White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ELECTRODE, DISPERSIVE DUAL FOIL W/10' CABLE DISP -- DHF

Facility

$33.71

Hospital Charge Code	82121799
Hospital Revenue Code	270
Rate for Payer: Cash Price	$22.92

ELECTRODE, DISPERSIVE DUAL FOIL W/10' CABLE DISP -- DHF

Facility

$33.71

Hospital Charge Code	82121799
Hospital Revenue Code	270
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$24.27
Rate for Payer: Amerigroup CHIP/Medicaid	$3.03
Rate for Payer: BCBS of TX Blue Advantage	$10.11
Rate for Payer: BCBS of TX Blue Essentials	$12.14
Rate for Payer: BCBS of TX PPO	$13.48
Rate for Payer: Cash Price	$22.92
Rate for Payer: Cigna Medicaid	$24.27
Rate for Payer: Molina CHIP/Medicaid	$24.27
Rate for Payer: Multiplan Auto	$21.91
Rate for Payer: Multiplan Commercial	$21.91
Rate for Payer: Multiplan Workers Comp	$21.91
Rate for Payer: Parkland Medicaid	$24.27
Rate for Payer: Scott and White EPO/PPO	$16.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.27
Rate for Payer: Superior Health Plan EPO	$4.58

ELECTRODE, ECG, RESTNG, TABSTYL, 10/CARD

Facility

$0.20

Hospital Charge Code	993229
Hospital Revenue Code	270
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.14
Rate for Payer: Amerigroup CHIP/Medicaid	$0.02
Rate for Payer: BCBS of TX Blue Advantage	$0.06
Rate for Payer: BCBS of TX Blue Essentials	$0.07
Rate for Payer: BCBS of TX PPO	$0.08
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna Medicaid	$0.14
Rate for Payer: Molina CHIP/Medicaid	$0.14
Rate for Payer: Multiplan Auto	$0.13
Rate for Payer: Multiplan Commercial	$0.13
Rate for Payer: Multiplan Workers Comp	$0.13
Rate for Payer: Parkland Medicaid	$0.14
Rate for Payer: Scott and White EPO/PPO	$0.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.14
Rate for Payer: Superior Health Plan EPO	$0.03

ELECTRODE, ECG, RESTNG, TABSTYL, 10/CARD

Facility

$0.20

Hospital Charge Code	993229
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.14

ELECTRODE, FOAM 455 SERIES FLUID RESISTANT -- DHF

Facility

$68.92

Hospital Charge Code	82030255
Hospital Revenue Code	270
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$49.62
Rate for Payer: Amerigroup CHIP/Medicaid	$6.20
Rate for Payer: BCBS of TX Blue Advantage	$20.68
Rate for Payer: BCBS of TX Blue Essentials	$24.81
Rate for Payer: BCBS of TX PPO	$27.57
Rate for Payer: Cash Price	$46.87
Rate for Payer: Cigna Medicaid	$49.62
Rate for Payer: Molina CHIP/Medicaid	$49.62
Rate for Payer: Multiplan Auto	$44.80
Rate for Payer: Multiplan Commercial	$44.80
Rate for Payer: Multiplan Workers Comp	$44.80
Rate for Payer: Parkland Medicaid	$49.62
Rate for Payer: Scott and White EPO/PPO	$34.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.62
Rate for Payer: Superior Health Plan EPO	$9.37

ELECTRODE, FOAM 455 SERIES FLUID RESISTANT -- DHF

Facility

$68.92

Hospital Charge Code	82030255
Hospital Revenue Code	270
Rate for Payer: Cash Price	$46.87

ELECTRODE LAPARASCOPIC WIRE L HOOK 44CM

Facility

$73.85

Hospital Charge Code	993951
Hospital Revenue Code	272
Rate for Payer: Cash Price	$50.22

