White Rock Medical Center

All Charges

Charge

Type

Setting

Price

E0685 Aph DRBC CP2D AS3 LR 1

Facility

$590.00

Hospital Charge Code	2401479
Hospital Revenue Code	390
Rate for Payer: Cash Price	$401.20

E1318 Thawed Aph FFP ACDA 400-600 mL

Facility

$92.00

Hospital Charge Code	2402527
Hospital Revenue Code	390
Rate for Payer: Cash Price	$62.56

E1318 Thawed Aph FFP ACDA 400-600 mL

Facility

$92.00

Hospital Charge Code	2402527
Hospital Revenue Code	390
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$66.24
Rate for Payer: Amerigroup CHIP/Medicaid	$8.28
Rate for Payer: BCBS of TX Blue Advantage	$27.60
Rate for Payer: BCBS of TX Blue Essentials	$33.12
Rate for Payer: BCBS of TX PPO	$36.80
Rate for Payer: Cash Price	$62.56
Rate for Payer: Cigna Medicaid	$66.24
Rate for Payer: Molina CHIP/Medicaid	$66.24
Rate for Payer: Multiplan Auto	$59.80
Rate for Payer: Multiplan Commercial	$59.80
Rate for Payer: Multiplan Workers Comp	$59.80
Rate for Payer: Parkland Medicaid	$66.24
Rate for Payer: Scott and White EPO/PPO	$46.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$66.24
Rate for Payer: Superior Health Plan EPO	$12.51

E1408 Thawed Aph FFP NaCitrate >600mL

Facility

$92.00

Hospital Charge Code	8728583
Hospital Revenue Code	390
Rate for Payer: Cash Price	$62.56

E1408 Thawed Aph FFP NaCitrate >600mL

Facility

$92.00

Hospital Charge Code	8728583
Hospital Revenue Code	390
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$66.24
Rate for Payer: Amerigroup CHIP/Medicaid	$8.28
Rate for Payer: BCBS of TX Blue Advantage	$27.60
Rate for Payer: BCBS of TX Blue Essentials	$33.12
Rate for Payer: BCBS of TX PPO	$36.80
Rate for Payer: Cash Price	$62.56
Rate for Payer: Cigna Medicaid	$66.24
Rate for Payer: Molina CHIP/Medicaid	$66.24
Rate for Payer: Multiplan Auto	$59.80
Rate for Payer: Multiplan Commercial	$59.80
Rate for Payer: Multiplan Workers Comp	$59.80
Rate for Payer: Parkland Medicaid	$66.24
Rate for Payer: Scott and White EPO/PPO	$46.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$66.24
Rate for Payer: Superior Health Plan EPO	$12.51

E2225 Thawed Aph Plasma ACDA Irr <200 mL

Facility

$92.00

Hospital Charge Code	2404069
Hospital Revenue Code	390
Rate for Payer: Cash Price	$62.56

E2225 Thawed Aph Plasma ACDA Irr <200 mL

Facility

$92.00

Hospital Charge Code	2404069
Hospital Revenue Code	390
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$66.24
Rate for Payer: Amerigroup CHIP/Medicaid	$8.28
Rate for Payer: BCBS of TX Blue Advantage	$27.60
Rate for Payer: BCBS of TX Blue Essentials	$33.12
Rate for Payer: BCBS of TX PPO	$36.80
Rate for Payer: Cash Price	$62.56
Rate for Payer: Cigna Medicaid	$66.24
Rate for Payer: Molina CHIP/Medicaid	$66.24
Rate for Payer: Multiplan Auto	$59.80
Rate for Payer: Multiplan Commercial	$59.80
Rate for Payer: Multiplan Workers Comp	$59.80
Rate for Payer: Parkland Medicaid	$66.24
Rate for Payer: Scott and White EPO/PPO	$46.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$66.24
Rate for Payer: Superior Health Plan EPO	$12.51

E2718 Thawed Plasma CPDA1 Cryo Red

Facility

$344.00

Hospital Charge Code	2404028
Hospital Revenue Code	390
Rate for Payer: Cash Price	$233.92

E2718 Thawed Plasma CPDA1 Cryo Red

Facility

$344.00

Hospital Charge Code	2404028
Hospital Revenue Code	390
Min. Negotiated Rate	$30.96
Max. Negotiated Rate	$247.68
Rate for Payer: Amerigroup CHIP/Medicaid	$30.96
Rate for Payer: BCBS of TX Blue Advantage	$103.20
Rate for Payer: BCBS of TX Blue Essentials	$123.84
Rate for Payer: BCBS of TX PPO	$137.60
Rate for Payer: Cash Price	$233.92
Rate for Payer: Cigna Medicaid	$247.68
Rate for Payer: Molina CHIP/Medicaid	$247.68
Rate for Payer: Multiplan Auto	$223.60
Rate for Payer: Multiplan Commercial	$223.60
Rate for Payer: Multiplan Workers Comp	$223.60
Rate for Payer: Parkland Medicaid	$247.68
Rate for Payer: Scott and White EPO/PPO	$172.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$247.68
Rate for Payer: Superior Health Plan EPO	$46.78

