,224.00
Rate for Payer: Superior Health Plan EPO	$8,731.20

Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open

Facility

$64,200.00

Service Code	HCPCS 49020
Hospital Charge Code	991072
Hospital Revenue Code	360
Rate for Payer: Cash Price	$43,656.00

Drainage of tendon sheath, digit and/or palm, each

Facility

$12,336.12

Service Code	HCPCS 26020
Hospital Charge Code	991127
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,388.56

Drainage of tendon sheath, digit and/or palm, each

Facility

$12,336.12

Service Code	HCPCS 26020
Hospital Charge Code	991127
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,882.01
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$8,882.01
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$8,882.01
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,882.01
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

DRAIN, CHANNEL, SILICONE, 19FR

Facility

$93.46

Hospital Charge Code	992296
Hospital Revenue Code	272
Min. Negotiated Rate	$8.41
Max. Negotiated Rate	$67.29
Rate for Payer: Amerigroup CHIP/Medicaid	$8.41
Rate for Payer: BCBS of TX Blue Advantage	$28.04
Rate for Payer: BCBS of TX Blue Essentials	$33.65
Rate for Payer: BCBS of TX PPO	$37.38
Rate for Payer: Cash Price	$63.55
Rate for Payer: Cigna Medicaid	$67.29
Rate for Payer: Molina CHIP/Medicaid	$67.29
Rate for Payer: Multiplan Auto	$60.75
Rate for Payer: Multiplan Commercial	$60.75
Rate for Payer: Multiplan Workers Comp	$60.75
Rate for Payer: Parkland Medicaid	$67.29
Rate for Payer: Scott and White EPO/PPO	$46.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.29
Rate for Payer: Superior Health Plan EPO	$12.71

DRAIN, CHANNEL, SILICONE, 19FR

Facility

$93.46

Hospital Charge Code	992296
Hospital Revenue Code	272
Rate for Payer: Cash Price	$63.55

DRAIN CHST PLEUREVAC PED DRY

Facility

$377.20

Hospital Charge Code	993657
Hospital Revenue Code	272
Rate for Payer: Cash Price	$256.50

DRAIN CHST PLEUREVAC PED DRY

Facility

$377.20

Hospital Charge Code	993657
Hospital Revenue Code	272
Min. Negotiated Rate	$33.95
Max. Negotiated Rate	$271.58
Rate for Payer: Amerigroup CHIP/Medicaid	$33.95
Rate for Payer: BCBS of TX Blue Advantage	$113.16
Rate for Payer: BCBS of TX Blue Essentials	$135.79
Rate for Payer: BCBS of TX PPO	$150.88
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cigna Medicaid	$271.58
Rate for Payer: Molina CHIP/Medicaid	$271.58
Rate for Payer: Multiplan Auto	$245.18
Rate for Payer: Multiplan Commercial	$245.18
Rate for Payer: Multiplan Workers Comp	$245.18
Rate for Payer: Parkland Medicaid	$271.58
Rate for Payer: Scott and White EPO/PPO	$188.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$271.58
Rate for Payer: Superior Health Plan EPO	$51.30

DRAIN, FLAT, HUBLESS, SILICONE, 10MM, FULL

Facility

$62.03

Hospital Charge Code	993759
Hospital Revenue Code	272
Rate for Payer: Cash Price	$42.18

DRAIN, FLAT, HUBLESS, SILICONE, 10MM, FULL

Facility

$62.03

Hospital Charge Code	993759
Hospital Revenue Code	272
Min. Negotiated Rate	$5.58
Max. Negotiated Rate	$44.66
Rate for Payer: Amerigroup CHIP/Medicaid	$5.58
Rate for Payer: BCBS of TX Blue Advantage	$18.61
Rate for Payer: BCBS of TX Blue Essentials	$22.33
Rate for Payer: BCBS of TX PPO	$24.81
Rate for Payer: Cash Price	$42.18
Rate for Payer: Cigna Medicaid	$44.66
Rate for Payer: Molina CHIP/Medicaid	$44.66
Rate for Payer: Multiplan Auto	$40.32
Rate for Payer: Multiplan Commercial	$40.32
Rate for Payer: Multiplan Workers Comp	$40.32
Rate for Payer: Parkland Medicaid	$44.66
Rate for Payer: Scott and White EPO/PPO	$31.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.66
Rate for Payer: Superior Health Plan EPO	$8.44

DRAIN, ROUND, CHANNEL, TROCAR, 15FR

Facility

$101.76

Hospital Charge Code	992297
Hospital Revenue Code	272
Min. Negotiated Rate	$9.16
Max. Negotiated Rate	$73.27
Rate for Payer: Amerigroup CHIP/Medicaid	$9.16
Rate for Payer: BCBS of TX Blue Advantage	$30.53
Rate for Payer: BCBS of TX Blue Essentials	$36.63
Rate for Payer: BCBS of TX PPO	$40.70
Rate for Payer: Cash Price	$69.20
Rate for Payer: Cigna Medicaid	$73.27
Rate for Payer: Molina CHIP/Medicaid	$73.27
Rate for Payer: Multiplan Auto	$66.14
Rate for Payer: Multiplan Commercial	$66.14
Rate for Payer: Multiplan Workers Comp	$66.14
Rate for Payer: Parkland Medicaid	$73.27
Rate for Payer: Scott and White EPO/PPO	$50.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$73.27
Rate for Payer: Superior Health Plan EPO	$13.84

