White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

DRY DOC CANNULA

Facility

$124.76

Hospital Charge Code	992642
Hospital Revenue Code	272
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$89.83
Rate for Payer: Amerigroup CHIP/Medicaid	$11.23
Rate for Payer: BCBS of TX Blue Advantage	$37.43
Rate for Payer: BCBS of TX Blue Essentials	$44.91
Rate for Payer: BCBS of TX PPO	$49.90
Rate for Payer: Cash Price	$84.84
Rate for Payer: Cigna Medicaid	$89.83
Rate for Payer: Molina CHIP/Medicaid	$89.83
Rate for Payer: Multiplan Auto	$81.09
Rate for Payer: Multiplan Commercial	$81.09
Rate for Payer: Multiplan Workers Comp	$81.09
Rate for Payer: Parkland Medicaid	$89.83
Rate for Payer: Scott and White EPO/PPO	$62.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.83
Rate for Payer: Superior Health Plan EPO	$16.97

DRY DOC CANNULA

Facility

$124.76

Hospital Charge Code	992642
Hospital Revenue Code	272
Rate for Payer: Cash Price	$84.84

DS003280

Facility

$3,987.67

Service Code	HCPCS C1713
Hospital Charge Code	994017
Hospital Revenue Code	278
Min. Negotiated Rate	$358.89
Max. Negotiated Rate	$2,871.12
Rate for Payer: Amerigroup CHIP/Medicaid	$358.89
Rate for Payer: BCBS of TX Blue Advantage	$1,196.30
Rate for Payer: BCBS of TX Blue Essentials	$1,435.56
Rate for Payer: BCBS of TX PPO	$1,595.07
Rate for Payer: Cash Price	$2,711.62
Rate for Payer: Cigna Medicaid	$2,871.12
Rate for Payer: Molina CHIP/Medicaid	$2,871.12
Rate for Payer: Multiplan Auto	$1,993.84
Rate for Payer: Multiplan Commercial	$1,993.84
Rate for Payer: Multiplan Workers Comp	$1,993.84
Rate for Payer: Parkland Medicaid	$2,871.12
Rate for Payer: Scott and White EPO/PPO	$1,993.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,871.12
Rate for Payer: Superior Health Plan EPO	$542.32

DS003280

Facility

$3,987.67

Service Code	HCPCS C1713
Hospital Charge Code	994017
Hospital Revenue Code	278
Min. Negotiated Rate	$996.92
Max. Negotiated Rate	$1,993.84
Rate for Payer: Cash Price	$2,711.62
Rate for Payer: Cigna Commercial	$996.92
Rate for Payer: Multiplan Auto	$1,993.84
Rate for Payer: Multiplan Commercial	$1,993.84
Rate for Payer: Multiplan Workers Comp	$1,993.84
Rate for Payer: Scott and White EPO/PPO	$1,993.84

DSDS0022

Facility

$1,536.14

Service Code	HCPCS C1713
Hospital Charge Code	991173
Hospital Revenue Code	278
Min. Negotiated Rate	$138.25
Max. Negotiated Rate	$1,106.02
Rate for Payer: Amerigroup CHIP/Medicaid	$138.25
Rate for Payer: BCBS of TX Blue Advantage	$460.84
Rate for Payer: BCBS of TX Blue Essentials	$553.01
Rate for Payer: BCBS of TX PPO	$614.46
Rate for Payer: Cash Price	$1,044.58
Rate for Payer: Cigna Medicaid	$1,106.02
Rate for Payer: Molina CHIP/Medicaid	$1,106.02
Rate for Payer: Multiplan Auto	$768.07
Rate for Payer: Multiplan Commercial	$768.07
Rate for Payer: Multiplan Workers Comp	$768.07
Rate for Payer: Parkland Medicaid	$1,106.02
Rate for Payer: Scott and White EPO/PPO	$768.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,106.02
Rate for Payer: Superior Health Plan EPO	$208.92

DSDS0022

Facility

$1,536.14

Service Code	HCPCS C1713
Hospital Charge Code	991173
Hospital Revenue Code	278
Min. Negotiated Rate	$384.04
Max. Negotiated Rate	$768.07
Rate for Payer: Cash Price	$1,044.58
Rate for Payer: Cigna Commercial	$384.04
Rate for Payer: Multiplan Auto	$768.07
Rate for Payer: Multiplan Commercial	$768.07
Rate for Payer: Multiplan Workers Comp	$768.07
Rate for Payer: Scott and White EPO/PPO	$768.07

DSDS1009

Facility

$222.90

Service Code	HCPCS C1769
Hospital Charge Code	991161
Hospital Revenue Code	272
Rate for Payer: Cash Price	$151.57

