White Rock Medical Center

All Charges

Charge

Type

Setting

Price

.ENA+DNA/DS+Sjogren's 016123 SO

Facility

$426.00

Service Code	HCPCS 86225
Hospital Charge Code	1605344
Hospital Revenue Code	302
Rate for Payer: Cash Price	$289.68

.ENA+DNA/DS+Sjogren's 016123 SO

Facility

$426.00

Service Code	HCPCS 86225
Hospital Charge Code	1605344
Hospital Revenue Code	302
Min. Negotiated Rate	$5.36
Max. Negotiated Rate	$306.72
Rate for Payer: Amerigroup CHIP/Medicaid	$5.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.74
Rate for Payer: Amerigroup Medicare	$13.74
Rate for Payer: BCBS of TX Blue Advantage	$127.80
Rate for Payer: BCBS of TX Blue Essentials	$153.36
Rate for Payer: BCBS of TX Medicare	$13.74
Rate for Payer: BCBS of TX PPO	$170.40
Rate for Payer: Cash Price	$289.68
Rate for Payer: Cash Price	$289.68
Rate for Payer: Cigna Medicaid	$306.72
Rate for Payer: Cigna Medicare	$13.74
Rate for Payer: Employer Direct Commercial	$13.74
Rate for Payer: Humana Medicare/TRICARE	$13.74
Rate for Payer: Molina CHIP/Medicaid	$306.72
Rate for Payer: Molina Dual Medicare/Medicaid	$13.74
Rate for Payer: Molina Medicare	$13.74
Rate for Payer: Multiplan Auto	$276.90
Rate for Payer: Multiplan Commercial	$276.90
Rate for Payer: Multiplan Workers Comp	$276.90
Rate for Payer: Parkland Medicaid	$306.72
Rate for Payer: Scott and White EPO/PPO	$17.18
Rate for Payer: Scott and White Medicare	$13.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$306.72
Rate for Payer: Superior Health Plan EPO	$13.74
Rate for Payer: Superior Health Plan Medicare	$13.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.74
Rate for Payer: Universal American Medicare	$13.74
Rate for Payer: Wellcare Medicare	$13.74
Rate for Payer: Wellmed Medicare	$13.74

enalapril 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77545401
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

enalapril 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77545401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

enalaprilat 1.25 mg/mL IV Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77545617
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

enalaprilat 1.25 mg/mL IV Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77545617
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

END CAP T2 SUPER CONDYLAR NAIL

Facility

$1,205.00

Service Code	HCPCS C1776
Hospital Charge Code	140511
Hospital Revenue Code	278
Min. Negotiated Rate	$301.25
Max. Negotiated Rate	$602.50
Rate for Payer: Cash Price	$819.40
Rate for Payer: Cigna Commercial	$301.25
Rate for Payer: Multiplan Auto	$602.50
Rate for Payer: Multiplan Commercial	$602.50
Rate for Payer: Multiplan Workers Comp	$602.50
Rate for Payer: Scott and White EPO/PPO	$602.50

END CAP T2 SUPER CONDYLAR NAIL

Facility

$1,205.00

Service Code	HCPCS C1776
Hospital Charge Code	140511
Hospital Revenue Code	278
Min. Negotiated Rate	$108.45
Max. Negotiated Rate	$867.60
Rate for Payer: Amerigroup CHIP/Medicaid	$108.45
Rate for Payer: BCBS of TX Blue Advantage	$361.50
Rate for Payer: BCBS of TX Blue Essentials	$433.80
Rate for Payer: BCBS of TX PPO	$482.00
Rate for Payer: Cash Price	$819.40
Rate for Payer: Cigna Medicaid	$867.60
Rate for Payer: Molina CHIP/Medicaid	$867.60
Rate for Payer: Multiplan Auto	$602.50
Rate for Payer: Multiplan Commercial	$602.50
Rate for Payer: Multiplan Workers Comp	$602.50
Rate for Payer: Parkland Medicaid	$867.60
Rate for Payer: Scott and White EPO/PPO	$602.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$867.60
Rate for Payer: Superior Health Plan EPO	$163.88

