White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Endoscopy, wrist, surgical, with release of transverse carpal ligament

Facility

$11,138.80

Service Code	HCPCS 29848
Hospital Charge Code	9900560
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cash Price	$7,574.38
Rate for Payer: Cash Price	$7,574.38
Rate for Payer: Cash Price	$7,574.38
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$8,019.94
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina CHIP/Medicaid	$8,019.94
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$8,019.94
Rate for Payer: Scott and White EPO/PPO	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,019.94
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

Endoscopy, wrist, surgical, with release of transverse carpal ligament

Facility

$10,000.00

Service Code	CPT 29848
Hospital Charge Code	36029848
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

ENDOSTITCH

Facility

$1,084.52

Hospital Charge Code	992679
Hospital Revenue Code	272
Rate for Payer: Cash Price	$737.47

ENDOSTITCH

Facility

$1,084.52

Hospital Charge Code	992679
Hospital Revenue Code	272
Min. Negotiated Rate	$97.61
Max. Negotiated Rate	$780.85
Rate for Payer: Amerigroup CHIP/Medicaid	$97.61
Rate for Payer: BCBS of TX Blue Advantage	$325.36
Rate for Payer: BCBS of TX Blue Essentials	$390.43
Rate for Payer: BCBS of TX PPO	$433.81
Rate for Payer: Cash Price	$737.47
Rate for Payer: Cigna Medicaid	$780.85
Rate for Payer: Molina CHIP/Medicaid	$780.85
Rate for Payer: Multiplan Auto	$704.94
Rate for Payer: Multiplan Commercial	$704.94
Rate for Payer: Multiplan Workers Comp	$704.94
Rate for Payer: Parkland Medicaid	$780.85
Rate for Payer: Scott and White EPO/PPO	$542.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$780.85
Rate for Payer: Superior Health Plan EPO	$147.49

ENDOSTITCH POLYSORB 3-0 170071

Facility

$98.43

Hospital Charge Code	116428
Hospital Revenue Code	272
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$70.87
Rate for Payer: Amerigroup CHIP/Medicaid	$8.86
Rate for Payer: BCBS of TX Blue Advantage	$29.53
Rate for Payer: BCBS of TX Blue Essentials	$35.43
Rate for Payer: BCBS of TX PPO	$39.37
Rate for Payer: Cash Price	$66.93
Rate for Payer: Cigna Medicaid	$70.87
Rate for Payer: Molina CHIP/Medicaid	$70.87
Rate for Payer: Multiplan Auto	$63.98
Rate for Payer: Multiplan Commercial	$63.98
Rate for Payer: Multiplan Workers Comp	$63.98
Rate for Payer: Parkland Medicaid	$70.87
Rate for Payer: Scott and White EPO/PPO	$49.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$70.87
Rate for Payer: Superior Health Plan EPO	$13.39

ENDOSTITCH POLYSORB 3-0 170071

Facility

$98.43

Hospital Charge Code	116428
Hospital Revenue Code	272
Rate for Payer: Cash Price	$66.93

ENDOSTITCH POLYSORB O 170052

Facility

$96.43

Hospital Charge Code	116426
Hospital Revenue Code	272
Rate for Payer: Cash Price	$65.57

ENDOSTITCH POLYSORB O 170052

Facility

$96.43

Hospital Charge Code	116426
Hospital Revenue Code	272
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$69.43
Rate for Payer: Amerigroup CHIP/Medicaid	$8.68
Rate for Payer: BCBS of TX Blue Advantage	$28.93
Rate for Payer: BCBS of TX Blue Essentials	$34.71
Rate for Payer: BCBS of TX PPO	$38.57
Rate for Payer: Cash Price	$65.57
Rate for Payer: Cigna Medicaid	$69.43
Rate for Payer: Molina CHIP/Medicaid	$69.43
Rate for Payer: Multiplan Auto	$62.68
Rate for Payer: Multiplan Commercial	$62.68
Rate for Payer: Multiplan Workers Comp	$62.68
Rate for Payer: Parkland Medicaid	$69.43
Rate for Payer: Scott and White EPO/PPO	$48.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.43
Rate for Payer: Superior Health Plan EPO	$13.11

ENDOSTITCH SOFSILK 2-0 170004

Facility

$271.54

Hospital Charge Code	116425
Hospital Revenue Code	272
Rate for Payer: Cash Price	$184.65

