White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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

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

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	$230.86
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; 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

$10,000.00

Service Code	CPT 93970
Hospital Charge Code	36093970
Hospital Revenue Code	360
Min. Negotiated Rate	$230.86
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 EPO/PPO	$230.86
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; 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 EPO/PPO	$146.95
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

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

Facility

$333.57

Service Code	HCPCS 93971
Hospital Charge Code	9900908
Hospital Revenue Code	921
Min. Negotiated Rate	$30.02
Max. Negotiated Rate	$240.17
Rate for Payer: Amerigroup CHIP/Medicaid	$30.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$100.07
Rate for Payer: BCBS of TX Blue Essentials	$120.09
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$133.43
Rate for Payer: Cash Price	$226.83
Rate for Payer: Cash Price	$226.83
Rate for Payer: Cash Price	$226.83
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$240.17
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 CHIP/Medicaid	$240.17
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$216.82
Rate for Payer: Multiplan Commercial	$216.82
Rate for Payer: Multiplan Workers Comp	$216.82
Rate for Payer: Parkland Medicaid	$240.17
Rate for Payer: Scott and White EPO/PPO	$146.95
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$240.17
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

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

Facility

$333.57

Service Code	HCPCS 93971
Hospital Charge Code	9900908
Hospital Revenue Code	921
Rate for Payer: Cash Price	$226.83

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

Dura-Y Sensor Oximeter

Facility

$1,154.52

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

DUST SHEET, 5X6, 500 SHEETS/CS

Facility

$0.76

Hospital Charge Code	993967
Hospital Revenue Code	270
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.55
Rate for Payer: Amerigroup CHIP/Medicaid	$0.07
Rate for Payer: BCBS of TX Blue Advantage	$0.23
Rate for Payer: BCBS of TX Blue Essentials	$0.27
Rate for Payer: BCBS of TX PPO	$0.30
Rate for Payer: Cash Price	$0.52
Rate for Payer: Cigna Medicaid	$0.55
Rate for Payer: Molina CHIP/Medicaid	$0.55
Rate for Payer: Multiplan Auto	$0.49
Rate for Payer: Multiplan Commercial	$0.49
Rate for Payer: Multiplan Workers Comp	$0.49
Rate for Payer: Parkland Medicaid	$0.55
Rate for Payer: Scott and White EPO/PPO	$0.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.55
Rate for Payer: Superior Health Plan EPO	$0.10

DUST SHEET, 5X6, 500 SHEETS/CS

Facility

$0.76

Hospital Charge Code	993967
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.52

DVCE ASPIRATING -- DHF

Facility

$216.11

Hospital Charge Code	80321151
Hospital Revenue Code	270
Min. Negotiated Rate	$19.45
Max. Negotiated Rate	$155.60
Rate for Payer: Amerigroup CHIP/Medicaid	$19.45
Rate for Payer: BCBS of TX Blue Advantage	$64.83
Rate for Payer: BCBS of TX Blue Essentials	$77.80
Rate for Payer: BCBS of TX PPO	$86.44
Rate for Payer: Cash Price	$146.95
Rate for Payer: Cigna Medicaid	$155.60
Rate for Payer: Molina CHIP/Medicaid	$155.60
Rate for Payer: Multiplan Auto	$140.47
Rate for Payer: Multiplan Commercial	$140.47
Rate for Payer: Multiplan Workers Comp	$140.47
Rate for Payer: Parkland Medicaid	$155.60
Rate for Payer: Scott and White EPO/PPO	$108.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$155.60
Rate for Payer: Superior Health Plan EPO	$29.39

DVCE ASPIRATING -- DHF

Facility

$216.11

Hospital Charge Code	80321151
Hospital Revenue Code	270
Rate for Payer: Cash Price	$146.95

DVCE CIRC AS -- DHF

Facility

$110.27

Hospital Charge Code	81741001
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.98

DVCE CIRC AS -- DHF

Facility

$110.27

Hospital Charge Code	81741001
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$79.39
Rate for Payer: Amerigroup CHIP/Medicaid	$9.92
Rate for Payer: BCBS of TX Blue Advantage	$33.08
Rate for Payer: BCBS of TX Blue Essentials	$39.70
Rate for Payer: BCBS of TX PPO	$44.11
Rate for Payer: Cash Price	$74.98
Rate for Payer: Cigna Medicaid	$79.39
Rate for Payer: Molina CHIP/Medicaid	$79.39
Rate for Payer: Multiplan Auto	$71.68
Rate for Payer: Multiplan Commercial	$71.68
Rate for Payer: Multiplan Workers Comp	$71.68
Rate for Payer: Parkland Medicaid	$79.39
Rate for Payer: Scott and White EPO/PPO	$55.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.39
Rate for Payer: Superior Health Plan EPO	$15.00