DSDS1009

Facility

$222.90

Service Code	HCPCS C1769
Hospital Charge Code	991161
Hospital Revenue Code	272
Min. Negotiated Rate	$20.06
Max. Negotiated Rate	$160.49
Rate for Payer: Amerigroup CHIP/Medicaid	$20.06
Rate for Payer: BCBS of TX Blue Advantage	$66.87
Rate for Payer: BCBS of TX Blue Essentials	$80.24
Rate for Payer: BCBS of TX PPO	$89.16
Rate for Payer: Cash Price	$151.57
Rate for Payer: Cigna Medicaid	$160.49
Rate for Payer: Molina CHIP/Medicaid	$160.49
Rate for Payer: Multiplan Auto	$144.88
Rate for Payer: Multiplan Commercial	$144.88
Rate for Payer: Multiplan Workers Comp	$144.88
Rate for Payer: Parkland Medicaid	$160.49
Rate for Payer: Scott and White EPO/PPO	$111.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$160.49
Rate for Payer: Superior Health Plan EPO	$30.31

DSDS1050

Facility

$1,168.67

Service Code	HCPCS C1713
Hospital Charge Code	991174
Hospital Revenue Code	278
Min. Negotiated Rate	$105.18
Max. Negotiated Rate	$841.44
Rate for Payer: Amerigroup CHIP/Medicaid	$105.18
Rate for Payer: BCBS of TX Blue Advantage	$350.60
Rate for Payer: BCBS of TX Blue Essentials	$420.72
Rate for Payer: BCBS of TX PPO	$467.47
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Medicaid	$841.44
Rate for Payer: Molina CHIP/Medicaid	$841.44
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Parkland Medicaid	$841.44
Rate for Payer: Scott and White EPO/PPO	$584.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$841.44
Rate for Payer: Superior Health Plan EPO	$158.94

DSDS1050

Facility

$1,168.67

Service Code	HCPCS C1713
Hospital Charge Code	991174
Hospital Revenue Code	278
Min. Negotiated Rate	$292.17
Max. Negotiated Rate	$584.34
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Commercial	$292.17
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Scott and White EPO/PPO	$584.34

DUAL CHAMBER IMPL DEFIBRILLATOR ELLIPS

Facility

$108,102.41

Service Code	HCPCS C1785
Hospital Charge Code	8394467
Hospital Revenue Code	275
Min. Negotiated Rate	$9,729.22
Max. Negotiated Rate	$77,833.74
Rate for Payer: Amerigroup CHIP/Medicaid	$9,729.22
Rate for Payer: BCBS of TX Blue Advantage	$32,430.72
Rate for Payer: BCBS of TX Blue Essentials	$38,916.87
Rate for Payer: BCBS of TX PPO	$43,240.96
Rate for Payer: Cash Price	$73,509.64
Rate for Payer: Cigna Medicaid	$77,833.74
Rate for Payer: Molina CHIP/Medicaid	$77,833.74
Rate for Payer: Multiplan Auto	$54,051.21
Rate for Payer: Multiplan Commercial	$54,051.21
Rate for Payer: Multiplan Workers Comp	$54,051.21
Rate for Payer: Parkland Medicaid	$77,833.74
Rate for Payer: Scott and White EPO/PPO	$54,051.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77,833.74
Rate for Payer: Superior Health Plan EPO	$14,701.93

DUAL CHAMBER IMPL DEFIBRILLATOR ELLIPS

Facility

$108,102.41

Service Code	HCPCS C1785
Hospital Charge Code	8394467
Hospital Revenue Code	275
Min. Negotiated Rate	$27,025.60
Max. Negotiated Rate	$54,051.21
Rate for Payer: Cash Price	$73,509.64
Rate for Payer: Cigna Commercial	$27,025.60
Rate for Payer: Multiplan Auto	$54,051.21
Rate for Payer: Multiplan Commercial	$54,051.21
Rate for Payer: Multiplan Workers Comp	$54,051.21
Rate for Payer: Scott and White EPO/PPO	$54,051.21

Dual edge shaver blade -40mm

Facility

$623.21

Hospital Charge Code	993582
Hospital Revenue Code	272
Min. Negotiated Rate	$56.09
Max. Negotiated Rate	$448.71
Rate for Payer: Amerigroup CHIP/Medicaid	$56.09
Rate for Payer: BCBS of TX Blue Advantage	$186.96
Rate for Payer: BCBS of TX Blue Essentials	$224.36
Rate for Payer: BCBS of TX PPO	$249.28
Rate for Payer: Cash Price	$423.78
Rate for Payer: Cigna Medicaid	$448.71
Rate for Payer: Molina CHIP/Medicaid	$448.71
Rate for Payer: Multiplan Auto	$405.09
Rate for Payer: Multiplan Commercial	$405.09
Rate for Payer: Multiplan Workers Comp	$405.09
Rate for Payer: Parkland Medicaid	$448.71
Rate for Payer: Scott and White EPO/PPO	$311.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$448.71
Rate for Payer: Superior Health Plan EPO	$84.76

Dual edge shaver blade -40mm

Facility

$623.21

Hospital Charge Code	993582
Hospital Revenue Code	272
Rate for Payer: Cash Price	$423.78