ENDOSTITCH SOFSILK 2-0 170004

Facility

$271.54

Hospital Charge Code	116425
Hospital Revenue Code	272
Min. Negotiated Rate	$24.44
Max. Negotiated Rate	$195.51
Rate for Payer: Amerigroup CHIP/Medicaid	$24.44
Rate for Payer: BCBS of TX Blue Advantage	$81.46
Rate for Payer: BCBS of TX Blue Essentials	$97.75
Rate for Payer: BCBS of TX PPO	$108.62
Rate for Payer: Cash Price	$184.65
Rate for Payer: Cigna Medicaid	$195.51
Rate for Payer: Molina CHIP/Medicaid	$195.51
Rate for Payer: Multiplan Auto	$176.50
Rate for Payer: Multiplan Commercial	$176.50
Rate for Payer: Multiplan Workers Comp	$176.50
Rate for Payer: Parkland Medicaid	$195.51
Rate for Payer: Scott and White EPO/PPO	$135.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.51
Rate for Payer: Superior Health Plan EPO	$36.93

ENDOSTITCH SUTURE DEVICE

Facility

$1,955.55

Hospital Charge Code	8538527
Hospital Revenue Code	272
Min. Negotiated Rate	$176.00
Max. Negotiated Rate	$1,408.00
Rate for Payer: Amerigroup CHIP/Medicaid	$176.00
Rate for Payer: BCBS of TX Blue Advantage	$586.66
Rate for Payer: BCBS of TX Blue Essentials	$704.00
Rate for Payer: BCBS of TX PPO	$782.22
Rate for Payer: Cash Price	$1,329.77
Rate for Payer: Cigna Medicaid	$1,408.00
Rate for Payer: Molina CHIP/Medicaid	$1,408.00
Rate for Payer: Multiplan Auto	$1,271.11
Rate for Payer: Multiplan Commercial	$1,271.11
Rate for Payer: Multiplan Workers Comp	$1,271.11
Rate for Payer: Parkland Medicaid	$1,408.00
Rate for Payer: Scott and White EPO/PPO	$977.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,408.00
Rate for Payer: Superior Health Plan EPO	$265.95

ENDOSTITCH SUTURE DEVICE

Facility

$1,955.55

Hospital Charge Code	8538527
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,329.77

ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES

Facility

$73,504.87

Service Code	MSDRG 213
Min. Negotiated Rate	$46,586.10
Max. Negotiated Rate	$73,504.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$46,586.10
Rate for Payer: Amerigroup Medicare	$46,586.10
Rate for Payer: BCBS of TX Medicare	$46,586.10
Rate for Payer: Cigna Commercial	$73,504.87
Rate for Payer: Cigna Medicare	$46,586.10
Rate for Payer: Employer Direct Commercial	$46,586.10
Rate for Payer: Humana Medicare/TRICARE	$46,586.10
Rate for Payer: Molina Dual Medicare/Medicaid	$46,586.10
Rate for Payer: Molina Medicare	$46,586.10
Rate for Payer: Scott and White Medicare	$46,586.10
Rate for Payer: Superior Health Plan EPO	$46,586.10
Rate for Payer: Superior Health Plan Medicare	$46,586.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$46,586.10
Rate for Payer: Universal American Medicare	$46,586.10
Rate for Payer: Wellcare Medicare	$46,586.10
Rate for Payer: Wellmed Medicare	$46,586.10

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC

Facility

$125,413.30

Service Code	MSDRG 266
Min. Negotiated Rate	$49,675.27
Max. Negotiated Rate	$125,413.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$49,675.27
Rate for Payer: Amerigroup Medicare	$49,675.27
Rate for Payer: BCBS of TX Medicare	$49,675.27
Rate for Payer: Cigna Commercial	$78,933.79
Rate for Payer: Cigna Medicare	$49,675.27
Rate for Payer: Employer Direct Commercial	$49,675.27
Rate for Payer: Humana Medicare/TRICARE	$49,675.27
Rate for Payer: Molina Dual Medicare/Medicaid	$49,675.27
Rate for Payer: Molina Medicare	$49,675.27
Rate for Payer: Multiplan Auto	$125,413.30
Rate for Payer: Multiplan Commercial	$125,413.30
Rate for Payer: Multiplan Workers Comp	$125,413.30
Rate for Payer: Scott and White EPO/PPO	$57,756.12
Rate for Payer: Scott and White Medicare	$49,675.27
Rate for Payer: Superior Health Plan EPO	$49,675.27
Rate for Payer: Superior Health Plan Medicare	$49,675.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$49,675.27
Rate for Payer: Universal American Medicare	$49,675.27
Rate for Payer: Wellcare Medicare	$49,675.27
Rate for Payer: Wellmed Medicare	$49,675.27