DRAIN, ROUND, CHANNEL, TROCAR, 15FR

Facility

$101.76

Hospital Charge Code	992297
Hospital Revenue Code	272
Rate for Payer: Cash Price	$69.20

DRAIN SILICONE ROUND 3/4 FLUT 19FR & 3/16 TROCAR

Facility

$40.86

Hospital Charge Code	993684
Hospital Revenue Code	270
Min. Negotiated Rate	$3.68
Max. Negotiated Rate	$29.42
Rate for Payer: Amerigroup CHIP/Medicaid	$3.68
Rate for Payer: BCBS of TX Blue Advantage	$12.26
Rate for Payer: BCBS of TX Blue Essentials	$14.71
Rate for Payer: BCBS of TX PPO	$16.34
Rate for Payer: Cash Price	$27.78
Rate for Payer: Cigna Medicaid	$29.42
Rate for Payer: Molina CHIP/Medicaid	$29.42
Rate for Payer: Multiplan Auto	$26.56
Rate for Payer: Multiplan Commercial	$26.56
Rate for Payer: Multiplan Workers Comp	$26.56
Rate for Payer: Parkland Medicaid	$29.42
Rate for Payer: Scott and White EPO/PPO	$20.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.42
Rate for Payer: Superior Health Plan EPO	$5.56

DRAIN SILICONE ROUND 3/4 FLUT 19FR & 3/16 TROCAR

Facility

$40.86

Hospital Charge Code	993684
Hospital Revenue Code	270
Rate for Payer: Cash Price	$27.78

DRAIN, SILICONE ROUND 3/4 FLUT 19FR & 3/16' TROCAR -- DHF

Facility

$83.23

Hospital Charge Code	81820649
Hospital Revenue Code	272
Rate for Payer: Cash Price	$56.60

DRAIN, SILICONE ROUND 3/4 FLUT 19FR & 3/16' TROCAR -- DHF

Facility

$83.23

Hospital Charge Code	81820649
Hospital Revenue Code	272
Min. Negotiated Rate	$7.49
Max. Negotiated Rate	$59.93
Rate for Payer: Amerigroup CHIP/Medicaid	$7.49
Rate for Payer: BCBS of TX Blue Advantage	$24.97
Rate for Payer: BCBS of TX Blue Essentials	$29.96
Rate for Payer: BCBS of TX PPO	$33.29
Rate for Payer: Cash Price	$56.60
Rate for Payer: Cigna Medicaid	$59.93
Rate for Payer: Molina CHIP/Medicaid	$59.93
Rate for Payer: Multiplan Auto	$54.10
Rate for Payer: Multiplan Commercial	$54.10
Rate for Payer: Multiplan Workers Comp	$54.10
Rate for Payer: Parkland Medicaid	$59.93
Rate for Payer: Scott and White EPO/PPO	$41.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.93
Rate for Payer: Superior Health Plan EPO	$11.32

DRAPE 38X16IN ABD MAJ ABS REINF FEN

Facility

$47.77

Hospital Charge Code	992829
Hospital Revenue Code	272
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$34.39
Rate for Payer: Amerigroup CHIP/Medicaid	$4.30
Rate for Payer: BCBS of TX Blue Advantage	$14.33
Rate for Payer: BCBS of TX Blue Essentials	$17.20
Rate for Payer: BCBS of TX PPO	$19.11
Rate for Payer: Cash Price	$32.48
Rate for Payer: Cigna Medicaid	$34.39
Rate for Payer: Molina CHIP/Medicaid	$34.39
Rate for Payer: Multiplan Auto	$31.05
Rate for Payer: Multiplan Commercial	$31.05
Rate for Payer: Multiplan Workers Comp	$31.05
Rate for Payer: Parkland Medicaid	$34.39
Rate for Payer: Scott and White EPO/PPO	$23.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.39
Rate for Payer: Superior Health Plan EPO	$6.50

DRAPE 38X16IN ABD MAJ ABS REINF FEN

Facility

$47.77

Hospital Charge Code	992829
Hospital Revenue Code	272
Rate for Payer: Cash Price	$32.48

DRAPE 76X54IN SHLDR U IMPRV PRXM

Facility

$20.60

Hospital Charge Code	993743
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14.01

DRAPE 76X54IN SHLDR U IMPRV PRXM

Facility

$20.60

Hospital Charge Code	993743
Hospital Revenue Code	272
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$14.83
Rate for Payer: Amerigroup CHIP/Medicaid	$1.85
Rate for Payer: BCBS of TX Blue Advantage	$6.18
Rate for Payer: BCBS of TX Blue Essentials	$7.42
Rate for Payer: BCBS of TX PPO	$8.24
Rate for Payer: Cash Price	$14.01
Rate for Payer: Cigna Medicaid	$14.83
Rate for Payer: Molina CHIP/Medicaid	$14.83
Rate for Payer: Multiplan Auto	$13.39
Rate for Payer: Multiplan Commercial	$13.39
Rate for Payer: Multiplan Workers Comp	$13.39
Rate for Payer: Parkland Medicaid	$14.83
Rate for Payer: Scott and White EPO/PPO	$10.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.83
Rate for Payer: Superior Health Plan EPO	$2.80

Know your out-of-pocket cost for care.

All Charges