DULoxetine 20 mg DR Cap

Facility

$25.50

Service Code	HCPCS J3490
Hospital Charge Code	78419952
Hospital Revenue Code	250
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$18.36
Rate for Payer: Amerigroup CHIP/Medicaid	$2.29
Rate for Payer: BCBS of TX Blue Advantage	$7.65
Rate for Payer: BCBS of TX Blue Essentials	$9.18
Rate for Payer: BCBS of TX PPO	$10.20
Rate for Payer: Cash Price	$17.34
Rate for Payer: Cigna Medicaid	$18.36
Rate for Payer: Molina CHIP/Medicaid	$18.36
Rate for Payer: Multiplan Auto	$16.57
Rate for Payer: Multiplan Commercial	$16.57
Rate for Payer: Multiplan Workers Comp	$16.57
Rate for Payer: Parkland Medicaid	$18.36
Rate for Payer: Scott and White EPO/PPO	$12.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.36
Rate for Payer: Superior Health Plan EPO	$3.47

DULoxetine 20 mg DR Cap

Facility

$25.50

Service Code	HCPCS J3490
Hospital Charge Code	78419952
Hospital Revenue Code	250
Rate for Payer: Cash Price	$17.34

DULoxetine 30 mg DR Cap

Facility

$30.10

Service Code	HCPCS j3490
Hospital Charge Code	77528696
Hospital Revenue Code	250
Rate for Payer: Cash Price	$20.47

DULoxetine 30 mg DR Cap

Facility

$30.10

Service Code	HCPCS j3490
Hospital Charge Code	77528696
Hospital Revenue Code	250
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$21.67
Rate for Payer: Amerigroup CHIP/Medicaid	$2.71
Rate for Payer: BCBS of TX Blue Advantage	$9.03
Rate for Payer: BCBS of TX Blue Essentials	$10.84
Rate for Payer: BCBS of TX PPO	$12.04
Rate for Payer: Cash Price	$20.47
Rate for Payer: Cigna Medicaid	$21.67
Rate for Payer: Molina CHIP/Medicaid	$21.67
Rate for Payer: Multiplan Auto	$19.57
Rate for Payer: Multiplan Commercial	$19.57
Rate for Payer: Multiplan Workers Comp	$19.57
Rate for Payer: Parkland Medicaid	$21.67
Rate for Payer: Scott and White EPO/PPO	$15.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.67
Rate for Payer: Superior Health Plan EPO	$4.09

Duplex scan of extremity veins including responses to compression and other maneuvers; complete bila

Facility

$10,000.00

Service Code	CPT 93970
Hospital Charge Code	36093970
Hospital Revenue Code	360
Min. Negotiated Rate	$239.69
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
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 Medicare	$239.69
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

Duplex scan of extremity veins including responses to compression and other maneuvers; complete bila

Facility

$705.00

Service Code	HCPCS 93970
Hospital Charge Code	9900907
Hospital Revenue Code	921
Rate for Payer: Cash Price	$479.40

Duplex scan of extremity veins including responses to compression and other maneuvers; complete bila

Facility

$705.00

Service Code	HCPCS 93970
Hospital Charge Code	9900907
Hospital Revenue Code	921
Min. Negotiated Rate	$63.45
Max. Negotiated Rate	$507.60
Rate for Payer: Amerigroup CHIP/Medicaid	$63.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$211.50
Rate for Payer: BCBS of TX Blue Essentials	$253.80
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$282.00
Rate for Payer: Cash Price	$479.40
Rate for Payer: Cash Price	$479.40
Rate for Payer: Cash Price	$479.40
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$507.60
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$507.60
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$458.25
Rate for Payer: Multiplan Commercial	$458.25
Rate for Payer: Multiplan Workers Comp	$458.25
Rate for Payer: Parkland Medicaid	$507.60
Rate for Payer: Scott and White EPO/PPO	$352.50
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$507.60
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or

Facility

$10,000.00

Service Code	CPT 93971
Hospital Charge Code	36093971
Hospital Revenue Code	360
Min. Negotiated Rate	$105.02
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
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 Medicare	$105.02
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

Dura-Y Sensor Oximeter

Facility

$1,154.52

Hospital Charge Code	993372
Hospital Revenue Code	270
Rate for Payer: Cash Price	$785.07

Dura-Y Sensor Oximeter

Facility

$1,154.52

Hospital Charge Code	993372
Hospital Revenue Code	270
Min. Negotiated Rate	$103.91
Max. Negotiated Rate	$831.25
Rate for Payer: Amerigroup CHIP/Medicaid	$103.91
Rate for Payer: BCBS of TX Blue Advantage	$346.36
Rate for Payer: BCBS of TX Blue Essentials	$415.63
Rate for Payer: BCBS of TX PPO	$461.81
Rate for Payer: Cash Price	$785.07
Rate for Payer: Cigna Medicaid	$831.25
Rate for Payer: Molina CHIP/Medicaid	$831.25
Rate for Payer: Multiplan Auto	$750.44
Rate for Payer: Multiplan Commercial	$750.44
Rate for Payer: Multiplan Workers Comp	$750.44
Rate for Payer: Parkland Medicaid	$831.25
Rate for Payer: Scott and White EPO/PPO	$577.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$831.25
Rate for Payer: Superior Health Plan EPO	$157.01

Know your out-of-pocket cost for care.

All Charges