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC

Facility

$98,051.40

Service Code	MSDRG 267
Min. Negotiated Rate	$39,652.11
Max. Negotiated Rate	$98,051.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$39,652.11
Rate for Payer: Amerigroup Medicare	$39,652.11
Rate for Payer: BCBS of TX Medicare	$39,652.11
Rate for Payer: Cigna Commercial	$61,319.10
Rate for Payer: Cigna Medicare	$39,652.11
Rate for Payer: Employer Direct Commercial	$39,652.11
Rate for Payer: Humana Medicare/TRICARE	$39,652.11
Rate for Payer: Molina Dual Medicare/Medicaid	$39,652.11
Rate for Payer: Molina Medicare	$39,652.11
Rate for Payer: Multiplan Auto	$98,051.40
Rate for Payer: Multiplan Commercial	$98,051.40
Rate for Payer: Multiplan Workers Comp	$98,051.40
Rate for Payer: Scott and White EPO/PPO	$45,155.25
Rate for Payer: Scott and White Medicare	$39,652.11
Rate for Payer: Superior Health Plan EPO	$39,652.11
Rate for Payer: Superior Health Plan Medicare	$39,652.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$39,652.11
Rate for Payer: Universal American Medicare	$39,652.11
Rate for Payer: Wellcare Medicare	$39,652.11
Rate for Payer: Wellmed Medicare	$39,652.11

ENDOVASCULAR CARDIAC VALVE REPLACEMENT W MCC

Facility

$125,413.30

Service Code	MSDRG 266
Min. Negotiated Rate	$49,675.27
Max. Negotiated Rate	$125,413.30
Rate for Payer: BCBS of TX Blue Advantage	$61,846.90
Rate for Payer: BCBS of TX Blue Essentials	$74,209.09
Rate for Payer: BCBS of TX PPO	$82,457.74

ENDOVASCULAR CARDIAC VALVE REPLACEMENT W/O MCC

Facility

$98,051.40

Service Code	MSDRG 267
Min. Negotiated Rate	$39,652.11
Max. Negotiated Rate	$98,051.40
Rate for Payer: BCBS of TX Blue Advantage	$50,293.66
Rate for Payer: BCBS of TX Blue Essentials	$60,346.54
Rate for Payer: BCBS of TX PPO	$67,054.31

EndoWrist Bipolar Forceps

Facility

$13,166.00

Hospital Charge Code	993686
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8,952.88

EndoWrist Bipolar Forceps

Facility

$13,166.00

Hospital Charge Code	993686
Hospital Revenue Code	270
Min. Negotiated Rate	$1,184.94
Max. Negotiated Rate	$9,479.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1,184.94
Rate for Payer: BCBS of TX Blue Advantage	$3,949.80
Rate for Payer: BCBS of TX Blue Essentials	$4,739.76
Rate for Payer: BCBS of TX PPO	$5,266.40
Rate for Payer: Cash Price	$8,952.88
Rate for Payer: Cigna Medicaid	$9,479.52
Rate for Payer: Molina CHIP/Medicaid	$9,479.52
Rate for Payer: Multiplan Auto	$8,557.90
Rate for Payer: Multiplan Commercial	$8,557.90
Rate for Payer: Multiplan Workers Comp	$8,557.90
Rate for Payer: Parkland Medicaid	$9,479.52
Rate for Payer: Scott and White EPO/PPO	$6,583.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,479.52
Rate for Payer: Superior Health Plan EPO	$1,790.58

ENEMA ADMIN ST -- DHF

Facility

$87.80

Hospital Charge Code	80321508
Hospital Revenue Code	270
Rate for Payer: Cash Price	$59.70

ENEMA ADMIN ST -- DHF

Facility

$87.80

Hospital Charge Code	80321508
Hospital Revenue Code	270
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$63.22
Rate for Payer: Amerigroup CHIP/Medicaid	$7.90
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.61
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$59.70
Rate for Payer: Cigna Medicaid	$63.22
Rate for Payer: Molina CHIP/Medicaid	$63.22
Rate for Payer: Multiplan Auto	$57.07
Rate for Payer: Multiplan Commercial	$57.07
Rate for Payer: Multiplan Workers Comp	$57.07
Rate for Payer: Parkland Medicaid	$63.22
Rate for Payer: Scott and White EPO/PPO	$43.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.22
Rate for Payer: Superior Health Plan EPO	$11.94

enoxaparin 100 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77545925
Hospital Revenue Code	636
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.77
Rate for Payer: BCBS of TX Blue Essentials	$2.12
Rate for Payer: BCBS of TX PPO	$2.35
Rate for Payer: Cash Price	$87.16
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

enoxaparin 100 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77545925
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

enoxaparin 120 mg/0.8 mL Inj Soln 0.8 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77545982
Hospital Revenue Code	636
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.77
Rate for Payer: BCBS of TX Blue Essentials	$2.12
Rate for Payer: BCBS of TX PPO	$2.35
Rate for Payer: Cash Price	$87.16
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

enoxaparin 120 mg/0.8 mL Inj Soln 0.8 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77545982
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

Know your out-of-pocket cost for care.

All Charges