White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$85.68

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 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
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

ECHOBRITE 20GX4 NEEDLE

Facility

$692.76

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

ECHOBRITE 20GX6 NEEDLE

Facility

$692.76

Hospital Charge Code	992616
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

ECHOBRITE 20GX6 NEEDLE

Facility

$692.76

Hospital Charge Code	992616
Hospital Revenue Code	272
Rate for Payer: Cash Price	$471.08

Echocardiogram Transesophageal (TEE) BCE

Facility

$2,932.00

Service Code	HCPCS 93314
Hospital Charge Code	8614517
Hospital Revenue Code	483
Rate for Payer: Cash Price	$1,993.76

Echocardiogram Transesophageal (TEE) BCE

Facility

$2,932.00

Service Code	HCPCS 93314
Hospital Charge Code	8614517
Hospital Revenue Code	483
Min. Negotiated Rate	$263.88
Max. Negotiated Rate	$2,111.04
Rate for Payer: Amerigroup CHIP/Medicaid	$263.88
Rate for Payer: BCBS of TX Blue Advantage	$879.60
Rate for Payer: BCBS of TX Blue Essentials	$1,055.52
Rate for Payer: BCBS of TX PPO	$1,172.80
Rate for Payer: Cash Price	$1,993.76
Rate for Payer: Cash Price	$1,993.76
Rate for Payer: Cigna Medicaid	$2,111.04
Rate for Payer: Molina CHIP/Medicaid	$2,111.04
Rate for Payer: Multiplan Auto	$1,905.80
Rate for Payer: Multiplan Commercial	$1,905.80
Rate for Payer: Multiplan Workers Comp	$1,905.80
Rate for Payer: Parkland Medicaid	$2,111.04
Rate for Payer: Scott and White EPO/PPO	$278.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,111.04
Rate for Payer: Superior Health Plan EPO	$398.75

ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES

Facility

$384,504.90

Service Code	MSDRG 003
Min. Negotiated Rate	$157,357.64
Max. Negotiated Rate	$384,504.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$160,320.12
Rate for Payer: Amerigroup Medicare	$160,320.12
Rate for Payer: BCBS of TX Medicare	$160,320.12
Rate for Payer: Cigna Commercial	$273,380.58
Rate for Payer: Cigna Medicare	$160,320.12
Rate for Payer: Employer Direct Commercial	$160,320.12
Rate for Payer: Humana Medicare/TRICARE	$160,320.12
Rate for Payer: Molina Dual Medicare/Medicaid	$160,320.12
Rate for Payer: Molina Medicare	$160,320.12
Rate for Payer: Multiplan Auto	$384,504.90
Rate for Payer: Multiplan Commercial	$384,504.90
Rate for Payer: Multiplan Workers Comp	$384,504.90
Rate for Payer: Scott and White EPO/PPO	$177,074.62
Rate for Payer: Scott and White Medicare	$160,320.12
Rate for Payer: Superior Health Plan EPO	$160,320.12
Rate for Payer: Superior Health Plan Medicare	$160,320.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$160,320.12
Rate for Payer: Universal American Medicare	$160,320.12
Rate for Payer: Wellcare Medicare	$160,320.12
Rate for Payer: Wellmed Medicare	$160,320.12

ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.

Facility

$384,504.90

Service Code	MSDRG 003
Min. Negotiated Rate	$157,357.64
Max. Negotiated Rate	$384,504.90
Rate for Payer: BCBS of TX Blue Advantage	$157,357.64
Rate for Payer: BCBS of TX Blue Essentials	$188,810.87
Rate for Payer: BCBS of TX PPO	$209,797.99

Economy insufflation tubing with 0.1 micron filter

Facility

$16.50

Hospital Charge Code	992789
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.22

Economy insufflation tubing with 0.1 micron filter

Facility

$16.50

Hospital Charge Code	992789
Hospital Revenue Code	272
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$11.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1.49
Rate for Payer: BCBS of TX Blue Advantage	$4.95
Rate for Payer: BCBS of TX Blue Essentials	$5.94
Rate for Payer: BCBS of TX PPO	$6.60
Rate for Payer: Cash Price	$11.22
Rate for Payer: Cigna Medicaid	$11.88
Rate for Payer: Molina CHIP/Medicaid	$11.88
Rate for Payer: Multiplan Auto	$10.72
Rate for Payer: Multiplan Commercial	$10.72
Rate for Payer: Multiplan Workers Comp	$10.72
Rate for Payer: Parkland Medicaid	$11.88
Rate for Payer: Scott and White EPO/PPO	$8.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.88
Rate for Payer: Superior Health Plan EPO	$2.24

ED Airway/Intubation Procedure -> Chest Tube Insertion

Facility

$819.00

Service Code	HCPCS 32551
Hospital Charge Code	3851086
Hospital Revenue Code	450
Rate for Payer: Cash Price	$556.92

