White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$5,571.08

Service Code	APR-DRG 1103
Min. Negotiated Rate	$5,252.61
Max. Negotiated Rate	$5,571.08
Rate for Payer: Amerigroup CHIP/Medicaid	$5,252.61
Rate for Payer: Cigna Medicaid	$5,252.61
Rate for Payer: Molina CHIP/Medicaid	$5,252.61
Rate for Payer: Parkland Medicaid	$5,252.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,571.08

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

Facility

$10,274.63

Service Code	APR-DRG 1104
Min. Negotiated Rate	$9,687.28
Max. Negotiated Rate	$10,274.63
Rate for Payer: Amerigroup CHIP/Medicaid	$9,687.28
Rate for Payer: Cigna Medicaid	$9,687.28
Rate for Payer: Molina CHIP/Medicaid	$9,687.28
Rate for Payer: Parkland Medicaid	$9,687.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,274.63

EAR, NOSE, MOUTH & THROAT MALIGNANCY W CC

Facility

$24,158.50

Service Code	MSDRG 147
Min. Negotiated Rate	$10,754.30
Max. Negotiated Rate	$24,158.50
Rate for Payer: BCBS of TX Blue Advantage	$10,754.30
Rate for Payer: BCBS of TX Blue Essentials	$12,903.91
Rate for Payer: BCBS of TX PPO	$14,338.23

EAR, NOSE, MOUTH & THROAT MALIGNANCY W MCC

Facility

$40,230.60

Service Code	MSDRG 146
Min. Negotiated Rate	$16,538.66
Max. Negotiated Rate	$40,230.60
Rate for Payer: BCBS of TX Blue Advantage	$16,538.66
Rate for Payer: BCBS of TX Blue Essentials	$19,844.47
Rate for Payer: BCBS of TX PPO	$22,050.26

EAR, NOSE, MOUTH & THROAT MALIGNANCY W/O 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: BCBS of TX Blue Advantage	$6,224.68
Rate for Payer: BCBS of TX Blue Essentials	$7,468.89
Rate for Payer: BCBS of TX PPO	$8,299.09

Easyfuse Instrument Packmid/Hindfoot

Facility

$3,427.70

Hospital Charge Code	146397
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,330.84

Easyfuse Instrument Packmid/Hindfoot

Facility

$3,427.70

Hospital Charge Code	146397
Hospital Revenue Code	272
Min. Negotiated Rate	$308.49
Max. Negotiated Rate	$2,467.94
Rate for Payer: Amerigroup CHIP/Medicaid	$308.49
Rate for Payer: BCBS of TX Blue Advantage	$1,028.31
Rate for Payer: BCBS of TX Blue Essentials	$1,233.97
Rate for Payer: BCBS of TX PPO	$1,371.08
Rate for Payer: Cash Price	$2,330.84
Rate for Payer: Cigna Medicaid	$2,467.94
Rate for Payer: Molina CHIP/Medicaid	$2,467.94
Rate for Payer: Multiplan Auto	$2,228.01
Rate for Payer: Multiplan Commercial	$2,228.01
Rate for Payer: Multiplan Workers Comp	$2,228.01
Rate for Payer: Parkland Medicaid	$2,467.94
Rate for Payer: Scott and White EPO/PPO	$1,713.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,467.94
Rate for Payer: Superior Health Plan EPO	$466.17

EASYFUSE INSTRUMENT PACKMID / HINDFOOT

Facility

$2,038.46

Hospital Charge Code	993542
Hospital Revenue Code	270
Min. Negotiated Rate	$183.46
Max. Negotiated Rate	$1,467.69
Rate for Payer: Amerigroup CHIP/Medicaid	$183.46
Rate for Payer: BCBS of TX Blue Advantage	$611.54
Rate for Payer: BCBS of TX Blue Essentials	$733.85
Rate for Payer: BCBS of TX PPO	$815.38
Rate for Payer: Cash Price	$1,386.15
Rate for Payer: Cigna Medicaid	$1,467.69
Rate for Payer: Molina CHIP/Medicaid	$1,467.69
Rate for Payer: Multiplan Auto	$1,325.00
Rate for Payer: Multiplan Commercial	$1,325.00
Rate for Payer: Multiplan Workers Comp	$1,325.00
Rate for Payer: Parkland Medicaid	$1,467.69
Rate for Payer: Scott and White EPO/PPO	$1,019.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,467.69
Rate for Payer: Superior Health Plan EPO	$277.23

