White Rock Medical Center

All Charges

Charge

Type

Setting

Price

E0162 DRBC CPD 450 LR Irr

Facility

$695.00

Hospital Charge Code	7266926
Hospital Revenue Code	390
Rate for Payer: Cash Price	$472.60

E0162 DRBC CPD 450 LR Irr

Facility

$695.00

Hospital Charge Code	7266926
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

E0164 DRBC CPD 450 LR

Facility

$590.00

Service Code	HCPCS P9016
Hospital Charge Code	7266927
Hospital Revenue Code	390
Rate for Payer: Cash Price	$401.20

E0164 DRBC CPD 450 LR

Facility

$590.00

Service Code	HCPCS P9016
Hospital Charge Code	7266927
Hospital Revenue Code	390
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$424.80
Rate for Payer: Amerigroup CHIP/Medicaid	$53.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$181.81
Rate for Payer: Amerigroup Medicare	$181.81
Rate for Payer: BCBS of TX Blue Advantage	$177.00
Rate for Payer: BCBS of TX Blue Essentials	$212.40
Rate for Payer: BCBS of TX Medicare	$181.81
Rate for Payer: BCBS of TX PPO	$236.00
Rate for Payer: Cash Price	$401.20
Rate for Payer: Cash Price	$401.20
Rate for Payer: Cash Price	$401.20
Rate for Payer: Cigna Commercial	$384.33
Rate for Payer: Cigna Medicaid	$424.80
Rate for Payer: Cigna Medicare	$181.81
Rate for Payer: Employer Direct Commercial	$181.81
Rate for Payer: Humana Medicare/TRICARE	$181.81
Rate for Payer: Molina CHIP/Medicaid	$424.80
Rate for Payer: Molina Dual Medicare/Medicaid	$181.81
Rate for Payer: Molina Medicare	$181.81
Rate for Payer: Multiplan Auto	$383.50
Rate for Payer: Multiplan Commercial	$383.50
Rate for Payer: Multiplan Workers Comp	$383.50
Rate for Payer: Parkland Medicaid	$424.80
Rate for Payer: Scott and White EPO/PPO	$295.00
Rate for Payer: Scott and White Medicare	$181.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$424.80
Rate for Payer: Superior Health Plan EPO	$181.81
Rate for Payer: Superior Health Plan Medicare	$181.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$181.81
Rate for Payer: Universal American Medicare	$181.81
Rate for Payer: Wellcare Medicare	$181.81
Rate for Payer: Wellmed Medicare	$181.81

E0404 DRBC CPD AS5

Facility

$401.91

Hospital Charge Code	2401040
Hospital Revenue Code	390
Rate for Payer: Cash Price	$273.30

E0404 DRBC CPD AS5

Facility

$401.91

Hospital Charge Code	2401040
Hospital Revenue Code	390
Min. Negotiated Rate	$36.17
Max. Negotiated Rate	$289.38
Rate for Payer: Amerigroup CHIP/Medicaid	$36.17
Rate for Payer: BCBS of TX Blue Advantage	$120.57
Rate for Payer: BCBS of TX Blue Essentials	$144.69
Rate for Payer: BCBS of TX PPO	$160.76
Rate for Payer: Cash Price	$273.30
Rate for Payer: Cigna Medicaid	$289.38
Rate for Payer: Molina CHIP/Medicaid	$289.38
Rate for Payer: Multiplan Auto	$261.24
Rate for Payer: Multiplan Commercial	$261.24
Rate for Payer: Multiplan Workers Comp	$261.24
Rate for Payer: Parkland Medicaid	$289.38
Rate for Payer: Scott and White EPO/PPO	$200.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$289.38
Rate for Payer: Superior Health Plan EPO	$54.66

E0487 ARBC Washed Open

Facility

$589.81

Hospital Charge Code	2403673
Hospital Revenue Code	390
Rate for Payer: Cash Price	$401.07

E0487 ARBC Washed Open

Facility

$589.81

Hospital Charge Code	2403673
Hospital Revenue Code	390
Min. Negotiated Rate	$53.08
Max. Negotiated Rate	$424.66
Rate for Payer: Amerigroup CHIP/Medicaid	$53.08
Rate for Payer: BCBS of TX Blue Advantage	$176.94
Rate for Payer: BCBS of TX Blue Essentials	$212.33
Rate for Payer: BCBS of TX PPO	$235.92
Rate for Payer: Cash Price	$401.07
Rate for Payer: Cigna Medicaid	$424.66
Rate for Payer: Molina CHIP/Medicaid	$424.66
Rate for Payer: Multiplan Auto	$383.38
Rate for Payer: Multiplan Commercial	$383.38
Rate for Payer: Multiplan Workers Comp	$383.38
Rate for Payer: Parkland Medicaid	$424.66
Rate for Payer: Scott and White EPO/PPO	$294.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$424.66
Rate for Payer: Superior Health Plan EPO	$80.21

E0634 Aph Dv RBC CP2D AS3 LR Irr 2 Open

Facility

$538.30

Hospital Charge Code	2408722
Hospital Revenue Code	390
Rate for Payer: Cash Price	$366.04

E0634 Aph Dv RBC CP2D AS3 LR Irr 2 Open

Facility

$538.30

Hospital Charge Code	2408722
Hospital Revenue Code	390
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$387.58
Rate for Payer: Amerigroup CHIP/Medicaid	$48.45
Rate for Payer: BCBS of TX Blue Advantage	$161.49
Rate for Payer: BCBS of TX Blue Essentials	$193.79
Rate for Payer: BCBS of TX PPO	$215.32
Rate for Payer: Cash Price	$366.04
Rate for Payer: Cigna Medicaid	$387.58
Rate for Payer: Molina CHIP/Medicaid	$387.58
Rate for Payer: Multiplan Auto	$349.89
Rate for Payer: Multiplan Commercial	$349.89
Rate for Payer: Multiplan Workers Comp	$349.89
Rate for Payer: Parkland Medicaid	$387.58
Rate for Payer: Scott and White EPO/PPO	$269.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$387.58
Rate for Payer: Superior Health Plan EPO	$73.21

E0685 Aph DRBC CP2D AS3 LR 1

Facility

$590.00

Hospital Charge Code	2401479
Hospital Revenue Code	390
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$424.80
Rate for Payer: Amerigroup CHIP/Medicaid	$53.10
Rate for Payer: BCBS of TX Blue Advantage	$177.00
Rate for Payer: BCBS of TX Blue Essentials	$212.40
Rate for Payer: BCBS of TX PPO	$236.00
Rate for Payer: Cash Price	$401.20
Rate for Payer: Cigna Medicaid	$424.80
Rate for Payer: Molina CHIP/Medicaid	$424.80
Rate for Payer: Multiplan Auto	$383.50
Rate for Payer: Multiplan Commercial	$383.50
Rate for Payer: Multiplan Workers Comp	$383.50
Rate for Payer: Parkland Medicaid	$424.80
Rate for Payer: Scott and White EPO/PPO	$295.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$424.80
Rate for Payer: Superior Health Plan EPO	$80.24

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
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

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

E2718 Thawed Plasma CPDA1 Cryo Red

Facility

$344.00

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

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
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

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

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

Know your out-of-pocket cost for care.

All Charges