White Rock Medical Center

All Charges

Charge

Type

Setting

Price

EKG Charges - EKG -> TEE w/ Probe w/o Contrast 93312

Facility

$3,210.00

Service Code	HCPCS 93312
Hospital Charge Code	2800498
Hospital Revenue Code	480
Rate for Payer: Cash Price	$2,182.80

ELCTRD BALL -- DHF

Facility

$2,150.54

Hospital Charge Code	81812000
Hospital Revenue Code	272
Min. Negotiated Rate	$193.55
Max. Negotiated Rate	$1,548.39
Rate for Payer: Amerigroup CHIP/Medicaid	$193.55
Rate for Payer: BCBS of TX Blue Advantage	$645.16
Rate for Payer: BCBS of TX Blue Essentials	$774.19
Rate for Payer: BCBS of TX PPO	$860.22
Rate for Payer: Cash Price	$1,462.37
Rate for Payer: Cigna Medicaid	$1,548.39
Rate for Payer: Molina CHIP/Medicaid	$1,548.39
Rate for Payer: Multiplan Auto	$1,397.85
Rate for Payer: Multiplan Commercial	$1,397.85
Rate for Payer: Multiplan Workers Comp	$1,397.85
Rate for Payer: Parkland Medicaid	$1,548.39
Rate for Payer: Scott and White EPO/PPO	$1,075.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,548.39
Rate for Payer: Superior Health Plan EPO	$292.47

ELCTRD BALL -- DHF

Facility

$2,150.54

Hospital Charge Code	81812000
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,462.37

ELCTRD EXPACE -- DHF

Facility

$2,192.88

Hospital Charge Code	82030453
Hospital Revenue Code	270
Min. Negotiated Rate	$197.36
Max. Negotiated Rate	$1,578.87
Rate for Payer: Amerigroup CHIP/Medicaid	$197.36
Rate for Payer: BCBS of TX Blue Advantage	$657.86
Rate for Payer: BCBS of TX Blue Essentials	$789.44
Rate for Payer: BCBS of TX PPO	$877.15
Rate for Payer: Cash Price	$1,491.16
Rate for Payer: Cigna Medicaid	$1,578.87
Rate for Payer: Molina CHIP/Medicaid	$1,578.87
Rate for Payer: Multiplan Auto	$1,425.37
Rate for Payer: Multiplan Commercial	$1,425.37
Rate for Payer: Multiplan Workers Comp	$1,425.37
Rate for Payer: Parkland Medicaid	$1,578.87
Rate for Payer: Scott and White EPO/PPO	$1,096.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,578.87
Rate for Payer: Superior Health Plan EPO	$298.23

ELCTRD EXPACE -- DHF

Facility

$2,192.88

Hospital Charge Code	82030453
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,491.16

ELCTRD FETAL -- DHF

Facility

$293.75

Hospital Charge Code	82030503
Hospital Revenue Code	270
Rate for Payer: Cash Price	$199.75

ELCTRD FETAL -- DHF

Facility

$293.75

Hospital Charge Code	82030503
Hospital Revenue Code	270
Min. Negotiated Rate	$26.44
Max. Negotiated Rate	$211.50
Rate for Payer: Amerigroup CHIP/Medicaid	$26.44
Rate for Payer: BCBS of TX Blue Advantage	$88.12
Rate for Payer: BCBS of TX Blue Essentials	$105.75
Rate for Payer: BCBS of TX PPO	$117.50
Rate for Payer: Cash Price	$199.75
Rate for Payer: Cigna Medicaid	$211.50
Rate for Payer: Molina CHIP/Medicaid	$211.50
Rate for Payer: Multiplan Auto	$190.94
Rate for Payer: Multiplan Commercial	$190.94
Rate for Payer: Multiplan Workers Comp	$190.94
Rate for Payer: Parkland Medicaid	$211.50
Rate for Payer: Scott and White EPO/PPO	$146.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$211.50
Rate for Payer: Superior Health Plan EPO	$39.95

ELCTRD LOOP -- DHF

Facility

$80.69

Hospital Charge Code	81823155
Hospital Revenue Code	270
Rate for Payer: Cash Price	$54.87