ENDO CATCH/SAC -- DHF

Facility

$1,541.75

Hospital Charge Code	80811110
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,048.39

ENDO CATCH/SAC -- DHF

Facility

$1,541.75

Hospital Charge Code	80811110
Hospital Revenue Code	272
Min. Negotiated Rate	$138.76
Max. Negotiated Rate	$1,110.06
Rate for Payer: Amerigroup CHIP/Medicaid	$138.76
Rate for Payer: BCBS of TX Blue Advantage	$462.52
Rate for Payer: BCBS of TX Blue Essentials	$555.03
Rate for Payer: BCBS of TX PPO	$616.70
Rate for Payer: Cash Price	$1,048.39
Rate for Payer: Cigna Medicaid	$1,110.06
Rate for Payer: Molina CHIP/Medicaid	$1,110.06
Rate for Payer: Multiplan Auto	$1,002.14
Rate for Payer: Multiplan Commercial	$1,002.14
Rate for Payer: Multiplan Workers Comp	$1,002.14
Rate for Payer: Parkland Medicaid	$1,110.06
Rate for Payer: Scott and White EPO/PPO	$770.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,110.06
Rate for Payer: Superior Health Plan EPO	$209.68

ENDOCLOSE

Facility

$220.64

Hospital Charge Code	992695
Hospital Revenue Code	272
Min. Negotiated Rate	$19.86
Max. Negotiated Rate	$158.86
Rate for Payer: Amerigroup CHIP/Medicaid	$19.86
Rate for Payer: BCBS of TX Blue Advantage	$66.19
Rate for Payer: BCBS of TX Blue Essentials	$79.43
Rate for Payer: BCBS of TX PPO	$88.26
Rate for Payer: Cash Price	$150.04
Rate for Payer: Cigna Medicaid	$158.86
Rate for Payer: Molina CHIP/Medicaid	$158.86
Rate for Payer: Multiplan Auto	$143.42
Rate for Payer: Multiplan Commercial	$143.42
Rate for Payer: Multiplan Workers Comp	$143.42
Rate for Payer: Parkland Medicaid	$158.86
Rate for Payer: Scott and White EPO/PPO	$110.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$158.86
Rate for Payer: Superior Health Plan EPO	$30.01

ENDOCLOSE

Facility

$220.64

Hospital Charge Code	992695
Hospital Revenue Code	272
Rate for Payer: Cash Price	$150.04

ENDOCLOSE -- DHF

Facility

$356.09

Hospital Charge Code	80811177
Hospital Revenue Code	272
Min. Negotiated Rate	$32.05
Max. Negotiated Rate	$256.38
Rate for Payer: Amerigroup CHIP/Medicaid	$32.05
Rate for Payer: BCBS of TX Blue Advantage	$106.83
Rate for Payer: BCBS of TX Blue Essentials	$128.19
Rate for Payer: BCBS of TX PPO	$142.44
Rate for Payer: Cash Price	$242.14
Rate for Payer: Cigna Medicaid	$256.38
Rate for Payer: Molina CHIP/Medicaid	$256.38
Rate for Payer: Multiplan Auto	$231.46
Rate for Payer: Multiplan Commercial	$231.46
Rate for Payer: Multiplan Workers Comp	$231.46
Rate for Payer: Parkland Medicaid	$256.38
Rate for Payer: Scott and White EPO/PPO	$178.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$256.38
Rate for Payer: Superior Health Plan EPO	$48.43

ENDOCLOSE -- DHF

Facility

$356.09

Hospital Charge Code	80811177
Hospital Revenue Code	272
Rate for Payer: Cash Price	$242.14

ENDOCRINE DISORDERS W CC

Facility

$19,475.00

Service Code	MSDRG 644
Min. Negotiated Rate	$8,707.50
Max. Negotiated Rate	$19,475.00
Rate for Payer: BCBS of TX Blue Advantage	$8,707.50
Rate for Payer: BCBS of TX Blue Essentials	$10,447.99
Rate for Payer: BCBS of TX PPO	$11,609.33