ELECTRODE LAPARASCOPIC WIRE L HOOK 44CM

Facility

$73.85

Hospital Charge Code	993951
Hospital Revenue Code	272
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$53.17
Rate for Payer: Amerigroup CHIP/Medicaid	$6.65
Rate for Payer: BCBS of TX Blue Advantage	$22.16
Rate for Payer: BCBS of TX Blue Essentials	$26.59
Rate for Payer: BCBS of TX PPO	$29.54
Rate for Payer: Cash Price	$50.22
Rate for Payer: Cigna Medicaid	$53.17
Rate for Payer: Molina CHIP/Medicaid	$53.17
Rate for Payer: Multiplan Auto	$48.00
Rate for Payer: Multiplan Commercial	$48.00
Rate for Payer: Multiplan Workers Comp	$48.00
Rate for Payer: Parkland Medicaid	$53.17
Rate for Payer: Scott and White EPO/PPO	$36.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53.17
Rate for Payer: Superior Health Plan EPO	$10.04

ELECTRODE, LAPARASCOPIC WIRE L HOOK 44CM -- DHF

Facility

$244.05

Hospital Charge Code	82121831
Hospital Revenue Code	271
Rate for Payer: Cash Price	$165.95

ELECTRODE, LAPARASCOPIC WIRE L HOOK 44CM -- DHF

Facility

$244.05

Hospital Charge Code	82121831
Hospital Revenue Code	271
Min. Negotiated Rate	$21.96
Max. Negotiated Rate	$175.72
Rate for Payer: Amerigroup CHIP/Medicaid	$21.96
Rate for Payer: BCBS of TX Blue Advantage	$73.22
Rate for Payer: BCBS of TX Blue Essentials	$87.86
Rate for Payer: BCBS of TX PPO	$97.62
Rate for Payer: Cash Price	$165.95
Rate for Payer: Cigna Medicaid	$175.72
Rate for Payer: Molina CHIP/Medicaid	$175.72
Rate for Payer: Multiplan Auto	$158.63
Rate for Payer: Multiplan Commercial	$158.63
Rate for Payer: Multiplan Workers Comp	$158.63
Rate for Payer: Parkland Medicaid	$175.72
Rate for Payer: Scott and White EPO/PPO	$122.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$175.72
Rate for Payer: Superior Health Plan EPO	$33.19

Electrolyte Panel

Facility

$272.00

Service Code	HCPCS 80051
Hospital Charge Code	1602804
Hospital Revenue Code	301
Rate for Payer: Cash Price	$184.96

Electrolyte Panel

Facility

$272.00

Service Code	HCPCS 80051
Hospital Charge Code	1602804
Hospital Revenue Code	301
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$195.84
Rate for Payer: Amerigroup CHIP/Medicaid	$2.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.01
Rate for Payer: Amerigroup Medicare	$7.01
Rate for Payer: BCBS of TX Blue Advantage	$81.60
Rate for Payer: BCBS of TX Blue Essentials	$97.92
Rate for Payer: BCBS of TX Medicare	$7.01
Rate for Payer: BCBS of TX PPO	$108.80
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cigna Medicaid	$195.84
Rate for Payer: Cigna Medicare	$7.01
Rate for Payer: Employer Direct Commercial	$7.01
Rate for Payer: Humana Medicare/TRICARE	$7.01
Rate for Payer: Molina CHIP/Medicaid	$195.84
Rate for Payer: Molina Dual Medicare/Medicaid	$7.01
Rate for Payer: Molina Medicare	$7.01
Rate for Payer: Multiplan Auto	$176.80
Rate for Payer: Multiplan Commercial	$176.80
Rate for Payer: Multiplan Workers Comp	$176.80
Rate for Payer: Parkland Medicaid	$195.84
Rate for Payer: Scott and White EPO/PPO	$8.76
Rate for Payer: Scott and White Medicare	$7.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.84
Rate for Payer: Superior Health Plan EPO	$7.01
Rate for Payer: Superior Health Plan Medicare	$7.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.01
Rate for Payer: Universal American Medicare	$7.01
Rate for Payer: Wellcare Medicare	$7.01
Rate for Payer: Wellmed Medicare	$7.01

Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s],

Facility

$601.86

Service Code	HCPCS 95972
Hospital Charge Code	9900909
Hospital Revenue Code	360
Min. Negotiated Rate	$48.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$54.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$95.50
Rate for Payer: Amerigroup Medicare	$95.50
Rate for Payer: BCBS of TX Blue Advantage	$180.56
Rate for Payer: BCBS of TX Blue Essentials	$216.67
Rate for Payer: BCBS of TX Medicare	$95.50
Rate for Payer: BCBS of TX PPO	$240.74
Rate for Payer: Cash Price	$409.26
Rate for Payer: Cash Price	$409.26
Rate for Payer: Cash Price	$409.26
Rate for Payer: Cigna Commercial	$201.88
Rate for Payer: Cigna Medicaid	$433.34
Rate for Payer: Cigna Medicare	$95.50
Rate for Payer: Employer Direct Commercial	$95.50
Rate for Payer: Humana Medicare/TRICARE	$95.50
Rate for Payer: Molina CHIP/Medicaid	$433.34
Rate for Payer: Molina Dual Medicare/Medicaid	$95.50
Rate for Payer: Molina Medicare	$95.50
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	$433.34
Rate for Payer: Scott and White EPO/PPO	$48.75
Rate for Payer: Scott and White Medicare	$95.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.34
Rate for Payer: Superior Health Plan EPO	$95.50
Rate for Payer: Superior Health Plan Medicare	$95.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$95.50
Rate for Payer: Universal American Medicare	$95.50
Rate for Payer: Wellcare Medicare	$95.50
Rate for Payer: Wellmed Medicare	$95.50

Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s],

Facility

$10,000.00

Service Code	CPT 95972
Hospital Charge Code	36095972
Hospital Revenue Code	360
Min. Negotiated Rate	$48.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$95.50
Rate for Payer: Amerigroup Medicare	$95.50
Rate for Payer: BCBS of TX Medicare	$95.50
Rate for Payer: Cigna Commercial	$201.88
Rate for Payer: Cigna Medicare	$95.50
Rate for Payer: Employer Direct Commercial	$95.50
Rate for Payer: Humana Medicare/TRICARE	$95.50
Rate for Payer: Molina Dual Medicare/Medicaid	$95.50
Rate for Payer: Molina Medicare	$95.50
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: Scott and White EPO/PPO	$48.75
Rate for Payer: Scott and White Medicare	$95.50
Rate for Payer: Superior Health Plan EPO	$95.50
Rate for Payer: Superior Health Plan Medicare	$95.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$95.50
Rate for Payer: Universal American Medicare	$95.50
Rate for Payer: Wellcare Medicare	$95.50
Rate for Payer: Wellmed Medicare	$95.50

Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s],

Facility

$601.86

Service Code	HCPCS 95972
Hospital Charge Code	9900909
Hospital Revenue Code	360
Rate for Payer: Cash Price	$409.26

Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (inclu

Facility

$1,089.88

Service Code	HCPCS 62370
Hospital Charge Code	9900758
Hospital Revenue Code	360
Min. Negotiated Rate	$98.09
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$98.09
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.54
Rate for Payer: Amerigroup Medicare	$308.54
Rate for Payer: BCBS of TX Blue Advantage	$110.89
Rate for Payer: BCBS of TX Blue Essentials	$132.80
Rate for Payer: BCBS of TX Medicare	$308.54
Rate for Payer: BCBS of TX PPO	$167.33
Rate for Payer: Cash Price	$741.12
Rate for Payer: Cash Price	$741.12
Rate for Payer: Cash Price	$741.12
Rate for Payer: Cigna Commercial	$652.19
Rate for Payer: Cigna Medicaid	$784.71
Rate for Payer: Cigna Medicare	$308.54
Rate for Payer: Employer Direct Commercial	$308.54
Rate for Payer: Humana Medicare/TRICARE	$308.54
Rate for Payer: Molina CHIP/Medicaid	$784.71
Rate for Payer: Molina Dual Medicare/Medicaid	$308.54
Rate for Payer: Molina Medicare	$308.54
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	$784.71
Rate for Payer: Scott and White EPO/PPO	$505.36
Rate for Payer: Scott and White Medicare	$308.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$784.71
Rate for Payer: Superior Health Plan EPO	$308.54
Rate for Payer: Superior Health Plan Medicare	$308.54
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.54
Rate for Payer: Universal American Medicare	$308.54
Rate for Payer: Wellcare Medicare	$308.54
Rate for Payer: Wellmed Medicare	$308.54

Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (inclu

Facility

$1,089.88

Service Code	HCPCS 62370
Hospital Charge Code	9900758
Hospital Revenue Code	360
Rate for Payer: Cash Price	$741.12

Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (inclu

Facility

$10,000.00

Service Code	CPT 62370
Hospital Charge Code	36062370
Hospital Revenue Code	360
Min. Negotiated Rate	$110.89
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.54
Rate for Payer: Amerigroup Medicare	$308.54
Rate for Payer: BCBS of TX Blue Advantage	$110.89
Rate for Payer: BCBS of TX Blue Essentials	$132.80
Rate for Payer: BCBS of TX Medicare	$308.54
Rate for Payer: BCBS of TX PPO	$167.33
Rate for Payer: Cigna Commercial	$652.19
Rate for Payer: Cigna Medicare	$308.54
Rate for Payer: Employer Direct Commercial	$308.54
Rate for Payer: Humana Medicare/TRICARE	$308.54
Rate for Payer: Molina Dual Medicare/Medicaid	$308.54
Rate for Payer: Molina Medicare	$308.54
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: Scott and White EPO/PPO	$505.36
Rate for Payer: Scott and White Medicare	$308.54
Rate for Payer: Superior Health Plan EPO	$308.54
Rate for Payer: Superior Health Plan Medicare	$308.54
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.54
Rate for Payer: Universal American Medicare	$308.54
Rate for Payer: Wellcare Medicare	$308.54
Rate for Payer: Wellmed Medicare	$308.54

Ellipse DR_ICD_UMRI_PR

Facility

$106,546.20

Service Code	HCPCS C1721
Hospital Charge Code	991302
Hospital Revenue Code	278
Min. Negotiated Rate	$9,589.16
Max. Negotiated Rate	$76,713.26
Rate for Payer: Amerigroup CHIP/Medicaid	$9,589.16
Rate for Payer: BCBS of TX Blue Advantage	$31,963.86
Rate for Payer: BCBS of TX Blue Essentials	$38,356.63
Rate for Payer: BCBS of TX PPO	$42,618.48
Rate for Payer: Cash Price	$72,451.42
Rate for Payer: Cigna Medicaid	$76,713.26
Rate for Payer: Molina CHIP/Medicaid	$76,713.26
Rate for Payer: Multiplan Auto	$53,273.10
Rate for Payer: Multiplan Commercial	$53,273.10
Rate for Payer: Multiplan Workers Comp	$53,273.10
Rate for Payer: Parkland Medicaid	$76,713.26
Rate for Payer: Scott and White EPO/PPO	$53,273.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76,713.26
Rate for Payer: Superior Health Plan EPO	$14,490.28

Ellipse DR_ICD_UMRI_PR

Facility

$106,546.20

Service Code	HCPCS C1721
Hospital Charge Code	110256
Hospital Revenue Code	278
Min. Negotiated Rate	$26,636.55
Max. Negotiated Rate	$53,273.10
Rate for Payer: Cash Price	$72,451.42
Rate for Payer: Cigna Commercial	$26,636.55
Rate for Payer: Multiplan Auto	$53,273.10
Rate for Payer: Multiplan Commercial	$53,273.10
Rate for Payer: Multiplan Workers Comp	$53,273.10
Rate for Payer: Scott and White EPO/PPO	$53,273.10

