White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED Sedation - Different Physician -> Each Addl 15 mins

Facility

$342.00

Service Code	HCPCS 99157
Hospital Charge Code	2161303
Hospital Revenue Code	450
Rate for Payer: Cash Price	$232.56

ED Sedation - Different Physician -> Each Addl 15 mins

Facility

$342.00

Service Code	HCPCS 99157
Hospital Charge Code	2161303
Hospital Revenue Code	450
Min. Negotiated Rate	$30.78
Max. Negotiated Rate	$246.24
Rate for Payer: Amerigroup CHIP/Medicaid	$30.78
Rate for Payer: BCBS of TX Blue Advantage	$102.60
Rate for Payer: BCBS of TX Blue Essentials	$123.12
Rate for Payer: BCBS of TX PPO	$136.80
Rate for Payer: Cash Price	$232.56
Rate for Payer: Cigna Medicaid	$246.24
Rate for Payer: Molina CHIP/Medicaid	$246.24
Rate for Payer: Multiplan Auto	$222.30
Rate for Payer: Multiplan Commercial	$222.30
Rate for Payer: Multiplan Workers Comp	$222.30
Rate for Payer: Parkland Medicaid	$246.24
Rate for Payer: Scott and White EPO/PPO	$171.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$246.24
Rate for Payer: Superior Health Plan EPO	$46.51

ED Sedation - Different Physician -> First 15 mins >= 5 years

Facility

$479.00

Service Code	HCPCS 99156
Hospital Charge Code	2161302
Hospital Revenue Code	450
Min. Negotiated Rate	$43.11
Max. Negotiated Rate	$344.88
Rate for Payer: Amerigroup CHIP/Medicaid	$43.11
Rate for Payer: BCBS of TX Blue Advantage	$143.70
Rate for Payer: BCBS of TX Blue Essentials	$172.44
Rate for Payer: BCBS of TX PPO	$191.60
Rate for Payer: Cash Price	$325.72
Rate for Payer: Cigna Medicaid	$344.88
Rate for Payer: Molina CHIP/Medicaid	$344.88
Rate for Payer: Multiplan Auto	$311.35
Rate for Payer: Multiplan Commercial	$311.35
Rate for Payer: Multiplan Workers Comp	$311.35
Rate for Payer: Parkland Medicaid	$344.88
Rate for Payer: Scott and White EPO/PPO	$239.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$344.88
Rate for Payer: Superior Health Plan EPO	$65.14

ED Sedation - Different Physician -> First 15 mins >= 5 years

Facility

$479.00

Service Code	HCPCS 99156
Hospital Charge Code	2161302
Hospital Revenue Code	450
Rate for Payer: Cash Price	$325.72

ED Sedation - Same Physician -> Each Addl 15 mins

Facility

$154.00

Service Code	HCPCS 99153
Hospital Charge Code	6100408
Hospital Revenue Code	450
Rate for Payer: Cash Price	$104.72

ED Sedation - Same Physician -> Each Addl 15 mins

Facility

$154.00

Service Code	HCPCS 99153
Hospital Charge Code	6100408
Hospital Revenue Code	450
Min. Negotiated Rate	$13.86
Max. Negotiated Rate	$110.88
Rate for Payer: Amerigroup CHIP/Medicaid	$13.86
Rate for Payer: BCBS of TX Blue Advantage	$46.20
Rate for Payer: BCBS of TX Blue Essentials	$55.44
Rate for Payer: BCBS of TX PPO	$61.60
Rate for Payer: Cash Price	$104.72
Rate for Payer: Cigna Medicaid	$110.88
Rate for Payer: Molina CHIP/Medicaid	$110.88
Rate for Payer: Multiplan Auto	$100.10
Rate for Payer: Multiplan Commercial	$100.10
Rate for Payer: Multiplan Workers Comp	$100.10
Rate for Payer: Parkland Medicaid	$110.88
Rate for Payer: Scott and White EPO/PPO	$77.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.88
Rate for Payer: Superior Health Plan EPO	$20.94