DVC EMBLZTN MICROSPHERE -- DHF

Facility

$794.05

Hospital Charge Code	80321268
Hospital Revenue Code	272
Rate for Payer: Cash Price	$539.95

DVC EMBLZTN MICROSPHERE -- DHF

Facility

$794.05

Hospital Charge Code	80321268
Hospital Revenue Code	272
Min. Negotiated Rate	$71.46
Max. Negotiated Rate	$571.72
Rate for Payer: Amerigroup CHIP/Medicaid	$71.46
Rate for Payer: BCBS of TX Blue Advantage	$238.22
Rate for Payer: BCBS of TX Blue Essentials	$285.86
Rate for Payer: BCBS of TX PPO	$317.62
Rate for Payer: Cash Price	$539.95
Rate for Payer: Cigna Medicaid	$571.72
Rate for Payer: Molina CHIP/Medicaid	$571.72
Rate for Payer: Multiplan Auto	$516.13
Rate for Payer: Multiplan Commercial	$516.13
Rate for Payer: Multiplan Workers Comp	$516.13
Rate for Payer: Parkland Medicaid	$571.72
Rate for Payer: Scott and White EPO/PPO	$397.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$571.72
Rate for Payer: Superior Health Plan EPO	$107.99

DVCE SIZING -- DHF

Facility

$285.37

Hospital Charge Code	80811086
Hospital Revenue Code	270
Min. Negotiated Rate	$25.68
Max. Negotiated Rate	$205.47
Rate for Payer: Amerigroup CHIP/Medicaid	$25.68
Rate for Payer: BCBS of TX Blue Advantage	$85.61
Rate for Payer: BCBS of TX Blue Essentials	$102.73
Rate for Payer: BCBS of TX PPO	$114.15
Rate for Payer: Cash Price	$194.05
Rate for Payer: Cigna Medicaid	$205.47
Rate for Payer: Molina CHIP/Medicaid	$205.47
Rate for Payer: Multiplan Auto	$185.49
Rate for Payer: Multiplan Commercial	$185.49
Rate for Payer: Multiplan Workers Comp	$185.49
Rate for Payer: Parkland Medicaid	$205.47
Rate for Payer: Scott and White EPO/PPO	$142.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$205.47
Rate for Payer: Superior Health Plan EPO	$38.81

DVCE SIZING -- DHF

Facility

$285.37

Hospital Charge Code	80811086
Hospital Revenue Code	270
Rate for Payer: Cash Price	$194.05

DVCE TORQUE -- DHF

Facility

$71.50

Hospital Charge Code	80811102
Hospital Revenue Code	272
Rate for Payer: Cash Price	$48.62

DVCE TORQUE -- DHF

Facility

$71.50

Hospital Charge Code	80811102
Hospital Revenue Code	272
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$51.48
Rate for Payer: Amerigroup CHIP/Medicaid	$6.43
Rate for Payer: BCBS of TX Blue Advantage	$21.45
Rate for Payer: BCBS of TX Blue Essentials	$25.74
Rate for Payer: BCBS of TX PPO	$28.60
Rate for Payer: Cash Price	$48.62
Rate for Payer: Cigna Medicaid	$51.48
Rate for Payer: Molina CHIP/Medicaid	$51.48
Rate for Payer: Multiplan Auto	$46.48
Rate for Payer: Multiplan Commercial	$46.48
Rate for Payer: Multiplan Workers Comp	$46.48
Rate for Payer: Parkland Medicaid	$51.48
Rate for Payer: Scott and White EPO/PPO	$35.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.48
Rate for Payer: Superior Health Plan EPO	$9.72

DVC INFLAT SINUS BLLN -- DHF

Facility

$338.45

Hospital Charge Code	81741118
Hospital Revenue Code	272
Rate for Payer: Cash Price	$230.15

DVC INFLAT SINUS BLLN -- DHF

Facility

$338.45

Hospital Charge Code	81741118
Hospital Revenue Code	272
Min. Negotiated Rate	$30.46
Max. Negotiated Rate	$243.68
Rate for Payer: Amerigroup CHIP/Medicaid	$30.46
Rate for Payer: BCBS of TX Blue Advantage	$101.53
Rate for Payer: BCBS of TX Blue Essentials	$121.84
Rate for Payer: BCBS of TX PPO	$135.38
Rate for Payer: Cash Price	$230.15
Rate for Payer: Cigna Medicaid	$243.68
Rate for Payer: Molina CHIP/Medicaid	$243.68
Rate for Payer: Multiplan Auto	$219.99
Rate for Payer: Multiplan Commercial	$219.99
Rate for Payer: Multiplan Workers Comp	$219.99
Rate for Payer: Parkland Medicaid	$243.68
Rate for Payer: Scott and White EPO/PPO	$169.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$243.68
Rate for Payer: Superior Health Plan EPO	$46.03

Know your out-of-pocket cost for care.

All Charges