White Rock Medical Center

All Charges

Charge

Type

Setting

Price

E5591 DRBC CPD AS1 Irr

Facility

$820.00

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

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

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
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

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

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
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

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

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

each additional 100 sq cm wound surface area, or part thereof-location face,scalp,neck,ears,genitalia,hands,feet, and/or multiple digits

Facility

$7,316.92

Service Code	HCPCS 15278
Hospital Charge Code	994056
Hospital Revenue Code	361
Min. Negotiated Rate	$658.52
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$658.52
Rate for Payer: BCBS of TX Blue Advantage	$2,195.08
Rate for Payer: BCBS of TX Blue Essentials	$2,634.09
Rate for Payer: BCBS of TX PPO	$2,926.77
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cigna Medicaid	$5,268.18
Rate for Payer: Molina CHIP/Medicaid	$5,268.18
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: Parkland Medicaid	$5,268.18
Rate for Payer: Scott and White EPO/PPO	$3,658.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,268.18
Rate for Payer: Superior Health Plan EPO	$995.10

each additional 100 sq cm wound surface area, or part thereof-location face,scalp,neck,ears,genitalia,hands,feet, and/or multiple digits

Facility

$7,316.92

Service Code	HCPCS 15278
Hospital Charge Code	994056
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,975.51

each additional anatomic site

Facility

$1,245.60

Service Code	HCPCS 0599T
Hospital Charge Code	994051
Hospital Revenue Code	361
Rate for Payer: Cash Price	$847.01

each additional anatomic site

Facility

$1,245.60

Service Code	HCPCS 0599T
Hospital Charge Code	994051
Hospital Revenue Code	361
Min. Negotiated Rate	$112.10
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$112.10
Rate for Payer: Cash Price	$847.01
Rate for Payer: Cash Price	$847.01
Rate for Payer: Cigna Medicaid	$896.83
Rate for Payer: Molina CHIP/Medicaid	$896.83
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: Parkland Medicaid	$896.83
Rate for Payer: Scott and White EPO/PPO	$622.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$896.83
Rate for Payer: Superior Health Plan EPO	$169.40

Ear Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107067
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$92.70
Rate for Payer: BCBS of TX Blue Essentials	$111.24
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$123.60
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cigna Medicaid	$222.48
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$222.48
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Ear Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107067
Hospital Revenue Code	306
Rate for Payer: Cash Price	$210.12

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$24,158.50

Service Code	MSDRG 147
Min. Negotiated Rate	$10,754.30
Max. Negotiated Rate	$24,158.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,078.94
Rate for Payer: Amerigroup Medicare	$14,078.94
Rate for Payer: BCBS of TX Medicare	$14,078.94
Rate for Payer: Cigna Commercial	$16,376.92
Rate for Payer: Cigna Medicare	$14,078.94
Rate for Payer: Employer Direct Commercial	$14,078.94
Rate for Payer: Humana Medicare/TRICARE	$14,078.94
Rate for Payer: Molina Dual Medicare/Medicaid	$14,078.94
Rate for Payer: Molina Medicare	$14,078.94
Rate for Payer: Multiplan Auto	$24,158.50
Rate for Payer: Multiplan Commercial	$24,158.50
Rate for Payer: Multiplan Workers Comp	$24,158.50
Rate for Payer: Scott and White EPO/PPO	$11,125.62
Rate for Payer: Scott and White Medicare	$14,078.94
Rate for Payer: Superior Health Plan EPO	$14,078.94
Rate for Payer: Superior Health Plan Medicare	$14,078.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,078.94
Rate for Payer: Universal American Medicare	$14,078.94
Rate for Payer: Wellcare Medicare	$14,078.94
Rate for Payer: Wellmed Medicare	$14,078.94

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility

$40,230.60

Service Code	MSDRG 146
Min. Negotiated Rate	$16,538.66
Max. Negotiated Rate	$40,230.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,278.56
Rate for Payer: Amerigroup Medicare	$20,278.56
Rate for Payer: BCBS of TX Medicare	$20,278.56
Rate for Payer: Cigna Commercial	$27,272.11
Rate for Payer: Cigna Medicare	$20,278.56
Rate for Payer: Employer Direct Commercial	$20,278.56
Rate for Payer: Humana Medicare/TRICARE	$20,278.56
Rate for Payer: Molina Dual Medicare/Medicaid	$20,278.56
Rate for Payer: Molina Medicare	$20,278.56
Rate for Payer: Multiplan Auto	$40,230.60
Rate for Payer: Multiplan Commercial	$40,230.60
Rate for Payer: Multiplan Workers Comp	$40,230.60
Rate for Payer: Scott and White EPO/PPO	$18,527.25
Rate for Payer: Scott and White Medicare	$20,278.56
Rate for Payer: Superior Health Plan EPO	$20,278.56
Rate for Payer: Superior Health Plan Medicare	$20,278.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,278.56
Rate for Payer: Universal American Medicare	$20,278.56
Rate for Payer: Wellcare Medicare	$20,278.56
Rate for Payer: Wellmed Medicare	$20,278.56

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC

Facility

$15,144.90

Service Code	MSDRG 148
Min. Negotiated Rate	$6,224.68
Max. Negotiated Rate	$15,144.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,602.04
Rate for Payer: Amerigroup Medicare	$10,602.04
Rate for Payer: BCBS of TX Medicare	$10,602.04
Rate for Payer: Cigna Commercial	$10,266.65
Rate for Payer: Cigna Medicare	$10,602.04
Rate for Payer: Employer Direct Commercial	$10,602.04
Rate for Payer: Humana Medicare/TRICARE	$10,602.04
Rate for Payer: Molina Dual Medicare/Medicaid	$10,602.04
Rate for Payer: Molina Medicare	$10,602.04
Rate for Payer: Multiplan Auto	$15,144.90
Rate for Payer: Multiplan Commercial	$15,144.90
Rate for Payer: Multiplan Workers Comp	$15,144.90
Rate for Payer: Scott and White EPO/PPO	$6,974.62
Rate for Payer: Scott and White Medicare	$10,602.04
Rate for Payer: Superior Health Plan EPO	$10,602.04
Rate for Payer: Superior Health Plan Medicare	$10,602.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,602.04
Rate for Payer: Universal American Medicare	$10,602.04
Rate for Payer: Wellcare Medicare	$10,602.04
Rate for Payer: Wellmed Medicare	$10,602.04

EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES

Facility

$3,234.02

Service Code	APR-DRG 1101
Min. Negotiated Rate	$3,049.15
Max. Negotiated Rate	$3,234.02
Rate for Payer: Amerigroup CHIP/Medicaid	$3,049.15
Rate for Payer: Cigna Medicaid	$3,049.15
Rate for Payer: Molina CHIP/Medicaid	$3,049.15
Rate for Payer: Parkland Medicaid	$3,049.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,234.02

EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES

Facility

$5,179.56

Service Code	APR-DRG 1102
Min. Negotiated Rate	$4,883.47
Max. Negotiated Rate	$5,179.56
Rate for Payer: Amerigroup CHIP/Medicaid	$4,883.47
Rate for Payer: Cigna Medicaid	$4,883.47
Rate for Payer: Molina CHIP/Medicaid	$4,883.47
Rate for Payer: Parkland Medicaid	$4,883.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,179.56

Know your out-of-pocket cost for care.

All Charges