White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DRS WND 5 1/2 X 5 7/8 -- DHF

Facility

$85.04

Hospital Charge Code	80249667
Hospital Revenue Code	270
Rate for Payer: Cash Price	$57.83

DRS WND 7X12 -- DHF

Facility

$261.97

Hospital Charge Code	80249659
Hospital Revenue Code	270
Min. Negotiated Rate	$23.58
Max. Negotiated Rate	$188.62
Rate for Payer: Amerigroup CHIP/Medicaid	$23.58
Rate for Payer: BCBS of TX Blue Advantage	$78.59
Rate for Payer: BCBS of TX Blue Essentials	$94.31
Rate for Payer: BCBS of TX PPO	$104.79
Rate for Payer: Cash Price	$178.14
Rate for Payer: Cigna Medicaid	$188.62
Rate for Payer: Molina CHIP/Medicaid	$188.62
Rate for Payer: Multiplan Auto	$170.28
Rate for Payer: Multiplan Commercial	$170.28
Rate for Payer: Multiplan Workers Comp	$170.28
Rate for Payer: Parkland Medicaid	$188.62
Rate for Payer: Scott and White EPO/PPO	$130.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$188.62
Rate for Payer: Superior Health Plan EPO	$35.63

DRS WND 7X12 -- DHF

Facility

$261.97

Hospital Charge Code	80249659
Hospital Revenue Code	270
Rate for Payer: Cash Price	$178.14

DRS WND ANY -- DHF

Facility

$40.74

Hospital Charge Code	80249592
Hospital Revenue Code	272
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$29.33
Rate for Payer: Amerigroup CHIP/Medicaid	$3.67
Rate for Payer: BCBS of TX Blue Advantage	$12.22
Rate for Payer: BCBS of TX Blue Essentials	$14.67
Rate for Payer: BCBS of TX PPO	$16.30
Rate for Payer: Cash Price	$27.70
Rate for Payer: Cigna Medicaid	$29.33
Rate for Payer: Molina CHIP/Medicaid	$29.33
Rate for Payer: Multiplan Auto	$26.48
Rate for Payer: Multiplan Commercial	$26.48
Rate for Payer: Multiplan Workers Comp	$26.48
Rate for Payer: Parkland Medicaid	$29.33
Rate for Payer: Scott and White EPO/PPO	$20.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.33
Rate for Payer: Superior Health Plan EPO	$5.54

DRS WND ANY -- DHF

Facility

$40.74

Hospital Charge Code	80249592
Hospital Revenue Code	272
Rate for Payer: Cash Price	$27.70

DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE

Facility

$6,352.24

Service Code	APR-DRG 7704
Min. Negotiated Rate	$5,989.11
Max. Negotiated Rate	$6,352.24
Rate for Payer: Amerigroup CHIP/Medicaid	$5,989.11
Rate for Payer: Cigna Medicaid	$5,989.11
Rate for Payer: Molina CHIP/Medicaid	$5,989.11
Rate for Payer: Parkland Medicaid	$5,989.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,352.24

DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE

Facility

$2,734.24

Service Code	APR-DRG 7703
Min. Negotiated Rate	$2,577.94
Max. Negotiated Rate	$2,734.24
Rate for Payer: Amerigroup CHIP/Medicaid	$2,577.94
Rate for Payer: Cigna Medicaid	$2,577.94
Rate for Payer: Molina CHIP/Medicaid	$2,577.94
Rate for Payer: Parkland Medicaid	$2,577.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,734.24

DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE

Facility

$1,282.82

Service Code	APR-DRG 7701
Min. Negotiated Rate	$1,209.49
Max. Negotiated Rate	$1,282.82
Rate for Payer: Amerigroup CHIP/Medicaid	$1,209.49
Rate for Payer: Cigna Medicaid	$1,209.49
Rate for Payer: Molina CHIP/Medicaid	$1,209.49
Rate for Payer: Parkland Medicaid	$1,209.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,282.82

DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE

Facility

$1,715.08

Service Code	APR-DRG 7702
Min. Negotiated Rate	$1,617.04
Max. Negotiated Rate	$1,715.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1,617.04
Rate for Payer: Cigna Medicaid	$1,617.04
Rate for Payer: Molina CHIP/Medicaid	$1,617.04
Rate for Payer: Parkland Medicaid	$1,617.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,715.08

Drug-induced sleep endoscopy, with dynamic evaluation of velum, pharynx, tongue base, and larynx for