ENDOCRINE DISORDERS WITH CC

Facility

$19,475.00

Service Code	MSDRG 644
Min. Negotiated Rate	$8,707.50
Max. Negotiated Rate	$19,475.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,272.34
Rate for Payer: Amerigroup Medicare	$12,272.34
Rate for Payer: BCBS of TX Medicare	$12,272.34
Rate for Payer: Cigna Commercial	$13,202.00
Rate for Payer: Cigna Medicare	$12,272.34
Rate for Payer: Employer Direct Commercial	$12,272.34
Rate for Payer: Humana Medicare/TRICARE	$12,272.34
Rate for Payer: Molina Dual Medicare/Medicaid	$12,272.34
Rate for Payer: Molina Medicare	$12,272.34
Rate for Payer: Multiplan Auto	$19,475.00
Rate for Payer: Multiplan Commercial	$19,475.00
Rate for Payer: Multiplan Workers Comp	$19,475.00
Rate for Payer: Scott and White EPO/PPO	$8,968.75
Rate for Payer: Scott and White Medicare	$12,272.34
Rate for Payer: Superior Health Plan EPO	$12,272.34
Rate for Payer: Superior Health Plan Medicare	$12,272.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,272.34
Rate for Payer: Universal American Medicare	$12,272.34
Rate for Payer: Wellcare Medicare	$12,272.34
Rate for Payer: Wellmed Medicare	$12,272.34

ENDOCRINE DISORDERS WITH MCC

Facility

$31,275.90

Service Code	MSDRG 643
Min. Negotiated Rate	$14,053.26
Max. Negotiated Rate	$31,275.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,824.38
Rate for Payer: Amerigroup Medicare	$16,824.38
Rate for Payer: BCBS of TX Medicare	$16,824.38
Rate for Payer: Cigna Commercial	$21,201.77
Rate for Payer: Cigna Medicare	$16,824.38
Rate for Payer: Employer Direct Commercial	$16,824.38
Rate for Payer: Humana Medicare/TRICARE	$16,824.38
Rate for Payer: Molina Dual Medicare/Medicaid	$16,824.38
Rate for Payer: Molina Medicare	$16,824.38
Rate for Payer: Multiplan Auto	$31,275.90
Rate for Payer: Multiplan Commercial	$31,275.90
Rate for Payer: Multiplan Workers Comp	$31,275.90
Rate for Payer: Scott and White EPO/PPO	$14,403.38
Rate for Payer: Scott and White Medicare	$16,824.38
Rate for Payer: Superior Health Plan EPO	$16,824.38
Rate for Payer: Superior Health Plan Medicare	$16,824.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,824.38
Rate for Payer: Universal American Medicare	$16,824.38
Rate for Payer: Wellcare Medicare	$16,824.38
Rate for Payer: Wellmed Medicare	$16,824.38

ENDOCRINE DISORDERS WITHOUT CC/MCC

Facility

$14,597.70

Service Code	MSDRG 645
Min. Negotiated Rate	$6,388.94
Max. Negotiated Rate	$14,597.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,390.97
Rate for Payer: Amerigroup Medicare	$10,390.97
Rate for Payer: BCBS of TX Medicare	$10,390.97
Rate for Payer: Cigna Commercial	$9,895.70
Rate for Payer: Cigna Medicare	$10,390.97
Rate for Payer: Employer Direct Commercial	$10,390.97
Rate for Payer: Humana Medicare/TRICARE	$10,390.97
Rate for Payer: Molina Dual Medicare/Medicaid	$10,390.97
Rate for Payer: Molina Medicare	$10,390.97
Rate for Payer: Multiplan Auto	$14,597.70
Rate for Payer: Multiplan Commercial	$14,597.70
Rate for Payer: Multiplan Workers Comp	$14,597.70
Rate for Payer: Scott and White EPO/PPO	$6,722.62
Rate for Payer: Scott and White Medicare	$10,390.97
Rate for Payer: Superior Health Plan EPO	$10,390.97
Rate for Payer: Superior Health Plan Medicare	$10,390.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,390.97
Rate for Payer: Universal American Medicare	$10,390.97
Rate for Payer: Wellcare Medicare	$10,390.97
Rate for Payer: Wellmed Medicare	$10,390.97