ED Sedation - Same Physician -> First 15 mins < 5 years

Facility

$427.00

Service Code	HCPCS 99151
Hospital Charge Code	5210309
Hospital Revenue Code	450
Min. Negotiated Rate	$38.43
Max. Negotiated Rate	$307.44
Rate for Payer: Amerigroup CHIP/Medicaid	$38.43
Rate for Payer: BCBS of TX Blue Advantage	$128.10
Rate for Payer: BCBS of TX Blue Essentials	$153.72
Rate for Payer: BCBS of TX PPO	$170.80
Rate for Payer: Cash Price	$290.36
Rate for Payer: Cigna Medicaid	$307.44
Rate for Payer: Molina CHIP/Medicaid	$307.44
Rate for Payer: Multiplan Auto	$277.55
Rate for Payer: Multiplan Commercial	$277.55
Rate for Payer: Multiplan Workers Comp	$277.55
Rate for Payer: Parkland Medicaid	$307.44
Rate for Payer: Scott and White EPO/PPO	$213.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$307.44
Rate for Payer: Superior Health Plan EPO	$58.07

ED Sedation - Same Physician -> First 15 mins < 5 years

Facility

$427.00

Service Code	HCPCS 99151
Hospital Charge Code	5210309
Hospital Revenue Code	450
Rate for Payer: Cash Price	$290.36

ED Sedation - Same Physician -> First 15 mins >= 5 years

Facility

$247.00

Service Code	HCPCS 99152
Hospital Charge Code	6100390
Hospital Revenue Code	450
Min. Negotiated Rate	$22.23
Max. Negotiated Rate	$177.84
Rate for Payer: Amerigroup CHIP/Medicaid	$22.23
Rate for Payer: BCBS of TX Blue Advantage	$74.10
Rate for Payer: BCBS of TX Blue Essentials	$88.92
Rate for Payer: BCBS of TX PPO	$98.80
Rate for Payer: Cash Price	$167.96
Rate for Payer: Cigna Medicaid	$177.84
Rate for Payer: Molina CHIP/Medicaid	$177.84
Rate for Payer: Multiplan Auto	$160.55
Rate for Payer: Multiplan Commercial	$160.55
Rate for Payer: Multiplan Workers Comp	$160.55
Rate for Payer: Parkland Medicaid	$177.84
Rate for Payer: Scott and White EPO/PPO	$123.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$177.84
Rate for Payer: Superior Health Plan EPO	$33.59

ED Sedation - Same Physician -> First 15 mins >= 5 years

Facility

$247.00

Service Code	HCPCS 99152
Hospital Charge Code	6100390
Hospital Revenue Code	450
Rate for Payer: Cash Price	$167.96

ED SMPL RPR WND FACE/EAR/EYELID/NOSE/LIP 7.6 TO 12.5 CM BCE

Facility

$987.00

Service Code	HCPCS 12015
Hospital Charge Code	8422451
Hospital Revenue Code	450
Rate for Payer: Cash Price	$671.16

ED SMPL RPR WND FACE/EAR/EYELID/NOSE/LIP 7.6 TO 12.5 CM BCE

Facility

$987.00

Service Code	HCPCS 12015
Hospital Charge Code	8422451
Hospital Revenue Code	450
Min. Negotiated Rate	$88.83
Max. Negotiated Rate	$710.64
Rate for Payer: Amerigroup CHIP/Medicaid	$88.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$671.16
Rate for Payer: Cash Price	$671.16
Rate for Payer: Cash Price	$671.16
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$710.64
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$710.64
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$641.55
Rate for Payer: Multiplan Commercial	$641.55
Rate for Payer: Multiplan Workers Comp	$641.55
Rate for Payer: Parkland Medicaid	$710.64
Rate for Payer: Scott and White EPO/PPO	$493.50
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$710.64
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

ED SMPL RPR WND S/N/A/GEN/TRNK 20.1 TO 30.0 CM BCE

Facility

$1,251.00

Service Code	HCPCS 12006
Hospital Charge Code	8912657
Hospital Revenue Code	450
Min. Negotiated Rate	$112.59
Max. Negotiated Rate	$900.72
Rate for Payer: Amerigroup CHIP/Medicaid	$112.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$850.68
Rate for Payer: Cash Price	$850.68
Rate for Payer: Cash Price	$850.68
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$900.72
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$900.72
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$813.15
Rate for Payer: Multiplan Commercial	$813.15
Rate for Payer: Multiplan Workers Comp	$813.15
Rate for Payer: Parkland Medicaid	$900.72
Rate for Payer: Scott and White EPO/PPO	$625.50
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$900.72
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

