White Rock Medical Center

All Charges

Charge

Type

Setting

Price

drs therahoney 4x5

Facility

$32.00

Hospital Charge Code	131624
Hospital Revenue Code	270
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$23.04
Rate for Payer: Amerigroup CHIP/Medicaid	$2.88
Rate for Payer: BCBS of TX Blue Advantage	$9.60
Rate for Payer: BCBS of TX Blue Essentials	$11.52
Rate for Payer: BCBS of TX PPO	$12.80
Rate for Payer: Cash Price	$21.76
Rate for Payer: Cigna Medicaid	$23.04
Rate for Payer: Molina CHIP/Medicaid	$23.04
Rate for Payer: Multiplan Auto	$20.80
Rate for Payer: Multiplan Commercial	$20.80
Rate for Payer: Multiplan Workers Comp	$20.80
Rate for Payer: Parkland Medicaid	$23.04
Rate for Payer: Scott and White EPO/PPO	$16.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.04
Rate for Payer: Superior Health Plan EPO	$4.35

drs therahoney 4x5

Facility

$32.00

Hospital Charge Code	131624
Hospital Revenue Code	270
Rate for Payer: Cash Price	$21.76

DRS VAC VERAFLO CLEANS CHOICE MED

Facility

$595.19

Hospital Charge Code	8570486
Hospital Revenue Code	272
Rate for Payer: Cash Price	$404.73

DRS VAC VERAFLO CLEANS CHOICE MED

Facility

$595.19

Hospital Charge Code	8570486
Hospital Revenue Code	272
Min. Negotiated Rate	$53.57
Max. Negotiated Rate	$428.54
Rate for Payer: Amerigroup CHIP/Medicaid	$53.57
Rate for Payer: BCBS of TX Blue Advantage	$178.56
Rate for Payer: BCBS of TX Blue Essentials	$214.27
Rate for Payer: BCBS of TX PPO	$238.08
Rate for Payer: Cash Price	$404.73
Rate for Payer: Cigna Medicaid	$428.54
Rate for Payer: Molina CHIP/Medicaid	$428.54
Rate for Payer: Multiplan Auto	$386.87
Rate for Payer: Multiplan Commercial	$386.87
Rate for Payer: Multiplan Workers Comp	$386.87
Rate for Payer: Parkland Medicaid	$428.54
Rate for Payer: Scott and White EPO/PPO	$297.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$428.54
Rate for Payer: Superior Health Plan EPO	$80.95

drs versatel 1-silicone

Facility

$15.25

Hospital Charge Code	130118
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10.37

drs versatel 1-silicone

Facility

$15.25

Hospital Charge Code	130118
Hospital Revenue Code	270
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$10.98
Rate for Payer: Amerigroup CHIP/Medicaid	$1.37
Rate for Payer: BCBS of TX Blue Advantage	$4.58
Rate for Payer: BCBS of TX Blue Essentials	$5.49
Rate for Payer: BCBS of TX PPO	$6.10
Rate for Payer: Cash Price	$10.37
Rate for Payer: Cigna Medicaid	$10.98
Rate for Payer: Molina CHIP/Medicaid	$10.98
Rate for Payer: Multiplan Auto	$9.91
Rate for Payer: Multiplan Commercial	$9.91
Rate for Payer: Multiplan Workers Comp	$9.91
Rate for Payer: Parkland Medicaid	$10.98
Rate for Payer: Scott and White EPO/PPO	$7.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.98
Rate for Payer: Superior Health Plan EPO	$2.07

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

Facility

$85.04

Hospital Charge Code	80249667
Hospital Revenue Code	270
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$61.23
Rate for Payer: Amerigroup CHIP/Medicaid	$7.65
Rate for Payer: BCBS of TX Blue Advantage	$25.51
Rate for Payer: BCBS of TX Blue Essentials	$30.61
Rate for Payer: BCBS of TX PPO	$34.02
Rate for Payer: Cash Price	$57.83
Rate for Payer: Cigna Medicaid	$61.23
Rate for Payer: Molina CHIP/Medicaid	$61.23
Rate for Payer: Multiplan Auto	$55.28
Rate for Payer: Multiplan Commercial	$55.28
Rate for Payer: Multiplan Workers Comp	$55.28
Rate for Payer: Parkland Medicaid	$61.23
Rate for Payer: Scott and White EPO/PPO	$42.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$61.23
Rate for Payer: Superior Health Plan EPO	$11.57

DRS WND 7X12 -- DHF

Facility

$261.97

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

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 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

$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 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-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	$2,871.63
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-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	$2,871.63
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

$1,008.72

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

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,

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, 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 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 Urine

Facility

$317.00

Service Code	HCPCS 80307
Hospital Charge Code	39411640102
Hospital Revenue Code	300
Rate for Payer: Cash Price	$215.56

Drug Screen Urine

Facility

$317.00

Service Code	HCPCS 80307
Hospital Charge Code	39411640102
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

Know your out-of-pocket cost for care.

All Charges