EASYFUSE INSTRUMENT PACKMID / HINDFOOT

Facility

$2,038.46

Hospital Charge Code	993542
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,386.15

EASYFUSE STAPLE 20X20 NITINOL 2-LEG

Facility

$15,234.34

Service Code	HCPCS C1776
Hospital Charge Code	992377
Hospital Revenue Code	278
Min. Negotiated Rate	$1,371.09
Max. Negotiated Rate	$10,968.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1,371.09
Rate for Payer: BCBS of TX Blue Advantage	$4,570.30
Rate for Payer: BCBS of TX Blue Essentials	$5,484.36
Rate for Payer: BCBS of TX PPO	$6,093.74
Rate for Payer: Cash Price	$10,359.35
Rate for Payer: Cigna Medicaid	$10,968.72
Rate for Payer: Molina CHIP/Medicaid	$10,968.72
Rate for Payer: Multiplan Auto	$7,617.17
Rate for Payer: Multiplan Commercial	$7,617.17
Rate for Payer: Multiplan Workers Comp	$7,617.17
Rate for Payer: Parkland Medicaid	$10,968.72
Rate for Payer: Scott and White EPO/PPO	$7,617.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,968.72
Rate for Payer: Superior Health Plan EPO	$2,071.87

EASYFUSE STAPLE 20X20 NITINOL 2-LEG

Facility

$15,234.34

Service Code	HCPCS C1776
Hospital Charge Code	992377
Hospital Revenue Code	278
Min. Negotiated Rate	$3,808.59
Max. Negotiated Rate	$7,617.17
Rate for Payer: Cash Price	$10,359.35
Rate for Payer: Cigna Commercial	$3,808.59
Rate for Payer: Multiplan Auto	$7,617.17
Rate for Payer: Multiplan Commercial	$7,617.17
Rate for Payer: Multiplan Workers Comp	$7,617.17
Rate for Payer: Scott and White EPO/PPO	$7,617.17

EATING DISORDERS

Facility

$7,232.98

Service Code	APR-DRG 7592
Min. Negotiated Rate	$6,819.50
Max. Negotiated Rate	$7,232.98
Rate for Payer: Amerigroup CHIP/Medicaid	$6,819.50
Rate for Payer: Cigna Medicaid	$6,819.50
Rate for Payer: Molina CHIP/Medicaid	$6,819.50
Rate for Payer: Parkland Medicaid	$6,819.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,232.98

EATING DISORDERS

Facility

$20,894.01

Service Code	APR-DRG 7594
Min. Negotiated Rate	$19,699.60
Max. Negotiated Rate	$20,894.01
Rate for Payer: Amerigroup CHIP/Medicaid	$19,699.60
Rate for Payer: Cigna Medicaid	$19,699.60
Rate for Payer: Molina CHIP/Medicaid	$19,699.60
Rate for Payer: Parkland Medicaid	$19,699.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,894.01

EATING DISORDERS

Facility

$14,308.66

Service Code	APR-DRG 7593
Min. Negotiated Rate	$13,490.71
Max. Negotiated Rate	$14,308.66
Rate for Payer: Amerigroup CHIP/Medicaid	$13,490.71
Rate for Payer: Cigna Medicaid	$13,490.71
Rate for Payer: Molina CHIP/Medicaid	$13,490.71
Rate for Payer: Parkland Medicaid	$13,490.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,308.66

EATING DISORDERS

Facility

$5,810.97

Service Code	APR-DRG 7591
Min. Negotiated Rate	$5,478.79
Max. Negotiated Rate	$5,810.97
Rate for Payer: Amerigroup CHIP/Medicaid	$5,478.79
Rate for Payer: Cigna Medicaid	$5,478.79
Rate for Payer: Molina CHIP/Medicaid	$5,478.79
Rate for Payer: Parkland Medicaid	$5,478.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,810.97