Ellipse DR_ICD_UMRI_PR

Facility

$106,546.20

Service Code	HCPCS C1721
Hospital Charge Code	110256
Hospital Revenue Code	278
Min. Negotiated Rate	$9,589.16
Max. Negotiated Rate	$76,713.26
Rate for Payer: Amerigroup CHIP/Medicaid	$9,589.16
Rate for Payer: BCBS of TX Blue Advantage	$31,963.86
Rate for Payer: BCBS of TX Blue Essentials	$38,356.63
Rate for Payer: BCBS of TX PPO	$42,618.48
Rate for Payer: Cash Price	$72,451.42
Rate for Payer: Cigna Medicaid	$76,713.26
Rate for Payer: Molina CHIP/Medicaid	$76,713.26
Rate for Payer: Multiplan Auto	$53,273.10
Rate for Payer: Multiplan Commercial	$53,273.10
Rate for Payer: Multiplan Workers Comp	$53,273.10
Rate for Payer: Parkland Medicaid	$76,713.26
Rate for Payer: Scott and White EPO/PPO	$53,273.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76,713.26
Rate for Payer: Superior Health Plan EPO	$14,490.28

Ellipse DR_ICD_UMRI_PR

Facility

$106,546.20

Service Code	HCPCS C1721
Hospital Charge Code	991302
Hospital Revenue Code	278
Min. Negotiated Rate	$26,636.55
Max. Negotiated Rate	$53,273.10
Rate for Payer: Cash Price	$72,451.42
Rate for Payer: Cigna Commercial	$26,636.55
Rate for Payer: Multiplan Auto	$53,273.10
Rate for Payer: Multiplan Commercial	$53,273.10
Rate for Payer: Multiplan Workers Comp	$53,273.10
Rate for Payer: Scott and White EPO/PPO	$53,273.10

EMBOSHIELD SYSTEM

Facility

$6,583.00

Hospital Charge Code	8450467
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,476.44

EMBOSHIELD SYSTEM

Facility

$6,583.00

Hospital Charge Code	8450467
Hospital Revenue Code	272
Min. Negotiated Rate	$592.47
Max. Negotiated Rate	$4,739.76
Rate for Payer: Amerigroup CHIP/Medicaid	$592.47
Rate for Payer: BCBS of TX Blue Advantage	$1,974.90
Rate for Payer: BCBS of TX Blue Essentials	$2,369.88
Rate for Payer: BCBS of TX PPO	$2,633.20
Rate for Payer: Cash Price	$4,476.44
Rate for Payer: Cigna Medicaid	$4,739.76
Rate for Payer: Molina CHIP/Medicaid	$4,739.76
Rate for Payer: Multiplan Auto	$4,278.95
Rate for Payer: Multiplan Commercial	$4,278.95
Rate for Payer: Multiplan Workers Comp	$4,278.95
Rate for Payer: Parkland Medicaid	$4,739.76
Rate for Payer: Scott and White EPO/PPO	$3,291.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,739.76
Rate for Payer: Superior Health Plan EPO	$895.29

emerel plus mutisurface cream cleanser

Facility

$15.00

Hospital Charge Code	993299
Hospital Revenue Code	270
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$10.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1.35
Rate for Payer: BCBS of TX Blue Advantage	$4.50
Rate for Payer: BCBS of TX Blue Essentials	$5.40
Rate for Payer: BCBS of TX PPO	$6.00
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cigna Medicaid	$10.80
Rate for Payer: Molina CHIP/Medicaid	$10.80
Rate for Payer: Multiplan Auto	$9.75
Rate for Payer: Multiplan Commercial	$9.75
Rate for Payer: Multiplan Workers Comp	$9.75
Rate for Payer: Parkland Medicaid	$10.80
Rate for Payer: Scott and White EPO/PPO	$7.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.80
Rate for Payer: Superior Health Plan EPO	$2.04

Know your out-of-pocket cost for care.

All Charges