Facility

$1,008.72

Service Code	HCPCS 42975
Hospital Charge Code	9900665
Hospital Revenue Code	360
Rate for Payer: Cash Price	$685.93

Drug-induced sleep endoscopy, with dynamic evaluation of velum, pharynx, tongue base, and larynx for

Facility

$1,008.72

Service Code	HCPCS 42975
Hospital Charge Code	9900665
Hospital Revenue Code	360
Min. Negotiated Rate	$68.14
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$68.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Amerigroup Medicare	$1,788.01
Rate for Payer: BCBS of TX Blue Advantage	$142.38
Rate for Payer: BCBS of TX Blue Essentials	$170.52
Rate for Payer: BCBS of TX Medicare	$1,788.01
Rate for Payer: BCBS of TX PPO	$214.86
Rate for Payer: Cash Price	$685.93
Rate for Payer: Cash Price	$685.93
Rate for Payer: Cash Price	$685.93
Rate for Payer: Cigna Commercial	$3,779.52
Rate for Payer: Cigna Medicaid	$726.28
Rate for Payer: Cigna Medicare	$1,788.01
Rate for Payer: Employer Direct Commercial	$1,788.01
Rate for Payer: Humana Medicare/TRICARE	$1,788.01
Rate for Payer: Molina CHIP/Medicaid	$726.28
Rate for Payer: Molina Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Molina Medicare	$1,788.01
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	$726.28
Rate for Payer: Scott and White EPO/PPO	$3,307.82
Rate for Payer: Scott and White Medicare	$1,788.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$726.28
Rate for Payer: Superior Health Plan EPO	$1,788.01
Rate for Payer: Superior Health Plan Medicare	$1,788.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Universal American Medicare	$1,788.01
Rate for Payer: Wellcare Medicare	$1,788.01
Rate for Payer: Wellmed Medicare	$1,788.01

Drug-induced sleep endoscopy, with dynamic evaluation of velum, pharynx, tongue base, and larynx for

Facility

$10,000.00

Service Code	CPT 42975
Hospital Charge Code	36042975
Hospital Revenue Code	360
Min. Negotiated Rate	$68.14
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$68.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Amerigroup Medicare	$1,788.01
Rate for Payer: BCBS of TX Blue Advantage	$142.38
Rate for Payer: BCBS of TX Blue Essentials	$170.52
Rate for Payer: BCBS of TX Medicare	$1,788.01
Rate for Payer: BCBS of TX PPO	$214.86
Rate for Payer: Cigna Commercial	$3,779.52
Rate for Payer: Cigna Medicare	$1,788.01
Rate for Payer: Employer Direct Commercial	$1,788.01
Rate for Payer: Humana Medicare/TRICARE	$1,788.01
Rate for Payer: Molina Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Molina Medicare	$1,788.01
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	$3,307.82
Rate for Payer: Scott and White Medicare	$1,788.01
Rate for Payer: Superior Health Plan EPO	$1,788.01
Rate for Payer: Superior Health Plan Medicare	$1,788.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Universal American Medicare	$1,788.01
Rate for Payer: Wellcare Medicare	$1,788.01
Rate for Payer: Wellmed Medicare	$1,788.01

Drug Screen 10 w/Conf,

Facility

$317.00

Service Code	HCPCS 80307
Hospital Charge Code	1640102
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$228.24
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$95.10
Rate for Payer: BCBS of TX Blue Essentials	$114.12
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$126.80
Rate for Payer: Cash Price	$215.56
Rate for Payer: Cash Price	$215.56
Rate for Payer: Cigna Medicaid	$228.24
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$228.24
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$228.24
Rate for Payer: Scott and White EPO/PPO	$77.67
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$228.24
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

Drug Screen 10 w/Conf,

Facility

$317.00

Service Code	HCPCS 80307
Hospital Charge Code	1640102
Hospital Revenue Code	300
Rate for Payer: Cash Price	$215.56

Drug Screen 10 w/Conf, Serum SO

Facility

$317.00

Service Code	HCPCS 80307
Hospital Charge Code	39401640102
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$228.24
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$95.10
Rate for Payer: BCBS of TX Blue Essentials	$114.12
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$126.80
Rate for Payer: Cash Price	$215.56
Rate for Payer: Cash Price	$215.56
Rate for Payer: Cigna Medicaid	$228.24
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$228.24
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$228.24
Rate for Payer: Scott and White EPO/PPO	$77.67
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$228.24
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