E3593 Thawed Pooled Cryo Irr Open

Facility

$70.00

Hospital Charge Code	2402519
Hospital Revenue Code	390
Rate for Payer: Cash Price	$47.60

E3593 Thawed Pooled Cryo Irr Open

Facility

$70.00

Hospital Charge Code	2402519
Hospital Revenue Code	390
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$50.40
Rate for Payer: Amerigroup CHIP/Medicaid	$6.30
Rate for Payer: BCBS of TX Blue Advantage	$21.00
Rate for Payer: BCBS of TX Blue Essentials	$25.20
Rate for Payer: BCBS of TX PPO	$28.00
Rate for Payer: Cash Price	$47.60
Rate for Payer: Cigna Medicaid	$50.40
Rate for Payer: Molina CHIP/Medicaid	$50.40
Rate for Payer: Multiplan Auto	$45.50
Rate for Payer: Multiplan Commercial	$45.50
Rate for Payer: Multiplan Workers Comp	$45.50
Rate for Payer: Parkland Medicaid	$50.40
Rate for Payer: Scott and White EPO/PPO	$35.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50.40
Rate for Payer: Superior Health Plan EPO	$9.52

E4540 Aph DRBC ACDA AS3 LR Irr 2

Facility

$695.00

Hospital Charge Code	2401644
Hospital Revenue Code	390
Rate for Payer: Cash Price	$472.60

E4540 Aph DRBC ACDA AS3 LR Irr 2

Facility

$695.00

Hospital Charge Code	2401644
Hospital Revenue Code	390
Min. Negotiated Rate	$62.55
Max. Negotiated Rate	$500.40
Rate for Payer: Amerigroup CHIP/Medicaid	$62.55
Rate for Payer: BCBS of TX Blue Advantage	$208.50
Rate for Payer: BCBS of TX Blue Essentials	$250.20
Rate for Payer: BCBS of TX PPO	$278.00
Rate for Payer: Cash Price	$472.60
Rate for Payer: Cigna Medicaid	$500.40
Rate for Payer: Molina CHIP/Medicaid	$500.40
Rate for Payer: Multiplan Auto	$451.75
Rate for Payer: Multiplan Commercial	$451.75
Rate for Payer: Multiplan Workers Comp	$451.75
Rate for Payer: Parkland Medicaid	$500.40
Rate for Payer: Scott and White EPO/PPO	$347.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$500.40
Rate for Payer: Superior Health Plan EPO	$94.52

E4565 Aph DRBC Washed LR 2 Open

Facility

$1,151.47

Hospital Charge Code	2408656
Hospital Revenue Code	390
Min. Negotiated Rate	$103.63
Max. Negotiated Rate	$829.06
Rate for Payer: Amerigroup CHIP/Medicaid	$103.63
Rate for Payer: BCBS of TX Blue Advantage	$345.44
Rate for Payer: BCBS of TX Blue Essentials	$414.53
Rate for Payer: BCBS of TX PPO	$460.59
Rate for Payer: Cash Price	$783.00
Rate for Payer: Cigna Medicaid	$829.06
Rate for Payer: Molina CHIP/Medicaid	$829.06
Rate for Payer: Multiplan Auto	$748.46
Rate for Payer: Multiplan Commercial	$748.46
Rate for Payer: Multiplan Workers Comp	$748.46
Rate for Payer: Parkland Medicaid	$829.06
Rate for Payer: Scott and White EPO/PPO	$575.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$829.06
Rate for Payer: Superior Health Plan EPO	$156.60

E4565 Aph DRBC Washed LR 2 Open

Facility

$1,151.47

Hospital Charge Code	2408656
Hospital Revenue Code	390
Rate for Payer: Cash Price	$783.00

E4640 Aph Plt ACDA Irr <3 X log 11 1

Facility

$2,180.99

Hospital Charge Code	2402253
Hospital Revenue Code	390
Min. Negotiated Rate	$196.29
Max. Negotiated Rate	$1,570.31
Rate for Payer: Amerigroup CHIP/Medicaid	$196.29
Rate for Payer: BCBS of TX Blue Advantage	$654.30
Rate for Payer: BCBS of TX Blue Essentials	$785.16
Rate for Payer: BCBS of TX PPO	$872.40
Rate for Payer: Cash Price	$1,483.07
Rate for Payer: Cigna Medicaid	$1,570.31
Rate for Payer: Molina CHIP/Medicaid	$1,570.31
Rate for Payer: Multiplan Auto	$1,417.64
Rate for Payer: Multiplan Commercial	$1,417.64
Rate for Payer: Multiplan Workers Comp	$1,417.64
Rate for Payer: Parkland Medicaid	$1,570.31
Rate for Payer: Scott and White EPO/PPO	$1,090.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,570.31
Rate for Payer: Superior Health Plan EPO	$296.61

E4640 Aph Plt ACDA Irr <3 X log 11 1

Facility

$2,180.99

Hospital Charge Code	2402253
Hospital Revenue Code	390
Rate for Payer: Cash Price	$1,483.07