EBV Early Antigen Ab, IgG SO

Facility

$126.00

Service Code	HCPCS 86663
Hospital Charge Code	1702224
Hospital Revenue Code	302
Min. Negotiated Rate	$5.12
Max. Negotiated Rate	$90.72
Rate for Payer: Amerigroup CHIP/Medicaid	$5.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.12
Rate for Payer: Amerigroup Medicare	$13.12
Rate for Payer: BCBS of TX Blue Advantage	$37.80
Rate for Payer: BCBS of TX Blue Essentials	$45.36
Rate for Payer: BCBS of TX Medicare	$13.12
Rate for Payer: BCBS of TX PPO	$50.40
Rate for Payer: Cash Price	$85.68
Rate for Payer: Cash Price	$85.68
Rate for Payer: Cigna Medicaid	$90.72
Rate for Payer: Cigna Medicare	$13.12
Rate for Payer: Employer Direct Commercial	$13.12
Rate for Payer: Humana Medicare/TRICARE	$13.12
Rate for Payer: Molina CHIP/Medicaid	$90.72
Rate for Payer: Molina Dual Medicare/Medicaid	$13.12
Rate for Payer: Molina Medicare	$13.12
Rate for Payer: Multiplan Auto	$81.90
Rate for Payer: Multiplan Commercial	$81.90
Rate for Payer: Multiplan Workers Comp	$81.90
Rate for Payer: Parkland Medicaid	$90.72
Rate for Payer: Scott and White EPO/PPO	$16.40
Rate for Payer: Scott and White Medicare	$13.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.72
Rate for Payer: Superior Health Plan EPO	$13.12
Rate for Payer: Superior Health Plan Medicare	$13.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.12
Rate for Payer: Universal American Medicare	$13.12
Rate for Payer: Wellcare Medicare	$13.12
Rate for Payer: Wellmed Medicare	$13.12

EBV Early Antigen Ab, IgG SO

Facility

$126.00

Service Code	HCPCS 86663
Hospital Charge Code	1702224
Hospital Revenue Code	302
Rate for Payer: Cash Price	$85.68

EBV Nuclear Antigen Ab, IgG SO

Facility

$108.02

Service Code	HCPCS 86664
Hospital Charge Code	1703040
Hospital Revenue Code	302
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$77.77
Rate for Payer: Amerigroup CHIP/Medicaid	$5.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.29
Rate for Payer: Amerigroup Medicare	$15.29
Rate for Payer: BCBS of TX Blue Advantage	$32.41
Rate for Payer: BCBS of TX Blue Essentials	$38.89
Rate for Payer: BCBS of TX Medicare	$15.29
Rate for Payer: BCBS of TX PPO	$43.21
Rate for Payer: Cash Price	$73.45
Rate for Payer: Cash Price	$73.45
Rate for Payer: Cigna Medicaid	$77.77
Rate for Payer: Cigna Medicare	$15.29
Rate for Payer: Employer Direct Commercial	$15.29
Rate for Payer: Humana Medicare/TRICARE	$15.29
Rate for Payer: Molina CHIP/Medicaid	$77.77
Rate for Payer: Molina Dual Medicare/Medicaid	$15.29
Rate for Payer: Molina Medicare	$15.29
Rate for Payer: Multiplan Auto	$70.21
Rate for Payer: Multiplan Commercial	$70.21
Rate for Payer: Multiplan Workers Comp	$70.21
Rate for Payer: Parkland Medicaid	$77.77
Rate for Payer: Scott and White EPO/PPO	$19.11
Rate for Payer: Scott and White Medicare	$15.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77.77
Rate for Payer: Superior Health Plan EPO	$15.29
Rate for Payer: Superior Health Plan Medicare	$15.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.29
Rate for Payer: Universal American Medicare	$15.29
Rate for Payer: Wellcare Medicare	$15.29
Rate for Payer: Wellmed Medicare	$15.29