ELCTRD LOOP -- DHF

Facility

$80.69

Hospital Charge Code	81823155
Hospital Revenue Code	270
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$58.10
Rate for Payer: Amerigroup CHIP/Medicaid	$7.26
Rate for Payer: BCBS of TX Blue Advantage	$24.21
Rate for Payer: BCBS of TX Blue Essentials	$29.05
Rate for Payer: BCBS of TX PPO	$32.28
Rate for Payer: Cash Price	$54.87
Rate for Payer: Cigna Medicaid	$58.10
Rate for Payer: Molina CHIP/Medicaid	$58.10
Rate for Payer: Multiplan Auto	$52.45
Rate for Payer: Multiplan Commercial	$52.45
Rate for Payer: Multiplan Workers Comp	$52.45
Rate for Payer: Parkland Medicaid	$58.10
Rate for Payer: Scott and White EPO/PPO	$40.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$58.10
Rate for Payer: Superior Health Plan EPO	$10.97

ELCTRD MULTIFUNCTION -- DHF

Facility

$93.29

Hospital Charge Code	82030578
Hospital Revenue Code	271
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$67.17
Rate for Payer: Amerigroup CHIP/Medicaid	$8.40
Rate for Payer: BCBS of TX Blue Advantage	$27.99
Rate for Payer: BCBS of TX Blue Essentials	$33.58
Rate for Payer: BCBS of TX PPO	$37.32
Rate for Payer: Cash Price	$63.44
Rate for Payer: Cigna Medicaid	$67.17
Rate for Payer: Molina CHIP/Medicaid	$67.17
Rate for Payer: Multiplan Auto	$60.64
Rate for Payer: Multiplan Commercial	$60.64
Rate for Payer: Multiplan Workers Comp	$60.64
Rate for Payer: Parkland Medicaid	$67.17
Rate for Payer: Scott and White EPO/PPO	$46.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.17
Rate for Payer: Superior Health Plan EPO	$12.69

ELCTRD MULTIFUNCTION -- DHF

Facility

$93.29

Hospital Charge Code	82030578
Hospital Revenue Code	271
Rate for Payer: Cash Price	$63.44

ELCTRD PACING -- DHF

Facility

$340.05

Hospital Charge Code	82030552
Hospital Revenue Code	271
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$244.84
Rate for Payer: Amerigroup CHIP/Medicaid	$30.60
Rate for Payer: BCBS of TX Blue Advantage	$102.02
Rate for Payer: BCBS of TX Blue Essentials	$122.42
Rate for Payer: BCBS of TX PPO	$136.02
Rate for Payer: Cash Price	$231.23
Rate for Payer: Cigna Medicaid	$244.84
Rate for Payer: Molina CHIP/Medicaid	$244.84
Rate for Payer: Multiplan Auto	$221.03
Rate for Payer: Multiplan Commercial	$221.03
Rate for Payer: Multiplan Workers Comp	$221.03
Rate for Payer: Parkland Medicaid	$244.84
Rate for Payer: Scott and White EPO/PPO	$170.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$244.84
Rate for Payer: Superior Health Plan EPO	$46.25

ELCTRD PACING -- DHF

Facility

$340.05

Hospital Charge Code	82030552
Hospital Revenue Code	271
Rate for Payer: Cash Price	$231.23

ELECTIVE HIP JOINT REPLACEMENT

Facility

$13,244.99

Service Code	APR-DRG 3243
Min. Negotiated Rate	$12,487.84
Max. Negotiated Rate	$13,244.99
Rate for Payer: Amerigroup CHIP/Medicaid	$12,487.84
Rate for Payer: Cigna Medicaid	$12,487.84
Rate for Payer: Molina CHIP/Medicaid	$12,487.84
Rate for Payer: Parkland Medicaid	$12,487.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,244.99

ELECTIVE HIP JOINT REPLACEMENT

Facility

$7,652.79

Service Code	APR-DRG 3242
Min. Negotiated Rate	$7,215.32
Max. Negotiated Rate	$7,652.79
Rate for Payer: Amerigroup CHIP/Medicaid	$7,215.32
Rate for Payer: Cigna Medicaid	$7,215.32
Rate for Payer: Molina CHIP/Medicaid	$7,215.32
Rate for Payer: Parkland Medicaid	$7,215.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,652.79

ELECTIVE HIP JOINT REPLACEMENT

Facility

$18,983.92

Service Code	APR-DRG 3244
Min. Negotiated Rate	$17,898.71
Max. Negotiated Rate	$18,983.92
Rate for Payer: Amerigroup CHIP/Medicaid	$17,898.71
Rate for Payer: Cigna Medicaid	$17,898.71
Rate for Payer: Molina CHIP/Medicaid	$17,898.71
Rate for Payer: Parkland Medicaid	$17,898.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,983.92