Drug Screen 10 w/Conf, Serum SO

Facility

$317.00

Service Code	HCPCS 80307
Hospital Charge Code	39401640102
Hospital Revenue Code	300
Rate for Payer: Cash Price	$215.56

Drug test(s)(1) drug per day; 1-7 drug class(es)

Facility

$457.72

Service Code	HCPCS G0480
Hospital Charge Code	991141
Hospital Revenue Code	301
Min. Negotiated Rate	$31.98
Max. Negotiated Rate	$329.56
Rate for Payer: Amerigroup CHIP/Medicaid	$31.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$114.43
Rate for Payer: Amerigroup Medicare	$114.43
Rate for Payer: BCBS of TX Blue Advantage	$137.32
Rate for Payer: BCBS of TX Blue Essentials	$164.78
Rate for Payer: BCBS of TX Medicare	$114.43
Rate for Payer: BCBS of TX PPO	$183.09
Rate for Payer: Cash Price	$311.25
Rate for Payer: Cash Price	$311.25
Rate for Payer: Cigna Medicaid	$329.56
Rate for Payer: Cigna Medicare	$114.43
Rate for Payer: Employer Direct Commercial	$114.43
Rate for Payer: Humana Medicare/TRICARE	$114.43
Rate for Payer: Molina CHIP/Medicaid	$329.56
Rate for Payer: Molina Dual Medicare/Medicaid	$114.43
Rate for Payer: Molina Medicare	$114.43
Rate for Payer: Multiplan Auto	$297.52
Rate for Payer: Multiplan Commercial	$297.52
Rate for Payer: Multiplan Workers Comp	$297.52
Rate for Payer: Parkland Medicaid	$329.56
Rate for Payer: Scott and White EPO/PPO	$143.04
Rate for Payer: Scott and White Medicare	$114.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$329.56
Rate for Payer: Superior Health Plan EPO	$114.43
Rate for Payer: Superior Health Plan Medicare	$114.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$114.43
Rate for Payer: Universal American Medicare	$114.43
Rate for Payer: Wellcare Medicare	$114.43
Rate for Payer: Wellmed Medicare	$114.43

Drug test(s)(1) drug per day; 1-7 drug class(es)

Facility

$457.72

Service Code	HCPCS G0480
Hospital Charge Code	991141
Hospital Revenue Code	301
Rate for Payer: Cash Price	$311.25

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish, per day; 15-21 drug class(es), including metabolite(s) if performed

Facility

$794.96

Service Code	HCPCS G0482
Hospital Charge Code	991143
Hospital Revenue Code	301
Min. Negotiated Rate	$31.98
Max. Negotiated Rate	$572.37
Rate for Payer: Amerigroup CHIP/Medicaid	$31.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$198.74
Rate for Payer: Amerigroup Medicare	$198.74
Rate for Payer: BCBS of TX Blue Advantage	$238.49
Rate for Payer: BCBS of TX Blue Essentials	$286.19
Rate for Payer: BCBS of TX Medicare	$198.74
Rate for Payer: BCBS of TX PPO	$317.98
Rate for Payer: Cash Price	$540.57
Rate for Payer: Cash Price	$540.57
Rate for Payer: Cigna Medicaid	$572.37
Rate for Payer: Cigna Medicare	$198.74
Rate for Payer: Employer Direct Commercial	$198.74
Rate for Payer: Humana Medicare/TRICARE	$198.74
Rate for Payer: Molina CHIP/Medicaid	$572.37
Rate for Payer: Molina Dual Medicare/Medicaid	$198.74
Rate for Payer: Molina Medicare	$198.74
Rate for Payer: Multiplan Auto	$516.72
Rate for Payer: Multiplan Commercial	$516.72
Rate for Payer: Multiplan Workers Comp	$516.72
Rate for Payer: Parkland Medicaid	$572.37
Rate for Payer: Scott and White EPO/PPO	$248.43
Rate for Payer: Scott and White Medicare	$198.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$572.37
Rate for Payer: Superior Health Plan EPO	$198.74
Rate for Payer: Superior Health Plan Medicare	$198.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$198.74
Rate for Payer: Universal American Medicare	$198.74
Rate for Payer: Wellcare Medicare	$198.74
Rate for Payer: Wellmed Medicare	$198.74

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish, per day; 15-21 drug class(es), including metabolite(s) if performed

Facility

$794.96

Service Code	HCPCS G0482
Hospital Charge Code	991143
Hospital Revenue Code	301
Rate for Payer: Cash Price	$540.57

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish, per day; 22+ drug class(es), including metabolite(s) if performed