ED SMPL RPR WND S/N/A/GEN/TRNK 20.1 TO 30.0 CM BCE

Facility

$1,251.00

Service Code	HCPCS 12006
Hospital Charge Code	8912657
Hospital Revenue Code	450
Rate for Payer: Cash Price	$850.68

ED Throat Procedures -> Dental surgery

Facility

$16,334.00

Service Code	HCPCS 41899
Hospital Charge Code	5202582
Hospital Revenue Code	450
Rate for Payer: Cash Price	$11,107.12

ED Throat Procedures -> Dental surgery

Facility

$16,334.00

Service Code	HCPCS 41899
Hospital Charge Code	5202582
Hospital Revenue Code	450
Min. Negotiated Rate	$237.93
Max. Negotiated Rate	$11,760.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,470.06
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	$11,107.12
Rate for Payer: Cash Price	$11,107.12
Rate for Payer: Cash Price	$11,107.12
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$11,760.48
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	$11,760.48
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
Rate for Payer: Multiplan Auto	$10,617.10
Rate for Payer: Multiplan Commercial	$10,617.10
Rate for Payer: Multiplan Workers Comp	$10,617.10
Rate for Payer: Parkland Medicaid	$11,760.48
Rate for Payer: Scott and White EPO/PPO	$8,167.00
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,760.48
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 TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT BCE

Facility

$1,091.00

Service Code	HCPCS 31502
Hospital Charge Code	9014974
Hospital Revenue Code	450
Min. Negotiated Rate	$98.19
Max. Negotiated Rate	$785.52
Rate for Payer: Amerigroup CHIP/Medicaid	$98.19
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	$741.88
Rate for Payer: Cash Price	$741.88
Rate for Payer: Cash Price	$741.88
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$785.52
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	$785.52
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
Rate for Payer: Multiplan Auto	$709.15
Rate for Payer: Multiplan Commercial	$709.15
Rate for Payer: Multiplan Workers Comp	$709.15
Rate for Payer: Parkland Medicaid	$785.52
Rate for Payer: Scott and White EPO/PPO	$545.50
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$785.52
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 TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT BCE

Facility

$1,091.00

Service Code	HCPCS 31502
Hospital Charge Code	9014974
Hospital Revenue Code	450
Rate for Payer: Cash Price	$741.88

ED Trauma Level -> Trauma Response - Level II Trauma

Facility

$5,316.00

Service Code	HCPCS G0390
Hospital Charge Code	4204072
Hospital Revenue Code	682
Rate for Payer: Cash Price	$3,614.88

ED Trauma Level -> Trauma Response - Level II Trauma

Facility

$5,316.00

Service Code	HCPCS G0390
Hospital Charge Code	4204072
Hospital Revenue Code	682
Min. Negotiated Rate	$478.44
Max. Negotiated Rate	$3,827.52
Rate for Payer: Amerigroup CHIP/Medicaid	$478.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,338.98
Rate for Payer: Amerigroup Medicare	$1,338.98
Rate for Payer: BCBS of TX Blue Advantage	$1,594.80
Rate for Payer: BCBS of TX Blue Essentials	$1,913.76
Rate for Payer: BCBS of TX Medicare	$1,338.98
Rate for Payer: BCBS of TX PPO	$2,126.40
Rate for Payer: Cash Price	$3,614.88
Rate for Payer: Cash Price	$3,614.88
Rate for Payer: Cash Price	$3,614.88
Rate for Payer: Cigna Commercial	$2,830.37
Rate for Payer: Cigna Medicaid	$3,827.52
Rate for Payer: Cigna Medicare	$1,338.98
Rate for Payer: Employer Direct Commercial	$1,338.98
Rate for Payer: Humana Medicare/TRICARE	$1,338.98
Rate for Payer: Molina CHIP/Medicaid	$3,827.52
Rate for Payer: Molina Dual Medicare/Medicaid	$1,338.98
Rate for Payer: Molina Medicare	$1,338.98
Rate for Payer: Multiplan Auto	$3,455.40
Rate for Payer: Multiplan Commercial	$3,455.40
Rate for Payer: Multiplan Workers Comp	$3,455.40
Rate for Payer: Parkland Medicaid	$3,827.52
Rate for Payer: Scott and White EPO/PPO	$2,658.00
Rate for Payer: Scott and White Medicare	$1,338.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,827.52
Rate for Payer: Superior Health Plan EPO	$1,338.98
Rate for Payer: Superior Health Plan Medicare	$1,338.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,338.98
Rate for Payer: Universal American Medicare	$1,338.98
Rate for Payer: Wellcare Medicare	$1,338.98
Rate for Payer: Wellmed Medicare	$1,338.98