E4644 Aph Plt ACDA LR <3 X log 11 1

Facility

$1,136.00

Hospital Charge Code	2403863
Hospital Revenue Code	390
Min. Negotiated Rate	$102.24
Max. Negotiated Rate	$817.92
Rate for Payer: Amerigroup CHIP/Medicaid	$102.24
Rate for Payer: BCBS of TX Blue Advantage	$340.80
Rate for Payer: BCBS of TX Blue Essentials	$408.96
Rate for Payer: BCBS of TX PPO	$454.40
Rate for Payer: Cash Price	$772.48
Rate for Payer: Cigna Medicaid	$817.92
Rate for Payer: Molina CHIP/Medicaid	$817.92
Rate for Payer: Multiplan Auto	$738.40
Rate for Payer: Multiplan Commercial	$738.40
Rate for Payer: Multiplan Workers Comp	$738.40
Rate for Payer: Parkland Medicaid	$817.92
Rate for Payer: Scott and White EPO/PPO	$568.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$817.92
Rate for Payer: Superior Health Plan EPO	$154.50

E4644 Aph Plt ACDA LR <3 X log 11 1

Facility

$1,136.00

Hospital Charge Code	2403863
Hospital Revenue Code	390
Rate for Payer: Cash Price	$772.48

E4649 Aph Plt ACDA LR Irr <3 X log 11 2

Facility

$1,241.61

Hospital Charge Code	2403871
Hospital Revenue Code	390
Rate for Payer: Cash Price	$844.29

E4649 Aph Plt ACDA LR Irr <3 X log 11 2

Facility

$1,241.61

Hospital Charge Code	2403871
Hospital Revenue Code	390
Min. Negotiated Rate	$111.74
Max. Negotiated Rate	$893.96
Rate for Payer: Amerigroup CHIP/Medicaid	$111.74
Rate for Payer: BCBS of TX Blue Advantage	$372.48
Rate for Payer: BCBS of TX Blue Essentials	$446.98
Rate for Payer: BCBS of TX PPO	$496.64
Rate for Payer: Cash Price	$844.29
Rate for Payer: Cigna Medicaid	$893.96
Rate for Payer: Molina CHIP/Medicaid	$893.96
Rate for Payer: Multiplan Auto	$807.05
Rate for Payer: Multiplan Commercial	$807.05
Rate for Payer: Multiplan Workers Comp	$807.05
Rate for Payer: Parkland Medicaid	$893.96
Rate for Payer: Scott and White EPO/PPO	$620.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$893.96
Rate for Payer: Superior Health Plan EPO	$168.86

E4655 Thawed FFP CPD

Facility

$92.00

Hospital Charge Code	8728582
Hospital Revenue Code	390
Rate for Payer: Cash Price	$62.56

E4655 Thawed FFP CPD

Facility

$92.00

Hospital Charge Code	8728582
Hospital Revenue Code	390
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$66.24
Rate for Payer: Amerigroup CHIP/Medicaid	$8.28
Rate for Payer: BCBS of TX Blue Advantage	$27.60
Rate for Payer: BCBS of TX Blue Essentials	$33.12
Rate for Payer: BCBS of TX PPO	$36.80
Rate for Payer: Cash Price	$62.56
Rate for Payer: Cigna Medicaid	$66.24
Rate for Payer: Molina CHIP/Medicaid	$66.24
Rate for Payer: Multiplan Auto	$59.80
Rate for Payer: Multiplan Commercial	$59.80
Rate for Payer: Multiplan Workers Comp	$59.80
Rate for Payer: Parkland Medicaid	$66.24
Rate for Payer: Scott and White EPO/PPO	$46.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$66.24
Rate for Payer: Superior Health Plan EPO	$12.51

E4995 ARBC Deglyc AS3

Facility

$2,463.20

Hospital Charge Code	2402584
Hospital Revenue Code	390
Rate for Payer: Cash Price	$1,674.98

E4995 ARBC Deglyc AS3

Facility

$2,463.20

Hospital Charge Code	2402584
Hospital Revenue Code	390
Min. Negotiated Rate	$221.69
Max. Negotiated Rate	$1,773.50
Rate for Payer: Amerigroup CHIP/Medicaid	$221.69
Rate for Payer: BCBS of TX Blue Advantage	$738.96
Rate for Payer: BCBS of TX Blue Essentials	$886.75
Rate for Payer: BCBS of TX PPO	$985.28
Rate for Payer: Cash Price	$1,674.98
Rate for Payer: Cigna Medicaid	$1,773.50
Rate for Payer: Molina CHIP/Medicaid	$1,773.50
Rate for Payer: Multiplan Auto	$1,601.08
Rate for Payer: Multiplan Commercial	$1,601.08
Rate for Payer: Multiplan Workers Comp	$1,601.08
Rate for Payer: Parkland Medicaid	$1,773.50
Rate for Payer: Scott and White EPO/PPO	$1,231.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,773.50
Rate for Payer: Superior Health Plan EPO	$335.00

Know your out-of-pocket cost for care.

All Charges