Facility

$987.68

Service Code	HCPCS G0483
Hospital Charge Code	991144
Hospital Revenue Code	301
Min. Negotiated Rate	$31.98
Max. Negotiated Rate	$711.13
Rate for Payer: Amerigroup CHIP/Medicaid	$31.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$246.92
Rate for Payer: Amerigroup Medicare	$246.92
Rate for Payer: BCBS of TX Blue Advantage	$296.30
Rate for Payer: BCBS of TX Blue Essentials	$355.56
Rate for Payer: BCBS of TX Medicare	$246.92
Rate for Payer: BCBS of TX PPO	$395.07
Rate for Payer: Cash Price	$671.62
Rate for Payer: Cash Price	$671.62
Rate for Payer: Cigna Medicaid	$711.13
Rate for Payer: Cigna Medicare	$246.92
Rate for Payer: Employer Direct Commercial	$246.92
Rate for Payer: Humana Medicare/TRICARE	$246.92
Rate for Payer: Molina CHIP/Medicaid	$711.13
Rate for Payer: Molina Dual Medicare/Medicaid	$246.92
Rate for Payer: Molina Medicare	$246.92
Rate for Payer: Multiplan Auto	$641.99
Rate for Payer: Multiplan Commercial	$641.99
Rate for Payer: Multiplan Workers Comp	$641.99
Rate for Payer: Parkland Medicaid	$711.13
Rate for Payer: Scott and White EPO/PPO	$308.65
Rate for Payer: Scott and White Medicare	$246.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$711.13
Rate for Payer: Superior Health Plan EPO	$246.92
Rate for Payer: Superior Health Plan Medicare	$246.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$246.92
Rate for Payer: Universal American Medicare	$246.92
Rate for Payer: Wellcare Medicare	$246.92
Rate for Payer: Wellmed Medicare	$246.92

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish, per day; 22+ drug class(es), including metabolite(s) if performed

Facility

$987.68

Service Code	HCPCS G0483
Hospital Charge Code	991144
Hospital Revenue Code	301
Rate for Payer: Cash Price	$671.62

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish per day; 8-14 drug class(es), including metabolite(s) if performed

Facility

$626.36

Service Code	HCPCS G0481
Hospital Charge Code	991142
Hospital Revenue Code	301
Rate for Payer: Cash Price	$425.92

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish per day; 8-14 drug class(es), including metabolite(s) if performed

Facility

$626.36

Service Code	HCPCS G0481
Hospital Charge Code	991142
Hospital Revenue Code	301
Min. Negotiated Rate	$31.98
Max. Negotiated Rate	$450.98
Rate for Payer: Amerigroup CHIP/Medicaid	$31.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.59
Rate for Payer: Amerigroup Medicare	$156.59
Rate for Payer: BCBS of TX Blue Advantage	$187.91
Rate for Payer: BCBS of TX Blue Essentials	$225.49
Rate for Payer: BCBS of TX Medicare	$156.59
Rate for Payer: BCBS of TX PPO	$250.54
Rate for Payer: Cash Price	$425.92
Rate for Payer: Cash Price	$425.92
Rate for Payer: Cigna Medicaid	$450.98
Rate for Payer: Cigna Medicare	$156.59
Rate for Payer: Employer Direct Commercial	$156.59
Rate for Payer: Humana Medicare/TRICARE	$156.59
Rate for Payer: Molina CHIP/Medicaid	$450.98
Rate for Payer: Molina Dual Medicare/Medicaid	$156.59
Rate for Payer: Molina Medicare	$156.59
Rate for Payer: Multiplan Auto	$407.13
Rate for Payer: Multiplan Commercial	$407.13
Rate for Payer: Multiplan Workers Comp	$407.13
Rate for Payer: Parkland Medicaid	$450.98
Rate for Payer: Scott and White EPO/PPO	$195.74
Rate for Payer: Scott and White Medicare	$156.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$450.98
Rate for Payer: Superior Health Plan EPO	$156.59
Rate for Payer: Superior Health Plan Medicare	$156.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.59
Rate for Payer: Universal American Medicare	$156.59
Rate for Payer: Wellcare Medicare	$156.59
Rate for Payer: Wellmed Medicare	$156.59

Drug test(s), presumptive, any number of drug classes, any number of dev

Facility

$317.00

Service Code	HCPCS 80305 QW
Hospital Charge Code	994046
Hospital Revenue Code	300
Rate for Payer: Cash Price	$215.56

Know your out-of-pocket cost for care.

All Charges