ED Trauma Level -> Trauma Response - Level I Trauma

Facility

$7,088.00

Service Code	HCPCS G0390
Hospital Charge Code	4204071
Hospital Revenue Code	681
Rate for Payer: Cash Price	$4,819.84

ED Trauma Level -> Trauma Response - Level I Trauma

Facility

$7,088.00

Service Code	HCPCS G0390
Hospital Charge Code	4204071
Hospital Revenue Code	681
Min. Negotiated Rate	$637.92
Max. Negotiated Rate	$5,103.36
Rate for Payer: Amerigroup CHIP/Medicaid	$637.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,338.98
Rate for Payer: Amerigroup Medicare	$1,338.98
Rate for Payer: BCBS of TX Blue Advantage	$2,126.40
Rate for Payer: BCBS of TX Blue Essentials	$2,551.68
Rate for Payer: BCBS of TX Medicare	$1,338.98
Rate for Payer: BCBS of TX PPO	$2,835.20
Rate for Payer: Cash Price	$4,819.84
Rate for Payer: Cash Price	$4,819.84
Rate for Payer: Cash Price	$4,819.84
Rate for Payer: Cigna Commercial	$2,830.37
Rate for Payer: Cigna Medicaid	$5,103.36
Rate for Payer: Cigna Medicare	$1,338.98
Rate for Payer: Employer Direct Commercial	$1,338.98
Rate for Payer: Humana Medicare/TRICARE	$1,338.98
Rate for Payer: Molina CHIP/Medicaid	$5,103.36
Rate for Payer: Molina Dual Medicare/Medicaid	$1,338.98
Rate for Payer: Molina Medicare	$1,338.98
Rate for Payer: Multiplan Auto	$4,607.20
Rate for Payer: Multiplan Commercial	$4,607.20
Rate for Payer: Multiplan Workers Comp	$4,607.20
Rate for Payer: Parkland Medicaid	$5,103.36
Rate for Payer: Scott and White EPO/PPO	$3,544.00
Rate for Payer: Scott and White Medicare	$1,338.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,103.36
Rate for Payer: Superior Health Plan EPO	$1,338.98
Rate for Payer: Superior Health Plan Medicare	$1,338.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,338.98
Rate for Payer: Universal American Medicare	$1,338.98
Rate for Payer: Wellcare Medicare	$1,338.98
Rate for Payer: Wellmed Medicare	$1,338.98

ED TX FX METACARPAL W/O MAN CLSD BCE

Facility

$745.00

Service Code	HCPCS 26600
Hospital Charge Code	8694547
Hospital Revenue Code	450
Rate for Payer: Cash Price	$506.60

ED TX FX METACARPAL W/O MAN CLSD BCE

Facility

$745.00

Service Code	HCPCS 26600
Hospital Charge Code	8694547
Hospital Revenue Code	450
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$536.40
Rate for Payer: Amerigroup CHIP/Medicaid	$67.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$181.96
Rate for Payer: BCBS of TX Blue Essentials	$217.92
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$274.58
Rate for Payer: Cash Price	$506.60
Rate for Payer: Cash Price	$506.60
Rate for Payer: Cash Price	$506.60
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$536.40
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$536.40
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$484.25
Rate for Payer: Multiplan Commercial	$484.25
Rate for Payer: Multiplan Workers Comp	$484.25
Rate for Payer: Parkland Medicaid	$536.40
Rate for Payer: Scott and White EPO/PPO	$372.50
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$536.40
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

ED TX FX TIBIAL SHAFT W/O MAN CLSD BCE

Facility

$834.00

Service Code	HCPCS 27750
Hospital Charge Code	8764560
Hospital Revenue Code	450
Rate for Payer: Cash Price	$567.12

Know your out-of-pocket cost for care.

All Charges