ELECTIVE HIP JOINT REPLACEMENT

Facility

$7,280.50

Service Code	APR-DRG 3241
Min. Negotiated Rate	$6,864.31
Max. Negotiated Rate	$7,280.50
Rate for Payer: Amerigroup CHIP/Medicaid	$6,864.31
Rate for Payer: Cigna Medicaid	$6,864.31
Rate for Payer: Molina CHIP/Medicaid	$6,864.31
Rate for Payer: Parkland Medicaid	$6,864.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,280.50

ELECTIVE KNEE JOINT REPLACEMENT

Facility

$9,805.78

Service Code	APR-DRG 3263
Min. Negotiated Rate	$9,245.24
Max. Negotiated Rate	$9,805.78
Rate for Payer: Amerigroup CHIP/Medicaid	$9,245.24
Rate for Payer: Cigna Medicaid	$9,245.24
Rate for Payer: Molina CHIP/Medicaid	$9,245.24
Rate for Payer: Parkland Medicaid	$9,245.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,805.78

ELECTIVE KNEE JOINT REPLACEMENT

Facility

$7,079.84

Service Code	APR-DRG 3262
Min. Negotiated Rate	$6,675.12
Max. Negotiated Rate	$7,079.84
Rate for Payer: Amerigroup CHIP/Medicaid	$6,675.12
Rate for Payer: Cigna Medicaid	$6,675.12
Rate for Payer: Molina CHIP/Medicaid	$6,675.12
Rate for Payer: Parkland Medicaid	$6,675.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,079.84

ELECTIVE KNEE JOINT REPLACEMENT

Facility

$16,436.01

Service Code	APR-DRG 3264
Min. Negotiated Rate	$15,496.45
Max. Negotiated Rate	$16,436.01
Rate for Payer: Amerigroup CHIP/Medicaid	$15,496.45
Rate for Payer: Cigna Medicaid	$15,496.45
Rate for Payer: Molina CHIP/Medicaid	$15,496.45
Rate for Payer: Parkland Medicaid	$15,496.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,436.01

ELECTIVE KNEE JOINT REPLACEMENT

Facility

$6,682.66

Service Code	APR-DRG 3261
Min. Negotiated Rate	$6,300.64
Max. Negotiated Rate	$6,682.66
Rate for Payer: Amerigroup CHIP/Medicaid	$6,300.64
Rate for Payer: Cigna Medicaid	$6,300.64
Rate for Payer: Molina CHIP/Medicaid	$6,300.64
Rate for Payer: Parkland Medicaid	$6,300.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,682.66

ELECTRODE, ABLATION HIP SUCTION COOLPULSE 90 -- DHF

Facility

$908.00

Hospital Charge Code	80826449
Hospital Revenue Code	272
Rate for Payer: Cash Price	$617.44

ELECTRODE, ABLATION HIP SUCTION COOLPULSE 90 -- DHF

Facility

$908.00

Hospital Charge Code	80826449
Hospital Revenue Code	272
Min. Negotiated Rate	$81.72
Max. Negotiated Rate	$653.76
Rate for Payer: Amerigroup CHIP/Medicaid	$81.72
Rate for Payer: BCBS of TX Blue Advantage	$272.40
Rate for Payer: BCBS of TX Blue Essentials	$326.88
Rate for Payer: BCBS of TX PPO	$363.20
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cigna Medicaid	$653.76
Rate for Payer: Molina CHIP/Medicaid	$653.76
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$653.76
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$653.76
Rate for Payer: Superior Health Plan EPO	$123.49

ELECTRODE, BLADE EXTENDED 6.50' STERILE DISPOSABLE -- DHF

Facility

$27.56

Hospital Charge Code	81723272
Hospital Revenue Code	272
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$19.84
Rate for Payer: Amerigroup CHIP/Medicaid	$2.48
Rate for Payer: BCBS of TX Blue Advantage	$8.27
Rate for Payer: BCBS of TX Blue Essentials	$9.92
Rate for Payer: BCBS of TX PPO	$11.02
Rate for Payer: Cash Price	$18.74
Rate for Payer: Cigna Medicaid	$19.84
Rate for Payer: Molina CHIP/Medicaid	$19.84
Rate for Payer: Multiplan Auto	$17.91
Rate for Payer: Multiplan Commercial	$17.91
Rate for Payer: Multiplan Workers Comp	$17.91
Rate for Payer: Parkland Medicaid	$19.84
Rate for Payer: Scott and White EPO/PPO	$13.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.84
Rate for Payer: Superior Health Plan EPO	$3.75

ELECTRODE, BLADE EXTENDED 6.50' STERILE DISPOSABLE -- DHF

Facility

$27.56

Hospital Charge Code	81723272
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18.74

Know your out-of-pocket cost for care.

All Charges