EBV Nuclear Antigen Ab, IgG SO

Facility

$108.02

Service Code	HCPCS 86664
Hospital Charge Code	1703040
Hospital Revenue Code	302
Rate for Payer: Cash Price	$73.45

ECHELON 60MM REINFORCEMENT ECH60R

Facility

$930.70

Hospital Charge Code	8708547
Hospital Revenue Code	272
Min. Negotiated Rate	$83.76
Max. Negotiated Rate	$670.10
Rate for Payer: Amerigroup CHIP/Medicaid	$83.76
Rate for Payer: BCBS of TX Blue Advantage	$279.21
Rate for Payer: BCBS of TX Blue Essentials	$335.05
Rate for Payer: BCBS of TX PPO	$372.28
Rate for Payer: Cash Price	$632.88
Rate for Payer: Cigna Medicaid	$670.10
Rate for Payer: Molina CHIP/Medicaid	$670.10
Rate for Payer: Multiplan Auto	$604.96
Rate for Payer: Multiplan Commercial	$604.96
Rate for Payer: Multiplan Workers Comp	$604.96
Rate for Payer: Parkland Medicaid	$670.10
Rate for Payer: Scott and White EPO/PPO	$465.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$670.10
Rate for Payer: Superior Health Plan EPO	$126.58

ECHELON 60MM REINFORCEMENT ECH60R

Facility

$930.70

Hospital Charge Code	8708547
Hospital Revenue Code	272
Rate for Payer: Cash Price	$632.88

Echelon Flex Standard Power Stapler, 45 mm

Facility

$1,235.55

Hospital Charge Code	992858
Hospital Revenue Code	272
Min. Negotiated Rate	$111.20
Max. Negotiated Rate	$889.60
Rate for Payer: Amerigroup CHIP/Medicaid	$111.20
Rate for Payer: BCBS of TX Blue Advantage	$370.67
Rate for Payer: BCBS of TX Blue Essentials	$444.80
Rate for Payer: BCBS of TX PPO	$494.22
Rate for Payer: Cash Price	$840.17
Rate for Payer: Cigna Medicaid	$889.60
Rate for Payer: Molina CHIP/Medicaid	$889.60
Rate for Payer: Multiplan Auto	$803.11
Rate for Payer: Multiplan Commercial	$803.11
Rate for Payer: Multiplan Workers Comp	$803.11
Rate for Payer: Parkland Medicaid	$889.60
Rate for Payer: Scott and White EPO/PPO	$617.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$889.60
Rate for Payer: Superior Health Plan EPO	$168.03

Echelon Flex Standard Power Stapler, 45 mm

Facility

$1,235.55

Hospital Charge Code	992858
Hospital Revenue Code	272
Rate for Payer: Cash Price	$840.17

ECHOBRITE 20GX4 NEEDLE

Facility

$692.76

Hospital Charge Code	992615
Hospital Revenue Code	272
Rate for Payer: Cash Price	$471.08

ECHOBRITE 20GX4 NEEDLE

Facility

$692.76

Hospital Charge Code	992615
Hospital Revenue Code	272
Min. Negotiated Rate	$62.35
Max. Negotiated Rate	$498.79
Rate for Payer: Amerigroup CHIP/Medicaid	$62.35
Rate for Payer: BCBS of TX Blue Advantage	$207.83
Rate for Payer: BCBS of TX Blue Essentials	$249.39
Rate for Payer: BCBS of TX PPO	$277.10
Rate for Payer: Cash Price	$471.08
Rate for Payer: Cigna Medicaid	$498.79
Rate for Payer: Molina CHIP/Medicaid	$498.79
Rate for Payer: Multiplan Auto	$450.29
Rate for Payer: Multiplan Commercial	$450.29
Rate for Payer: Multiplan Workers Comp	$450.29
Rate for Payer: Parkland Medicaid	$498.79
Rate for Payer: Scott and White EPO/PPO	$346.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$498.79
Rate for Payer: Superior Health Plan EPO	$94.22

Know your out-of-pocket cost for care.

All Charges