ENDOCRINE DISORDERS W MCC

Facility

$31,275.90

Service Code	MSDRG 643
Min. Negotiated Rate	$14,053.26
Max. Negotiated Rate	$31,275.90
Rate for Payer: BCBS of TX Blue Advantage	$14,053.26
Rate for Payer: BCBS of TX Blue Essentials	$16,862.28
Rate for Payer: BCBS of TX PPO	$18,736.59

ENDOCRINE DISORDERS W/O CC/MCC

Facility

$14,597.70

Service Code	MSDRG 645
Min. Negotiated Rate	$6,388.94
Max. Negotiated Rate	$14,597.70
Rate for Payer: BCBS of TX Blue Advantage	$6,388.94
Rate for Payer: BCBS of TX Blue Essentials	$7,665.99
Rate for Payer: BCBS of TX PPO	$8,518.09

ENDO GIA RELOAD PURPLE

Facility

$464.36

Hospital Charge Code	992368
Hospital Revenue Code	272
Rate for Payer: Cash Price	$315.76

ENDO GIA RELOAD PURPLE

Facility

$464.36

Hospital Charge Code	992368
Hospital Revenue Code	272
Min. Negotiated Rate	$41.79
Max. Negotiated Rate	$334.34
Rate for Payer: Amerigroup CHIP/Medicaid	$41.79
Rate for Payer: BCBS of TX Blue Advantage	$139.31
Rate for Payer: BCBS of TX Blue Essentials	$167.17
Rate for Payer: BCBS of TX PPO	$185.74
Rate for Payer: Cash Price	$315.76
Rate for Payer: Cigna Medicaid	$334.34
Rate for Payer: Molina CHIP/Medicaid	$334.34
Rate for Payer: Multiplan Auto	$301.83
Rate for Payer: Multiplan Commercial	$301.83
Rate for Payer: Multiplan Workers Comp	$301.83
Rate for Payer: Parkland Medicaid	$334.34
Rate for Payer: Scott and White EPO/PPO	$232.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$334.34
Rate for Payer: Superior Health Plan EPO	$63.15

Endo Gla articulating stapler device, medium to thick staple, purple, 45mm

Facility

$820.60

Hospital Charge Code	992797
Hospital Revenue Code	272
Min. Negotiated Rate	$73.85
Max. Negotiated Rate	$590.83
Rate for Payer: Amerigroup CHIP/Medicaid	$73.85
Rate for Payer: BCBS of TX Blue Advantage	$246.18
Rate for Payer: BCBS of TX Blue Essentials	$295.42
Rate for Payer: BCBS of TX PPO	$328.24
Rate for Payer: Cash Price	$558.01
Rate for Payer: Cigna Medicaid	$590.83
Rate for Payer: Molina CHIP/Medicaid	$590.83
Rate for Payer: Multiplan Auto	$533.39
Rate for Payer: Multiplan Commercial	$533.39
Rate for Payer: Multiplan Workers Comp	$533.39
Rate for Payer: Parkland Medicaid	$590.83
Rate for Payer: Scott and White EPO/PPO	$410.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$590.83
Rate for Payer: Superior Health Plan EPO	$111.60

Endo Gla articulating stapler device, medium to thick staple, purple, 45mm

Facility

$820.60

Hospital Charge Code	992797
Hospital Revenue Code	272
Rate for Payer: Cash Price	$558.01

Endo Gla articulating stapler device, medium to thick staple, purple, 60mm

Facility

$1,079.68

Hospital Charge Code	992798
Hospital Revenue Code	272
Rate for Payer: Cash Price	$734.18

Know your out-of-pocket cost for care.

All Charges