White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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

E5591 DRBC CPD AS1 Irr

Facility

$820.00

Hospital Charge Code	2400794
Hospital Revenue Code	390
Min. Negotiated Rate	$73.80
Max. Negotiated Rate	$590.40
Rate for Payer: Amerigroup CHIP/Medicaid	$73.80
Rate for Payer: BCBS of TX Blue Advantage	$246.00
Rate for Payer: BCBS of TX Blue Essentials	$295.20
Rate for Payer: BCBS of TX PPO	$328.00
Rate for Payer: Cash Price	$557.60
Rate for Payer: Cigna Medicaid	$590.40
Rate for Payer: Molina CHIP/Medicaid	$590.40
Rate for Payer: Multiplan Auto	$533.00
Rate for Payer: Multiplan Commercial	$533.00
Rate for Payer: Multiplan Workers Comp	$533.00
Rate for Payer: Parkland Medicaid	$590.40
Rate for Payer: Scott and White EPO/PPO	$410.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$590.40
Rate for Payer: Superior Health Plan EPO	$111.52

E5591 DRBC CPD AS1 Irr

Facility

$820.00

Hospital Charge Code	2400794
Hospital Revenue Code	390
Rate for Payer: Cash Price	$557.60

E6001 Pooled Platelets CPD B Test

Facility

$1,136.00

Hospital Charge Code	2402568
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

E6001 Pooled Platelets CPD B Test

Facility

$1,136.00

Hospital Charge Code	2402568
Hospital Revenue Code	390
Rate for Payer: Cash Price	$772.48

E6655 Aph ARBC Deglyc AS3 LR Irr 1 Open

Facility

$1,492.00

Hospital Charge Code	2408748
Hospital Revenue Code	390
Rate for Payer: Cash Price	$1,014.56

E6655 Aph ARBC Deglyc AS3 LR Irr 1 Open

Facility

$1,492.00

Hospital Charge Code	2408748
Hospital Revenue Code	390
Min. Negotiated Rate	$134.28
Max. Negotiated Rate	$1,074.24
Rate for Payer: Amerigroup CHIP/Medicaid	$134.28
Rate for Payer: BCBS of TX Blue Advantage	$447.60
Rate for Payer: BCBS of TX Blue Essentials	$537.12
Rate for Payer: BCBS of TX PPO	$596.80
Rate for Payer: Cash Price	$1,014.56
Rate for Payer: Cigna Medicaid	$1,074.24
Rate for Payer: Molina CHIP/Medicaid	$1,074.24
Rate for Payer: Multiplan Auto	$969.80
Rate for Payer: Multiplan Commercial	$969.80
Rate for Payer: Multiplan Workers Comp	$969.80
Rate for Payer: Parkland Medicaid	$1,074.24
Rate for Payer: Scott and White EPO/PPO	$746.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,074.24
Rate for Payer: Superior Health Plan EPO	$202.91

E7916 Thawed FFP CPD LR

Facility

$92.00

Hospital Charge Code	8728581
Hospital Revenue Code	390
Rate for Payer: Cash Price	$62.56

E7916 Thawed FFP CPD LR

Facility

$92.00

Hospital Charge Code	8728581
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

E8694 Thawed Aph Plasma ACDA 400-600 mL

Facility

$92.00

Hospital Charge Code	8728584
Hospital Revenue Code	390
Rate for Payer: Cash Price	$62.56

E8694 Thawed Aph Plasma ACDA 400-600 mL

Facility

$92.00

Hospital Charge Code	8728584
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

E9284 Thawed Aph Plasma ACDA <24h 1

Facility

$92.00

Hospital Charge Code	8728585
Hospital Revenue Code	390
Rate for Payer: Cash Price	$62.56

E9284 Thawed Aph Plasma ACDA <24h 1

Facility

$92.00

Hospital Charge Code	8728585
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

E9285 Thawed Aph Plasma ACDA <24h 2

Facility

$92.00

Hospital Charge Code	8728580
Hospital Revenue Code	390
Rate for Payer: Cash Price	$62.56

E9285 Thawed Aph Plasma ACDA <24h 2

Facility

$92.00

Hospital Charge Code	8728580
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

Know your out-of-pocket cost for care.

All Charges