ED Airway/Intubation Procedure -> Chest Tube Insertion

Facility

$819.00

Service Code	HCPCS 32551
Hospital Charge Code	3851086
Hospital Revenue Code	450
Min. Negotiated Rate	$73.71
Max. Negotiated Rate	$4,110.45
Rate for Payer: Amerigroup CHIP/Medicaid	$73.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Amerigroup Medicare	$1,581.33
Rate for Payer: BCBS of TX Blue Advantage	$2,723.99
Rate for Payer: BCBS of TX Blue Essentials	$3,262.26
Rate for Payer: BCBS of TX Medicare	$1,581.33
Rate for Payer: BCBS of TX PPO	$4,110.45
Rate for Payer: Cash Price	$556.92
Rate for Payer: Cash Price	$556.92
Rate for Payer: Cash Price	$556.92
Rate for Payer: Cigna Commercial	$3,342.63
Rate for Payer: Cigna Medicaid	$589.68
Rate for Payer: Cigna Medicare	$1,581.33
Rate for Payer: Employer Direct Commercial	$1,581.33
Rate for Payer: Humana Medicare/TRICARE	$1,581.33
Rate for Payer: Molina CHIP/Medicaid	$589.68
Rate for Payer: Molina Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Molina Medicare	$1,581.33
Rate for Payer: Multiplan Auto	$532.35
Rate for Payer: Multiplan Commercial	$532.35
Rate for Payer: Multiplan Workers Comp	$532.35
Rate for Payer: Parkland Medicaid	$589.68
Rate for Payer: Scott and White EPO/PPO	$186.86
Rate for Payer: Scott and White Medicare	$1,581.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$589.68
Rate for Payer: Superior Health Plan EPO	$1,581.33
Rate for Payer: Superior Health Plan Medicare	$1,581.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Universal American Medicare	$1,581.33
Rate for Payer: Wellcare Medicare	$1,581.33
Rate for Payer: Wellmed Medicare	$1,581.33

ED Airway/Intubation Procedure -> Cricothyrotomy

Facility

$1,090.00

Service Code	HCPCS 31605
Hospital Charge Code	8914571
Hospital Revenue Code	450
Min. Negotiated Rate	$98.10
Max. Negotiated Rate	$784.80
Rate for Payer: Amerigroup CHIP/Medicaid	$98.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$237.93
Rate for Payer: Amerigroup Medicare	$237.93
Rate for Payer: BCBS of TX Blue Advantage	$340.08
Rate for Payer: BCBS of TX Blue Essentials	$407.28
Rate for Payer: BCBS of TX Medicare	$237.93
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cash Price	$741.20
Rate for Payer: Cash Price	$741.20
Rate for Payer: Cash Price	$741.20
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$784.80
Rate for Payer: Cigna Medicare	$237.93
Rate for Payer: Employer Direct Commercial	$237.93
Rate for Payer: Humana Medicare/TRICARE	$237.93
Rate for Payer: Molina CHIP/Medicaid	$784.80
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
Rate for Payer: Multiplan Auto	$708.50
Rate for Payer: Multiplan Commercial	$708.50
Rate for Payer: Multiplan Workers Comp	$708.50
Rate for Payer: Parkland Medicaid	$784.80
Rate for Payer: Scott and White EPO/PPO	$397.86
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$784.80
Rate for Payer: Superior Health Plan EPO	$237.93
Rate for Payer: Superior Health Plan Medicare	$237.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$237.93
Rate for Payer: Universal American Medicare	$237.93
Rate for Payer: Wellcare Medicare	$237.93
Rate for Payer: Wellmed Medicare	$237.93

ED Airway/Intubation Procedure -> Cricothyrotomy

Facility

$1,090.00

Service Code	HCPCS 31605
Hospital Charge Code	8914571
Hospital Revenue Code	450
Rate for Payer: Cash Price	$741.20

ED Airway/Intubation Procedure -> Endotracheal intubation

Facility

$1,049.00

Service Code	HCPCS 31500
Hospital Charge Code	300533
Hospital Revenue Code	450
Min. Negotiated Rate	$94.41
Max. Negotiated Rate	$755.28
Rate for Payer: Amerigroup CHIP/Medicaid	$94.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$237.93
Rate for Payer: Amerigroup Medicare	$237.93
Rate for Payer: BCBS of TX Blue Advantage	$340.08
Rate for Payer: BCBS of TX Blue Essentials	$407.28
Rate for Payer: BCBS of TX Medicare	$237.93
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cash Price	$713.32
Rate for Payer: Cash Price	$713.32
Rate for Payer: Cash Price	$713.32
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$755.28
Rate for Payer: Cigna Medicare	$237.93
Rate for Payer: Employer Direct Commercial	$237.93
Rate for Payer: Humana Medicare/TRICARE	$237.93
Rate for Payer: Molina CHIP/Medicaid	$755.28
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
Rate for Payer: Multiplan Auto	$681.85
Rate for Payer: Multiplan Commercial	$681.85
Rate for Payer: Multiplan Workers Comp	$681.85
Rate for Payer: Parkland Medicaid	$755.28
Rate for Payer: Scott and White EPO/PPO	$170.07
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$755.28
Rate for Payer: Superior Health Plan EPO	$237.93
Rate for Payer: Superior Health Plan Medicare	$237.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$237.93
Rate for Payer: Universal American Medicare	$237.93
Rate for Payer: Wellcare Medicare	$237.93
Rate for Payer: Wellmed Medicare	$237.93

ED Airway/Intubation Procedure -> Endotracheal intubation

Facility

$1,049.00

Service Code	HCPCS 31500
Hospital Charge Code	300533
Hospital Revenue Code	450
Rate for Payer: Cash Price	$713.32

Know your out-of-pocket cost for care.

All Charges